Every finding on record at Sanctuary at Wilmington Place

Based on medical record review, staff interview, and policy review, the facility failed to notify the medical provider of resident seizure activity. This affected one (Resident #36) of three residents reviewed for notification of change in condition. The facility census was 57 residents. Findings include: Review of the medical record for Resident #36 revealed an admission date of 04/03/25 with diagnosis of epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 06/12/26 revealed the resident was cognitively intact and dependent on staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #36 dated 04/17/25 revealed the resident was at risk for complications related to diagnosis of seizure disorder. Interventions included the following: document intensity, length of seizure and any other issues related to seizure activity, notify physician of seizure activity. Review of the progress note for Resident #36 dated 06/06/26 at 1:18 P.M. revealed nurse administered Ativan due the resident having a seizure. Review of the progress note for Resident #36 dated 06/06/26 at 1:58 P.M. revealed the Ativan was effective and the resident felt better but was still shaking.Review of the progress note for Resident #36 dated 06/07/26 at 4:47 P.M. revealed the nurse administered Ativan due to the resident having a seizure.Review of the progress notes for Resident #36 dated 06/06/26 and 06/07/26 revealed they did not include documentation of notification to the resident's medical provider of the resident's seizure activity. Interview on 07/23/26 at 10:54 A.M. with Regional MDS Nurse #78 confirmed there was no documentation of the provider being notified of Resident #36's seizure activity on 06/06/26 and 06/07/26. Review of the facility policy titled Notification of Changes dated 2025 revealed the facility must inform the resident, consult with the residents physician and or notify the resident's family member or legal representative when there is a change in resident condition.

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure staff provided timely incontinence care for dependent residents. This affected one (Resident #51) of four residents reviewed for incontinence care. The facility census was 57 residents. Findings include: Review of the medical record for Resident #51 revealed an admission date of 03/24/24 with diagnoses including hemiplegia and hemiparesis, morbid obesity, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 04/22/26 revealed the resident was cognitively intact and dependent on staff assistance for toileting and personal hygiene.Observation on 07/23/26 at 9:43 A.M. revealed Resident #51's call light being was activated. Interview on 07/23/26 at 10:00 A.M. with Resident #51 confirmed she had activated her call light about 15 minutes ago because she needed assistance with incontinence care. Resident #51 stated she usually pressed the call light for assistance earlier than she needed it because it typically took a long time to get assistance. Observation on 07/23/26 at 10:11 A.M. revealed a staff member went into Resident #51's room and turned the light off.Interview on 07/23/26 at 10:20 A.M. with Resident #51 verified an aide entered her room and informed the resident they would be back soon to assist. Interview on 07/23/26 at 11:34 A.M. with the Administrator confirmed 10 to 15 minutes was an acceptable call light response time and anything over 30 minutes was too long. Interview on 07/23/26 at 1:24 P.M. with Resident #51 confirmed the staff assisted her with incontinence care at 10:36 A.M. Review of the policy titled Activities of Daily Living dated 2025 revealed care and services will be provided for the following, toileting. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number 3033989 and Complaint Number 3042923.

Based on medical record review, staff interview, and policy review, the facility failed to ensure laboratory services were completed as ordered by the physician. This affected one (Resident #36) of three residents reviewed for laboratory services. The facility census was 57 residents. Findings include: Review of the medical record for Resident #36 revealed an admission date of 04/03/25 with a diagnosis of epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 06/12/26 revealed the resident was cognitively intact and was dependent on staff assistance for activities of daily living (ADLs.) Review of the physician's orders for Resident # 36 revealed orders dated 06/05/26 for phenobarbital level to obtained every six months and an order for a thyroid stimulating hormone (TSH) leve to be drawn every 12 months starting on 07/01/26. Review of the medical record for Resident #36 revealed the phenobarbital and TSH were not drawn or resulted in July 2026. Interview on 07/23/26 at 10:54 A.M. with Regional MDS Nurse #78 confirmed the TSH and phenobarbital labs were not completed for Resident #36 as ordered. Review of the facility policy titled Laboratory Services and Reporting dated 08/01/25, revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory services to meet the needs of its residents. The facility was responsible for the timeliness of the services.

Based on observation, interview, and record review, the facility failed to provide timely assistance with eating for a dependent resident. This affected one (Resident #22) of four residents reviewed for feeding assistance. The facility census was 55. Findings include:Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, unspecified dementia, anxiety disorder, essential hypertension, overactive bladder, and spinal stenosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had moderately impaired cognition and required supervision for meals. Review of the care plan dated 04/30/25 revealed Resident #22 required assistance with meals as needed. Review of the medical record revealed Resident #22 had physician orders dated 05/28/25 for pureed texture, thin/regular consistency, for upright during meals, and total supervision during meals as resident needs assistance with feeding.Review of the quarterly nutrition assessment dated [DATE] revealed Resident #22 had orders for supervision at meals with full dependence required at times. Observation on 01/22/26 at 8:35 A.M. revealed Resident #22 sitting in chair in his room with his eyes closed with a breakfast tray in front of him, with a lid on it. Observation on 01/22/26 at 8:42 A.M. revealed Resident #22 sitting in chair in his room with a breakfast tray in front of him, with a lid on it. Observation and interview on 01/22/26 at 8:51 A.M. revealed Certified Nurse Aide (CNA) #34 went into Resident #22's room to feed Resident #22. CNA #34 reported CNA #58 delivered the tray to the residents room earlier. Observation and interview on 01/22/26 at 8:54 A.M. revealed CNA #58 entered Resident #22's room to feed him. CNA #58 stated she put the tray in Resident #22's room around 8:35 A.M. CNA #58 stated staff usually put the trays in the resident's room on the table if they need assistance with eating, and then they deliver the other trays, and return back to the room to assist with eating. Interview on 01/22/26 at 1:02 P.M. with the Dietary Supervisor (DS) #82 and Corporate Compliance (CC) #111 confirmed the CNAs or any other staff should not be delivering the trays to the residents ' rooms who need assistance with eating until they are ready to assist the residents to eat. Interview on 01/27/26 at 12:57 P.M. with Dietician #112 revealed Resident #22 needs assistance and supervision at all times when eating, the resident tries to help when getting assistance with eating.Review of the policy titled, Activities of Daily Living, dated 2025 revealed care and services will be provided for the following activities of daily living: eating to include meals and snacks.This deficiency represents non-compliance investigated under Complaint Number 2621161.

Based on medical record review, staff interviews, and policy review, the facility failed to notify a resident's responsible party/power of attorney (POA) of health changes. This affected one (#30) of the three residents reviewed for notification. The facility census was 59. Findings include: Review of the medical record of Resident #30 revealed an admission date of 04/12/24. Diagnoses included Parkinson's disease, anxiety, hypertension (HTN ), and glaucoma. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 had severely impaired cognition. Resident #30's son was listed as the POA. Review of a progress note dated 09/23/24 for Resident #30, revealed the resident had a change in condition due to the resident's oxygen saturation being low at 82 percent (%) and was wheezing. The physician was called and ordered for the resident to receive oxygen, a breathing treatment and a chest X-ray. There was no documented evidence of the resident's POA being notified. Review of a progress notes dated 02/21/25 for Resident #30, revealed the resident was lethargic, and unable to awaken after receiving medications. There was no documented evidence of the resident's POA being notified. Interview with Registered Nurse (RN) #59 on 05/22/24 at 3:00 P.M., verified there was no notification made to Resident #30's POA when the resident had changes in condition on 09/23/24 and 02/21/25. Review of the facility policy titled Notification of Change dated 12/2024, revealed family should be notified of changes in physical, mental or psychosocial deterioration of residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00164992.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure an updated Pre-admission Screening and Resident Review (PASARR) was completed. This affected one (#41) of the two residents reviewed for PASARR. The facility census was 59. Findings include: Review of the medical record for Resident #41 revealed an admission date of 01/06/23. Diagnoses included Dementia and Schizoaffective disorder bipolar type. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status (BIMS) of eight. Review of the medical record for Resident #41, revealed a PASARR was completed on 01/06/23, indicating Resident #41 had no indications of serious mental illness such as Schizophrenia, mood disorders, delusional disorders, panic or other severe anxiety disorders, somatic symptom disorders, personality disorders, or other psychotic disorders. Further review of the medical record for Resident #41, revealed a diagnosis of schizoaffective disorder bipolar type was added on 11/21/23. There were no documented evidence an updated PASARR was completed. Interview with Social Service Director (SSD) #70 on 05/29/25 at 3:52 P.M., confirmed the only PASARR Resident #41 had completed was dated for 01/06/23. Review of the facility policy titled Resident Assessment, Coordination with PASARR Program, dated 12/2024, revealed any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability (ID) authority for a level II resident review.

Based on record review, staff interview, and policy review, the facility failed to timely develop and implement fall interventions to help reduce and/or eliminate falls. This affected one (#210) of the three residents reviewed for falls. The facility census was 59. Findings include: Review of the closed medical record for Resident #210 revealed an admission date of 02/11/25 and a discharge date of 02/16/25. Diagnoses included encephalopathy, altered mental status, Type Two diabetes mellitus (DM II) with hyperglycemia, depression, acute respiratory failure with hypoxia, chronic kidney disease, anemia, peripheral vascular disease, visual hallucinations, congestive heart failure (CHF), chronic atrial fibrillation, and obstructive sleep apnea (OSA). Review of the admission Assessment initiated on 02/11/25 and completed on 02/16/25, revealed Resident #210 was at risk for falls. The interventions marked were to follow the facility's fall protocol and anticipate the resident's needs. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #210 was cognitively intact. Resident #210 was assessed to require setup assistance for eating and oral hygiene, substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, and bed mobility, and was dependent for transfers. Review of an Incident Report dated 02/15/25, revealed the nurse heard a loud noise, and Resident #210 was found on the floor between the wall and bed. The resident was assessed and noted to have a skin tear on the left elbow, which was treated, and the resident was assisted back to the bed. Review of the care plan initiated 02/16/25, revealed Resident #210 was at risk for falls related to other lack of coordination, difficulty walking, morbid obesity, osteomyelitis, and peripheral vascular disease. Interventions included analyze previous resident falls to determine whether a pattern/trend can be addressed, anticipate and meet the resident's needs, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, follow the facility's fall protocol, and have commonly used articles within easy reach. Interview on 06/02/25 at 4:25 P.M. with MDS Coordinator #59, revealed the admission Assessment transfers over to the care plan when completed, and verified there were no fall interventions care planned for Resident #210 until 02/16/25. Review of the undated facility policy titled Fall Prevention Program revealed the nurse would initiate fall interventions on the resident's baseline care plan. This deficiency represents non-compliance investigated under Complaint Number OH00162762.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (#05) of the two residents reviewed for oxygen therapy. The facility census was 59. Findings include: Review of the medical record for Resident #05 revealed an admission date of 02/01/22 with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and a history of pulmonary embolism. Review of a physician order for Resident #05 dated 10/27/22, revealed the resident was ordered to have oxygen applied continuously at two liters per minute (LPM) via nasal cannula at bedtime. An additional physician order dated 08/17/23, revealed for staff to change the oxygen tubing weekly on Sundays. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #05 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Observation of Resident #05's room on 05/28/25 at 12:31 P.M., revealed an oxygen concentrator next to the bed with oxygen tubing dated 05/11/25. Interview with Resident #05 during the observation, revealed she wears oxygen at bedtime. Interview on 05/28/25 at 12:36 PM with Certified Nursing Assistant (CNA) #106 verified the date on Resident #05's oxygen tubing being 05/11/25. Review of the facility policy titled Oxygen Administration, dated 2025, revealed the staff shall perform hand hygiene and apply gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include changing oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure medications were administered by the nurse who prepared the medications. This affected one (#15) of the seven residents investigated for medication administration. This had the potential to affect all twelve Residents (#08, #11, #15, #20, #21, #22, #25, #28, #31, #32, #38, and #47) on 200-hall. The facility census was 59. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/22/25. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke) and dementia. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment. Resident was dependent on staff for medications. Observation of medication administration on 05/27/25 from 5:06 P.M. through 5:09 P.M. with Licensed Practical Nurse (LPN) #53, revealed LPN #53 pulled and prepared medications from the medication cart for Resident #15. LPN #53 handed the medicine cup of medications to LPN #42, who took the medications into the resident's room and administered them to Resident #15. Interview on 05/27/25 at 5:09 P.M. with LPN #53, verified she pulled and prepared medications for Resident #15 and handed the medications to LPN #42 to administer to the resident. LPN #53 stated the nurse who prepared the medications should be the same one who administered them. Interview on 05/27/25 at 5:14 P.M. with LPN #42, verified she administered medications to Resident #15 that LPN #53 prepared. Review of the undated facility policy titled Medication Administration policy, revealed medications are administered by licensed nurses in accordance with standards of practice and then the nurse signs the medication administration record after administration.

Based on medical record review, staff interview, and interview with contracted pharmacy staff, the facility failed to implement pharmacy recommendations agreed upon by the facility's physician. This affected one (#15) of the five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/22/25 with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke). Review of a New admission Review by the contracted pharmacy dated 04/25/25, revealed a recommendation by the pharmacist for the ordered Lidocaine Patch (topical pain medications applied in a patch) as needed (PRN) every twelve hours to be changed to one Lidocaine patch daily. Additional recommendations included discontinuing Oxybutynin (for overactive bladder) and change Xarelto (anticoagulant) to Eliquis (anticoagulant). The physician reviewed the recommendations (undated) and ordered the Lidocaine Patch to be changed to apply one patch daily, discontinue Xarelto and start Eliquis five milligrams (mg) two times daily. Further review of the medical record for Resident #15, revealed the pharmacy recommendations dated 04/25/25, were never implemented after the facility physician approved the changes. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment. Resident was dependent on staff for medications. Interview on 05/29/25 at 9:02 A.M. with Minimum Data Set (MDS) Nurse #59, verified the pharmacy recommendations dated 04/25/25 were approved by the physician and the facility never implemented the orders. MDS Nurse #59 stated Resident #15 was receiving Hospice services, and they should have addressed the pharmacy's recommendations. Interview on 05/29/25 at 11:27 A.M. with the Director of Nursing (DON), verified the facility did not have any documentation related to the 04/25/25 pharmacy recommendations being implement for Resident #15 after they were approved by the facility physician. Interview on 05/29/25 at 11:33 A.M. with Hospice Registered Nurse (RN) #123 revealed, Hospice was never contacted when the facility's physician approved the pharmacy's recommendations for Xarelto to be changed to Eliquis or Lidocaine patch order to be changed from PRN to daily. RN #123 stated the DON contacted her today to discuss the concern with her and if Hospice had known, they would have contacted the hospice physician and the approval department.

Based on medical record review and staff interviews, the facility failed to administer medications per physician orders. This affected one (#15) of the seven residents investigated for medication administration. The facility census was 59. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/22/25 with diagnoses of chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke) and dementia. Review of the five day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment. Review of the May 2025 Medication Administration Record (MAR) revealed the following: a) On 05/15/25 at 11:00 A.M., Rivaroxaban 20 mg for Deep Vein Thrombosis (DVT) was not administered due to being out of stock. b) On 05/23/25 at 10:19 A.M., Rivaroxaban 20 mg was not administered due to being out of stock and the pharmacy was notified. c) On 05/24/25 at 8:55 A.M., Rivaroxaban 20 mg was not administered due to medication being unavailable and a reorder was sent to the pharmacy. d) On 05/27/25 at 10:46 A.M., Rivaroxaban 20 mg was not administered due to medication being on order and the pharmacy was notified. Interview on 05/28/25 at 3:34 P.M. with the Director of Nursing (DON), verified there was no documented evidence Resident #15 received Rivaroxaban on 05/15/25, 05/23/25, 05/24/25, and 05/27/25 and the MAR indicated the medication was not available. Review of the undated facility policy titled Medication Administration, revealed medications are administered as ordered by the physician and in accordance with standards of practice.

Based on observation, staff interview, record review and policy review, the facility failed to ensure medications were stored properly. This affected one (#30) of the 12 residents who resided on the 400-hall and received medications. The facility census was 59. Findings include: Review of medical record for Resident #30 revealed the resident was admitted on [DATE]. Diagnoses included open angle glaucoma, hypertension, Parkinson's Disease, and chronic kidney disease Review of the May 2025 active physician orders for Resident #30, revealed the resident was ordered Rhopressa Ophthalmic solution (for open angle glaucoma) 0.02 percent (%) one drop instilled in both eyes daily. Observation of the 400-hall medication cart on 05/29/25 at 08:01 A.M., with Licensed Practical Nurse (LPN) #39, revealed an open container of Rhopressa 0.02 % Ophthalmic Solution for Resident #30 with no open date. Interview with LPN #39 at the same time, verified the container of Rhopressa was opened and undated. Interview with Licensed Practical Nurse (LPN) #39 at the time of the observation, verified the bottle was opened, not dated and should have been dated when it was opened. Review of online resources from Medsccape.com (https://reference.medscape.com/drug/rhopressa-netarsudil-1000159#11), revealed the an open bottle of Rhopressa could be stored up to six weeks. Review of facility's policy titled Medication Storage revealed all medications will be stored in the pharmacy and/or medication rooms according to the manufacturer recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.

2) Review of the undated facility form titled Legionella Environmental Assessment Form with Maintenance Supervisor (MS) #58, revealed the facility's WMP included monthly chlorine testing and visual inspections for biofilm. The Legionella Assessment form did not include a description or diagram of the facility's water system. Interview on 06/02/25 at 2:29 P.M. with MS #58, verified there was no description or diagram of the facility's water system. MS #59 stated he had no documentation related to biofilm inspections or chlorine testing because they had not been completed. Review of the facility's undated Water Management Program revealed the facility would establish a WMP for reducing risk of pathogens in the facility's water systems. The policy indicated a variety of control measures may be used, such as visual inspections and disinfectant level control. The policy also stated testing protocols and control limits would be established, and individuals responsible for testing or conducting visual inspections would record the information. Review of online resources from CDC, (https://www.cdc.gov/control-legionella/php/healthcare/index.html) dated 03/15/24, revealed healthcare facilities should develop and implement comprehensive WMP to reduce the risk of Legionella growth and transmission. Developing and maintaining a WMP is a multi-step process that requires continuous review. The seven steps to building an effective Legionella water management program are briefly described as the following: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Make sure the program runs as designed and is effective 7. Document and communicate all the activities Based on staff interview, record review, observation and review of the Centers for Medicare and Medicaid Services (CMS) guidance for Enhanced Barrier Precautions (EBPs) in nursing homes, review of online resources from the Centers for Disease Control and Prevention (CDC), and review of the facility's Water Management Plan (WMP), the facility failed to ensure EBPs were utilized during a resident's chronic pressure ulcer dressing change. The facility also failed to ensure the appropriate infection control techniques were performed during a resident's pressure ulcer dressing change. This affected one (#24) of the two residents observed for dressing changes of pressure ulcers. The facility also failed to develop and implement a Water Management Program (WMP) to reduce the risk of Legionella (a type of bacteria which causes Legionnaires' disease and poses a significant risk in nursing homes due to their complex water systems and vulnerable resident populations). This had the potential to affect all residents in the facility. The facility census was 59. Findings include: 1) Review of the medical record for Resident #24 revealed the resident was admitted on [DATE] with diagnosis including pressure ulcer on sacrum and buttocks, Type II Diabetes Mellitus (DM II), hypertension, heart failure, and anemia. Review of the May 2025 active physician orders for Resident #24, revealed there were no orders for the resident to be in EBP. The physician orders revealed for the resident to have his pressure ulcer on sacrum and buttocks cleansed twice daily and as needed (PRN) with normal saline, iodine applied, peri-guard barrier applied and covered with an abdominal (ABD) dressing pad. Interview with Resident #24 on 05/27/25 at 10:37 A.M., revealed he was receiving treatment twice a day and as needed for a pressure ulcer that he was admitted with. Observation of Resident #24's dressing change on 05/28/25 at 1:26 P.M. with Licensed Practical Nurse (LPN) #54 and LPN #42, revealed no EBP signage or personal protective equipment (PPE) cart outside the resident's room. LPN #54 and LPN #42 announced they were there to conduct a dressing change and entered the resident's room. The dressing change supplies were placed on a rolling bedside table and both nurses washed hands and applied gloves. Resident #24 independently rolled to the left side and LPN #42 removed the resident's pants, incontinent brief, the old dressing, and disposed of the incontinence brief and the old dressing. LPN #42 washed hands and applied new gloves. LPN #54 poured normal saline (NS) into small cup, submerged a cotton wipe and washed from the outside of the wound towards the center of the wound. LPN #42 submerged a second cotton wipe in the NS, and the wound was again cleansed from the outside of the wound towards the center of the wound. LPN#54 then applied iodine to the wound using two gauze four by fours (4x4s). LPN #54 washed hands and applied new gloves, opened an ABD pad and applied peri-guard barrier cream using a tongue depressor. LPN #54 applied the ABD pad to the wound and was assisted by LPN#42 with pulling up Resident#24's incontinent brief and pants. Both LPNs removed and disposed of gloves and washed hands. Interview with LPN #54 on 05/28/25 at 1:45 P.M., verified Resident #24 had a pressure ulcer to his sacrum and buttocks and the resident should have been in EBP. LPN #54 verified she and LPN #42 didn't follow the EBP guidelines by wearing gowns during the resident's dressing change procedure. LPN #54 also verified she cleansed the pressure ulcer from the outside towards the center instead of from the center towards the outside of the pressure ulcer. Review of online resources from CDC (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html) dated 06/28/24, revealed EBPs are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBPs involves at minimum gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical device. EBP expands the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on the use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBPs are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using EBPs. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBPs for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized. Preventing infection by cleaning a wound from the center to the outer edges helps to remove bacteria and debris from the wound and minimize the chance of introducing microorganisms from the surrounding skin back into the wound bed. A moistened gauze pad can be used or other suitable cleaning material, starting at the center of the wound and wiping or dabbing outwards in concentric circles. Discard the used gauze pad or cloth and use a fresh one for each subsequent wipe as you work your way outwards Review of CMS QSO Memorandum [QSO-24-08-NH] dated 03/20/24, revealed new guidance for Long Term Care (LTC) facilities on the use of EBPs to align with nationally accepted standards. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. EBP recommendations now include the use of EBPs for residents with chronic wounds (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) or indwelling medical devices during high-contact resident care activities regardless of their MDRO status.

Based on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed ensure medications were available to administer as ordered. This affected one (#13) of three residents received for medication administration. The census was 54. Findings Included: Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder. Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had a medication order for the decongestant guaifenesin 600 mg one tablet every 12 hours. Review of a physician order dated 12/17/24 revealed Resident #13 was ordered guaifenesin extended release 600 mg one tablet twice daily for cough for seven days. Review of a nursing progress note dated 12/17/24 by Registered Nurse (RN) #219 revealed Resident #13's guaifenesin 600 mg extended release tablet twice a day for seven days for cough was on order. Review of Resident #13's December 2024 medication administration record (MAR) revealed the resident received the first dose of guaifenesin on 12/18/24 at 9:00 A.M. Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of the ordered guaifenesin 600 extended release tablets and did not received the first dose until 12/17/24. Review of a facility policy titled, Medication Administration, dated 2024, revealed medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325.

Based on medical record review, hospital documentation review, resident and staff interview, review of a photograph of a medication package, review of a contingent medication inventory list, and review of a facility policy, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected one (#13) of three residents reviewed for medication administration. The facility census was 54. Findings Included: Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder. Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had medication orders for the diuretic furosemide 20 milligrams (mg) by mouth once a day and the steroid Medrol dose package (pack) four (4) mg with instructions to follow the dose pack. Review of physician orders dated 12/16/24 revealed Resident #13 was ordered Medrol 4 mg two (2) tablets in the morning scheduled for 9:00 A.M., 2 tablets by mouth at 2:00 P.M., 2 tablets by mouth at 6:00 P.M., 2 tablets by mouth at 8:00 P.M., and 2 tablets by mouth at 9:00 P.M. Review of a physician order dated 12/28/24 revealed Resident #13 was ordered Medrol 4 mg once daily until 12/30/24. Review of physician orders dated 12/30/24 revealed Resident #13 was ordered Medrol 4 mg once daily at 3:00 P.M. and 6:00 P.M. Review of a physician order dated 12/17/24 revealed Resident #13 was ordered furosemide 20 mg daily. Review of Resident #13's December 2024 medication administration record (MAR) revealed Resident #13's Medrol 4 mg was administered on 12/16/24 at 2:00 P.M., 6:00 P.M., 8:00 P.M., and 9:00 P.M.; on 12/28/24 at 6:00 A.M.; on 12/29/24 at 6:00 A.M.; and on 12/30/24 at 6:00 A.M. and 3:00 P.M. Further review of the December 2024 MAR revealed Resident #13 received furosemide 20 mg on 12/18/24 at 9:00 A.M. Interview on 12/30/24 at 2:36 P.M. with Resident #13 stated she did not receive her medications for several days after she was admitted to the facility. Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of furosemide 20 mg and was not administered Medrol 4 mg correctly per physician order. ADON #262 verified furosemide 20 mg was in stock in the facility contingency medication supply and should have been pulled by the nurse. Review of photograph of a Medrol 4 mg medication pack, supplied by the facility on 12/31/24, revealed on the first day to take 2 tablets before breakfast, one tablet after lunch, and one tablet after supper, and two tablets at bedtime. The pack instructions continued on the second day take one tablet before breakfast, one tablet after lunch, one tablet after supper, and two tablets at bedtime. On the third day, take one tablet before breakfast, one tablet after lunch, one tablet after supper, and one tablet at bedtime. On the fourth day, take one tablet before breakfast, one tablet after lunch, and one tablet at bedtime. On the fifth day, take one tablet before breakfast, and one tablet at bedtime. On the sixth day, take one tablet before breakfast. Further review revealed eight Medrol 4 mg tablets were removed from the pack and 13 tablets remained not administered. Interview on 12/31/24 at 3:13 P.M. with Administrator confirmed the photograph of the Medrol 4 mg pack was Resident #13's medication that was left and not administered. Review of facility document titled, Inventory on Hand, dated 12/30/24, revealed 16 furosemide 20 mg tablets were on hand at the facility stock. Review of the facility policy titled, Medication Administration, dated 2024, revealed medication are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Medications are to be administered as ordered in accordance with manufacturer specifications. This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325.

Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure the appropriate size brief was provided to the residents who require and prefer a specific size brief. This affected two (#8 and #16) of two residents reviewed for briefs. The facility census was 60. Findings include: 1. Medical record review for Resident #7 revealed an admitted [DATE]. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder. Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the nursing aides do not provide her with a brief that fits. She has asked many times for a three x-large (XML) brief and the facility doesn't have them. Observation of Resident #7 on 11/21/24 at 3:30 P.M. with Certified Nursing Aide (CNA) #169 revealed CNA #169 stated Resident #7 had on a two XL brief and the right side was fastened ok, but the left side you could see her skin exposed through the fasteners. Interview with CNA #169 on 11/21/24 at 3:35 P.M. verified Resident #7 had on a two XL brief, and Resident #7 required a three XL brief. CNA #169 stated the facility doesn't have any three XL briefs in the facility so she wasn't able to put one on the resident. During an observation of incontinence care for Resident #7 and staff interviews on 11/24/24 at 6:40 A.M. with CNA #186 and CNA #188 both said the brief that was on the resident was a two XL and the agency worked yesterday and didn't put on a three XL on the resident. CNA #186 stated she searched the closet and there wasn't any three XL briefs, so a two XL was placed on Resident #7. Again the right side of the brief fit the resident, but the left side of the brief, one could see her skin through the fasteners. Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms. 2. Medical record review for Resident #16 revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, respiratory failure, and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact. She was frequently incontinent for bowel and bladder. Interview with Resident #16 on 11/24/24 at 2:40 P.M. revealed she wore a size three x-large (XL) brief and she wasn't able to get them because the facility runs out of them, and it happens all the time. She said when a two XL brief was placed on her and it makes her raw. Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms. Review of the policy titled Resident Rights dated 2024 revealed the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. This deficiency represents non-compliance investigated under Complaint Number OH00158992.

Based on medical record review, staff interview, and policy review the facility failed to ensure a change of condition was reported to the physician. This affected one (#64) of three residents reviewed for change of condition. The facility census was 60. Findings include: Medical record review for Resident #64 revealed an admitted [DATE]. Diagnoses included aftercare for a displaced supracondylar fracture with intercondylar extension of lower end of right femur, diabetes mellitus, arthritis, and cerebrovascular accident. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of the Physical Therapy (PT) notes dated 08/12/24, 08/16/24, 08/20/24, 08/21/24, and 08/22/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding. Review of the Occupational Therapy (OT) notes dated 08/12/24, 08/22/24, and 08/30/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding. Review of the progress notes from 08/12/24 through 08/30/24 revealed the notes were absent for notifying the physician about the bleeding from her surgical incision site to Resident #64's right lower extremity. Review of the Wound Nurse Practitioner (NP) #189 notes on 08/21/24 revealed there was no mention of Resident #64's incision site was bleeding. Interview with NP #189 on 11/26/24 at 9:55 A.M. verified the staff did not notify her there was bleeding from Resident #64's incision site. NP #189 stated she would have notified the surgeon if she knew about the bleeding. Review of the undated policy titled Notification of Changes revealed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00159578.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided appropriately and thoroughly. This affected one (Resident #7) of three residents reviewed for incontinence. The facility census was 60. Findings include: Medical record review for Resident #7 revealed an admitted [DATE]. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder. Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the aides do not clean her very good when they provide her with incontinence care. Observation of incontinence care for Resident #7 on 11/24/24 at 6:40 A.M. with Certified Nursing Aide (CAN) #186 and CNA #188 revealed CNA #186 took a end of the bath towel and wet it and placed soap in the cloth and washed the front of the resident with it and turned the resident over on her side towards CNA #188 and washed the backside of the resident with the bath towel without tuning it over to wash her. While the CNAs were cleaning the resident, she had urinated down the front of her legs and down in between them too. CNA #188 said it was urine running down the resident's legs. STNA #188 took a clean cloth and washed down the front of the resident and didn't wipe her legs. Interview with CNA #186 on 11/24/24 at 6:50 A.M. verified she had to use the same towel, because she didn't have anything else to wipe the back side of Resident #7 with. Interview with CNA #188 on 11/24/24 at 6:55 A.M. verified she saw urine running down Resident #7's legs and verified she did not wash Resident #7's legs afterwards. Review of the undated policy titled Perineal Care revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Females: a. Assist resident in bending her knees slightly and spreading her legs. b. Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth. c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus). d. Repeat on opposite side using separate section of washcloth or new disposable wipe. e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke. f. Pat dry with towel. This deficiency represents non-compliance investigated under Complaint Number OH00158992.

Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were administered the COVID-19 vaccine when requested. This affected one (#7) of three residents reviewed for vaccines. The facility census was 60. Findings included: Medical record review for Resident #7 revealed an admitted [DATE]. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Review of the vaccine consent form dated 11/05/24 revealed Resident #7 had read the above information concerning risks for vaccines and had an opportunity to ask questions. The form was checked mark the resident requested to have two COVID-19 vaccines administered. Review of the progress notes and the Medication Administration Record (MAR) from 11/05/24 through 11/25/24 revealed no evidence the COVID-19 vaccines were administered to Resident #7. Interview with Resident #7 on 11/21/24 at 3:21 P.M. stated she had been asking for the COVID-19 vaccines since September 2024 and has not received them yet. Interview with Assistant Director of Nursing (ADON) #141 on 11/25/24 at 2:00 P.M. confirmed Resident #7 did not receive her COVID-19 vaccines. Review of the policy titled COVID-19 Vaccination dated 2024 revealed it is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complication from COVID-19 (SAR'S-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. This deficiency represents non-compliance investigated under Complaint Number OH00158992.

Based on medical record review and resident and staff interviews, the facility failed to ensure residents were assisted with arranging transportation to physician appointments. This affected one (#52) of three residents reviewed for appointments. The censes was 57. Findings include: Review of Resident #52's medical record revealed an admitted d of 12/27/23. Diagnoses listed include type two diabetes mellitus, chronic obstructive pulmonary disease, chronic viral hepatitis, hypertension, and osteoarthritis of the hip. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of a possible 15. Review of physician orders revealed an order dated 12/28/23 for schedule an appointment with ortho (orthopedic physician). An order dated 01/19/24 was for schedule a follow-up with cardiologist (heart physician). Review of progress notes and transportation information revealed Resident #52 had yet to be seen by an orthopedic physician or cardiologist. A orthopedic appointment was first scheduled for on 02/24/24 for 02/28/24. Further record review revealed there was no documented reason for Resident #52 missing the appointment on 02/28/24. Resident #52 then missed orthopedic appointments on 03/11/24, 03/14/24, and 04/01/24 due to transportation related issues. An appointment for a cardiologist was first scheduled on 04/10/24 for 04/16/24. Record review revealed there was no documented reason for Resident #52 missing the appointment on 04/16/24. Interview with Resident #52 on 04/24/24 at 10:18 A.M. revealed he had yet to go to an orthopedic physician or cardiologist appointment while at the facility. Interview with the Director of Nursing (DON) on 04/24/24 at 8:30 A.M. confirmed there was delay in scheduling Resident #52's orthopedic and cardiologist appointments. The DON stated that Resident #52 was not able to to transported to the 04/01/24 orthopedic and 04/16/24 cardiologist appointments due to a change in payor source that was not caught before the scheduled appointment dates. The DON that facility staff were responsible for contacting transportation companies and providing correct payor source information. This deficiency represents non-compliance investigated under Complaint Number OH00152779.

Based on medical record review, staff, resident, and Certified Nurse Practitioner (CNP) #19 interviews and policy review, the facility failed to appropriately assessment and implement a physician ordered treatment for a residents newly identified skin breakdown on the residents toes on the left foot. This resulted in Actual Harm when Resident #22's newly identified open areas on the resident's left toes were not assessed, and a physician ordered treatment was not implemented subsequently resulting in worsening of the area and hospitalization . This affected one (#22) of three residents reviewed for skin breakdown. Facility census was 53. Findings include: Review of medical record for Resident #22 revealed an admitted [DATE] and was recently readmitted on [DATE]. Diagnoses include prostate cancer, dementia, peripheral vascular disease, depression, anxiety, contact and expected exposure to other hazardous substances (agent orange), lower extremity venous insufficiency with recurrent ulceration, and non-pressure chronic ulcer of right lower leg and left lower leg. Review of Resident #22's care plan dated 06/08/23 revealed the resident at risk for alterations in skin integrity related to requiring assistance with personal care, peripheral vascular disease, dementia, Alzheimer's disease, incontinence, morbid obesity, osteoarthritis and prostate cancer. The care plan instructed staff to provide skin care as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating impaired cognition. Resident #22 required set up for eating, maximum assistance for toileting, lying to sitting and dependent for transfers. Review of Resident #22's progress notes revealed a late entry for 10/04/23 which was created on 10/10/23 at 7:53 A.M. by the Director of Nursing (DON) documented Resident #22's toes on his left foot were open and bleeding. The physician was notified and a treatment order to cleanse with normal saline, pat dry, apply collagen sheet and cover with bordered super absorbent dressing was obtained. The note did not identify which toes were affected on Resident #22's left foot and no further assessment/measurements were documented. Review of Resident #22's physician orders to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing was ordered on 10/05/23 and was created and discontinued on 10/10/23. Further review of the October 2023 Treatment Administration Record (TAR) revealed there was no order to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing. Review of the Wound Clinic Notes dated 10/09/23 revealed Resident #22 presented to his appointment for chronic bilateral foot wounds, the clinic documented there were new wounds to the second and third toes with exposed bone. Review of the hospital notes for Resident #22 revealed he was referred from the wound clinic with new left foot wounds to the second and third digit with exposed bone and a concern for osteomyelitis. Review of Resident #22's hospital note dated 10/11/23 revealed an Magnetic Resonance Imaging (MRI) was completed and the the findings were suggestive of osteomyelitis involving the second proximal and middle phalanges as well as the third middle and distal phalanges. No definite abscess. Review of Resident #22's a surgical note dated 10/12/23 documented surgical amputation of the left foot second and third digit. Resident #22 was readmitted to the facility following the hospitalization on [DATE]. Interview on 11/14/22 at 10:53 A.M. with Resident #22 revealed he had seen an outside physician for the care of his foot wounds due to poor circulation of the lower extremities. Resident #22 was unable to recall how long he had the wounds to his lower extremities and left foot, but did share he had two toes on the left foot removed the month prior. Observation on 11/14/23 at 4:05 P.M. of Resident #22's dressing change by Registered Nurse (RN) #12 revealed the dressing dated 11/14/23 was removed from Resident #22's left foot. Further observations revealed Resident #22 had amputations on the left second and third digits and there were no signs of infection noted. Interview on 11/15/23 at 2:53 P.M. with the DON revealed Resident #22 had been admitted to the facility with chronic bilateral ulcers for which he received treatment from a wound clinic. The DON verified Resident #22 had new wounds observed on 10/04/23 and the physician was notified of the new areas; however, the treatment order was not implemented. The DON confirmed there were no measurements or further assessment documented of Resident #22's left toes on 10/04/23 through 10/09/23. The DON confirmed Resident #22 went to the wound clinic on 10/09/23 and was subsequently hospitalized due to worsening of the left toe areas. Interview on 11/15/23 at 3:42 P.M. with CNP #19 revealed she did assess Resident #22 at the facility on 10/05/23 and denied anyone from the facility informing her on the day of visit a concern with the resident toes to the left foot. CNP #19 further stated Resident #22 was seen by an outside physician for wound care related to ongoing issues with wounds to the lower extremities, and she generally only checked to ensure the dressing appeared dry and intact. Review of an undated facility policy revealed the effectiveness of treatments will be monitored through ongoing assessment of the wound. This deficiency represents non-compliance investigated under Complaint Number OH00147600.

Based on a closed medical record review, observation, staff interview, family interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the Self-Reported Incident (SRI), review of the facility procedure guide for Cardiopulmonary Resuscitation (CPR), review of the facility policy for Basic Life Support/CPR, review of the Abuse Policy and Procedure, review of the Condition Change of Resident Policy and review of the American Heart Association Journal, the facility failed to ensure a resident was free from neglect when staff did not respond timely or correctly to a medical emergency for Resident #54 who had a change in condition, was not promptly assessed, and who did not receive immediate and appropriate CPR when the resident was found unresponsive. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or ultimate death when Resident #54 was heard making gagging sounds when he had complained of his stomach hurting and he was sick. State tested Nursing Assistant (STNA) #350 responded to the resident ' s room, sat the resident up, and handed him an emesis basin. STNA #350 then left the room and went to find his nurse, Registered Nurse (RN) #500, who had not returned from her break. Subsequently, STNA #350 passed by Resident #54 ' s room, approximately 15 minutes later, and saw the resident ' s leg dangling off the side of the bed. STNA #350 entered the resident ' s room and found Resident #54 unresponsive. Furthermore, staff did not immediately initiate CPR or contact Emergency Medical Services (EMS) for approximately seven minutes after he was discovered unresponsive, with no pulse, and a pale skin tone. Moreover, when CPR was started, Resident #54 remained on a low air loss mattress which did not provide a firm surface, and the suctioning equipment on the crash cart was not working. This affected one (#54) of three residents reviewed for neglect related to a change in condition. The facility census was 54. On [DATE] at 1:01 P.M., the Administrator, Minimum Data Set (MDS) Registered Nurse (RN) #135 and the Vice President of Operations #145 were notified Immediate Jeopardy began on [DATE] at approximately 2:55 P.M. when Resident #54, was heard making gagging sounds and when he had complaints of his stomach hurting and he was sick. STNA #350 responded to the resident ' s room, sat him up, handed Resident #54 an emesis basin. STNA #350 left the room to find his nurse, RN #500, who had not returned from her break. No staff returned to the room to assist the resident. Subsequently, STNA #350 passed by Resident #54 ' s room, approximately 15 minutes later, and noticed the resident ' s leg dangling off the side of the bed. STNA #350 entered the resident ' s room and found Resident #54 unresponsive. Furthermore, staff did not immediately initiate CPR or contact EMS for approximately seven minutes after he was discovered unresponsive, with no pulse, and a pale skin tone. Moreover, when CPR was started, Resident #54 remained on a low air loss mattress which did not provide a firm surface, and the suctioning equipment on the crash cart was not working. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Unit Manager LPN #450 replaced the suction machine on crash cart and audited the crash cart to ensure it was properly stocked. To maintain the crash cart being fully stocked, the nurse who runs a code will be responsible for stocking the cart with items that were used during the code. · On [DATE], the Administrator initiated an investigation of the incident. The Administrator and Human Resources #215 suspended RN #500 pending the outcome of the investigation. · On [DATE], Human Resources #215 completed an audit of licensed employee files for active CPR certification after it was brought to the facility attention by the surveyor that LPN #150 had no current CPR certification. Three (3) licensed nurses were found to have expired CPR certification (LPN #150, LPN #155, and LPN #650). Human Resources will maintain a CPR log and will notify the DON of upcoming expirations of CPR certifications every month ongoing. · On [DATE], Education on Mock Codes was initiated by MDS #135 per CPR policy, educating on proper CPR technique, air mattress versus non-air mattress. STNAs also received education on Mock Codes and the role they play. · On [DATE], MDS #135 educated all facility licensed nurses on the timeliness of initiating a code. This education will be ongoing for newly hired licensed staff. · On [DATE] the MDS #135 performed a mock code per CPR policy. The MDS #135 will perform two more mock codes on [DATE] on the following shifts (7:00 A.M., to 7:00 P.M., and 7:00 P.M., to 7:00 A.M.), then weekly times four weeks then monthly times two months with licensed nurses performing return demonstration. · On [DATE] the MDS #135 began education to licensed nurses on how to properly put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This education will be ongoing for all newly hired licensed staff. · On [DATE], the MDS RN #135 updated the Crash Cart auditing check list to include all equipment is functioning. If not functioning, notification will be made to the Nurse Manager immediately. · On [DATE], the MDS RN #135 applied labels on the crash cart and audited and organized the supplies. · On [DATE], the DON audited the crash cart checklist and will continue weekly times four weeks, then biweekly for two months. · On [DATE], CPR certification the from American Heart class was held at the facility for all nurses who had no current certification and/or who wanted a refresher course. (LPN #150, LPN #155, LPN #650, STNA #125, STNA #550, and STNA #811 were in attendance). · On [DATE], the DON/designee educated the licensed nursing staff on how to leave the floor or during breaks by notifying other nursing staff. This training will be completed by [DATE]. · On [DATE], the MDS #135 reeducated all licensed staff on location of code status in the electronic health record, PCC. Licensed Staff may also reference the hard chart. · The MDS #135 nurse will audit and ensure that the code status of the resident is correct in Point Click Care (PCC). These audits will be conducted upon admission and then quarterly thereafter. · On [DATE], A Quality Assurance Performance Improvement (QAPI) meeting was completed with the Interdisciplinary team. Those in attendance included Marketing/Admissions #165, Therapy Manager #175, Dietary #185, Social Services #195, Maintenance #205, Activities #210, Human Resources #215, the Administrator, Medical Director #220, the DON, Unit Manager LPN#450, Assistant Director of Nursing #225, MDS #135, Scheduler #230, and Regional Director of Clinical Services #800. · On [DATE]. the Regional Director of Clinical Services #800 will audit every week times four weeks to ensure compliance with the removal plan. · The Administrator or designee will audit completion of all audit ' s weekly times four weeks and monthly times two months and as needed after that. · The results of the audits will be forwarded to the facility QAPI meeting for further review and recommendations weekly times four weeks and monthly times two months and as needed after that. · On [DATE], the DON/Designee began education for all nurses and nurse aides on change in condition and the need for nurse aides to immediately notify the nurse of a change in condition and the nurse to timely assess the resident when there is a change in condition. All nurses and nurse aides will be educated by [DATE]. Those not educated by that time will not be permitted to work until the training is complete. · On [DATE], the DON/Designee began education for all nursing staff on the abuse, neglect, misappropriation policy. All nursing staff will be educated by [DATE]. Those not educated by that time will not be permitted to work until the training is complete. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #54 ' s medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission assessment dated [DATE] revealed Resident #54 was dependent, and required two person staff assistance for dressing, grooming, bathing, bed mobility and transfers. Resident #54 was non-weight bearing. He required one person supervision set up for eating. Review of the physician orders dated [DATE] revealed Resident #54 was a Full Code status. Review of the nursing progress note dated [DATE] RN #500 documented at 3:20 P.M. she was called to Resident #54 ' s room by an unknown State tested Nursing Assistant (STNA), who stated he was not breathing. The nurse, RN #500 went into Resident #54 ' s room and found no pulse, started CPR, and called for someone to call 911. RN #500 continued with CPR and documented LPN #150 and LPN #600 were in attendance. There was no documented assessment of Resident #54 for his stomach hurting or feeling sick. Review of the facility investigation witness statement dated [DATE] revealed LPN #150 stated an STNA #550 came to get her and stated Resident #54 was not breathing and they could not find the nurse, RN #500. LPN #150 paged for the nurse, as she followed the aide to the resident ' s room. LPN #150 paged for nurse again and when she received no response, LPN #150 paged for the AL nurse, LPN #600, to come to the 100-hall to assist and to call RN #500 who was not responding. LPN #150 had not gotten a response, so LPN #150 started CPR and asked the STNA # 550 to check the code status of Resident #54. The STNA #550 yelled he was a full code, so LPN #150 started CPR again. LPN #150 stated when LPN #600 came, she assisted with the CPR. Shortly after RN #500 came and assisted with CPR. LPN #150 expressed the need to always carry walkie-talkies and notify the staff when they were going outside. Review of the facility investigation witness statement dated [DATE], STNA #550 stated Resident #54 ' s aide came to get her for help in pulling him up. STNA #550 noticed he wasn ' t breathing, then STNA #550 used the walkie-talkie to call for RN #500 to the room because she went outside. The STNA #550 checked his code status, yelled he was a full code and LPN #150 started CPR. STNA #550 then ran to the AL to get the nurse, LPN #600. STNA #550 stated LPN #150 was paging/yelling to get RN #500. STNA #550 was too and that was why she physically went to get the nurse in AL, LPN #600. When she ran back, RN #500 was coming in. STNA #550 told her what was going on and they ran to the room. RN #500 then took over and she called 911. STNA #550 noted CPR was started by LPN #150. STNA #550 stated she had not noticed another nurse because she ran to AL to get the other nurse. Review of the facility investigation witness statement dated [DATE] revealed LPN #600 stated LPN #150 was paging and yelling on walkie-talkie. STNA #550 came to get her and said Resident #54 was not breathing. When LPN #600 arrived at the room, RN #500 was already in the room, so LPN #600 assisted giving breaths and RN #500 gave chest compressions. LPN #600 stated the other nurse LPN #150 was going around to find the back board and suction. LPN #600 stated CPR was provided until Emergency Medical Services (EMS) showed up. LPN #600 could not answer what time the CPR was started. Review of the facility investigation witness statement undated revealed RN #500 stated CPR was started by RN #500. RN #500 stated the other nurse LPN #600 entered the room. RN #500 stated the role of LPN #600 was she used the ambu bag on Resident #54. RN #500 recognized he required suctioning and, RN #500 stated LPN #150 took over chest compressions, but LPN #150 was not compressing deep enough, so RN #500 took back over. RN #500 stated Resident #54 was fine when she went on break. RN #500 stated when she heard the walkie-talkie, she entered the building immediately and ran to Resident #54 ' s room. RN #500 was very emotional about the incident and explained how Resident #54 was fine and was breathing when she was going out on her break. RN #500 stated she had been racking her brain because she completed everything right that she was taught to do Review of the facility investigation witness statement undated revealed Maintenance #205 stated RN #500 was coming from the outside, as an STNA #550 was coming through the door (from the building) and all he heard was and he is a full code. Maintenance #205 stated he came out; everyone was running down the hall. Maintenance #205 went down by the door and saw LPN #150 giving CPR. RN #500 went inside the room, asked about the crash cart, she came out of the door yelling where ' s the crash cart. She grabbed the suction machine, came back out and pulled the entire cart in the room and was rummaging through (cart) slamming the doors after that, Maintenance #205 went to hall to look for EMS. Maintenance #205 stated CPR was started by LPN #150. Maintenance #205 stated he was outside warming up his car and had not heard the beginning of situation. Interview on [DATE] at 3:16 P.M., STNA #550 stated STNA #350 came to get her to reposition Resident #54. STNA #550 stated when entering Resident #54 ' s room he was leaning towards the wall. STNA #550 stated she noticed his color was off and his mouth was wide open. STNA #550 tried to arouse Resident #54 but there was no response. STNA #550 stated she ran to grab LPN #150 who was in the next hall. STNA #550 stated while running she used the walkie-talkie to call for RN #500 who was on break, but there was no response. STNA #550 stated LPN #150 came back to Residents #54 ' s room, where she left to run and get LPN #600 in the Assisted Living for help. STNA #550 stated when she came back from the AL, she saw RN #500 coming back from break. STNA #550 stated that RN #500 took over right when she went into Resident #54 ' s room. STNA #550 stated that RN #500 delegated her to go call 911. STNA #550 stated when she went back to the room, she saw RN #500 and LPN #150 doing chest compressions and alternating. STNA #550 stated the resident had an air mattress where you were to pull the cord to flatten it. No one pulled the cord to deflate the air mattress. Interview on [DATE] at 10:22 A.M. revealed STNA #350, who was an agency aid, stated she took care of Resident #54. STNA #350 stated she went into the room because the resident was yelling to see what he needed. STNA #350 stated she worked with STNA #550 who stated the resident might need changed because of him yelling out. STNA #350 stated she laid the resident back and proceeded to change the resident. Resident #54 complained of his stomach hurting and was sick. STNA #350 stated she sat the resident up and gave him the emesis basin to get sick. STNA #350 stated she went out into the hall in the facility to see if the nurse, RN #500 was back from break and she was not back., she had not alerted his nurse or any other nurse of Resident #54 being sick. She was unsure and did not know the times when all of this occurred. STNA #350 stated she walked past the room later, still unsure of the time, and saw the resident was leaning in bed and his leg was out of the bed part way. STNA #350 left the room to seek help from STNA #550 and brought her back to the room. STNA #550 completed a sternal rub on Resident #54 ' s chest. STNA #550 stated she thought he passed but was not sure and they had to find a nurse. STNA #350 stated she ran with STNA #550 to the ,d+[DATE] hall. At that time LPN #150 was notified of the emergency. She stated STNA #550 was at the nurse station and then ran to the Assisted Living. STNA #350 stated she was not sure on the times, but one nurse was looking in the chart for a code status, while another nurse started CPR after finding a code status. Interview on [DATE] at 11:00 A.M. LPN #600 stated STNA #550 came to get her about 3:45 P.M. stating Resident #54 was not breathing and needed help. LPN #600 stated she was on her way down to the room when she saw RN #500 come in from break outside because of the screaming on the walkie-talkie by LPN #150. LPN #600 stated RN #500 was going into Resident #54 ' s room. When LPN #600 got there, RN #500 was performing chest compressions. LPN #600 assisted with the ambu bag for breaths. LPN #600 stated the crash cart was already inside the room. LPN #600 stated she was not able to compress the ambu bag and the breaths were not going in. LPN #600 stated she could see red, pink liquid filled up the bulb of the ambu bag. LPN #600 stated she tried to use the suction machine from the crash cart and the machine was not suctioning. LPN #600 stated LPN #150 looked for another suction machine but could not find one in the facility. LPN #600 stated she called the residents power of attorney (POA) over the phone making notification the resident had [CONDITION(S)] and the squad was working on Resident #54. Telephone interview on [DATE] at 11:12 A.M., RN #500 stated she worked on Sunday [DATE] and she had just been in with Resident #54 and his daughter who had been feeding him Italian shaved ice. She gave him his scheduled dose of pain medication and had football on the television for him. His daughter left and she let Resident #54 know she was going to take a little break; she was unsure of the exact time. She said she had not left the campus and went out to her car to smoke a couple of cigarettes. She was able to smoke only one cigarette when she heard some muffled sound on her walkie-talkie and then a little bit later, she heard what sounded like panic. She went in and STNA #550 said Resident #54 was not breathing. She went to the room and felt for a pulse and started chest compressions immediately. She yelled out for the crash cart and the back board. The AL nurse, LPN #600 started to use the Ambu bag on Resident #54 and the breaths would not go in. He had fluid coming out and she kept yelling for the crash cart and the back board repeatedly and once the crash cart arrived, she hooked the suction machine up and it would not work. She had LPN #150 take over compressions and her compressions were not effective, and LPN #150 only completed one round when RN #500 took back over compressions. She was unable to suction Resident #54 as the machine was not working. She handed the suction tubing over to LPN #150, who verified it was not working. She continued to do compressions until the EMS arrived. They took over care and suctioned a whole canister of fluid from Resident #54. She finally received the back board and shoved it underneath Resident #54 to provide a hard/firm surface for the compressions to be affective. She said Resident #54 was on an air mattress and compressions were just not effective., she said she had not pulled the cord to deflate the air mattress upon arriving to the resident room. She said no one could find his code status and when she arrived at the room of Resident #54 there was no staff, no crash cart, and no emergency equipment in the room. It was like she was yelling for things while everyone just stood in the hallway and watched. She said the family had a video in the room and we could watch it. She said she could not remember the exact times, but her charting had the times she noted when the events took place. Interview on [DATE] at 5:29 P.M. Unit Manager LPN #450 stated she replaced the suction machine on [DATE], when the nurses had reported the suction machine on the crash cart had not worked during the code on [DATE]. She said they had spare working suction machines in the oxygen room and could not answer why the nurses ran around looking for another suction machine. She also verified the inspection sheet on the crash cart had missed documentation including on [DATE]. Telephone interview on [DATE] at 11:37 A.M., the family of Resident #54 stated they had an audio/video inside the room of Resident #54 which the facility was aware of, and she gave a timeline of the events that occurred on [DATE]. The family stated Resident #54 asked for help at 2:50 P.M., he was changed, then at 2:55 P.M., you could hear him gagging or vomiting, the aid came in and handed him a bowl and walked away. At 3:15 P.M., you could tell he was dead he was slumped over with his mouth open and his leg hanging off the bed. For ,d+[DATE] minutes two aides ran around and did not know what to do. No one started chest compressions until they found his nurse RN #500. She said she could hear staff ask, if they should call 911 and another staff said no he is a full code we need to wait for RN #500. She then reiterated they just left him when he was getting sick, and he died . She said they had an autopsy completed however those results would not be available for four to six weeks. Interview on [DATE] at 11:00 A.M. revealed LPN #150 stated she went into room and saw Resident #54 who was leaning toward the wall. LPN #150 stated she did check the residents ' pulse on wrist and pulled the resident to middle of the bed, she noted the resident had vomited. LPN #150 stated she started CPR and stopped CPR to find out if he was a full code. LPN #150 stated once the STNA #550 yelled full code, she gave resident CPR. LPN #150 stated she had back board under resident. LPN #150 stated she did stop CPR to leave room to find a crash cart for back board to use. LPN #150 stated she did CPR with the AL nurse who was using Ambu-bag. Interview on [DATE] at 11:30 A.M. revealed STNA #250 was not aware there was video in Resident #54 room and did not see the sign indicating there was a camera in the resident ' s room. STNA #250 stated she was scheduled that day on 400-hall when STNA #550 came running and stated Resident #54 was not breathing. LPN #150 sent her for the crash cart. STNA #250 stated she passed the crash cart and did not realize because it was another color. STNA #250 stated she thought the crash cart was red and this one was tan. She stated she was right there and could not find the crash cart, she then said STNA #550 found the crash cart. STNA #250 stated she yelled for someone to call 911. STNA #250 stated there was not a back board on the crash cart. STNA #250 stated had not seen LPN #150 leave the room before RN #500 came in. Before RN #500 arrived at the room, LPN #600 was doing chest compression alternating with chest compressions with LPN #150. A follow-up interview on [DATE] at 12:39 P.M., revealed LPN #150 said she had learned there was a video in the room on the day of the incident. She said she was called to the room and started chest compressions, she stopped to find out what his code status was. She said she had been trained in CPR, however, did not have a valid certification as it had expired. She said she stated wait a minute on calling 911 as she needed to know his code status. She said she left the room to go and find equipment. LPN #150 stated she had not pulled the cord on the air mattress to deflate it. Interview on [DATE] at 1:07 P.M., the Administrator stated she had not requested the videos of the incident from the family however, the family told the Social Service Designee (SSD) #195 she would share the videos with the facility and the family ended up not sharing them. Interview on [DATE] at 1:15 P.M., the SSD #195 stated when the family of Resident #54 arrived to clean out his room they told her they were concerned about events which took place over the weekend. SSD #195 said most of the complaints were about him not being fed and they were upset with his nurse, RN #500. SSD #195 showed the family how to share the videos and the family was going to share the videos and have a meeting the following day with the Administrator and the Regional Director of Clinical Services #800. The family never sent the videos, and they would not return any calls. A follow-up interview on [DATE] at 2:16 A.M. with LPN #600 stated she was the third nurse. LPN #600 stated she saw RN #500 come in from the outside and ran to Resident #54 ' s room. LPN #600 stated when she reached the residents room, RN #500 was doing chest compressions. LPN #600 said LPN #150 was running around gathering supplies. LPN #600 stated she never did CPR with LPN #150. LPN #600 stated she used the Ambu bag with RN #500. LPN #600 stated LPN #150 performed chest compressions for a moment, but RN #500 took over because the chest compressions were not deep enough. Interview on [DATE] at 4:20 P.M., the Administrator reported she had not followed up on any of the witness statement discrepancies due to surveys were in process. Interview on [DATE] at 3:29 P.M., the Administrator stated there could have been suspected neglect from RN #500, although not purposeful. Interview on [DATE] at 12:19 P.M., the local Coroner Staff #231 stated Resident #54 ' s death certificate was strictly performed from a medical record review, and it reported the cause of death as natural. The Coroner Staff #231 stated a few days later a full autopsy was requested and was currently in the process of being completed. She said the medical examiner who was performing the autopsy, Medical Doctor (MD) #232 had asked how they would update/change the death certificate. Coroner Staff #231 stated she told the MD #232 they would just complete an amended death certificate with a new cause of death related to the full autopsy. Coroner Staff #231 stated most likely the cause of Resident #54 ' s death will change after the full autopsy was complete. She also stated this could take eight to 12 weeks. Observation on [DATE] at 3:48 P.M. on the 200-hall where the crash cart was located, an orange back board hung behind the cart, a suction machine covered in plastic on top of the crash cart, and a full-size oxygen tank to the side of crash cart secured. The inspection sheet located on top of the crash cart had many days it had not been routinely checked including [DATE]. Observation on [DATE] at 5:40 P.M., with the Unit Manager LPN #450 revealed the oxygen supply closet had several suction machines available, which were turned on by the Unit Manager, LPN #450. LPN #450 was not able to identify which suction machine was removed from the crash cart on [DATE] and the suction machines were not labeled. Review of the EMS run report, dated [DATE], revealed EMS received the call on [DATE] at 3:22 P.M. The EMS arrived at the facility at 3:26 P.M. and was at Resident #54 ' s bedside at 3:28 P.M. The report revealed upon entering Resident #54 ' s room the resident crew immediately checked for pulse. None was found and a cardiopulmonary assist device was placed on Resident #54. The monitor and pads were put in place and after two minutes of CPR and ventilations a bag valve mask the pulse was checked. The resident was in Asystole (flatline). The resident ' s airway had to be suctioned continuously. The endotracheal tube was unable to be placed due to vomit. After five cycles of ventilation, CPR, and drugs Resident #54 showed no change in rhythm. Consultation was made to the physician at the local hospital who advised a field termination. The time of death was called at 4:34 P.M. Review of the facility crash cart inspection sheet dated ,d+[DATE] and ,d+[DATE] revealed inspections by the nurse for every 12-hour shifts were to be performed. The inspection sheet dated ,d+[DATE] revealed day shift from 7:00 A.M. to 7:00 P.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet dated ,d+[DATE] revealed night shift from 7:00 P.M. to 7:00 A.M. had no inspection completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet for ,d+[DATE] revealed day shift from 7:00 A.M. to 7:00 P.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet for ,d+[DATE] revealed night shift from 7:00 P.M. to 7:00 A.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the SRI Number 9 dated [DATE] revealed the facility reported an allegation of neglect due to a possible delay in CPR. The facility unsubstantiated the allegation. Review of Protekt Aire 3000 8 Low Air Loss/Alternating pressure mattress system (picture provided by facility) revealed the CPR valve to pull was in outer upper right corner of mattress. (The mattress for Resident #54 ' s bed was against the wall, causing obstruction to access to pull the cord to deflate the air mattress). Review of the facility procedure guide for Cardiopulmonary Resuscitation, undated, revealed check for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call 911 and return to the victim. If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Interruptions in chest compressions, even if brief, produce a dramatic decline in coronary perfusion pressures and worsens outcomes. Minimize pauses in chest compressions as much as possible. The policy also stated to place the resident on his or her back, supporting head and neck on a hard surface. Review of the facility policy titled Basic Life Support/CPR, undated, revealed that the facility can and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians, such as a DNRs and the resident ' s advance directives. Policy also revealed that the facility must ensure that properly trained personnel, certified in CPR for healthcare providers are available immediately, 24-hours per day, to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional, the resident ' s advance directives and physician ' s orders. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110XXX 5, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. Review of the facility policy titled Abuse Policy and Procedure undated revealed neglect was defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm [TRUNCATED]

Based on a closed medical record review, observation, staff interview, family interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the facility procedure guide for Cardiopulmonary Resuscitation (CPR), review of the facility policy for Basic Life Support/CPR, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) for one resident (#54) found unresponsive, without a pulse, and who was identified as a Full Code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or ultimate death when Resident #54 did not receive CPR for approximately seven minutes after he was discovered unresponsive, with no pulse, and a pale skin tone. When CPR was started Resident #54 remained on an inappropriate surface and suction equipment was not available and not working. This affected one Resident (#54) of three residents (#54, #56, and 58) reviewed for death in the facility. The facility census was 54. On [DATE] at 1:42 P.M., the Administrator, Minimum Data Set (MDS) Registered Nurse (RN) #135, Vice President of Operations #145 and the Regional Director of Clinical Services #800 were notified Immediate Jeopardy began on [DATE] at 3:15 P.M. when Resident #54, who had a Full Code status, was found in his bed by State tested Nursing Assistant (STNA) #350 unresponsive and slumped over. STNA #350 immediately notified STNA #550 she needed assistance in Resident #54 ' s room. STNA #350 and STNA #550 went to Resident #54, verified unresponsiveness, and immediately notified Licensed Practical Nurse (LPN) #150. LPN #150 responded to Resident #54 ' s room, and he was unresponsive and not breathing. LPN #150 felt for a pulse on his wrist and there was no pulse. LPN #150 reported to have started CPR and then she stopped as she had to retrieve the needed equipment. LPN #150 stated she had not pulled the cord to deflate the mattress. LPN #150 was the only nurse in the area, and she called for RN #500 via her walkie-talkie and did not get a response. When LPN #150 had not received a response from RN #500 she called LPN #600 who was on duty in the Assisted Living (AL). RN #500 responded approximately seven minutes later to find Resident #54 not breathing and without a pulse. RN #500 immediately started CPR and yelled for someone to call nine-one-one (911). RN #500 continued to call out for the back board as Resident #54 was lying on an inflated low air loss mattress when she arrived. While performing CPR there was a need to remove fluid from Resident #54 ' s airway, when the suction machine from the emergency crash cart was connected suction was attempted, however the suction machine was not working properly, and they were unable to suction Resident #54 ' s airway. Emergency Medical Services (EMS) arrived on the scene at 3:28 P.M. and Resident #54 was pronounced deceased by EMS, in consultation with the local hospital physician at 4:34 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Unit Manager LPN #450 replaced the suction machine on crash cart and audited the crash cart to ensure it was properly stocked. To maintain the crash cart being fully stocked, the nurse who runs a code will be responsible for stocking the cart with items that were used during the code. · On [DATE], the Administrator initiated an investigation of the incident. The Administrator and Human Resources #215 suspended RN #500 pending the outcome of the investigation. · On [DATE], Human Resources #215 completed an audit of licensed employee files for active CPR certification after it was brought to the facility attention by the surveyor that LPN #150 had no current CPR certification. Three (3) licensed nurses were found to have expired CPR certification (LPN #150, LPN #155, and LPN #650). Human Resources will maintain a CPR log and will notify the DON of upcoming expirations of CPR certifications every month ongoing. · On [DATE], Education on Mock Codes was initiated by MDS #135 per CPR policy, educating on proper CPR technique, air mattress versus non-air mattress. STNAs also received education on Mock Codes and the role they play. · On [DATE], MDS #135 educated all facility licensed nurses on the timeliness of initiating a code. This education will be ongoing for newly hired licensed staff. · On [DATE] the MDS #135 performed a mock code per CPR policy. The MDS #135 will perform two more mock codes on [DATE] on the following shifts (7:00 A.M., to 7:00 P.M., and 7:00 P.M., to 7:00 A.M.), then weekly times four weeks then monthly times two months with licensed nurses performing return demonstration. · On [DATE] the MDS #135 began education to licensed nurses on how to properly put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This education will be ongoing for all newly hired licensed staff. · On [DATE], the MDS RN #135 updated the Crash Cart auditing check list to include all equipment is functioning. If not functioning, notification will be made to the Nurse Manager immediately. · On [DATE], the MDS RN #135 applied labels on the crash cart and audited and organized the supplies. · On [DATE], the DON audited the crash cart checklist and will continue weekly times four weeks, then biweekly for two months. · On [DATE], CPR certification the from American Heart class was held at the facility for all nurses who had no current certification and/or who wanted a refresher course. (LPN #150, LPN #155, LPN #650, STNA #125, STNA #550, and STNA #811 were in attendance). · On [DATE], the DON/designee educated the licensed nursing staff on how to leave the floor or during breaks by notifying other nursing staff. This training will be completed by [DATE]. · On [DATE], the MDS #135 reeducated all licensed staff on location of code status in the electronic health record, PCC. Licensed Staff may also reference the hard chart. · The MDS #135 nurse will audit and ensure that the code status of the resident is correct in Point Click Care (PCC). These audits will be conducted upon admission and then quarterly thereafter. · On [DATE], A Quality Assurance Performance Improvement (QAPI) meeting was completed with the Interdisciplinary team. Those in attendance included Marketing/Admissions #165, Therapy Manager #175, Dietary #185, Social Services #195, Maintenance #205, Activities #210, Human Resources #215, the Administrator, Medical Director #220, the DON, Unit Manager LPN#450, Assistant Director of Nursing #225, MDS #135, Scheduler #230, and Regional Director of Clinical Services #800. · On [DATE]. the Regional Director of Clinical Services #800 will audit every week times four weeks to ensure compliance with the removal plan. · The Administrator or designee will audit completion of all audit ' s weekly times four weeks and monthly times two months and as needed after that. · The results of the audits will be forwarded to the facility QAPI meeting for further review and recommendations weekly times four weeks and monthly times two months and as needed after that. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #54 ' s medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission assessment dated [DATE] revealed Resident #54 was dependent, and required two person staff assistance for dressing, grooming, bathing, bed mobility and transfers. Resident #54 was non-weight bearing. He required one person supervision set up for eating. Review of the physician orders dated [DATE] revealed Resident #54 was a Full Code status. Review of the nursing progress note dated [DATE] RN #500 documented at 3:20 P.M. she was called to Resident #54 ' s room by an unknown State tested Nursing Assistant (STNA), who stated he was not breathing. The nurse, RN #500 went into Resident #54 ' s room and found no pulse, started CPR, and called for someone to call 911. RN #500 continued with CPR and documented LPN #150 and LPN #600 were in attendance. Review of the facility investigation witness statement dated [DATE] revealed STNA #200 stated an unknown STNA came running saying there was an emergency, the resident wasn ' t breathing, and she couldn ' t find the nurse. STNA #200 noted we all ran to the 100-hall. LPN #150 kept yelling and paging the 100-hall nurse (RN #500) but there was no response. LPN #150 called the AL nurse LPN #600 and instructed her to come help and to call RN #500 because they could not find her. STNA #200 reported CPR was started by LPN #150. She was unsure of the time and said no-one else was in the room at the time and the AL nurse LPN #600 eventually came and assisted with giving breaths. STNA #200 noted we really tried to call and page RN #500; the aides were literally sprinting down the hall trying to find her. Review of the facility investigation witness statement dated [DATE] revealed STNA #311 heard someone yelling on the walkie-talkie. People were yelling in the hall, STNA #311 was in bathroom, upon exiting the bathroom STNA #311 assisted with whatever was needed. Everyone was yelling for 100-hall nurse, RN #500, who was outside of the facility with someone. RN #500 eventually came, and everyone helped even the maintenance guy. STNA #311 noted CPR was started four to five minutes by LPN #150. LPN #600 was helping with CPR. Review of the facility investigation witness statement dated [DATE] revealed LPN #150 stated an STNA #550 came to get her and stated Resident #54 was not breathing and they could not find the nurse, RN #500. LPN #150 paged for the nurse, as she followed the aide to the resident ' s room. LPN #150 paged for nurse again when and when she received no response, LPN #150 paged for the AL nurse, LPN #600 to come to the 100-hall to assist and to call RN #500 who was not responding. LPN #150 had not gotten a response, so LPN #150 started CPR and asked the STNA # 550 to check the code status of Resident #54. The STNA #550 yelled he was a full code, so LPN #150 started CPR again. LPN #150 stated when LPN #600 came, she assisted with the CPR. Shortly after RN #500 came and assisted with CPR. LPN #150 expressed the need to always carry walkie-talkies and notify the staff when they were going outside. Review of the facility investigation witness statement dated [DATE] STNA #550 stated Resident #54 ' s aide came to get her for help in pulling him up. STNA #550 noticed he wasn ' t breathing, then STNA #550 used the walkie-talkie to call for RN #500 to the room because she went outside. The STNA #550 checked his code status, yelled he was a full code and LPN #150 started CPR. STNA #550 then ran to the AL to get the nurse, LPN #600. STNA #550 stated LPN #150 was paging/yelling to get RN #500. STNA #550 was too and that was why she physically went to get the nurse in AL, LPN #600. When she ran back, RN #500 was coming in. STNA #550 told her what was going on and they ran to the room. RN #500 then took over and she called 911. STNA #550 noted CPR was started by LPN #150. STNA #550 stated she had not noticed another nurse because she ran to AL to get the other nurse. Review of the facility investigation witness statement dated [DATE] revealed LPN #600 stated LPN #150 was paging and yelling on walkie-talkie. STNA #550 came to get her and said Resident #54 was not breathing. When LPN #600 arrived at the room, RN #500 was already in the room, so LPN #600 assisted giving breaths and RN #500 gave chest compressions. LPN #600 stated the other nurse LPN #150 was going around to find the back board and suction. LPN #600 stated CPR was provided until Emergency Medical Services (EMS) showed up. LPN #600 could not answer what time the CPR was started. Review of the facility investigation witness statement undated revealed RN #500 stated CPR was started by RN #500. RN #500 stated the other nurse LPN #600 entered the room. RN #500 stated the role of LPN #600 was she used the ambu bag on Resident #54. RN #500 recognized he required suctioning and, RN #500 stated LPN #150 took over chest compressions, but LPN #150 was not compressing deep enough, so RN #500 took back over. RN #500 stated Resident #54 was fine when she went on break. RN #500 stated when she heard the walkie-talkie, she entered the building immediately and ran to Resident #54 ' s room. RN #500 was very emotional about the incident and explained how Resident #54 was fine and was breathing when she was going out on her break. RN #500 stated she had been racking her brain because she completed everything right that she was taught to do Review of the facility investigation witness statement undated revealed Maintenance #205 stated RN #500 was coming from the outside, as an STNA #550 was coming through the door (from the building) and all he heard was and he is a full code. Maintenance #205 stated he came out; everyone was running down the hall. Maintenance #205 went down by the door and saw LPN #150 giving CPR. RN #500 went inside the room, asked about the crash cart, she came out of the door yelling where ' s the crash cart. She grabbed the suction machine, came back out and pulled the entire cart in the room and was rummaging through (cart) slamming the doors after that, Maintenance #205 went to hall to look for EMS. Maintenance #205 stated CPR was started by LPN #150. Maintenance #205 stated he was outside warming up his car and had not heard the beginning of situation. Interview on [DATE] at 3:16 P.M., STNA #550 stated STNA #350 came to get her to reposition Resident #54. STNA #550 stated when entering Resident #54 ' s room he was leaning towards the wall. STNA #550 stated she noticed his color was off and his mouth was wide open. STNA #500 tried to arouse Resident #54 but there was no response. STNA #550 stated she ran to grab LPN #150 who was in the next hall. STNA #550 stated while running she used the walkie-talkie to call for RN #500 who was on break, but there was no response. STNA #550 stated LPN #150 came back to Residents #54 ' s room, where she left to run and get LPN #600 in the Assisted Living for help. STNA #550 stated when she came back from the AL, she saw RN #500 coming back from break. STNA #550 stated that RN #500 took over right when she went into Resident #54 ' s room. STNA #550 stated that RN #500 delegated her to go call 911. STNA #550 stated when she went back to the room, she saw RN #500 and LPN #150 doing chest compressions and alternating. STNA #550 stated the resident had an air mattress where you were to pull the cord to flatten it. No one pulled the cord to deflate the air mattress. Interview on [DATE] at 10:22 A.M. revealed STNA #350, who was an agency aid, stated she took care of Resident #54. STNA #350 stated she went into the room because the resident was yelling to see what he needed. STNA #350 stated she worked with STNA #550 who stated the resident might need changed because of him yelling out. STNA #350 stated she laid the resident back and proceeded to change the resident. Resident #54 complained of his stomach hurting and was sick. STNA #350 stated she sat the resident up and gave him the emesis basin to get sick. STNA #350 stated she went out into the hall in the facility to see if the nurse, RN #500 was back from break. She was unsure and did not know the times when all of this occurred. STNA #350 stated she walked past the room later, still unsure of the time, and saw the resident was leaning in bed and his leg was out of the bed part way. STNA #350 left the room to seek help from STNA #550 and brought her back to the room. STNA #550 completed a sternal rub on Resident #54 ' s chest. STNA #550 stated she thought he passed but was not sure and they had to find a nurse. STNA #350 stated she ran with STNA #550 to the ,d+[DATE] hall. At that time LPN #150 was notified of the emergency. She stated STNA #550 was at the nurse station and then ran to the Assisted Living. STNA #350 stated she was not sure on the times, but one nurse was looking in the chart for a code status, while another nurse started CPR after finding a code status. Interview on [DATE] at 11:00 A.M. LPN #600 stated STNA #550 came to get her about 3:45 P.M. stating Resident #54 was not breathing and needed help. LPN #600 stated she was on her way down to the room when she saw RN #500 come in from break outside because of the screaming on the walkie-talkie by LPN #150. LPN #600 stated RN #500 was going into Resident #54 ' s room. When LPN #600 got there, RN #500 was performing chest compressions. LPN #600 assisted with the ambu bag for breaths. LPN #600 stated the crash cart was already inside the room. LPN #600 stated she was not able to compress the ambu bag and the breaths were not going in. LPN #600 stated she could see red, pink liquid filled up the bulb of the ambu bag. LPN #600 stated she tried to use the suction machine from the crash cart and the machine was not suctioning. LPN #600 stated LPN #150 looked for another suction machine but could not find one in the facility. LPN #600 stated she called the residents power of attorney (POA) over the phone making notification the resident had [CONDITION(S)] and the squad was working on Resident #54. Telephone interview on [DATE] at 11:12 A.M., RN #500 stated she worked on Sunday [DATE] and she had just been in with Resident #54 and his daughter who had been feeding him Italian shaved ice. She gave him his scheduled dose of pain medication and had football on the television for him. His daughter left and she let Resident #54 know she was going to take a little break; she was unsure of the exact time. She said she had not left the campus and went out to her car to smoke a couple of cigarettes. She was able to smoke only one cigarette when she heard some muffled sound on her walkie-talkie and then a little bit later, she heard what sounded like panic. She went in and STNA #550 said Resident #54 was not breathing. She went to the room and felt for a pulse and started chest compressions immediately. She yelled out for the crash cart and the back board. The AL nurse, LPN #600 started to use the Ambu bag on Resident #54 and the breaths would not go in. He had fluid coming out and she kept yelling for the crash cart and the back board repeatedly and once the crash cart arrived, she hooked the suction machine up and it would not work. She had LPN #150 take over compressions and her compressions were not effective, and LPN #150 only completed one round when RN #500 took back over compressions. She was unable to suction Resident #54 as the machine was not working. She handed the suction tubing over to LPN #150, who verified it was not working. She continued to do compressions until the EMS arrived. They took over care and suctioned a whole canister of fluid from Resident #54. She finally received the back board and shoved it underneath Resident #54 to provide a hard/firm surface for the compressions to be affective. She said Resident #54 was on an air mattress and compressions were just not effective, she said she had not pulled the cord to deflate the air mattress upon arriving to the resident room. She said no one could find his code status and when she arrived at the room of Resident #54 there was no staff, no crash cart, and no emergency equipment in the room. It was like she was yelling for things while everyone just stood in the hallway and watched. She said the family had a video in the room and we could watch it. She said she could not remember the exact times, but her charting had the times she noted when the events took place. Interview on [DATE] at 5:29 P.M. Unit Manager LPN #450 stated she replaced the suction machine on [DATE], when the nurses had reported the suction machine on the crash cart had not worked during the code on [DATE]. She said they had spare working suction machines in the oxygen room and could not answer why the nurses ran around looking for another suction machine. She also verified the inspection sheet on the crash cart had missed documentation including on [DATE]. Telephone interview on [DATE] at 11:37 A.M., the family of Resident #54 stated they had an audio/video inside the room of Resident #54 which the facility was aware of, and she gave a timeline of the events that occurred on [DATE]. The family stated Resident #54 asked for help at 2:50 P.M., he was changed, then at 2:55 P.M., you could hear him gagging or vomiting, the aid came in and handed him a bowl and walked away. At 3:15 P.M., you could tell he was dead he was slumped over with his mouth open and his leg hanging off the bed. For ,d+[DATE] minutes two aides ran around and did not know what to do. No one started chest compressions until they found his nurse RN #500. She said she could hear staff ask, if they should call 911 and another staff said no he is a full code we need to wait for RN #500. Interview on [DATE] at 11:00 A.M. revealed LPN #150 stated she went into room and saw Resident #54 who was leaning toward the wall. LPN #150 stated she did check the residents ' pulse on wrist and pulled the resident to middle of the bed. LPN #150 stated she started CPR and stopped CPR to find out if he was a full code. LPN #150 stated once the STNA #550 yelled full code, she gave resident CPR. LPN #150 stated she had back board under resident. LPN #150 stated she did stop CPR to leave room to find a crash cart for back board to use. LPN #150 stated she did CPR with the AL nurse who was using Ambu-bag. Interview on [DATE] at 11:30 A.M. revealed STNA #250 was not aware there was video in Resident #54 room and did not see the sign indicating there was a camera in the resident ' s room. STNA #250 stated she was scheduled that day on 400-hall when STNA #550 came running and stated Resident #54 was not breathing. LPN #150 sent her for the crash cart. STNA #250 stated she passed the crash cart and did not realize because it was another color. STNA #250 stated she thought the crash cart was red and this one was tan. She stated she was right there and could not find the crash cart, she then said STNA #550 found the crash cart. STNA #250 stated she yelled for someone to call 911. STNA #250 stated there was not a back board on the crash cart. STNA #250 stated had not seen LPN #150 leave the room before RN #500 came in. Before RN #500 arrived at the room, LPN #600 was doing chest compression alternating with chest compressions with LPN #150. A follow-up interview on [DATE] at 12:39 P.M., revealed LPN #150 said she had learned there was a video in the room on the day of the incident. She said she was called to the room and started chest compressions, she stopped to find out what his code status was. She said she had been trained in CPR, however, did not have a valid certification as it had expired. She said she stated wait a minute on calling 911 as she needed to know his code status. She said she left the room to go and find equipment. Interview on [DATE] at 1:07 P.M., the Administrator stated she had not requested the videos of the incident from the family however, the family told the Social Service Designee (SSD) #195 she would share the videos with the facility and the family ended up not sharing them. Interview on [DATE] at 1:15 P.M., the SSD #195 stated when the family of Resident #54 arrived to clean out his room they told her they were concerned about events which took place over the weekend. SSD #195 said most of the complaints were about him not being fed and they were upset with his nurse, RN #500. SSD #195 showed the family how to share the videos and the family was going to share the videos and have a meeting the following day with the Administrator and the Regional Director of Clinical Services #800. The family never sent the videos and they would not return any calls. A follow-up interview on [DATE] at 2:16 A.M. with LPN #600 stated she was the third nurse. LPN #600 stated she saw RN #500 come in from the outside and ran to Resident #54 ' s room. LPN #600 stated when she reached the residents room, RN #500 was doing chest compressions. LPN #600 said LPN #150 was running around gathering supplies. LPN #600 stated she never did CPR with LPN #150. LPN #600 stated she used the Ambu bag with RN #500. LPN #600 stated LPN #150 performed chest compressions for a moment, but RN #500 took over because the chest compressions were not deep enough. Interview on [DATE] at 4:20 P.M., the Administrator reported she had not followed up on any of the witness statement discrepancies due to the current survey in process. Observation on [DATE] at 3:48 P.M. on the 200-hall where the crash cart was located, an orange back board hung behind cart, a suction machine covered in plastic on top of the crash cart, and a full-size oxygen tank to the side of crash cart secured. The inspection sheet located on top of the crash cart had many days it had not been routinely checked including [DATE]. Review of the EMS run report, dated [DATE], revealed EMS received the call on [DATE] at 3:22 P.M. The EMS arrived at the facility at 3:26 P.M. and was at Resident #54 ' s bedside at 3:28 P.M. The report revealed upon entering Resident #54 ' s room the resident crew immediately checked for pulse. None was found and a cardiopulmonary assist device was placed on Resident #54. The monitor and pads were put in place and after two minutes of CPR and ventilations a bag valve mask the pulse was checked. The resident was in Asystole (flatline). The resident ' s airway had to be suctioned continuously. The endotracheal tube was unable to be placed due to vomit. After five cycles of ventilation, CPR, and drugs Resident #54 showed no change in rhythm. Consultation was made to the physician at the local hospital who advised a field termination. The time of death was called at 4:34 P.M. Review of the facility crash cart inspection sheet dated ,d+[DATE] and ,d+[DATE] revealed inspections by the nurse for every 12-hour shifts were to be performed. The inspection sheet dated ,d+[DATE] revealed day shift from 7:00 A.M. to 7:00 P.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet dated ,d+[DATE] revealed night shift from 7:00 P.M. to 7:00 A.M. had no inspection completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet for ,d+[DATE] revealed day shift from 7:00 A.M. to 7:00 P.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The inspection sheet for ,d+[DATE] revealed night shift from 7:00 P.M. to 7:00 A.M. had not had inspections completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Protekt Aire 3000 8 Low Air Loss/Alternating pressure mattress system (picture provided by facility) revealed the CPR valve to pull was in outer upper right corner of mattress. (The mattress for Resident #54 ' s bed was against the wall, causing obstruction to access to pull the cord to deflate the air mattress). Review of the facility procedure guide for Cardiopulmonary Resuscitation, undated, revealed check for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call 911 and return to the victim. If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Interruptions in chest compressions, even if brief, produce a dramatic decline in coronary perfusion pressures and worsens outcomes. Minimize pauses in chest compressions as much as possible. The policy also stated to place the resident on his or her back, supporting head and neck on a hard surface. Review of the facility policy titled Basic Life Support/CPR, undated, revealed that the facility can and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians, such as a DNRs and the resident ' s advance directives. Policy also revealed that the facility must ensure that properly trained personnel, certified in CPR for healthcare providers are available immediately, 24-hours per day, to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional, the resident ' s advance directives and physician ' s orders. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110XXX 5, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. This deficiency substantiates Master Complaint Number OH .

Based on medical record review, hospital record review, staff and Certified Nurse Practitioner (CNP) interview, and review of the Medscape resource, the facility failed to follow a physician's orders [REDACTED]. Actual harm occurred to Resident #55 when the facility failed to implement nutrition interventions, obtain physician ordered laboratory work, and report abnormal laboratory values to the physician. The resident was admitted to the hospital for acute kidney injury and dehydration. This affected one (Resident #55) of three residents reviewed for dehydration. The facility identified five residents who were at risk for dehydration. The facility census was 53. Findings include: Review of Resident #55's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care, dated 01/25/21, revealed the resident was at risk for malnutrition and altered hydration related to multiple co-morbidities including dementia and post-surgery. Interventions included to alert the dietitian if consumption was poor for more than forty-eight hours, provide assistance with meals, monitor and record food intake, monitor for signs and symptoms of dehydration and obtain labs as indicated. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/26/21, revealed the resident was severely cognitively impaired and the resident required setup help and supervision for eating. Review of the Nutrition Assessment, dated 01/27/21, revealed the resident was at a high risk for malnutrition and dehydration. The resident's calculated estimated energy needs were 1424 kcals per day and 1280 to 1500 milliliters (ml.) of fluids per day. The goal was to continue to encourage oral fluid intake throughout the stay to prevent dehydration. The medical record revealed there was no additional follow up from the dietitian from 01/28/21 to 02/19/21. Review of the resident's meal intake from 02/04/21 to 02/19/21 revealed the resident's meal intake ranged from zero to 75 percent (%) meal intake. Her fluid intake ranged from zero to 240 ml. each meal. During this 15-day window, the resident's average meal intake was 66% of the time when the resident ate zero to 50%. The resident's average fluid intake was 460 ml. per day. Review of Certified Nurse Practitioner (CNP) #111's telehealth assessment, dated 02/09/21, revealed the reason for the appointment was to address increased confusion and the resident not wanting to eat. The progress note revealed the resident was noted with dysuria on 02/01/21. The urinalysis and urine culture and sensitivity (C&S) from 02/01/21 revealed a Pseudomonas infection. The resident was treated with [MEDICATION NAME] (antibiotic) for a three-day course. CNP #111 stated in her note that the resident had completed the treatment for [REDACTED]. CNP #111 wrote it was unclear if the confusion was related to infection or with underlying dementia. CNP #111's progress notes further revealed the resident's labs upon admission included a sodium of 138 (135-145), potassium of 4.6 (3.5-5.3), a Urea Nitrogen (BUN) of 32 (7-25) and a creatinine of 1.4 (0.6-1.3). CNP #111 ordered a complete blood count (CBC) (can detect infections, [MEDICAL CONDITION], and [MEDICAL CONDITION]) and a basic metabolic panel (BMP). Review of the physician's orders [REDACTED]. Review of the medical record revealed there was no evidence there were lab results from 02/10/21 through 02/15/21. There was nothing mentioned in the medical record explaining why the physician order [REDACTED].>Review of the nursing progress note, dated 02/14/21 at 3:46 P.M., revealed Resident #55's daughter voiced concerns related to the resident's general decline, especially with cognition and increased confusion. The nurse documented she placed the concerns on the physician's board for review. Review of the physician order, dated 02/15/21, revealed another order for CBC, BMP and urinalysis to be drawn on 02/16/21. Review of the lab work, dated 02/16/21, revealed the resident's sodium was 134 (135-145), carbon [MEDICATION NAME] 16 (21-33), BUN 97 (7-25), [MEDICATION NAME] 2.5 (0.6-1.3), BUN/[MEDICATION NAME] ratio 39 (6-25), glomerular filtration rate (GFR) 22 (greater than 60). The lab work form stated it was reported to the facility on [DATE] at 4:55 P.M. Review of the medical record revealed there were no evidence the laboratory values were reviewed and reported to the CNP and/or physician from 02/16/21 through 02/18/21. Review of the progress note, dated 02/19/21 written by Registered Nurse (RN) #77, revealed a therapist reported the resident had labs drawn on 02/16/21 and they should be addressed with the physician. RN #77 stated she called CNP #111 and received an order to send the patient to the hospital related to critical labs and possible acute kidney injury. Review of the hospital records, dated 02/19/21, revealed the resident was treated for [REDACTED]. The resident's lab values were BUN 111, creatinine 2.3 and the BUN/Creatinine ratio was 48. The physician ordered for the resident to receive gentle hydration on 02/19/21. Subsequently, the resident was admitted to the hospital and was discharged to another facility at an unknown date. Interview on 03/11/21 at 1:15 P.M. with Physical Therapist #100 revealed he had not initially worked with the resident, however in reviewing her documentation, she had significant decline in her strength. Review of the therapy notes with PT #100 for the week of 02/13/21 through 02/19/21 revealed the resident appeared to have a decline in function and in her activities of daily living. The progress notes also revealed the resident required increased physical assistance, and increased verbal and tactile cues. Telephone interview on 03/11/21 at 3:11 P.M. with RN #77 revealed the resident was noted on or around the second week in February to have a decline in her strength. RN #77 further stated the resident was not eating well and seemed more confused. RN #77 stated the CNP did complete an assessment on 02/09/21 in response to the reported decline. RN #77 stated the resident was transferred to the hospital on [DATE] because of critical labs. Interview on 03/17/21 at 4:54 P.M. with CNP #111 confirmed a telehealth assessment on 02/09/21 was completed on Resident #55. CNP #111 stated the resident was seen related to concerns the resident was not wanting to eat or drink and concerns of the resident being more confused. CNP #111 stated she ordered lab work which was a CBC and a BMP to be completed on 02/10/21. During the interview, the CNP #111 had no explanation as to why the labs on 02/10/21 were not completed. CNP #111's expectation was that the facility contacts the physician when abnormal labs were received. Review of the labs dated 02/16/21 with CNP #111 revealed she would have transferred the resident to the hospital on [DATE] had she reviewed them. The CNP further stated her expectation of the abnormal labs received on 02/16/21 was the facility should have provided the results to the physician when they were received from the lab on 02/16/21. Subsequent interview on 03/18/21 at 1:37 P.M. with the CNP #111 revealed the BUN and creatinine were not like a potassium level that has a very specific critical value. CNP #111 stated there was no specific clear number that makes the BUN a critical level. CNP #111 compared the lab results on 02/16/21 with the lab results obtained on 02/19/21 from the hospital and stated there was not a significant difference. CNP #111 did confirm the lab results from 02/16/21 and 02/19/21 revealed the resident was dehydrated. Interview on 03/18/21 at 3:11 P.M. with the DON confirmed the lab results for Resident #55 on 02/16/21 were not provided timely to the physician. The DON also confirmed she did not have an explanation as to why the lab work was not completed on 02/10/21 per the physician's written order on 02/09/21. The DON was not able to provide any evidence the dietitian was notified of Resident #55's decreased intake of food and fluids which were noted on or around 02/09/21. Interview on 03/18/21 at 4:34 P.M. with Registered Dietitian (RD) #444 revealed she completed the admission dietary assessment on 01/27/21. The RD stated Resident #55 was at high risk for nutritional concerns and dehydration and the resident scored a 13 which was considered at high risk for nutrition and dehydration. The RD stated she was at the facility one day a week. The RD stated the nurses and/or the physician will refer residents to be evaluated or followed. The RD stated she was never provided a request or asked to review Resident #55 for hydration or nutrition. There was a meeting one time a week to review high risk residents. Resident #55 was not on the list to be reviewed. Review of the Medscape's online resource titled Blood Urea Nitrogen (BUN), dated 11/19/19, revealed the reference range for adults was 10-20 milligrams (mg.) per deciliter (dL.) and elderly may be slightly raised beyond adult levels. A possible critical value was greater than 100 mg. per dL and it indicated seriously impaired renal function. This deficiency substantiates Complaint Number OH 642.

Based on record review and staff and resident interview, the facility failed to provide adequate pain control for a resident after her admission to the facility. This resulted in actual harm when nursing staff failed to ensure Resident #110 received an as needed (PRN) pain medication when she rated her pain a 10 out of 10 (a scale indicating zero for no pain and ten being the worse pain ever) and when interviewed described it as excruciating pain resulting in crying. This affected one (#110) of six residents reviewed for pain during the annual survey. The facility identified 24 residents on a pain management program. The facility census was 60. Findings include: Record review for Resident #110 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care, dated 11/18/19, revealed the resident was at risk for acute and chronic pain related to her left [MEDICAL CONDITIONS], arthritis, chronic back pain, [MEDICAL CONDITION], and generalized pain. Interventions included to administer medications as ordered, anticipate the resident's needs for pain relief and respond immediately to any compliant of pain and to monitor for potential side effects of medications. Review of the physician orders, dated 11/18/19, revealed orders for [MEDICATION NAME] (narcotic pain medication) five milligrams (mg.) every six hours as needed for pain and [MEDICATION NAME] five mg. every six hours scheduled for seven days. Review of the progress notes, dated 11/18/19, revealed Resident #110 was admitted to the facility at 2:43 P.M. on 11/18/19. Review of the Pain Admission Assessment, dated 11/18/19 at 2:46 P.M., revealed Resident #110 rated her pain a 10 out of 10 (a scale indicating zero for no pain and ten being worse pain ever). Review of the Medication Administration Record [REDACTED].M. on 11/18/19. This was over seven hours after reporting a pain level of 10 to the nurse. Interview with Resident #110 on 11/26/19 at 2:00 P.M. revealed she doesn't remember much about the evening she arrived at the facility. She revealed she was in excruciating pain and was crying. She stated she had requested pain medication and reported she did not receive any medication that evening. Interview on 11/26/19 at 1:15 P.M. with Licensed Practical Nurse (LPN) #100 stated it was her understanding that the new admission orders [REDACTED]. LPN #100 stated the physician was normally in the facility and if the physician was not in the facility then it would be faxed both to the physician and the pharmacy to be reviewed. LPN #100 stated the day shift nurse (LPN #99) had not completed the three admissions from her shift and had stated that she would remain in the nursing station before she left. LPN #100 stated she had been walking down the hallway at an unknown time and went past the closed door of the resident and had heard a noise, which was described as crying out. LPN #100 stated that the resident informed her that she had been in the facility since 1:00 P.M. and had not had any pain medication. LPN #100 stated when she returned to the nurse ' s station, LPN #99 had left, and not completed any of the new admission checklists for any of three new admissions and she had no way to know what was done and what was not done. LPN #100 stated prior to LPN #99 leaving, the LPN had informed her that she had three new admissions and she had not had a chance to get them all done. LPN #100 stated she had to sort through all three admissions to figure out what was needed done. LPN #100 stated before she could go through any of the admission paperwork, she did her medication pass on the 200 hallway and then came to sort through the admission paperwork and then went to do the medications on the 100 hallway. The LPN verified she administered the [MEDICATION NAME] to Resident #110 at 10:10 P.M. Interview with the Director of Nursing (DON) on 11/26/19 at 2:20 P.M. confirmed LPN #99 did not fax over the prescription for the [MEDICATION NAME] to the pharmacy. She also revealed the facility cannot pull out of their E-Box (emergency drug box) until a prescription had been faxed to the pharmacy. The DON confirmed that LPN #99 should have faxed all medications and prescriptions over to the pharmacy before leaving for the day and the [MEDICATION NAME] should have been administered sooner to Resident #110. The DON also confirmed the resident received [MEDICATION NAME] at 10:10 P.M., more than seven hours after the resident expressed a pain level of 10 to the nurse. The DON stated LPN #99 no longer worked at this facility. This deficiency substantiated Complaint Number OH 453.