Every finding on record at Solaris Healthcare Merritt Island

Based on observation, interview, and record review, the facility failed to provide a homelike environment, by serving residents' meals on serving trays in an institutional manner, for all residents who ate meals in the dining area on the secured unit for three different meals observed.Findings: On 6/22/26 at 11:29 AM, during meal observation in the dining area on the secured unit, 8 residents were observed seated at the tables in the dining area. Each resident was noted to have a serving tray on the table in front of them which contained the lunch meal. The plates, cups, bowls and eating ware remained on the tray and were not removed from the trays at the table. On 6/23/26 at 11:05 AM, during meal observation, 9 residents were observed seated in the dining area. Each resident had a serving tray in front of them with their meal, dinnerware and eating utensils on the tray. On 6/24/26 at 11:30 AM, 12 residents were observed seated at tables in the dining area on the secured unit. Each resident's lunch meal was served on a tray which was placed on the table in front of each resident. Dinnerware with meals, cups and eating utensils remained on the trays and were not removed and placed on the table in front of each resident. On 6/24/26 at 11:41 AM, Licensed Practical Nurse (LPN) A was in the secured unit dining area. She acknowledged the residents in the dining area were served on trays and items were not removed and placed on the table. LPN A stated she spoke with the Director of Nursing (DON) and the residents were served on trays as a way to establish a boundary for the residents. She explained that due to their cognitive status, this helped the residents to better identify what items were theirs and what items were someone else's. LPN A stated they had not considered using placemats or something similar, instead of trays to serve the same purpose. The nurse said she did not believe they had any placemats available for use. On 6/24/26 at 11:53 AM, the DON confirmed the trays were used to establish a border for the residents to identify what items were theirs due to their cognitive status. She stated the use of trays was care planned for most of the residents. The DON acknowledged they had not considered the use of placemats to serve the same purpose, which she acknowledged, would be more homelike. On 6/25/26 at 8:00 AM, review of the electronic medical record (EMR) for residents on the secured unit showed that 9 of the residents who ate in the dining area were not care planned for the use of trays prior to survey. The facility's policy and procedure for Homelike Environment dated January 2024 read, The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.

Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 46 residents, (#199).Findings:Resident #199 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation, generalized anxiety disorder, chronic obstructive pulmonary disease and depression.A review of resident #199' s electronic medical record did not indicate he could self-administer medications in the physician's orders and there was no assessment completed for self-administration of medications. The most recent assessment on 6/19/26 revealed a Brief Interview for Mental Status score of 14 out of 15 which meant he was cognitively intact.On 6/22/26 at 11:55 AM, resident #199 was sitting up in bed and said he administered the artificial tears that were on his dresser, himself, twice a day for his dry eyes. The resident said facility nurses were aware he administered the artificial tears, because they can see it right there on the dresser.On 6/22/26 at 12:23 PM, the assigned Licensed Practical Nurse (LPN) B verified there were no orders for eyedrops in resident #199's electronic medical record. LPN B then retrieved the bottle of eye drops from the resident's room and stated he was not allowed to administer the medication by himself. She explained that she would call the doctor for an order for the eyedrops.On 6/22/26 at 3:02 PM, LPN B said there was now an order for artificial tears and that facility staff would administer the eyedrops.On 6/22/26 at 3:12 PM, resident #199 said someone spoke to him about self-administration of medications and that it seemed like too much trouble for the facility staff because they have to have a locked box, so they are going to administer it.On 6/24/26 at 3:24 PM, the Bayside Unit Manager (UM) said this was the second bottle of eye drops they removed from the resident, and she was unsure where he got it from. The Director of Nursing (DON) was at the nurse's station and acknowledged a self-administration Assessment was not done for resident #199 because she thought the resident preferred the facility nurse to administer the eyedrops. The DON explained that medications should not be left out at the bedside for safety reasons.The undated facility's policy on Self -Administration of Medications indicated, in order to, maintain a residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to Activities of Daily Living (ADLs) for Dependent Residents and Activities to Meet Resident Interest or Needs. Findings: Review of the facility's survey history revealed repeat deficiency concerns for ADL care and activities during the past 5 years, and again during current survey. The concerns for ADL care specifically nail care and activities to meet the residents' interests and needs to attain their highest practicable well-being would reflect the third time in five years deficiencies were cited for these areas of concern. On 8/22/24 at 4:00 PM, the Administrator and Risk Manager spoke about the facility's QAPI program. The Administrator verified they completed a plan of correction for ADLs and activities last year and did not currently have any Performance Improvement Plans (PIPs), or other audits for the areas of concern regarding ADL care and activities to meet resident needs and interests. The Administrator was asked how the QAPI committee addressed and/or prevented repeat concerns and deficiencies. The Administrator said, the committee looked at the concerns monthly after receiving deficiencies until they felt the facility was in substantial compliance with the regulation. The Administrator acknowledged the facility had not considered looking at the repeated deficiencies again before the next survey cycle or any alternative measures to help ensure the facility did not continue to have repeated deficiencies with their annual surveys. Review of the facility Quality Assurance and Performance Improvement Plan date 1/1/24 read, The purpose of QAPI in our organization is to take a proactive approach to continually improve .Criteria for prioritizing and selecting PIPs are bases on prevalence .The key elements of the QAPI program will be reviewed to assure that they are occurring, that the program is efficient .Ongoing training needs will be identified and addressed .

Based on observation and interview, the facility failed to ensure food items were stored in a manner to prevent contamination by keeping them sealed, dated and discarded before their expiration date. This failure had the potential to negatively effect 158 of 158 residents who consumed food items by mouth. Findings: 1. On 8/19/24 at 10:20 AM, during the initial kitchen inspection with the Certified Dietary Manager (CDM), the walk-in freezer was observed to contain multiple cardboard shipping boxes in which the interior bag holding food items was unsealed, leaving the food items open to the air. These unsealed and undated items were beef patties, Rib type-meat, Plant-Based Chick-N-Strips, eggs, and pancakes. A box of popsicles was observed with a large build-up of ice encasing approximately half the popsicles in the box. In the walk-In refrigerator, there was a half-pan of cooked rice dated 8/14. The CDM confirmed the date on the half-pan of rice and stated their policy was to discard prepared food after three days, and discarded the rice. A package with approximately 8-10 sausage patties were also found open to the air, unsealed with no date to indicate when it was opened. In addition, previously opened containers of soup base and parmesan cheese were also found undated. The CDM acknowledged these findings and threw the food items away. In the dry storage area, a box with an unsealed, open plastic bag was found. The plastic bag contained thickening agent which was not sealed or dated. The CDM confirmed the open plastic bag and stated he would have a staff member repackage this dry food item properly. 2. On 8/21/24 at 1:43 PM, the walk-in freezer and refrigerator were re-inspected with the CDM. In the walk-in refrigerator, again a half-pan of cooked rice and an opened container of Parmesan cheese were found undated. Also a full pan of leftover ham was observed with the plastic wrap open/unsealed. Review of the facility's Dietary Services policy for Food Receiving and Storage dated 1/30/24 revealed dry foods stored in bins would be removed from original packaging, labeled and dated. The policy also indicated all food stored in the refrigerator and freezer would be covered, labeled, and dated, and other opened containers of food and beverages must be dated, sealed, or covered and held no longer than 72 hours.

Based on observation, interview, and record review, the facility failed to secure one (1) treatment cart to prevent unauthorized access and promote resident safety, (Riverside), and failed to properly store medications and bottles of liquids in four (4) medication carts and one (1) treatment cart, (Bayside, Oceanside, and Riverside), for 6 of 8 carts inspected during the Medication Storage task, of a total of 14 medication/treatment carts. Findings: 1. On 8/19/24 at 10:15 AM, the 300 hallway treatment cart was observed between rooms [ROOM NUMBERS], on the Riverside Unit. The drawers faced the hallway and the lock protruded from the cart to indicate it was unlocked. All drawers opened smoothly and the contents of each drawer were easily accessible. On 8/19/24 at 10:18 AM, Licensed Practical Nurse (LPN) F verified the treatment cart was unlocked, which allowed all drawers to be opened. She looked to the left of the cart and confirmed there was at least one confused resident in the hallway by the cart. She acknowledged there were other confused residents near the nurses' station. Observation of the treatment cart drawers revealed they contained medications and treatment supplies including scissors, prescription ointments and lotions, and wound cleanser solutions which could be toxic if ingested. LPN F confirmed she had the key for the treatment cart and was responsible for its security. She explained she had not accessed the treatment cart since the start of the shift at 7:00 AM. She stated the cart was probably unlocked since the overnight shift. LPN F acknowledged medication and treatment carts should never be unlocked and unattended. She said, We want to prevent patients or anybody else getting into the carts. Most items are by prescription which means only the nurse should have access to them. 2. On 8/20/24 at 9:53 AM, LPN E retrieved a bottle of liquid protein supplement from the Riverside Unit 300 hallway medication cart. There was a significant amount of hardened sticky residue in lines that extended from the top of the plastic bottle to its base. The dried liquid was noted on all sides of the container. LPN E attempted to scrape the residue off the plastic bottle and said, It's so bad. It's hard to come off. She stated each nurse was responsible for cleaning any spills that occurred when the thick liquid was poured from the bottle. 3. On 8/21/24 at 1:26 PM, Registered Nurse (RN) I confirmed she was responsible for the Bayside Unit high-600 hallway medication cart. During inspection of the cart, RN I discovered two boxes of skin protectant in the bottom right drawer. She confirmed treatment supplies were not to be stored in a medication cart. In another drawer, a plastic bottle of liquid protein had dark, dried, spilled residue stuck to the sides. RN I started to pick at the hardened substance on the bottle but she was unable to get it all off. She explained all nurses were responsible for cleaning bottles after use. Observation of the drawer revealed there was residue from the bottle of liquid protein in a circular shape. RN I stated she noticed the substance stuck in the bottom of the drawer, and although she tried to scrape it off with scissors, she was never able to get it out. 4. On 8/21/24 at 1:39 PM, RN I stated she would return the two boxes of skin protectant to the Bayside Unit 600 hallway treatment cart. She opened the bottom drawer of the treatment cart to show a bottle of Betadine antiseptic solution lying on its side. A large amount of the dark brown liquid contents of the bottle had spilled in the drawer and there was residue dried onto the sides of the bottle. RN I reached in and discovered the bottle was stuck to bottom of drawer in the hard, dried pool of liquid. 5. On 8/21/24 at 2:12 PM, during inspection of the Oceanside Unit 100 hallway medication cart, LPN H removed an old, soiled, almost opaque plastic bag that contained a bottle of liquid iron supplement. There was dark brown, spilled medication on the sides of the bottle that partially covered the label, and dried residue in the bottom of the plastic bag. An old rubber band was stretched around the plastic bag to secure it to the bottle. LPN H explained the night nurse usually deep-cleaned the medication cart on a Sunday night. She acknowledged the bottle should have been cleaned and placed in a clean plastic bag. 6. On 8/22/24 at 11:45 AM, during inspection of the Riverside Unit 400 hallway medication cart, LPN G opened a drawer that contained five prescription inhalers, one COVID-19 test kit, and six syringes of normal saline flush. There was no divider in the drawer and the inhalers were adjacent to two large containers of germicidal wipes. LPN G confirmed cleaning supplies should not be stored in the same drawer as medication. Review of the facility's policy and procedure for Storage of Medications, revised in January 2018, revealed medications and biologicals were to be stored safely, securely, and properly. The document indicated medication supply should be accessible only to licensed nursing personnel and pharmacy personnel. The policy revealed medication rooms, carts, supplies would be locked when not attended. The document indicated potentially harmful substances including cleaning supplies and disinfectants should be clearly identified and stored separately from medication. The policy revealed deteriorated medications and soiled containers would be removed from the cart, disposed of, and re-ordered as indicated.

Based on observation, interview, and record review, the facility failed to ensure an individualized activities program was provided for 1 of 2 residents reviewed for Activities, of a total sample of 51 residents, (#156). Findings: Review of the medical record revealed resident #156, an [AGE] year old female was admitted to the facility on [DATE] with diagnoses of left hip fracture, difficulty in walking, cognitive communication deficit, psychotic disturbance, dementia, Alzheimer's Disease, mood disorder, depression, and anxiety. The Minimum Data Set (MDS) Modified Admission assessment with an Assessment Reference Date (ARD) of 7/14/24 identified during the look back periods, resident #156 often required help with reading. The Brief Interview for Mental Status score of 3 out of 15 indicated the resident was severely cognitively impaired. The assessment showed she had inattention that fluctuated, and she often felt lonely or isolated from those around her. No behaviors or rejections of evaluation or care were noted. The resident's Functional Abilities and Goals of everyday activities showed she was dependent on staff to eat, complete Activities of Daily Living (ADL), mobility functions, walk or transport herself out of her room, and she was always incontinent of bladder and bowel functions. The Preferences for Customary Routine and Activities section documented it was very important for the resident to listen to music she liked, keep up with the news, do favorite activities, go outside for fresh air in good weather, and do things with groups of people. The Comprehensive Care Plan's focuses included impaired ambulation, inability to independently complete ADLs, decreased strength/endurance, adverse effects of psychotropic medications, memory problems, confusion and forgetfulness. Interventions included staff to encourage visits from family, friends, and volunteers and involve her in facility activities. Another focus for a risk for decline in mood/behavior related to depression had an intervention to assist in setting a structured routine; reinforce physical activity, socialization, and encourage visits from family, friends, and volunteers. The Recreation/Wellness Problem created by the Activities Director read, Dependent of staff for activities, cognitive stimulation, and social interaction . Approach adapt activities of preference to cognitive level and skill function. Allow patient/resident to be a spectator in activities. Invite to food related activities . Provide activities in an outside setting . Verbally check with patient/resident/or family frequently to determine satisfaction in activities. On 8/20/24 at 10:29 AM, resident #156 was observed alone in her room approximately 50 feet from the nurse's station. She was sitting in a wheelchair with her head down towards her lap. She looked up and asked, Where are all the girls? The handwritten Activity Admission 72 Hour Note completed by the Activities Director showed information was obtained from resident #156's family. It was noted the resident's former vocation was a realtor, and it was very important for her to have music (oldies), keep up with the news, go outside on walks, paint, play bingo, card games, and bridge, and see comedy. The form read, Loves to be around people . going out to lunch with friends . On 8/20/24 at 11:19 AM, the resident was observed in her room awake and lying in bed. The resident looked anxious and restless while she repeatedly pulled at the bed cover. On 8/21/24 at 11:24 AM, the Activities Director explained she was responsible for the facility's Activities program. She said the department coordinated and provided activities for residents, and she conducted interviews with residents and/or their family to develop and implement individualized care plans. On 8/21/24 at 11:35 AM, the Activities Assistant explained resident #156 sometimes participated in manicures and she enjoyed socializing with the ladies. She stated, She looks through a book or she watches TV (television). On 8/21/24 at 12:04 PM, five residents were observed in the Bayside dining room for lunch. Certified Nursing Assistants (CNAs) P and Q assisted the residents with eating. CNA P explained resident #156 ate in her room and he was provided a list of residents who needed assistance to get to the dining room for meals by the Bayside Unit Manager. On 8/21/24 at 12:15 PM, the Bayside Unit Manager said the Dietary Menu Development Coordinator provided a list of residents that ate in the dining room, and it was kept at the nurse's station for the CNAs. On 8/21/24 at 1:52 PM, CNA P explained he often had resident #156 on his assignments, and was not aware of what activities she liked. He could not recall any times she participated in group activities. The CNA stated, That's a good question; I usually get her up in a chair and have her in the hallway but today I had to go to the dining room. On 8/22/24 at 1:27 PM, the Dietary Menu Development Coordinator explained that Unit Managers provided a list of residents on their unit who ate in the group dining room to the Registered Dietician. She said she didn't have input for who goes on the list, and she only typed it up and gave it to the Unit Managers. Review of the list of residents who ate in group dining provided by the Bayside Unit Manager included 7 residents on the unit who participated in group dining. Resident #156 was not on the list. On 8/22/24 at 9:27 AM, an overhead announcement was heard for group activities on the Bayside Unit. At 10:13 AM, the Bayside Unit Manager said the Activities staff had not arrived yet for group activities. At 10:35 AM, no residents were observed in the unit's TV/group room/common area. On 8/22/24 at 10:38 AM, resident #156 was observed sitting in her room in a wheelchair pulling at her clothing. The TV was not on nor were there any reading materials observed within reach of the resident. The resident stated, I don't know if my daughter is coming. In a telephone interview with resident #156's daughter, she recalled that about one month prior, the Activities Director asked her a lot of questions about her mother's normal preferences and activities. She was distressed when she explained she had asked nursing staff to take her mother to the dining room and help her participate in group activities. She said two days prior, she wheeled the resident down to an exercise class. She said she watched through the window and saw her participating while she had her hands up and seemed to enjoy it. She stated, I have seen them maybe a total of three times get her out of her room and they put her in that room where the TV is and leave her there; it makes her feel better to be out of her room and socialize; they don't take her outside, she likes that very much; she always enjoyed going out and eating with friends; she is still able to socialize if she's in the right environment; even when I wheel her down the hall she starts talking to people and she lights up, I think, there's my mom. On 8/21/24 at 11:24 AM, the Activities Director said the CNAs were responsible for assisting residents out of their rooms for activities. She did not explain why resident #156 spent most of her time in her room. On 8/22/24 at 1:30 PM, the Bayside Unit Manager explained residents who needed assistance with eating or who preferred to, ate in the group dining area. She said it was important to assist the residents to ensure they were eating well, getting adequate nutrition, and they could socialize. She said resident #156 normally did not come out of her room and she ate her meals there because that was her daughter's preference. She stated, I'm not sure why she hasn't been in the day room; I will look into that. On 8/22/24 at 10:42 AM, the Social Services Director explained it was important for residents to have activities for emotional support and adjustment disorders. She said going outside, getting involved with activities, and socializing helped with residents' depression, eating, and sleeping. She stated, Isolation can cause people to be depressed or withdraw even more; it's important to stimulate them and try to get them involved in interactions. Review of the facility's standards and guidelines dated 2/27/20 and titled 2.8 Activities Programs read, . Our activities programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interest of each resident .Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and to provide fun and enjoyment .

Based on observation, interview, and record review, the facility staff failed to treat residents with dignity and respect as evidenced by addressing them as, feeders, and not allowing a resident's choice to ambulate freely while waiting for meals, for 4 of 17 residents on the locked memory care unit, (#104, #94, #122 and #61). Findings: 1. On 8/20/24 at 11:16 AM, Certified Nursing Assistant (CNA) K was overheard to question, [Activity Personnel M's name], are you going to feed [resident #104]? Activity Personnel M replied, Sure, who do you want me to feed? CNA K answered, Resident 104. Then CNA K repeated, Resident 104 is a feeder. A short time later, CNA K was asked whether it was appropriate for staff to call residents, Feeders, while speaking about the residents. CNA K replied, I said that? I didn't even realize I said it. She then stated she was aware it was a dignity issue to identify residents using that term. 2. On 8/20/24 at approximately 11:30 AM, Activity Personnel M repeatedly called out resident #94's last name when the resident was starting to leave the lunch area. Activity Personnel M stated she called the resident by her last name because the resident responded when called by her last name instead of her given name. She explained when she called a resident by their last name, it was just a way of referring to them. Activity Personnel M elaborated that this resident used to be on another unit and was called by her last name there as well. On 8/21/24 at 12:40 PM, Nurse Supervisor O stated she herself did not call resident #94 by her last name but referred to her with the prefix or courtesy title of Ms. in front of her last name. In the resident's medical record, it stated this resident preferred name was a shortened version of her first name. 3. On 8/20/24 at 3:50 PM, resident #122 was observed as she tried to leave the dining room area with one sock in her hand. Activity Personnel M asked the resident where she was going and encouraged her to instead stay seated. Resident #122 continued to leave and CNA K redirected resident #122 back to her seat to watch TV. On 8/22/24 at 4:10 PM, Activity Personnel M stated resident #122 had decreased balance and needed someone to walk with her. She explained, if there was another CNA close by, she would have asked them to stay with the other residents and would have walked with the resident. She was surprised to learn that another CNA was close-by who also redirected the resident to sit back down. 4. On 8/20/24 at 3:52 PM, resident #61, using her walker, headed toward the unit's exit door and stated she was looking for her jacket. CNA L stated, I will find your jacket, go sit in your chair. A short time later at 4:10 PM, resident #61 got out of her chair and started walking with her walker and again asked about her jacket. CNA L redirected resident #61 back to the chair and parked her walker to the side of the chair telling her dinner would be there soon even though it was over an hour until dinner was scheduled for that unit. CNA L stated she redirected the resident to sit in the chair instead of allowing her to walk around because she was afraid the resident would fall. On 08/22/24 at 1:38 PM, Nurse Supervisor N stated if a resident was able to walk on their own safely, CNAs were expected to let them walk or if not safe, instead walk with them. She stated resident #61 did not usually go far, was pretty safe to ambulate on her own, and realized her limitations. Nurse Supervisor N explained resident #61 didn't usually try to leave but would use her walker to go to her room. Nurse Supervisor N stated she trained the CNA's that it was important for residents to be able to walk and wander, otherwise they would get restless and eventually would forget how to walk. On 8/21/24 at 1:18 PM, the Lakeside Unit Manager stated if a resident got up to walk around, CNA's were expected to assist them as needed because walking around was good for them. It maintained their mobility and gave them a sense of well-being. On 8/22/24 at 3:45 PM, the Activities Director stated If you don't use it, you will lose it, when discussing the importance of residents being allowed to walk when they wanted to walk. On 8/22/24 at 3:21 PM, Nurse Supervisor N, stated she trained the CNAs to treat residents with dignity. She explained, some of the staff had worked on this unit for many years and perhaps had developed habits that were difficult to break. The facility's Policy on Dignity dated 2/27/20 stated residents would be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. This policy indicated residents would be called by their name of choice, in a manner to promote dignity and would be assisted in the activities of their choice.

Based on interview and record review, the facility failed to implement its abuse prohibition policy and procedures related to an allegation of mistreatment by 1 of 2 residents reviewed for abuse, of a total sample of 51 residents, (#146). Findings: Review of the medical record revealed resident #146, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy or a brain disorder, and adult failure to thrive. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 7/12/24 revealed resident #146 had clear speech and was usually able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed during the 14-day lookback period, resident #146 showed no evidence of acute onset mental status change. She exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident required substantial to maximal assistance to roll from left to right in bed and to maintain personal hygiene. She was totally dependent on staff for toileting hygiene and bathing. On 8/19/24 at 2:28 PM, resident #146 described an incident that occurred with a Certified Nursing Assistant (CNA) within the previous two to three days, during the day shift. The resident said, She was very rough while turning me. She does not tell me when she is doing anything. The resident explained the CNA habitually rolled her quickly from side to side without warning her or explaining what she was going to do, and was not gentle. When asked if she reported the incident to anyone, resident #146 confirmed she asked someone to get the head nurse to come to her room. The resident could not recall the name of the CNA who was rough with her nor the name of the nurse who responded. She stated she told the nurse the CNA was rough with her and she did not want that person assigned to her again. On 8/19/24 at 2:41 PM, the Riverside Unit Manager (UM) stated she was not aware of an allegation of rough treatment by resident #146. On 8/19/24 at 2:44 PM, resident #146 repeated the allegation as she informed the Riverside UM that a CNA was rough with her during care. The resident told the UM that the CNA had been rough with her several times before, but she finally had enough that day, and decided to tell a nurse. On 8/19/24 at 2:47 PM, when asked about the facility's policy to prevent abuse, the Riverside UM stated the nurse who resident #146 spoke with should have reported the information to the supervisor. She acknowledged any employee who was made aware of a grievance, concern, or an allegation of mistreatment, abuse, or neglect should report it to a supervisor immediately to ensure the information was properly passed along to facility administration. On 8/19/24 at 2:51 PM, the facility's Administrator was informed of resident #146's allegation of rough care by a CNA. He confirmed staff were expected to follow all policies and procedures for prevention of abuse and neglect. On 8/19/24 at 3:39 PM, the Administrator stated he interviewed resident #146 and she confirmed she felt abused while she was being repositioned in bed by a CNA. He explained the resident was able to describe the CNA, and after review of the schedule, the preliminary investigation showed the resident referred to CNA J. The Administrator said, [The resident] said a nurse came in and she explained everything to the nurse. It was not reported to us. He stated his expectation was the nurse should have reported the allegation so it could have been thoroughly investigated by the Risk Manager (RM). The Administrator verified residents did not have to use the word abuse to ensure an allegation was investigated. He explained at the very least, the concern should have triggered the grievance process, and it would have been escalated to an abuse investigation if indicated. On 8/19/24 at 5:32 PM, the Administrator stated the facility's investigation showed resident #146's assigned nurse on the day of the incident was Licensed Practical Nurse (LPN) B. He explained LPN B denied the resident told her she was abused by CNA J. He acknowledged even if the word abuse was not used, it was not LPN B's decision whether it was an abuse situation or not. He said, But the nurse wrote it up as a grievance on Friday and we just haven't had time to go over them yet. You guys showed up this morning. However, the Administrator reviewed the grievance log and confirmed resident #146's concern was not recorded on the document. On 8/20/24 at 10:07 AM, LPN B confirmed she was resident #146's assigned nurse on the day of the alleged abuse incident. She recalled she responded to the resident's call light and was also told by CNA J that the resident wanted to speak to her. LPN B stated the resident seemed a little confused and said she did not care for the CNA's personality as she, did not seem to be that nice. She denied the resident reported the CNA was rough with her. LPN B explained resident #146 sometimes had memory problems and was only alert and oriented 60% to 70% of the time. LPN B refuted the Administrator's statement and denied she wrote a grievance form on the day of the incident. She recalled the resident expressed the concern towards the end of the day shift, and instead of writing a grievance form, she called the facility's Social Services Director (SSD) and left a message for her regarding resident #416 not caring for CNA J's personality. LPN B then corrected herself and stated she actually had a telephone conversation with the SSD, who told her thanks for the information and she would take care of it. LPN B stated the SSD did not ask if CNA J was removed from resident #146's assignment. She acknowledged she did not document her conversations with either the resident or the SSD in the medical record. LPN B scrolled through her personal phone and provided the SSD's telephone number. On 8/20/24 at 10:23 AM, the facility's SSD stated the telephone number provided by LPN B was her personal cell phone number. However, she denied receiving a telephone call from LPN B regarding any issues concerning resident #146. She reviewed her cell phone log for Friday 8/16/24 and emphasized there were no calls from LPN B. The SSD stated she was not aware of the incident involving resident #146 and CNA J until the facility was informed by the State Survey Agency on 8/19/24. She verified resident #146 was cognitively intact and her complaint of unsatisfactory care or rough treatment should have been recorded and reported. The SSD explained there are evening supervisors in the building every day, and on the weekends there are both a weekend supervisor and a manager on duty. The SSD stated LPN B should have reported the resident's concerns to the supervisor on site. Review of the facility's policy and procedure for Resident Mistreatment, Neglect and Abuse Prohibition, dated 1/24/23, revealed the facility was committed to protecting the physical and emotional well-being of every resident. The document indicated the definition of abuse was the willful infliction of injury or intimidation that resulted in physical harm, pain, or mental anguish. The document revealed mandated reporting was a legal obligation to formally report suspected or witnessed abuse or mistreatment of residents. Residents and staff would be able to report any concerns, incidents, or grievances, and supervisory and administrative staff would provide regular direct/indirect supervision of nursing home employees and resident care. The policy read, All employees are required to immediately report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that the facility responsibilities to protect residents and promptly investigate occurrences can be met.

Based on observation, interview, and record review, the facility failed to implement the comprehensive care plan related to interventions to prevent falls and injuries for 1 of 5 residents reviewed for accidents, of a total sample of 51 residents, (#51). Findings: Review of the medical record revealed resident #51, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included syncope and collapse, dementia, anemia, vertigo, anxiety, and stroke. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/13/24 revealed resident #51 had a Brief Interview for Mental Status score of 6 which indicated she had severe cognitive impairment. The document revealed the resident exhibited fluctuating inattention and disorganized thinking that varied in severity. The MDS assessment indicated the resident displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve the resident's goals for health and well-being. Resident #51 had functional limitation in range of motion with impairment of both lower extremities. She was dependent on staff for toileting hygiene, lower body dressing, and transfers between her bed and wheelchair. The MDS assessment revealed resident #51 had one fall with no injury since admission or the prior assessment. Review of the medical record revealed resident #51 had a care plan for risk for falls related to impaired mobility, weakness, history of falls, vertigo, and vision impairment, initiated on 6/15/22 and edited on 7/08/24. The goal was the resident would have a reduced risk for injury related to falls. The care plan approaches included keep the resident's bed in a low position for safety, apply hipsters while in bed, encourage use of geri-sleeves, provide a perimeter mattress with raised sides, and place bilateral floor mats when she was in bed. The care plan indicated staff could remove the hipsters to perform skin checks and hygiene. Hipster garments look like shorts with pads on the hip areas to protect bones from injuries associated with falls. Geri-sleeves are a stocking-type garment for the extremities that protects against injuries such as skin tears. On 8/20/24 at 1:16 PM, resident #51 was observed in her room with her bed in low position. A handwritten sign posted on the wall above the bed revealed instructions to ensure the bed was lowered to the floor as the resident experienced increased anxiety since she fell out of bed. Photographic evidence was obtained. There were two floor mats leaning against the wall next to the door and the resident did not wear geri-sleeves on her arms. Certified Nursing Assistant (CNA) A explained she completed personal hygiene care for the resident after lunch and left her in bed to rest. She acknowledged she did not place the floor mats on both sides of the bed before she left the room. When asked if the resident wore a hipster garment, CNA A said, We don't put the hipsters on anymore.they are uncomfortable. We told the daughter and she said it's ok. CNA A explained sometimes resident #51 would remove the geri-sleeves, but she did not respond when asked if she applied them this morning. CNA A stated the facility's system for communication of care directives for each resident was a paper form located in a plastic sleeve on the back of the room door. Review of the Resident Care Card/Information Sheet for resident #51 revealed a section designated for Fall Management that included one approach, use of a one-way glide device in her wheelchair. The document did not reflect any of the fall and injury prevention interventions listed in the comprehensive care plan. The active care plan approaches of right and/or left fall mats, low bed, and hipsters were not checked off on the document, and the need for geri-sleeves was not noted. On 8/20/24 at 1:23 PM, the Risk Manager (RM) confirmed the facility did not have a fully electronic care card system and CNAs were expected to obtain care instructions from the paper form that was kept in the resident's room. On 8/20/24 at 4:49 PM, CNA C stated she was on staff for over seven months and was resident #51's regularly assigned evening shift CNA. During joint observation of resident #51, she validated the resident still did not wear geri-sleeves and she had not attempted to apply them since her arrival at 2:00 PM. When asked if she usually applied the resident's hipsters, CNA C said, I don't know what they are. On 8/20/24 at 4:54 PM, the Riverside Unit Manager (UM) was informed of concerns regarding the CNAs' access to and knowledge of fall prevention interventions to ensure the care plan approaches were appropriately implemented for resident #51. She was told the resident's fall mats, hipsters, and geri-sleeves were not in place during the day shift, and the resident still did not have geri-sleeves or hipsters placed for the evening shift. The UM acknowledged if the regularly assigned CNA did not know what hipsters were, then she probably had not been providing the garment for the resident. She stated her expectation was staff would ask the assigned nurse for clarification if they did not understand care directives. On 8/20/24 at 4:56 PM, the Riverside UM entered resident #51's room and described the hipster garment to CNA C. They both searched the resident's shelves, dresser drawers, and closet, but neither staff member was able to locate hipsters. The UM stated CNAs were to follow instructions on the resident's care cards. She retrieved resident #51's care card and verified the comprehensive care plan interventions were not transcribed to the document. On 8/21/24 at 12:13 PM, the Lead MDS Coordinator explained fall prevention interventions were usually added to residents' care plans by the RM. She confirmed floor nurses and UMs could initiate care plan interventions and they were responsible for updating the CNA care card to reflect revised approaches. The Lead MDS Coordinator stated care plan interventions would not be effective if they were not documented and made available to direct care staff. On 8/21/24 on 1:54 PM, in a telephone interview, resident #51's daughter explained she was familiar with her mother's care as she visited at least five days a week and she was also the primary contact person. She confirmed her mother had a couple falls from bed so she created and placed the sign above her mother's bed to remind staff to keep it in a low position. The resident's daughter said, I still find the bed in a high up position sometimes. When asked if her mother tolerated the hipsters as an intervention to prevent injury, resident #51's daughter stated she did not understand the question. After being given a description of the garment, the daughter said, That all sounds good, but I have never heard of that. On 8/22/24 at 1:34 PM, the Director of Nursing (DON) stated her expectation was nurses would initiate appropriate fall prevention interventions immediately after a fall. She explained when the interdisciplinary team met to identify the root cause of a fall, interventions might be modified if necessary. The DON stated the RM was responsible for adding new interventions to residents' care cards and UMs were responsible for auditing the care cards to ensure accuracy. The DON acknowledged the purpose of a complete and accurate care card was to ensure residents received appropriate care. Review of the facility's policy and procedure for Comprehensive Care Plans (undated) revealed each resident would have an individualized, comprehensive care plan developed to meet his/her medical and nursing needs. The policy indicated the comprehensive care plan would incorporate identified problem areas, risk factors, wishes regarding care and treatment goals, and reflect current standards of practice. The document read, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. The facility's policy and procedure for Using the Care Plan, dated 1/30/24, read, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care and services to the resident. The policy indicated care cards would list necessary care plan interventions for CNA would be updated as needed.

Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care related to personal hygiene for 1 of 1 resident reviewed for ADLs, of a total sample of 51 residents, (#146). Findings: Review of the medical record revealed resident #146, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy or a brain disorder, and adult failure to thrive. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 7/12/24 revealed resident #146 had clear speech and was usually able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed during the 14-day lookback period, resident #146 showed no evidence of acute onset mental status change. She exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident required substantial to maximal assistance to maintain personal hygiene. Review of the medical record revealed resident #146 had a care plan for ADLs, initiated on 7/14/23. The document indicated she was unable to complete ADLs independently due to weakness and dementia, preferred to wear gowns and kept her fingernails long. The goal was resident #146 would have her ADL needs met daily, with staff assistance. The approaches included, assist with hygiene as needed. A care plan for behaviors related to cognitive impairment, initiated on 7/26/23, had the goal that the resident would have fewer episodes of resisting care. The care plan approaches directed staff to divert the resident's attention, re-approach her later when agitated, discuss behaviors when unacceptable, reinforce positive behaviors, and anticipate her needs. On 8/19/24 at 11:16 AM, resident #146 lifted both hands to show that all fingernails were long and dirty. The resident's fingernails extended approximately one-half inch or more past her fingertips and there was a significant amount of a dark brown to black substance packed tightly under all fingernails. Resident #146 unsuccessfully attempted to use the tip of one fingernail to dislodge the substance under another fingernail. The resident explained she liked her fingernails long but would never keep them as dirty as they were if she had a choice. She emphasized she definitely did not want to eat with fingernails that looked the way they did. Resident #146 could not recall when she last received nail care and said, It has been a while. She stated the situation was not really the fault of staff as they were often too busy to do little things like clean her hands and trim her fingernails. The resident explained she planned to ask someone to give her a basin so she could soak her fingernails. Certified Nursing Assistant (CNA) A entered the room and stated she was not assigned to resident #146, but overheard the conversation, and would provide nail care for her. CNA A validated the resident's fingernails were long and very dirty. She confirmed all CNAs were responsible for personal hygiene care, and residents should receive nail care at least twice weekly on shower days. On 8/19/24 at 2:27 PM, resident #146 unwrapped small chocolates and held them in her fingers as she ate them. She showed her fingernails and stated she was happy they were finally clean. The resident confirmed she liked her fingernails, to be a little long, but nothing like this. Resident #146 held a chocolate between her right thumb and index finger to demonstrate how difficult it was to grasp food, and keep the nails clean when her fingernails were that long. On 8/19/24 at 2:39 PM, the Riverside Unit Manager (UM) stated nail care should be done with daily ADL care, by staff on any shift. She said, There is no reason nail care should not be done regularly. On 8/19/24 at 2:42 PM, resident #146 informed the Riverside UM that a CNA soaked her fingernails earlier in the day. She told the UM the CNA had to, dig out the dirt, and she now wanted her fingernails trimmed shorter. The resident informed the UM she could pay for a manicure if necessary, but the UM reassured her that cleaning and trimming her nails were regular tasks to be performed by CNAs. Review of the CNA Shower Sheet/Skin Inspection forms for August 2024 revealed CNA documentation that resident #146 received bed baths on 8/07/24, 8/10/24, 8/13/24, and 8/17/24. The forms indicated the resident, refused nail care. Review of nursing progress notes for August 2024 revealed no evidence nurses were made of aware of multiple refusals of care by resident #146. There was no documentation to show nurses noted the condition of the resident's fingernails during daily interactions with her. The progress notes did not indicate nurses instructed CNAs to perform nail care or that they implemented any of the care plan approaches developed to address refusals of care. Review of the facility's policy and procedure for Supporting Activities of Daily Living, revised on 1/25/23, revealed residents who were unable to independently perform ADLs would receive the services necessary to maintain good grooming and personal hygiene.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician, in accordance with professional standards, for 2 of 3 residents reviewed for respiratory care, of a total sample of 51 residents, (#57 and #77). Findings: 1. Review of the medical record revealed resident #57, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included hypertensive heart disease with heart failure, history of COVID-19, and cardiomegaly or an enlarged heart. Resident #57 had a terminal condition, end-stage heart disease, with a projected life expectancy of six months or less. The Minimum Data Set (MDS) Annual assessment with assessment reference date (ARD) of 7/08/24 revealed the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated the resident had moderate cognitive impairment. The MDS assessment indicated resident #57 displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident received oxygen therapy. According to the American Heart Association, oxygen therapy is one of the treatments used to improve the quality of life for persons with a diagnosis of heart failure. Delivery of concentrated oxygen to the lungs increases the amount of oxygen in the blood and improves shortness of breath, (retrieved on 8/26/24 from www.heart.org/en/health-topics/heart-failure/treatment-options-for-heart-failure/medications-used-to-treat-heart-failure). Review of the medical record revealed resident #57 had a care plan for the risk for complications related to cardiac disease, initiated on 8/21/20. The interventions included observe for signs and symptoms of cardiac complications such as chest pain and shortness of breath, and administer oxygen as ordered. A care plan for risk of complications related to respiratory disease, initiated on 7/17/24, revealed resident #57 was dependent on supplemental oxygen. The goal was the resident would not develop signs and symptoms of respiratory complications. The interventions instructed nursing staff to monitor for respiratory concerns including shortness of breath and administer oxygen as ordered. Review of resident #57's medical record revealed a physician order dated 8/20/20 for oxygen at 2 liters per minute (L/min) via nasal cannula, every shift, 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. On 8/19/24 at 11:06 AM, resident #57 was in bed and wore a nasal cannula. The tubing was connected to an oxygen concentrator at the right side of her bed, out of the resident's reach, which was set at a flow rate of 1 L/min. An Advanced Practice Registered Nurse entered the room and explained whenever she assessed the resident, the concentrator was usually set at 1 L/min. She suggested it was possible the attending physician's order was to titrate the resident's oxygen flow rate between 1 and 2 L/min. On 8/19/24 at 11:07 AM, Licensed Practical Nurse (LPN) D confirmed she was resident #57's assigned nurse. She checked the physician order for oxygen therapy and stated the resident's oxygen flow rate should be 2 L/min. She inspected the oxygen concentrator and validated the machine was set at a flow rate of 1 L/min. LPN D explained nurses were required to document on the resident's oxygen use once per shift and she would could do that at any time between 7:00 AM and 7:00 PM. LPN D verified she administered resident #57's scheduled morning medication earlier in the shift, but she did not check the oxygen concentrator while she was at the resident's bedside. On 8/20/24 at 4:32 PM, the Riverside Unit Manager (UM) validated it was important to follow physician orders for oxygen administration. She stated her expectation was the nurse would check the flow rate at the beginning of the shift or at the time of administration of morning medications. The UM explained resident #57 required oxygen therapy as she has a history of the respiratory virus, COVID-19, and had been dependent on oxygen for several years due to a diagnosis of heart failure. 2. Review of the medical record revealed resident #77, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included dementia, anemia, and insomnia. Resident #77 had a terminal condition, cerebral atherosclerosis, with a projected life expectancy of six months or less. The MDS Annual assessment with ARD of 6/14/24 revealed resident #77 had a BIMS score of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no acute onset mental changes, no behavioral symptoms, and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document showed the resident received oxygen therapy. Review of the medical record revealed resident #77 had a care plan for risk for complications related to respiratory disease, initiated on 1/11/24. The goal was the resident would not develop signs or symptoms of respiratory complications. The approaches included observe for signs and symptoms of respiratory complications and administer oxygen as ordered. Review of resident #77's medical record revealed a physician order dated 3/14/24 for oxygen at 2 L/min via nasal cannula, to keep oxygen saturation levels above 92% every shift, 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. Review of the Medication Administration Record (MAR) for August 2024 revealed from 8/01/24 to 8/19/24 there was no documentation of resident #77's oxygen saturation levels. On 8/19/24 at 11:13 AM, resident #77 was seated in a wheelchair beside her bed. She had a nasal cannula in place connected to an oxygen concentrator located out of reach, behind the wheelchair. The oxygen flow rate was set at 3 L/min. On 8/19/24 at 11:20 AM, LPN D, resident #77's assigned nurse, reviewed the physician orders and stated the resident's oxygen flow rate was supposed to be 2 L/min. On 8/19/24 at 11:22 AM, LPN D validated resident #77's oxygen concentrator was incorrectly set at 3 L/min. On 8/20/24 at 4:38 PM, the Riverside UM reiterated nurses should check oxygen concentrators when they entered residents' rooms. She explained oxygen orders were listed on the electronic MAR and were easily visible when nurses prepared medications for administration. The UM stated resident #77 required oxygen therapy related to a history of COVID-19. On 8/22/24 at 12:24 PM, the Riverside UM confirmed the physician order for oxygen therapy indicated nurses were to assess resident #77's oxygen saturation levels every shift. The UM validated the resident's oxygen level was not routinely monitored prior to 8/19/24 when noted by State Survey Agency staff. She explained the MAR was revised on 8/20/24 to reflect the requirement for documentation of oxygen saturation levels every shift. On 8/22/24 at 1:30 PM, the facility's Director of Nursing (DON) provided a record of resident #77's oxygen saturation levels from June to August 2024. The document revealed between 6/01/24 and 8/17/24, the residents oxygen level was checked only seven times during the 11-week period. The DON acknowledged nurses did not obtain and document the resident's oxygen saturation levels as ordered. Review of the facility's policy and procedure for Oxygen Administration, dated 1/30/24, revealed the purpose was to provide guidelines for safe oxygen administration. The policy instructed nursing staff to review the resident's physician order or protocol for oxygen administration, check the tubing and start the flow of oxygen at the ordered rate. The document read, Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on observation, interview, and record review, the facility failed to administer medications according to physician orders to prevent medication errors for 2 of 5 residents reviewed during the Medication Administration task, of a total sample of 51 residents, (#33 & #62). There were 4 errors in 29 opportunities for a medication error rate of 13%. Findings: 1. Review of the medical record revealed resident #33, a [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included unspecified pain and constipation. Resident #33 had a care plan for risk of developing pain related to a thigh wound, acid reflux, and a potential for abnormal bowel pattern, initiated on 7/03/23. The goal was the resident would experience pain reduction or relief. The care plan approaches instructed nurses to administer pain medications according to the physician's order. Review of the Physician Order Report revealed resident #33 had an order dated 3/13/24 for Colace 100 milligrams (mg) twice daily for constipation, scheduled at 9:00 AM and 5:00 PM. The document showed an order dated 3/21/24 for Ibuprofen 400 mg twice daily for pain, scheduled at 9:00 AM and 5:00 PM. On 8/19/24 at 4:24 PM, Licensed Practical Nurse (LPN) D stood at her medication cart. She stated she was ready to administer resident #33's scheduled 5:00 PM medication. She removed a blister pack from the drawer and placed one tablet of Ibuprofen 400 mg in a medication cup. She reviewed the electronic Medication Administration Record (MAR), closed her computer screen, and entered the resident's room to administer the tablet. After resident #33 swallowed the tablet, LPN D returned to the medication cart to record the medication administration task as completed. During the process of reconciling resident #33's physician orders with the MAR, there was a discrepancy identified. The MAR showed LPN D's initials to validate she administered two medications, the scheduled 5:00 PM doses of one tablet Ibuprofen 400 mg and one capsule Colace 100 mg. On 8/20/24 at 4:23 PM, the Riverside Unit Manager (UM) was informed resident #33's medical record showed LPN D administered his Colace 100 mg capsule although it was not given during observation of medication administration. She stated the nurse could have realized she forgot the medication and then returned to administer it at a later time. The UM provided a record of the actual administration time of Colace 100 mg. Review of the detailed Administration History revealed LPN D documented administration of both scheduled medications, Ibuprofen 400 mg and Colace 100 mg, on 8/19/24 at 4:27 PM. The UM stated her expectation was nurses would administer scheduled medications as ordered, and accurately record administration at the time it occurred. On 8/22/24 at 3:05 PM, LPN D validated she administered only one tablet during the medication administration observation on 8/19/24. She was unable to explain why she documented administration of two drugs instead of one. 2. Review of the medical record revealed resident #62, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included atrial fibrillation, hypertension, anemia, generalized muscle weakness, and long-term use of anticoagulant or blood thinner medication. Resident #62 had a care plan for risk for abnormal bleeding or hemorrhage because of anticoagulant use, initiated on 3/20/23 and reviewed/revised on 5/21/24. The goal was the resident would be free from signs and symptoms of abnormal bleeding. The approaches included administer anticoagulant medication as prescribed. Review of the medical record revealed a care plan for risk of complications related to cardiac disease diagnoses including hypertension and atrial fibrillation, initiated on 3/20/23. The goal was the the resident would not develop signs or symptoms of cardiac complications. The approaches instructed nurses to administer medications as ordered. Resident #62 had a care plan for receiving crushed medication related to difficulty swallowing whole tablets, initiated on 10/25/23. The goal was the resident would tolerate crushed medications without difficulty. The approaches included crush medications as ordered and, Meds may be crushed (if med crushable) and administered as a single oral bolus as the benefits outweigh the risks of individual administration [due to] difficulty swallowing. Review of the Physician Order Report revealed resident #62 had physician orders dated 5/07/24 for Dabigatran etexilate 150 mg twice daily for atrial fibrillation, one tablet Daily Multivitamin supplement once daily, and Ferrous sulfate 325 mg once daily for anemia. On 8/20/24 at 9:35 AM, LPN E prepared to administer resident #62's scheduled morning medications. She retrieved blister packs from a drawer of the medication cart and place medication including one capsule Dabigatran etexilate 150 mg, one tablet Daily Multivitamin with Minerals, and one tablet Ferrous sulfate 325 mg in a medication cup. LPN E explained resident #62 had difficulty swallowing and her medication had to be crushed and given in food, either applesauce or pudding. She proceeded to crush all the tablets and placed them in another medication cup, then she opened the capsule and sprinkled its contents on top of the crushed tablets. LPN E mixed the medication into the resident's preferred food and administered the medication. On 8/20/24 at 11:21 AM, and 11:47 AM, after reconciliation of resident #62's medication orders with the MAR, LPN E was asked to compare the resident's order for a Daily Multivitamin to the bottle she had in the medication cart. She read the bottle and confirmed she administered a Multivitamin with Minerals. She checked the unit's medication room and stated there was no plain multivitamin available. LPN E stated she had not noticed the discrepancy during medication administration. She acknowledged it was essential to read containers carefully and compare them to physician orders prior to administration. She was asked to retrieve the bottle of Dabigatran and joint review of the label revealed the instruction, Swallow capsule whole. LPN E stated she had not noticed the warning. She verified she should have called the physician regarding the resident's inability to swallow the capsule and requested another form or type of medication. LPN E checked the bottle of Ferrous Sulfate and stated there were no instructions regarding not crushing the drug. When prompted to pour a Ferrous Sulfate tablet from the bottle, she noted it had a shiny coating. On 8/20/24 at 11:50 AM, LPN E contacted the facility's pharmacy to clarify medication administration instructions for resident #62 related to her inability to swallow medications whole. During the conversation on speakerphone between pharmacy representatives and LPN E, she was told Dabigatran capsules should not be opened and Ferrous Sulfate tablets should not be crushed. The pharmacy representative recommended contacting the resident's physician to obtain appropriate orders. On 8/20/24 at 1:26 PM, the Central Supply staff stated the facility's formulary included only Multivitamins with Minerals tablets, not Daily Multivitamins. He explained if a resident needed a plain multivitamin, nurses would have to get it ordered from the pharmacy or he could obtain it from a local pharmacy. On 8/20/24 at 4:09 PM, the Riverside UM acknowledged all nurses should follow the facility's policies and procedures and accepted standards of nursing practice for medication administration. She stated her expectation was nurses would read all medication labels carefully and follow the five rights of medication administration. The UM confirmed resident #62's nurses should have identified potential concerns related to crushing her medication and opening the capsule, and called the physician, researched drug manufacturers' instructions, or called the pharmacy. Review of the facility's policy and procedure for Medication Administration - General Guidelines, revised in January 2018, revealed medications would be administered as prescribed in accordance with good nursing principles and practices. The document listed the five rights of medication administration as the right resident, right drug, right dose, right route, and right time. The policy instructed staff to practice a triple check method that involved first selecting the medication and checking the label, container, and contents for integrity, and comparing it to the MAR. The second check was to be done during preparation of the dose by removing the drug from container and verifying it against the label and MAR. The third check was to occur during completion of dose preparation when nurses would re-verify the label against the MAR. The policy read, If it is safe to do, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing. The document instructed nurses to check with the pharmacist before opening capsules or crushing tablets to identify alternative medications if indicated.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during distribution of lunch trays and set up of lunch meals on 1 of 2 hallways, (400 hallway), on 1 of 4 units, (Riverside Unit). Findings: On 8/19/24 at 11:47 AM, Certified Nursing Assistant (CNA) J distributed lunch trays on the 400 hallway. Without performing hand hygiene, she removed a tray from the meal cart, entered room [ROOM NUMBER], and placed it on a table. CNA J touched the table, removed lids from containers, and then exited the room without using hand sanitizer. CNA J returned to the meal cart, retrieved another tray, and entered room [ROOM NUMBER]. She placed the tray on the table beside bed A, uncovered food items, and set up the meal. During the process, she touched the table and the back of the resident's chair. CNA J did not perform hand hygiene prior to exiting the room and she returned to the meal cart to continue distributing lunch trays. Next, she retrieved a tray and returned to room [ROOM NUMBER] where she placed it on the table beside bed B. CNA J removed the plate cover, opened a box of milk, and removed plastic lids from other containers on the tray to complete meal set up. As she exited the room, the resident in bed A reminded her he did not get a box of milk on his tray. CNA J acknowledged the request, and again left the room without performing hand hygiene. She then used both hands, one on each meal cart, to pull the carts further down the hallway. CNA J left the carts, walked to the nourishment room to retrieve a box a milk, and found there was no milk in the refrigerator. As she walked to the main kitchen to get a box of milk, CNA J commented on the warm temperature in the hallway and wiped sweat from her forehead by moving her left forearm to the back of her hand and her fingers across her forehead. On 8/19/24 at 11:53 AM, CNA J stood at the kitchen door and received a box of milk from dietary staff. She held the box in her left hand as she walked back towards the Riverside Unit. On the way back to the 400 hallway, CNA J raised her right arm and again wiped away sweat by dragging her right forearm to the back of her hand and fingers across her forehead. She entered room [ROOM NUMBER], placed the box of milk on the table beside bed A, and used both hands to open the box. She removed the wrapper from a straw and inserted the straw into the milk. On 8/19/24 at 11:56 AM, CNA J exited room [ROOM NUMBER] and did not perform hand hygiene before returning to the meal cart to continue distribution of residents' meal trays. She retrieved another tray, entered room [ROOM NUMBER], and placed it on the table beside bed A. CNA J uncovered the meal, removed the lid on the juice container, opened the box of milk, and poured the contents into a specialty cup. As she exited the room, CNA J raised her hand to touch her hair. Next, she retrieved another meal tray from the cart and returned to room [ROOM NUMBER] to place it on the table beside bed B. She adjusted the back of the resident's wheelchair, then touched the tray and picked up the packet of utensils without performing hand hygiene. On 8/19/24 at 12:00 PM, when CNA J walked towards the meal cart to retrieve another tray, she was prompted to pause the distribution of lunch meal trays. She was informed of concerns regarding the omission of hand hygiene prior to touching items on residents' lunch meal trays, after touching surfaces in residents' rooms, and after touching her skin and hair. CNA J validated she did not perform hand hygiene before touching each resident's tray and items on the tray. On 8/19/24 at 12:02 PM, the Riverside Unit Manager (UM) stated her expectation was all staff would sanitize their hands frequently during meal distribution to reduce the spread of germs. The UM verified there were easily accessible hand sanitizer dispensers in the hallways and resident rooms. The facility's policy and procedure for Assistance with Meals, revised on 1/18/18, read, All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Review of the facility's policy and procedure for Handwashing/Hand Hygiene, dated 1/30/24, revealed the facility considered hand hygiene to be the primary means to prevent the spread of infections. The policy noted hand hygiene products and supplies including soap and alcohol-based hand rub or hand sanitizer would be accessible and convenient for staff to promote compliance with proper infection control practices. The document indicated staff would perform hand hygiene after contact with objects in the resident's immediate vicinity, before handling food, and before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. Record review of resident #117's clinical records revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on 9/23/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions read Clarify duration and frequency when entering order. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 10/11/22 indicated the resident was rarely/never understood and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's Occupational Therapy Discharge Summary with dates of service from 6/17/22 to 9/13/22, read, Patient will tolerate RHS [right hand splint] to R [right] hand for 4 hours for contracture management. On 10/31/22 at 10:48 AM, 10/31/22 at 3:54 PM, on 11/01/22 at 9:32 AM, 11/01/22 at 11:10 AM, 11/01/22 at 3:42 PM, and on 11/02/22 at 11:35 AM, resident #117 was observed in bed. Her right hand was contracted, and she was not wearing a splint. A splint was observed in the wall mounted container to the right of the resident's bed. On 11/01/22 at 3:26 PM, Licensed Practical Nurse (LPN) L stated resident #117 had two strokes and her right hand was contracted. The LPN indicated Restorative Nursing Program (RNP) was working with resident for donning/doffing of her splint. On 11/01/22 at 3:46 PM, the Oceanside Registered Nurse (RN) Unit Manager (UM) stated splint orders were usually placed by therapy, and she confirmed resident #117 had an active order dated 9/23/22 for right resting hand splint to be donned and doffed daily as needed. The UM said if the task was done, documentation would be in the facility's electronic documentation system. She noted RNP was responsible for donning /doffing of the resident's splint, and for completing documentation regarding splinting. On 11/01/22 at 4:08 PM, Certified Nursing Assistant (CNA) M stated she had not seen the resident with splints. CNA M said RNP would don and doff the resident's splint. On 11/01/22 at 4:25 PM, and on 11/02/22 at 9:55 AM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained when therapy gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS Coordinators would discuss the resident's progress with the RNP CNAs. She stated resident #117's order for splint was a general nursing order and was never for RNP. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 was on Occupational Therapy (OT) caseload from 6/17/22 to 9/13/22. She explained the resident was hospitalized on [DATE], and on readmission to the facility on [DATE], she was referred to RNP, for upper extremity strengthening. She said the splint order dated 9/23/22 was pulled over from the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Rehab services were contracted to the facility, and they had very limited services of OT for the last couple of months. She added that OT was coming in a couple hours per week, due to limited staff. She indicated that based on the resident's history, an OT screen to evaluate for continued need for splint application should have been completed. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated there was some talk about the resident's splints not being placed, and she was told by staff the resident had refused splint application. She said on 7/25/22 there was an order by therapy to don/doff splint daily as needed, and documentation for Special Instructions were to clarify duration and frequency when entering order. The UM stated resident #117 was hospitalized from 9/15/22 to 9/23/22, and on readmission, she reinstated the previous order for splint application. The resident's clinical records were reviewed by the RN/UM, and she stated that as far as she knew, there was no documentation to indicate the resident's right-hand splint was placed, or that the splint order was clarified as directed. She noted the resident should have been screened by OT, to ensure the splint was still appropriate, and if it was not, the order should have been discontinued. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated the resident's splint order was placed by the prior OT who no longer worked at the facility, and was reactivated by the Oceanside UM on the resident's readmission to the facility. She explained no follow up was done to ensure the resident was re-screened by OT on her return from the hospital. The DON verbalized that if the OT screen was done, they would have made a referral for continued/discontinued use of her splints. She said therapy gave orders for splinting, and the UMs were responsible to check orders, and obtain clarification as needed. The DON noted resident #117 had not worn her right-hand splint since her readmission to the facility, and documentation could not be identified to indicate splints were applied on an as needed basis. She explained the order should populate on the resident's Treatment Administration Record (TAR), and verbalized the order was not a good order and should have been clarified. She stated MDS/RNP reported to her, and she was responsible to oversee the RNP. On 11/02/22 at 2:51 PM, the Director of Rehab stated OT was initiated for resident #117 on 5/04/22 for right hand weakness, and discharged from OT on 9/14/22, but a RNP was not developed for splint application. She said the resident's right-hand splint was ordered and started by OT on 5/30/22 to be donned/doffed by therapy. She confirmed that an OT screen was not completed for the resident status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS with ARD of 9/07/22 revealed the resident's cognition was severely impaired, with a Brief Interview for mental Status (BIMS) score of 00/15. The resident was assessed to require extensive assistance for bed mobility, dressing, and personal hygiene, and was totally dependent on staff for toilet use. The assessment showed the resident had functional limitation in range of motion (ROM) to one side of his upper and lower extremities The resident's care plan ADL (Activities of Daily Living) Functional/rehabilitation Potential created on 3/03/22 indicated the resident was unable to complete activities of daily living independently due to cardiovascular accident with right sided [CONDITION(S)] and [CONDITION(S)]. Approaches listed included, 4/07/22 RNP for splint application to right upper extremity, which was noted as discontinued on 9/13/22. OT Treatment Encounter Notes dated 4/05/22 indicated discharge from OT services and splint wear schedule was discussed with the resident. OT positioned splint on RUE [right upper extremity]. Patient tolerated splint for 3 hours without s/s [signs/symptoms] of irritation or redness. The OT discharge summary dated 4/05/22 revealed discharge status and recommendations were, Orthotic Management: Splint/orthotic recommendation: RUE splint for 3 hours/day without s/s of irritation or redness for contracture management RNP for contracture management including splint wear schedule. Progress note dated 9/16/22 read, decreased tolerance of PROM (passive range of motion) to RUE noted and refusing application of splint. Therapy referral placed. Progress note documented by RNP and dated 10/21/22 read, Resident is participating in the Restorative Program for PROM BLE (bilateral lower extremity), RUE . He also has a RUE splint. He is tolerating the program fair. Continue current plan. On 10/31/22 at 11:00 AM, and on 11/01/22 at 3:39 PM, resident #143 was lying in bed on his back, his right hand was contracted, and the resident was not wearing a splint. On 11/01/22 at 3:37 PM, LPN L stated the resident was admitted to the facility with contracture of his right hand, and RNP was to do splinting for 3 hours daily. On 11/01/22 at 3:46 PM, the Oceanside RN/UM stated resident #143 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated MDS had responsibility for the RNP, and if the task was done, it would be documented in the electronic clinical record. On 11/01/22 at 4:25 PM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained that when therapy gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS coordinator would discuss the resident's progress with the RNP CNAs. The resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, if the resident refused splints, a referral would be placed to Rehab for screening/reassessment. Observations on various occasions of resident # 143 with contracted right hand, and not wearing a splint was shared with the MDS Coordinators. The Assistant MDS Coordinator stated a progress note on 9/16/22 revealed decreased tolerance and refusal of splint, but another progress note on 10/20/22 indicated the resident was tolerating splinting. On 11/02/22 at 10:02 AM, the MDS Coordinator stated review of clinical records for the resident showed he had been refusing splinting. She recalled a couple of weeks ago the RNP CNAs, said the resident's splint was not fitting as before. She verbalized the RNP CNAs would report any concerns to the MDS Coordinator, who would then report to Rehab. The MDS Coordinator said she did not know if concerns with the resident's splint was reported to Rehab. On 11/02/22 at 10:31 AM, the Director of Rehab stated RNP would report any concerns of a splint not fitting to therapy. She stated that during the morning clinical meetings, refusal of splints would be discussed. She said she was not aware resident#143 was refusing, his right hand/elbow splint, and was told about the splint not fitting this morning (11/02/22). She said if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy and if retraining of staff was required. She verbalized the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks as he previously did. On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Therapy on 9/16/22 due to the resident's complaint of pain, and staff not being able to apply his splint. She verbalized she would have to speak to the rehab director to see what was done with the referral. The DON stated the MDS Coordinators had responsibility for the restorative program, and would be the ones to follow up with Rehab for any concerns/issues with the program. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was placed on 9/13/22. The DON stated the OT screen was not done, but could not say why the screen was not done. She stated the order for splint application for the resident was not discontinued and was still active. On 11/03/22 at 10:32 AM, Restorative CNA K stated resident #143 was oriented x 2 and had a tendency to refuse splinting, stating the splint was uncomfortable for him. CNA K said she reported this to the restorative nurse in September and a request for OT screen was placed. The CNA verbalized she had not placed the resident splint since then.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the preferences and needs for 6 of 12 residents reviewed for activities of a total sample of 62 residents, (#10,#21,#51,#118,#137,#139). Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 7/13/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was somewhat important for the resident to listen to music, do her favorite activities, and go outside to get fresh air. Resident#10 required extensive assistance of two persons for transfers and total assist of one person for locomotion. Review of resident #10's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 3:53 PM, resident#10 was observed lying in bed with her eyes open, looking at the ceiling. There was no music playing in the room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking at the ceiling. There was no music or television on in the room. On 11/03/22 at 9:19 AM, resident#10 was observed lying in bed looking at the ceiling. There was no television or music in the room. 2. Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's MDS significant change assessment with ARD of 9/16/22, indicated the resident was rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was very important for her to have books, newspapers, and magazines to read and it was somewhat important for her to keep up with the news and to go outside for fresh air. Resident #10 required extensive assistance of two persons for transfers and was totally dependent on staff for locomotion. Review of the resident's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Provide small group activities such as music and crafts. On 11/01/22 at 12:21 PM, resident #21 was observed lying in bed, with no activities observed. On 11/01/22 at 3:53 PM, the resident was observed lying in bed with her eyes open, looking at roommate's television. At this time, there was a music activity taking place in the dining room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking around the room. There was no music or television in the room. 3. Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS assessment for change in condition with ARD of 9/13/22 indicated resident #51's BIMS was 09 which indicated significant cognitive impairment. The assessment noted she required supervision of one person for bed mobility, transfers, and walking. Review of resident #51's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. On 11/01/22 at 12:02 PM, resident #51 was observed in the dining room sitting in a chair with no activities being provided. On 11/02/22 at 10:13 AM, the resident was observed sitting in the day room with the television on but no activities provided. On 11/02/22 at 2:06 PM, the resident was sleeping in her chair in the day room and no activities. On 11/02/22 at 3:56 PM, the resident remained sleeping in her chair in the the day room with television on and no activities being provided. On 11/03/22 at 9:27 AM, resident #51 slept in her chair in the day room with television on and no activities in progress. 4. Resident #118 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS quarterly assessment with ARD of 9/14/22 revealed the resident had a BIMS score of 5 which indicated she had severe cognitive impairment. The assessment indicated she required supervision of one person for transfers and walking. Resident #118's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Invite/encourage resident to attend/participate in offered live music programs. On 11/01/22 at 12:19 PM, resident#118 was observed lying in bed with her eyes closed with no activities in progress. On 11/01/22 at 3:54 PM, resident#118 was observed lying in bed while live music activity in progress in the dining room. On 11/02/22 at 10:08 AM, the resident sat in the day room with no activities. The television was on but the resident was not watching it. On 11/03/22 at 9:27 AM, resident#118 was observed sitting in day room with no activities. 5. Resident #137 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS quarterly assessment with ARD of 10/13/22 revealed the resident had a BIMS score of 04 which indicated severe cognitive impairment. Review of resident #137's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/02/22 at 10:08 AM, resident#137 was observed sitting in the day room, with no activities. The television was on but the resident did not pay any attention to it. On 11/03/22 at 9:27 AM, resident#137 was observed sitting in day room with no activities. 6. Resident #139 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS quarterly assessment with ARD of 9/09/22 revealed the resident had a BIMS score of 99 which indicated she had severe cognition impairment. Review of resident #139's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 12:39 PM, resident #139 was observed in her room with no activities noted. On 11/01/22 at 3:52 PM, the resident was observed lying in bed with eyes closed. On 11/02/22 at 10:10 AM, resident#139 was observed lying in bed with eyes closed. On 11/02/22 at 11:22 AM, the resident was observed lying in bed with eyes closed and lunch tray on the over bed table next to her bed untouched. On 11/02/22 at 3:43 PM, the resident was observed lying in bed with her eyes closed. On 11/02/22 at 2:35 PM, Certified Nursing Assistant (CNA) Q stated they used to have a full-time activity person on the unit but now they only had someone from activities department occasionally. She added there also used to be three CNAs on the unit and it was much more manageable to provide activities for all the residents. She said there was no time for CNAs to provide activities as most of the residents needed a lot of care. On 11/03/22 9:30 AM, Registered Nurse (RN) N stated, we used to have an activity CNA who was in the day room with the residents all the time but not anymore. On 11/03/22 at 10:26 AM, CNA P said they had a CNA who stayed in the day room with the residents and did activities, but we don't have her anymore. She said, We try to do the best we can with providing some sort of activities but we are too busy providing care and do not really have time to sit in the day room and do any activities with them. I love these residents but I feel so bad because I just do not have time to give them what they need. On 11/03/22 at 11:23 AM, the Activities Director (AD) stated when new residents were admitted , she interviewed the resident or family member to determine their activity preferences and develop a plan of care. She said, if the resident was bed bound, we do friendly room visits, lotion therapy, read to them, talk to them. Make sure they are comfortable. We have 1 on 1 logs for documenting what was done during room visits. She stated activities department had 3 staff and one of them was full time on the memory care unit. On 11/03/22 at 11:54 AM, the memory care Unit Manager stated the memory care unit did not have a full time activities person. She said the CNA staff tried to provide activities when they had some spare time. Observation of the Memory Care unit from 10/31/22-11/03/22 revealed an activities staff on the unit on 10/31/22 who handed out popcorn and put a movie on the television and left the unit. On 11/01/22 live music was provided in the dining room from 3:00 PM-4:00 PM. On 11/02/22 an activity staff sat at a table with three residents. One of the residents was sleeping in her chair and the other two had ice cream with the associate. Review of the activities calendar indicated the residents should have had an activity almost every hour. None of the activities listed on the calendar were being followed. Review of the residents' 1 to 1 logs for activities revealed no activities provided to any of the residents at any time from 10/22/22-11/02/22. All documentation indicated the residents were either asleep or refused. The activities logs were not documented in chronological order.

Based on interview, and record review, the facility failed to provide Occupational Therapy as needed to address splint application and assessments for 3 of 3 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143, #175). Findings: 1. Clinical record review revealed resident #117 was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on 9/23/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions read Clarify duration and frequency when entering order. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 had a stroke and had right hand splint provided by therapy to prevent contractures. She verbalized the resident was previously on Occupational Therapy (OT) caseload with start of care on 6/17/22 and was discharged from OT on 9/13/22. She explained the resident was hospitalized on [DATE], and was readmitted to the facility on [DATE], and a new Rehab screening should have been done on the resident's return to the facility, however, the screening by OT was not done. She stated Rehab services were contracted to the facility, and they had very limited services from OT for the last few months. she explained OT was coming into the facility for a couple hours per week, due to limited staff. She indicated that based on the resident's history, she should have had an OT screen to evaluate for continued need for splint application. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated resident #117 was hospitalized from 9/15/22 to 9/23/22, and on readmission to the facility she reinstated the resident's previous order for splint application. She said the resident should have been screened by OT after her readmission, to ensure the splint was still appropriate. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated no follow up was done by nursing or Rehab to ensure the resident was re-screened by OT on her return from the hospital. She noted if the OT screen was done, they would have made a referral for continued/discontinued use of the resident's right-hand splint. On 11/02/22 at 2:51 PM, the Director of Rehab explained all newly admitted or readmitted residents were screened by Rehab for all three disciplines, Physical Therapy, Speech Therapy, and Occupational Therapy. She confirmed that an OT screen was not completed for resident #117 after hospitalization . She noted an OT screen should have been completed, and order regarding the resident's right-hand splint should have been clarified or discontinued. 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated 9/16/22 read, decreased tolerance of PROM [passive range of motion] to RUE [right upper extremity] noted and refusing application of splint. Therapy referral placed. On 11/02/22 at 10:31 AM, the Director of Rehab stated Restorative Nursing Program (RNP) would report any concerns with the plan of care for the residents, and if a splint was not fitting, it should be reported to therapy. She stated she was not aware resident #143 refused his right hand/elbow splint and was told about the splint not fitting this morning, on 11/02/22. She said, if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy or if retraining of the RNP staff was required. She explained the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks he previously could. On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Rehab on 9/16/22 by RNP due to the resident's complaints of pain, and staff not being able to apply his splint. She verbalized she would have to get with the Director of Rehab to see what was done regarding the referral. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was requested on 9/13/22. The DON stated the Director of Rehab was struggling to get OT staff and the resident's OT screen was not done as requested. 3. Resident #175 was admitted to the facility from the hospital on 10/3/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/31/22 10:25 AM, interview with resident #175 said that she was upset that she had not received the results and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that during hurricane [NAME] she had rammed her car into a parking space's cement stop that could not be seen because it was under water. The resident said the accident had caused her right sided pain and that she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #175's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . OT [Occupational Therapy] to evaluate and treat as indicated. Review of therapy evaluations and progress notes for resident #175 revealed that a PT evaluation was conducted on 10/4/22. There was not any evidence that an OT evaluation was conducted. On 11/3/22 at 9:26 AM, interview with OT A said that he worked per diem for the rehabilitation department at the facility. He explained that he worked a couple times a week for 5 to 8 hours at a time and had another full-time job at a home health agency. OT A reviewed the rehabilitation records for resident #175 and acknowledged that the resident had not received an OT evaluation since her admission on 10/3/22. He stated that to his knowledge, the facility's therapy department did not currently have a full-time evaluating OT. On 11/3/22 at 9:35 AM , during an interview with the Therapy Director/Certified Occupational Therapy Assistant (COTA), she acknowledged that resident #175's OT evaluation order was dated 10/3/22. She confirmed that an OT evaluation had not yet been done. The Therapy Director reported that around the first of October this year, the facility's contracted therapy company changed. When this happened, the two full time OTs who had previously worked for the old therapy company had resigned. She stated that the facility's therapy department has only one evaluating OT at this time who works on per diem basis. She indicated that because of this, resident #175 did not receive her initial OT evaluation ordered at admission. She said the resident refused many of the PT sessions while waiting on a second Magnetic Resonance Imaging Report. Review of orders revealed that the physician had held therapy orders from 10/6/22-10/10/22, but then reinstated therapy on 10/10/22 without ambulation. The Therapy Director said that the per diem OT would attempt to conduct her OT evaluation today, 11/3/22, and verbalized that she was looking to hire a full time OT. The new therapy company's policies and procedures related to therapy evaluation expectations and timeframes were requested but not readily available upon request. The Therapy Director conveyed on 11/3/22 at about 9:45 AM that the process regarding timeframes to conduct therapy evaluations was within 48 hours of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure nail care was provided for 3 of 6 dependent residents, (#1, #4, #119) and failed to ensure facial hair was removed for 1 of 6 dependent residents, (#479) reviewed for Activities of Daily Living (ADL) out of a total sample of 62 residents. Findings: 1. Review of resident #1's medical record documented she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident #1 had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making and she required total assistance of one staff member with personal hygiene and bathing. Review of resident #1's comprehensive ADL care plan dated 12/09/19 documented she required total assistance from staff with ADLs. On 11/01/22 at 10:05 AM, and on 11/02/22 at 10:05 AM, the resident's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #1 received bed baths or showers on Monday and Thursday on the 2 PM - 10 PM shift. 2. Review of resident #4's medical record showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] documented resident #4 had short-term and long-term memory problems and severely impaired skills for daily decision making. She required total assistance of one staff member with personal hygiene and bathing. Review of resident #4's comprehensive ADL care plan dated 04/01/21 documented she required staff assistance with ADL's. On 10/31/22 at 1:24 PM, 11/01/22 at 10:02 AM, and on 11/02/22 at 9:54 AM, resident #4's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #4's showers were on Tuesdays and Fridays on the 6 AM -2 PM shift. 3. Review of resident #119's medical record documented he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] noted he was cognitively intact and required extensive assistance with personal hygiene and bathing. Review of resident #119's comprehensive ADL care plan dated 09/14/20 showed he was unable to complete ADL's independently related to weakness, and end stage diagnosis. The goal included to have ADLs met daily with staff assistance. The approach was for one person to assist with ADLs and ADL assistance was expected to fluctuate due to his end stage diagnosis. Observations conducted on 10/31/22 at 10:00 AM, 11/01/22 at 9:58 AM, and on 11/02/22 at 9:51 AM revealed resident #119's fingernails were long, and jagged with a brown substance under the fingernails. Review of the 400 Unit shower schedule indicated resident #119's showers were to be given on Wednesdays and Saturdays on the 2 PM - 10 PM shift. On 11/02/22 at 10:15 AM, Registered Nurse (RN) D stated all staff were responsible for residents' ADLs. She explained the Certified Nursing Assistants (CNAs) were responsible for providing ADL care daily. She explained each resident had a schedule and would receive 2 bed baths or showers per week based on the schedule. RN D said ADL care included brushing teeth, shaving, dressing, nail and hair care. On 11/02/22 at 11:43 AM, the 400 Unit Manager stated residents received a bed bath or shower 2 days per week based on unit schedule or preference. She noted ADL care included a head to toe bed bath or shower, hair and nail care, and shaves. It is the same with a shower and fingernails are to be kept clean, short, and trimmed. On 11/02/22 at 11:55 AM observations of resident #1, #4 and #119's fingernails were completed with the 400 Unit Manager. She stated all 3 residents' fingernails needed to be cut and cleaned. On 11/03/22 at 12:54 PM, CNA F stated routine resident care included cleaning of face, hands, teeth, toileting, dressing, and incontinent care. She indicated bed baths and/or showers were done 2 times a week per schedule or resident preference. We wash the body, wash and dry hair, nail care, and shaves. Review of the Facility's Guideline CNA Sheet/Skin Inspection, dated January 18, 2017, read, Purpose: Documentation of showers and skin inspection completed with showers. Procedure: . 4. CNA is to trim nails with shower . If resident is diabetic or on anti-coagulants file nails only. Notify nurse if resident refuses nail care. 4. Resident #479 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #479's Admission Observation Nursing assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation. Review of his baseline care plan dated 10/25/22 for activities of daily living included approaches to assist the resident with bathing, grooming, dressing, and personal hygiene as needed. On 10/31/22 at 10:57 AM, resident #479 was observed sitting in a wheelchair by his bed. He was unshaven with facial hair about 1/3 inch to 1/2 inches long. On 11/1/22 at 1:20 PM, and on 11/2/22 at 12:50 PM, resident #479 remained unshaven. He indicated he needed help to shave as he tired easily and was short of breath. He said he had not shaved since he came to the facility and staff had not offered to assist him. On 11/2/22 at 1 PM, the resident's CNA C and CNA B said shaving would typically be done during shower days which were scheduled twice per week, and sometimes during morning care. CNA C indicated she did not know resident #479 well, and had not asked him if he wanted to be shaved today. At this time, CNA C went to the resident's room and confirmed the resident wanted help to be shaved a little later in the day. At 5 PM, the resident was still not shaved. On 11/3/22 at 11:45 AM, resident #479's CNA documentation for the level of assistance required for personal hygiene was reviewed with the Minimum Data Set (MDS) Coordinator. The ADL flowsheets revealed that from 10/26/22 through 11/2/22 the resident consistently required limited to extensive assistance with personal hygiene and bathing care. There was not any documentation that indicated he had refused to be shaved. On 11/3/22 at 3 PM, the Director of Nursing (DON) said staff were expected to offer and/or provide shaving needs with showers twice per week and as needed. Review of the facility's ADL Supporting Policy and Procedure read, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) assessments timely for 2 of 4 residents reviewed for MDS assessments, from a total sample of 62 residents, (#105, #123). Findings: Resident #105 was admitted to the facility on [DATE]. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/2022 at 10:10 AM, the Registered Nurse (RN) MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] was not transmitted timely. Resident #123 was admitted to the facility on [DATE]. On 11/2/2022 at 10:10 AM the RN MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] had not been transmitted. She validated the assessment should have been transmitted 14 days after completion. The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021, page 3 titled, MDS Completion and Submission Timeframes item 2 contained the regulatory timeframes and noted, timeframes will be observed by the facility.

Based on interview, and record review, the facility failed to complete Minimum Data Set (MDS) assessments within required timeframes for 3 of 4 residents reviewed for MDS comprehensive assessments from a total sample of 62 residents, (#60, #123, #154). Findings: Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS annual comprehensive assessment dated ,d+[DATE]//22 revealed the assessment's final completion was dated 11/2/2022. On 11/2/2022 at 10:10 AM, the Registered Nurse (RN) MDS Coordinator stated the annual comprehensive MDS must be completed within 14 days after the assessment reference date (ARD), or 10/5/2022. She verified the MDS assessment was in progress and was not completed timely. Resident #123 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS annual comprehensive assessment dated [DATE] revealed the assessment completion date was 10/6/2022. On 11/2/2022 at 10:11 AM, the RN MDS Coordinator stated the annual comprehensive MDS was required to be completed within 14 days after the ARD, or 9/30/2022. She verified the MDS was completed on 10/6/2022 and was late. Resident #154 was admitted to the facility on [DATE], discharged on [DATE], and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission comprehensive MDS dated [DATE] showed the MDS completion date was 5/30/2022. On 11/3/2022 at 10:09 AM, the RN MDS Coordinator verified the admission comprehensive MDS required completion within 13 days after the admitted , or 5/25/2022. She verified the MDS was completed on 5/30/2022 and was late. The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021 page 3 titled, MDS Completion and Submission Timeframes (2.) contained the regulatory timeframes and read, timeframes will be observed by the facility.

Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for life expectancy for 1 of 5 residents reviewed for unnecessary medications, (#81) and failed to accurately reflect the discharge status for 1 of 3 residents reviewed for discharges, (#176), of a total sample of 62 residents. Findings: 1. Review of resident #81's medical record revealed she was 98-years-old, admitted to the facility on [DATE] with a recent readmission of 10/04/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Given the information available, and per my examination, the patient has a life expectancy of 6 months or less. The resident's care plan for terminal/end stage diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission MDS, with Assessment Reference Date (ARD) of 8/26/22 revealed the question in Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?' was coded 0 indicating No. On 11/03/22 at 9:44 AM, the MDS Assistant Coordinator explained she gathered information from the resident's clinical records, including the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission MDS with ARD of 8/26/22, and the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged the resident had an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assistant Coordinator stated the MDS assessment was coded incorrectly, and the section for prognosis should have been coded with a 1, indicating yes for life expectancy of 6 months or less. The Center for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0, revised October 2019 Section J1400 directions for coding read, Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. o Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. 2. Resident #176 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #176's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 10/02/22 read, Resident discharged to home with sister and niece at 11:30 this morning. Review of the MDS discharge assessment with assessment reference date 10/02/22 inaccurately reflected the resident was discharged to an acute hospital on 10/02/22. On 11/02/22 at 1:35 PM, the MDS Director reviewed resident #176's discharge assessment and acknowledged the assessment reflected a discharge to an acute hospital rather than home. She explained the assessment was inaccurate. The facility policy and procedure Resident Assessment Instrument revised 1/17/18 read, All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information.

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility unnoticed, and failed to secure and monitor exit doors to maintain a safe and secure environment, for 1 of 17 residents on the secure Memory Care unit, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, gotten lost or been hit by a car had he reached the parking lot or street. On 2/18/21 at approximately 8:00 PM, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until staff members located him lying in the grass on the east side of facility, over 380 feet away from his room. Resident #1 had abrasions on his knees and forearms when he was found. Resident #1 exited the secure Memory Care unit and walked along an uneven, poorly lit pathway to the rear of the unit. He climbed over a 6-foot gate and landed on the pavement on the other side. Resident #1 traveled through soft, sandy soil, and over uneven, sloping terrain in the darkness as he walked away from the building. He navigated over and around hazards such as raised tree roots and concrete drainage structures until he slipped and fell . The facility failed to ensure resident #1 was adequately supervised based on his identified risk for elopement and failed to secure and monitor exit doors on the Memory Care unit to ensure vulnerable residents did not exit the facility without supervision. There were 19 facility residents who were identified as at risk for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 2/18/21 and was removed on 2/19/21. F689 was determined to be past noncompliance when the facility fully corrected the noncompliance on 3/09/21. Findings: Resident #1, a [AGE] year old male, was admitted to the facility from another long-term care center on 9/22/20. His [DIAGNOSES REDACTED]. Review of progress notes from resident #1's previous long-term care facility revealed he was assessed by an Advance Practice Registered Nurse (APRN) on 9/09/20. The APRN's progress note indicated resident #1 was confused, did not follow instructions, and had tremors and unsteady gait with multiple falls. The ARNP determined resident #1 had poor safety judgement. In a progress note dated 9/11/20, the ARNP noted resident #1 always forgot to lock the wheels on his walker and was at high risk for falls. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 9/16/20 revealed resident #1's Patient Risk Alerts included elopement, falls, and [MEDICAL CONDITION]. On admission to the facility, resident #1's Elopement Risk evaluation dated 9/22/20 revealed prior to admission he had a history of [REDACTED]. The document indicated resident #1 was cognitively impaired with poor decision-making skills, had visual and auditory deficits, and a [DIAGNOSES REDACTED].#1's elopement risk score was 2 and the form read, The patient is at risk for elopement. Proceed with appropriate safety intervention. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 1/01/21 revealed resident #1 was 5 feet 5 inches tall, weighed 113 pounds, had impaired vision, and did not wear glasses. The MDS assessment indicated he exhibited physical, verbal, and other behavioral symptoms on 1 to 3 days in the 7-day look back period. Resident #1 required supervision for walking in his room and around the Memory Care unit. He had unsteady balance, used a walker for mobility and was able to stabilize himself without assistance from staff. Since the prior assessment, resident #1 had 2 falls. Review of resident #1's Physician order [REDACTED]. Resident #1 had physician's orders [REDACTED]. He received Nuplazid at bedtime and [MEDICATION NAME] in the evening for [MEDICAL CONDITION] and [MEDICATION NAME] at bedtime for [MEDICAL CONDITION]. Resident #1 took multiple medications for [MEDICAL CONDITION] including Ropinirole three times daily, [MEDICATION NAME]-[MEDICATION NAME] every 4 hours [MEDICATION NAME] 4 hours. Review of resident #1's medical record revealed an Initial Psychiatric Evaluation form dated 1/12/21. The consultation was ordered to address resident #1's [MEDICAL CONDITION] and depressed mood. The psychiatric ARNP assessed resident #1 and determined he showed symptoms of depression, was dealing with placement adjustment, and exhibited excessive worry and anxiety. A quarterly Elopement Risk evaluation dated 1/25/21 revealed in addition to the findings on the admission elopement evaluation, resident #1 had become resistive to placement in the facility and verbalized the desire to leave the facility or go home. As a result, resident #1's elopement risk score increased from 2 to 3. A Safety Events - Elopement report dated 2/18/21 read, Resident observed outside. The document was completed by the facility's Director of Nursing (DON) who noted resident #1 was found in the grass, lying on his back with his walker nearby. The event report revealed resident #1 suffered abrasions to his knees and forearms. The event description included resident #1's report of climbing over the gate to the Memory care unit's courtyard. The document indicated resident #1 stated he wanted to go home to his family and prior to the elopement, he resided in the Memory Care unit, exhibited anger related to placement in the facility, spoke about leaving, and had elopement attempts in past - unsuccessful. The Elopement Risk evaluation done on 2/18/21, immediately after resident #1 eloped from the facility, indicated his elopement risk score remained at 3. The document revealed resident #1 . exhibited new behavior that would cause concern related to wandering exit seeking or safety. However, the evaluation erroneously noted that resident #1 was not resistive to facility placement and did not have visual deficits. Review of the medical record revealed resident #1 had a care plan for cognitive deficits related to [MEDICAL CONDITION] and dementia, initiated on 10/01/20. The care plan approaches included to provide cues and reminders, and monitor for cognition changes. Resident #1 had a care plan initiated on 9/22/20 for inability to complete ADLs independently related to dementia, weakness, and [MEDICAL CONDITION] tremors. The care plan indicated resident #1 frequently removed his identification bracelet. An approach included providing education on safety awareness and noted his assistance with ADLs varies depending time of day and severity of tremors. A care plan initiated on 9/22/20 revealed resident #1 was at risk for falls related to impaired mobility, poor safety awareness, unsteady gait, [MEDICAL CONDITION] tremors, and dementia. The approaches directed staff to cue resident #1 for safety awareness and keep his environment safe. On 3/15/21 at 6:03 PM, Certified Nursing Assistant (CNA) A described resident #1 as very stubborn and difficult to redirect. She said, He will stand at the exit doors with his walker. He used to hang around the doors. I heard that he got out when I got back to work. I was surprised but I wasn't shocked. CNA A explained resident #1 walked with a 4-wheeled walker with a bench seat. She stated he was sometimes unsteady, especially when he was tired, and had a [MEDICAL CONDITION] shuffle. The American Parkinson Disease Association (APDA) lists common symptoms of [MEDICAL CONDITION] including gait difficulties such as small, shuffling steps with episodes of feet becoming frozen to the floor, rhythmic tremors of the extremities or face, balance problems with a tendency to fall backwards, [MEDICAL CONDITION] and cognitive changes (Retrieved on 3/19/21 from www.apdaparkinson.org). CNA A stated resident #1 enjoyed sitting outside the Memory Care unit in the enclosed courtyard. She explained the unit's 2 exterior exit doors were locked and someone would have had to unlock the doors either with a code or with the switch at the nurses' station for resident #1 to get into the courtyard. CNA A stated if the exit door was unlocked, a doorbell chime sounded when it opened, but there was no continuous alarm. On 3/15/21 at 6:28 PM, CNA E stated resident #1 was alert with confusion and like all residents on the unit, he needed to be watched carefully. CNA E said, These residents are here on this unit because they might try to get out of the facility. She stated she usually worked on the Memory Care unit during the overnight shift from 10:00 PM to 6:00 AM and had observed resident #1 walking around the unit. CNA E stated he sometimes asked to use the phone at the nurses' station at 2:00 AM and had to be reminded it was too late to call his family. On 3/15/21 at 6:36 PM, Licensed Practical Nurse (LPN) C stated he completed his shift on the Memory Care unit at about 7:15 PM on the evening resident #1 eloped. He recalled when he left the unit, resident #1 was standing at the nurses' station. LPN C said, He was on the phone as usual or attempting to make a call. He makes a lot of calls. On 3/15/21 at 7:04 PM, LPN B recalled on the evening of 2/18/21, she heard an overhead page for Code E from the Memory Care unit, which indicated a missing resident. LPN B stated she assisted staff to search the Memory Care unit and when resident #1 was not located she followed LPN D, the evening shift nursing supervisor, and other staff to search outside the facility. LPN B stated the front and side parking lots were dimly lit and she walked on the pathway towards the right side of the facility behind LPN D. She said, It was pitch black. It was very difficult for me to see. I was terrified. It's dark and you just never know what could happen out there. LPN B explained they used a flashlight and she caught up with LPN D at the same time LPN D found resident #1. LPN B stated resident #1 was lying on his back in the grass with his walker nearby. She stated he was found in the area outside the Memory Care unit's dining room windows, but it was so dark staff would not have seen him if they looked through the windows. LPN B stated resident #1 was not able to answer their questions as his speech was mumbled and incoherent. She explained they placed resident #1 on the bench seat of his wheeled walker and pushed and pulled him through the grass and dirt towards the front of the facility. LPN B said, It was hard even for both of us to get him over the grass and dirt onto the sidewalk. On 3/15/21 at 7:28 PM, LPN F stated she was assigned to the Memory Care unit on the night resident #1 eloped. She recalled she gave resident #1 his scheduled medication and observed him return to his room between 7:30 PM and 8:00 PM. LPN F explained during administration of medications to other residents on the hallway, she realized she did not hear resident #1's normal continuous humming vocalizations. LPN F checked and searched resident #1's room but did not find him. She then instructed other staff to search the unit and notified the nursing supervisor. She stated after searching for 10 minutes, she paged Code E overhead to alert all staff in the facility. LPN F described the Memory Care unit as a lockdown unit and stated resident #1 needed to be there as he was at risk for elopement. She said, I was aware he was an elopement risk from something in his chart. When asked about door security on the Memory Care unit, LPN F explained several residents including resident #1 often attempted to push on the unit's exit door. She said, It cannot open by pushing. Someone has to open it . On 3/15/21 at 7:56 PM, LPN D stated she was the house supervisor on the night resident #1 eloped. She recalled being notified of the situation at about 8:30 PM. LPN D explained everyone on the Memory Care unit was an elopement risk and the doors that led from the unit to the rest of the facility and the doors to the enclosed courtyard should always be locked. LPN D stated the doors could only be opened by staff who would either enter a code on the keypad beside the door or use a wall-mounted switch at the nurses' station. LPN D said, The staff usually used the switch to unlock the door. When it opens it made a short chiming sound like a doorbell. It only rings once, a short low sound. From the daytime they might have left it open and he could have walked out. On 3/15/21 at 8:16 PM, the grassy area where resident #1 was located was observed with LPNs B and D. Both nurses reiterated how dark the area was at 8:45 PM on the night they found resident #1 lying in the grass. Historical weather data showed the temperature on 2/18/21 at 7:56 PM was 73 degrees Fahrenheit and sunset was at 6:15 PM that evening (Retrieved on 3/19/21 from www.timeanddate.com). The area identified by LPNs B and D was almost totally dark and a flashlight was necessary to see objects more than 3 feet away. The outline of a tall tree was visible against the sky, but the ground below appeared black. LPN D explained resident #1 did not respond to her shouting his name and she came upon him suddenly in the darkness. The terrain sloped downward from the facility at a high point and the ground was uneven. Walking on the soft, sandy soil was difficult and each step forward required considerable effort to maintain one's balance. A thick layer of leaves covered sections of the grass and made the area even more dangerous by creating a slippery surface. LPN B described the challenge of pulling resident #1 on his walker while LPN D pushed it from behind. LPN B said, I was sweating. It was a struggle. LPN D stated the ground was so soft resident #1 would not have been able to easily roll his walker along. Observation of the wooden fence and 6-foot gate was limited due to the dim lighting in the facility's back parking lot. The obstacles along the route from the gate to the grassy area would have been barely visible to resident #1 in the darkness due to his visual deficit, and the uneven terrain and deep layer of leaves would have created difficult walking conditions with his gait issues. On 3/16/21 at 10:08 AM, resident #1 was alert and oriented to person and place but not to time. He stated he used a walker because his legs were very stiff as a result of [MEDICAL CONDITION]. He explained he sat on his walker's bench seat when he stopped somewhere or if he got tired. Resident #1 acknowledged he exited the facility recently in an attempt to go home. He explained with words and gestures that he walked through the Memory Care unit's open side door into the courtyard, went along the pathway past his window until he got to a gate. Resident #1 said, Went over. He used his left hand to represent the fence and the fingers on his right hand simulated the motion of going up and over the gate. When asked how he was able to lift the walker over the gate, he said, It doesn't weigh much. The weight of resident #1's walker was obtained by a staff member and was 16.4 pounds. A few minutes later at 10:29 AM, resident #1 walked along the hallway from his room towards the nurses' station with his walker. He had a slow, shuffling gait and his right foot and leg dragged slightly. Resident #1 was confused, and his conversation was inappropriate as he stated he had recently been thinking of being re-trained so he can return to work as a police officer. On 3/16/21 at 4:14 PM, resident #1's elopement route was re-traced. From the doorway of his room, resident #1 walked approximately 70 feet to the courtyard exit door by the nurses' station. It is unknown whether a staff member unlocked the door for resident #1, or if he accessed the wall switch inside the nurses' station to unlock the door himself. He crossed the courtyard and reached over a 3-foot high gate to unlatch it, then walked along an uneven poorly lit pathway until he reached a similar gate near the rear door of the Memory Care unit. Resident #1 unlatched the second gate in the same manner and followed the path to the end where it stopped at a 6-foot wooden fence with a locked gate, a total distance of approximately 233 feet from his room. Next, resident #1 folded his wheeled walker, threw it over the 6-foot fence and climbed over the wooden gate by using a rail as a foothold. Resident #1 landed on a paved area in front of the gate and turned right. He walked approximately 160 feet from that point to the grassy area where he was found by staff. Resident #1 walked past numerous hazards including concrete parking stops, raised tree roots, concrete drains with metal grates and shrubs as he crossed the uneven, sloping terrain. Resident #1 eventually fell in the grass, over 380 feet from his room. If resident #1 had continued walking around the building in the darkness, he could have fallen into a steep-sided dry retention pond or reached the street in front of the facility and been hit by a car. On 3/16/21 at 4:43 PM, CNA G stated resident #1 was on her assignment on the night he eloped from the facility. She stated although she had worked on the Memory Care unit before, that shift was the first time she was assigned to resident #1 and she did not know he was at risk for elopement. She said, If I knew he was an elopement risk I would have kept a better eye on him. CNA G recalled resident #1 liked to sit in the hallway beside the nurses' station and he was at the unit's double exit doors by the nurses' station when LPN C left at the end of his shift. CNA G confirmed she last saw resident #1 before 8:00 PM as he walked towards his room. She stated sometime later, LPN F informed staff resident #1 was missing and she joined other staff in the search. CNA G stated after resident #1 was found and returned to the Memory Care unit he appeared to be exhausted. She said, I asked where he was going, and he told me he climbed the fence. I had a hard time believing it because he is so wobbly sometimes . he never went out to the courtyard after dinner. I did not let him out. On 3/16/21 at 12:08 PM, the Social Services Assistant (SSA) stated resident 1# was transferred from another facility because he required a secure unit. The SSA said, He tried to escape from a window. I don't think he got out. I know he had exit-seeking behaviors before coming here. On 3/16/21 at 12:42 PM, the Admissions Director (AD) stated another facility contacted her regarding placement for resident #1. She said, I believe I was told he had exit-seeking behavior. If we feel there is a possibility that any resident in their confused state would be exit-seeking or wandering off the property we would place them in the secure unit. On 3/16/21 at 1:19 PM, the Lead MDS Coordinator stated residents admitted to the Memory Care unit had care plans for wandering or behaviors. She explained all newly admitted residents were discussed and their charts reviewed in daily clinical team meetings. The Lead MDS Coordinator stated resident #1 should have also had a care plan for elopement risk due to his history of exit-seeking behavior and elopement attempt(s). MDS Coordinator H confirmed resident #1 only had a care plan for wandering prior to the elopement incident although the transfer form from the previous facility indicated an elopement risk alert. Both MDS Coordinators reviewed resident #1's care plans and acknowledged there were no specific interventions for exit-seeking and elopement prior to the event although the resident had a known history. They acknowledged there was a difference between wandering and exit-seeking behaviors and care plan interventions should have included appropriate interventions for each resident's behaviors. Review of the medical record revealed a care plan initiated on 10/01/20 for potential for mood decline related to adjustment disorder, depression, [MEDICAL CONDITION], history of paranoia and hallucinations and frequent verbalization of wanting to go home and missing his family. The approaches included to monitor for mood changes and validate feelings and concerns. Resident #1 had a care plan for behaviors including wandering, hallucinations, and delusions, initiated on 10/07/20. The goal was that resident #1 would have fewer episodes of hallucinations and delusional behavior. The care plan approaches directed staff to anticipate resident's needs, monitor his behavior episodes and determine causative factors. The care plans did not include any interventions specific to resident #1's known exit-seeking behavior and elopement risk. The approaches did not address his behaviors of positioning himself at the Memory Care exit doors and nurses' station where he could visualize the door codes and the process of unlocking doors with the unsecured wall switch. The approaches were not revised and updated to reflect resident #1 pushed on exit doors and his escalating and repeated verbalizations of wanting to leave the facility and return home to his family. A care plan for risk for elopement was initiated on 2/18/21 after resident #1 was found outside the facility. The document revealed he had intermittent confusion and the approaches included 1:1 supervision as needed and do not allow resident into secure courtyard without staff present. The elopement risk care plan did not include individualized approaches to instruct staff to redirect or remove resident #1 from exit doors and to use caution when entering keypad codes to unlock doors. Interviews were conducted with the facility's DON and Risk Manager (RM) on 3/16/21 at 3:06 PM and 3/17/21 at 1:19 PM. The DON stated she was on the telephone with LPN D when resident #1 was found outside on 2/18/21 at approximately 8:46 PM. Review of the facility's investigative timeline indicated this was almost 1 hour after he was last seen by staff on the Memory Care unit. The RM stated she assessed resident #1 after he was returned to the building and noted he had abrasions on both knees and scratches on his forearms. She described the areas as having the appearance of rug burns. The DON was asked how the facility determined the secure Memory Care unit was appropriate for resident #1 prior to his admission. The DON said, We got it in report from the other facility that he was a wander risk and needed a secure unit. We did not have all the information. After he eloped I called the DON at the other facility. She told me he was actually exit-seeking. He was seen trying to open a window. The DON stated she was not aware resident #1 was capable of climbing a gate or fence. The DON was informed resident #1's transfer form on admission clearly indicated he was an elopement risk. She acknowledged the facility did not implement a care plan to mitigate the risk for elopement prior to the incident. She explained the facility implemented a care plan for resident #1 for wandering behaviors. She said, Wandering is more aimless, and exit-seeking is purposeful. The DON and RM explained after the elopement they had a conversation with resident #1's daughter and she informed them her father had eloped before. They stated the facility did not have a process in place prior to the elopement incident to ensure comprehensive information on elopement risk was obtained from either family members or transferring facilities. The DON said, We did not know the risk level. He would not have been allowed in the courtyard without supervision if we had known. The RM stated during the facility's investigation she interviewed resident #1 and he informed her he exited the Memory Care unit through the courtyard exit door by the nurses' station. She stated resident #1 did not say whether someone let him out or if the door was already unlocked. The RM stated LPN F recalled the wall switch at the nurses' station was engaged at the start of her shift at 7:00 PM that evening. The RM explained the wall switch was visible and accessible. She said, There is speculation that (resident #1) turned off the switch. The nurses' station might have been empty if the nurse was passing meds and the CNAs giving care. Review of the Facility Assessment updated on 3/03/21 revealed the facility provided care for residents whose needs ranged from short-term rehabilitation to a long-term secure unit. The document indicated the facility could provide necessary care and services for residents with psychiatric and mood disorders, and other behaviors that required intervention. In addition, the facility also offered care and services for residents with [MEDICAL CONDITION] and non-Alzheimer's dementia. The assessment described the facility's 22-bed secure unit that had a keypad lock system requiring a code for entry and exit. The document indicated there were secured exit doors on that unit that led to an enclosed patio and sidewalk. Review of the Resident Elopement Risk Management Guidelines revised on 11/01/18 revealed the facility's intent . provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. The document defined elopement as occurring when a resident left a safe area . without authorization and/or any necessary supervision to do so. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: * On 2/18/21, resident #1 was assessed on return to the facility. He received first aid for minor injuries and the required notifications were made to the physician and family. Diagnostic x-rays were ordered to rule out major injury and the results were negative. He remained on the secure unit with increased supervision, every 15 minutes by a CNA. *On 2/18/21, resident #1 was re-evaluated for elopement risk and a care plan was initiated. After resident #1 was admitted , the facility added a registered nurse to the admissions team to assist with pre-admission screening. * On 2/18/21, a head count was done to verify the safety of all residents in the facility and the courtyard was closed until further notice. Employees were informed the doors were to be locked and no residents were to be permitted to enter that area. * On 2/18/21, the functionality of all doors was verified by the Director of Maintenance. Weekly door checks were on-going and daily door checks on the Memory Care unit were implemented. * On 2/18/21, secondary audible screamer alarms were installed on 2 of 2 exterior exit doors in the Memory care unit. * On 2/18/21, elopement education was provided for all staff on the 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts. The topics included the elopement policy and procedures, securing the courtyard, secondary audible alarms, temporary closure of the courtyard and not sharing door codes with residents or family members. Additional in-services were scheduled for every shift until all staff were educated. * On 2/19/21, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting with the interdisciplinary team (IDT) was conducted to review the immediate plan of action. The daily audit tool was developed to monitor safety interventions including function of doors and screamer alarms. *On 2/19/21, all residents in the facility were re-evaluated for elopement risk and their care plans were reviewed. There were no newly identified residents at risk for elopement and no other discrepancies noted. *On 2/19/21, maintenance staff initiated a fence project and on that day removed the 3-foot fence with gate and replaced it with a 6-foot fence. *On 2/19/21, a secure lock box was placed over the manual wall switch used to unlock the doors. Key access by the Director of Maintenance only. *On 2/19/21, 54% of all staff were educated. *From 2/19/21 to 2/22/21, construction of a 6-foot fence was completed. *On 2/23/21, weekly door checks were reviewed. *On 2/26/21, the IDT reviewed door code changing intervals and codes will be changed every 4 months. *On 3/02/21, 3/04/21 and 3/05/21, the nurse leadership team conducted elopement drills to cover all shifts with a review of the elopement policy and procedure. *On 3/03/21, the elopement was reviewed at the Safety Team meeting. This QAPI sub-committee determined it would be prudent to increase the height of the 6-foot fence to 8 feet in some areas. *From 2/20/21 to 3/09/21, elopement education continued in person or by phone prior to employees' next working shift. Compliance with education achieved for 97.5% of staff including contracted rehabilitation department staff. *On 3/09/21, the event was reviewed at the scheduled monthly QAPI meeting with the IDT and Medical Director. Review of audits revealed 100% compliance and the IDT agreed with recommendations from the Safety Team. A contractor was hired to complete the new 8-foot fenced areas. The IDT also determined all employees should have a card with all safety codes attached to their badges. *On 3/11/21, the front door lock timer was reset to reflect the change to Daylight Saving Time. *Interviews conducted from 3/15/21 to 3/17/21 with 16 staff members (9 CNAs representing all shifts, 2 housekeepers, 2 therapy staff, 2 dietary staff and 1 maintenance assistant) indicated they were knowledgeable of the elopement policy and procedures, supervision of residents at risk for elopement and restrictions related to door code access. The sample was expanded to include 4 additional residents who were at risk for elopement. Three residents resided on the Memory Care unit and one resided on an open long-term unit. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #2, #3, #4 & #5.

Based on record review and interview, the facility did not provide adequate supervision to prevent falls and injury for 1 of 4 sampled residents reviewed for falls (#3). The facility's failure to communicate the needs of the resident to provide adequate supervision to prevent falls resulted in actual harm. Resident #3 sustained a fracture to her right clavicle (collar bone) and exacerbated injury to her ribs when she had 2 falls within a 24-hour period. Findings: Record review revealed resident #3 was admitted to the facility on [DATE] at 7 PM with a known history of fall with injury that occurred prior to admission. Her [DIAGNOSES REDACTED]. muscle weakness, degenerative joint disease, and hypertension. The resident was discharged to another skilled nursing facility 6 days later, on 8/03/16. Review of the Admission Data Collection dated 7/28/16 listed primary [DIAGNOSES REDACTED]. Kyphoplasty is a surgical procedure to stabilize broken bone ( <http://www.webmd.com/a-to-z-guides/vertebroplasty-kyphoplasty-compression-fractures-spince-overview>). The section for fall risk data collection included 6 parameters to determine the risk for falls: mental status, history of falls, ambulation/elimination status, vision, gait/balance, systolic blood pressure, medications, and predisposing diseases. A score of 10 or above represents a high risk for falls. The nurse completing the form indicated that resident #3 had a total score of 4. The section for systolic blood pressure was incomplete and did not have any score. The section for predisposing diseases indicated none present and it was scored with a zero. When 3 or more diseases or conditions were present, the score for this section should have been 4. Review of the resident's Diagnostic Problem List indicated the resident had 3 predisposing conditions: osteoarthritis, osteoporosis, and fractures. The section for medications indicated the resident did not take any medications listed (antihypertensive, diuretic, narcotics, or psychotropics) currently or within the last 7 days and it was scored with a zero. Review of the physician's order [REDACTED]. The medications were: antihypertensive-Norvasc 10 milligrams (mg) daily, Metoprolol Tartrate 100 mg daily, Diovan 320 mg daily, diuretic-triamterine/Hydrochlorothiazide 37.5 mg/25 mg daily, narcotic-oxycodone-acetaminophen 5 mg-325 mg (Percocet) every 4 hours as needed for pain, psychotropic-Trazodone 50 mg daily. Based on the inaccurate and/or incomplete risk information, the resident's fall risk was incorrect and should have put her at a high risk for falls. The Fall Risk Interim Plan of Care was documented on the same form as the admission data collection dated 7/28/16. The problem was listed as Resident is at risk for falls as related to: history of fall past 31-180 days. Other problems such as unsteady gait, decreased safety awareness, use of psychoactive medications, and other were not checked as problems for resident #3's risk for falls. Interventions included: orient patient to the environment and the call bell system, keep the call bell in reach, ensure appropriate footwear on when out of bed, evaluate for incontinence and assist to the toilet as needed, keep items within reach: i.e. water, TV remote, call light, keep environment free of clutter, use non-skid footwear, assess need for and provide adaptive equipment/walker. The goal for the resident was to have reduced opportunities for falls with interventions. On 9/02/16 at 10:39 AM, the occupational therapist (OT), who did her initial evaluation of resident #3 on 7/29/16, said she was aware the resident had a history of [REDACTED]. During her initial OT evaluation, the resident had pain in her back. The resident was not able to raise her arms up to shoulder height to put on her shirt or brush her hair, but did not have any complaints of pain in her right shoulder or rib area at that time. The OT said she notified the nurse about the resident's pain level and documented information about the resident toileting, transfer, and hygiene needs on the Care Card which is kept in the resident's closet. She said therapy staff update the Care Card as needed, but verbal instructions regarding the resident's needs were not routinely conveyed to nursing. The OT said resident #3 required contact guard minimal assistance and the use of a walker to get into the bathroom. The OT said the resident would not have been safe to leave alone in the bathroom because she did not understand the need to wait for assistance. The OT said the resident required multiple cuing to wait for assistance, and had poor balance and poor safety awareness. Review of the OT evaluation dated 7/29/16 revealed the resident required OT services due to new onset of decreased strength and functional mobility, reduced ability to safely ambulate, reduced balance due to pain and generalized weakness, and risk for falls. On 9/02/16 at 11:23 AM, physical therapist (PT) A said she did the initial evaluation for resident #3 for therapy on 7/29/16. She indicated the facility was aware resident had a history of [REDACTED]. The PT said the resident initially needed contact guard assistance and used a 4-wheel rolling walker. During the resident's initial therapy, she had pain in her abdomen and lower back. She did not have any complaints of pain in her ribs or shoulders. Her goals for therapy were to get back to the Assisted Living Facility, to be able to transfer, and walk on her own with the walker. The PT said the resident needed supervision for transfers and walking, would not allow her to be in the bathroom on her own, and would convey the information to the nursing staff by writing it down on the Care Card. She could not remember if she had talked with the nursing staff regarding resident #3. Review of the PT evaluation dated 7/29/16 indicated the resident needed PT services due to a new onset of decrease in strength, pain, an increased need for assistance from others, a reduced ability to safely ambulate, and a risk for falls. On 9/02/16 at 12 PM, the director of nursing (DON) said the Care Card is to communicate care for the resident between staff members. When asked to review the Care Card for resident #3, the DON said that it is shredded after the resident is discharged from the facility and is not available for review. The 5-day Minimum Data Set Assessment (MDS), dated for the review period of 7/28/16 to 8/03/16, indicated a Brief Interview for Mental Status (BIMS) was 11 out of a total of 15. The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. A score of 11 indicated the resident had moderate cognitive impairment meaning the resident's decisions were poor and she required reminders, cues and supervision. Her functional status showed that she required extensive physical assistance with 1-2 persons for all activities of daily living (ADLs), except that she could eat independently. Her balance moving from seated to standing, walking, transferring, and moving on and off the toilet was not steady. She had impaired mobility in both upper extremities and she normally used a walker and/or wheelchair. She was occasionally incontinent of bladder and had less than 7 episodes of incontinence during the assessment period. The pain assessment interview was not conducted because the assessment indicated the resident was rarely understood. The staff assessment for pain in the last 5 days indicated the resident had vocal complaints of pain daily. She received scheduled pain medication and received as needed pain medication during the last 5 days of the assessment period. She had a history of [REDACTED]. She had 2 falls since admission to the facility, 1 with no injury and 1 with major injury, bone fractures. Resident #3's medical record revealed she fell in the facility for the first time on Saturday, 7/30/16 at 5:15 AM and she fell again on Sunday, 7/31/16 at 4:20 AM. Review of the Post Falls Nursing Assessment dated 7/30/16, indicated the resident was found lying on the floor in front of her bed on her right side at 5:15 AM. The documentation indicated the resident had no pain following the fall. It listed pain medication, Percocet, was given prior to the fall at 5:10 AM on 7/30/16, but the medication administration record (MAR) showed no evidence of Percocet being given at that time. Her range of motion for all extremities did not change from her baseline. Immediate interventions were to keep assistive devices within the resident's reach. Additional comments indicated that staff were educated to remain at the bathroom door while the resident is in the bathroom, and not to leave the resident unattended. It did not address any other interventions regarding toileting. The documentation indicated the physician was notified and no orders were received. Review of the progress notes for Nursing dated 7/30/16 at 4:48 AM, documented events from the previous evening, 7/29/16, up until that time. The notes reflected that the resident had some intermittent confusion. Bed alarms were added for safety per the daughter's request and the resident was agreeable to the alarms. Review of the MAR revealed the last time resident #3 received pain medication for back pain was at 8:41 PM on 7/29/16 and it was documented as effective at 9:11 PM. Review of the progress notes for Nursing dated 7/30/16 at 7:33 AM documented the nurse found the resident on the floor as noted above at 5:20 AM. The notes indicated the resident exited the bathroom unassisted and fell on her way back to bed. The bed alarms were not sounding at the time the resident was found on the floor. On 8/30/16 at 12:20 PM, licensed practical nurse (LPN) C said she was assigned to care for resident #3 on the night shift from 7 PM to 7 AM on 7/29/16 to 7/30/16. She said the resident was pleasant, alert and oriented but had periods of confusion, had a history of [REDACTED]. She confirmed that she was the nurse who found the resident on the floor on 7/30/16 at 5:15 AM. She said she saw the resident on the floor in front of her bed on her right side. The LPN said that she did not appear to have any injuries or shoulder pain, and that she did the neurological assessment, which was normal. The resident's range of motion was the same as her baseline. The LPN said that CNA D was new to the facility and that was her first night off orientation. She said she instructed CNA D at the beginning of the shift not to leave resident #3 in the bathroom unsupervised because she was a high risk for falls. However, CNA D did not follow her instructions and she left the resident in the bathroom unsupervised. LPN C indicated that she re-educated CNA D regarding care of residents who are high fall risk after the resident's fall. She said the physician and family were notified of the fall, and report was given to the day nurse and night time supervisor regarding the resident's fall. She did not indicate whether or not the therapy department was notified of the resident's fall. On 8/30/16 at 2:30 PM, certified occupational therapy assistant (COTA) E indicated that on 7/30/16 at 1:45 PM, resident #3 said she did not want to go to therapy and was not feeling well. However, after she explained to the resident the importance of therapy, the resident agreed to have therapy. COTA E was able to review log rolling while in bed with the resident, got her to sit up on the edge of the bed and then into the wheelchair, and took her to the therapy room. She said the resident was able to do upper body strengthening exercises using a very light resistance yellow Thera-band. After doing a few repetitions, she said the resident wanted to go to the bathroom, so the COTA brought her back to her room via wheelchair, then assisted her into the bathroom with contact guard assistance and the use of a gait belt. She said she stayed with the resident during toileting because she needed supervision and contact guard assistance, and she did not want her to fall. She said after the resident voided, she was able to do her own hygiene, but needed assistance pulling up her pants and getting back into the wheelchair. Once back in the wheelchair, she assisted her with turning toward the sink to wash her hands, and then took her back to bed via the wheelchair. COTA E said she was not aware that the resident had a fall the morning prior to therapy until it was brought to her attention by the resident while helping her back into bed. COTA E said that nursing staff usually tells them of any changes in the resident's condition, and they will usually report falls. However, she did not find out about the resident's fall until after she finished therapy with the resident and it was brought to her attention by the resident. On 9/02/16 at 11:14 AM, physical therapy assistant (PTA) O said she did therapy with resident #3 on 7/30/16 and was not aware the resident fell earlier this day. She said the resident was able to walk with minimal assistance and used a walker. She said she only needed to place her hand on the gait belt worn by the resident. She said the resident required repetitive cuing and had poor safety awareness. She said the resident did have back pain during therapy but did not complain of shoulder or rib pain on that day. Review of the Post Falls Nursing Assessment dated 7/31/16, revealed that resident #3 had a second fall less than 24 hours after the first fall, on 7/31/16 at 4:20 AM. The assessment reflected that certified nursing assistant (CNA)-F found the resident sitting on the bathroom floor and the bed alarm was disconnected. The assessment indicated she was assessed for injury and the resident had mild right shoulder pain, her range of motion in all extremities did not have any change from baseline. Interventions from this assessment post fall read, (Resident #3) was reminded to use call light and not to disarm (the alarm). The documentation indicated the physician was notified and no orders were received. It did not address any other interventions regarding toileting even though this was resident #3's second fall involving toileting. On 8/31/16 at 2:05 PM, CNA F said on Sunday, 7/31/16 she found the resident on the floor. She said she did not know how long she had been on the floor. She said that earlier in her shift she heard the resident's alarm going off and the resident was trying to get out of bed. She said at the time she found the resident on the floor, the alarm did not sound because it was unplugged. When asked about supervision in the bathroom, the CNA said it would not be safe to leave the resident in the bathroom unsupervised because she was very confused. She indicated the resident was not capable of pushing on the call bell and had been accidentally pressing the TV button instead of the call bell during her shift. On 8/30/16 at 6:44 PM, LPN G She said she worked the 12-hour shift at the time the resident fell on the morning of 7/31/16. She said the resident had periods of confusion, more often at night, would wake up and not know where she was. She said that the resident was a high risk for falls and had a history of [REDACTED]. She said CNA F was in the room and yelled out into the hall We have a (resident) on the floor. The LPN indicated that she immediately went to the resident's room and found her sitting on the floor in the bathroom between the toilet and the sink. She said the resident told her she was going to wash her hands after she used the restroom, slid down, and did not fall hard. The LPN said the resident did not have physical injuries, so she brought the resident back into bed, took off her gown, examined her entire body, took her vital signs, and said everything was within normal limits. She said the resident did not have new pain, shoulder pain or head trauma after that fall at that time. LPN G said that the resident did not have any shoulder pain, but she documented on the Post Fall Nursing Assessment that the resident had mild pain in the right shoulder area. The progress note for nursing dated 8/01/16 at 11:42 AM, indicated the advanced registered nurse practitioner/physicians' assistant (ARNP/PA) came in to see the resident and decided to order a chest X-ray due to recent falls and rib pain. The ARNP did not document a progress note for the visit on 8/01/16. Radiology report for chest X-ray conducted on 8/01/16 revealed it was final and signed by the radiologist at 6:35 PM. It showed no evidence of infiltrate or congestive heart failure. It did not document any sign of fracture. On 8/31/16 at 4:49 PM, LPN J, who works on the 7 AM to 7 PM shift, confirmed she cared for resident #3 on 7/29/16, 8/01/16, and 8/02/16 on the day shift. She said that the resident was confused at times. She said the nurses and CNAs give a face to face report during the change of shift and use the Care Card to communicate information between nursing and therapy regarding the resident's cognition, use of alarms, and transfer needs. LPN J said that the ARNP came in sometime prior to 11:42 AM on 8/01/16 to see the resident and gave her a verbal order for a chest X-ray due to the resident's recent falls. On 9/02/16 at 10:06 AM, CNA N indicated that she cared for resident #3 on 7/30/16, 7/31/16 and 8/01/16 day shift. CNA N indicated that resident #3 had periods of confusion, and on 7/31/16 the resident was pressing the TV remote instead of the call bell. CNA N was able to take the resident to the bathroom with a walker and said she would not leave her alone in the bathroom because the resident was confused and did not know how to use the pull string for the call light in the bathroom. She said information is communicated between the CNAs by report given from CNA to CNA and also by looking at the Care Card that is kept in the resident's closet. It (care card) gives us a picture of what is going on with the residents. CNA N said that she was aware that the resident had falls that weekend. She was having a lot more pain in her breast area, and it took her longer to do care for the resident. The CNA indicated that she did not notice any bruising or swelling in her right shoulder area when changing the resident's clothes, but the resident had pain, which she reported to the nurse. CNA N indicated she was in the room the morning of 8/01/16 when the ARNP saw the resident who complained of pain in the right chest area to the ARNP at that time. On 9/02/16 at 11:34 AM, occupational therapy assistant (OTA) P said that on 8/01/16 at approximately 4 PM, resident #3 did not want to do therapy due to pain all over her body. The OTA said she offered to take the resident to the bathroom. She said the resident needed contact guard assistance due to poor safety awareness, was bumping into the wall, and needed frequent cuing and re-direction the whole time. The OTA indicated that she reported the resident's status regarding refusing therapy to social services. She did not indicate that nursing was made aware of the resident's refusal for therapy or complaints of pain all over. On 9/02/16 at 11:41 AM, physical therapy assistant (PTA) Q said he tried to do therapy with the resident on 8/01/16 at approximately 3 PM but resident #3 refused therapy due to complaints of pain in her ribs and told him that she was waiting to have X-rays done of her chest and arm. He notified the nurse of the resident's complaint of rib pain, and that she did not want to do therapy. On 9/02/16 at 11:52 AM, OTA R indicated that resident #3 refused therapy on 8/02/16 at approximately 2 PM due to complaints of pain and said the desk nurse was notified. The OTA did not ask the location of the resident's pain because she was lying in bed dressed at the time. On 9/01/16 at 9:36 AM, a telephone interview was conducted with the Night Supervisor Registered Nurse (RN) L. She said she worked on 7/28/16, 7/29/16, 8/02/16 and 8/03/16, and was involved in the care of resident #3. RN L said she was present after resident #3 fell the morning of Saturday, 7/30/16 at 5:15 AM and that CNA D did not say why she left the resident in the bathroom unattended. After the resident was examined by LPN C, there were no injuries. She said that the LPN did re-education with the CNA regarding staying with the resident when assisting to the bathroom. RN L said that resident #3 was alert and oriented to place and time with some intermittent confusion. RN L said that she does not give a verbal report to the director of nursing (DON) or unit mangers (UM) regarding resident falls but, writes it down in the Supervisor Book. RN L said that she did not remember if she wrote anything in the book regarding resident #3's fall on 7/30/16. RN L did not work on the night of 7/30/16 or 8/01/16, and then returned to work on 8/02/16. She said that on 8/02/16 at approximately 9:15 PM, she was approached by resident #3's daughter regarding concerns about the resident's right shoulder swelling, not able to move her arm, and complaining of pain on that side. RN L indicated that she went to look at resident #3 and observed that the resident did have swelling of the right shoulder at that time. The resident could only lift her right arm up 4-5 inches. The resident was wincing in pain and said, it hurt so bad. The daughter told her that when she was trying to help her mother change her gown, she noticed the swelling and pain in the right shoulder. RN L said that after she assessed the resident, she called the physician and asked for orders for X-rays of the shoulder and rib area, then called the portable X-ray company at 9:30 PM and told them that it was a STAT order. (STAT is a common medical abbreviation for urgent). The daughter indicated she wanted her mother to go to the hospital and did not want to wait any longer. The daughter took the resident to the emergency room (ER) at approximately 10:35 PM. RN L said that she was present when on 8/03/16 when the resident came back from the hospital via ambulance at approximately 4:10 AM. The resident's daughter told her the X-ray results at the hospital showed fractured ribs and clavicle. On 9/02/16 at 1:23 AM, PT A indicated that resident #3 was doing really well in therapy during evaluation on 7/29/16. After the 2 falls on 7/30/16 and 7/31/16, she refused therapy due to increased pain. PT A said the resident declined in her function after the falls. Initially on 7/29/16, she needed minimal assistance with ambulation and by her discharge on 8/03/16 she needed maximal assistance. PT A said she saw the resident on 8/03/16, and she was not able to do therapy due to pain and the resident's right arm was immobilized. An interview with the risk manager regarding an investigation for resident #3's falls on 9/02/16 at 2:02 PM confirmed both falls occurred on the weekend and they were reviewed on Monday, 8/01/16, in the morning meeting. Their investigation determined the CNA did not follow instructions to stay with the resident when toileting on 7/30/16. Their investigation for the fall on 7/31/16 indicated the CNA caring for resident #3 at the time of the fall on 7/31/16 indicated the resident's bed alarm was sounding several times during the night and the resident was confused because she was pressing her remote control for the television instead of her call light. The investigation did not indicate any new or revised interventions for fall prevention on 7/31/16 when the resident was confused and setting off the bed alarm frequently during the night. On 9/02/16 at 1:04 PM, the DON confirmed that the Admission Assessment, dated 7/28/16, for Fall Risk was not accurate. She reviewed the documentation and confirmed that the resident was given a score of 4 but should have been 10 or greater, which would have indicated the resident was a high risk for falls. The DON confirmed that after resident #3 fell on [DATE] and then again on 7/31/16, there were no other new interventions for fall prevention, except for the education that the nurse did with the staff regarding not to leave fall risk residents unsupervised in the bathroom during toileting. Review of the hospital records from the ER visit on 8/03/16 revealed X-rays were completed of both shoulders and the ribs at 12:05 AM. The X-ray report indicated the results were compared with previous X-rays from 7/13/16 and 7/19/16. The results showed fracture of the distal right clavicle without separation, remote bilateral rib fractures, no definite acute rib fracture, and marked degenerative change in left shoulder, limited degenerative change in right shoulder. On 9/02/16 at 3:21 PM, the medical director reviewed resident #3's record regarding X-rays that were done on dates 5/06/16 to 8/03/16. He confirmed that the X-ray results from 8/03/16 showed a new fracture of the distal right clavicle without separation. He stated, The results of fracture of the distal right clavicle without separation was most likely due to recent falls occurring at the facility on the weekend of 7/30/16 to 7/31/16, since this would have been the only event that we know of that would have contributed to the current results. Review of the Policy for Fall Management dated 8/07/2005, revealed The facility will identify each resident at risk for accidents and/or falls, and adequately plan care and implement procedures to prevent accidents/falls. The policy included a list of potential risk factors including but not limited to, cognitive status mobility, history of falls, medications, decline in function. The policy included a list of interventions including but not limited to, toileting schedule, recommendations from therapy, and medications for pain relief. The policy indicates the facility will develop an individualized care plan to address prevention with specific interventions and it will be revised based on the resident needs, including recurring falls and prevention strategies. The policy directs nursing staff to observed for delayed complications of a fall for approximately 48 hours and to identify causes of the incident within 24 hours of the fall.

Based on interviews with the facility's nursing, admissions, social services and administrative staff, the attending physician, the medical director, the resident's durable power of attorney (DPOA)/legal health care surrogate (HCS), and review of the clinical record and facility policies and procedures, it was determined that the facility failed to promote the rights of residents to exercise choices regarding cardiopulmonary resuscitation/do not resuscitate (DNR) orders for 1 of 4 sampled residents reviewed who returned after being discharged without an anticipated readmission to the facility (#8). The facility failed to communicate effectively with resident #8 and the DPOA/HCS and failed to follow policies and procedures to verify and document the continued wishes for a DNR upon readmission to the facility. The resident was denied her wishes for a peaceful and dignified death when the facility initiated cardiopulmonary resuscitation (CPR) and called 911. The resident received chest compressions and artificial ventilation until emergency medical personnel arrived. They continued resuscitation efforts and the resident was intubated. She was transported via ambulance to the hospital where the emergency room record documented her son/DPOA stated that she (resident) never wanted this outcome. She died in the hospital approximately 10 hours after CPR was initiated in the nursing home against her wishes. These findings resulted in immediate jeopardy which was removed on [DATE] and the severity and scope was reduced to no actual harm with the potential for more than minimal harm- Isolated. Findings: Resident #8 was admitted to the facility on [DATE] for rehabilitation after surgical repair to a right [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED]. The medical certification for Medicaid Long-Term Care Services Transfer form Agency for Healthcare Administration-,[DATE] completed by the hospital on [DATE] identified that the resident required a surrogate for decision making. The Advance Care Planning section listed yes to the following items: advanced directives, living will, and Do Not Resuscitate (DNR). Review of the Sigma Care electronic medical record (EMR) document noted that the DNR was scanned into the facility record on [DATE] at 2:40 PM. The Physicians' Orders printed from ,[DATE] to [DATE] noted an Advanced Directives order dated [DATE]: Do Not Resuscitate (DNR) was electronically signed by the physician on [DATE] at 8:02 PM. On [DATE] at 4:13 PM the physician electronically signed an order for [REDACTED]. Review of the Admission Agreement revealed it was completed by the resident #8's DPOA/HCS on [DATE]. Section P (page 11) Obligations of Legal representative listed the type and authority as Unlimited/durable power of attorney and health care surrogate. Section R (page 12) of the contract was for additional acknowledgements noting that The DPOA/HCS had received the patient rights booklet and advanced directives brochure. That page was signed and dated [DATE]. The resident was sent to the hospital [DATE] and returned on [DATE]. A new admission order dated [DATE] documented the Advance Directives as DNR and incapacity. On [DATE] the resident was sent to the hospital and returned on [DATE]. The advanced directives for Do Not Resuscitate was ordered and signed by the physician on [DATE]. An Advanced Directive care plan was initiated on the [DATE] admission. The goal was listed honor resident wishes. The approaches included that the patient has advance directives on file: DNR, living will, HCS, and DPOA. The care plan was reviewed on [DATE] and the next review of the care plan was to be on [DATE]. This was present in the resident's electronic record. Resident #8 was discharged on [DATE] to an assisted living facility. Review of the discharge instructions and recapitulation of stay completed on [DATE] identified that the resident was discharged to a lower level of care. The advanced directives documented a Do Not Resuscitate Order. The resident had a new admission to the facility on [DATE] after a hospitalization for surgical repair to a [MEDICAL CONDITION] femur. This was 9 days after the discharge to the assisted living facility (ALF), [DATE]. An interview was conducted with the admissions director on [DATE] at 1:06 PM. She stated that resident #8 was admitted to the facility on [DATE], discharged on [DATE], and the resident was readmitted on [DATE], 9 days later. She said that when a patient/resident goes into the community, the facility can use the same admission packet/contract and orders if the readmission was less than 30 days from the prior admission. She said the advanced directives (DNR/HCS/DPOA) should be in the electronic medical records system. She said, The family or resident would not have to complete any new paperwork if the admission was less than 30 days from the discharge. All the signed forms would be pulled forward from the old chart. The POA and DNR would not be pulled forward from the old chart. The POA and the DNR would not be pulled forward since they are already in the computer. We would probably go and look in the financial folders not the hard chart. Further interview on [DATE] at 1:30 PM, she stated that the DNRO should have been completed upon the new admission. She did not admit the resident. She was not responsible for having the family (HCS/DPOA) complete the DNR form. Review of the admission contract for resident #8 revealed the only contract was the one that was signed on [DATE] by the DPOA/HCS. There was no additional contracts or admission agreements or receipt of additional acknowledgements related to patient rights (page 11,12), signed by the DPOA/HCS when the resident/patient was readmitted to the facility on [DATE]. In an interview with the admissions assistant on [DATE] at 1:46 PM, she confirmed that she completed the admission information for resident #8 when she was readmitted on [DATE]. During the admission process from hospital, she said that she talked directly with resident #8 on the telephone in her room. She said that she asked the resident her date of birth, if she was choosing same physician, if the insurance the same, and if her advanced directives were the same. The admissions assistant said that the resident did not understand what advanced directive meant. She said that she asked the resident if the POA was still her son and asked if the living will and health care surrogate was the same, and she said yes. The admissions assistant then asked her for consent to be admitted to the nursing home and provide care. In an interview with resident #8's DPOA/HCS on [DATE] at 5:38 PM, he revealed his mother (resident#8) was admitted to the facility on [DATE] after the hospital stay of [DATE] to [DATE]. He said she was in the assisted living facility for one day after her discharge from the nursing home and then she went to the hospital for a [MEDICAL CONDITION] and surgical repair. He said that he was informed by the nursing home that since the resident had been discharged less than 30 days from the previous admission, he did not have to complete a new admission packet. He said that the facility already had a copy of the resident's living will and advance directive, including the do not resuscitate order, from the first admission on [DATE]. When he was he was asked if any staff asked him about the advance directive/DNR on the [DATE] admission, he said that he was not asked about the DNR. When he checked with his other family members that were with his mother (resident #8) when she was admitted that day, he said that no staff had asked that information the resident's daughter. He said that he was contacted on [DATE] around 10:30 PM by a nurse from the facility. The nurse said that cardiopulmonary resuscitation (CPR) was started and they said his mother was going to the hospital. He said he told the nurse that she had a DNR form that was provided to the facility on her first admission and she did not want CPR. He said he was very upset that his mother ' s right to have a DNR order was not honored. He said, she did not want to die like this. Review of the hospital records indicated the family members decided to withdraw care and stop any further potential resuscitation. They wanted to have comfort measures only. The intubation tube was removed and the resident died at 9:35 AM on [DATE]. Resident #8 and her DPOA/HCS communicated her wishes for a DNR when she entered the facility on each occasion on [DATE], [DATE], and [DATE]. The resident did not have any episodes in which her circulatory or respiratory function ceased during those times. On the last admission to the facility on [DATE], the facility did not follow her wishes for a DNR. On this last admission, circulatory and respiratory function ceased. Instead of having the right to die peacefully, she received resuscitation measures against her wishes. An interview was conducted with nurse H on [DATE] at 3 PM. She was involved with the care for resident #8 on [DATE]. She said that somewhere around/after 10 PM, one of the certified nursing assistants (CNAs) asked her to look at resident #8. She said the resident was still breathing and she went to the desk to call 911. She said, As I was walking back to room, she coded, the other nurse brought the crash cart. She said she helped the CNA with CPR for approximately ,[DATE] minutes and that the emergency medical technicians said she was gone. She said, I told the son that 911 was here and we got her back and were taking her to hospital. The son said she (resident #8) had a DNR and why did they do CPR? Nurse H said a DNR was not in her chart. Her chart was documented as a Full Code. A full code is a term used to describe a patient in cardiopulmonary arrest and immediate resuscitative efforts are initiated. (http://www.medicinenet.com/) An interview with the nurse supervisor was completed on [DATE] at 9:57 AM. She was involved with the care for resident #8 on [DATE]. She said, I was completing my med (medication) pass on the 100 hall around 10:20 PM on [DATE]. Nurse H, the 200 hall nurse, came to check on me, but on the way a CNA asked her to check on a patient (resident #8). After looking at resident #8 she and I looked at her (the resident) again, she still breathing, but she was in respiratory distress. Two CNAs were with the resident at that time. We (nurses) checked code status, looked in chart and computer for advanced directive. She was a Full Code. Nurse H called 911. I went to get the crash cart and oxygen. The CNAs informed us that she took her last breath and I told them to start CPR. Once I got in there I took over for one of the CNAs until the EMTs showed up and took over. When asked if the events as described were documented on a designated form, she said, There is no designated form to track time during a code. The nursing progress note dated [DATE] at 12:14 AM with a correction noted at 8:36 AM confirmed the events as described by the nurse supervisor. The notes documented that the resident was in respiratory distress, took her last breath, CPR was initiated, 911 was called, the physicians answering service was notified, and the resident's son was notified. The resident was transferred to the hospital by the EMTs. A phone interview was conducted with CNA K on [DATE] at 10:28 AM. She confirmed that she worked on [DATE] from 5:45 PM to 6:15 AM. She was involved with the care for resident #8 on [DATE]. She said that she was working the 100 hall, but she was not assigned to resident #8. She said, at 10:15 PM resident #8 was non-responsive and had a pulse. The nurse checked her pulse, I grabbed the ambu-bag (manual pump device used to force air through a mask and into the lungs). There was no pulse when the nurse checked. I placed the ambu- bag over the resident's nose and mouth, as they (nurse and CNAs) provided CPR. The EMT ' s came in and I backed up. When questioned how to identify a full code or DNR, CNA K said, If she was a do not resuscitate or full code it would be on the back of her care card on the closet door. There would have been yellow sheet on the care card. When we get report and get a new patient we always go the room and look at the care card. Do not resuscitate is not marked on the care card itself. The care card is located in the closet of the resident. An interview was conducted with the director of nursing on [DATE] at 3:15 PM regarding providing CPR to resident #8 when she had a DNR order since her first admission on [DATE]. She was questioned regarding the process of physician review of resident status. She said either he knows the patient (resident) or looks at patient history. The desk nurse puts in the orders from the hospital and clarifies them with the physician. She confirmed that Resident #8 did not have complete information on the hospital 3008 transfer form from the hospital at the time of the admission on [DATE]. She said, we did not have a DNR order from the hospital so we documented a full code. In an interview with the administrator on [DATE] at 3:15 PM, she stated that she was notified by the son the resident #8 was a Do Not Resuscitate when the facility called him on [DATE] to tell him that she coded and on the way to the hospital. She said, we changed the nurse to nurse tool (not a part of the clinical record) for preadmission to include specifically current hospital code status. Interview with the administrator on [DATE] at 11:30 AM revealed, that they started reviewing the process of admission and return within 30 days. They determined that a new contract needed to be executed. They did not identify that the clinical portion/ resident rights acknowledgement should be completed upon a new admission. The admissions/social services were not aware that they needed to redo the acknowledgement section of the admission contract. A phone interview was conducted with resident #8's primary physician on [DATE] at 1:45 PM. He was asked how he finds out a resident ' s DNR status. He said the information on the patient comes from hospital with appropriate documentation. He said he would talk with the resident or family regarding DNR. He said he reviews the record when he comes to see the patient, he the reviews the orders with the nurse, and he would tell the nurse when he determined the patient is incapacitated. The physician was questioned regarding how the DNR status is determined when a resident is readmitted in less than 30 days of discharge. He said he would verify the DNR status with family or resident. When questioned specifically regarding resident #8, he stated he did not know what happened. He was asked if he was aware that a full code was in place and that resident #8 was resuscitated and died . He said I don't recall that she was a DNR from the prior admission. He was asked if he had reviewed previous documents related to DNR. He had no response. An interview was conducted on [DATE] at 2:10 PM with the medical director regarding how admission and readmission information would be reviewed. He said, Usually I check the computer advanced directive area. I assume the documented orders are appropriate. I can go back in the documents if needed. There should be a yellow copy and I can look in the history. I have never had to review the opposite of reinstituting a previously existing DNR on readmission. (Changing a DNR status to a Full Code resuscitation). He was asked what could have done to prevent the Full Code from being documented in the record and physician orders [REDACTED]. He said he would Review 3008 (hospital discharge information), check for blanks, and verify the information on the form. He would also determine what the resident's wishes were regarding DNR by talking to the resident/family and review previous history in the electronic medical record. An interview as conducted with the social services director/case manager (SSD/CM) on [DATE] at 4:42 PM regarding admission process. She said that it starts with the admission department. Nurse liaison does a nurse to nurse report, admission director handles the admitting process and paperwork. The chart goes to the nurses' station. The desk nurse and floor admitting nurse complete initial assessment and paper work. The nurse to nurse (hospital nurse to facility nurse) would ask about advanced directives DNR status and the floor nurse would ask about DNR status. When questioned regarding resident #8, the SSD/CM stated the paperwork noted full code. An interview was conducted with the social services/case worker/Staff L on [DATE] at 2:44 PM She was questioned regarding the admission process and advanced directives. She said that when she does a new admission she asks for advance directives and legal paperwork. She said, If (the patient was) in hospital it says they would get family to bring it in. We can use legal paperwork from previous admission. We go through the process of requesting DNR as soon as we can establish the wishes. I met the son for resident #8. I looked into whether she was her own person. Someone should have re-established her DNR information. Nurse B was the nurse for resident #8 at the time of admission on [DATE]. She was interviewed on [DATE] at 4:45 PM. Nurse B was aware of the admission when the admission staff entered it on the dry erase board at the nurses' station (sub-acute wing). She said, I get admission packet from the chart at the nurses' station. I introduce myself to resident with aide. I take vitals, and start completing the admission packet/ Admission Data Collection/Interim Plan of Care Form. The resident name and the physician's name was on paper work. Sometimes it notes full code. Full code was written on the admission data collection form for resident #8. I didn't write it. I don't know if it was there. They (nurse liaison or desk nurse) get the nurse to nurse report from the hospital and put the code on the admission form. She stated that is was not her writing. She said that nurse F was the desk nurse at the time and she entered the order for DNR on [DATE]. A progress note for Admission Advanced directives- Discharge Plans was dated [DATE] and timed 4:39 PM completed by the admissions director. The admitted [DATE] documented: Advanced Directives/Advanced directives Information discussed verbally with family. The progress note had a specific section for Advanced Directives on file: with instructions to: Check all that Apply: included a list of Living Will, Health Surrogate designation, POA for Health Care, Organ Donation, DNR, other. None of the times were checked on this progress note dated [DATE]. A check mark was placed in the section Resident Preference: The resident has/or will provide facility with copies of Advanced Directives and understands that they will be honored at that time. A statement under this section: if resident/legal representative desires a DNR and DH for 1896 has not been signed, nursing will obtain an order for [REDACTED]. Review of the resident's advanced directives on file under History/Documents of the electronic medical record under tab Admissions/legal included the: State of Florida Do Not Resuscitate Order dated [DATE] and signed by the surrogate and durable power of attorney dated [DATE] and signed by a physician. The form was scanned into the medical record on [DATE] and it was re-scanned on [DATE]. Other records scanned under the document/history on [DATE] at 9 AM was the Living Will, the HCS and the DPOA. The living will declared on [DATE] signed by the resident identified if she had a terminal condition, end-stage disease, or persistent vegetative and if my attending or treating physician and another consulting physician have determined that there is no probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or performance of any medical procedure deemed necessary to provide me with comfort care or alleviate pain. Also initialed: I do desire that nutrition and hydration (water) be withheld or withdrawn. Review of the [DATE] admission paperwork revealed the Hospital Florida Medicare Certification Form Long-term Care Services and Patient Transfer Form (FL 3008) dated [DATE] documented that resident #8 had the Decision making capacity as requiring a Surrogate. The section for Advance care planning was not completed for Advanced directive, living will, Do not resuscitate (DNR), Do not intubate. The questions related to Do not hospitalize, no artificial feeding or hospice were answered, no. A progress note for Admission Advanced directives- discharge Plans was dated [DATE] and timed 12:42 PM completed by the admissions director. admitted [DATE] documented Advanced Directives/Advanced directives Information discussed verbally with resident. The progress note had a specific section for Advanced Directives on file: With instructions to: Check all that Apply included living will, Health Surrogate designation, POA for Health Care, Organ Donation, DNR, other. No items were checked. A check mark was placed in the section Resident Preference: The resident has/or will provide facility with copies of Advanced Directives and understands that they will be honored at that time. A statement under this section. If resident/legal representative desires a DNR and DH for 1896 has not been signed, nursing will obtain an order for [REDACTED]. The nurse liaison/nurse A was interviewed on [DATE] at 12:03 PM to determine how a resident was admitted to the facility. She said that she calls the hospital for nurse reports and helps the director of admissions Staff E gather admissions data. Sometimes Nurse A talked with the patient prior to admission, Nurse A usually no contact after admission. She did not participate in the admission process that weekend that resident #8 was admitted it should have been Nurse C. When questioned regarding the information gathered she said, we ask the hospital if they have advanced directives for the patient, ask direct care nurse at hospital, ask patient if alert and oriented or ask next of kin to see who is POA (power of attorney) and call that person. Whether the patient would be a readmission or a new admission from previous stay, she said she always verified the information and get consent to treat. Interview with the admissions director on [DATE] at approximately 1:50 PM confirmed that she completed the Admissions progress note on [DATE]. She said she gathered the information from the admission worksheet. She documented that she verbally discussed advanced directive and advance directive information with the resident. This information was actually collected/done by her assistant on [DATE]. She did not document that there were Advanced directives on file that were already present in the resident ' s document section of the electronic medical record system. She documented that the resident has or will provide the facility with copies of the advance directives and understands that they will be honored at that time. There was no follow-up by admissions staff with resident #8 ' s son who was the DPOA/health surrogate to discuss and/or confirm the change of status from DNR to full code. A phone interview was conducted with Nurse C on [DATE] at 3:06 PM. She was the nurse supervisor on the [DATE] when resident #8 was admitted . She said, The admissions office gave me a packet of papers and if the admissions coordinator had done a nurse to nurse interview. Nurse C said that she spoke to the nurse at the hospital on [DATE]. Nurse C was asked if she knew that the resident had recently been at the facility and she said that she did not know she was a previous resident recently discharged on [DATE]. She said she was the supervisor that day, [DATE], and she did not complete resident #8's admission. She said that the admitting nurse would ask the patient or representative if there was a DNR. An interview was conducted with nurse G/risk manager on [DATE] at 10 AM. She said she completed a review of DNR audits and EMR (electronic medical records). I brought up the physician orders [REDACTED]. If there was nothing I would circle it. If was ordered I checked document to see if we scanned it. If it said full code I did not check to see if there was a previous history of DNR. On [DATE] at 10:30 AM she documented that she had completed the DNR audit on [DATE] which reflected that resident #8 had a DNR in patient orders on her [DATE] admission. Another audit was done at the end of June reflecting resident #8's [DATE] admission. The audit showed that resident #8 was a full code in the patient orders, but the audit did not reveal the full code was ordered without consideration of the resident and family wishes for a DNR. Review of Patient Care Policies page 4 dated R/[DATE] 1. Patient Rights. Patient Rights policies are adopted by the Governing Body of the center as binding policies. 1.1 Center Policy on the Patient ' s Right to Self Determination, Including the Right to Formulate Directives in Advance. Policy: Individuals have the right to participate in planning and machining decisions about their own care, including the right to accept or refuse medical or surgical treatment. Page 5 .Patients have the right to make provisions for guiding decisions made on their behalf in the event their own decision-making ability is compromised. This center will honor these provisions, including advance directives, as permitted under State statutory and case law . Ethics Committee . 1.3 Center is responsible for maintaining written record of patient ' s consent to treatment. The initial consent is found in the Admission Financial Agreement. (F1) Approval of the Patient Care Plan is the ongoing manner of documenting consent. Page 7 2.0 Admission is accomplished with the mutual agreement of the patient and the center. The admission and Financial Agreement, and the related Arbitration Agreement details the terms of contract between the center and the patient and signed by both parties, must be complete prior to the arrival/admission of the patient. A. Patient must give informed consent to admission to long-term care. B. The center, reviewing the patient ' s current medical status and needs, agrees that the center partners can reasonably be expected to meet the patient ' s medical, physical and psychosocial needs. Has necessary partners and consultants and physicians with the requires skills and knowledge, and the center has the capacity to meet the patient ' s infection control requirements. C. Patients are admitted by the order of a legally licensed physician . E. The patient may designate a representative to speak on his/ her behalf in arranging for admission and for ongoing decision making. (Interview with the administrator on [DATE] at 4:05 PM clarified this as the Health Care Proxy/ power of attorney) Do Not Resuscitate Orders: dated [DATE] Policy: The facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Interpretations and Guidelines. DNR Orders Do not resuscitate orders must be signed by the resident ' s attending physician on the physician's order [REDACTED]. DNR Order Forms. A Do Not Resuscitate Order (DNRO) form must be completed and signed by the attending physician and resident (or resident ' s legal surrogate, as permitted by State law) and placed in the front of the resident ' s medical record. (NOTE: Use only State approved DNR forms. If no State form is required, use facility approved form.) Providing DNR Order forms to EMT Personnel. Should resident be transferred DNRO form must be provided to the EMT personnel transporting Rescinding DNR Order Do not resuscitate orders (DNRO) will remain in effect until the resident (or legal surrogate) provided the facility with a signed and dated request to end the DNR order. (NOTE: verbal order to cease DNRO will be permitted when two (2) staff members witness such request . Quarterly review of Advance Directives. DNR inquiries. DNR Policy & Procedure (no identified implementation date) Per interview with the administrator on [DATE] at approximately 12:30 PM, this policy had been in effect since [DATE]. Prior to admission, the admission nurse and/or admission ' s rep.(representative) will inquire of DNR status. If it is determined that the patient is a DNR, the admission nurse will request to have the DNR faxed or sent with the admission packet. If the patient has not signed DNR and would like to complete a DNR, the admission nurse or admission rep. will place a DNR in the chart with the nurse assessment. The DNR will have the patient ' s name or legal rep. filled in prior to placing in chart. If the legal rep. is signing the DNR, the admissions director with the legal paperwork with the designated decision maker and place in the legal tab of the patient ' s chart. The nurse that will assess the patient upon admission will bring the DNR to the patient ' s room for completion. Once signed by the patient and/or legal rep., this nurse will fax the DNR to the attending physician. If the physician is unable to sign the DNR after the patient/rep. ha signed, two nurses may receive a telephone order until the physician can sign it. This will ensure timely activation of patient wishes. Two nurses must hear the physician give the verbal order over the phone. The nurse will then activate the Telephone DNR order in SIGMA (electronic record system). Both nurses will sign the DNR paper with name, date and time and place it in the front of the patient ' s chart. At that point, the DNR will be considered activated. The order will stay in place until the physician signs the DNR form. Once signed by physician. The order changed to DNR order in Sigma and place a copy of the DNR on yellow paper in the Patient ' s chart (inside binder/insert in clear sleeve) and yellow copy behind the patient ' s care card (closet door in resident room . All nurses and physicians will be familiar with the location of the document tab in Sigma. Any advance directive will be filed under this tab for reference. This will include Power of Attorney and Health Care Surrogate Designations and Living Wills. Nurses and physicians will have access to any written treatment decisions and refusals pertaining to the patient related to life-prolonging care. All Nurses will be instructed that a DNR can only be signed by the patient or the patient ' s legal representative (if the patient is deemed incapacitated) with supporting legal paperwork. Review of the Social Work Service Manual original dated 1999 revised dated [DATE] Section number 7000 Subject Advance Directives. Purpose. On [DATE], Congress passed the Patient Self-Determination Act (PSDA) as an amendment to the Omnibus Budget Reconciliation Act of 1990 . 3) The right to prepare an advance directive The center policy and protocol on the patient ' s right to self-determine their care as it relates to advance directives can be found in the Administrator ' s Manual. The procedures are found in this manual and the nursing procedures manual for the DNR process. Procedure: I. Initial Discussion: Admission: Upon admission the admissions coordinator/social worker will inquire whether patient has m

Based on interview with the facility's admissions, social services, administrative, and nursing staff, the resident's durable power of attorney (DPOA)/legal health care surrogate (HCS), review of the clinical record, and review facility policies and procedures, the facility failed to provide medically related social services to ensure instructions for a do not resuscitate order (DNRO) were identified and provided for 1 of 4 sampled residents who returned after being discharged without an anticipated readmission to the facility (#8). The facility admissions/social services staff failed to communicate effectively with the resident and the DPOA/HCS and failed to follow policies and procedures to verify and document the continued wishes for a DNRO upon readmission to the facility. The resident was denied her wishes for a peaceful and dignified death when the facility initiated cardiopulmonary resuscitation (CPR) and called 911. The resident received chest compressions and artificial ventilation until emergency medical personnel arrived. They continued resuscitation efforts and the resident was intubated. She was transported via ambulance to the hospital where emergency room staff documented her son/DPOA stated the resident never wanted this outcome. The resident died in the hospital approximately 10 hours after CPR was initiated in the nursing home against her wishes. These findings resulted in Immediate Jeopardy which was removed on [DATE] and the severity and scope was reduced to no actual harm with the potential for more than minimal harm-isolated. Findings: Upon entrance to the facility on [DATE] at 11:45 AM, the assistant director of nursing was asked which staff was responsible for the admission/social services for residents. She said the director of admissions, admissions assistant, and the nurse liaison gather nursing/admission information and complete the initial information for a resident who is a new admission to the facility. This information includes advance directives, including living will, DNRO, and DPOA/HCS. She said the social workers may gather and complete admission information on the weekends. Review of the DNR policy and procedure implemented [DATE], per interview with the administrator on [DATE], noted: Prior to admission, the Admission Nurse and/or Admission's Rep.(representative) will inquire of DNR status.If the legal rep. is signing the DNR, the Admission ' s Rep. will obtain legal paperwork with the designated decision maker and place in the legal tab of the patient ' s chart. Review of the facility roster revealed 6 staff who work in the social services department. Two staff work in admissions and four are social workers. The nurse liaison is part of nursing administration. Resident #8's record revealed she was initially admitted to the facility on [DATE] for rehabilitation after surgical repair to the right hip. Her [DIAGNOSES REDACTED]. The admissions process was completed by the admissions staff who is part of the social services department. Review of the resident #8 ' s physician's admitting orders noted an Advanced Directives order, dated [DATE], read Do Not Resuscitate (DNR) which was electronically signed by the physician on [DATE] at 8:02 PM. On [DATE] at 4:13 PM, the physician electronically signed an order for [REDACTED]. Review of the Admission Agreement was completed by the resident's DPOA/HCS on [DATE]. Section P. (page 11) Obligations of Legal representative indicated the type and authority as Unlimited/durable power of attorney and health care surrogate. Section R (page 12) of the contract was for additional acknowledgements, noting that the resident's DPOA/HCS had received the patient rights booklet, and advanced directives brochure. That page was signed and dated [DATE] by the resident's DPOA/HCS. Resident #8's clinical record revealed she was sent to the hospital on [DATE] and returned on [DATE]. A new admission order, dated [DATE], documented the Advance Directives order as DNR and incapacity. On [DATE], the resident was sent to the hospital and returned on [DATE]. The advance directive order for DNR was ordered and signed by the physician on [DATE]. Review of the care plan for Advanced Directives, dated [DATE] and initiated from the [DATE] admission, established resident goals to honor resident wishes. The approaches included that the patient has advance directives on file: DNR, living will, HCS and DPOA. The review of the care plan was to be on [DATE]. Review of the electronic record system (EMR) confirmed that the DNRO was scanned into the document section of the EMR. Review of the resident ' s advanced directives on file under history/documents in the EMR for the facility included the State of Florida Do Not Resuscitate Order, dated [DATE] and signed by the surrogate and durable power of attorney, dated [DATE], and signed by a physician. Review of the EMR revealed that the DNRO was scanned into the document section labeled Admissions/legal dated [DATE], and again on [DATE]. There was no additional copy of the DNRO added on the [DATE] admission. Review of the living will, declared on [DATE] and signed by the resident, identified if she had a terminal condition, end-stage disease, or persistent vegetative and if my attending or treating physician and another consulting physician have determined that there is no probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or performance of any medical procedure deemed necessary to provide me with comfort care or alleviate pain. Also initialed: I do desire that nutrition and hydration (water) be withheld or withdrawn. The record revealed resident #8 was discharged on [DATE] to an assisted living facility. Review of the discharge instructions and recapitulation of stay created on [DATE] and completed on [DATE] identified that the resident was discharged on [DATE] to a lower level of care. The final summary identified that the resident was discharged to an assisted living facility (ALF). The advanced directives documented a DNRO. Review of the admission record revealed that the resident had a new admission to the facility on [DATE] after a hospitalization for surgical repair to a fracture of the right femur. This was 9 days after the discharge to the ALF. An interview was conducted with the Admissions director on [DATE] at 1:06 PM, She stated that resident #8 was admitted to the facility on [DATE] and discharged on [DATE], and readmitted on [DATE]. She said when a resident goes into the community, the facility can use the same admission packet, contract and orders, if the readmission was less than 30 days from the prior admission. The advanced directives (DNRO/HCS/DPOA) should be in the EMR system. Everything is scanned into the system. She said the family or resident would not have to complete any new paperwork if the admission was less than 30 days from the discharge. All the signed forms would be pulled forward from the old Chart. The POA and DNRO would not be pulled forward from the old chart. The POA and the DNRO would not be pulled forward since they are already in the computer. We would probably go and look in the financial folders and not the hard chart. Further interview on [DATE] at 1:30 PM , she stated that DNRO should have been completed upon the new admission. She did not admit the resident. She was not responsible for having the family (HCS/DPOA) complete the DNR form. Review of the admission contract revealed only the contract was signed on [DATE] by the DPOA/HCS. There were no additional contracts or admission agreements or receipt of Additional Acknowledgements related to patient rights (page 11,12) signed by the DPOA/HCS when the patient was readmitted to the facility on [DATE]. On [DATE] at 1:46 PM, the admissions assistant confirmed that she completed the admission information for resident #8 on the [DATE] admission. During the admission process from hospital, she talked directly with resident #8. The resident did not answer her phone. She asked the nurse at hospital, who confirmed that the patient was cognitive to speak to. She was going to locate her. The hospital nurse said she was in her room and the admissions assistant could call now. She asked the resident her date of birth, if she was choosing same physician, if the insurance was the same and if advanced directives were the same. The resident did not understand what advanced directives meant. The administrative assistant asked the resident if the POA was still her son, asked if living will and health care surrogate was the same, and she said Yes. The admissions assistant said she asked the resident for consent to be admitted and provide care. On [DATE] at 5:38 PM, resident #8 ' s health care surrogate revealed resident #8 was admitted to the facility on [DATE] from the hospital stay of [DATE] to [DATE] after a fall at the ALF. He said the resident was in the ALF for one day after her discharge from the nursing home on [DATE]. He said the resident did not ask for help and fell . She went to the hospital due to a fractured femur and had it surgically repaired. He was informed by the nursing home that since the resident had been discharged less than 30 days from the previous admission, he did not have to complete a new admission packet. He said they did not specify what type of paperwork, business or health care. He said that the facility had a copy of the resident ' s living will and advance directive, including the DNRO from the first admission. When asked if staff had asked him about the advance directive and DNRO on [DATE] admission, he said staff did not ask the resident ' s daughter, who was with the resident at the time of admission. He added that the resident died 12 hours after admission to the hospital. He said he a nurse from the facility contacted him on [DATE] around 10:30 PM and told him CPR was initiated and that resident #8 was being sent to the hospital. He informed the nurse that the resident did have a DNRO form which was provided to the facility on her first admission. He said he was very upset that his mother ' s right to have a DNRO was not honored. On [DATE] at 3 PM nurse H said that somewhere around/after 10 PM, one of the CNAs asked me to look at her (resident #8). She called 911. The resident was still breathing. As I was walking back to room, she coded. The other nurse grabbed crash cart. Helped CNA with CPR approximately ,[DATE] minutes. The EMTs said she was gone. Told the son 911 was here and we got her back and taking her to hospital. Son said she had a DNRO. Why did they do it? Nurse H said it was not in her chart and that resident #8 was documented as a Full Code. Review of the Hospital Florida Medicare Certification Form Long-term Care Services and Patient Transfer Form (FL 3008), dated [DATE], reflected that resident #8 did not have decision making capacity and required a surrogate. The section for advanced care planning was blank for Advanced Directive, Living Will, DNRO, and Do Not Intubate. The questions related to Do Not Hospitalize, no artificial feeding or hospice were answered NO. This form was not completed to provide a full description of the resident ' s advanced care planning wishes. It is still the responsibility of the accepting facility to get accurate information regarding Advanced Directives including DNR. On [DATE] at 1:06 PM, the Admissions director was asked to describe the system in place for Advanced directives. She said that the Advance Directives (living will, Do Not Resuscitate form, Health Care Surrogate, Power of Attorney for Health Care,Organ donation,other). The nurse liaison does this during preadmission. Review be done when patient was physically admitted into the facility with the admissions coordinator (or designee) including information noted on the nursing data collection admission form. If the resident was a short term admission this review would be within ,[DATE] days. The admission data collection sheet would be completed and checked within 24 hours by an RN. On [DATE] at 3:15 PM, the administrator was notified by staff that resident #8 ' s son said the resident was a DNR when the nurse called him to tell him that she coded and on the way to the hospital. The administrator said when she returned to work on [DATE], the staff reviewed their system, trained, added checking history for prior code status, changed the Nurse to Nurse tool (not part of the clinical record) for preadmission to include specifically current hospital code status. She said they also needed to look at prior history for DNR status. In an interview on [DATE] at 11:30 AM, the administrator revealed that they had not looked at the process of readmissions from discharges less than 30 days. A new contract was not executed for a financial contract. They reviewed the process of admission and return within 30 days. They determined that a new contract did need be executed. Previously, they did not identify that the clinical portion/resident rights acknowledgement should be completed upon the new admission. The admissions/social services were not aware to redo the acknowledgement for page 11 section P- obligations of legal representative to act on the patient ' s behalf including Power of Attorney, Limited/unlimited and scope including unlimited health care and page 12 Section R.-Additional Acknowledgement. Confirming receipt including the patient rights handbook and Advanced Directives brochure. An interview was conducted with the director of social services/case manager regarding the admission process on [DATE] at 4:42 PM. She stated that admission starts with admission department. The Nurse liaison does nurse to nurse report (with the hospital), the admission director handled admitting process, paperwork. The chart goes to nurses station. The desk nurse and floor admitting nurse completes initial assessment and paper work. If the nurse to nurse communication was not done the desk or floor nurse would contact the hospital. She was asked how information related to resident rights to choose advanced directives were completed. She said we would look at paperwork from hospital. If it was a full code, we would readdress Do Not Resuscitate (DNR) status at admission. If the patient was a readmission the previous orders would be reviewed. Information regarding admissions was shared at Rounds meetings daily. We discuss patients and conditions change of status. When questioned how soon social services becomes involved with the resident, she said when the Assessment of social services needs was completed ,[DATE] days after admission. When specifically questioned regarding advanced directives she stated that they are now reviewing previous DNR on file with the present admission directives with family or resident the assessment since [DATE] after resident #8 had CPR ([DATE]). The nurse liaison was interviewed on [DATE] at 12:03 PM to determine how a resident was admitted to the facility. She said that she calls the hospital for nurse reports and helps the director of admissions gather admissions data. Sometimes the nurse liaison talked with the patient prior to admission, she usually had no contact after admission. She did not participate in the admission process that weekend that resident #8 was admitted it should have been Nurse C. When questioned regarding the information gathered she said we ask the hospital if they have advanced directives for the patient, ask direct care nurse at hospital, ask patient if alert and oriented or ask next of kin to see who is POA (power of attorney) and call that person. Whether the patient would be a readmission or a new admission from previous stay she always verified the information and get consent to treat. Interview with the admissions assistant on [DATE] at 1:46 PM confirmed that she completed the admission information for resident #8 on the [DATE] admission. During admission process from hospital, she talked directly with resident #8. At first, the resident did not answer her phone. She asked the nurse at hospital, who confirmed that the patient was cognitive to speak to. The hospital nurse would locate her. The hospital nurse said she was in her room and admissions assistant could call now. The admissions assistant asked the resident her date of birth, if she was choosing same physician, if the insurance the same and asked her if advanced directives were the same. She (the resident) did not understand what advanced directive meant. The admissions assistant asked her if the POA was still her son, asked if living will and health care surrogate was the same and the resident said yes. She asked the resident for consent (to be admitted and provide care). She then tells the nurse about information from the patient, give receptionist the packet to prepare chart. The 3008 and PASRR is faxed to admissions then given to nurse on duty. The admissions assistant did not verify the resident ' s cognitive status to make health care decisions. There was no evidence to show that she followed-up or informed nursing to follow-up with the POA/HCS or family members when the resident was admitted on [DATE]. The advance directive related to resident #8 ' s living will or Do Not Resuscitate Order was not completed upon admission. Further interview with the admissions director on [DATE] at approximately 1:50 PM confirmed that she completed the Admissions progress note on [DATE]. She gathered the information from the admission worksheet. She documented that she verbally discussed Advanced directive/and advance directive information with resident #8 This was actually done by her assistant on [DATE]. She did not document that there were Advanced directives on file that were present in the resident ' s document section of SIGMA (the electronic medical record system). Review of the Hospital Florida Medicare Certification Form Long-term Care Services and Patient Transfer Form (FL 3008) dated [DATE] noted that Resident #8 required a Health Care Surrogate to make Health care decisions. A progress note for Admission Advanced directives- discharge Plans was dated [DATE] and timed 12:42 PM completed by the admissions director. admitted [DATE] documented Advanced Directives/Advanced directives Information discussed verbally with resident. The progress note had a specific section for Advanced Directives on file: With instructions to: Check all that Apply included living will, Health Surrogate designation, POA for Health Care, Organ Donation, DNR, other. No items were checked. A check mark was placed in the section Resident Preference: The resident has/or will provide facility with copies of Advanced Directives and understands that they will be honored at that time. A statement under this section. If resident/legal representative desires a DNR and DH for 1896 has not been signed, nursing will obtain an order for [REDACTED]. A progress note for Admission Advanced directives- discharge Plans was dated [DATE] and timed 4:39 PM completed by the admissions director. admitted [DATE] documented Advanced Directives/Advanced directives Information discussed verbally with family. The progress note had a specific section for Advanced Directives on file: With instructions to: Check all that Apply included living will, Health Surrogate designation, POA for Health Care, Organ Donation, DNR, other. No items were checked. A check mark was placed in the section Resident Preference: The resident has/or will provide facility with copies of Advanced Directives and understands that they will be honored at that time. A statement under this section. If resident/legal representative desires a DNR and DH for 1896 has not been signed, nursing will obtain an order for [REDACTED]. An interview was conducted with nurse C on [DATE] at 3:06 PM. She said that the admissions office gave her a packet of papers for resident #8 and notes if the admissions coordinator had done a nurse to nurse interview/ spoke to nurse at hospital. She did not know that resident #8 was a previous resident. She did not complete the admission for resident #8. Review of the clinical record revealed that there was no further documentation that review of the resident's history for advance directives or resident capacity to make health care decisions, even when the information on the Hospital transfer information for [DATE] included on the State 3008 form was incomplete. Review of the resident's advanced directives on file under history/documents of the electronic medical record with the facility included the State of Florida Do Not Resuscitate Order dated [DATE] and signed by the surrogate and durable power of attorney dated [DATE] and signed by a physician. This was form was labeled Admissions/ legal -the DNR was present and scanned [DATE], re-scanned on [DATE]. There was no follow-up by any admissions, social services, or admitting nursing staff with resident #8's son who was the DPOA/health surrogate to confirm the change of status from DNR to full code after [DATE]. An interview was conducted with staff M on [DATE] at 1:05 PM. She was the social worker for the long term units, the 100- 200 hall and admissions on weekends. She described her responsibilities for admissions on weekends: We are to receive referral from the hospital, we review the documentation from hospital, go over with supervisor nurse at this nursing home. From that point the nurse does a nurse to nurse report about patient to ensure we can meet the patient's needs here. The nurse reviews information and okays to accept the resident. I ask the nurse if resident is alert oriented and own person. From there I double check with case manager at the hospital to verify person to communicate with. I call the patient or legal representative and gather background information for admission, consent to treat and advanced directives. I ask if they understand what advanced directives mean. Living will, power of attorney, health surrogate. I ask if the resident was a full code or do not resuscitate. If DNR, asks if they are going to bring it in with them. I let them know it has to be brought in as soon as possible. From there on (after admission), I answer any questions they may have regarding facility or transfer to the facility. If DNR was in the history, I would ask them if they still want it. She was asked the process used when a new admission after comes in after a recent discharge. She would review the history and ask again to verify full code or DNR with resident or legal representative and document on admission assessment. She stated that resident #8 was transferred to her unit (long term hall) on [DATE]. She did not review the DNR. She did not work the weekend. She did not have the opportunity to review Resident #8's information on Friday [DATE]. She would have reviewed it on [DATE]. She said that at the morning meeting on [DATE] resident #8 was discussed. Since then we (social services) have been working on gathering advanced directives and honoring advanced directives. They said they (the Administrator, director of nursing and key staff) were going to start a Quality Assurance plan. Review of the Social Work Service Manual original dated 1999 revised dated [DATE] Section number 7000 Subject Advance Directives. Purpose. On [DATE], Congress passed the Patient Self-Determination Act (PSDA) as an amendment to the Omnibus Budget Reconciliation Act of 1990 . 3) The right to prepare an advance directive The center policy and protocol on the patient ' s right to self-determine their care as it relates to advance directives can be found in the Administrator ' s Manual. The procedures are found in this manual and the nursing procedures manual for the DNR process. Procedure: I. Initial Discussion: Admission: Upon admission the admissions coordinator/social worker will inquire whether patient has made provisions for advance directives, either in the form of a Living Will, Durable Power of Attorney for Health Care, Health Care Surrogate or other written instructions. Patient with and advance directive: If the patient or the patient ' s agent does wish to present his/her already prepared advance directive, the admissions coordinator/social worker will obtain a copy of the patient ' s document for the medical record and a copy for the financial file. A progress note to this effect will be place in the advance directives/legal section of the medical record. II. Ongoing Discussions regarding treatment options: . Incapacitated patient without advance directives: In the event the patient no longer has capacity to participate meaningfully in the decision making process, the physician will seek any designated agent empowered by state law to speak on the patient ' s behalf; failing that, the physician will seek close family member or friends with knowledge of patient ' s views and likely decision making processes. DNR Policy & Procedure (no identified implementation date) Per interview with the administrator on [DATE] at approximately 12:30 PM this policy had been in effect since [DATE]. Prior to admission, the admission nurse and/or admission ' s rep.(representative) will inquire of DNR status. If it is determined that the patient is a DNR, the admission nurse will request to have the DNR faxed or sent with the admission packet. If the patient has not signed DNR and would like to complete a DNR, the admission nurse or admission rep. will place a DNR in the chart with the nurse assessment. The DNR will have the patient ' s name or legal rep. filled in prior to placing in chart. If the legal rep. is signing the DNR, the admissions director with the legal paperwork with the designated decision maker and place in the legal tab of the patient ' s chart. The nurse that will assess the patient upon admission will bring the DNR to the patient ' s room for completion. Once signed by the patient and/or legal rep., this nurse will fax the DNR to the attending physician. If the physician is unable to sign the DNR after the patient/rep. ha signed, two nurses may receive a telephone order until the physician can sign it. This will ensure timely activation of patient wishes. Two nurses must hear the physician give the verbal order over the phone. The nurse will then activate the Telephone DNR order in SIGMA (electronic record system). Both nurses will sign the DNR paper with name, date and time and place it in the front of the patient ' s chart. At that point, the DNR will be considered activated. The order will stay in place until the physician signs the DNR form. Once signed by physician. The order changed to DNR order in Sigma and place a copy of the DNR on yellow paper in the Patient ' s chart (inside binder/insert in clear sleeve) and yellow copy behind the patient ' s care card (closet door in resident room) . All nurses and physicians will be familiar with the location of the document tab in Sigma (electronic medical record system). Any advance directive will be filed under this tab for reference. This will include Power of Attorney and Health Care Surrogate Designations and Living Wills. Nurses and physicians will have access to any written treatment decisions and refusals pertaining to the patient related to life-prolonging care. All Nurses will be instructed that a DNR can only be signed by the patient or the patient ' s legal representative (if the patient is deemed incapacitated) with supporting legal paperwork. The Job Description for Social worker was dated ,[DATE] General Description: In the absence of the Admissions Coordinator, will be able to coordination admission to the facility including handling inquires either over the phone or in person and needs assessment of the patient seeking admission and consideration of alternatives, if the Center is not capable of meeting these needs. 2. Working with individual patients and families toward adjustment to institutional life and crisis of illness, disability, and death. 3. Serving in an advocacy role for patients and their families in expressing, defining and resolving grievances. Duties: 1. Admission: a. Interview and develop trusting relationship with applicant and their families b. Obtain accurate, relevant information to be used in determining appropriateness of placement c. Coordinate with admissions committee: (DON, administrator and admissions coordinator) in determining appropriateness of placement. d. Serve as liaison with hospital, family, and patient in affecting admission . Interview with the director of nursing on [DATE] at 3:15 PM revealed that after the incident on [DATE] where resident #8 had a physician order [REDACTED]. Documentation of what followed the event on [DATE]: -During walking rounds the following day, discussed with staff advanced directions and how we (the facility) will be initiating a QAPI study on advance directives/DNR with admissions, readmissions, and return from hospital stay. -Education began on [DATE] with initial changes to tools, education continued as forms/tools were updated. -On [DATE] during the monthly Quality Assurance Committee meeting the new Advance Directive QAPI ' s was discussed. Members of the time were assigned to include social service, R.N. night supervisor, nurse liaison, and Health Information Management. The Admission nurse report was review and made changes -full code vs. DNR. -On [DATE] they developed an identification sheet which will document DNR or full code to be communicated from Hospital nurse to facility nurse. -Nursing staff were verbally educated at the stand-up meetings beginning [DATE] in the afternoon and on [DATE] in the AM related to the nurse to nurse information, admission process, nurse check off list, how to verify if patient was a prior admission, review history in electronic record to include advanced directives DNR, and discussed hospital transfer form 3008 report. Upon identification of system compromise on [DATE]: -A full audit was conducted to determine if other residents who have advanced Directives were appropriately determined and implemented in accordance with their own informed consent or upon direction of their legal representative with appropriate legal representative with appropriate written authority to communicate the Advance Directives of residents for the individual plans of care -Current patients (22) admitted from ,[DATE]-[DATE] were audited. The information reviewed was the Nurse to Nurse Report Form, State Form 3008 (transfer form from hospital), nursing checklist form, nursing admission data collection progress note, code status indication. -copy of advanced directives will be verified in the clinical record. On [DATE]: -all current residents with prior stay histories at the facility were reviewed to compare current code status with prior stay code status. This involved 67 residents and demonstrated accuracy with 100% compliance. -Policies for DNR, CPR, Advance Directives and Admissions were reviewed. No changes were made. -Procedures were revised on the internal tools to prompt staff to review, prior stay history, previous advance directive, review of the State Form 3008 (transfer form from hospital) to determine the appropriate decision maker, the hospital Code status (DNR/Full Code), and physical printing of prior Advance Direct

Based on record review and interview, the primary care physician failed to review the total plan of care and the clinical record to ensure a do not resuscitate (DNR) order was documented for 1 of 4 sampled residents reviewed who returned after being discharged without an anticipated readmission to the facility (#8). The facility failed to ensure resident #8's physician reviewed the previous history, communicated with the resident and/or the DPOA/HCS, and followed procedures to verify and document the continued wishes for a DNR upon readmission to the facility. The resident was denied her wishes for a peaceful and dignified death when the facility initiated cardiopulmonary resuscitation (CPR) and called 911. The resident received chest compressions and artificial ventilation until emergency medical personnel arrived. They continued resuscitation efforts and the resident was intubated. She was transported via ambulance to the hospital where emergency room record documented her son/DPOA state that she (resident) never wanted this outcome. She died in the hospital approximately 10 hours after CPR was initiated in the nursing home. These findings resulted in immediate jeopardy which was removed on [DATE] and the severity and scope was reduced to no actual harm with the potential for more than minimal harm- Isolated. Findings: Review of the record for resident #8 revealed that she was admitted to the facility on [DATE] for rehabilitation after surgical repair to a right [MEDICAL CONDITION]. She was under the care of her selected physician. Other [DIAGNOSES REDACTED]. The Medical certification for Medicaid Long-Term Care Services Transfer form AHCA-,[DATE] completed by the hospital on [DATE] identified that the resident required a surrogate for decision making. The Advance Care Planning section identified that yes- the resident had advanced directives, living will and Do Not Resuscitate (DNR). The documents were attached with the transfer form. Review of the Electronic Physicians' Orders at admission noted an Advanced Directives order dated [DATE]- Do Not Resuscitate (DNR) signed by her Physician on [DATE] 8:02 PM. Further review of the record revealed that on [DATE] at 4:13 PM her physician electronically signed an order for [REDACTED]. Review of resident #8 ' s face sheet and record documented multiple admissions and discharges. The resident was discharged to the hospital from ,[DATE]-,[DATE]. She returned to the facility on [DATE]. The physician electronically signed the order dated [DATE] DNRO and incapacity upon her readmission from the hospital on [DATE] at 9:42 PM. The resident #8 was again sent to the hospital on [DATE]. She returned to the facility on [DATE]. The physician electronically signed the DNR order dated [DATE] at 10:17 PM. Review of the resident's advanced directives on file under history/documents of the electronic medical record (EMR) with the facility included the State of Florida Do Not Resuscitate Order dated [DATE] and signed by the surrogate and durable power of attorney dated [DATE] and signed by a physician. This was form was labeled Admissions/ legal -the DNR was present and scanned [DATE], re-scanned on [DATE]. Also scanned under the document/history on [DATE] at 9 AM under the tab Admission/legal, was the Living Will, the HCS and the DPOA. The living will declared on [DATE] signed by the resident identified if she had a terminal condition, end-stage disease, or persistent vegetative and if my attending or treating physician and another consulting physician have determined that there is no probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or performance of any medical procedure deemed necessary to provide me with comfort care or alleviate pain. Also initialed: I do desire that nutrition and hydration (water) be withheld or withdrawn. The resident was discharged to an assisted living facility on [DATE]. Review of the admission face sheet resident #8 returned to the facility on [DATE] after hospitalization related to a fracture of her right femur. She selected the same physician that she used during her previous stay 9 days prior to the [DATE] admission. Review of the new electronic Physician Orders on [DATE] that included advanced directives of Full Code. The order was electronically signed by her physician on [DATE] at 9:46 PM. Review of the medical progress note dated [DATE] revealed that the resident was seen by her physician ' s advanced registered nurse practitioner (ARNP) on [DATE]. The Progress note was timed 3:34 PM, noting that the patient was seen and examined. The case was discussed with the nurses. Medical records, labs and orders were reviewed in detail. There was no documentation or note referring to the resident ' s change in status from DNR to full code. Review of the progress dated [DATE] noted that the ARNP saw the resident on [DATE] time 2:27 PM. The patient was seen and examined. discussed with the nurses. Medical records, labs and orders were reviewed in detail. Again, there was no documentation or note referring to the resident ' s change in status from DNR to full code. Review of the physician ' s progress noted dated [DATE] documented that the physician visited resident #8. He completed the resident ' s history and physical examination [REDACTED]. He noted that patient seen an examined case was discussed with the nurses, Medical records, lab and orders were reviewed in detail. I have examined this patient and have determined that he/she may make informed decisions concerning -Financial decisions=NO, Health Care Decisions=NO. The history of present illness noted history of Parkinson and dementia with recent fall and [MEDICAL CONDITION] with surgical repair. He noted past medical history/ past social history: reviewed and as per chart. The note under plan: (2) history and physical, consults, and discharge summary reviewed in detail. (3) medications and plan of treatment were reviewed in detail. Further review of the EMR revealed that the physician did not write an order for [REDACTED]. There was no physician progress notes [REDACTED]. In an interview with resident #8 ' s DPOA/HCS on [DATE] at 5:38 PM, he revealed his mother (resident#8) was admitted to the facility on [DATE] after the hospital stay of [DATE] to [DATE]. He said she was in the assisted living facility for one day after her discharge from the nursing home and then she went to the hospital for a [MEDICAL CONDITION] and surgical repair. He said that he was informed by the nursing home that since the resident had been discharged less than 30 days from the previous admission, he did not have to complete a new admission packet. He said that the facility already had a copy of the resident ' s living will and advance directive, including the do not resuscitate order, from the first admission on [DATE]. When he was he was asked if any staff asked him about the advance directive/DNR on the [DATE] admission, he said that he was not asked about the DNR. When he checked with his other family members that were with his mother (resident #8) when she was admitted that day, he said that no staff had asked that information the resident ' s daughter. He said that he was contacted on [DATE] around 10:30 PM by a nurse from the facility. The nurse said that cardiopulmonary resuscitation (CPR) was started and they said his mother was going to the hospital. He said he told the nurse that she had a DNR form that was provided to the facility on her first admission and she did not want CPR. He said he was very upset that his mother ' s right to have a DNR order was not honored. He said, she did not want to die like this. Review of the hospital records indicated the family members decided to withdraw care and stop any further potential resuscitation. They wanted to have comfort measures only. The intubation tube was removed and the resident died at 9:35 AM on [DATE]. Review of the nursing progress note dated [DATE] 12:14 AM with a correction noted at 8:36 AM, documented: Approximately 2225(10:25 PM) the nurse from 200 hall was coming down the hall on the 100 hall and the CNA (certified nursing assistant) was in this patient ' s (resident #8) room and she asked her to look at her breathing. She (CNA) informed the nurse from the 200 hall that she was just talking to her and she was not sure of where she was and then her breathing became labored. The nurse from 200 hall called for me and I came up and we went to get oxygen due to patient having respiratory distress. One of the CNA ' s from the 100 hall came out and stated she just took her last breath. This occurred while the nurse from the 200 hall was on the phone calling 911 due to respiratory distress. This nurse took the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) down. Zero pulse Zero respiration (correction). The CNA had started doing chest compression while I was applying oxygen. This nurse assisted with CPR (cardiopulmonary resuscitation). (2 of the nurses and 2 CNA ' s assisted with CPR) EMT arrived and the took over. Patient left the building at 10:50 PM. Son was notified. Call was place to Doctor ' s answering service. Spoke with on call Dr. and informed her of the patient having respiratory distress and that patient had coded and patient was revived and had been taken to the hospital. The physician was interviewed on [DATE] at 1:45 PM regarding what he does when a patient was admitted to his care. When the patient was from hospital they come with appropriate documentation. He would talk with the resident or family regarding DNR. He reviews the record when he comes to see the patient. He reviews the orders with the nurse. He would tell nurse when he determined the patient is incapacitated. He was questioned regarding how a readmission of less than 30 days he said would verify the DNR status with family or resident. He did not respond. When questioned specifically about resident #8 he stated, he did not know what happened. He was asked if he was aware that a full code was in place and that the resident was resuscitated and subsequently died . He said I don ' t recall that she was a DNR from the prior admission. He was asked if he had reviewed previous documents related to DNR. He had no response. The medical director was interviewed regarding the process of reviewing past medical history and documents from recent previous admissions specifically history of advanced directives related to Do Not Resuscitate Status/Orders on [DATE] at 2:10 PM. He usually checks the computer (electronic medical record) advanced directive area. I am assuming the documented orders are appropriate. I can go back in the documents, there should be a yellow copy (DNRO) and I can look in the history. I have never had to review opposite of reinstituting a previously existing DNR on readmission. When questioned what could have been done to prevent a resident with a previous Do Not Resuscitate order changed to a Full code, he said review of 3008 (Medicaid Long-Term Care Services Transfer form Agency for Healthcare Administration-,[DATE],), check for blanks and verify the form and determine resident ' s wishes regarding DNR. Interview with the administrator on [DATE] at approximately 11 AM revealed that the Medical Director sent an education e-mail to all physicians that see patients in the facility. It included review of Advance Directive Status, Do not Resuscitate Orders and how to find history of the information in the documents section of the electronic medical record. Upon identification of system compromised on [DATE]: -A full audit was conducted to determine if other residents who have advanced directives were appropriately determined and implemented in accordance with their own informed consent or upon direction of their legal representative with appropriate legal representative with appropriate written authority to communicate the Advance Directives of residents for the individual plans of care. -Current patients (22) admitted from ,[DATE]-[DATE] were audited. The information reviewed was: Nurse to Nurse Report Form, Hospital 3008 transfer form nursing checklist from, nursing admission data collection progress note, code status indication. -copy of advanced directives verified in the clinical record. On [DATE]: -all current residents with prior stay histories at the facility were reviewed to compare current code status with prior stay code status. This involved 67 residents and demonstrated accuracy with 100% compliance. -Policies for DNR, CPR, Advance Directives and Admissions were reviewed. No changes were made. -Procedures were revised on the internal tools to prompt staff to review prior stay history, previous advance directive, review the State Form 3008 (transfer form from hospital) to determine the appropriate decision maker, the hospital Code status (DNR/Full Code), and physical printing of prior Advance Directives if applicable to confirm continues status. The updated tools/forms purpose is: -Nurse to nurse report form helps gather information by the nurse liaison to ascertain care of patient prior to admission to the facility from a medical professional at the referring health care provider. The information is utilized to determining that the facility can meet the patients ' ongoing care needs. -Admissions Return within 30 days Checklist created on [DATE] with final revision on [DATE]. This form was created to address specific concerns for those patients returning from a prior stay (return not anticipated) due to the facility policy that a new financial contract is not required; however, other required information, forms and documents will need to be completed for the continuity of care. -Admissions Return from Transfer Checklist. The form is to address informational needs for patients returning from return anticipated transfer to assure that no changes to prior Advance Directives, Code Status or financial support have taken place during temporary absence from facility. -Nursing Admission Checklist. To prompt admitting nurses to address each essential element for the patient admission and to assure comprehensive information is obtained for continuity of care. -Monitoring to determine that Advance Directives and Code (DNR/Full Code): an R.N. will review the nursing admission process as a second check on each admission within 24 hours. The nursing Supervisor will review all admissions from the previous day each morning 7 per week. The Interdisciplinary team will review all new admission for accurate Code status during Monday-Friday daily stand up meetings. -Education began on [DATE] with initial changes to tools. 100% of licensed personnel, and staff involved in admission and intake process were educated with completion on [DATE] for a total of 93 employees. 13 RNs, 36 LPNs, 6 Social service staff including admissions personnel and 38 additional pertinent staff including CNAs, Occupational, Physical and Speech Therapists and medical records staff. -In-service Education and Competency Evaluation for Licensed Nurses and Social services department began [DATE] regarding Nursing admission process, Center policy and procedures for Advance directives and use of the revised checklist form and Nurse to Nurse report form. -Additional consultants for the Electronic medical record system for monitoring and oversight were used ,[DATE]-[DATE]. They trained relevant procedures to pull forward documents from prior admission and stays. Reviewed specific physician order input for DNR and upload of Advance directive documents. They Quality Management Report related to Code Status were monitored and review of Advance Directive Documents for audit functions. These reports will be incorporated into the QAPI program. Based on the quality assurance planning in progress and the additional steps taken by the facility to address the incident which occurred on [DATE], the Immediate Jeopardy was found to be removed on [DATE] at 5:53 PM and the Severity and Scope was reduced to a D.

Based on interview and record review, the facility failed to provide care in a manner to promote the highest practicable mental, psychosocial, and physical well-being for a resident with [MEDICAL CONDITION], Non-Alzheimer's dementia and Anxiety who resisted care that resulted in a fractured right femur, pain, and substantial psychological distress for 1 of 5 sampled residents reviewed for injuries while providing activities of daily living (ADL) care (#1). Findings: Record review revealed resident #1 was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. The resident had bilateral knee replacements done in 2000. Review of the current quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment, is sometimes understood, can express her needs, and has no hallucinations or delusions. She exhibits neither physical nor verbal behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching, with no behaviors exhibited for rejection of care. The resident is frequently incontinent of bladder and of bowel. Review of facility's Federal Immediate Report dated 11/13/14 at 5:15 p.m. revealed that resident #1 "expressed the need to have a bowel movement. Two CNAs (certified nursing assistants) took her to the shower room to transfer the resident to the toilet. The patient (resident) was agitated, screaming, and yelling, and very combative, striking out. The CNAs were able to put the gait belt on the patient. (Resident #1) grabbed hold of the safety bar next to the toilet with one hand. The CNAs got her up, turned and positioned on to the toilet. (The resident) was yelling that her legs were broke.....Today (11/14/14) the patient complained of pain in her leg the physician was called and an x-ray was ordered...." Review of facility's Five Day Report dated 11/13/14 at 5:15 PM read, "The transfer occurred on Thursday, November 13th at that time there was no apparent injury....Friday, November 14th the patient felt warm was running a low grade fever and there was swelling noted to the leg. The physician was called and an x-ray ordered and done at that time. The x-ray came back with a fracture....When the patient said she felt her leg was broke they had the nurse come in and check her out.....She....did complain of pain once in bed. Again the nurse checked the patient's leg and there was no sign of injury....In the morning a slight temperature was noted and swelling in the leg. The physician was then called." Review of the resident's medication record (MAR), dated 11/13/14 at 5:56 p.m., revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 2 milligrams (mg.) 1 tablet by oral route and [MEDICATION NAME] (APAP) 325 mg. 2 tabs by oral route by registered nurse (RN) #M of Oceanside unit. RN #M was in charge for caring for resident #1 on the 7 a.m.-7 p.m. shift on 11/13/14. Nurse #M entered the above documentation on 11/13/14 at 6:25 p.m. during the time of the above incident with the resident and 3 CNAs (#E, K & L). The time the medication was documented as given was different from the time documented that the resident was transferred from the wheelchair to the toilet in the shower room at 6:25 p.m. on 11/13/14. Review of nurses' notes revealed the following: On 11/13/14 at 2:35 p.m., nurse's note read, "res awake, alert, anxious overall...medicated earlier with [MEDICATION NAME] (antianxiety medication), relief voiced post. Res was yelling loudly and chanting, other residents were becoming annoyed...." On 11/13/14 at 6:25 p.m., nurse's note read, "res (resident) very anxious this evening, yelling and confused. Non compliant with meds, taken after several reattempts....Sara lifted to toilet after dinner by 3 CNAs in central bath. Res was disruptive and resistive to the transfer gripping and not letting go of the rails. Yelling the whole time with anxiety. Res pants ripped, resident thought it was her legs breaking. Staff reassured her it wasn't, no bruising evident or injury sustained to her legs but resident adamant her legs are broken. Res then mechanically lifter (lifted) by 3 can (CNAs) assist and this nurse watching as res is very disruptive and loud. Reassured the whole time with no calming result. Apap and [MEDICATION NAME] admin (administered). Settled to bed with alarm in place for her safety." On 11/14/14 at 9:47 a.m., nurse's note read, "Dtr in law (daughter-in-law) called and updated about pts condition, pts behavior on 11/13/14, pt now c/o pain in right knee, MD and Nurse practitioner notified, awaiting orders." On 11/14/14 at 12 p.m., nurse's note read, "right knee swollen, pt c/o (complained of) pain. Order received from nurse practitioner." On 11/14/14 at 12:08 p.m., nurse's note read, "Pt also running a fever this am. Nurse practitioner notified and U/A (urinalysis), C/S (culture & sensitivity) ordered." On 11/14/14 at 3:42 p.m., nurse's note read, "X-ray taken of right knee, fracture of distal femur noted. MD notified and orders received to send pt to WMHR ED...." Review of a message that was sent with normal priority to the resident's physician by the Ocean Side unit manager on 11/14/14 at 8:34 a.m. read, "Pt combative with transfer last night with Sara lift. This morning her right knee is swollen, she c/o (complained of) pain and she has a fever of 100.8. May we get an x-ray?" The facility did not notify the resident's physician when the resident was agitated, screaming and yelling, very combative, striking out and complained her legs were broken twice from 11/13/14 at 6:25 p.m. and again on 11/14/14 at 8:34 a.m. A total of 14 hours passed before the unit manager of Oceanside notified the physician of the resident's complaint of pain when transferred from the wheelchair to the toilet on the evening of 11/13/14. The resident had a care plan dated 11/07/14 for potential for mood decline due to [DIAGNOSES REDACTED]. The goal was the resident will exhibit calm demeanor daily as evidenced by relaxed facial expressions and reduced episodes of calling out. The care approaches included to monitor mood and provide emotional support as needed. Review of the facility procedures for the Lift Program Skills for mechanical lifts revealed that the Sara 2000/Sarita lifts are used for extensive assistance for partial weight bearing individuals. Sara 2000/Sarita takes someone from a sitting position (Chair, bed) to a standing position to accomplish pivot transfers or to help out with activities such as toileting, changing clothes, changing incontinence pads, and repositioning. Questions that need to be answered prior to utilizing the Sara 2000/Sarita are: 1. Can individual bear weight on at least one leg? 2. Does individual have any upper body strength? 3. Does individual have reasonable cognitive ability? 4. Is individual combative? 5. Does individual weigh less than 400 pounds (Sara 2000)? 6. Does individual weigh less than 350 pounds (Sarita)? Documentation in resident #1's medical record indicated she was combative at times and had decreased cognitive ability. The radiology report from 11/14/14 of the right knee read, "There is an acute moderately displaced fracture of distal shaft of the femur just above the level of the femoral component of the knee prosthesis. There is evidence of total knee replacement with intact femoral and tibial components in anatomical alignment. There is no radiographic evidence of loosening or particle disease. There is soft tissue welling of knee. There is joint effusion of knee. The bony mineralization is severely decreased." "Knee effusion or swelling of the knee....occurs when excess fluid accumulates in or around the knee joint." (wikipedia.com). Review of hospital consultation on 11/14/14 read in part, "Apparently....(resident #1) did have bilateral total knee replacement....before 2000....In the process of transferring her...she did sustain a supracondylar fracture with some angulation and slight comminution....Obviously this patient is not reliable to follow instructions and follow commands about weight-bearing." "Comminuted fracture is a type of fracture which includes the presence of three or more bone fragments. This is a serious type of fracture and the treatment may be rather challenging. Due to multiple bone fragments there is an increased risk of complications...." (steadyhealth.com). In an interview with RN #M on 12/04/14 at 2:45 p.m., she indicated that she assessed the resident in the central bath room after the resident complained that her leg was broken after transferring from the wheelchair to the toilet. She indicated that she felt the resident's legs and thighs, feeling deep to her bones. She said there were no signs of swelling, and they did not feel hot. RN #M indicated that she reassessed the resident after she was transferred to her bed. At this time, the resident was yelling out and complained of pain. The RN indicated said she gave the resident [MEDICATION NAME] and Tylenol for pain. She said, "My shift is from 7 a.m. until 7 p.m." She indicated that she did not notify the resident's physician and gave the report of the resident's status to the oncoming 7 p.m.- 6 a.m. nurse. In an interview with CNA #K on 12/04/14 at 3:20 p.m., she indicated that on the 2-10 p.m. shift on 11/13/14, resident #1 was very agitated and confused in the central bath room. She indicated that she helped to assist CNA #L and was able to use the gait belt to transfer the resident from the wheelchair to the commode. She said the time was about 5:15 p.m. She said CNA #E came in to help assist with the resident transfer using the Sara lift from the toilet to the wheelchair and back to her bed. In an interview with CNA #L on 12/04/14 at 3:35 p.m., she indicated that she was assigned to care for resident #1 on 11/13/14 on the 2-10 p.m. shift. She indicated that the resident was very agitated all evening and had pain in her right knee. She said "We were able to use the gait belt and transferred the resident from the wheelchair to the commode." She said CNA #K and CNA #E came in to help assist with the resident transfer using the Sara lift from the commode to the wheelchair and back to her bed. In an interview with CNA #E on 12/04/14 at 4 p.m., she indicated that on 11/13/14 on the 2-10 p.m. shift, she was asked to help assist CNAs #K and #L because she knew the resident. She said the resident was sitting on the toilet when she came into the central bath to assist. She asked the resident "Are you alright?" She indicated that the resident was very agitated and crying out all evening. She said "We helped assist with the resident transfer using the Sara lift from the commode to the wheelchair and back to her bed."

Based on observations, interviews and record reviews, the facility failed to ensure residents requiring management of pain and blood pressures had assessments provided by appropriately qualified staff within their scope of practice for the Nurse Practice Act which met professional standards of quality for 1 of 31 sampled residents (#431) The findings include: Florida Board of Nursing, Nurse Practice Act, 464.003(3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring specialized knowledge, judgement, and nursing skills based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: (1) the observation,assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments. 1. During an interview with resident #431 on 9/13/11 at 11:54 a.m. she stated she has been having trouble receiving the necessary pain medications to control her pain following knee replacement surgery on 9/2/11, 4 days ago. She stated she had received pain medication at the hospital at about 8:30 a.m. prior to transfer to the facility on [DATE] at about 11:30 a.m. She stated she asked for pain medication at about 12:00 p.m. and was told she had no orders for pain medication and the physician would have to be notified to obtain an order. She stated she continued to request pain medication and she was given Tylenol 325 milligrams (mg) 2 tablets at 3:11 p.m. prior to being placed in the Continuous Perpetual Motion (CPM) machine for physical therapy. She said the pain medication was ineffective in controlling the pain because she was receiving [MEDICATION NAME] in the hospital. She stated the pain continued and she eventually was crying and could not get comfortable; she felt she needed to go back to the hospital at this point if she could not get the pain under control. She stated she called her daughter in tears and got her all upset because she could not get medication to control her pain. She stated the pain continued and she finally received [MEDICATION NAME] 5mg-500 mg 2 tablets for the pain at 8:31 p.m. which relieved her pain (9 hours after her initial request and 12 hours after receiving her last dose of [MEDICATION NAME] at the hospital). Further interview with the resident on 9/14/11 at 12:30 p.m., revealed she had requested pain medication the previous evening (9/13/11) at about 6:30 p.m. because he knee was very painful from using the CPM, but again did not receive the pain medication until 7:55 p.m. ( 1 1/2 hours after her request). She stated her knee was very painful since using the CPM machine last evening and she did not think her pain was not being controlled. A nursing progress note written 9/7/11 at 3:29 a.m. showed the resident was "alert and oriented x 3, able to make needs known to staff. Medicated as ordered and meds well tolerated. Pt. complained of pain in right knee which was relieved with [MEDICATION NAME]." Another nursing progress note written 9/14/11 at 8:09 p.m. showed the resident was "alert and oriented x 3, able to make needs known...Pt voiced concerns of receiving pain meds on time supervisor aware." During an interview with the resident and the resident's roommate on 9/15/11 at 12:20 p.m., the roommate stated the resident was in severe pain and was crying all afternoon on 09/06/11. She stated the resident was continually asking for pain medication on the afternoon after admission on 9/6/11. She stated she overheard the nurse tell resident #431 that she did not have an order for [REDACTED]. Resident #431 stated she finally got some Tylenol for pain right before therapy evaluated her and placed her on the CPM machine at 3:11 p.m.; she stated her pain was not fully relieved by the Tylenol. During an interview on 9/15/11 at 1:30 p.m. with the resident, the Administrator and the Director of Nursing the resident confirmed the failure to provide medications to manage her pain on the day of admission (9/6/11) and and again on 9/13/11. The Administrator stated the resident should have received the medications as needed to manage her pain and apologized to her for the lack of pain management on both dates. Record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the face sheet indicated the resident was admitted to the facility at 11:30 a.m. while admission nursing information indicated the resident was admitted at 1:30 p.m. Her Clinical Assessment at the time of admission was not complete as to date and time of admission. During an interview with the Assistant Director of Nursing (ADON) on 9/13/11 at about 11:45 p.m., she stated she contacted the resident's daughter to confirm the resident was brought to the facility for admission at 11:30 a.m. She stated the assessment was completed by the floor nurse who is a licensed practical nurse (LPN) and a registered nurse (RN) always reviews the accuracy of the assessment within about 24 hours; she agreed the assessment was not complete and was unaware of the inaccurate assessment until 9/13/11 (7 days after admission). Documentation was not available to show the assessment had been reviewed by an RN. Documentation on the Admission Review/Interim plan of care dated 9/06/11 at the time of admission indicated the resident stated she had "throbbing, pressure/heaviness of pain" which was previously relieved by medication and cold therapy. Documentation showed "current pain medication: requesting [MEDICATION NAME], patient informed nurse that is what she was taking in the hospital." Medication orders received from the hospital at the time of admission on 9/6/11 showed an order for [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order was written for [MEDICATION NAME] 5mg-500 mg 2 tablets every 8 hours for 5 days for pain. Documentation on the MAR indicated [REDACTED]. The resident was monitored for pain on 2 shifts (7:00 a.m.-7:00 p.m. and 7:00 p.m. to 7:00 a.m.) daily. Documentation of pain assessments were not consistent or accurate with the resident's complaints of pain. Pain assessment on 9/6/11 and 9/7/11 on the 7:00 a.m. - 7:00 p.m. shift (at 7:33 p.m.) indicated the resident had no pain ("0" on a scale of 1-10) even though she was complaining of throbbing pain at the time of admission at 11:30 a.m. which continued throughout the shift, and she was medicated for pain on that shift on both days. Pain assessment on 9/13/11 on the 7:00 p.m. - 7:00 a.m. shift indicated the resident had no pain ("0") even though she was complaining of pain at 6:30 p.m., and told the surveyor on 9/14/11 her knee was very painful at that time, and she was medicated for pain at 7:55 p.m. During an interview with the floor nurse responsible for the initial admission assessment, the administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the nurse consultant on 9/15/11 at 12:00 p.m., the floor nurse stated the resident did not complain of pain at the time of admission; she agreed the initial assessment was not complete because she did not save the form. She also stated the section related to "Pain Assessment - Part 1" was related to the overall picture of the resident's pain and not just the current status, even though the documentation indicated the "resident verbalizes pain which was throbbing and pressure/heaviness" at the time of the assessment. She also stated she checked the resident frequently during the shift and at no time did the resident complain of pain or show signs of pain even though both the resident and the resident's roommate confirmed the uncontrolled pain from the time of admission until after the [MEDICATION NAME] was received at 8:31 p.m. She stated she did not document the frequent checks of the resident except at the end of her shift when she documented no pain on the MAR (0). The nurse agreed she should have done more documentation of the resident's condition, but did not have the time. The DON stated the nurses do a lot of tasks without documenting them and "just because there is no documentation does not mean the tasks were not done." 2. During an interview with resident #431 on 9/12/11 at about 2:30 p.m. she stated she did not receive her blood pressure medication on 9/6/11 at 9:00 p.m. and she knew her blood pressure was elevated on the day shift on 09/07/11 because she didn't feel well. She was concerned because her history of [MEDICAL CONDITION] and hypertension delayed her knee surgery in July. She stated she had been taking blood pressure medication to control her blood pressure twice a day since July. She said received her morning dose at the hospital on [DATE]. Her blood pressure was recorded as 180/90 on the day shift on 9/7/11. Record review on 9/13/11 revealed the resident was admitted to the facility on [DATE] at 11:30 a.m. with an order for [REDACTED]. Documentation on the MAR indicated [REDACTED]. Record review also revealed 2 other medications Senna and [MEDICATION NAME] were ordered at 9:00 p.m. and were given on 9/06/11. During an interview with the Assistant Director of Nursing (ADON) on 9/14/11 at 10:45 a.m., she stated she did not know why the blood pressure medication was not given as the medication is in the Emergency Drug Kit (EDK) and was available for administration. She agreed the medication should have been given as ordered on admission and the physician should have been notified when the blood pressure was elevated.

Based on observations, interviews and record review the facility failed to provide the necessary care and services to maintain the highest physical well-being relative to pain management and blood pressure control in accordance with a comprehensive assessment and plan of care for 1 of 31 sampled residents. (#431) The findings include: 1. During an interview with resident #431 on 9/13/11 at 11:54 a.m. she stated she has been having trouble receiving the necessary pain medications to control her pain following knee replacement surgery on 9/2/11, 4 days ago. She stated she had received pain medication at the hospital at about 8:30 a.m. prior to transfer to the facility on [DATE] at about 11:30 a.m. She stated she asked for pain medication at about 12:00 p.m. and was told she had no orders for pain medication and the physician would have to be notified to obtain an order. She stated she continued to request pain medication and she was given Tylenol 325 milligrams (mg) 2 tablets at 3:11 p.m. prior to being placed in the Continuous Perpetual Motion (CPM) machine for physical therapy. She said the pain medication was ineffective in controlling the pain because she was receiving [MEDICATION NAME] in the hospital. She stated the pain continued and she eventually was crying and could not get comfortable; she felt she needed to go back to the hospital at this point if she could not get the pain under control. She stated she called her daughter in tears and got her all upset because she could not get medication to control her pain. She stated the pain continued and she finally received [MEDICATION NAME] 5mg-500 mg 2 tablets for the pain at 8:31 p.m. which relieved her pain (9 hours after her initial request and 12 hours after receiving her last dose of [MEDICATION NAME] at the hospital). Further interview with the resident on 9/14/11 at 12:30 p.m., revealed she had requested pain medication the previous evening (9/13/11) at about 6:30 p.m. because he knee was very painful from using the CPM, but again did not receive the pain medication until 7:55 p.m. ( 1 1/2 hours after her request). She stated her knee was very painful since using the CPM machine last evening and she did not think her pain was not being controlled. A nursing progress note written 9/7/11 at 3:29 a.m. showed the resident was "alert and oriented x 3, able to make needs known to staff. Medicated as ordered and meds well tolerated. Pt. complained of pain in right knee which was relieved with [MEDICATION NAME]." Another nursing progress note written 9/14/11 at 8:09 p.m. showed the resident was "alert and oriented x 3, able to make needs known...Pt voiced concerns of receiving pain meds on time supervisor aware." During an interview with the resident and the resident's roommate on 9/15/11 at 12:20 p.m., the roommate stated the resident was in severe pain and was crying all afternoon on 09/06/11. She stated the resident was continually asking for pain medication on the afternoon after admission on 9/6/11. She stated she overheard the nurse tell resident #431 that she did not have an order for [REDACTED]. Resident #431 stated she finally got some Tylenol for pain right before therapy evaluated her and placed her on the CPM machine at 3:11 p.m.; she stated her pain was not fully relieved by the Tylenol. During an interview on 9/15/11 at 1:30 p.m. with the resident, the Administrator and the Director of Nursing (DON) the resident confirmed the failure to provide medications to manage her pain on the day of admission (9/6/11) and and again on 9/13/11. She stated she realized the need to continue with her therapy so she could go home but felt she should have had pain relief because she felt it was impacting her ability to complete the therapy and she hoped she would still be able to go home on Friday. The Administrator stated the resident should have received the medications as needed to manage her pain and apologized to her for the lack of pain management on both dates. During an observation on 9/14/11 at 12:30 p.m. the resident's was reddened and swollen. This was observed by the floor nurse responsible for her care who stated the knee appeared to be more swollen and reddened than the day before. She also apologized for not giving the resident the pain medication when requested at 6:30 p.m. on 9/13/11 and agreed she should have checked on the resident's pain level and request for pain medications before leaving for the day. Record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the face sheet indicated the resident was admitted to the facility at 11:30 a.m. while admission nursing information indicated the resident was admitted at 1:30 p.m. Her Clinical Assessment at the time of admission was not complete as to date and time of admission. During an interview with the Assistant Director of Nursing (ADON) on 9/13/11 at about 11:45 p.m. she stated she contacted the resident's daughter to confirm the resident was brought to the facility for admission at 11:30 a.m. She stated the assessment was completed by the floor nurse who is a licensed practical nurse (LPN) and a registered nurse (RN) always reviews the accuracy of the assessment within about 24 hours; she agreed the assessment was not complete and was unaware of the inaccurate assessment until 9/13/11 (7 days after admission). Documentation was not available to show the assessment had been reviewed by an RN. An interim care plan was written for "comfort altered related to joint replacement" with the goal of "decreased or resolved indicators of discomfort (verbal complaints of pain, crying, agitation, moaning, restlessness, [MEDICAL CONDITION], etc." Approaches included pain screening, meds as ordered and monitor effectiveness of medications and side effects." Documentation at the time of admission indicated the resident indicated she had "throbbing, pressure/heaviness of pain" which was previously relieved by medication and cold therapy. Documentation showed the resident was "requesting [MEDICATION NAME], patient informed nurse that is what she was taking in the hospital." Medication orders received from the hospital at the time of admission on 9/6/11 showed an order for [REDACTED]. A review of the contents of the Emergency Drug Kit (EDK) revealed the medication was available for administration at the time of the resident's first complaints of pain. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order was written for [MEDICATION NAME] 5mg-500 mg 2 tablets every 8 hours for 5 days for pain. Documentation on the MAR indicated [REDACTED]. The resident was monitored for pain on 2 shifts (7:00 a.m.-7:00 p.m. and 7:00 p.m. to 7:00 a.m.) daily. Documentation of pain assessments were not consistent or accurate with the resident's reports of pain. Pain assessment on 9/6/11 and 9/7/11 on the 7:00 a.m. - 7:00 p.m. shift (at 7:33 p.m.) indicated the resident had no pain ("0" on a scale of 1-10). even though she was complaining of throbbing pain at the time of admission at 11:30 a.m. which continued throughout the shift and she was medicated for pain on that shift on both days. Pain assessment on 9/13/11 on the 7:00 p.m. - 7:00 a.m. shift indicated the resident had no pain ("0") even though she was complaining of pain at 6:30 p.m. and told the surveyor on 9/14/11 it was very painful, and she was medicated for pain at 7:55 p.m. on that shift. During an interview with the floor nurse on 9/14/11 at about 9:30 a.m. she stated the resident had just received pain medication this morning which seemed to relieve the pain. She stated the resident has to ask for pain medication before it is given since it is ordered as needed (prn). The nurse stated the resident usually likes it before therapy or or when using the CPM machine when her pain increases. During an interview with the ADON on 9/14/11 at 9:45 a.m. she stated the resident did not come in with order for pain medications. She also stated that during her investigation she determined the resident did not complain of pain until well after admission and Tylenol was given before the CPM machine instituted at about 3:00 p.m. on 9/6/11. During an interview with the floor nurse responsible for the initial admission assessment, the administrator, the DON, ADON, and the nurse consultant on 9/15/11 at 12:00 p.m., the floor nurse stated the resident did not complain of pain at the time of admission; she agreed the initial assessment was not complete because she did not save the form. She also stated the section related to "Pain Assessment - Part 1" related to the overall picture of the resident's pain and not just the current status even though the documentation indicated the "resident verbalizes pain which was throbbing and pressure/heaviness" at the time of the assessment. She also stated she checked the resident frequently during the shift and at no time did the resident complain of pain or show signs of pain even though both the resident and the resident's roommate confirmed the uncontrolled pain from the time of admission until after the [MEDICATION NAME] was received at 8:31 p.m. She stated she did not document the frequent checks of the resident except at the end of her shift when she documented no pain on the MAR (0). The nurse agreed she should have done more documentation of the resident's condition but did not have the time. The DON stated the nurses do a lot of tasks without documenting them and "just because there is no documentation does not mean the tasks were not done." 2. During an interview with resident #431 on 9/12/11 at about 2:30 p.m. she stated she did not receive her blood pressure medication on 9/6/11 at 9:00 p.m. and she knew her blood pressure was elevated on the day shift on 09/07/11 because she didn't feel well. She was concerned because her history of [MEDICAL CONDITION] and hypertension delayed her knee surgery in July. She stated she had been taking blood pressure medication to control her blood pressure twice a day since July. She said received her morning dose at the hospital on [DATE]. Her blood pressure was recorded as 180/90 on the day shift on 9/7/11. Record review on 9/13/11 revealed the resident was admitted to the facility on [DATE] at 11:30 a.m. with an order for [REDACTED]. Documentation on the MAR indicated [REDACTED]. Record review also revealed 2 other medications Senna and [MEDICATION NAME] were ordered at 9:00 p.m. and were given on 9/06/11. During an interview with the Assistant Director of Nursing (ADON) on 9/14/11 at 10:45 a.m., she stated she did not know why the blood pressure medication was not given as the medication is in the Emergency Drug Kit (EDK) and was available for administration. She agreed the medication should have been given as ordered on admission and the physician should have been notified when the blood pressure was elevated.