Every finding on record at Riverside Post Acute

Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure completion of the Pre-admission Screening and Resident Review (PASRR) process for two (Residents #51 and #127) residents who were identified with a newly evident or a possible serious Mental Disorder (MD), Intellectual Disability (ID) or related condition, from a total survey sample of 33 residents who were reviewed for PASRR.The findings include:1.A 12/2/25 review of Resident #51's PASRR, dated 9/14/22, revealed in Section I: PASRR Screen Decision-Making, that the resident did not have diagnoses or suspected diagnoses of anxiety disorder, bipolar disorder, depressive disorder, or schizophrenia. (Copy obtained)A review of Resident #51's record revealed an admission date of 12/31/22. Her diagnoses as of 8/7/24 included schizophrenia, unspecified; depression, unspecified; generalized anxiety disorder, and bipolar disorder, unspecified.A review of Resident #51's physician's orders included:Alprazolam (benzodiazepine often used to treat anxiety) oral tablet 0.25 mg (milligrams), give 1 tablet by mouth every 8 hours for anxiety (ordered 8/20/25).Escitalopram oxalate (antidepressant) oral tablet 10 mg, give 1 tablet by mouth one time a day for depression with anxiety (ordered 10/23/25). Olanzapine (antipsychotic) 10 mg tabs, give 1 tablet orally at bedtime for schizophrenia (ordered 10/22/25).Trazodone (antidepressant) 50 mg tabs, give 1 tablet orally at bedtime for depression (ordered 11/11/25).A review of the resident's Annual Minimum Data Set (MDS) assessment, dated 11/19/25, revealed that the resident entered this facility from a short-term general hospital (acute care hospital), and her Brief Interview for Mental status (BIMS) score was documented as 4 out of 15 possible points, indicating severe cognitive impairment.An interview was conducted with Social Services Director (SSD) K on 12/3/25 at 3:52 p.m. She provided the only PASRR she stated she had for Resident #51 which was dated 9/14/22. She stated at the time this evaluation was completed there was no indication that the resident suffered from anxiety, bipolar disorder, depressive order, or schizophrenia. Section IV of the screening indicated that no diagnosis or suspicion of Serious Mental Illness Disability was indicated, and that the Level II PASRR evaluation was not required. On 8/7/24 (almost two years after the resident's admission and completion of the 9/14/22 PASRR), Resident #51 was diagnosed with schizophrenia, depression, generalized anxiety disorder and bipolar disorder. SSD K stated the PASRR provided was the only PASRR on file for this resident and another one had not been completed.Another interview was conducted with SSD K on 12/4/25 at 8:57 a.m. She stated there was no PASRR on file (other than the one dated 9/14/22) for Resident #51 when she was interviewed yesterday (12/3/25 at 3:52 p.m.). She said she was aware that the facility was out of compliance. SSD K provided a PASRR that was completed on 12/3/25 for Resident #51. SSD K detailed the facility's process for identifying residents with a possible MD, ID, or related condition. SSD K said this process was the primary responsibility of the psychiatric provider. The psychiatric provider assessed residents at the facility. The provider then completed blood work to check for underlying issues or possible UTIs. The provider would assess/evaluate the resident a few times before diagnosing them. 2.A review of Resident #127's medical record on 12/1/25 at 12:20 p.m. revealed the resident's PASRR dated 12/11/24. (Copy Obtained)Further review of Resident #127's record revealed an admission date of 12/13/24. Her diagnoses included bipolar disorder, current episode depressed, mild or moderate severity, unspecified; depression, unspecified; unspecified dementia, unspecified severity, with other behavioral disturbance; other insomnia. A review of Resident #127's physician's orders revealed:Memantine HCl Oral Tablet 5 mg (milligrams - Namenda, primarily used to treat the symptoms of moderate-to-severe Alzheimer's disease), give 1 tablet by mouth one time a day for dementia (ordered 12/14/24),Zyprexa oral tablets 5 mg (Olanzapine - antipsychotic), give 1 tablet by mouth at bedtime for psychosis (ordered 10/22/25).Ramelteon tablets 8 mg (Rozerem - sedative/hypnotic), give 1 tablet by mouth at bedtime for insomnia (ordered 10/22/25).Monitor for side effects of anti-psychotic medications every shift which may include but is not limited to sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention, other (specify in progress notes) every shift (ordered 12/13/24)Monitor for side effects of hypnotic medications every shift, which may include but is not limited to sedation, drowsiness, morning hangover, ataxia, other (specify in progress notes) every shift (ordered 12/13/24).Behavior intervention #1: Monitor for biting, hitting, intervention codes may include but are not limited to: 1.Redirection 2.(1:1) 3.Activity 4.Toilet 5.Food/Fluid Offered 6.Position Change 7.Other Intervention (specify in progress notes) 8. Medication every day shift (ordered 12/14/24).Behaviors/intervention: Monitor for (sign/symptoms difficulty sleeping) intervention codes may include but are not limited to 1. Redirection 2. (1:1) 3. Activity 4.Toilet 5 .Food/Fluid Offered 6. Position Change 7. Other Intervention (specify in progress notes) 8. Medication every night shift (ordered 12/15/24).Other orders included Acetaminophen Oral Tablet 500 mg, give 1 tablet by mouth two times a day for Pain (ordered 8/26/25), andDo Not Resuscitate (DNR) (ordered 12/13/24). A review of the Minimum Data Set (MDS) assessment, dated 9/21/25, revealed that the resident entered from a short-term hospital (acute care hospital) and her Brief Interview for Mental status (BIMS) score was 7 out of 15 possible points, indicating severe cognitive impairment. An interview was conducted with Social Services Director (SSD) K on 12/4/25 at 12:13 p.m. When she was asked to explain the facility's process for identifying residents with a possible MD, ID, or related condition prior to admission to the facility, she replied that residents were discussed in clinical meetings. SSD K or any staff member would inform the primary provider when the nurse identified a resident's unusual behavior. Residents were assessed by the psychiatric provider. Hospital records were reviewed for new residents with no documented history of mental illness or behaviors. SSD K also stated she was responsible for ensuring that a referral was sent to the appropriate state-designated authority. When asked if a resident was identified as having a newly evident or possible MD, ID, or related condition after admission, what the facility's process was for referring the resident to the appropriate state-designated authority, SSD K replied that if she knew of the concern, she would contact the family member and complete/update the care plan. When asked if the resident was identified as having an evident or possible MD, ID, or related condition, and a referral to the appropriate state-authority was not made, why that was. SSD K stated she was not notified by the psychiatric provider. SSD K confirmed the resident had a new diagnosis and the PASRR should have been updated.A review of the facility's policy and procedure titled admission Criteria (effective 2001), revealed:Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: . 8. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. a. the facility conducts a level l PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. if the level l screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level ll (evaluation and determination) screening process. 1. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. 2. The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs. And whether placement in the facility is appropriate. d. The State PASRR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASRR representative, the potential resident and his or her representative are notified. (Copy Obtained)

Based on observations, record reviews, interviews, and a review of facility policies and procedures, the facility failed to provide appropriate fingernail care for two (Residents #182 and #196) residents who required assistance with grooming out of 56 residents whose fingernails were observed. Failure to provide consistent grooming and hygiene for residents who require assistance can negatively impact their sense of self-worth and dignity, as well as potentially spread infection and/or contribute to skin tears or other injuries. The findings include:1.A review of Resident #182's medical record revealed an admission date of 7/15/24 and diagnoses including hemiplegia/hemiparesis following a cerebral infarction (stroke) affecting the resident's right dominant side and seizures.On 12/01/25 at 12:33 PM, Resident #182 was observed propelling himself in a wheelchair down a corridor within the facility. He was observed to be speech impaired but was able to answer simple yes or no questions. He was able to understand what was being conveyed, but could only answer verbally, yeah. He also used gestures to convey his answers. The fingernails on his left hand were observed to be elongated and soiled. The fingernails on his right hand were difficult to observe because his fingers were contracted. (photographic evidence obtained)On 12/02/25 at 12:36 PM, Resident #182 was observed sitting up in a wheelchair in his room watching television. He was speech impaired but understood what was being asked and responded appropriately. He was asked if he'd received any fingernail care from the staff today. He shook his head no. He was asked if he desired fingernail care and he stated, Yeah. The fingernails on his left hand were elongated with brown matter underneath the nails. (photographic evidence obtained)On 12/02/25 at 12:46 PM, an interview was conducted with Certified Nursing Assistant (CNA) D who stated her resident assignment today included both Resident #182 and Resident #196.She was asked if the facility provided training/education for abuse and neglect prevention and reporting. She stated, Yes. She was asked if the facility provided training/education on (ADL) Activity of Daily Living Care. She stated, Yes. She was asked to describe what ADL care consisted of. She stated, Bathing, changing clothes, showers, bed baths, and fixing the bed. She was asked what she thought grooming consisted of. She stated, Shaving the resident, brushing the teeth, combing the hair, and cutting the nails. She was asked how often grooming should be provided. She stated, Daily and when needed. For instance, I need to change his [Resident #182] shirt often because he has lots of dry skin from his hair that falls on his shirt. She was accompanied to the resident's room where he was watching television. He was asked if we could observe his fingernails. He held up his left hand. He was unable to hold up his right hand. The CNA was asked if she thought he needed fingernail care. She stated, Yes. The resident was asked if he would allow the CNA to provide fingernail care. The resident stated, Yeah.On 12/02/25 at 1:58 PM, an interview was conducted with Licensed Practical Nurse (LPN) E/Unit Manager. She was asked if the facility provided training/education for abuse and neglect prevention and reporting. She stated, Yes. She was asked if the facility provided training/education on (ADL) Activity of Daily Living care. She stated, Yes. She was asked to describe what ADL care consisted of. She stated, Dressing, feeding, toileting, changing, showering, bathing, and hygiene. She was asked what she thought grooming consisted of. She stated, Hair, trimming nails, peri-care, washing the hands and face, toenails, facial hair, and shaving. She was asked how often grooming should be provided. She stated, Daily and when needed. For instance, trimming nails should be every two weeks. Nail care should be provided with showers. On 12/3/25 at 10:38 AM, further review of Resident #182's record revealed a modification of the resident's Quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 9/20/25. The modification revealed adequate hearing and vision, unclear speech, he usually understands, and was usually understood. His BIMS (brief interview for mental status) scored 11/15 which was indicative of moderate cognitive impairment. The resident required clean-up or set-up assistance from staff for eating and bed mobility. He required supervision/touching assistance with toileting, and partial/moderate staff assistance with transfers and personal hygiene. A review of the resident's physician's orders revealed:Keppra Oral Tablet (anticonvulsant) 500 mg (milligrams) by mouth two times a day for seizures (ordered 10/25/24).Escitalopram Oxalate Oral Tablet (antidepressant), 20 mg by mouth daily for depression (ordered 10/25/24).Gabapentin Oral Capsule (anticonvulsant used to treat nerve pain), 100 mg, 2 capsules by mouth every 8 hours for neuropathy (ordered 10/30/24).Lacosamide Oral Tablet (anticonvulsant) 200 mg by mouth two times a day for seizures (ordered 2/15/25).Baclofen Oral Tablet (muscle relaxant) 5 mg by mouth three times a day for muscle spasms (ordered 4/6/25). A review of the active care plan revealed the following Focus Areas:Focus: I have an ADL/Self-Care Performance Deficit r/t (related to) CVA (stroke) with hemiplegia (paralysis affecting one side of the body). Date Initiated: 10/23/2024 Revision on: 10/23/2024. Goal: I will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the next review date. Date Initiated: 10/23/2024 Revision on: 01/03/2025 Target Date: 09/13/2025. Interventions: Personal Hygiene: I require staff assistance with grooming/personal hygiene. Date Initiated: 10/23/2024 2.A review of Resident #196's medical record revealed an admission date of 12/21/22 and diagnoses including unspecified dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. On 12/01/25 at 12:16 PM, Resident #196 was observed in bed, alert and answering questions appropriately. Her fingernails were elongated with brown matter underneath them. She was asked if the staff provided her fingernail care. She stated, Yes, I guess they do. I was going to try to do them myself. (photographic evidence obtained)On 12/02/25 at 12:33 PM, Resident #196 was observed in bed. She was asked if the staff had provided any fingernail care for her today. She stated, No. Her fingernails were elongated with brown matter underneath, just as they were observed on 12/01/25 at 12:16 PM. (photographic evidence obtained)On 12/04/25 at 10:01 AM, an interview was conducted with CNA F. She confirmed that she was assigned to Resident #196 today. She was asked if the facility provided any training or education on prevention and reporting of abuse/neglect. She stated, Yes. She was asked if the facility provided any training/in-service education on how to perform ADL care. She replied, Yes. She was asked to describe what ADL care consisted of. She stated, ADL care is how you take care of them on a daily basis. She was asked what grooming consisted of. She stated, Combing the hair, making sure they are well dressed, keeping them nice and dry. She was asked how often grooming should be provided. She stated, For me, I do it two to three times daily. She was asked how often the residents' fingernails should be cleaned. She stated, Daily. She was asked how often the resident's fingernails should be trimmed. She stated, I don't cut the fingernails, I only file them. She was asked what she would do if she was caring for a resident and she observed that the resident's fingernails needed to be trimmed. She stated, I would tell the nurse. She was accompanied to Resident #196's room. The resident was observed in bed, alert and responding appropriately. She was asked if the staff could look at her fingernails. The resident complied. CNA F was asked if she believed Resident #196 needed fingernail care. She stated, Yes, she does.On 12/3/25 at 3:38 PM, a review of Resident #196's Quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 9/21/25 revealed adequate hearing and vision, clear speech, she understands and was understood. Her BIMS (brief interview for mental status) scored 14/15, which was indicative of intact cognitive function. The resident required clean-up or set-up assistance from staff for eating and substantial/maximal staff assistance for bed mobility and personal hygiene. She was dependent on staff for toileting and transfers. A review of the resident's physician's orders revealed:Gabapentin 100 mg orally three times a day for neuropathy (ordered 9/8/24).Meloxicam Oral Tablet (nonsteroidal anti-inflammatory drug), 7.5 mg by mouth one time a day for pain (ordered 2/19/25).Trazodone HCl Tablet (antidepressant), 150 mg by mouth at bedtime for insomnia (ordered 8/19/25). A review of the resident's active care plan revealed the following focus areas:Focus: I have an ADL/Self Care Performance Deficit r/t Impaired Balance, Impaired Mobility. I am bedfast all or most of the time. I prefer to stay in bed most days and get out of bed to go to the hair salon and do special activity outings and appointments. Date Initiated: 10/08/2024 Revision on: 12/09/24. Goal: I will be clean, well groomed, and appropriately dressed daily with staff assistance through the next review date. Date Initiated: 10/08/24 Revision on: 01/03/25 Target Date: 09/11/25, Intervention: Personal Hygiene: I require staff assistance with grooming/personal hygiene. Date Initiated: 10/08/24. A review of the facility's policy and procedure titled Care of Fingernails/Toenails (Version 1.2 (H5MAPR0043), Revision Date: February 2018), revealed:Purpose:The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections.General Guidelines:Nail care includes daily cleaning and regular trimming.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide respiratory therapy, consistent with professional standards of practice, for three (#9, #63, and #181) of 21 residents receiving oxygen therapy. Oxygen flow rates set for these residents were not in accordance with their physicians' orders. The findings include: 1.On 12/01/25 at 11:46 AM, Resident #9 was observed resting in bed with oxygen infusing at 4 liters per minute (LPM) via nasal cannula (NC). (photographic evidence obtained) On 12/02/25 at 9:25 AM, a review of the resident's active physician's orders revealed an order for oxygen at a flow rate of 3 LPM via NC for Congestive Heart Failure (CHF) (ordered 10/29/25). On 12/02/25 at 1:37 PM, Resident #9 was observed sitting up in bed with her lunch meal on the bedside table in front of her. Oxygen was infusing at 4 LPM via NC. (photographic evidence obtained) A review of Resident #9's medical record revealed an admission date of 2/13/24 and diagnoses including Chronic Obstructive Pulmonary Disease (COPD), unspecified, and Congestive Heart Failure (CHF). On 12/03/25 at 12:29 PM, a review of the Significant Change MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/5/25, revealed a BIMS (brief interview for mental status) score of 7 out of 15 possible points, indicating severe cognitive impairment. The resident required set-up or clean-up assistance with eating, and she was dependent on staff assistance for toileting, bed mobility and toileting. The resident was documented as receiving oxygen and hospice services. A review of the resident's active care plan revealed the following focus areas: Focus: I have an ADL/Self-Care Performance Deficit r/t polyneuropathy and deconditioning s/p hospitalization, impaired mobility, and pain Date Initiated: 12/13/24 Revision on: 10/29/25. Focus: I have altered respiratory status r/t COPD., respiratory failure and OSA (obstructive sleep apnea). Date Initiated: 05/08/25 Revision on: 09/03/25. Goal: I will have no complications of altered respiratory status through the next review date. Date Initiated: 05/22/25 Revision on: 09/23/25. Interventions: Administer oxygen as ordered. Date Initiated: 05/22/25. Focus: At risk for respiratory complications r/t COPD Date Initiated: 05/08/25 Revision on: 05/22/25. Goal: My risk for respiratory complications and infections will be mitigated through the next review date. Date Initiated: 05/08/25 Revision on: 09/23/25 Target Date: 12/25/25. Interventions: Administer respiratory treatments and inhalants as ordered. Monitor effectiveness and for side effects. Report abnormal findings to practitioner. Document findings and interventions. Date Initiated: 05/08/25. On 12/04/25 at 4:30 PM, an interview was conducted with Certified Nursing Assistant (CNA) H. She was asked if the facility provided any training/education for prevention and reporting abuse/neglect. She stated, Yes. She was asked if the facility provided any training/education about how to care for a resident who received oxygen. She stated, Yes. She was asked what her role was in taking care of a resident who received oxygen. She stated, I look at the number on the concentrator and make sure it's correct per the nurse, and I make sure the tubing is in place on their face and the line is clear. On 12/04/25 at 4:34 PM, an interview was conducted with CNA I. She was asked if the facility provided any training/education for prevention and reporting of abuse/neglect. She stated, Yes. She was asked if the facility provided any training/education about how to care for a resident who received oxygen. She stated, Yes. She was asked what her role was in taking care of a resident who received oxygen. She stated, I notice if the resident is struggling to breathe and get the nurse. I also make sure the tubing is in the right position on their face. She was asked if there was ever a circumstance in which she would change the flow rate setting on an oxygen concentrator. She stated, No, that is for the nurse to do, not me. On 12/04/25 at 4:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) J. She was asked if the facility provided any training/education for prevention and reporting of abuse/neglect. She stated, Yes. She was asked if the facility provided any training/education about how to administer oxygen therapy. She stated, Yes. She was asked to explain the proper way to administer oxygen therapy. She stated, First check for orders, gather the equipment, set the oxygen setting per order, connect the water and the tubing and place the cannula. I always check to see if I feel the air coming out. A review of the facility's oxygen administration policy and procedure (Version 1.1 H5MAPR0207), revealed: Policy: The purpose of this policy is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's order or the facility protocol for oxygen administration. Steps in the procedure: 10: Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 2. On 12/01/25 at 2:06 PM, Resident #63 was observed resting in bed with his oxygen cannula dislodged and resting against his right cheek. He was coughing and said he didn't know how long the cannula had been dislodged. He explained that he did not know how to insert the cannula nor manipulate the oxygen flow rate on his concentrator. An observation of the concentrator revealed that oxygen was infusing at 2.50 – 3 liters per minute (LPM). (photographic evidence obtained) On 12/03/25 at 11:09 AM, an observation of the resident's oxygen concentrator revealed a flow rate of 2.5 – 3 LPM. (photographic evidence obtained) A review of the resident's medical record revealed an admission date of 09/09/25 with diagnoses including alcoholic hepatic failure, Parkinson's disease, chronic congestive heart failure (CHF), pleural effusion, chronic obstructive pulmonary disease (COPD), asthma, chronic respiratory failure with hypoxia, and pneumonia. A review of the resident's active physician's orders revealed: O2 (oxygen) at 2L (two liters) via nasal cannula as needed for SOB (shortness of breath), administer for O2 SAT (saturation) <92% (ordered 11/6/25). A review of the resident's November 2025 and December 2025 medication administration records (MARs) revealed, O2 at 2L via nasal cannula as needed for SOB. A review of the minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. A review of the resident's active care plan revealed the following focus areas: Focus: I require supplemental oxygen r/t (related to) CHF. Date Initiated: 10/29/2025 Revision on: 11/17/25. Goal: I will remain free of symptoms and complications of low oxygen levels, such as shortness of breath, dizziness, tachycardia, headache through next review date. Date Initiated: 10/29/2025 Target Date: 11/13/2025 Interventions: Add humidity to oxygen as needed. Date Initiated: 10/29/25. Change tubing as per facility protocol. Date Initiated: 10/29/25. Monitor and document breath sounds, breathing patterns, and dyspnea with exertion or while lying flat. Report abnormal findings to physician or designee. Document findings and interventions. Date Initiated: 10/29/25. Monitor skin on ears and nose for breakdown from oxygen tubing. Pad tubing as needed. Report abnormal findings to practitioner. Document findings and interventions. Date Initiated: 10/29/25. Monitor vital signs, including pulse oximeter, as ordered and clinically indicated. Report abnormal findings to practitioner. Document findings and interventions. Date Initiated: 10/29/25. On 12/04/25 at 12:20 PM, Licensed Practical Nurse (LPN) C was interviewed. She reported she had worked at the facility for six weeks. She observed Resident #63 and stated she saw the resident was receiving oxygen via nasal cannula at a flow rate of 2 LPM. She reviewed the Resident's O2 order in the electronic medical record and said she thought the resident's order was for continuous oxygen. She verified that the MARs lacked documented evidence that the resident was currently receiving O2 and verified that the MAR for December 2025 was blank. She stated the resident was capable of pulling out the nasal cannula but was not mentally or physically capable of independently inserting the cannula, turning the oxygen concentrator on/off, or manipulating the oxygen flow rate. 3. On 12/02/25 at 10:24 AM, Resident #181 was interviewed. She stated she was supposed to receive her oxygen at a flow rate of 4 LPM. An observation of her oxygen concentrator revealed that the flow rate was set at 3 LPM. (photographic evidence obtained) A review of the resident's active physician's orders revealed: Oxygen at 4 liters per minute via nasal cannula continuously every day and night shift for COPD (chronic obstructive pulmonary disease). (ordered 11/05/25)

Based on observation, interviews, record review, and a review of facility policies and procedures, the facility failed to demonstrate safe, sanitary infection control and prevention procedures while providing resident care and services. The findings include:On 12/04/25 at 12:18 PM, an observation was made of Registered Nurse (RN) G performing scheduled fingerstick blood glucose testing/monitoring. After checking the resident's blood glucose, the nurse discarded the used lancet in a trash container in the resident's bathroom. When the act of throwing the used lancet in the trash container was brought to RN G's attention, she acknowledged that she had disposed of the lancet in the trash container and not the used sharps container. RN G then extended her ungloved hand into the trash container and retrieved the used lancet. She stated, It doesn't have a sharp end on it after we use it. She did not wash her hands before returning to her medication cart. Once there, she applied hand sanitizer and proceeded to move her medication cart to the next resident she intended to service. On 12/04/25 at 12:28 PM, an interview was conducted with RN G. She was asked to explain the facility's process for resident fingerstick blood glucose monitoring. The following was her step-by-step account of the facility's procedure:Make sure we have an order.Make sure we have all equipment.Clean equipment, wipe down the glucometer.Wash my hands.Apply gloves.Wipe the site with alcohol.Let it dry.Poke the finger to get the blood specimen.Get the blood on the test strip.Get the result.Administer the insulin according to the order.Make sure the patient is dry and clean.Dispose of gloves and dispose of your lancet and trash.Document what you gave.Tell the resident how much insulin they got.When she was asked where she was expected to dispose of used lancets, she replied, In the sharps container. She acknowledged that she did not wash her hands after the procedure, nor did she wash her hands after retrieving the used lancet from the trash container.On 12/4/25 at 12:43 PM, an interview was conducted with the Director of Nursing (DON). She was asked how she expected the nursing staff to dispose of used sharps materials. She stated, They've been trained to dispose of it in the sharps containers, and we have plenty of them. On 12/04/25 at 4:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) J. She was asked to explain the facility's procedure for resident fingerstick blood glucose monitoring. She stated the process was to gather the equipment (alcohol, test strips, lancet, clean glucometer, gloves), enter the resident's room and explain the procedure to the resident, then wash your hands, put on clean gloves, wipe the resident's finger with alcohol, wipe the first drop of blood with a napkin, squeeze another drop, test the blood, tell the resident what the result was and how much insulin they should get, then check the sliding scale order, and give the insulin. She was asked what was done after this. She stated, I dispose of the lancet in the sharps, remove my gloves and wash my hands. A review of the facility's policy and procedure titled Sharps Disposal (2011 MED-PASS, Inc., version 1.1 (H5MAPL0817), revealed:Policy Statement: This facility shall discard contaminated sharps into designated containers.Policy Interpretation and Implementation: Whoever uses contaminated sharps will discard them immediately or as soon as feasible onto designated containers. A review of the facility's policy and procedure titled Obtaining a Fingerstick Glucose Level (Revision Date: January 2012), revealed:Steps in the procedure:. 16. Dispose of the lancet in the sharps disposal container . 20. Wash hands.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in regard to 1) call light not properly working in Resident #6's room, and 2) water dripping from a vent in the ceiling going into a trash bin in Resident #5's room, out of 8 resident rooms sampled. The findings include:1.During a tour of the Memory Care unit in the facility on 9/2/2025 at 10:05 am, a flashing red light making an audible sound was observed above room [ROOM NUMBER]. Two (2) staff members were at the nurses' station approximately 5 feet away room as well as several residents in the lounge area approximately 3 feet away from the room. Several staff members were observed walking on the unit. None of them made an effort to respond to the flashing red call light or the audible sound that it was making. Further observation revealed a housekeeper was cleaning the room. The light remained flashing, making an audible sound after the housekeeper exited the resident's room. The housekeeper was asked about the observation of the illuminated light. She stated that she believed the light was broken and needed to be fixed. She reentered the room, without knocking, and examined the call light box affixed to the wall and said it was broken. Employee C, a Licensed Practical Nurse (LPN) and Unit Manager of the Memory Care unit, entered the room and intervened. He asked if he could provide additional information. He explained that the room with the flashing light belonged to Resident #6.An interview was conducted on 9/2/2025 at 10:11 am with Employee C. He was advised of the observation of the flashing light and the audible sound it was making. When asked about the observation, he stated that a contractor had been in and attempted to repair the issue. He explained that a repair order had been submitted through the facility's electronic maintenance reporting system. When asked how long the issue had persisted, he stated that it had been about 2 days, possibly longer. He stated that initially there were two call lights in need of repair. One was repaired, and this one had remained broken. He explained that the light located in the resident's restroom needed repair. He confirmed that Resident #6 used the restroom and was assisted with toileting. When asked what would happen if the aide assisting the resident with toileting required assistance. He stated, The aide would have to verbally call for help. An interview was conducted on 9/2/2025 at 10:25 am with Employee D, a Certified Nursing Assistant (CNA) who was assigned to Resident #6. She was asked about the observation of the flashing call light. She stated that it had been broken for less than a week. She stated that she reports repairs to the Memory Care Director or Unit Manager who then reports it to the Maintenance Director. She confirmed she had not reported the call light issue. 2. On 9/2/2025 at 1:50 pm, a trash bin collecting water dripping from a vent in the ceiling was observed in room [ROOM NUMBER] (Resident #5's room). The resident was observed sitting up in bed with a yellow wrist band labeled fall risk on her left wrist. A wooden cane and wheelchair were located near the bed. An interview was conducted with Resident #5 on 9/2/2025 at 1:54 pm. The resident confirmed the wheelchair and cane belonged to her. She was able to stand and take steps but required assistance. When the resident was asked about the trash bin collecting water dripping from the vent in the ceiling. She was not sure how long it had been in place. She explained that she did not toilet independently. The resident could not provide any additional information on the trash bin located near the entrance of her room.An interview was conducted on 9/2/2025 at 2:12 pm with the Maintenance Director. After conducting a search via the facility's electronic maintenance reporting system. He confirmed there were no active orders for the two resident rooms in question. He conducted a search for work orders that had been completed within 30 days prior to the survey and confirmed there were no completed orders for those rooms either. He confirmed there were no active repair orders for the call light in Resident #6's room. He explained that he was made aware of the issue the day before the interview. He had contacted a technician to repair the call light; however, there was no availability for 2 more days. When asked about the process if the resident needed to call for assistance. He stated that the resident would be moved but did not say when this would occur. On 9/2/2025 at 2:40 pm a tour of Resident #6 and Resident #5 rooms was conducted with the Maintenance Director. Upon entering the Memory Care Unit where Resident #6's room was located a muffled sound could be heard throughout the unit. The red light continued to flash above the resident's room door. Resident #6's personal belongings were still present in the room. The tour continued to Resident #5's room. Upon approaching the resident's room, the Maintenance Director immediately acknowledged the trash bin collecting water dripping from a vent in the room. He stated he was not aware of the concern and again confirmed that there had not been a work order received for repairs.

Based on interviews, facility grievance log review, and complaint and grievance policy review, the facility failed to follow facility policy in providing required written notification of the outcome of the grievance investigation for 5 of 5 grievances submitted by four (Residents #4, #5, #6, and #7) residents. The findings include: On 4/24/24 at 10:34 am, an interview was conducted with Registered Nurse-A, Manager 1 North regarding resident grievances. He explained that if a resident has a complaint or grievance, staff is to let the manager know. The manager will then try to resolve the issue at bedside, if unable, the manager will contact social services and the issue will be discussed in morning meeting. On 4/24/24 at 11:25 am, an interview was conducted with Licensed Practical Nurse-B. She stated that if a resident or family member complains, she attempts to resolve the issue at bedside. If she's unable to resolve the issue, then she would let the manager know. A review of the facility grievance log from December 2023 to present revealed the following: (Copy obtained) 12/22/23: Resident #4: Property loss/theft; reported missing $30.00: the facility was unable to provide evidence that a written notification of resolution was provided to the resident. 12/28/23: Resident #5: Food temperature issue: the facility was unable to provide evidence that a written notification of resolution was provided to the resident 1/8/24: Resident #6: Room too cold: the facility was unable to provide evidence that a written notification of resolution was provided to the resident. 1/23/24: Resident #7: Access to medical records: the facility was unable to provide evidence that a written notification of resolution was provided to the resident. 1/23/24: Resident #7: Care issue: the facility was unable to provide evidence that a written notification of resolution was provided to the resident. The grievance log did not have any complaints logged for February and March 2024. On 4/24/24 at 2:00 pm, a joint interview was conducted with the Social Services Director (SSD) and Social Services Assistant (SSA). When asked what the complaint/grievance process was for the facility, SSD replied, The managers discuss complaint/grievances in morning meeting. The Quality Director (QD) logs them into the Electronic Reporting System (ERS) because she did not have access to the program. When asked why she didn't have access, the SSD only offered, they hadn't given her access. When asked how she followed up on the complaints/grievances, SSD replied, I write it down. When asked if she kept those documents, she did not offer a response. When asked who was sending the letters to the complainants (Residents #4, #5, #6, and #7), SSD replied, I'm not sure what letters you are talking about. When the SSD was told the facility policy regarding Complaints and Grievances, stated that final decisions would be provided in writing within 30 days of receipt. She replied, oh. The SSA stated that he didn't have access to ERS either. On 4/24/24 at 2:58 pm, a joint interview was conducted with the Administrator and Director of Nurses (DON). When the DON was asked who the Grievance Official was, she replied, the SSD. The DON was asked to describe the Complaint/Grievance process. She stated complaints typically come to either the staff or the managers. The managers try to resolve the issues at the bedside, if unable to resolve the issue, they relay the information to the team at morning meeting. The complaint is then assigned to the appropriate manager, such as SSD, Nursing, Pharmacy, Maintenance, Food Service. When asked where it is documented, the DON replied, it should be in the ERS. When asked who documents it the system, DON replied, whoever is handling the issue or its reported to the Quality Director (QD) and they enter it. When the DON was asked if she was aware the SSD didn't have access to the ERS, she replied, no. When asked how complaints and grievances are reported to the Quality Assurance and Performance Improvement (QAPI) committee. Both DON and Administrator replied, QD runs a report and presents it to the committee. The DON was asked if she questioned the lack of complaints/grievances on the report. She replied, no, I did not pick up on the report not showing them, I knew I was addressing issues. The Administrator stated, It is clear our process is ineffective, with multiple gaps in the process that need fixing; we will be working to fix this issue today. Review of the facility's Complaints and Grievances policy (last revised 5/2021) revealed the following: Page 1 of 5, Definitions Complaint - Any simple service issue or concern received from residents or family members regarding treatment or services provided in the community that are easily resolved by associates. Grievance - Any moderately complex complaint or service issue received verbally or in writing from residents or resident representative regarding treatment or services provided that require management intervention and a written resolution letter. All written complaints received by residents or resident representative through any means will be considered a grievance. Page 2 & 3 of 5, Minimum Requirements, item 2. Identifying a designated community Grievance Official Each community must designate a Grievance Official to oversee and ensure responses to complaints and grievances in accordance to policy. a. The Grievance Official or designee, will be responsible for the complaint and grievance process through their conclusion to include: 1. Review and provide an acknowledgement of receipt of grievances to complainant 2. Coordinating the investigation by the community to include but not limited to: i. Reviewing reports for any reportable issues ii. Interviewing complainant, staff, and/or witnesses iii. Reviewing the medical records (if applicable) iv. Coordinating with other departments, when needed 3. Maintaining confidentiality of all information associated with the complaint or grievance. 4. Acknowledge the grievance within 7 working days from receipt 5. Issuing a final written grievance decision to the resident and/or family members within a reasonable time frame but not to exceed 30 days. Page 4 of 5, item 4 Response timeline for complaints and grievances will be as follows. a. All complaints and grievances received by associates will be documented and reported by end of shift. b. Acknowledgment of grievance will be provided to complainant when available withing 7 working days from date of receipt c. Issuing of a final decision in writing on all grievances will be provided to the complainant when available within a reasonable time frame but not to exceed 30 days from date of receipt d. If resolution to grievance is delayed beyond 30 days, an extension letter will be provided to complainant to include an explanation for the delay and estimated resolution date. (Copy obtained) Ascension Living Complaint and Grievance Process (pamphlet given to residents on admission) Rights, Process, Timelines Under Resident Rights, you have the right to file a complaint or grievance anonymously, orally or in writing. You also have right to receive a written response to all filed grievances within a reasonable timeline. For all complaints, the community will make every attempt to resolve the issue/concern promptly. For all grievances, the following process and timelines will be followed. Grievance Official (or designee) will provide you (if contact information is available) a written acknowledgement within 7 working days. Final decisions will be provided in writing and within 30 days from receipt. (Copy obtained)

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent falls for one (Resident #135) of seven residents reviewed for falls, from a total sample of 41 residents. The findings include: A review of Resident #135's medical record revealed that he was admitted to the facility on [DATE], with his most recent readmission occurring on 7/31/23. Resident #135's diagnoses included unspecified fall, unspecified motor vehicle accident with injury; other injury of unspecified body region; and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of the resident's Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/14/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were documented. His functional status was documented as follows: Bed Mobility/Self Performance - Total dependence, full staff performance of one staff member Transfer Self-Performance: Activity occurred only once or twice during the look-back period. Assistance of two staff members required. The resident was documented as non-ambulatory. Locomotion on the unit did not occur during the look-back period. Locomotion off the unit only occurred once or twice during the look-back period and required one-person physical assistance. Range of Motion to both upper extremities was impaired. He was always incontinent of bladder and bowel. (Copy obtained) A review of the resident's active Care Plans revealed the following Focus Areas: Focus: Falls [Resident #135] has potential for fall/fall-related injury due to deconditioning with functional decline secondary to motor vehicle accident with fractured pelvis, spinal cord injury status-post C-spine surgery, PEG tube (feeding tube) placement for dysphagia. Start date: 7/31/23. Interventions included: Keep bed at the appropriate height. Keep personal items within reach. Patient educated to call for assistance if needing to be repositioned. Low bed with mats. Start date: 7/31/23. Focus: Pressure Ulcers/Skin Prevention [Resident #135] is at risk for pressure ulcers and other skin related injuries due to healed wounds to right upper coccyx, healed area to left hip, impaired mobility, and bowel and bladder incontinence. Start date: 11/1/23. Focus: Pain [Resident #135] has risk for pain related to spinal cord injury status post stabilization. Start date: 7/31/23. [Resident #135] states exertion makes it worse. Interventions include: Offer and encourage as indicated nonpharmacological pain management and repositioning. Focus: Neurological Conditions [Resident #135] will not develop complications of spinal cord injury requiring outside medical intervention. Start date: 7/31/23. Interventions included: Maintain spinal stability as ordered. Utilize log rolling for bed mobility and avoid twisting the spine. Start date: 7/31/23. Focus: ADL (Activities of Daily Living) Functional/Rehab Potential [Resident #135] needs assistance with daily ADL care. Start date: 7/31/23. Interventions included: Bed Mobility: I need total assistance with one-person staff support. I use slide sheet assistive devices. Transfers: I need total assistance with two person staff support. I use a total lift assistance device. Mobility: I need total assistance of one-person staff support. I use wheelchair assistive device(s). (Copies of all Care Plans obtained) On 11/14/23 at 12:28 p.m., Resident #135 was observed in his room. His sister, who was his Power of Attorney (POA), was also present. The resident's bed was in the lowest position. Blue fall mats were present on each side of the bed. The resident was asked if he had fallen. He confirmed that he had fallen on 7/30/23. He stated a Certified Nursing Assistant (CNA), later identified as CNA N, was on her cell phone as she was providing him incontinence care. He stated he gave her several warnings that he was going to fall, however, she denied it and walked away before she had finished providing care. When she did, he rolled off the bed onto his side. The bed was in high position, and the resident stated the fall resulted in a laceration to his forehead which required five sutures. The resident's sister stated the facility notified her of the fall after the resident was transferred to the hospital. She was advised that he was found on the floor and was being transferred to the hospital for an injury he sustained. She stated this was unusual, as the resident had fallen in the past, however, because his bed had always remained in the lowest position, he had never sustained any injuries. She stated when she arrived at the hospital she observed the resident with blood over his right eye. When she asked the resident how he had sustained the injury, he advised her that his bed was raised up high while CNA N was providing incontinence care. He told her that CNA N was talking on her cell phone while providing his care and walked away before she was finished. Resident #135 told her he made attempts to warn CNA N that he was falling before she walked away. Prior to this incident, the resident rolled out of bed on 7/23/23, however the bed was low to the floor, so he didn't get hurt. The sister stated the nurse on duty at the time of the incident confirmed that CNA N was in the room at the time of the incident. She further stated the nurse was no longer employed by the facility. She was advised that the incident was reported, but she was never told to whom it was reported. She was never provided with any detailed information. She stated prior to this interview (11/14/23 at 12:28 p.m.), the facility provided her with a printout of an Interdisciplinary Note entered into the resident's record on the date of the fall. Per the note, Around 1800 p.m. (6:00 p.m.) today, the CNA called for assistance of staff RN to room [ROOM NUMBER]. Found patient lying on his right side on the floor . The entry was electronically signed by the registered nurse (RN) on 7/30/23 at 20:48 (8:48 p.m.). (Photographic evidence obtained) On 11/15/23 at 11:08 a.m., a facility staff member advised the survey team that the resident's sister/POA asked to speak with the team. The resident's sister entered the conference room where an interview was conducted in the presence of the entire survey team. She confirmed the full name of the nurse she had spoken with regarding the details of the fall Resident #135 sustained on 7/30/23. She stated both she and the resident gave specific details regarding the fall, including the fact that CNA N was on her cell phone while providing care. They explained to the facility that the resident attempted to warn CNA N several times that he was falling prior to the actual fall. She was asked for the details of the investigation of the fall. She advised the survey team that she was not aware of any investigation. The sister stated she, Resident #135, and the previous nurse (who was no longer employed by the facility) had advised Risk Manager S that CNA N had been on her cell phone while providing care and after that, no one came to ask them anything else regarding the incident. She was asked about the nurse and CNA N. She stated the nurse was no longer employed at the facility, but CNA N was still employed and was working on another nursing unit. During an interview with Licensed Practical Nurse (LPN)/Risk Manager S on 11/15/23 at 3:19 p.m., she was asked to provide the details of Resident #135's fall. She stated it occurred on 7/30/2023. He had a laceration across his eyebrow. She stated she interviewed the resident, and he told her he was trying to sit on the side of the bed, which was too high, when he fell and hit the floor. She stated he told her he did not press his call light. He told her that it was within reach. The resident was given a low bed with mats and was educated to use his call bell for help. She confirmed that the incident was unwitnessed. She was asked why it was not reported. She replied: I don't know. She was asked whether the facility typically reported a fall if it was unwitnessed, and the resident sustained an injury requiring them to be transferred out of the facility for a higher level of care. She replied, It should've been reported. On 11/16/23 at 12:32 p.m., CNA N was contacted via telephone for an interview. She stated she was familiar with Resident #135. She was asked if she was aware of any accidents the resident had while in the facility. She stated she was in the resident's room when the resident fell on [DATE]. She was asked to provide details of the incident. She stated it happened at the end of her shift. She was in the room changing the resident and his sheets. She stated the bed was raised and when she went to turn the resident over, he wasn't on his other side or on the edge of the bed. When she went to the other side of the bed, he was slightly in the middle. She stated she was not sure if the resident jerked or moved over, but he rolled and hit the floor. She grabbed at his leg to try to prevent him from falling. She stated she didn't touch the resident while he was on the floor, but she did ask him several times if he was okay. He responded each time that he was okay. She stated she noticed that He nicked his head, and he was bleeding. At that time, she went to tell the nurse. She could not remember the nurse's name. She stated the resident denied pain. He was sent out to the hospital overnight and came back the next day. She was asked about the resident's functional status and whether he could sit up on the side of the bed without assistance. She referred to the resident as a total assist x 1, indicating that he was totally dependent, requiring one-person assistance for all of his ADLs. She gave him bed baths, as the shower bed was too uncomfortable for him. She stated the resident was unable to sit up on his own and required assistance due to lack of trunk support. She was asked about any statements and/or investigations regarding the incident. She stated she was required to submit a written statement to LPN/Risk Manager S with the details of the fall. She confirmed she documented that she was in the room with Resident #135 at the time he fell . On 11/16/23 at 2:37 p.m., Resident #135 was observed lying in bed. The bed was in the lowest position with fall mats present on each side. When asked, the resident denied pain. The resident was asked again about the falls he sustained in the facility. He stated the first incident (7/23/23) occurred when he rolled out of bed. He did not sustain any injuries as the bed was in the lowest position. The second fall (7/30/23) occurred when CNA N was on the phone while changing him with the bed raised in the high position. He was asked if the CNA held the phone by hand, used earbuds, or used another hands-free device. He stated she had the phone in her hand, and he told her he was falling, but she turned her back. He stated as he began to fall she quickly turned around and tried to catch him, but she didn't have time to, and he fell to the floor hitting his head. During an interview with LPN F on 11/16/23 at 1:43 p.m., she stated she was familiar with Resident #135. She stated the resident was unable to sit up unassisted and that she felt keeping his bed low was the best thing for him. The resident was not able to apply pressure to his arms to move himself, nor did he have enough tone in his legs to bear weight. He was able to make his needs known and would let her know if he was experiencing pain when she administered his medications. He can make his needs known. He hasn't had any falls recently. They do all of his ADLs, and his sister tells them to brush his teeth. She stated the resident was totally dependent for all his ADLs. During an interview with CNA G on 11/16/23 at 3:19 p.m., she stated she was familiar with Resident #135. The resident didn't like to sit up, and when he was placed in a sitting position, he would holler and scream out in pain. She stated the resident told her it hurt him to sit up, and that he would not stay in his wheelchair. The resident was unable to sit up unassisted. He required total assistance from staff. He could feed himself and move his arms but was unable to sit up or get out of bed unassisted. She stated the resident preferred to remain in a fetal position, and when attempts were made to move him out of that position, he would ask to be returned to that position. A review of a facility report, dated 7/30/23 at 6:00 p.m., revealed that following the fall, Resident #135 stated he was okay. He was asked what he was trying to do, and he stated he was trying to sit on the side of the bed, but the bed was a little too high. The fall was documented as unwitnessed. The resident was documented as not incontinent at the time of the incident, and range of motion was documented as within normal limits. Interventions included a low bed with mats. The nurse's signature was illegible. (Copy obtained) A review of a facility Huddle Report dated 7/30/23 at 6:00 p.m., revealed the following: What human factors impacted the outcome? Answer: No assist at time of fall. The report indicated that staff were competent and no changes to in-servicing or orientation were necessary. Safety measures documented were non-skid socks. Two team members were documented as having attended the Huddle meeting. Their signatures were illegible. (Copy obtained) A review of a facility report dated 7/31/23 at 11:00 a.m., revealed that Resident #135 was interviewed by the QD (Quality Director). The resident stated he was trying to sit on the side of the bed, and it was too high. He stated he lost his balance and fell hitting his head. It was documented that the QD asked the resident whether he had used his call light for assistance and he responded that he did not. According to the report, the QD explained to the resident that he had been educated before to call for assistance. Interventions: low bed and mats. (Copy obtained) A review of an undated, unsigned, typed statement from the assigned nurse on duty at the time of the resident's fall, revealed that the name typed on the statement was the same name that was given to the survey team by the resident's sister, who stated this was the nurse who assessed the resident after he fell on [DATE]. This name was also listed on the Interdisciplinary Note. The statement indicated that at 6:00 p.m. on 7/30/23, the nurse was summoned to Resident #135's room to find him lying on the floor on his right side. The resident said he was trying to sit on the edge of the bed and fell to the floor, sustaining a laceration to his right eyebrow. The laceration was draining a moderate amount of sanquinous fluid. A pressure dressing was applied. The resident was alert and oriented x4 (person, place, time, and event). The nurse assisted support staff in getting the resident back in bed while awaiting emergency transport to the emergency room for further evaluation due to the laceration to his eyebrow. The bed was noted in high position. His call bell was clipped to the sheet and had not been activated. The nurse educated the resident by reminding him to use the call light for assistance with sitting up. (Copy obtained) An interview was conducted on 11/16/23 at 4:40 p.m. with the survey team, the current Administrator, the new Administrator, the Director of Nursing (DON), and LPN/Risk Manager S. The DON was asked about the nurse's unsigned and undated statement. She was specifically asked when the statement was written and why the nurse was not required to sign it. She stated, I don't know when she wrote it. She didn't sign it. We have it in our records. The LPN/Risk Manager S stated the resident gave her his statement the day he returned from the hospital (7/31/23). He was alert and oriented. She was asked about the resident's functional status. She replied, I have never transferred him, so I can't say what his functional status is. I just met with him in his room. That was the only time that I saw him. There were no follow-up interviews with him. She was asked about the assigned nurse's unsigned statement. She replied, We attempted to have her come back in many times to have her sign it. On 11/16/23 at 4:59 p.m., the DON was accompanied to Resident #135's room. The resident was greeted and stated he did not know the DON. The DON greeted the resident. The resident was asked about the falls he sustained while in the facility. He explained during his first fall (7/23/23), he rolled out of bed on his own but wasn't hurt because the bed was in the low position. He then stated he fell when CNA N was changing him. She had the bed raised too high and she was on the phone. He stated she tried to catch him, but she couldn't because her back was turned. He stated he was sent out to the hospital because he had a cut over his right eye that required five sutures. The DON asked Resident #135 if anyone had come in to talk to him about the fall the day it occurred. He replied no. She asked if anyone came to speak with him the next day when he returned from the hospital and again he said no. She asked him if he was able to sit up on the side of the bed and he replied that he could not. He stated the aides had to help him get up. He stated he could not sit up on the side of the bed independently.

Based on observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene and disposable glove use during meal service, as well as proper sanitation practices when cleaning and using the meat slicer to prevent cross contamination, with the potential to affect all of the residents in the facility who received food from the facility's kitchen. Specific instruction on hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Failure to thoroughly clean and sanitize the meat slicer could result in the development of a cross-contamination infection and clinical compromise. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the kitchen on 11/13/2023 at 9:30 a.m., the meat slicer was covered with a large sheet of plastic. The Certified Dietary Manager (CDM) confirmed that the slicer had been cleaned and was always stored with the plastic covering after it was cleaned. She stated it was used to slice deli meats mostly because it was more economical to purchase the meat in bulk and then slice it. The plastic was removed and the slicer was observed to have encrusted food debris on the blade, the backplate and the collection area. (Photographic evidence obtained) The CDM was asked to remove the cover for the blade sharpener on the top of the machine. She asked Dietary Employee I to remove it. Employee I removed the cover and food debris was observed stuck on the inside of the cover. (Photographic evidence obtained) The CDM stated the machine had not been cleaned appropriately. She stated she did not have a procedure for cleaning the machine. During the lunch meal service on 11/14/2023 from 12:38 p.m. to 1:00 p.m. in satellite dining rooms on the 1 North unit and the 2 South unit, Dietary Supervisor J was observed assisting Dietary Employee L in the process of plating food. Employee J failed to wash her hands for a minimum of 15 seconds when she washed her hands. She washed her hands 4 times and only washed them for 3 seconds each time. Employee L failed to wash her hands after opening the drawer handle for the garbage can to discard her disposable gloves. She then donned new gloves to continue the meal service. During the lunch meal service on 11/15/23 at 11:31 a.m. on the 2 South unit, Employee L failed to wash her hands appropriately. The Assistant Director of Dining (ADD) stopped her and made her re-wash them. She failed to wash them for a minimum of 15 seconds. The ADD again stopped her and made her re-wash her hands. Employee L turned off the faucet with her bare hand. The ADD again made her re-wash her hands and use a towel to turn off the faucet. The ADD acknowledged that Employee L needed retraining on hand hygiene. On 11/15/2023 at 12:54 p.m., the meat slicer was observed covered with a large sheet of plastic. The plastic sheet was removed. The slicer had water standing on the base. The blade and backplate had food debris stuck on them. (Photographic evidence obtained) The CDM was asked to remove the cover for the blade sharpener on the top of the machine. She could not get it to release. Employee I was asked if she was finished using it today and if she had washed it. She confirmed that she was finished and had washed it. She was asked to take the cover off the machine. She struggled with it for 10 minutes. The CDM and Employee I were shown the food debris and water standing on the slicer and they acknowledged it. Employee I stated, Does it need to air dry? and then stated, I need to wash it again. The CDM agreed that she would have to disassemble it, wash and sanitize it again. Employee I confirmed she had been trained by another dietary staff member on how to clean the meat slicer. During an interview with the CDM on 11/16/2023 at 2:45 p.m., she confirmed that she did not have a procedure for cleaning the meat slicer. She would have to develop one and train the staff. She also confirmed that the staff needed training on hand hygiene. A review of the Facility Associate Food Safety & Sanitation Handbook used to train the dietary staff (revised 8/2022), revealed: Cleaning - Removal of visible soil from the surfaces of equipment and utensils. Includes removal of large soils, washing with soap and rinsing. Food contact surface - a surface that comes into direct contact with foods. Examples are slicers. Biological cross-contamination. Cross-contamination usually occurs when germs from raw food are transferred to a cooked or ready-to-eat food via contaminated equipment. Cross - contamination can occur during preparation, storage, and display. Unclean or improperly cleaned food contact surfaces. Hand Washing is a key factor in preventing food contamination. When to wash: Before putting on gloves, or when changing gloves. After changing gloves. How to wash: Wet hands, apply soap, vigorously scrub hands, arms (up to elbows if exposed), between fingers and under fingernails for 10-15 seconds. Rinse thoroughly. Dry hands using single-use paper towel. Use the towel to turn off the faucet to prevent contaminating your hands after washing them. Sanitation Practices: Cleaning means removing the things we can see such as the visible food debris, grease, and other dirt from the surface. Food contact surfaces MUST be cleaned and sanitized. Clean-in-place - Used for equipment that is too big or not able to be moved into the dish machine or three-compartment sink. Food contact surfaces must be cleaned and sanitized after each use. Steps to clean and sanitize: Pre-scrape, wash, rinse, sanitize and air-dry. Never store items until they are dry. The acknowledgment of the handbook training was signed by Employee I on 07/26/2023. The New Associate Orientation checklist for Employee I, dated 07/17/2023, revealed she received instruction on use of the slicer and a return demonstration was required. Sanitation standards were covered during the training she received on 8/31/2023. A review of the Attendance Verification Sheet, dated 8/31/2023, for the staff in-service training on handwashing revealed that Employees J and L both received training that day. A review of the Attendance Verification Sheet dated 3/15/2023 for the staff in-service training on infection prevention and control revealed that Employees J and L both received training that day. A review of the facility's policy and procedure titled Food Handling Guidelines (Policy #B007, issued 5/1995 and revised 1/2023), revealed: Food shall be protected against cross-contamination by appropriately separating types of raw animal products such as beef, fish, lamb, pork and poultry during processing with the use of separate equipment or areas or by scheduling and cleaning; and appropriately separating raw and ready-to-eat foods during preparation. Cutting boards and other food contact surfaces are cleaned and sanitized between different food preparation steps. Use clean sanitized equipment and food contact surfaces (e.g. slicers, etc.) for each task. A review of the facility's policy and procedure titled Cleaning of Food and Nonfood Contact Surfaces (Policy #F013, issued 5/1995, revised 1/2023), revealed: To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. A review of the facility's policy and procedure titled Hand Hygiene (Policy #F007, issued 5/1995, revised 1/2023), revealed: In the Food and Nutrition Services Department: All associates handling food shall wash hands at the following times: Before putting on gloves, after handling garbage, after handling clean equipment, after removing gloves, after any other activity that may contaminate the hands. Hands must be washed with soap and water when plating food on the resident units. Wet hands with warm water and apply a disinfectant soap, lathering up to mid-arm. Work lather into hands for 20 seconds, including areas under fingernails, between fingers, on the inside and outside of hands. Rinse thoroughly under warm running water, allowing the water to flow from the arms down to the fingertips. Use a paper towel to turn off the faucet to avoid contact with faucet germs. Per the 2022 Food Code, Sections 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. U.S. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: Hand Hygiene Employees must wash their hands after any activity which may result in contamination of the hands. All aspects of proper handwashing are important in reducing microbial transients on the hands. However, friction and water have been found to play the most important role. This is why the amount of time spent scrubbing the hands is critical in proper handwashing. It takes more than just the use of soap and running water to remove the transient pathogens that may be present. It is the abrasive action obtained by vigorously rubbing the surfaces being cleaned that loosens the transient microorganisms on the hands. Research has shown a minimum 10-15 second scrub is necessary to remove transient pathogens from the hands and when an antimicrobial soap is used, a minimum of 15 seconds is required. Soap is important for the surfactant effect in removing soil from the hands and a warm water temperature is important in achieving the maximum surfactant effect of the soap. Every stage in handwashing is equally important and has an additive effect in transient microbial reduction. Therefore, effective handwashing must include scrubbing, rinsing, and drying the hands. When done properly, each stage of handwashing further decreases the transient microbial load on the hands. It is equally important to avoid recontamination hands by avoiding direct hand contact with heavily contaminated environmental sources, such as manually operated handwashing sink faucets, paper towel dispensers, and rest room door handles after the handwashing procedure. This can be accomplished by obtaining a paper towel from its dispenser before the handwashing procedure, then, after handwashing, using the paper towel to operate the hand sink faucet handles and restroom door handles. Per the 2022 Food Code, Sections 4-603.15 Washing, Procedures for Alternative Manual Warewashing. Annex 3 - 179. U.S. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: Equipment Some pieces of equipment are fixed or too large to be cleaned in a sink. Nonetheless, cleaning of such equipment requires the application of cleaners for the removal of soil and rinsing for the removal of abrasive and cleaning chemicals, followed by sanitization. Per the 2022 Food Code, Sections 4-901.11 Equipment and Utensils, Air-Drying Required. Annex 3 - 181. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: Items must be allowed to drain and to air-dry before being stacked or stored.

Based on interviews and record review, the the facility failed to provide documented evidence that all alleged violations of abuse, neglect, exploitation, and/or mistreatment were thoroughly investigated for one (Resident #75) of 41 residents sampled. Failure to thoroughly investigate alleged violations places other residents at risk for abuse, neglect, exploitation and mistreatment. The findings include: On 11/13/23 at 1:54 p.m., Resident #75 stated last week she noted that $400.00 of her money was missing. She stated she notified the nurse and added that she was afraid to leave her room, as she did not know what else might come up missing. A review of Resident #75's record revealed that she was admitted to the facility on [DATE] with a readmission on 9/11/23. Her diagnoses included type 2 diabetes with diabetic neuropathy, anxiety disorder, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 9/29/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. A review of the facility's Grievance/Complaint Log revealed a grievance/complaint dated 11/6/23, indicating that Resident #75 reported she was missing $400.00 in $100.00 bills. The log further indicated that the resident stated she had the money last night (11/5) in her change purse, in her room, under her pillow. A room search was conducted by the social worker who could not locate the money. The grievance concern resolution read, Social worker spoke to the family and the family has not given the resident any money. Investigation ongoing. (Copy obtained) In an interview on 11/14/23 at 11:30 a.m., Risk Manager S was asked what a grievance/complaint listed on the log meant. She explained that a complaint was when an issue could be solved right away, and a grievance was something that could not be resolved right away, requiring an investigation. On 11/15/23 at 2:39 p.m., the Long-Term Care (LTC) Social Worker was asked about Resident #75's grievance/complaint. He stated the resident reported to him that she lost her money ($400.00 in $100.00 bills). When he was asked where she had obtained the money, he stated she reported that she received it from family (not specific regarding which family member). The LTC Social Worker stated he called the resident's daughter, who stated she was not aware of any family member having given the resident money. He added that the daughter stated Resident #75 had been more confused lately. He was asked if the resident was cognitively aware enough to make such an allegation, and he replied yes. He was asked for the investigative findings of the grievance/complaint. He stated the grievance/complaint was closed after talking to the resident's daughter. He confirmed that he did not interview staff or make a report. Another interview was conducted with Risk Manager S on 11/15/23 at 4:06 p.m She was asked about Resident #75's grievance/complaint. She said, The social worker handles that. She was again asked if she was aware of the resident's missing money. She said, Yes, I'm aware, but the social worker is handling that. She was then asked how the facility protected the residents from misappropriation of property. She said, By investigating allegations and reporting. She then stated, That should have been reported. A review of the facility's policy and procedure titled Abuse Investigation and Reporting (last revised on 7/2022), revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the Ascension Living Abuse Prevention policy. The policy interpretation and implementation role of the investigator section (page 2) revealed that the individual conducting the investigation will at a minimum: 4. Interview any witnesses to the incident. 7. Interview associates/members (on all shifts) who have had contact with the resident during the period of the alleged incident. 8. Interview the resident's roommate, family members and visitors. 9. Interview the residents to whom the accused employee provides care or services, and 10. Review events leading up to the alleged incident. The policy's Reporting Section (page 3) indicated that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The State Licensing/Certification Agency responsible for surveying /licensing the community. 2. Other officials in accordance with State Law, including Adult Protective Services where state law provides for jurisdiction in long-term care facilities. 38804

Based on observation, interview, resident record review, and facility policy review, the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid, to the maximum extent practicable, to avoid duplicative testing and effort for one (Resident #17) of 41 residents sampled. The facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disability, or a related condition for a level II resident review. The findings include: A record review for Resident #17 was conducted on 11/14/23 at 10:45 a.m. The PASARR could not be located. The facility was asked to provide the documentation. Two PASARRs were provided, one dated 4/24/2015 and the other dated 12/31/2015. Neither of the PASARRs reflected the resident's diagnosis of dementia or unspecified psychosis. The record revealed that Resident #17 was readmitted to the facility on [DATE] after having been hospitalized . Her diagnoses included unspecified convulsions; unspecified dementia; unspecified psychosis not due to a substance or known physiological conditions; metabolic encephalopathy; acute kidney failure; personal history of other specified conditions; dysphagia; personal history of other infectious and parasitic disease; atherosclerotic heart disease; hemiplegia affecting left non-dominant side, and type 2 diabetes mellitus. An 11/14/23 review of the current, active Physician's Orders included: Quetiapine (Seroquel) 25 mg (milligrams), two tablets every 12 hours; Escitalopram (Lexapro) 20 mg daily; Lacosamide (anticonvulsant) 250 mg twice a day; Topiramate (anticonvulsant & nerve pain) 100 mg twice a day; Levetiracetam (anticonvulsant) 1000 mg twice a day. During an interview with Social Worker P on 11/15/2023 at 2:23 p.m., he stated it was the responsibility of the Admissions Department to review the PASARRs for accuracy when residents were admitted /readmitted to the facility. He added that he had a Masters of Social Work (MSW) degree and would complete a PASARR if a resident did not have one. If there were any changes, he would also complete another PASARR. He stated the hospital completed a new PASARR each time a resident returned to the facility after being transferred for care. He was shown the PASARRs the facility provided for Resident #17, and he confirmed the dates on the PASARRs provided as 4/24/2015 and 12/31/2015. When he was asked how this was possible considering the resident's admission and readmitted s, he stated this was all that was available for the resident. They weren't scanned into her electronic chart as they should have been. He was asked if the resident had any qualifying diagnoses. He confirmed the resident did have a diagnosis of unspecified psychosis. He was asked if it was possible that another PASARR was done that could have captured this diagnosis. He stated not that he was aware of. No additional PASSAR documentation was provided during the survey. During an interview conducted on 11/15/2023 at 5:00 pm with Registered Nurse (RN) M, he stated he was familiar with Resident #17. He cited her diagnoses as dementia, unspecified psychosis, and added that she also had seizures. He listed her medications as Escitalopram 20 mg daily for depression, Lacosamide 250 mg twice a day for seizures, Topiramate 200 mg every 12 hours for seizures and Seroquel (antipsychotic) 25 mg every 12 hrs. He noted the resident's physician's orders and medication administration record listed the Seroquel was for depression. He stated the diagnosis was inaccurate, Sometimes they put the wrong diagnosis. After reviewing the eMAR, RN M confirmed the resident had received the medication as ordered. Further review of Resident #17's medical record revealed that she was seen by Mental Health Services on 10/16/2023. The chief complaint was documented as: depression, anxiety, confusion, psychosis and follow-up visit. The following was included in the 10/16/23 mental health services documentation: HISTORY OF PRESENT ILLNESS: Chief complaint has been occurring for: several months Appears to be: better For the past: weeks History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: blocking Insight/judgement: poor Oriented to: place Immediate memory: partially impaired Recent memory: partially impaired Remote memory: partially impaired Thought content and perceptions: delusions Mood/Affect: depressed, anxious SIGNS AND SYMPTOMS: Patient shows apathy with poor social interaction Patient has sleep disturbances Patient is feeling depressed and sad Patient feels restless and anxious Patient is psychotic with: delusions DIAGNOSES: Vascular dementia with behavioral disturbance Major depressive disorder, recurrent, moderate Generalized anxiety disorder Unspecified psychosis not due to a substance or known physiological condition Further review of the resident's 10/16/23 Mental Health Services note, authored by her psychiatric Advanced Practice Registered Nurse (APRN), revealed that Seroquel (antipsychotic medication) 50 mg (milligrams), one by mouth twice daily for a diagnosis of psychosis was to be continued. A review of the facility's policy titled Change in Resident's Condition or Status (original date of 12/2016, last revised on 2/2022 and last approved on 3/2022) revealed: Policy Interpretation and Implementation: (G) In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified of a significant change in the mental health or physical condition of a resident with a mental disorder or intellectual disability.

Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #2) of 41 residents sampled, was appropriately screened for a mental disorder (MD), intellectual disability (ID) or other related conditions prior to admission. Failure to ensure residents are pre-screened for MD/ID or a related condition, prior to admission to the facility, could prevent the resident from attaining or maintaining his/her highest practicable level or result in decline in the resident's physical, mental or psychosocial well-being. The findings include: A review of Resident #2's medical record revealed that a Level 1 PASARR (Pre-admission Screening and Resident Review) evaluation was documented and dated 07/28/2010, which was more than [AGE] years prior to her admission to this facility on 02/17/2021. Per the resident's Annual, Comprehensive Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/1/2022, there was no indication of where the resident was admitted from. A review of the [AGE] year-old 07/28/2010 PASARR revealed the following: On page 1, section I, the resident was documented as having indications of, or a diagnosis of a major mental illness as defined in the DSM-IV R, limited to schizophrenia, mood disorder, severe anxiety disorder, or a mental illness that may lead to a chronic disability. The form's instructions indicated that if there was a positive answer in section I, the writer should continue to section II. On page 1, section II, the form asked whether the resident had a primary diagnosis of dementia (including Alzheimer's disease) or a related condition, or a non-primary diagnosis of dementia with a primary diagnosis that was not a major mental illness. The answer documented was no. Form instructions indicated the writer should continue to section three of the form if the answer was no. Section III asked whether the resident was being admitted from a hospital requiring nursing facility services and whether the resident's physician had certified before admission that the resident was likely to need less than 30 days of nursing facility services. The Documented answer was no. The form indicated that the writer should proceed to section IV. Section IV was for provisional admission to the nursing facility under time-limited categories related to a need to evaluate the resident after delirium cleared, in emergecy situations requiring protective services, and/or respite care for in-home caregivers. The documentation indicated that none of that was applicable. Instructions indicated the writer should proceed to section V. Section V indicated that a level II evaluation was required for individuals with MI (mental illness) or MR (mental retardation) who met one of the following advanced group determinations of the need for nursing facility services or for those who did not meet one of the categorical or advanced group determinations in sections III, IV, or V of the form. The level II evaluation and determination must be received prior to NF (nursing facility) admission. Question #1 of section V asked whether the resident required convalescent care from an acute physicial illness that required hospitalization and did not meet all of the criteria for an exempt hospital discharge. The answer was documented as yes. No terminal illness or severe physical illness was documented. The form's space for signature, date completed, title of the form's author, agency, date of mental health evaluation, date referred for level II, and level II agency were all blank. On page three of the form, Resident #2 was marked as having diagnoses or an indication of severe anxiety/panic disorder and bipolar disorder. Question #2 asked whether the level I screen indicated the diagnoses/disorders resulted in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the resident's developmental stage. The answer was documented as no. The answer to question #3 indicated the resident had serious difficulty with interpersonal functioning, concentration, and adaptation to change. The answer to Question #4 indicated the resident had not received in-patient psychiatric treatment within the last two years, and had not experienced an episode of significant disruption to her normal living situation. (Copy obtained) Further review of the resident's record revealed current, active diagnoses of epilepsy, unspecified, not intractable, w/o status epilepticus; bipolar disorder, unspecified; unspecified dementia without behaviors/psychosis; generalized anxiety disorder; sleep apnea; unspecified abnormalities of gait and mobility; personal history of transischemic attacks, and hypertension. A review of the most recently completed Quarterly MDS assessment with an ARD of 08/18/2023, included coding of Resident #2's diagnoses to include dementia, anxiety disorder, and bipolar disorder. She had received antipsychotic and hypnotic medications during the MDS look-back period. A review of the resident's care plan, dated 09/18/2023, revealed the following problem areas: Organic brain syndrome with cognitive deficits. She has poor impulse control and is sometimes difficult to redirect. She is oriented to person, family, and staff. Potential for psychosocial well-being concerns related to impaired cognition. She is impulsive and not socially appropriate at times. She has periods of agitation and a diagnosis/history of bipolar disorder, organic brain injury, and chronic encephalopathy. Resident is emotionally labile person whose mood fluctuates throughout the day, from pleasant to verbally abusive behaviors related to bipolar disorder. She seeks attention from people and likes to have them listen to her music or listen to her sing. She can become anxious and agitated when it is time for ADL (activities of daily living) care or time to have her hair washed. She does not like being interrupted throughout the day to toilet and can become verbally inappropriate, yelling at staff, you are killing me, you hate me and stop it. She has history of telling passers-by that staff are killing her or hurting me. She will yell loudly, lock her chair, plant her feet firmly on the ground, and will not move when she doesn't want to be bothered. She seeks immediate gratification for her needs. She can become immediately agitated and verbally inappropriate if there is a barrier to her fulfilling a need or want. She asks repetitive questions and has anxious complaints. She is prescribed psychotropic medication and is at risk for side effects. She has impaired behavior related to her impaired cognitive skills. She has the potential for drug related complications associated with use of psychotropics. She is at risk for increased behavioral expressions, altered mood and elopement. She uses a seat belt. The level I PASARR is negative/level II PASARR is not needed. Resident does not have a diagnosis of mental disorder, intellectual disability, and will not need specialized services. On 11/16/23 at 3:53 p.m., the Long-Term Care Social Worker was interviewed. He stated he had been employed in his position since February of 2023. When asked to explain the PASARR process, he stated, Since I've been here, we usually get a PASARR from the hospital before admission. If the patient comes from home, the facility has asked me to do it. The Admissions Department receives the admission packet and assures all residents are admitted with the 3008 (hospital transfer form) and PASARR already completed. If there is something that needs to be reviewed with the PASARR, the Admissions Department will refer it to Social Services for further review. Admissions gives the packet to the unit managers or whoever in nursing services will be processing the admission, so the resident can be admitted . Then the packet is given to Medical Records who scans all the admission paperwork into the medical record. Apparently, when the resident was admitted in 2011 the facility accepted the PASARR that was completed and signed on 07/28/2010, and failed to reevaluate the need for a new screening. On 11/16/23 at 4:03 p.m., the Health Information Manager (HIM/Medical Records) was interviewed. She stated the PASARR dated 07/28/2010 was the only screening that she could locate and that she would continue to look for any other PASARR screening information that may have been included in the resident's medical record. On 11/16/23 at 4:05 p.m., the Interim Director of Social Services (IDSS) was interviewed. She stated she had been employed in her position since October of 2023. She stated Resident #2 was a transfer from another skilled nursing facility, and that may have been the reason the PASARR, dated 07/28/2010, was accepted by the facility at that time. She reviewed the resident's medical record and stated Resident #2's record indicated that she was admitted to this facility from an acute care hospital. She was not able to verify from the medical record exactly which long-term care facility the resident was actually transferred from. When asked how often PASARR screenings were reviewed or updated, she replied, Since I've been here, I've been trying to look into that, and that was one of the things that the long-term care social worker and I were trying to get implemented here. I don't know what was done before I came, but we became aware that an audit process was needed. She further stated, I just got off the phone with Kepro. I was trying to find out if a Level II had ever been established for Resident #2, and they told me that they don't even have any information on her in their system. They tried to look her up by her name and date of birth and could not find any information at all. When asked what would trigger another PASARR level I evaluation after a resident has been admitted to the facility, she stated, looking at the PASARR mental health part, if the PASARR indicates the resident has diagnoses of schizophrenia or something of that nature, and the facility starts to notice any behavioral issues, you want to go ahead and submit that information to Kepro for guidance on whether the resident needs to be re-evaluated for proper placement in a long term care facility, and if a level II may be indicated. We will let Kepro provide us with that guidance. Usually, the facility may get the doctor to order a psychological/psychiatric evaluation before Kepro is alerted, and then any new conditions or diagnoses can also be sent to Kepro, along with the rest of the information they need to make a determination. When asked what diagnoses would trigger a re-evaluation, she responded, the PASARR form lists the mental illness diagnoses, the intellectual disability or related conditions that need to be checked on the form. She was asked if Resident #2 had any mental illness diagnoses checked on the form dated 07/28/2010 and she answered yes. When asked if Resident #2 had an intellectual disability checked on the form dated 07/28/2010, she answered no. When asked if Resident #2 had any related conditions checked on the form dated 07/28/2010, she answered no. She was asked what Resident #2's current active diagnoses were that might indicate that she would need to be re-evaluated. She replied, generalized anxiety disorder, bipolar disorder, epilepsy, and dementia. She also stated, The resident probably should have been re-evaluated for an updated Level I PASARR. A review of the facility's policy and procedure titled PASARR (Pre Admission Screening and Resident Review) (last reviewed on 07/2018) revealed: Policy Statement: The purpose of this policy is to outline the screening of residents with a history of serious mental illness and developmental disability. The community will not admit any new resident who is suspected of having: A serious mental illness unless: The state mental authority determines that the physical and mental condition of the individual requires the level of services provided by the facility. The state mental health authority determines whether or not the individual requires specialized services for mental illness. These determinations are based on an independent physical and mental evaluation that is performed prior to admission. An independent evaluation is an evaluation performed by a person or entity other than the state mental health authority. Procedure: A.Complete Level I screen of the PASARR on new admissions. 1. Readmits do not require a PASARR to be completed. 2. Residents being transferred to another nursing home do not require another PASARR to be completed. The nursing home must send with the resident all screens. 3. Those residents whose attending physician has certified, before admission to the community that the individual is likely to require less than 30 days of nursing facility services, do not require a PASARR to be completed.

Based on observation, interview, medical record review, and facility policy and procedure review, the facility failed to provide an ongoing activity program that met residents' interests and supported the physical, mental, and psychosocial well-being of one (Resident #73) of 41 sampled residents. Facility activities programs that incorporate residents' interests, hobbies and cultural preferences are intregal in maintaining and/or improving residents' physical, mental, and psychosocial well-being and independence. The findings include: On 11/13/2023 at 11:03 a.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes or respond when her name was called. The room was dark. The television was not on and no music was playing from any device in her room. The room was not homelike as evidenced by no personal belongings visible anywhere in the room and the walls were bare. There was no Activities calendar in the resident's room. During the lunch meal service on the 1 North unit on 11/13/2023 from 12:10 p.m. to 1:15 p.m., Resident #73 was not observed in the dining room or in any of the common areas. During the lunch meal service on the 1 North unit on 11/14/2023 from 12:38 p.m. to 1:00 p.m., Resident #73 was not observed in the dining room or in any of the common areas. On 11/14/2023 at 12:45 p.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes when her name was called. The room was dark and the television was not on. No music was playing from any device in her room. There was no Activities calendar in the resident's room. On 11/14/2023 at 2:30 p.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes or respond when her name was called. The room was dark. The television was not on and no music was playing from any device in her room. There was no Activities calendar in the resident's room. On 11/15/2023 at 2:51 p.m., Resident #73 was observed lying in bed with the bed covers up over her chest under her chin. Her eyes were closed. She did not answer when her name was called. The room was dark and the television was not on. There was no Activities calendar in the resident's room. During an interview with Licensed Practical Nurse (LPN) F on 11/15/2023 at 2:58 p.m., she stated she was the assigned nurse for Resident #73. She stated she had not worked at this facility long, but since she had been employed, she had not seen the resident up out of bed. She confirmed that Resident #73 was not receiving hospice or palliative care services. She stated she did not know why the resident was always in bed. She had not been ill. A review of the employee roster for the facility revealed that LPB F began employment at this facility on 10/17/2023. On 11/16/2023 at 9:39 a.m., Resident #73 was observed lying in bed. Certified Nursing Assistant (CNA) G was spoon-feeding the resident thickened orange juice from a cup. The resident did not respond to her. She did not open her eyes but would open her mouth to take the juice. The CNA stated sometimes the resident would not respond because her first language was not English. The CNA touched the resident on her shoulder and called her name. The resident did not respond. When asked if the resident ever got up out of bed or attended activities, she stated the resident sometimes did. She confirmed the resident had not been up today. The resident's room was dark and the television was not on. No music was playing from any device in her room. There was no Activities calendar in the resident's room. On 11/16/2023 at 11:09 a.m., upon entering the 1 North unit, the Unit Manager stated, Guess who's up out of bed? He confirmed it was Resident #73. Resident #73 was observed seated in her wheelchair in the dining room. She was fully dressed. Her eyes were closed and she had her hand up over her face as though she was in pain. Upon approach she was greeted in Spanish, her first language, and she opened her eyes briefly and made eye contact but did not speak. She then closed her eyes and did not respond again. No group activity was being conducted. During an interview with Activities Assistant (AA) P on 11/16/23 at 11:00 a.m., she was asked to produce the Activities participation logs. She went to the Activities department office and found the logs. She brought the months of August, September, October and November of 2023 for review. A review of the logs revealed that Resident #73 received activities on the following dates: 11/10/2023 the box was initialed V indicating she had a visitor. 1 day out of 15. 10/25/2023 the box was initialed EX 10/17/2023 the box was initialed TV, indicating she watched television. 10/09/2023 the box was initialed TV 3 days out of 31 9/01/2023 the box was initialed TH indicating therapy. 9/04/2023 the box was initialed V, indicating she had a visitor. 9/06/2023 the box was initialed EX and PC 9/14/2023 the box was initialed TV 9/19/2023 the box was initialed DR, indicating she was in the dining room. 09/21/2023 the box was initialed DR and MIN 9/26/2023 the box was initialed V and T.T. 7 days out of 30 8/08/2023 the box was initialed D.R. and T. T. 8/11/2023 the box was initialed V. and D.R. 8/16/2023 the box was initialed POD and EX 8/17/2023 the box was initialed DR and MN. 8/22/2023 the box was initialed MN 5 days out of 31 (Copies obtained) Per the facility's documentation, at no other time did the resident receive activities. During an interview with AA P on 11/16/2023 at 2:20 p.m., she stated she was not sure what TT, POD, EX or MN stood for. She stated Resident #73 was not assigned to the unit that she worked on and she was not familiar with the documentation for the Activities Assistant who was assigned to Resident #73. She confirmed that the Activities Assistant assigned to Resident #73 was out on leave and the Activities Director was also out on leave. She could not explain why Resident #73 was offered activities so seldom. A review of Resident #73's medical record revealed that the face sheet indicated she was admitted on [DATE]. She was readmitted on [DATE]. She was admitted with diagnoses including but not limited to fracture of left hip, metabolic encephalopathy, hyperosmolality and hypernatremia, hypertension, unspecified dementia, unspecified severity, without behaviors/psychosis/mood/anxiety, tachycardia, elevated white blood cell count, acidosis, acute kidney failure, hyperlipidemia, polyneuropathy, and sepsis. (Copy obtained) A review of the Activities Quarterly note, dated 08/31/2020, revealed: Assessment for [Resident #73]. She enjoys looking at tv in her room and talking with her roommate and staff. She loves her snacks on Fridays and sitting in the hall looking out of the window. A review of the Activities Quarterly note, dated 02/24/2021, read: Quarterly note for [Resident #73]. Is often found in her room or in the day room watching tv. [Resident #73] loves conversation with her roommate and some staff. We will continue to assist as needed. A review of the Minimum Data Set (MDS) Annual assessment, dated 05/25/2022, revealed that when the resident was interviewed, she stated it was very important to her to listen to music and to go outside when the weather was good. It was somewhat important to her to do her favorite activities and to do things with groups of people. (Copy obtained) A review of the MDS Quarterly assessment, dated 07/20/2023, revealed Resident #73's mental status could not be determined. The summary score was 00, indicating the resident was not able to complete the interview. The resident was assessed as being totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing and toilet use. She required extensive assistance for eating. (Copy obtained) A review of the Care Plan, dated 5/16/2023 with no revisions, revealed: Resident #73 is at risk for changed activity preferences due to advancing dementia. [Resident #73] primarily attends activities passively and enjoys music. Resident will participate in preferred activities weekly through the review period. (A) Activity assistant will visit with [Resident #73] regularly for companionship and inform her of the current activities available. She watches her television and listens to music. (A) Offer and assist, to activity of choice. [Resident #73] enjoys music programs but will often sit as an observer for other activities. (A) Offer music therapy in room. Departments responsible for this care plan were Activities, All, Nursing and Social Services. (Copy obtained) A review of the facility's policy and procedure titled Activities (dated 12/2016 and revised 01/2020) revealed: The community should provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychological well-being of each resident, encouraging both independence and interaction in the community. Residents are encouraged to choose the types of recreational, cultural and religious activities and social events in which they prefer to participate. As much as possible, the community will provide activities, social events, and schedules, that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. Activities are scheduled 7 days a week and residents are given an opportunity to contribute to the programs. Activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include activities not necessarily limited to formal activities. Other community activities associates, volunteers, visitors and residents and family members may also provide activities. Activity schedules are also provided individually to residents who can not access the posted schedule (e.g. bed bound or visually impaired residents). Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Residents who choose not to attend group activities will maintain an independent program. It is the responsibility of the community and the activity associates to make regular contacts and offer supplies, as needed. Residents requiring assistance to and from scheduled activities will be assisted by the Activity Department, Nursing Services and community volunteers. A list of activities scheduled for the month is posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bed bound). Each resident's activities care plan relates to her comprehensive assessment and reflects her individual needs. (Copy obtained)

Based on observation, interview, and record review, the facility failed to ensure that two (Residents #53 and #20) of three residents sampled for review of respiratory care, from a total sample of 41 residents, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The findings include: 1. On 11/13/23 at 2:45 p.m., Resident #53 was observed in her room. She was sitting up in a wheelchair receiving oxygen via a nasal cannula. A dark blue oxygen concentrator was positioned behind the resident next to her bed. The oxygen flow rate was set at 3 liters per minute (LPM). The resident was asked what the flow rate should be set at and she replied that the flow rate should be 2 LPM. (Photographic evidence obtained) On 11/15/2023 at 12:02 p.m., Resident #53's oxygen flow was observed to be set at 3 LPM. On 11/15/2023 at 4:25 p.m., Resident #53's oxygen flow rate was observed to be set at 3 LPM. (Photographic evidence obtained) A record review revealed the resident was admitted to the facility on [DATE]. Her diagnoses included fluid overload; end stage renal disease; dependence on renal dialysis; chronic obstructive pulmonary disease (COPD); chronic respiratory failure; heart failure; pulmonary hypertension; peripheral vascular disease; type 2 diabetes with diabetic chronic kidney disease; hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease or end-stage renal disease. A review of the resident's active physician's orders revealed: O2 (oxygen) at 2 LPM; Eliquis 2.5 mg (milligrams) every 12 hours; Novolog 100 unit/ml (units per milliliter), inject per sliding scale four times a day; change oxygen tubing and humidifier bottle weekly. A review of the 8/3/2023 Quarterly Minimum Data Set (MDS) assessment, revealed that Resident #53 scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating that she was cognitively intact. The assessment did not capture the resident's functional abilities and goals. She was listed as being always continent of bladder and bowel. The assessment did not document the administration of oxygen during or prior to being a resident. A review of the most recent Care Plan with a start date of 7/20/23, revealed a focus area of Pulmonary: [Resident #53] has the potential for SOB (shortness of breath) and/or respiratory complications related to history of congestive heart failure (CHF) and pulmonary edema. The goals included: Administer medications per orders and monitor for response. Observe for side effects and inform physician PRN (as needed). The interventions included: Provide treatment per physician's orders and monitor for response, observe for side effects and inform physician; monitor oxygen saturation and administer O2 per physician's orders; monitor for complications such as dyspnea, shortness of breath, cyanosis, or tachypnea. Registered Nurse (RN) M was observed at a medication cart positioned outside of Resident #53's room. When approached he stated he was familiar with Resident #53. He was asked about the resident's order for oxygen. After reviewing the resident's physician's orders, he confirmed that the resident's oxygen should be administered at 2 LPM. He stated the night shift nurse was responsible for changing the tubing weekly. RN M was accompanied into the resident's room. The resident was seated in a wheelchair at the foot of her bed. She was receiving oxygen via a nasal cannula. Observation of the oxygen concentrator positioned next to the head of the resident's bed revealed that the flow rate was set at 3 LPM. RN M confirmed this and stated it should have been set at 2 LPM and not 3 LPM. He immediately began to adjust the dial on the front of the concentrator so that the setting was on 2 LPM. The resident was asked about her oxygen. She again stated it should be set at 2 LPM. She added that the nurse from the previous night's shift had set the concentrator. A review of the facility's policy titled Procedure: Oxygen Administration (original date of 12/2016, last revised on 10/2018 and last approved on 12/2022) revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: (A) Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration. (B) Review the resident's care plan to assess for any special needs of the resident. (C) Assemble the equipment and supplies as needed. A review of the facility's policy titled Medication and Treatment Orders (original date of 12/2016, last revised on 12/2017 and last approved on 1/2022) revealed: Purpose: Orders for medication and treatment will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation: (A) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 28892 2. A review of Resident #20's medical record revealed an admitted [DATE], hospitalization on [DATE], and readmission to the facility on [DATE]. The resident's diagnoses included urinary tract infection (UTI), sepsis, encephalopathy, supraventricular tachycardia, dysphagia, overactive bladder, pneumonia, nosocomial condition, acute respiratory failure with hypoxia, bradycardia, tachycardia, thrombocytopenia, acute kidney failure, atrial fibrillation, unspecified dementia, and unspecified severity. On 11/14/23 at 11:43 a.m., the resident was observed resting in bed with a nasal cannula dislodged and hanging beneath her nose. The resident's oxygen concentrator flow rate was set at 2.5 LPM. (Photographic evidence obtained) The resident showed no signs of cyanosis (i.e., blue tone to the skin and mucous membranes); hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion), or oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing). A review of the resident's physician's order, dated 09/29/23, revealed: Oxygen at 3 LPM to keep oxygen saturation levels above 92%. 3 LPM inhalation every shift. On 11/15/23 at 10:13 a.m., a second observation was made of the resident resting in bed with her eyes open. The resident's nasal cannula was dislodged and hanging beneath her nose. The resident explained that she did not like the nasal cannula, and told staff she did not like wearing the nasal cannula because it felt uncomfortable. The oxygen concentrator flow rate was observed to be set at 2.5 LPM. (Photographic evidence obtained) The resident said she was incapable of adjusting the oxygen flow rate herself. The resident showed no signs of cyanosis, hypoxia, or oxygen toxicity. On 11/16/23 at 10:14 a.m., a third observation was made of the resident resting in bed and with her nasal cannula inserted and delivering oxygen. The oxygen concentrator was set at a flow rate of 2.5 LPM. (Photographic evidence obtained). The resident showed no signs of cyanosis, hypoxia, or oxygen toxicity. A review of the Quarterly MDS assessment, dated 11/13/23, revealed a BIMS score of 5 out of 15 possible points, indicating severe cognitive impairment. The resident was assessed with limited range of motion with impairment on one side of the upper extremities. The assessment further noted the resident required partial to moderate assistance with eating, and she was totally dependent for toileting, showers, bathing, upper and lower body dressing, putting on and taking off footwear and personal hygiene. The assessment also documented oxygen therapy as continuous through a nasal cannula. A review of the resident's care plan, dated 10/06/23, documented a pulmonary focus area, noting the resident had Potential for Shortness of Breath and/or Respiratory Complications related to a recent hospitalization secondary to respiratory failure and on oxygen via nasal cannula. The care plan goal noted the resident would have no respiratory complications or signs or symptoms of shortness of breath (SOB). Interventions were to administer medications per order and monitor for response, observe for side effects, and inform the physician as needed. The care plan also must be administered per physician's orders and monitor for response. A review of the resident's physician's order, initiated on 09/29/23, documented oxygen was to be administered at 3 LPM to keep oxygen saturation levels above 92%. Three liters to be administered per minute via inhalation every shift. A review of the resident's electronic treatment administration record (eTAR) documented an oxygen flow rate set at three liters per minute. On 11/16/23 at 11:49 a.m., Certified Nursing Assistant (CNA) D was interviewed. The employee reported she had worked at the facility for two years and always checked oxygen levels first thing in the morning while checking residents' vital signs. She explained that she was not aware of what oxygen flow rates should be and only viewed the set flow rate on the oxygen concentrator, recorded the flow rate on paper and provided it to the resident's nurse. It was the nurse's responsibly to enter the oxygen flow rate into the facility's eTAR. On 11/16/23 at 11:59 a.m., Licensed Practical Nurse (LPN) E was interviewed. She stated she had worked at the facility since 09/25/23. She further explained that she was familiar with the resident and her oxygen needs. LPN E checked the electronic medical record and stated the physician's order for Resident #20's oxygen was for a flow rate of 3 LPM via nasal cannula. She said the resident often moved the nasal cannula out of her nose but did not remove it completely from her face. LPN E further explained the process for ensuring oxygen flow rates were accurate included CNAs checking oxygen flow rates and documenting them on a piece of paper and providing it to the nurse. The nurse entered the oxygen flow rate into the eTAR. She stated the night nurse changed the tubing and documented it in the eTAR. She explained that she checked resident oxygen flow rates in the morning and during rounds. On 11/16/23 at 12:06 p.m., LPN E was accompanied into Resident #20's room. She stood above the oxygen concentrator [NAME] and reported the resident's oxygen flow rate was set at 3 LPM. Upon further inspection and viewing the oxygen concentrator [NAME] at eye level, LPN E admitted the oxygen concentrator [NAME] read 2.5 LPM. On 11/16/23 at 6:49 p.m., an interview was conducted with the Director of Nursing (DON), who reported that she had worked at the facility for three and a half years. She explained the process to ensure oxygen flow rates were set per the physicians' orders and included that CNAs did not administer oxygen. If a CNA noticed a concentrator was empty or observed another issue with an oxygen concentrator, they should report it to a nurse. Nurses must check resident oxygen flow rates during each shift and oxygen flow rates should be documented on the medication administration record (MAR).

Based on observations, interviews, and record review, the facility failed to ensure that two (Residents #41 and #17) of five residents sampled for medication review, from a total of 41 residents sampled, were free from unnecessary drugs. An unnecessary drug includes any drug used without adequate monitoring. The findings include: 1. A review of Resident #41's medical record revealed and admission to the facility on [DATE]. Her most recent readmission was on 8/18/2023. Her diagnoses included acute kidney failure; chronic systolic (congestive) heart failure; delusional disorder; atherosclerotic heart disease of native coronary artery; visual hallucinations; Parkinson's disease; unspecified dementia; type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). A review of the resident's active physician's orders revealed she was receiving Seroquel (antipsychotic) 50 mg (milligrams) daily; Namenda XR (cognition-enhancing medication) 14 mg daily; Buspar (anxiolytic) 5 mg twice a day; Novolog U-100 insulin aspart 100 unit/ml (units per milliliter), inject subcutaneously per sliding scale four times a day. A review of the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), revealed that the medications were being administered as ordered however, there was no documented evidence of monitoring for behaviors and/or side effects related to the medications. A review of the 10/31/2023 Quarterly Minimum Data Set (MDS) assessment, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. There were no documented moods or behaviors. She was reported with occasional incontinence of bladder and always incontinent of bowel. During an interview with Registered Nurse (RN) M on 11/15/2023 at 4:26 p.m., he stated he was familiar with Resident #41. He stated she took her medications whole and had no recent behaviors. He referred to her as diabetic and insulin dependent. He stated she had diagnoses which included delusional disorder, visual hallucinations, Parkinson's disease, unspecified dementia without mood issues, and anxiety. She had active physician's orders which included Aricept (cognition-enhancing medication) 5 mg at 8:00 p.m. nightly; Namenda XR 14 mg daily for dementia, Seroquel 50 mg twice a day for delusions, Buspar for her anxiety and he added that she also took insulin. He stated there was no specific diagnosis of anxiety, adding that it was only attached with the diagnosis of unspecified dementia. He was asked about behavior monitoring related to the resident's antipsychotic and anxiolytic medications. He stated there was a section of the resident's eMAR that listed the purpose of the medication along with the mood and behaviors to monitor. He stated the nurse was to document any behaviors in the eMAR every shift. After reviewing the November 2023 eMAR for Resident #41, he was unable to locate any documentation of behavior monitoring and/or medication side effects in the resident's electronic medical record. He confirmed the resident had consistently received the aforementioned medications as ordered. He called for RN O/Unit Manager, who was located in a nearby office. Upon approaching the medication cart RN M asked RN O for the location of the behavior monitoring and/or medication side effect monitoring in the electronic record for Resident #41. RN O advised him that the information should have been located in the eTAR. She then accessed Resident #41's eTAR. There was no documentation verifying monitoring for behaviors and/or medication side effects for this resident. Upon seeing this she stated, It doesn't look like there are any in there. Both RNs continued attempting to locate the information in the resident's electronic chart. They were unsuccessful. RN O stated the resident had been transferred out to the hospital and that often when residents went out and came back, not all of the orders were added back into the system. She stated nursing should have added the orders back in when the resident returned from the hospital. She stated anytime a resident was transferred and remained out of the facility beyond midnight, the orders had to be manually added back into the system. If the nurse on duty was Agency staff or new, they may not be aware of that. She was asked for the date the resident returned to the facility after being hospitalized . She stated she would need to verify that. She returned at 4:57 p.m. and stated she misspoke earlier. Resident #41 had not been transferred out to the hospital as she originally stated. Again, it was confirmed there was no documented evidence of behavior and/or side effect monitoring in the resident's eTAR prior to the 11/15/23 4:26 p.m. interview. A record review revealed that Resident #41 was seen in the facility on 10/16/2023 by a third-party provider for mental health services. Mental Health Services documentation noted the following: CHIEF COMPLAINT: Patient exhibits changes in mental status or behavior consisting of: Depression, anxiety, agitation, confusion, psychosis Other: Follow up visit with medication review HISTORY OF PRESENT ILLNESS: Chief complaint has been occurring for several: Months But appears to be: Better For the past: Days History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: Normal Insight/judgement: Poor Oriented to: Person, place, circumstances Immediate memory: Partially impaired Recent memory: Partially impaired Remote memory: Intact Thought content and perceptions: Delusions Mood/Affect: Depressed, anxious, irritable SIGNS AND SYMPTOMS: Patient has sleep disturbances. Patient is feeling depressed and sad. Patient feels restless and anxious. Resistive to care. Difficult to redirect. Patient is psychotic with: Delusions DIAGNOSES: Unspecified dementia with behavioral disturbance Major depressive disorder, recurrent, moderate Generalized anxiety disorder Unspecified psychosis not due to a substance or known physiological condition Primary insomnia 2. During an observation of Resident #17 on 11/13/2023 at 12:59 p.m., she was found in bed with a pillow over her head. There were fall mats present on the floor on each side of the bed. The resident was greeted and responded pleasantly. When asked about the observation of the fall mat the resident denied having any falls. The resident then began asking about being discharged home. She stated she had multiple properties which were currently being occupied by other people. It was suggested that she contact the facility's Social Services Director (SSD). The resident continued to repeat her questions regarding discharge and talking about the many properties she owned. She was increasingly confused, so the interview was concluded. A record review for Resident #17 revealed she was readmitted to the facility on [DATE] after being hospitalized for acute care. Her diagnoses included unspecified convulsions; unspecified dementia; unspecified psychosis not due to a substance or known physiological conditions; metabolic encephalopathy; acute kidney failure; personal history of other specified conditions; dysphagia; personal history of other infectious and parasitic disease; atherosclerotic heart disease; hemiplegia affecting left non-dominant side, and type 2 diabetes mellitus. A review of the current, active Physician's orders included Quetiapine (Seroquel - antipsychotic) 25 mg, two tablets every 12 hours; Escitalopram (for treating depression and generalized anxiety), 20 mg daily; Lacosamide (anticonvulsant) 250 mg twice a day; Topiramate (anticonvulsant and nerve pain medication) 100 mg twice a day; Levetiracetam (anticonvulsant) 1000 mg twice a day. A review of the 9/22/2023 Quarterly MDS assessment, dated 09/22/23, revealed that Resident #17 scored 5 out of 15 possible points on her BIMS assessment, indicating significant cognitive impairment. She required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. She was independent with eating. A review of the November 2023 eMAR revealed no concerns. The aforementioned medications were administered as ordered. Review of the November 2023 eTAR revealed no documented evidence of monitoring for medication side effects or resident behaviors. During an interview with Social Worker P on 11/15/2023 at 2:23 p.m., he confirmed that Resident #17 had a diagnosis of unspecified psychosis. During an interview with RN M on 11/15/2023 at 5:00 p.m., he stated he was familiar with Resident #17. He cited her diagnoses as dementia, unspecified psychosis and added that she also had seizures. He listed her medications as Escitalopram 20 mg daily for depression, Lacosamide 250 mg twice a day for seizures, Topiramate 200 mg every 12 hours for seizures, and Seroquel 25 mg every 12 hrs. He noted the resident orders and eMAR listed the medication was for depression. He stated the diagnosis was inaccurate. Sometimes they put the wrong diagnosis. After reviewing the eMAR, RN M confirmed the resident had received the aforementioed medications as ordered. He was asked about medication side effects and behavior monitoring for the medications. He stated the resident had not had any side effects that he was aware of. He then attempted to access the eTAR for review. There were no behavior monitoring or side effect monitoring orders there. He confirmed there was no documented evidence of behavior or side effect monitoring for this resident. He again contacted RN O/Unit Manager for assistance. An interview was then conducted with RN O at this time. She stated Resident #17 had been readmitted after a transfer to the hospital. She confirmed the orders for behavior and side effect monitoring were not on the eTAR. She stated the orders had not been added back when the resident was readmitted to the facility on [DATE]. She stated the orders needed to be signed. She was asked who was responsible for ensuring all orders were added back into a resident's chart upon readmission. She stated it was the responsibility of the nurse conducting the assessment and putting in the hospital orders upon the resident's return to the facility. She stated sometimes the monitoring was documented in the progress notes. She then reviewed all progress notes entered for Resident #17 from 9/16/2023 through 11/15/2023. During her search RN M commented that the information needed to be documented. You can't give a medication like that without monitoring it. After searching in multiple locations of the resident's electronic record, RN O confirmed there was no evidence of documentation of resident behavior and/or medication side-effects during that time. Further record review revealed that Resident #17 was seen in the facility on 10/16/2023 by a third-party provider for mental health services. The Mental Health Services documentation revealed the following: CHIEF COMPLAINT: Patient exhibits changes in mental status or behavior consisting of: Depression, anxiety, confusion, psychosis Other: Follow up visit HISTORY OF PRESENT ILLNESS: Chief complaint has been occurring for several: Months But appears to be: Better For the past: Weeks History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: Blocking Insight/judgement: Poor Oriented to: Place Immediate memory: Partially impaired Recent memory: Partially impaired Remote memory: Partially impaired Thought content and perceptions: Delusions Mood/Affect: Depressed, anxious SIGNS AND SYMPTOMS: Patient shows apathy with poor social interaction. Patient has sleep disturbances. Patient is feeling depressed and sad. Patient feels restless and anxious. Patient is psychotic with: Delusions DIAGNOSES: Vascular dementia with behavioral disturbance Major depressive disorder, recurrent, moderate Generalized anxiety disorder Unspecified psychosis not due to a substance or known physiological condition A review of the facility's policy titled Medication and Treatment Orders (original date of 12/2016, last revised on 12/2017 and last approved on 1/2022): Purpose: Orders for medication and treatment will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation: (A) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. (C) Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Though requested, no additional policies related to medication side effect monitoring or behavior monitoring were provided for review during the survey period.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5% based on 32 opportunities for error with two errors identified, resulting in an error rate of 6.25 %. The errors affected two (Residents #454 and Resident # 86) of seven residents observed during medication administration, from a total of 41 residents in the sample. Failure to administer medications correctly, as ordered, could result in side effects including serious harm to a resident. The findings include: During medication administration observation on 11/14/23 at 12:34 p.m., Licensed Practical Nurse (LPN) Q was observed administering insulin to Resident #454. LPN Q obtained a blood glucose reading of 167. After reviewing the resident's sliding scale order, LPN Q stated the resident needed 2 units of NovoLog insulin. He obtained a NovoLog kwik pen and dialed the pen to 2 units. He administered the insulin in the resident's lower abdomen. In an interview with LPN Q on 11/14/23 at 12:45 p.m., he was asked how he ensured that there were no air bubbles in the kwik pen. He replied, by looking through the pen. He was then asked how the kwik pen should be primed. He replied, To be honest, I don't know how to prime it. I never prime it. He added that he would consult with the Unit Manager. He confirmed that without priming the pen, it would not be possible to tell whether or not the resident received the 2 units. Another medication administration observation was made on 11/15/23 at 9:40 a.m. LPN R was observed administering medication to Resident #86. She obtained a tube of Diclofenac gel 1%. She went to the resident's room and squeezed some of the gel on her gloved hand and applied it on both of the resident's hands. A review of medication label, dated 10/27/23, revealed: Diclofenac gel 1%. Apply 2 grams (gm) topically to both hands every 12 hours for pain. In an interview on 11/15/23 at 9:45 a.m., LPN R was asked how she ensured that she administered 2 gm of the medication. She replied, To be honest, I don't know. I just squeeze a little on my hand. She further stated, Sometimes the label is not accurate and we have to go with what is in the computer. She looked at the computer order and stated it did not include the medication dosage. When she was asked to describe the components of a medication order, she stated there should be a dosage. She stated she should have clarified the order. A review of the facility's policy and procedure for Administering Medication (last revised on 12/2021), revealed: Medications shall be administered in a safe and timely manner and as ordered. The policy interpretation and implementation indicated that medications shall be administered in accordance with the orders. The individual administering medication must check the label three times to verify the right resident, right medication, right dosage and right method of administration before administering the medication.

Based on observation, interview, and a policy and procedure review, the facility failed to secure/store medications in locked compartments to limit unauthorized access to medications for two (Residents #35 and #57) of 41 sampled residents. Failure to ensure medications are secure and/or inaccessible could result in residents ingesting medications and suffering significant adverse consequences. The findings include: 1. On 11/13/23 at 12:26 p.m., Resident #35 was observed resting in bed. Bottles of over-the-counter Systane ultra dry eye relief and Systane complete dry eye relief were observed on the resident's bedside table. (Photographic evidence obtained) When he was asked whether the facility had evaluated him to self-administer medication, Resident #35 stated he liked to administer the eye drops at night to help reduce his dry eyes. On 11/15/23 at 10:36 a.m., Resident #35's eye drops were still observed at bedside. A review of Resident #35's active physician's orders revealed no orders for the Systane eye drops and no assessment for self-administration of medication. In an interview with LPN B on 11/16/23 at 4:34 p.m., she confirmed that she was assigned to Resident #35. When asked if the resident administered his own medication, she replied, Only his eye drops. When asked if the resident had an assessment conducted for self-administration of medications, she stated she was not sure because she could not find one in the computer. She was then asked if the resident had an order for the Systane eye drops. She replied, I added the orders today. 2. During another observation on 11/13/23 at 2:12 p.m., Resident #57 was observed with medication on his bed side table. He stated, I have to keep these (cough drops, Albuterol inhaler, Refresh eyedrops, saline mist nasal spray, Fluticasone nasal spray, and Budesonide inhaler) because these new and Agency nurses don't always know what they are doing, and they don't give them to me when I need them. (Photographic evidence obtained) The resident was asked if he was assessed by the facility to self-administer his medication. He replied no. He added, I take this yellow one (Budesonide) two times a day. The blue one is my rescue; I use it as needed, and my eye drops and nasal spray I use as needed. A review of Resident #57's active physician's orders, dated 3/19/23, revealed Fluticasone nasal spray 50 micrograms (mcg) twice a day as needed. Saline Mist 0.65% nasal spray, one spray in each nostril three times a day as needed for allergic rhinitis. Refresh Optive advanced 0.5%-1%-0.5%, one drop in both eyes every 8 hours as needed for dry eyes. Albuterol sulfate 90 mcg/actuation aerosol, two puffs every 4 hours as needed for COPD (chronic obstructive pulmonary disease). Cepacol extra lozenges. One lozenge every 8 hours as needed for sore throat. Budesonide 0.25 mg/2 ml suspension for nebulization, 2 ml (milliliters) inhalation every day for chronic respiratory failure with hypoxia. In an interview with Licensed Practical Nurse (LPN) A on 11/16/23 at 2:42 p.m., she stated there were no residents in her section of the facility who administered their own medications. When asked about Resident #57's eye drops, nasal spray and inhalers, she said, He does not administer his own medication. He has severe COPD and we always do his medications. She checked the assessments and stated Resident #57 did not have an assessment for self-administration of medications. She was accompanied to the resident's room and confirmed that the resident had two inhalers, two bottles of nasal spray, one bottle of eye drops, and a bag of cough drops at bedside. In an interview with Registered Nurse (RN) C/Unit Manager on 11/16/23 at 4:36 p.m., she confirmed that neither Resident #35 nor Resident #57 had assessments for self-administration of medication. A review of the facility's policy and procedure titled Storage of Medication (last reviewed on 12/2017), revealed: The community shall store drugs and biologicals in a safe, secure and orderly manner. The nursing associate shall be responsible for maintaining medication storage and preparation area in a clean, safe and sanitary manner. A reviewed of the facility's policy and procedure titled Administering Medication (last revised on 12/2021), revealed: The policy interpretation and implementation (w.) indicated that residents may self administer their own medication only if the attending physician, in conjunction with the nurse assessment, has determined that they have the capacity to do so safely.

Based on record review, interviews, and facility policy review, the facility failed to ensure that alleged violations involving neglect, and misappropriation of resident property, were reported no later than 24 hours to the State Survey Agency for two (Residents #1 and #2) of 4 residents reviewed for reportable incidents. The findings include: 1. A review of the facility's adverse incidence report revealed that Resident #1 had an incident on 8/8/2023. A review of the clinical record for Resident #1 revealed an admitted [DATE], with re- entries on 7/3/23, 7/31/23, 08/16/23, 8/27/23, and discharged on [DATE]. Her diagnoses included Diabetes Mellitus, Cardiovascular accident, chronic kidney disease, seizure disorder and bipolar disorder. Physician's orders for Resident #1 dated 8/1/23 revealed orders for insulin Levemir 100 units/milliliter (ml) inject 11 units subcutaneous two times a day (BID) and Humalog 100 units/inject 6 units three times a day and sliding scale during meals. On 8/3/23 there was an orders to increase Levemir 100 units/milliliter (ml) inject 11 units subcutaneous two times a day (BID). There was no indication if the order to increase Levemir to 15 ml was executed (Copy obtained) Nursing progress notes authored by LPN A as late entry dated 8/8/23 indicated that at 11:15 am Resident #1's blood sugar was 377, 10 units of lispro administered, resident symptomatic with shortness of breath (SOB) respiratory distress unable to lay supine without increased SOB/fear. Grossly edematous to bilateral upper and lower extremities to include abdominal area. Physician assistant notified and orders received and implemented to increase Lasix to 40 mg by mouth daily. Floor manager updated on resident status. A joint interview was conducted with the Director of Nursing (DON) and the Risk Manager on 9/12/23 at 12:28 pm. The Risk Manager stated that on 8/8/23 around 2:00 pm, she was called to the unit by the unit manager to assess Resident #1, as she had a change in condition. Upon assessment, the resident was noted to be diaphoretic with altered mental status with a blood sugar reading of 428. When the Licensed Practical Nurse (LPN A) assigned to the resident was asked what the blood sugar during meals was and how many units of insulin she had administered, she stated that the blood sugar was 377, and she had given three units of Humolog. The risk manager then checked the resident's chart which indicated that she should have received 10 units of Humalog insulin per sliding scale and 6 units standard (total of 16 units). The risk manager also noted new orders to increase Lasix and Levemir that were written at 7:00 am which had not been entered in the computer system. She added that resident #1 was sent out to the hospital for evaluation and was admitted with diabetic ketoacidosis. 2. A review of a second adverse incident dated 7/17/23 indicated that LPN B notified the DON that LPN C had incorrectly signed off narcotic medication for Resident #2. A review of the clinical record for Resident #2 revealed an admitted [DATE] with diagnoses that included stroke with aphasia, dementia, hypertension, left hip pain, and fracture femur. Physician's orders for Resident #2 dated 7/17/23 indicated the resident was on oxycodone 5 mg every 4 hours as needed for pain. Care plan dated 7/17/23 indicated the resident had pain related to left hip fracture with interventions to administer medication as ordered and monitor effectiveness. An interview was conducted with the DON and the Risk Manger on 10/2/2023 at 3:50 pm. The DON stated that Resident #2's clinical record indicated she was admitted to the facility on [DATE] with an order for Oxycodone immediate release (IR) 5 milligrams (mg) ever 4 hours as needed. Medication arrived from the pharmacy on 7/19/23 at 01:00 am. LPN A signed off the medication on the narcotic record as administered on 7/16/23 at 10:00 pm and 7/17/23 at 2:00 am (at this time resident was not in the facility). DON added that LPN A did not cooperate with the facility for investigation and the sheriff's department was notified. When asked if a federal report was made related to the incidences on 7/17/23 and 8/8/23, they both replied, No. Both the DON and the risk manager stated that they thought that the adverse incident was sufficient. When asked what the facility policy was related to reporting, neither could identify what these allegations were related to. They then obtained the facility policy and confirmed that the incident on 8/8/23 was related to neglect and incident on 7/17/23 was related to misappropriation, therefore, a federal report should have been made and Department of Children and Families (DCF) should have been notified. A reviewed of the facility's policy and procedure titled, Administering Medications, last revised 12/2021, revealed: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. The policy Interpretation and Implementation. section C, indicated that Medications shall be administered in accordance with the orders. (Copy obtained) Further review of the facility's policy titled, Abuse Prevention, last revised on 6/2020, page 2 revealed: Definitions (Page 2) Neglect, means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Reporting/Response (Page 6) The community will immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and/or designee, State Agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frames. (Copy obtained)

Based on interviews, record review, and facility policy review, the facility failed to respond promptly to grievances and failed to demonstrate their response and rationale to nursing related complaints documented during the facilities Resident Council meetings for 3 (October, November, and December 2022) of 3 months reviewed. The findings include: On 1/4/23 at 12:25 PM, an interview was conducted with Resident #4. The resident was in bed eating lunch. When asked if she had any complaints or grievances who she would tell, she stated, she had voiced concerns at Resident Council, but it doesn't do any good, nothing was done. When asked if she voiced her concern to anyone else, she stated, No. She stated, Menus aren't honored, and I've told them I would like staff to knock before coming into my room and they still haven't fixed it. She said, I met with a kitchen person, but my trays are still wrong and staff still doesn't knock before coming in. A review of the facility's Complaints and Grievances Policy (last revised 5/2021) read the following on Page 1 and 2: Definitions: Complaint - any simple service issue or concern received from residents or family members regarding treatment or services provided in the community that are easily resolved by associates. Grievance - any moderately complex complaint or service issue received verbally or in writing from residents or resident representative regarding treatment or services provided that require management intervention and a written resolution letter. All written complaints received by residents or resident representatives through any means will be considered a grievance. (Copy obtained) On Page 2 and 3 - Item 2. Identifying a designated community Grievance Official, a. 13. Report appropriate issues raised by the Resident Council through the Complaint and Grievance process. a. 14. Attend the community QAPI Committee for tracking and trending of complaint and grievance data to identify gaps and opportunities for individual education, system and systemic improvements. (Copy obtained) On Page 3 and 4 - Item 3. Documentation of complaints and grievances must be captured and include: a. Date the grievance or complaint was received orally or in writing b. A summary statement of the resident's or resident representative's grievance c. The steps actions taken to investigate the grievance d. A summary of the pertinent findings or conclusions regarding the resident's/resident representative's concerns(s) e. A statement as to whether the grievance was confirmed or not confirmed f. Any corrective action taken or to be taken by the community as a result of the grievance g. Date the written decision was issued to complainant in response to their grievance (Copy obtained) Review of the Resident Council minutes for the months of October, November, and December 2022, revealed Resident #4 attended all three meetings. The December questionnaire revealed Resident #4 had voiced complaint regarding menus under the Dietary section. Under the Nursing section there was a complaint regarding staff not knocking before entering residents rooms. (Copy obtained) On 1/4/23 at 2:15 PM, an interview was conducted with the Director of Quality Management (DQM) regarding the Resident Council minutes and the complaint log. When asked why the complaints documented in the minutes were not part of the complaint log. The DQM stated, if the complaints are addressed at the time, they did not need to be on the complaint log. When asked how they show evidence the complaints were addressed? She stated, since they were addressed on the spot, they didn't need to show evidence. On 1/4/23 at 2:50 PM, an interview was conducted with the Administrator. When asked how resident council concerns were addressed, she stated, she had only been at the facility 3 months and was still learning the system. The administrator stated, she had consulted with a regional person who told her if the issues were addressed and had a resolution, it did not have to be on the complaint log. When she was asked to provide evidence that the concerns had been addressed and resolved, the Administrator stated, she would follow up with the Activities Director who was the designated staff member to facilitate Resident Council. On 1/4/23 at 3:50 PM, an interview was conducted with the Activities Director/Resident Council facilitator. When asked how Resident Council meetings were conducted, she stated during face-to-face meetings, she had the Directors of different departments attend to address any issues from the meeting; when there is a COVID outbreak she sent around questionnaires. When the meetings were done, the notes/minutes from the meeting were forwarded to the Directors for follow up on any voiced concerns. When she was asked why the concerns were not logged as complaints or grievances, she stated, she was not aware they needed to be if they were being addressed. When asked how she knew the concerns were addressed, she stated, she didn't because she emailed the minutes to the Directors, and they resolved the concern and the minutes were reviewed at Quality Assurance Performance Improvement (QAPI). When she was asked to review the December questionnaire and explain how and when the highlighted items were added to the notes, the Activities Director indicated she did not know. On 1/4/23 at 4:00 PM, an interview was conducted with the Director of Nursing (DON). The DON reviewed the minutes of the last three resident council meetings and was asked if she had any documentation to show the nursing concerns had been addressed. She stated, she had not received the resident council minutes in her email. When asked if she recalled hearing about the concerns during QAPI, she stated, she did not recall. When asked if a family member called her with a concern/complaint, would be recorded on the complaint log, she stated, it depended on whether she could answer their questions at that time. When asked if she recalled receiving any phone calls from Resident #1's family, she stated, No. When asked how she followed the various concerns if there was no documentation of the call/resolution of an issue, she didn't have an answer. When asked if voiced concerns regarding medication administration, incontinence care, and rounding could be investigated and resolved quickly as a complaint or would those be considered grievances. She said, Possibly depending on what the issue was. When asked if there was evidence of the issues being resolved, she stated, No.

Based on a review of resident records, the facility's policy, and procedure for CPR (Cardio-pulmonary resuscitation), facility reports, and interviews with staff, the facility failed to act in accordance with the resident's Advance Directives in accordance with her Full Code status (the desire to be resuscitated in the event her heart or breathing stopped) after finding her unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status deprived her of potentially lifesaving measures. On [DATE], Resident #1 was admitted with a full-code status, indicating that she wanted to be resuscitated in the event of cardiac/respiratory arrest. On [DATE] at 11:20 am, CNA B (Assigned to Resident #1) notified LPN A (Assigned to Resident #1) that Resident #1 was unresponsive. The resident was in bed, pale, with her mouth open, but her skin was warm. When LPN A arrived at the resident's room, she assessed the resident and told CNA B that the resident was gone and to clean the resident up. CNA B reminded LPN A that the resident was a full code, and LPN A replied that she would contact the resident's physician. Cardiopulmonary resuscitation (CPR) was not initiated. Emergency Medical Services (EMS) was not called. At no point did facility staff consult the resident's medical record to verify code status. LPN A contacted the resident's family to make them aware of Resident #1's death, they provided her with the name of the funeral home they chose to use, and LPN A called the funeral home to come pick up Resident #1. On [DATE], the facility census was 143. There were 106 residents who had a full-code status at the time of the survey. The Administrator was notified of Immediate Jeopardy at 12:30 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F678 A review of the medical record, indicated that Resident #1 was admitted to the facility for rehabilitation and strengthening on [DATE], following a fall with no injuries. Her physician's orders, dated [DATE], indicated her Code Status was CPR. A review of her Care Plan, dated [DATE], indicated that Advanced Directives would be reviewed upon admission and a consultation would be made with the physician for verification of the resident's code status. A nursing progress note authored by Licensed Practical Nurse (LPN) A on [DATE] at 11:33 a.m. read, Resident discovered in bed with no pulse and no respirations at 11:20 a.m. Physician notified. Daughter notified and is now contacting the family and will call back with funeral home information. (Photographic evidence obtained) A written statement authored by LPN A and dated [DATE], indicated that she was called to Resident #1's room by CNA B, who had discovered Resident #1 unresponsive. When LPN A arrived, she found the resident unresponsive, with no pulse and no respirations. The resident's mouth was open, and he was very cool to the touch. (There was no documentation indicating that she initiated CPR.) (Photographic evidence obtained) In an interview with Certified Nursing Assistant (CNA) B on [DATE] at 1:48 p.m., she stated she had been employed by the facility for [AGE] years. She stated when a resident was found unresponsive, the first thing to do was to notify the resident's nurse. She added that the staff were expected to check the resident's door label (If the resident's name was written on a green label, staff were to initiate CPR, but if the resident's name was written on a white label, he/she was designated do not resuscitate.) When asked if she worked with Resident #1, CNA B said, Yes, she was totally dependent with care since admission and had been declining. She would not even eat. I even spoke with the doctor, and he started her on antibiotics. When asked if she worked with the resident at the time of the incident she said, Yes, she refused breakfast that morning and would not even open her mouth. I notified the nurse, and I returned to her room in about two hours to check on her and found her unresponsive. This was around 11:00 a.m. I immediately called the nurse and returned to the resident's bedside. When the nurse came to the room, she checked the resident and said [Resident #1] was gone. I again told the nurse that [Resident #1] was a full code, because there was a green tag on her door, and the nurse said that she would contact the doctor. When CNA B was asked the resident's status when she found her, CNA B stated that she had her mouth open and her skin was pale, but she was still warm. CNA B stated she was instructed by LPN A to clean the resident up. On [DATE] at 12:00 p.m., a joint interview was conducted with the Risk Manager and the Director of Nursing (DON). The DON stated she was contacted by LPN A on [DATE] at around 12:45 p.m. notifying her that Resident #1 had expired and that she had not performed CPR. The DON stated LPN A was notified by CNA B that Resident #1 was unresponsive, and upon assessment, she was cool to the touch, and she did not feel that CPR would have been successful. LPN A contacted the resident's physician around 11:24 a.m., who pronounced the resident's death. The DON continued to state that she immediately contacted the Administrator, the Risk Manager, and the resident's physician, and LPN A was immediately suspended pending investigation. When asked about the facility's protocol for when a resident was found unresponsive, the DON stated the licensed staff should initiate CPR until EMS arrives or they are advised to stop by the physician. The Risk Manager added that after determining that the resident was full code, licensed staff should initiate CPR. LPN A could not pronounce the resident's death and had no reason not to initiate CPR. The DON also stated she had worked with LPN A, and that LPN A was always proactive and she could not tell what had happened on that day. In a telephone interview with the Medical Director on [DATE] at 9:30 a.m., he stated LPN A sent him a text message on [DATE] at 11:24 a.m. which read, The patient that you started on Rocephin a day ago is no longer with us. He stated that was an unusual text because the nurses were aware of the need to call the on call physician in the case of an emergency and not send a text message. He added that luckily he saw the text and called the nurse about two minutes later to gather more information. He asked LPN A what happened, and she reported that Resident #1 was found with no respirations and no pulse. He asked the resident's code status, and LPN A reported that the resident was a full code. He asked if CPR was initiated, and LPN A said no. He added that LPN A told him Resident #1 was long gone. The Medical Director then notified the nurse that this was not the protocol; CPR should be initiated and then the facility should contact the physician. No matter when a resident is found unresponsive, one should at least attempt CPR if the resident is a full code. He added that at the time of his conversation with LPN A, he felt the resident was already brain dead. It takes four minutes without oxygen for brain death to occur. He then asked LPN A if she had contacted the family and the DON, and she replied that she had already contacted them. The Medical Director stated it was frustrating that the same thing is happening in the facility a little over a year after it happened before. He added that he advised the facility's Administrator to ensure that all licensed staff were trained on the facility's CPR protocol. On [DATE] at 1:48 p.m., CNA D stated at around 11:00 a.m. on [DATE], she overhead CNA B notifying LPN A that there was a resident who was unresponsive. She added that she followed LPN A to the resident's room. Upon entering the room, LPN A performed sternal rubs, then pulled the sheet up over Resident #1's chest and walked out of the room. She stated LPN A did not check the code status or give instructions to start CPR. She added that it was unusual because it was clear that Resident #1 was a full code; her name label on her door was green. She added, [LPN A] might have been absent-minded because at 5:00 p.m., the body was still in the building, because [LPN A] contacted a funeral home that was located in a different state. In an interview on [DATE] at 2:10 p.m., Resident #3 stated she was in the room when her roommate expired. She added that Resident #1 was confused and the curtain was always pulled, so she didn't know what was going on. When asked about her Advanced Directives, she stated she was a full code and expected her wish to be honored in the event of an emergency. A review of the facility's policy and procedure titled Advanced Directives (last revised on ,d+[DATE]), read, It is the policy of Ascension Living to inform resident/resident representatives about Advanced Directives, assist those who wish to complete Advanced Directives, honor choices identified in the Advanced Directives, and maintain the records in accordance with the federal, state and community policy. Policy interpretation and implementation: retrieve A. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and formulate Advanced Directives if he or she chooses to do so. F. Information about whether or not a resident has executed an Advanced Directive shall be displayed prominently in the medical record. I. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or Advanced Directives.

Based on a review of resident records, the facility's policy, and procedure for CPR (Cardio-pulmonary resuscitation), facility reports and staff interviews, the facility failed to provide CPR in accordance with the resident's physician's order and Advance Directives when an unresponsive resident stopped breathing. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status (the desire to be resuscitated in the event that her heart or breathing stopped), deprived her of potentially lifesaving measures. On [DATE], Resident #1 was admitted with a full-code status, indicating that she wanted to be resuscitated in the event of cardiac/respiratory arrest. On [DATE] at 11:20 am, Certified Nursing assistant (CNA) B (Assigned to Resident #1) notified Licensed Practical Nurse (LPN) A (Assigned to Resident #1) that Resident #1 was unresponsive. The resident was in bed, pale, with her mouth open, but her skin was warm. When LPN A arrived at the resident's room, she assessed the resident and told CNA B that the resident was gone and to clean the resident up. CNA B reminded LPN A that the resident was a full code, and LPN A replied that she would contact the resident's physician. Cardiopulmonary resuscitation (CPR) was not initiated. Emergency Medical Services (EMS) was not called. At no point did facility staff consult the resident's medical record to verify code status. LPN A contacted the resident's family to make them aware of Resident #1's death, they provided her with the name of the funeral home they chose to use, and LPN A called the funeral home to come pick up Resident #1. On [DATE], the facility census was 143. There were 106 residents who had a full-code status at the time of the survey. The Administrator was notified of Immediate Jeopardy at 12:30 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F578 A review of the medical record, indicated that Resident #1 was admitted to the facility for rehabilitation and strengthening on [DATE], following a fall with no injuries. Her physician's orders, dated [DATE], indicated her Code Status was CPR. A nursing progress note authored by Licensed Practical Nurse (LPN) A on [DATE] at 11:33 a.m. read, Resident discovered in bed with no pulse and no respirations at 11:20 a.m. Physician notified. Daughter notified and is now contacting the family and will call back with funeral home information. (Photographic evidence obtained) A written statement authored by LPN A and dated [DATE], indicated that she was called to Resident #1's room by CNA B, who had discovered Resident #1 unresponsive. When LPN A arrived, she found the resident unresponsive, with no pulse and no respirations. The resident's mouth was open, and he was very cool to the touch. (There was no documentation indicating that she initiated CPR.) (Photographic evidence obtained) In an interview with Certified Nursing Assistant (CNA) B on [DATE] at 1:48 p.m., she stated she had been employed by the facility for [AGE] years. She stated when a resident was found unresponsive, the first thing to do was to notify the resident's nurse. She added that the staff were expected to check the resident's door label (If the resident's name was written on a green label, staff were to initiate CPR, but if the resident's name was written on a white label, he/she was designated do not resuscitate.) When asked if she worked with Resident #1, CNA B said, Yes, she was totally dependent with care since admission and had been declining. She would not even eat. I even spoke with the doctor, and he started her on antibiotics. When asked if she worked with the resident at the time of the incident she said, Yes, she refused breakfast that morning and would not even open her mouth. I notified the nurse, and I returned to her room in about two hours to check on her and found her unresponsive. This was around 11:00 a.m. I immediately called the nurse and returned to the resident's bedside. When the nurse came to the room, she checked the resident and said [Resident #1] was gone. I again told the nurse that [Resident #1] was a full code, because there was a green tag on her door, and the nurse said that she would contact the doctor. When CNA B was asked the resident's status when she found her, CNA B stated that she had her mouth open and her skin was pale, but she was still warm. CNA B stated she was instructed by LPN A to clean the resident up. On [DATE] at 12:00 p.m., a joint interview was conducted with the Risk Manager and the Director of Nursing (DON). The DON stated she was contacted by LPN A on [DATE] at around 12:45 p.m. notifying her that Resident #1 had expired and that she had not performed CPR. The DON stated LPN A was notified by CNA B that Resident #1 was unresponsive, and upon assessment, she was cool to the touch, and she did not feel that CPR would have been successful. LPN A contacted the resident's physician around 11:24 a.m., who pronounced the resident's death. The DON continued to state that she immediately contacted the Administrator, the Risk Manager, and the resident's physician, and LPN A was immediately suspended pending investigation. When asked about the facility's protocol for when a resident was found unresponsive, the DON stated the licensed staff should initiate CPR until EMS arrives or they are advised to stop by the physician. The Risk Manager added that after determining that the resident was full code, licensed staff should initiate CPR. LPN A could not pronounce the resident's death and had no reason not to initiate CPR. The DON also stated she had worked with LPN A, and that LPN A was always proactive and she could not tell what had happened on that day. In a telephone interview on [DATE] at 4:19 p.m., LPN C stated a resident's code status could be obtained three different ways. Their code status was color coded on their door placard (green - CPR and white - DNR (Do Not Resuscitate), a DNR folder was on the crash cart, and the electronic medical record (EMR)/resident charts also indicated their code status. When asked what the expectations was if a resident was found unresponsive without respirations or a pulse, she said, The first thing you do is verify the code status. If the resident is a full code, you call the code and initiate CPR. When asked whether she would initiate CPR if the resident was cool to the touch, she said, If they are a full code, I will still call a code, start CPR and wait for directions from the physician or EMS.'' She stated she worked with LPN A on [DATE], and she overheard LPN A saying that there was a resident that expired. LPN A did not state that the resident was a full code, nor did she ask for assistance. In a telephone interview with the Medical Director on [DATE] at 9:30 a.m., he stated LPN A sent him a text message on [DATE] at 11:24 a.m. which read, The patient that you started on Rocephin a day ago is no longer with us. He stated that was an unusual text because the nurses were aware of the need to call the on call physician in the case of an emergency and not send a text message. He added that luckily he saw the text and called the nurse about two minutes later to gather more information. He asked LPN A what happened, and she reported that Resident #1 was found with no respirations and no pulse. He asked the resident's code status, and LPN A reported that the resident was a full code. He asked if CPR was initiated, and LPN A said no. He added that LPN A told him Resident #1 was long gone. The Medical Director then notified the nurse that this was not the protocol; CPR should be initiated and then the facility should contact the physician. No matter when a resident is found unresponsive, one should at least attempt CPR if the resident is a full code. He added that at the time of his conversation with LPN A, he felt the resident was already brain dead. It takes four minutes without oxygen for brain death to occur. He then asked LPN A if she had contacted the family and the DON, and she replied that she had already contacted them. The Medical Director stated it was frustrating that the same thing is happening in the facility a little over a year after it happened before. He added that he advised the facility's Administrator to ensure that all licensed staff were trained on the facility's CPR protocol. On [DATE] at 1:48 p.m., CNA D stated at around 11:00 a.m. on [DATE], she overhead CNA B notifying LPN A that there was a resident who was unresponsive. She added that she followed LPN A to the resident's room. Upon entering the room, LPN A performed sternal rubs, then pulled the sheet up over Resident #1's chest and walked out of the room. She stated LPN A did not check the code status or give instructions to start CPR. She added that it was unusual because it was clear that Resident #1 was a full code; her name label on her door was green. She added, [LPN A] might have been absent-minded because at 5:00 p.m., the body was still in the building, because [LPN A] contacted a funeral home that was located in a different state. A review of the facility's policy and procedure for Cardiopulmonary Resuscitation and protected Code Blue (COVID-19) (Revised on ,d+[DATE]) revealed that the policy indicated that licensed staff were required to complete training on cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Procedure: B. The chances of surviving sudden cardiac arrest (SCA) may be increased if CPR is initiated immediately upon collapse. C. Early delivery of a shock with a defibrillator plus CPR with ,d+[DATE] minutes of collapse can further increase chances of survival. D. If an individual (resident, visitor, or staff) is found unresponsive and not breathing, a staff member who is certified in CPR/BLS shall initiate CPR unless: 1. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or 2. There are obvious signs of irreversible death (e.g., decapitation - the emergency is the result of beheading and/or decomposition - rotting or decay) E. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR. If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Emergency Procedure (Page 2) A if an individual is found unresponsive for more than 10 seconds, assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: 1. Instruct a staff member to activate the emergency response system (code) and call 911. 2. Instruct a staff member to retrieve the automatic external defibrillator if applicable. 3. Verify or instruct a staff member to verify the DNR or code status of the individual. 4. Initiate the basic life support (BLS) sequence events.

Based on a review of facility and resident medical records, a review of the facility's policies Advance Directives and Advance Directives and Code Status, and interviews with staff, the facility failed to act in accordance with residents' Advance Directives and honor Do Not Resuscitate Orders (DNROs) after finding a resident unresponsive and without respirations or a pulse. This affected one (Resident #1) of eight residents reviewed for Advance Directives. On [DATE], Resident #1 was admitted to the facility and executed a Do Not Resuscitate Order. On [DATE] at 5:55 PM, Resident #1 was discovered unresponsive by her certified nursing assistant. A Code Blue was called, and cardiopulmonary resuscitation was initiated by Licensed Practical Nurses (LPNs) A and B without checking Resident #1 ' s code status first. Paramedics arrived, took over cardiopulmonary resuscitation and transported the resident to the emergency room where life-sustaining efforts were continued. After the resident was transported to the emergency room , facility staff located the Do Not Resuscitate Order in her medical record. On [DATE] at midnight, Resident #1 expired in the hospital after prolonged life-sustaining efforts had been made, including administration of medications, intubation, fluid boluses, and placing the resident on a ventilator. Resident #1 could not express her reaction to this event. Applying the reasonable person concept, Resident #1 would likely experience serious psychosocial harm by being resuscitated against her wishes and put on life support. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 12:40 p.m. on [DATE]. On [DATE] at 5:55 p.m., the Immediate Jeopardy (IJ) began. On [DATE] at 3:30 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed on [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D for F578. There were 12 residents under LPN A's care and 13 residents under LPN B's care on the day of the event, including four residents with DNROs. Those residents were at risk of receiving improper care should they become unresponsive and require staff to act per their Advance Directives. The findings include: Cross Reference F678 A review of Resident #1's electronic medical record found she was admitted on [DATE] and was [AGE] years old. Her Discharge Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], revealed that Resident #1 was admitted from, and discharged back to the hospital on [DATE]. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was care planned on [DATE] for Resuscitate: No CPR/DNR. The problem area noted Resident #1 would have her Advance Directives revived upon admission. The goal was to have her preferences followed and reviewed through the next review period. Approaches included: 1. Obtain Advanced Directives, as indicated by (Resident #1/resident representative) and 2. Consult physician for verification of code status. (Photographic evidence obtained) The Social Services Director (SSD) admission progress note, dated [DATE], indicated that Advance Directives and resident rights were discussed with Resident #1 and her code status was DNR. The DNRO was on file. (Photographic evidence obtained) An electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) Resident #1's electronic medical record's dashboard (home page) boldly indicated her No CPR/DNR election. In addition, a scanned copy of the resident's DNRO (DH Form 1896, revised [DATE]), signed by Resident #1 and her physician on [DATE], was filed under the Advance Directives link on the dashboard. (Photographic evidence obtained) A review of the facility's investigative report, dated [DATE], found that on [DATE] at approximately 5:55 p.m., Resident #1 was found unresponsive, not breathing and without a pulse by her Certified Nursing Assistant (CNA). After Code Blue was called, CPR was initiated and provided until paramedics arrived. Resident #1 was transported to the hospital. After the event, staff located Resident #1's DNRO. LPN A was noted as the assigned nurse during the event. LPN B was noted to have assisted with the Code Blue response. Facility interviews conducted after the incident indicated the nursing staff initiated CPR in a time of high stress before checking Resident #1's Advance Directives file or code status indicators. There was a signed DNRO in her file. A review of facility staffing assignments found there were 12 residents under LPN A's care and 13 residents LPN B's care on [DATE], the day of the event, including four residents with DNROs. A review of the nursing progress notes confirmed that on [DATE] at 5:55 p.m., LPN A reported that a CNA found Resident #1 pale and apparently without respirations. Upon checking, LPN A confirmed that Resident #1 was pale, warm to the touch and without respirations or a pulse. CPR was initiated and continued until rescue arrived. (Photographic evidence obtained) A review of hospital records, dated [DATE], found Resident #1 had been brought into the emergency department (ED) in cardiac and respiratory arrest. On [DATE], she was found unresponsive at the facility and paramedics were called. Resident #1 received chest compressions, [MEDICATION(S)] (adrenaline, which causes elevated heart rate and blood pressure), [MEDICATION(S)] (Bicarbonate, used to regulate the body's pH balance) and was intubated (a tube placed down the throat and into the windpipe to facilitate air movement in and out of the lungs) in the field. She was still in cardiopulmonary arrest upon arrival to the ED. [MEDICATION(S)] (used to treat low blood pressure and heart failure) was initiated and she was given multiple fluid boluses. Resident #1 was admitted to the intensive care unit (ICU). Of note, during a review of outside medical records, the ED physician discovered the resident was a DNR, though no Florida DNRO was signed in the resident's hospital chart. The facility's policy Advance Directives ( 99 - dated ,d+[DATE] and last revised ,d+[DATE]) read: It is the policy of (facility) to inform resident/resident representatives about Advance Directives, to assist those who wish to complete Advance Directives, honor choices identified in the Advance Directives and to maintain records in accordance with federal, state law and community policy. Policy Interpretation and Implementation: . F. Information about whether or not a resident has executed an Advance Directive shall be displayed prominently in the medical chart . . I. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or Advance Directives. J. The resident has the right to refuse treatment, whether or not he or she has an Advance Directive. A resident will not be treated against his or her own wishes . (Photocopy obtained) The facility's Advance Directives and Code Status policy ( 76 - dated ,d+[DATE]) indicated Advance Directives would be respected in accordance with state law and community policy. Under Interpretation and Implementation, the policy stated the Admission Coordinator or designee would: 1. Ask the resident and/or resident representative for copies of Advance Directives (AD) . B. Social Services or Designee will: 1. Scan into electronic chart or place into paper chart (The filing of Advance Directives should be consistently placed in the same area of the chart or electronic record for ease of locating) . . 3. Care plan for DNR or other choices identified in the AD . . 4. Notify clinical associate in charge when resident is acting different than usual or not responding. A CPR certified associate to check the code status of resident (may delegate someone to bring chart, paper or electronic to view) who is not breathing or who does not have a pulse. 2. If DNR is resident/resident representative's choice: a. Call attending physician. b. Call resident representative. c. Initiate process for death in the community. The Director of Nursing (DON) was interviewed on [DATE] at 12:52 p.m. She confirmed that on the date of the event ([DATE]), Resident #1's nurses did not follow protocol and started CPR prior to checking the resident's code status. They later discovered Resident #1 was a DNR. LPN A, the nurse assigned to Resident #1 the day of the event, was interviewed via telephone on [DATE] at 5:45 p.m. She recalled the CNA found Resident #1 unresponsive and she started CPR. She admitted she did not check Resident #1's code status as she should have prior to starting CPR. She later discovered the DNR status. In an interview with the Administrator on [DATE] at 3:35 p.m., he stated he did not understand why the Immediate Jeopardy determination was made, as staff had provided CPR which had no harmful outcome for Resident #1. He was advised that not only was the CPR provided against the resident's Advanced Directives for a DNR, but CPR, when done properly, could cause painful physical and psychosocial trauma. Additionally, unwanted medical life-sustaining interventions were made while Resident #1 was in the hospital. The Administrator did not respond. 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: 1. LPN B was re-educated on [DATE], and LPN A was re-educated on [DATE], on the aforementioned facility's Advanced Directives and Code Status policy and procedure. The education also included a guide What Needs to be Done Within the First 3 Minutes of a Code Blue Situation. Instructions stated, After checking for pulse and breathing, check the resident's code status. Training also included a pamphlet, Advance Directives: Code Status and Community Process, that noted, Advanced Directives are a legal document. The resident is the primary decision maker until they are legally deemed incompetent or are not responsive. The pamphlet coincided with the facility's policy in the process for obtaining and filing Advance Directives. Under Initiating Advanced Directives instructions directed staff to follow state specific forms for Advanced Directives/DNR. Further instructions included visually identifying the code status of the resident on the resident's name plate. Instructions clarified that the signed DNR was to be verified and was the legal indicator of a resident's code status. The DNR was to be signed by the resident/resident representative and physician to be active, and should be verified to determine the resident's choice (look at paper of view in electronic record) should the resident become unresponsive. LPNs A and B signed an acknowledgement of the training on their respective training dates. (Photocopies obtained) 2. All 132 current residents were reviewed on [DATE] by Social Services to ensure proper documentation of code status and code directives. All documentation matched the information on file. 3. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held by the interdisciplinary team on [DATE]. The plan was to re-educate all clinical associates, conduct additional Mock Code drills, and conduct audits of resident code status and Advance Directives. 4. The Medical Director was notified of the incident by the Administrator on [DATE]. 5. Both nurses (LPNs A and B) involved in the incident were re-educated on [DATE]. 81 of 149 clinical associates were re-educated by the Educator or designee on Advance Directives between [DATE] and [DATE]. By [DATE], or prior to their next working shift, all 149 current clinical associates were or would be re-educated by the Educator or designee on Advance Directives. Understanding would be confirmed through completion of a post-test. 6. The Interdisciplinary team reviewed the Advance Directives procedure on [DATE], and it was in compliance with the regulations. Advance Directives are located in the Advance Directives attachment of the EMR (electronic medical record). Printed copies of the Advance Directives are kept in a DNR binder on each unit. 7. Beginning on [DATE], residents with code status changes were reviewed by the Interdisciplinary Team during the daily clinical meeting for compliance with procedure and completion of documentation. This procedure is ongoing. 8. During weekly Resident at Risk meetings, the Interdisciplinary Team reviews the clinical record of residents with code status changes. The reviews were documented in the residents' clinical records.

Based on observations, a review of facility and resident medical records, the facility's policies Advance Directives and Code Status, Do Not Resuscitate Orders (DNROs) and Advance Directives, and interviews with staff, the facility failed to withhold basic life support, including cardiopulmonary resuscitation (CPR), in accordance with the residents' Advance Directives for one (Resident #1) of eight residents reviewed for Advance Directives. On [DATE], Resident #1 was admitted to the facility and executed a Do Not Resuscitate Order. On [DATE] at 5:55 PM, Resident #1 was discovered unresponsive by her certified nursing assistant. A Code Blue was called, and cardiopulmonary resuscitation was initiated by Licensed Practical Nurses (LPNs) A and B without checking Resident #1 ' s code status first. Paramedics arrived, took over cardiopulmonary resuscitation and transported the resident to the emergency room where life-sustaining efforts were continued. After the resident was transported to the emergency room , facility staff located the Do Not Resuscitate Order in her medical record. On [DATE] at midnight, Resident #1 expired in the hospital after prolonged life-sustaining efforts had been made, including administration of medications, intubation, fluid boluses, and placing the resident on a ventilator. Resident #1 could not express her reaction to this event. Applying the reasonable person concept, Resident #1 would likely experience serious psychosocial harm by being resuscitated against her wishes and put on life support. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 12:40 p.m. on [DATE]. On [DATE] at 5:55 p.m., the Immediate Jeopardy (IJ) began. On [DATE] at 3:30 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed on [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D for F678. There were 12 residents under LPN A's care and 13 residents under LPN B's care on the day of the event, including four residents with DNROs. Those residents were at risk of receiving improper care should they become unresponsive and require staff to act per their Advance Directives. The findings include: Cross Reference F578 A review of the facility's investigative report, dated [DATE], found that on [DATE] at approximately 5:55 p.m., Resident #1 was found unresponsive, not breathing and without a pulse by her Certified Nursing Assistant (CNA). After Code Blue was called, CPR was initiated and provided until paramedics arrived. Resident #1 was transported to the hospital. After the event, staff located Resident #1's DNRO. LPN A was noted as the assigned nurse during the event. LPN B was noted to have assisted with the Code Blue response. Facility interviews conducted after the incident indicated the nursing staff initiated CPR in a time of high stress before checking Resident #1's Advance Directives file or code status indicators. There was a signed DNRO in her file, and the resident's room was color-coded white for Do Not Resuscitate. A review of facility staffing assignments found there were 12 residents under LPN A's care and 13 residents LPN B's care on [DATE], the day of the event, including four residents with DNROs. On [DATE] at 9:45 a.m., a tour of the facility was conducted. A crash cart was observed behind each of the second floor's North and South Unit's nursing stations. Each cart had a white 3-ring binder sitting on top. Inside were multiple, blank goldenrod sheets of paper. The first floor unit crash cart held no binder at all. Resident room name plates were color-coded either blue, green or white. On [DATE] at 10:00 a.m., another tour of the facility was conducted. The first floor unit crash cart was still without a binder. With assistance from a nurse, it was found sitting on the nursing station desk. It was prominently labeled and contained goldenrod copies of resident DNRO forms. Each of the second floor North and South unit's crash carts were again observed with the DNR binders sitting on top of them. A review of Resident #1's Discharge Return Anticipated Minimum Data Set (MDS) assessment, with an assessment reference date of [DATE], revealed that Resident #1 was admitted from an acute hospital on [DATE] and had an unplanned discharge back to the hospital on [DATE]. The resident was [AGE] years old. She required extensive assistance with bed mobility, transfers, and toileting, and did not walk. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Active discharge planning was not occurring. Per the [DATE] Admission MDS assessment, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating she was cognitively intact. Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copies of both assessments were obtained.) Resident #1 was care planned on [DATE] for No CPR/DNR- Advance Directives. Problem Area: Will have Advance Directives reviewed upon admission. Goal: Will have their preferences followed and reviewed through next review period. Interventions: Obtain Advance Directive as indicated by resident/representative and consult physician for verification of code status. (Photographic evidence obtained) The Social Services Director (SSD) authored an admission progress note on [DATE], stating Advance Directives and resident rights were discussed, and Resident #1 was a DNR. The DNR was on file. (Photographic evidence obtained) The scanned DNRO (DH Form 1896, revised [DATE]), executed by Resident #1 and her physician on [DATE], was located in her electronic record dashboard (home page) under the Advance Directives link. The dashboard banner also boldly indicated Resident #1's No CPR/DNR status. Finally, Resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) A review of the nursing progress notes confirmed that on [DATE] at 5:55 p.m., LPN A reported that a CNA found Resident #1 pale and apparently without respirations. Upon checking, LPN A confirmed that Resident #1 was pale, warm to the touch and without respirations or a pulse. CPR was initiated and continued until rescue arrived. (Photographic evidence obtained) A review of hospital records, dated [DATE], found Resident #1 had been brought into the emergency department (ED) in cardiac and respiratory arrest. On [DATE], she was found unresponsive at the facility and paramedics were called. Resident #1 received chest compressions, [MEDICATION(S)] (adrenaline, which causes elevated heart rate and blood pressure), [MEDICATION(S)] (Bicarbonate, used to regulate the body's pH balance) and was intubated (a tube placed down the throat and into the windpipe to facilitate air movement in and out of the lungs) in the field. She was still in cardiopulmonary arrest upon arrival to the ED. [MEDICATION(S)] (used to treat low blood pressure and heart failure) was initiated and she was given multiple fluid boluses. Resident #1 was admitted to the intensive care unit (ICU). Of note, during a review of outside medical records, the ED physician discovered the resident was a DNR, though no Florida DNRO was signed in the resident's hospital chart. Resident #1 expired in the hospital at midnight on [DATE], six hours after CPR was initiated against her wishes. A review of the facility's Do Not Resuscitate Order policy ( 40 - dated ,d+[DATE] and revised ,d+[DATE]) revealed: Our community will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions for a resident when there is a Do Not Resuscitate Order in effect. Section E. stated, Do Not Resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the community with a signed and dated request to end the DNR order. (Photocopy obtained) A review of the facility's policy Advance Directives and Code Status ( 76 - dated ,d+[DATE]) revealed that Advance Directives would be respected in accordance with state law and community policy . The Interpretation and Implementation section reported that the Admission Coordinator or designee would: 1. Ask the resident and/or resident representative for copies of Advance Directives . B. Social Services or Designee will: 1. Scan into electronic chart or place into paper chart (The filing of Advance Directives should be consistently placed in the same area of the chart or electronic record for ease of locating) . . 3. Care plan for DNR or other choices identified in the Advance Directives . . 4. Notify clinical associate in charge when resident is acting different than usual or not responding. A CPR certified associate to check the code status of resident (may delegate someone to bring chart, paper or electronic to view) who is not breathing or who does not have a pulse. 1. If the resident has chosen FULL CODE or if status is not known, A. Call emergency services (delegate). b. Initiate CPR immediately unless: decapitation, decomposition. 2. If DNR is resident/resident representative's choice: a. Call attending physician. b. Call resident representative. c. Initiate process for death in the community. (Photocopy obtained) An interview was conducted with LPN C on [DATE] at 10:06 a.m. She explained there was a DNR binder on the crash cart. She pointed to the cart which had a large white 3-ring binder on top and goldenrod copies of DNR orders inside. If Code Blue was called, the nurse was supposed to first go in and confirm the resident's condition, then go to the computer to check the code status. If the resident had a DNRO, the DNR binder was to be checked for the DNRO form. Registered Nurse (RN) D was interviewed on [DATE] at 12:14 p.m. She explained that when a resident was found unresponsive, the process was to verify the resident's code status before starting CPR. There is a DNR binder on the crash cart that had to be checked. All the crash carts had the binders. Once CPR was initiated, it could not be stopped. God forbid if you break gramma's rib. There should also be a flag on the electronic medical record's dashboard indicating the code status of the resident. RN D said she was not aware of the color coding on the doors reflecting residents' code status. Unit Clerk K interjected and explained that if a resident's name tag on the door was green, it meant to initiate CPR. If it was white, it meant the resident was a DNR. She stated this was not a new system. Unit Manager E stated in an interview on [DATE] at 12:30 p.m., that when a resident coded or was found unresponsive, she checked the computer. If it indicated the resident was a DNR, then she checked the binder on the crash cart. The social worker makes sure all DNRs are in the book on the crash carts. There is typically the idea that the nurse who calls the code has already checked the book. Of course, it is always a good idea to have a second person look. If there is no DNR copy in the book, then CPR is initiated. While she acknowledged the color-coded name plates at each door, the Unit Manager explained those could change, so you must go by the chart. LPN F was interviewed on [DATE] at 12:35 p.m. She stated she had been trained not to leave an unresponsive resident. You are supposed to get someone to call the Code Blue, and all nurses come with their crash carts. As soon as the crash cart arrives, the binder is checked for the DNRO. The DNROs are on the cart, that is the first thing you are supposed to check. You can also verify status on the computer, but it takes so long if the resident isn't already pulled up in the system. The book is always updated. It only takes one nurse to verify the resident's code, the nurse who is responsible for that patient. The Director of Nursing (DON) was interviewed on [DATE] at 12:52 p.m. She confirmed on the day of the event ([DATE]), Resident #1's nurses did not follow protocol by not checking the resident's code status after finding her unresponsive. Neither nurse checked, and to her knowledge, neither one questioned the other. They just started CPR until paramedics arrived. The facility later discovered Resident #1 was a DNR. The DON explained that the resident's Advance Directives and the DNRO were in place at the time of the event. Resident #1 had a white tag on her door, a goldenrod copy of her DNR form in the DNR binder, a scanned DNR document in her electronic record, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained that when someone was found unresponsive, the very first thing to do was check the door for the color code. More importantly, the code status must be checked either in the DNR book or the electronic health record. One nurse could do this, and anybody could check the code status. Even CNAs knew where the binders were. This had always been the process. LPN A, the nurse assigned to Resident #1 the day of the event, was interviewed via telephone on [DATE] at 5:45 p.m. She recalled the incident saying the CNA came to get her after finding Resident #1 unresponsive. LPN A said they started CPR on Resident #1. She admitted she did not check Resident #1's code status as she should have but could not explain why she failed to check it before initiating CPR. LPN A did not discover Resident #1 was a DNR until the hospital called the facility. Hospital staff reported having Resident #1 listed as a DNR but no signed copy of the form. When Resident #1's chart was checked by facility staff, the DNRO was located. CNA L was interviewed on [DATE] at 9:58 a.m. She explained that if a resident was unresponsive, she would check the DNR book at the nurses' station. Also, if the door sign was white, it meant DNR and green meant give CPR. It was also located in the electronic medical record. LPN M was interviewed on [DATE] at 10:02 a.m. If a resident is found unresponsive, the first thing to do is look at the wall. If the sticker is white, it means DNR. Green means give CPR. You then check the book at the nurses' station for the actual DNR form. You cannot just go by the sticker. If the book is missing, the code status is on the electronic dashboard. CNA I stated in an interview on [DATE] at 10:25 a.m., that she had worked in the facility for two days. She was taught during orientation that if a resident was found unresponsive, the resident's code status was on the kiosk in the electronic chart. The DNR binder was behind the nurses' station on the crash cart. In an interview with the Administrator on [DATE] at 3:35 p.m., he stated he did not understand why the Immediate Jeopardy determination was made, as staff had provided CPR, which had no harmful outcome for Resident #1. He was advised that not only was the CPR provided against the resident's wishes, but CPR, when done properly, could cause painful physical and psychosocial trauma. Additionally, Resident #1 was intubated, placed on a respirator, and was provided with additional unwanted life-sustaining interventions against her wishes. The Administrator did not respond. 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: 1. LPN B was re-educated on [DATE], and LPN A was re-educated on [DATE], on the aforementioned facility's Advanced Directives and Code Status policy and procedure. The education also included a guide What Needs to be Done Within the First 3 Minutes of a Code Blue Situation. Instructions stated to take no longer than 10 seconds to check for pulse and breathing then check the code status. If code status is DNR, call doctor. Training also included a pamphlet, Advance Directives: Code Status and Community Process, that noted, Advanced Directives are a legal document. The resident is the primary decision maker until they are legally deemed incompetent or are not responsive. The pamphlet coincided with the facility's policy in the process for obtaining and filing Advance Directives. Resident Code Status Identifier (page 6): Visually identify code status on name plate. This helps with identification (the signed DNR is to be verified and is the legal indicator of code status). The paper that the resident's name is on indicates code status: -White - Indicates that the resident has chosen to be a DNR. -Green - Indicates that the resident has chosen to be full code . .The signed DNR should be verified to determine resident's choice (look at paper or view in electronic medical record) should resident become unresponsive. Matrix Care (electronic records database): Chart Flag Status is triggered when the order for DNR is entered in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Red is DNR. Medical Emergency: It is a medical emergency when a resident is not breathing and/or does not have a pulse. -Notify the clinical associate in charge. -Clinical Associate (Nurse/CPR certified associate) to: Check code status of resident. Do Not Resuscitate (DNR): If DNR is the resident's choice (confirmed by signed DNR in chart; either paper or electronic): -Call attending physician. -Call the Resident Representative. The training materials provided to LPNs A and B included a Quick Reference Guide, which also provided the following information: -Code Status Identifier: Color of paper the resident's name is outside their door. Green = full code, White = DNR. -Physician Order: May be obtained per verbal order and signed per state/federal regulations. -Chart Identifier: Resident's electronic chart to identify chosen code status. LPNs A and B signed an acknowledgement of the training on their respective training dates. (Photocopies of training materials and signature sheets were obtained.) 2. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held by the interdisciplinary team on [DATE]. The plan was to re-educate all clinical associates, conduct additional Mock Code drills, and conduct audits of resident code status and Advance Directives. 3. The Medical Director was notified of the incident by the Administrator on [DATE]. 4. All 132 current residents were reviewed on [DATE] by Social Services to ensure proper documentation of code status and code directives. 5. Both nurses (LPNs A and B) involved in the incident were re-educated on [DATE]. 81 of 149 clinical associates were re-educated by the Educator or designee on Code Response between [DATE] and [DATE]. By [DATE], or prior to their next working shift, all 149 current clinical associates were or would be re-educated by the Educator or designee on Code Response. Understanding would be confirmed through completion of a post-test. 6. The Interdisciplinary team reviewed the Code Status procedure on [DATE], and it was in compliance with the regulations. Code Status is located in the EMR (electronic medical record), in the physicians' orders. Printed copies of the residents' code status are kept in a DNR binder on each unit if they are a DNR. 7. Beginning on [DATE], residents with code status changes were reviewed by the Interdisciplinary Team during the daily clinical meeting for compliance with procedure and completion of documentation. Code status is checked by the EMR chart flag, physicians' orders, Advance Directives attachment, Care Plan, and room doorplate. This procedure is ongoing. 8. During weekly Resident at Risk meetings, the Interdisciplinary Team reviews the clinical record of residents with code status changes. The reviews were documented in the residents' clinical records.

Based on record review and interviews the facility failed to ensure qualified staff reconcile new medication orders, order medications and administer all medications as ordered, assess residents with change in respiratory status, notify physician of changes, document and communicate sudden onset change in condition and perform oxygen saturation levels to further assess acute respiratory onset resulted in the death of 1 of 1 sampled residents. (Resident #1) The findings include: Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. Review of the physician orders [REDACTED].#1 revealed all medications were entered and ordered by Licensed Practical Nurse LPN (Emp B) on [DATE]. Further review of the December and January MAR indicated [REDACTED]. There was no order found to discontinue the Eliquis. Review of the nursing notes did not indicate any changes to medications. An interview was conducted with Assistant Director of Nursing (ADON) at 2:15pm, she was asked to review the December and January Medication Administration Record [REDACTED]. When asked when was the error discovered she wasn't sure, but it was after he went to hospital. Review of the nursing notes from [DATE]-[DATE] revealed nurses only documented on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. There were no daily assessments of his condition, change in condition or care and treatment provided by nursing. There was no documentation regarding the administration of oxygen or obtaining oxygen saturation levels to assess respiratory status. Also there was no documentation for the indwelling urinary catheter, catheter care or monitoring output and signs and symptoms of infection. Review of the physician orders [REDACTED]. On [DATE] [MEDICATION NAME] 1 mg daily for urine retention,[MEDICATION NAME] mg every third day for UTI on [DATE] and [MEDICATION NAME] 40 mg IM on [DATE]. There was no nursing documentation of new orders, urinary tract infection, [MEDICAL CONDITION] or need for [MEDICATION NAME] IM for increased swelling of right arm. During an interview with the ADON on [DATE] at 4:10pm she confirmed there was no documentation regarding oxygen, urinary catheter, urinary tract infection, [MEDICAL CONDITION] or change in condition. She was asked what was the facility policy regarding how often nurses should document on residents receiving skilled services, she said at a minimum every 24 hours and whenever there are changes in condition. Each shift charts vital signs, meal intake and change in condition. When there was a change in condition each shift must chart for a minimum of 72 hours after the change was noted or until stable. Review of the physical therapy (PT) note date [DATE] revealed Res #1 was very short of breath during activity and reported something was wrong with his nasal cannula. Oxygen was at 3 liters per minute when he arrived at gym. His oxygen saturation level was 87% and heart rate 167, he was doing a lot of mouth breathing. He reported he was very cold and covered with blanket and returned to unit. The therapist conferred with Registered Nurse (EMP A) regarding his vital signs. PT note dated [DATE] revealed Res #1 demonstrated increased swelling to right upper arm with leaking fluid through skin. Nursing (unit manager )was notified about right arm and labored breathing. PT note dated [DATE] revealed oxygen saturation levels and heart rate were monitored, oxygen saturation levels lower secondary to mouth breathing. Also noted Res #1 started on [MEDICATION NAME] due to excessive right upper arm swelling The RN (Emp A ) notified of the vital signs and labored breathing. Review of the nursing notes found no documentation that changes in condition reported by therapist on ,[DATE], ,[DATE], and ,[DATE] were followed up. There were no assessments or vital signs performed and no notification to the physician. During an interview with ADON on [DATE] at 4:40pm, she was asked to review the PT notes of ,[DATE], ,[DATE] and ,[DATE]. She was then asked to review the nursing notes for those days. When asked if the nurses had documented communication with therapists on those days, she said no. Was the physician notified of the changes, she said no however the physician visited on [DATE]. When asked if the nurse documented the physician visit and any new orders, she said no. On [DATE], Resident #1's family requested oxygen saturation level be checked as he was very short of breath. RN (Emp A) documented at 1:30pm oxygen saturation level was 72% and was on 4 liters of oxygen. The physician notified and ordered venous Doppler of right arm and [MEDICATION NAME] 40 mg IM. There was no assessment of respiratory condition, oxygen saturation or vital signs after administration of [MEDICATION NAME]. Venous Doppler showed [MEDICAL CONDITION] of right brachial vein. At 4:30pm blood sugar level was 203 and insulin coverage given. No documentation of respiratory assessment or oxygen sat level. At 5:40pm Certified Nursing Assistant (Emp D) found him unresponsive with no vital signs found. Emp D informed the RN (EMP A). 911 called and CPR initiated. When EMS arrived Res #1 was intubated and immediately transported to hospital. He died on [DATE].

Based on record reviews and interviews the facility failed to reconcile admission orders [REDACTED]. On [DATE] the facility census was 143. There were 34 residents admitted in past 30 days and were at risk AND Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15 PM on [DATE], which is ongoing. On [DATE] at 8:55 PM, the Administrator was notified of the IJ determination. The findings include: Record review for Resident #1 revealed [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert with confusion. Required extensive assist with activities of daily living except for independence with eating. He was admitted with orders for wound care for surgical site left foot and oxygen 3 liters as needed. He was also ordered physical and occupational therapy five times a week. The admission nursing assessment dated [DATE] indicated there was a urinary catheter, there were no orders found for catheter or catheter care. The following medications were ordered upon admission: Eliquis 5 mg twice a day (anticoagulant to treat [MEDICAL CONDITION]), [MEDICATION NAME] sliding scale insulin, Magnesium 400 mg daily, Potassium chloride ER 20 meq 2 tablets daily, [MEDICATION NAME] 0.4 mg daily, [MEDICATION NAME] 50 mg daily, Pantoprazole 40 mg daily, [MEDICATION NAME] 125 mcg daily, [MEDICATION NAME] 100 mg twice day, [MEDICATION NAME] ER 90 mg daily, [MEDICATION NAME] 0.25 mcg daily and Atorvastatin 40 mg daily. Review of the physician orders [REDACTED]. There was no order found to discontinue the Eliquis. Review of the nursing notes did not indicate any changes to medications. An interview was conducted with Assistant Director of Nursing (ADON) at 2:15pm, she was asked to review the December and January Medication Administration Record [REDACTED]. When asked when was the error discovered she wasn't sure, but it was after he went to hospital. Review of the nursing notes from [DATE]-[DATE] revealed nurses only documented on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. There were no daily assessments of his condition, change in condition or care and treatment provided by nursing. There was no documentation regarding the administration of oxygen or obtaining oxygen saturation levels to assess respiratory status. Also there was no documentation for the indwelling urinary catheter, catheter care or monitoring output and signs and symptoms of infection. Review of the physician orders [REDACTED]. On [DATE] [MEDICATION NAME] 1mg daily for urine retention,[MEDICATION NAME] every third day for UTI on [DATE] and [MEDICATION NAME] 40 mg IM on [DATE]. There was no nursing documentation of new orders, urinary tract infection, [MEDICAL CONDITION] or need for [MEDICATION NAME] IM. During an interview with the ADON on [DATE] at 4:10pm she confirmed there was no documentation regarding oxygen, urinary catheter, urinary tract infection, [MEDICAL CONDITION] or change in condition. She was asked what was the facility policy regarding how often nurses should document on residents receiving skilled services, she said at a minimum every 24 hours and whenever there are changes in condition. Each shift charts vital signs, meal intake and change in condition. When there was a change in condition each shift must chart for a minimum of 72 hours after the change was noted or until stable. Review of the physical therapy (PT) note date [DATE] revealed Res #1 was very short of breath during activity today and reported something was wrong with his nasal cannula. Oxygen was at 3 liters per minute when he arrived at gym. His oxygen saturation level was 87% and heart rate 167, he was doing a lot of mouth breathing. He reported he was very cold and covered with blanket and returned to unit. The therapist conferred with Registered Nurse (EMP A) regarding his vital signs. PT note dated [DATE] revealed Res #1 demonstrated increased swelling to right upper arm with leaking fluid through skin. Nursing (unit manager )was notified about right arm and labored breathing. PT note dated [DATE] revealed oxygen saturation levels and heart rate were monitored, oxygen saturation levels lower secondary to mouth breathing. Also noted Res #1 started on [MEDICATION NAME] due to excessive right upper arm swelling The RN (Emp A ) notified of the vital signs and labored breathing. Review of the nursing notes found no documentation that changes in condition reported by therapist on ,[DATE], ,[DATE], and ,[DATE] were followed up. There were no assessments or vital signs performed and no notification to the physician. During an interview with ADON on [DATE] at 4:40pm, she was asked to review the PT notes of ,[DATE], ,[DATE] and ,[DATE]. She was then asked to review the nursing notes for those days. When asked if the nurses had documented communication with therapists on those days, she said no. Was the physician notified of the changes, she said no however the physician visited on [DATE]. When asked if the nurse documented the physician visit and any new orders, she said no. On [DATE], Resident family requested oxygen saturation level be checked as he was very short of breath. RN (Emp A) documented at 1:30pm oxygen saturation level was 72% and was on 4 liters of oxygen. The physician notified and ordered venous Doppler of right arm and [MEDICATION NAME] 40 mg IM. There was no assessment of respiratory condition, oxygen saturation or vital signs after administration of [MEDICATION NAME]. Venous Doppler showed [MEDICAL CONDITION] of right brachial vein. At 4:30pm blood sugar level was 203 and insulin coverage given. No documentation of respiratory assessment or oxygen sat level. At 5:40pm Certified Nursing Assistant (Emp D) found him unresponsive with no vital signs found. Emp D informed the RN (EMPA). 911 called and CPR initiated. When EMS arrived Res #1 was intubated and immediately transported to hospital. He died on [DATE]. Review of the adverse incident report filed by Risk Manager (RM) on [DATE] revealed the incident of Res #1 occurred on [DATE]. An investigation was conducted on [DATE]. Analysis of the incident revealed there was failure to correctly order admission medications, no documentation to support this was addressed by nursing and elevated to physician. Anticoagulant medication Eliquis entered on admission but never administered because of an order entry error. Medication reconciliation was not completed until 20 days post admission, failed to recheck oxygen saturation levels after administration of [MEDICATION NAME] 40 mg IM. Resident #1 died at hospital on [DATE]. The final [DIAGNOSES REDACTED]. An interview was conducted with Res #1's physician on [DATE] at 1:15pm. He was asked if he had been notified of Res #1 not receiving Eliquis during his stay, he said it was brought to his attention after the fact by the Medical Director, not the nursing staff. He said he did not know why he was not getting the medication. It was his understanding that Resident #1 was getting the medication as he was supposed to. He stated I can not tell you for sure where the disconnect was.

Based on record review and staff interviews the failed to ensure there was a system in place to reconcile all new admission orders [REDACTED]. (Resident #1). On 7/16/20 the facility census was 143. There were 34 residents admitted in past 30 days and were at risk AND Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15 PM on 7/16/20, which is ongoing. On 7/21/20 at 8:55 PM, the Administrator was notified of the IJ determination. The findings include: Record review for Resident #1 revealed [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert with confusion. Required extensive assist with activities of daily living except for independence with eating. He was admitted with orders for wound care for surgical site left foot and oxygen 3 liters as needed. The admission nursing assessment dated [DATE] indicated there was a urinary catheter, there were no orders found for catheter or catheter care. The following medications were ordered upon admission: Eliquis 5 mg twice a day (anticoagulant to treat [MEDICAL CONDITION]), [MEDICATION NAME] sliding scale insulin, Magnesium 400 mg daily, Potassium chloride ER 20 meq 2 tablets daily, [MEDICATION NAME] 0.4 mg daily, [MEDICATION NAME] 50 mg daily, Pantoprazole 40 mg daily, [MEDICATION NAME] 125 mcg daily, [MEDICATION NAME] 100 mg twice day, [MEDICATION NAME] ER 90 mg daily, [MEDICATION NAME] 0.25 mcg daily and Atorvastatin 40 mg daily. Review of the physician orders [REDACTED]. The order for Eliquis had a start date of 12/20/19 and stop date 12/21/19. There was no order found to discontinue the Eliquis. Review of the nursing notes did not indicate any changes to medications. An interview was conducted with Assistant Director of Nursing (ADON) on 7/20/20 at 2:15pm, she was asked to review the December and January Medication Administration Record [REDACTED]. When asked when was the error discovered she wasn't sure, but it was after he went to the hospital. She was asked who was responsible to reconcile new admission orders [REDACTED]. If a medication was not received from pharmacy what was the protocol. The pharmacy was to be called to inquire as to why the medication had not been sent and call physician if there would be delay in obtaining the medication. Also the unit managers were to check all admission orders [REDACTED]. When asked if that had been done, she said not consistently. She was asked what was the issue with order entry, she said there had been issues with medications entered into the computer and when the orders get to the pharmacy. She said if a medication was ordered and was not sent by pharmacy the nurse would need to enter the order again, however the medication had to be discontinued before entering order again. The problem that was happening was that when the order was discontinued and re-entered, the new order did not show up on pharmacy side. The pharmacy computer showed as discontinued and medication was not dispensed. An interview was conducted with Unit Manager (Emp F) on 7/21/20 at 10:37 am. She was asked if she was aware of the issue regarding Resident #1 not receiving Eliquis while in the facility. She said she was made aware after he was transferred to the hospital. She was asked how did the error occur. She responded for some reason it was discontinued from the Medication Administration Record [REDACTED]. We didn't know the pharmacy could not see it on their end. The pharmacy could not see where the medication was put back on the MAR. The pharmacy could not see the orders were duplicated In order to correct duplication, one of the entries for the medication had to be discontinued. However, once the discontinue order was entered, the order was canceled at pharmacy and medication was not sent. She stated she did not realize the issue until it happened to her about a month later. She had entered a new order for Res #5 for Trazadone and ordered from pharmacy. When the medication did not arrive, she called the pharmacy and was told the order was discontinued by Emp F, she stated that was me and I did not discontinue the medication order. The pharmacy said they could not see duplication order, only the discontinued order. She immediately thought of Res #1 and realized what had happened and why he had not received his Eliquis. She was asked if the issue was brought to the attention of administration and what was done. She said there was a meeting but does not remember when. She said she did discuss with other unit managers. When asked if there had been in-service training with facility and pharmacy to rectify the issue, she said not that she was aware. An interview was conducted via phone with nurse (Emp C) on 7/21/20 at 12:13pm. She was asked if there had been any issues with entering medications and not receiving from the pharmacy. She said she has notified the administration about the frustration with the orders (missing medications, duplicate orders) numerous times. She was asked if the issue was addressed. She said she was not sure what they are doing about it. There's a glitch in the system. It's time consuming because you have to wait for the pharmacy to answer and wait for the medication when it should have been delivered after the ordered entered. An interview was conducted with Director of Nursing (DON) on 7/21/20 at 2:45pm. She was asked if she was aware of the incident related to Res #1 on 1/19/20. She stated she was not employed at the facility at the time. She started in March of this year. When asked if she was made aware of issues with glitches in the computer system related to order entry and the pharmacy, she said no. She added that the facility would be changing pharmacies next week. When asked if the facility would continue to use current software system, she stated yes. She was asked if the new pharmacy had been made aware of issues with order entries, not that she knew but would bring it up. An interview was conducted with the Consultant Pharmacist at 4:55pm. She was asked what dates she reviewed medications for Res#1. She said all residents are reviewed within 72 hours of admission. He was admitted on [DATE]. His orders came to the pharmacy on 12/22/19 and she reviewed his medications on 12/24/19. He was discharged previous to her next monthly review. She was asked if Res #1 had Eliquis ordered. She said there was no record for Eliquis for him from 12/22/19 forward. The pharmacy had no record at all. The pharmacy never received a duplicate order or discontinued order. She had pharmacy check and there was not even an incomplete order. On the facility's physician's orders [REDACTED]. It was discontinued in Matrix before we ever received his orders on 12/22/2019. The nurses are expected to contact the pharmacy if a medication is not in or if there's a problem not re-order and discontinue it. When she did his review, she didn't see the [DIAGNOSES REDACTED]. She said she could not see the hospital discharge summary or any of that information. When she did the reviews, she looked for any omissions, duplications, chronic conditions anything high risk. In his case we just never got the order.

Based on record reviews and staff interviews and the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to ensure quality assurance monitoring of facility processes related to adverse events and to ensure identification of potential significant problems. The lack of follow up to adverse events related to reconciling new medications, ordering medications and administering medications as ordered, assessing residents for change in condition and notifying physician resulted in the death of one resident. (Resident #1) Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 8:55pm on [DATE], the Administrator and Director of Nursing was notified of the IJ determination. The findings include: Review of the records for Resident #1 revealed upon admission on [DATE], he was ordered Eliquis 5 mg twice a day for [MEDICAL CONDITION]. The admitting nurse Emp B entered the orders into the computer and ordered all new medications. Review of the Medication Administration Record [REDACTED]. The medication had not been discontinued, however the nurses did not follow up and Res #1 never received the medication to prevent blood clots. The facility was not aware that Res#1 had not been administered the medication until after he was transferred to the hospital on [DATE]. On [DATE], Resident #1's family requested oxygen saturation level be checked as he was very short of breath. RN (Emp A) documented at 1:30pm oxygen saturation level was 72% and was on 4 liters of oxygen. The physician notified and ordered venous Doppler of right arm and [MEDICATION NAME] 40 mg injection. There was no assessment of respiratory condition, oxygen saturation or vital signs after administration of [MEDICATION NAME]. Venous Doppler showed [MEDICAL CONDITION] of right brachial vein. At 4:30pm blood sugar level was 203 and insulin coverage given. No documentation of respiratory assessment, oxygen sat level or if there was decrease in swelling of right arm At 5:40pm Certified Nursing Assistant (Emp D) found him unresponsive with no vital signs found. Emp D informed the RN (EMPA). 911 called and CPR initiated. When EMS arrived Res #1 was intubated and immediately transported to hospital. He died on [DATE]. Review of the adverse incident report filed by previous Risk Manager (RM) on [DATE] revealed the incident regarding Res #1 occurred on [DATE]. An investigation was conducted on [DATE]. The analysis of the incident revealed the following: there was failure to correctly order admission medications, no documentation to support this was addressed by nursing and elevated to physician. Anticoagulant medication Eliquis entered on admission but never administered because of an order entry error. Medication reconciliation was not completed until 20 days post admission, failure to recheck oxygen saturation levels after administration of [MEDICATION NAME] 40 mg IM. Resident #1 died at hospital on [DATE]. The final [DIAGNOSES REDACTED]. An interview was conducted RM, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and Administrator, on [DATE] at 12:50pm. The RM stated was not employed at the time of the incident. Administrator was asked if Quality Assurance/Performance Improvement (QAPI) meeting was convened after the incident regarding Res #1. He said there was a meeting on [DATE] via phone with himself, Medical Director, attending physician, ADON, RM and corporate risk manager. The Administrator was asked how the facility made aware of Res #1 not been administered Eliquis for [DATE]-[DATE]. He stated I believe when Resident was transferred to hospital, but we are not sure, I'm still looking into that. He was asked if an action plan was initiated following the incident, he said there was and would provide a copy. Review of the action plan initiated by the facility included: root cause: medical record review: solution, medical record review to be completed less than 24 hours post admission, unit manager to review all medical records. Matrix care order entry, physician notification and recognizing high risk conditions. The SDC was asked what training, education, in services, competencies were conducted regarding the action plan, she said she would provide all training she had conducted. Review of the in=service materials provided revealed the only training provided was related to CPR and care planning. There was no training or education to address issues with order entries in computer causing medication errors and failure to administer medications, change in condition, notification to physician regarding changes and appropriate assessment of residents with high risk conditions. An interview was conducted with Medical Director on [DATE] at 11:59 am via telephone. When asked if he had been notified of the incident regarding Res #1 he said the administrator notified him. After he was notified he reviewed the patient chart. He stated from what I gathered when the doctor came to see the patient the paper chart was not available so he could not review the chart. The paperwork the doctor had did not have the Eliquis on it. I'm not sure if it's a data entry error or not. I spoke to medical records and told them that the information needs to be scanned in so that the doctor has access to all information when he sees the patients. He also said that when the attending physician saw the patient, it was not scanned in, so he was not aware of that medication. He further added he review all of the records and talked to the doctor and the nurses. The Administrator told me that there was an error. He said he was involved in the plan of action. He told the administration that the nurse needs to call the doctor and go over every medication with the doctor. He stated I did a lot of education. I talked to the charge nurse and the patient's nurse. He said the unit clerk is supposed to put the information in, and the nurse checks it. I talked to both of them and the DON and Medical Records. The nurse has to review all of the Unit Clerks entries. When asked if he was aware there was an issue with the how the orders were entered into the computer and what information the pharmacy received. He said he was not aware there was an issue with the pharmacy not receiving all orders. An interview was conducted with administrator at 12:50pm. He was asked if he had found out how the facility was made aware of the medication error for Res#1. He said the hospital called the facility. When asked who received the call from the hospital, he stated he did not know, maybe risk manager. Ask what date the call came he did not know. When he was made aware he notified medical director and ADON who was the acting DON at the time. Medical director notified the attending physician. An interview was conducted with Res #1's physician at 1:15pm. He was asked what was the expectation of the nursing staff when a resident has not received medications as ordered. He expected to be notified immediately. He said it was brought to his attention by the Medical Director not the nursing staff that Res #1 did not receive Eliquis. He said the Medical Director told him that it was brought to his attention after the fact. He said he did not know why he wasn't getting it. He stated it was his understanding that he was getting the medications as he was supposed to. I cannot tell you for sure where the disconnect was. An interview was conducted with Director of Nursing (DON) on [DATE] at 2:45pm. She was asked if she was aware of the incident related to Res #1 on [DATE]. She stated she was not employed at the facility at the time. She started in March of this year. When asked if she was made aware of issues with glitches in the computer system related to order entry and the pharmacy, she said no. She added that the facility would be changing pharmacies next week. When asked if the facility would continue to use current software system, she stated yes. She was asked if the new pharmacy had been made aware of issues with order entries, not that she knew but would bring it up. During an interview with the Administrator at 2:53pm he was asked if he was aware of the problem with order duplication and discontinue errors with the pharmacy, he said we can start tracking and do an audit of that. During an interview with SDC, on [DATE] at 3:20pm she confirmed there was no training regarding Matrix care, notification of change to MD or signs and symptoms of high risk conditions. She stated during the interview that she was not aware of the incident regarding Res #1, she said she was not included in morning meetings and not kept informed of any changes. She said all her time is devoted to orientation that includes large HR component. She spends very little time on the units. She was told of the need to review CPR and conduct mock code drills, which she did provide. She was unaware of the issues with the computer system regarding order entry and she was the person training all new nurses on the Matrix care software At the time of the survey, the facility had no monitoring/audit process for ensuring nursing staff were appropriately trained and competent to provide necessary care to the facility residents. Staff interviews revealed ongoing issues with order entry, ordering and obtaining medications timely with no follow up from nursing administration to ensure issues were resolved to prevent further incidents of residents not being administered medications. There was no monitoring or auditing by nursing administration regarding reconciling and ordering medications to ensure all medications were administered as prescribed, even after the death of Res #1.

Based on staff interview and record review, and the nursing center's Life Safety Code recertification survey report of 1/30/20 (ASPEN Event ID FRRY21, K345), the facility administration failed to use its resources effectively and efficiently to ensure that the facility had a reliable fire alarm system. The administration failed to recognize that based on the 11/22/19 annual fire alarm inspection, the facility had 168 out of 272 smoke detectors that failed the biennial sensitivity test. This represented an overall 60% failure rate of their smoke detectors, with a 70% failure rate on the 2nd floor. These administration inactions placed the residents, staff and visitors at risk for serious injury, harm, such as [MEDICAL CONDITION] smoke inhalation, or death, if a fire should occur. Failure of a smoke detector and a fire alarm system will delay or hinder the detection of fire or smoke. The smoke detector sensitivity ensures proper operations and lessens the chance of delayed or malfunctioning alarm activation under smoke/hazardous conditions. The facility Director of Maintenance notified the facility Ascension corporate leadership; however, neither of them communicated these issues to the facility Administrator. The facility administration, including the Director of Maintenance, and the Ascension corporate leadership failed to put interim life safety measures in effect, such as a 24 hour fire watch, to protect the building occupants. This systemic failure resulted in non-compliance at widespread Immediate Jeopardy. The facility census was 198. The Immediate Jeopardy began on 11/22/19. The facility's administrator was notified of the Immediate Jeopardy on 2/06/20 at 10:55 AM. Immediate Jeopardy was removed on 2/07/20 at 11:10 AM after review of facility policies, documentation of training, and interviews with administrative staff confirmed that the facility had restructured communication between departments and the corporate entity to ensure the facility administrator would be included in all aspects that have a potential to affect the health and safety of residents. The facility remains out of compliance at a lower severity and scope of F, widespread no actual harm with potential for more than minimal harm, to ensure that changes to communication between all areas of administration and monitoring of systems put in place are effective. Cross reference to K345 on the 01/30/2020 St Catherine Laboure Manor, Inc. Fire & Life Safety recertification Statement of Deficiencies report, CMS-2567, Event ID FRRY21. The finding included: During the Fire & Life Safety recertification survey from 1/29/20 to 1/30/20, the Life Safety Code (LSC) surveyor identified noncompliance at K 345 as Immediate Jeopardy. During document review with the Director of Maintenance (a contracted position for facility maintenance) at 12:30 PM on 1/29/2020, the LSC surveyor identified that the fire alarm inspection report dated 11/22/2019, included the smoke detector sensitivity which contained numerous failures. Out of the 272 smoke detectors, 168 (60%) of them were found out of range for the sensitivity as set by the manufacturer. At that time the surveyor deemed the system unreliable and immediately asked the facility to begin a fire watch consisting of 2 persons (due to the size of the 2 story facility, 107,000 sq. ft). During the LSC surveyor interview with the Director of Maintenance at 12:32 PM on 1/29/2020, he acknowledged that there were extensive failures and agreed that the report showed an unreliable system. He stated that upon his awareness of the issue (end of (MONTH) 2019) he notified the facility corporate management and retrieved bids for replacing the detectors from various contractors. He said he did not inform the facility Administrator. He also acknowledged that the Administrator should have been in the conversation and probably the first to be aware of the situation. The Director of Maintenance could not speak to why Ascension corporate administration did not communicate with the facility Administrator. On 1/30/20, the LSC surveyor reviewed the electronic communications the facility provided between the fire inspector, maintenance staff, and the Ascension corporate management. The facility Administrator was not included in the emails that informed the others of the alarm systems failure. On 1/31/20 at 12:30 PM, the LSC surveyor conducted a telephone interview with the facility Administrator. The Administrator stated that yes, he was aware of the fire inspection frequency requirements. He stated it would be expected that the in-house Director of Maintenance would relay the results of those inspections to him. He stated that the Director of Maintenance usually attends the quarterly Quality Assessment and Assurance Committee (QAA)meetings, but not every monthly meeting. He stated that typically the results of the fire inspections would be given to him verbally, which did not occur. The LSC surveyor conducted further interview with the facility Administrator and Director of Maintenance on 01/31/20 at 1:05 PM. When the inspection took place on 11/22/19 by the contract company, no feedback was given to the Director of Maintenance or Administrator about the results. It was not until the end of (MONTH) 2019 when the full report was received that the Director of Maintenance was aware of the extent of the systems failure. The inspection report included a summary that listed no failures; however, the full, itemized report listed the extent of the system failures. Upon learning of the failures, the Director of Maintenance retrieved bids for the replacement of the smoke detectors which were sent to Ascension corporate management, but not the facility Administrator. The Director of Maintenance stated he should have notified the Administrator, as well. Purchase approval for repairs for previous fire system issues related to the main panel and annunciator panels was received on 12/12/19. Upon considering the large cost of the additional smoke detector repairs, corporate management determined that it would be best to replace the whole system instead. The Administrator stated he had not seen the detailed report until it was brought to his attention during this survey. Once he was aware, the facility received full purchase approval to replace the entire system on 1/30/20. When asked why there was a delay from Ascension obtaining approval for a replacement system sooner, the Administrator stated that was what they were attempting to find out and expressed his frustration. This additional purchase requisition for replacement of the entire system was signed off by the facility Administrator on 1/30/20. The facility implemented an IJ removal plan to include a procedure for reporting and communication with the facility administrator related to all contracted services and life safety inspections. Facility department heads, corporate representatives and the administrator documented their meetings regarding the plan. The Administrator and Director of Maintenance confirmed their understanding of the revised procedures on 2/7/20 at 9:20 AM. On 2/7/20 at 10:15 AM, the Director of Maintenance reiterated the revised reporting structure ensures the facility administrator is now included on all reports and issues concerning the facility. Immediate Jeopardy was removed on 2/7/20 at 11:10 AM following verification that the facility had implemented its IJ removal plan.

Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures to prevent neglect for one (Residents #447) of 52 residents residing on the facility's secured unit. The facility failed to: 1. Address Resident #447's high risk for elopement. 2. Ensure the Wanderguard (wrist/ankle bracelet that sounds an alarm when the resident is near an exit) system was in place for Resident#447. 3. Ensure the security of the locked unit. The door code was posted next to the keypad, and was displayed for any individual to enter or exit the unit. 4. Supervise direct-care staff responsible for Resident #447 and ensure supervision for residents who were in the locked unit. 5. Supervise and inform direct-care staff of their role for monitoring Resident #447, and keeping nursing staff aware of the resident's whereabouts. 6. Complete hourly rounds assessments. 7. Implement the facility's elopement policy to prevent residents from eloping. This resulted in Resident #447's (diagnosed with [REDACTED]. Resident #447 eloped in a high-traffic area near highways 10 and 95, and the St. John's River. He was found in the front yard of a house that was not his (address unknown). Per the emergency medical service report, he had been a victim of possible assault. The facility's failure placed Resident #447 in immediate jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). This deficient practice affected one resident (Resident #447), who eloped from the facility, and had the potential to affect the remaining 24 out of 52 residents in the facility who were capable of eloping. Immediate Jeopardy (IJ) existed from 1/19/17 to 1/25/17. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on 8/4/2017. The immediate jeopardy was removed on 1/25/2017. The plan of action was developed on 1/23/17 with the formal staff training completed on 1/25/17. The facility correction date of the deficient practice was 1/25/17. The findings include: A clinical record review revealed that Resident #447 was admitted to the facility for long-term care on 1/19/17, with a known history of exit-seeking behavior and elopement. A review of the face sheet revealed Resident #447 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 1/23/17, revealed he had short and long-term memory problems, and cognition was moderately impaired (decisions poor; cues and supervision required). The nurse's note written on 1/21/17 at 7:28: AM, revealed he was out of bed ambulating about the unit, trying to find a way out, and was exit seeking for a portion of the shift. There was no documentation indicating Resident #447 required a Wanderguard while residing at the facility. There was no documentation regarding the application or checking of a Wanderguard. A review of a written statement from Employee A7, Licensed Practical Nurse (LPN), dated 1/23/17 revealed, I was wrong for assuming he had a Wanderguard on. An interview was conducted with the Director of Nursing (DON) on 08/03/2017 at 5:18 PM. She confirmed Resident #447 was not assessed for this (Wanderguard) immediate need. A record review of the electronic Interdisciplinary Nurse's Notes, dated 1/23/17 at 7:51 AM, revealed that the nursing supervisor documented, At about 3:45 AM, received a call from resident's (Resident #447) daughter that her father was found 3.5 miles from the facility, and is right now at Shands Hospital. Nobody saw him get out since this is a locked unit. Further review revealed the resident had been at the facility for three days. The resident was a [AGE] year-old male with Alzheimer's dementia, who eloped on 1/23/17 while residing at the facility. Resident #447 was not assessed for elopement risk from the facility. No care plan was developed that addressed his potential to wander or exit the unit, or the measures the facility was taking to prevent wandering/elopement. No interventions were initiated at the time of or since admission to 'Check Wanderguard placement and function'. The Wanderguard was not applied to inform staff members of attempts to exit the building. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She stated that the previous practice involved a code that was displayed right next to the keypad exit door in the locked unit. She stated the facility corrected this immediately after the incident by removing the code and placing a locked cover over the keypad. The only way to exit the unit after the incident was by using a push button behind the nurses' station. She also explained additional security measures that were put in place after the incident. A staff member was stationed at the front desk in the lobby after the receptionist left for the evening to ensure that around the clock monitoring of the main entrance was in place. During observations on 8/4/17, no one was present at the front desk from 07:59 AM to 08:03 AM. A federal surveyor who was present during the survey confirmed this observation. An interview with Employee A8 (administrative assistant) at 8:04 AM, confirmed that the certified nursing assistant (CNA) (Employee A12) on the previous shift should have waited for her replacement before leaving to ensure that the desk was not left unattended. On 08/03/2017 at 6:00 PM, the DON stated that no one knew how Resident #447 eloped from the facility. She explained that the facility did not have cameras. She was made aware when the resident's daughter called the facility. She stated, No one knew until he was in the hospital. The hospital called his daughter, and the daughter called us. He was found 3.5 miles from the facility, and had sustained a fall. Observations on 7/31/17 at 7:00 AM of the area surrounding the facility revealed that the facility was located adjacent to the St. John's River and St. Vincent's hospital in a heavy traffic area. There was traffic traveling in both directions in front of the facility. A review of the facility's investigation identified Resident #447 as ambulatory and requiring supervision due to his history of elopement. It reflected that the resident was not assessed for elopement risk while residing at the facility. A Wanderguard was not used for this resident. It was noted that the resident was not monitored appropriately. No alarms were noted to sound. The facility never initiated a search, because they did not know the resident eloped. Resident #447 never returned to the facility. Further review revealed that a nursing aide reported that on 1/23/17, he was last seen at 12:30 AM lying in bed. A review of the hospital emergency record, dated 1/23/17, revealed that the resident was admitted at 12:55 AM. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She revealed that the CNA (Employee A9) was terminated due to falsifying information and not performing hourly rounding. Employee A11 was terminated for not identifying Resident #447 as an elopement risk. Employee A10, Charge Nurse, was terminated for not completing required admission assessments. Further review of the hospital record, dated 1/23/17, revealed a trauma evaluation was requested by emergency services and was completed at 3:07 AM. Upon arrival on 1/23/17 at 12:55 AM, Resident #447 was complaining of moderate pain to left side of his face and forehead. He had injuries to his left eye. He had left eye periorbital (surrounding the eye) [MEDICAL CONDITION], bruising, and sub-conjunctival (below the mucous membranes covering the eye and lining the inside of the lids) hemorrhage, as well as left facial [MEDICAL CONDITION] (swelling) and ecchymosis (bruising). History of present illness revealed that Resident #447 was the victim of an assault. He was found in the front yard of a house that was not his. The doctor noted obvious head trauma. A telephone interview was conducted on 08/11/17 at 12:00 PM with a family member (daughter). She stated that her father was harmed. He was found with a bloody face and bloody clothes. He had no pants, but he was wearing a brief. The hospital only had his bloody shirt and no other clothes when he arrived. She received a call from the hospital saying that they had her father. She immediately called the facility to ask them about it. She said that they told her they would get back to her. She did not hear back from them for a while. She said that she knew they weren't telling the truth when they said that they saw him at 12:30 AM, because she had the ambulance report indicating that he was picked up at 12:02 AM, three miles from the facility. She said that his face was bruised, and he had scratches on his arms. He apparently ended up in someone's yard. She does not know who called emergency medical services (EMS). She said that he did not remember how he got out of the facility. No one knows exactly what happened. She said that her father was now living at a different facility that had a secured unit. An interview was conducted with the Administrator on 08/04/2017 at 3:45 PM. She stated that she was hired on 2/27/17. She could not offer many details about the incident (elopement of Resident #447) other than to say she was not working for the facility when it occurred. She stated a new Wanderguard system was to be installed. No installation date was specified, however. She explained that the current Wanderguard system was in working condition. A facility record review revealed corrective actions taken after the incident began on 1/23/17. The Wanderguard system was checked by the survey team between 7/31/17 and 8/4/17. The facility Wanderguard alarm was observed sounding loudly when placed near the facility exits, and it was easy to hear the alarm sounding from the nursing stations. A review of disciplinary actions taken revealed that Employee A10, Nurse, was suspended after the incident pending investigation on 1/23/17 for failing to complete the admission risk assessment for elopement. She was later terminated. Employee A9, CNA, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Employee A11, Nurse, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Hourly rounding sheets were re-implemented for all residents after the incident on 1/23/17. Re-education for all staff regarding elopement began on 1/23/17 after the incident, and was completed on 1/25/17. Elopement drills were conducted to ensure all staff understood and were knowledgeable regarding how to implement the facility policy on 1/23/17 and 1/24/17. The facility's elopement policies were reviewed with all staff. Attendees included all nurses, CNAs, and all other staff. All of the nurses received in-servicing related to completion of admission and all other assessments in a timely manner. There were no elopements from the facility's secured unit prior to the event, and none have occurred since the event on 1/23/17. The facility reviewed all residents' charts for the accuracy of their elopement risk status, and to ensure Wanderguards were present for the residents who required them. This was audited from 1/23/17 to 1/25/17. The locked unit signs at the entrance reflected 'please do not share your code with anyone, be aware of residents attempting to exit, do not assist any residents in exiting the facility, and ask staff for assistance to exit.' The facility's Elopement Policy, dated 2/2016 No. 70.70, read that once a resident was identified as missing, Code Gray would be announced over the public address system. A search would be conducted in the facility and on the facility grounds. If the resident was not found, the police would be contacted.

Based on observations, interviews, and record reviews, the facility did not provide adequate supervision to prevent an accident for Resident #447 (diagnosed with [REDACTED]. Failure to provide appropriate supervision resulted in Resident #447 eloping from the facility and wandering into an area with potential access to a large body of water (St. John's River) and dangerous traffic conditions. Resident #447's elopement resulted in injuries to his left eye (periorbital edema, bruising, and sub conjunctival hemorrhage) and forehead (laceration). According to the emergency medical services (EMS) record, the resident had been a victim of an assault. The facility's failure placed Resident #447 in immediate jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). This deficient practice affected one resident (Resident #447), who eloped from the facility, and had the potential to affect the remaining 24 out of 52 residents in the facility who were capable of eloping. Immediate Jeopardy (IJ) existed from 1/19/17 to 1/25/17. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on 8/4/2017. The immediate jeopardy was removed on 1/25/2017. The plan of action was developed on 1/23/17 with the formal staff training completed on 1/25/17. The facility correction date of the deficient practice was 1/25/17. The findings included: A clinical record review revealed that Resident #447 was admitted to the facility for long-term care on 1/19/17, with a known history of exit-seeking behavior and elopement. A review of the face sheet revealed Resident #447 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 1/23/17, revealed he had short and long-term memory problems, and cognition was moderately impaired (decisions poor; cues and supervision required). The nurse's note written on 1/21/17 at 7:28: AM, revealed he was out of bed ambulating about the unit, trying to find a way out, and was exit seeking for a portion of the shift. There was no documentation indicating Resident #447 required a Wanderguard while residing at the facility. There was no documentation regarding the application or checking of a Wanderguard. A review of a written statement from Employee A7, Licensed Practical Nurse (LPN), dated 1/23/17 revealed, I was wrong for assuming he had a Wanderguard on. An interview was conducted with the Director of Nursing (DON) on 08/03/2017 at 5:18 PM. She confirmed Resident #447 was not assessed for this (Wanderguard) immediate need. A record review of the electronic Interdisciplinary Nurse's Notes, dated 1/23/17 at 7:51 AM, revealed that the nursing supervisor documented, At about 3:45 AM, received a call from resident's (Resident #447) daughter that her father was found 3.5 miles from the facility, and is right now at Shands Hospital. Nobody saw him get out since this is a locked unit. Further review revealed the resident had been at the facility for three days. The resident was a [AGE] year-old male with Alzheimer's dementia, who eloped on 1/23/17 while residing at the facility. Resident #447 was not assessed for elopement risk from the facility. No care plan was developed that addressed his potential to wander or exit the unit, or the measures the facility was taking to prevent wandering/elopement. No interventions were initiated at the time of or since admission to 'Check Wanderguard placement and function'. The Wanderguard was not applied to inform staff members of attempts to exit the building. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She stated that the previous practice involved a code that was displayed right next to the keypad exit door in the locked unit. She stated the facility corrected this immediately after the incident by removing the code and placing a locked cover over the keypad. The only way to exit the unit after the incident was by using a push button behind the nurses' station. She also explained additional security measures that were put in place after the incident. A staff member was stationed at the front desk in the lobby after the receptionist left for the evening to ensure that around the clock monitoring of the main entrance was in place. During observations on 8/4/17, no one was present at the front desk from 07:59 AM to 08:03 AM. A federal surveyor who was present during the survey confirmed this observation. An interview with Employee A8 (administrative assistant) at 8:04 AM, confirmed that the certified nursing assistant (CNA) (Employee A12) on the previous shift should have waited for her replacement before leaving to ensure that the desk was not left unattended. On 08/03/2017 at 6:00 PM, the DON stated that no one knew how Resident #447 eloped from the facility. She explained that the facility did not have cameras. She was made aware when the resident's daughter called the facility. She stated, No one knew until he was in the hospital. The hospital called his daughter, and the daughter called us. He was found 3.5 miles from the facility, and had sustained a fall. Observations on 7/31/17 at 7:00 AM of the area surrounding the facility revealed that the facility was located adjacent to the St. John's River and St. Vincent's hospital in a heavy traffic area. There was traffic traveling in both directions in front of the facility. A review of the facility's investigation identified Resident #447 as ambulatory and requiring supervision due to his history of elopement. It reflected that the resident was not assessed for elopement risk while residing at the facility. A Wanderguard was not used for this resident. It was noted that the resident was not monitored appropriately. No alarms were noted to sound. The facility never initiated a search, because they did not know the resident eloped. Resident #447 never returned to the facility. Further review revealed that a nursing aide reported that on 1/23/17, he was last seen at 12:30 AM lying in bed. A review of the hospital emergency record, dated 1/23/17, revealed that the resident was admitted at 12:55am. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She revealed that the CNA (Employee A9) was terminated due to falsifying information and not performing hourly rounding. Employee A11 was terminated for not identifying Resident #447 as an elopement risk. Employee A10, Charge Nurse, was terminated for not completing required admission assessments. Further review of the hospital record, dated 1/23/17, revealed a trauma evaluation was requested by emergency services and was completed at 3:07 AM. Upon arrival on 1/23/17 at 12:55 AM, Resident #447 was complaining of moderate pain to left side of his face and forehead. He had injuries to his left eye. He had left eye periorbital (surrounding the eye) edema, bruising, and sub-conjunctival (below the mucous membranes covering the eye and lining the inside of the lids) hemorrhage, as well as left facial edema (swelling) and ecchymosis (bruising). History of present illness revealed that Resident #447 was the victim of an assault. He was found in the front yard of a house that was not his. The doctor noted obvious head trauma. A telephone interview was conducted on 08/11/17 at 12:00 PM with a family member (daughter). She stated that her father was harmed. He was found with a bloody face and bloody clothes. He had no pants, but he was wearing a brief. The hospital only had his bloody shirt and no other clothes when he arrived. She received a call from the hospital saying that they had her father. She immediately called the facility to ask them about it. She said that they told her they would get back to her. She did not hear back from them for a while. She said that she knew they weren't telling the truth when they said that they saw him at 12:30 AM, because she had the ambulance report indicating that he was picked up at 12:02 AM, three miles from the facility. She said that his face was bruised, and he had scratches on his arms. He apparently ended up in someone's yard. She does not know who called emergency medical services (EMS). She said that he did not remember how he got out of the facility. No one knows exactly what happened. She said that her father was now living at a different facility that had a secured unit. An interview was conducted with the Administrator on 08/04/2017 at 3:45 PM. She stated that she was hired on 2/27/17. She could not offer many details about the incident (elopement of Resident #447) other than to say she was not working for the facility when it occurred. She stated a new Wanderguard system was to be installed. No installation date was specified, however. She explained that the current Wanderguard system was in working condition. A facility record review revealed corrective actions taken after the incident began on 1/23/17. The Wanderguard system was checked by the survey team between 7/31/17 and 8/4/17. The facility Wanderguard alarm was observed sounding loudly when placed near the facility exits, and it was easy to hear the alarm sounding from the nursing stations. A review of disciplinary actions taken revealed that Employee A10, Nurse, was suspended after the incident pending investigation on 1/23/17 for failing to complete the admission risk assessment for elopement. She was later terminated. Employee A9, CNA, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Employee A11, Nurse, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Hourly rounding sheets were re-implemented for all residents after the incident on 1/23/17. Re-education for all staff regarding elopement began on 1/23/17 after the incident, and was completed on 1/25/17. Elopement drills were conducted to ensure all staff understood and were knowledgeable regarding how to implement the facility policy on 1/23/17 and 1/24/17. The facility's elopement policies were reviewed with all staff. Attendees included all nurses, CNAs, and all other staff. All of the nurses received in-servicing related to completion of admission and all other assessments in a timely manner. There were no elopements from the facility's secured unit prior to the event, and none have occurred since the event on 1/23/17. The facility reviewed all residents' charts for the accuracy of their elopement risk status, and to ensure Wanderguards were present for the residents who required them. This was audited from 1/23/17 to 1/25/17. The locked unit signs at the entrance reflected 'please do not share your code with anyone, be aware of residents attempting to exit, do not assist any residents in exiting the facility, and ask staff for assistance to exit.' The facility's Elopement Policy, dated 2/2016 No. 70.70, read that once a resident was identified as missing, Code Gray would be announced over the public address system. A search would be conducted in the facility and on the facility grounds. If the resident was not found, the police would be contacted.

Based on observations, interviews, and record review, the Administrator (ADM), Director of Nursing (DON), and Charge Nurse (CN) in the secured unit failed to oversee the unit and the facility effectively and efficiently in order to attain or maintain the highest level of well-being for one (Resident #447) of 52 residents residing in the facility's secured unit. 1. The ADM, DON and CN failed to implement the facility's neglect policy and procedures to prohibit neglect for residents. 2. The ADM, DON and CN failed to address Resident #447's high risk for elopement as a priority. 3. The ADM, DON and CN failed to ensure the wander guard system was in place for Resident #447. 4. The ADM, DON and CN failed to ensure the security of the locked unit. The code was posted next to the keypad and displayed for any individual to enter or exit the unit. 5. The DON and Charge Nurse failed to supervise nursing staff regarding Resident #447, and ensure staff provided supervision to residents who were in the locked unit. 6. Charge Nurse failed to supervise and inform her direct staff of their roles related to monitoring Resident #447, and keeping nursing staff aware of the resident's whereabouts. 7. The facility failed to complete hourly rounds assessments. 8. The ADM, DON and CN failed to implement the facility's Elopement Policy to prevent residents from eloping. The facility's failure placed Resident #447 in immediate jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). This deficient practice affected one resident (Resident #447), who eloped from the facility, and had the potential to affect the remaining 24 out of 52 residents in the facility who were capable of eloping. Immediate Jeopardy (IJ) existed from 1/19/17 to 1/25/17. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on 8/4/2017. The immediate jeopardy was removed on 1/25/2017. The plan of action was developed on 1/23/17 with the formal staff training completed on 1/25/17. The facility correction date of the deficient practice was 1/25/17. The findings include: A clinical record review revealed that Resident #447 was admitted to the facility for long-term care on 1/19/17, with a known history of exit-seeking behavior and elopement. A review of the face sheet revealed Resident #447 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 1/23/17, revealed he had short and long-term memory problems, and cognition was moderately impaired (decisions poor; cues and supervision required). The nurse's note written on 1/21/17 at 7:28: AM, revealed he was out of bed ambulating about the unit, trying to find a way out, and was exit seeking for a portion of the shift. There was no documentation indicating Resident #447 required a Wanderguard while residing at the facility. There was no documentation regarding the application or checking of a Wanderguard. A review of a written statement from Employee A7, Licensed Practical Nurse (LPN), dated 1/23/17 revealed, I was wrong for assuming he had a Wanderguard on. An interview was conducted with the Director of Nursing (DON) on 08/03/2017 at 5:18 PM. She confirmed Resident #447 was not assessed for this (Wanderguard) immediate need. A record review of the electronic Interdisciplinary Nurse's Notes, dated 1/23/17 at 7:51 AM, revealed that the nursing supervisor documented, At about 3:45 AM, received a call from resident's (Resident #447) daughter that her father was found 3.5 miles from the facility, and is right now at Shands Hospital. Nobody saw him get out since this is a locked unit. Further review revealed the resident had been at the facility for three days. The resident was a [AGE] year-old male with Alzheimer's dementia, who eloped on 1/23/17 while residing at the facility. Resident #447 was not assessed for elopement risk from the facility. No care plan was developed that addressed his potential to wander or exit the unit, or the measures the facility was taking to prevent wandering/elopement. No interventions were initiated at the time of or since admission to 'Check Wanderguard placement and function'. The Wanderguard was not applied to inform staff members of attempts to exit the building. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She stated that the previous practice involved a code that was displayed right next to the keypad exit door in the locked unit. She stated the facility corrected this immediately after the incident by removing the code and placing a locked cover over the keypad. The only way to exit the unit after the incident was by using a push button behind the nurses' station. She also explained additional security measures that were put in place after the incident. A staff member was stationed at the front desk in the lobby after the receptionist left for the evening to ensure that around the clock monitoring of the main entrance was in place. During observations on 8/4/17, no one was present at the front desk from 07:59 AM to 08:03 AM. A federal surveyor who was present during the survey confirmed this observation. An interview with Employee A8 (administrative assistant) at 8:04 AM, confirmed that the certified nursing assistant (CNA) (Employee A12) on the previous shift should have waited for her replacement before leaving to ensure that the desk was not left unattended. On 08/03/2017 at 6:00 PM, the DON stated that no one knew how Resident #447 eloped from the facility. She explained that the facility did not have cameras. She was made aware when the resident's daughter called the facility. She stated, No one knew until he was in the hospital. The hospital called his daughter, and the daughter called us. He was found 3.5 miles from the facility, and had sustained a fall. Observations on 7/31/17 at 7:00 AM of the area surrounding the facility revealed that the facility was located adjacent to the St. John's River and St. Vincent's hospital in a heavy traffic area. There was traffic traveling in both directions in front of the facility. A review of the facility's investigation identified Resident #447 as ambulatory and requiring supervision due to his history of elopement. It reflected that the resident was not assessed for elopement risk while residing at the facility. A Wanderguard was not used for this resident. It was noted that the resident was not monitored appropriately. No alarms were noted to sound. The facility never initiated a search, because they did not know the resident eloped. Resident #447 never returned to the facility. Further review revealed that a nursing aide reported that on 1/23/17, he was last seen at 12:30 AM lying in bed. A review of the hospital emergency record, dated 1/23/17, revealed that the resident was admitted at 12:55 AM. An interview was conducted with the DON on 08/03/2017 at 5:18 PM. She revealed that the CNA (Employee A9) was terminated due to falsifying information and not performing hourly rounding. Employee A11 was terminated for not identifying Resident #447 as an elopement risk. Employee A10, Charge Nurse, was terminated for not completing required admission assessments. Further review of the hospital record, dated 1/23/17, revealed a trauma evaluation was requested by emergency services and was completed at 3:07 AM. Upon arrival on 1/23/17 at 12:55 AM, Resident #447 was complaining of moderate pain to left side of his face and forehead. He had injuries to his left eye. He had left eye periorbital (surrounding the eye) [MEDICAL CONDITION], bruising, and sub-conjunctival (below the mucous membranes covering the eye and lining the inside of the lids) hemorrhage, as well as left facial [MEDICAL CONDITION] (swelling) and ecchymosis (bruising). History of present illness revealed that Resident #447 was the victim of an assault. He was found in the front yard of a house that was not his. The doctor noted obvious head trauma. A telephone interview was conducted on 08/11/17 at 12:00 PM with a family member (daughter). She stated that her father was harmed. He was found with a bloody face and bloody clothes. He had no pants, but he was wearing a brief. The hospital only had his bloody shirt and no other clothes when he arrived. She received a call from the hospital saying that they had her father. She immediately called the facility to ask them about it. She said that they told her they would get back to her. She did not hear back from them for a while. She said that she knew they weren't telling the truth when they said that they saw him at 12:30 AM, because she had the ambulance report indicating that he was picked up at 12:02 AM, three miles from the facility. She said that his face was bruised, and he had scratches on his arms. He apparently ended up in someone's yard. She does not know who called emergency medical services (EMS). She said that he did not remember how he got out of the facility. No one knows exactly what happened. She said that her father was now living at a different facility that had a secured unit. An interview was conducted with the Administrator on 08/04/2017 at 3:45 PM. She stated that she was hired on 2/27/17. She could not offer many details about the incident (elopement of Resident #447) other than to say she was not working for the facility when it occurred. She stated a new Wanderguard system was to be installed. No installation date was specified, however. She explained that the current Wanderguard system was in working condition. A facility record review revealed corrective actions taken after the incident began on 1/23/17. The Wanderguard system was checked by the survey team between 7/31/17 and 8/4/17. The facility Wanderguard alarm was observed sounding loudly when placed near the facility exits, and it was easy to hear the alarm sounding from the nursing stations. A review of disciplinary actions taken revealed that Employee A10, Nurse, was suspended after the incident pending investigation on 1/23/17 for failing to complete the admission risk assessment for elopement. She was later terminated. Employee A9, CNA, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Employee A11, Nurse, was suspended after the incident pending investigation on 1/23/17 for not making hourly rounds. She never returned to work, and was later terminated. Hourly rounding sheets were re-implemented for all residents after the incident on 1/23/17. Re-education for all staff regarding elopement began on 1/23/17 after the incident, and was completed on 1/25/17. Elopement drills were conducted to ensure all staff understood and were knowledgeable regarding how to implement the facility policy on 1/23/17 and 1/24/17. The facility's elopement policies were reviewed with all staff. Attendees included all nurses, CNAs, and all other staff. All of the nurses received in-servicing related to completion of admission and all other assessments in a timely manner. There were no elopements from the facility's secured unit prior to the event, and none have occurred since the event on 1/23/17. The facility reviewed all residents' charts for the accuracy of their elopement risk status, and to ensure Wanderguards were present for the residents who required them. This was audited from 1/23/17 to 1/25/17. The locked unit signs at the entrance reflected 'please do not share your code with anyone, be aware of residents attempting to exit, do not assist any residents in exiting the facility, and ask staff for assistance to exit.' The facility's Elopement Policy, dated 2/2016 No. 70.70, read that once a resident was identified as missing, Code Gray would be announced over the public address system. A search would be conducted in the facility and on the facility grounds. If the resident was not found, the police would be contacted.

Based on observations, record reviews, and interviews, the facility failed to provide an ongoing program of activities based on the comprehensive assessment and care plan, which was designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, by failing to assess residents' individual needs, ensure adequate staff were available, and facilitate resident participation for one (Resident #379) of a sample of 29 residents. Failure to meet these needs resulted in Resident #379's experiencing social isolation, feelings of dehumanization, and wanting to kill himself. According to the American Journal of Epidemiology (Volume. 109, No. 2, pages 186-204), social disconnectedness (lack of contact with others) can exacerbate a person's feelings of low self-worth, loneliness, depression, and worsening of health status. Social isolation can contribute to mental illness, poor physical healing, and 'In part, socially isolated people were between two and three times more likely to die.' The findings include: Based on the clinical record, Resident #379 was a [AGE] year-old man who was diagnosed with [REDACTED]. Prior to admission, he was receiving [MEDICAL CONDITION]. Resident #379 was living in a single private room located near the end of the corridor on 1-South of the facility. The resident was initially admitted in May 2017, and then readmitted in June 2017. On 08/01/2017 at 11:09:50 AM, during a tour, a check of Resident #379's room revealed a television, but no other items to entertain the resident. When he was asked whether the staff provided items so that he could do activities on his own, he responded, No. I think if someone would come talk to me for 10 or 15 minutes, I would feel okay with that. Resident #379 lived a very active, outdoor-type lifestyle prior to admission to the facility (fishing, gardening, spending time in the water) as per his wife during this time. Resident #379 spontaneously responded stating, I have [MEDICAL CONDITION]. I get very lonely. If it was not for my wife who comes in around 2:00 PM, I would shoot myself. Resident #379 was observed at varying times throughout the survey from 7/31/2017 to 8/4/2017, and the resident was never seen engaged in any activity. Resident #379 was observed only out of his room when his wife visited and took him out to the gardens or around the facility. A review of the admission comprehensive assessment, dated 6/3/2017, revealed that the resident's physiological status and cognition was assessed, but there were no assessments of his interests or psychosocial needs. (Evidence obtained) A review of the care plan revealed the resident was not care planned for activities until 8/3/2017. (Evidence obtained) Review of the facility's activity calendar revealed the only activity listed as being conducted on the unit was Catholic Mass. The resident was of Baptist faith. (Evidence obtained) No individualized activity programs were noted. The Activity Director provided a written formal assessment done on 6/5/2017, which listed things the resident found very important, like making choices regarding bed and shower times, family and friends involvement, the telephone, having a private space, books, newspapers, magazines, and keeping up with the news were all very important to the resident. Review of the resident activity assessment, dated 6/3/2017, revealed for the question regarding 'how important is it for you to go outside, to get fresh air when the weather is good' was not addressed by the facility, as there was no documentation related to that information. (Evidence obtained) Review of interdisciplinary team (IDT) documentation and records, dated 6/9/2017, Social Services wrote, Resident has been through a lot this year. (Evidence obtained) Review of an IDT note dated 8/3/2017, was the first record of the resident being offered any activity. The resident was reported as saying he liked to look out the window at the water, and commented that he liked fishing. He was offered a fishing magazine, which he declined. The report stated body and soul music was offered at bedside and Resident #379 stated, I really enjoyed it, bravo. (Evidence obtained) Review of an IDT note, dated 8/4/2017, revealed that the Social Worker documented that the resident made suicidal comments out of frustration, because he was having a hard time breathing and had pain. (Evidence obtained) During an interview on 08/03/2017 at 5:46:57 PM with Resident #379 and his wife, they were asked about the circumstances leading up to admission, the type of lifestyle that they previously enjoyed, and how admission to the facility had affected them. Resident #379's wife stated that before coming to the facility, he did a lot of outdoor stuff like gardening, fishing, working in the garage; he always loved the outdoors, and we would go fishing. She went on to say, In January 2017, (resident) fell and broke his hip on the left. He came for rehab at the facility, then returned home and was having active treatment with [MEDICAL CONDITION]. Then about two months ago, he fell again around May, and then had a partial hip replacement on the right. Following this, he came to the facility for rehabilitation to strengthen him enough to go home and resume [MEDICAL CONDITION]. While in the facility, he received news from his oncologist that the treatment for [REDACTED]. He was told that he had a few months to live, and therapy was stopped at that time. During the interview with Resident #379 and his wife, he spoke of feeling isolated, and that the only meaningful thing was when his wife came, and they sat outside watching the water. When asked how activity made him feel, he replied, It makes me feel like a human being. When the wife was asked if she noticed any changes in her husband's mood or behavior after therapy stopped (on 7/19/17), she stated, Yes, he complained of feeling lonely. He became more depressed with nothing else to do as a distraction. All he could do was stare at the walls, and I noticed that he began eating less or not at all. Resident #379 stated, There was nothing to do; no activity, and there was no one to talk to. When asked whether he had ever spoken to staff about how he felt, he indicated that he had asked several of them to stay and talk with him, but they were unable to because they were busy. When asked if staff told him about activities in the facility, he stated, Yes, they did once on Fathers' day. They told me, and I went to the activity. When asked whether he had ever been offered 1:1 sessions with activity staff, both he and his wife replied no. During an interview with the Activity Director, on 08/03/2017 9:26:58 AM, she was asked when residents were assessed after admission. She stated, We have an activity assistant on each floor. We go around and meet them and find out their likes and dislikes, and try to meet their needs. When asked who was doing activities with the 52 residents on 1-South, Staff A stated the activity assistant for 1-South (where Resident #379 resided) left in June 2017, so she had been doing the assessments. There was no one specifically for 1-South. She stated that the activities staff went to 1-South and passed out activity calendars and mail to the residents. Sometimes the residents would see the calendars and want to come. The surveyor asked how the facility kept track of what residents engaged in and whether they were offered any activities. The Activity Director stated that when a resident participated in an activity, their name would be recorded in the participation log. This surveyor and the Activities Director reviewed the participation log, and the Activities Director stated she could not see Resident #379's name anywhere in the log. She went on to say that perhaps Resident #379 was not offered any activities as there was no one from Activities assigned to his unit. She agreed that activities were important because they increased socialization, decreased depression, kept their minds away from being in the facility. During an interview with Social Worker E on 08/03/2017 at 11:32:47 AM, he was asked what he did for residents on admission, and he stated he completed a brief interview for mental status (BIMS) and PHQ9, which was a depression scale. Employee E was asked whether he had completed a PHQ9 assessment for Resident #379. He replied that he was not Resident #379's social worker; he was really just filling in. He was asked whether he was familiar with Resident #379, and he stated, I was told about him this morning (8/3/2017), and will do a second level depression assessment today. He is not my resident; I am only doing it for someone else.

Based on record reviews and staff interviews, the facility failed to provide care of peripherally inserted central catheters (PICCs) and services in a manner that met professional standards of care for 1 of 3 residents (Resident #1) requiring peripherally inserted catheter care, and for 1 of 2 residents (Resident #3) receiving antibiotics. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) Nursing [DIAGNOSES REDACTED]. (f) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. The findings include: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders revealed the following: [MEDICATION NAME] (pain medication), 10-325 mg (milligrams) by mouth every 6 hours, ordered 3/7/17 [MEDICATION NAME] 2 gm (grams) intravenously (IV) every 8 hours, ordered 3/7/17 and discontinued 3/26 Normal saline flush 10 ml (milliliters), flush both ports once a shift and after intravenous medication, ordered 3/9/17. A review of the Medication Administration Record (MAR) for the month of March 2017, revealed the resident did not receive [MEDICATION NAME] on March 9th at 12:00 AM and 6:00 AM as ordered. (Photographic evidence obtained) A review was conducted of the policy for Central Venous and Midline Catheter Flushing. The facility policy stated no physician's order was needed for this procedure. (Photographic evidence obtained) A review of the MAR, progress notes, and physicians' orders revealed no documentation regarding flushing of the PICC line until March 7, 2017, and both ports were clogged. The physician was notified regarding the clogged PICC line, pain, and swelling of the right arm, and an order was received for an ultrasound of the right arm. The ultrasound revealed a clot, so the PICC line was removed and reinserted in the left arm. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 6/15/17 at 10:27 AM. She stated that the port was cleaned with alcohol and flushed before and after the medication administration. The caps were changed after each infusion of medication. The flushes were documented in the progress notes or MAR. The dressings were changed once a week at the PICC line site. On 6/15/17 at 12:24 PM, a review of the record for Resident #1 was conducted with the Director of Nursing (DON). The order for the Doppler was received on 3/7/17, and it was completed the same day. The result revealed a right axillary blood clot. On 3/9/17, a physician's order was given to restart aspirin, Eliquis, and the IV (intravenous) antibiotic following PICC line placement. A review of the orders and notes (physician and nurses') for March 4th - 8th confirmed no orders for flushing or dressing the PICC line, and no documentation was located in the progress notes regarding flushing. The first documentation was noted on 3/7/17 regarding flushing of the PICC line. On 3/7, there was documentation that the PICC line was flushed per progress notes. The DON reviewed the MAR and confirmed the resident did not receive pain medication at 12:00 AM and 6:00 AM on 3/9/17 as ordered. 2. A record review for Resident #3 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of a physician's order dated 3/31/17, showed [MEDICATION NAME] 1.25 grams IV every day until 4/24/17. A review of the Medication Administration Record (MAR) for March and April of 2017 showed [MEDICATION NAME] 1.25 grams given once a day, starting on 4/2/17, and given through 4/16/17. (Photographic evidence obtained) According to labtestsonline.org: [MEDICATION NAME] is an antibiotic drug used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents. The reference range for [MEDICATION NAME] trough levels is 10-20 µg/mL (micrograms per milliliter) (15-20 µg/mL for complicated infections). The reference range for [MEDICATION NAME] peak levels is 25-50 µg/mL. A review of the lab results on 4/3/17 showed the [MEDICATION NAME] trough was within normal range. On 4/17/17, the [MEDICATION NAME] level was elevated. A review of the physician's and nurses' progress notes revealed no documentation regarding lab results having been called to the physician on 4/17/17. A review of the physician's progress notes dated 4/11/17, revealed no documentation of [MEDICATION NAME] level. A review of the physician's orders revealed no changes to [MEDICATION NAME] dosing. (Photographic evidence obtained) Resident #3 was sent to the emergency roiagnom on [DATE] for an evaluation per physician's orders. The resident was admitted with acute kidney injury and [MEDICATION NAME] toxicity per the hospital progress notes. An interview was conducted with the Director of Nursing on 6/15/17 at 3:57 PM to review Resident #3's chart for admission on 3/31-4/7. The order for [MEDICATION NAME] to continue in the facility was approved by the physician when the resident was admitted to the facility from the hospital. The physician was following the [MEDICATION NAME] dosing with two [MEDICATION NAME] troughs ordered. Once the resident was admitted to the facility, the pharmacy was sent a recent 'height and weight', and the most recent lab work. The DON confirmed no documentation was noted in the progress notes or computer for 4/11/17. The resident was seen on 4/11/17 by the physician, and there was no documentation regarding the [MEDICATION NAME] trough. The [MEDICATION NAME] 1.25 mg intravenous every day was given on 4/2/17 until 4/16/17, and documented on the MAR daily. The medication was not delivered from the pharmacy until 4/1/17 in the afternoon. The [MEDICATION NAME] trough was done on 4/3, 4/11, and 4/17. The only orders for a [MEDICATION NAME] trough were for 4/3, 4/11, and 4/17. On 6/15/17 at 5:34 PM, an interview was conducted with the physician. He gave the order to continue [MEDICATION NAME] as ordered from the hospital . The pharmacy followed the trough, and dosed the medication accordingly. When asked about an order for [REDACTED]. On 6/16/17 at 12:34 PM, an interview was conducted with the pharmacist regarding the dose of [MEDICATION NAME] and trough levels drawn in April 2017. The resident received [MEDICATION NAME] on 4/2 through 4/16/17 per the physician's orders. In most of the facilities, the pharmacy monitors the trough level and dosing of [MEDICATION NAME]. Since St. Catherine's was so close to the hospital, the physicians do it half the time. The pharmacist reviewed the notes from April and said she had called the facility on 4/5/17, and was told the physician was monitoring the trough level and dosing the [MEDICATION NAME].

Based on record reviews and staff interviews, the facility failed to provide the necessary care and treatment to attain or maintain the highest practicable physical, mental and psychosocial well-being by not providing appropriate care of a peripherally inserted central catheter (PICC) for 1 of 3 residents (Resident #1) requiring peripherally inserted catheter care, and for 1 of 2 residents (Resident #3) receiving antibiotics. The facility also failed to provide routinely ordered pain medication for 1 of 3 sampled residents (Resident #1). The findings include: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders revealed the following: [MEDICATION NAME] (pain medication), 10-325 mg (milligrams) by mouth every 6 hours, ordered 3/7/17 [MEDICATION NAME] 2 gm (grams) intravenously (IV) every 8 hours, ordered 3/7/17 and discontinued 3/26 Normal saline flush 10 ml (milliliters), flush both ports once a shift and after intravenous medication, ordered 3/9/17. A review of the Medication Administration Record (MAR) for the month of March 2017, revealed the resident did not receive [MEDICATION NAME] on March 9th at 12:00 AM and 6:00 AM as ordered. (Photographic evidence obtained) A review was conducted of the policy for Central Venous and Midline Catheter Flushing. The facility policy stated no physician's order was needed for this procedure. (Photographic evidence obtained) A review of the MAR, progress notes, and physicians' orders revealed no documentation regarding flushing of the PICC line until March 7, 2017, and both ports were clogged. The physician was notified regarding the clogged PICC line, pain, and swelling of the right arm, and an order was received for an ultrasound of the right arm. The ultrasound revealed a clot, so the PICC line was removed and reinserted in the left arm. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 6/15/17 at 10:27 AM. She stated that the port was cleaned with alcohol and flushed before and after the medication administration. The caps were changed after each infusion of medication. The flushes were documented in the progress notes or MAR. The dressings were changed once a week at the PICC line site. On 6/15/17 at 12:24 PM, a review of the record for Resident #1 was conducted with the Director of Nursing (DON). The order for the Doppler was received on 3/7/17, and it was completed the same day. The result revealed a right axillary blood clot. On 3/9/17, a physician's order was given to restart aspirin, Eliquis, and the IV (intravenous) antibiotic following PICC line placement. A review of the orders and notes (physician and nurses') for March 4th - 8th confirmed no orders for flushing or dressing the PICC line, and no documentation was located in the progress notes regarding flushing. The first documentation was noted on 3/7/17 regarding flushing of the PICC line. On 3/7, there was documentation that the PICC line was flushed per progress notes. The DON reviewed the MAR and confirmed the resident did not receive pain medication at 12:00 AM and 6:00 AM on 3/9/17 as ordered. 2. A record review for Resident #3 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of a physician's order dated 3/31/17, showed [MEDICATION NAME] 1.25 grams IV every day until 4/24/17. A review of the Medication Administration Record (MAR) for March and April of 2017 showed [MEDICATION NAME] 1.25 grams given once a day, starting on 4/2/17, and given through 4/16/17. (Photographic evidence obtained) According to labtestsonline.org: [MEDICATION NAME] is an antibiotic drug used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents. The reference range for [MEDICATION NAME] trough levels is 10-20 µg/mL (micrograms per milliliter) (15-20 µg/mL for complicated infections). The reference range for [MEDICATION NAME] peak levels is 25-50 µg/mL. A review of the lab results on 4/3/17 showed the [MEDICATION NAME] trough was within normal range. On 4/17/17, the [MEDICATION NAME] level was elevated. A review of the physician's and nurses' progress notes revealed no documentation regarding lab results having been called to the physician on 4/17/17. A review of the physician's progress notes dated 4/11/17, revealed no documentation of [MEDICATION NAME] level. A review of the physician's orders revealed no changes to [MEDICATION NAME] dosing. (Photographic evidence obtained) Resident #3 was sent to the emergency roiagnom on [DATE] for an evaluation per physician's orders. The resident was admitted with acute kidney injury and [MEDICATION NAME] toxicity per the hospital progress notes. An interview was conducted with the Director of Nursing on 6/15/17 at 3:57 PM to review Resident #3's chart for admission on 3/31-4/7. The order for [MEDICATION NAME] to continue in the facility was approved by the physician when the resident was admitted to the facility from the hospital. The physician was following the [MEDICATION NAME] dosing with two [MEDICATION NAME] troughs ordered. Once the resident was admitted to the facility, the pharmacy was sent a recent 'height and weight', and the most recent lab work. The DON confirmed no documentation was noted in the progress notes or computer for 4/11/17. The resident was seen on 4/11/17 by the physician, and there was no documentation regarding the [MEDICATION NAME] trough. The [MEDICATION NAME] 1.25 mg intravenous every day was given on 4/2/17 until 4/16/17, and documented on the MAR daily. The medication was not delivered from the pharmacy until 4/1/17 in the afternoon. The [MEDICATION NAME] trough was done on 4/3, 4/11, and 4/17. The only orders for a [MEDICATION NAME] trough were for 4/3, 4/11, and 4/17. On 6/15/17 at 5:34 PM, an interview was conducted with the physician. He gave the order to continue [MEDICATION NAME] as ordered from the hospital . The pharmacy followed the trough, and dosed the medication accordingly. When asked about an order for [REDACTED]. On 6/16/17 at 12:34 PM, an interview was conducted with the pharmacist regarding the dose of [MEDICATION NAME] and trough levels drawn in April 2017. The resident received [MEDICATION NAME] on 4/2 through 4/16/17 per the physician's orders. In most of the facilities, the pharmacy monitors the trough level and dosing of [MEDICATION NAME]. Since St. Catherine's was so close to the hospital, the physicians do it half the time. The pharmacist reviewed the notes from April and said she had called the facility on 4/5/17, and was told the physician was monitoring the trough level and dosing the [MEDICATION NAME].