Every finding on record at Solaris Healthcare Osceola

Based on interview, and record review, the facility failed to prevent an avoidable accident with major injury for a physically impaired resident by failing to ensure the care plan was followed for transfers with mechanical lifts for 1 of 4 residents sampled for accidents, (#1). These failures contributed to a staff member disregarding a resident's prescribed transfer method and resulted in the resident sustaining a left knee fibular head fracture. On 10/11/24 at approximately 11:45 AM, Certified Nursing Assistant (CNA A) was in resident #1's room to get her up for a shower. Resident #1 requested to use her personal four-wheel walker for the transfer from bed to wheelchair instead of the mechanical lift. CNA A brought the walker over to the bedside and resident #1 attempted to use the walker and CNA A's assistance to stand. Shortly after standing, resident #1 complained of weakness to her legs and started to go down to the floor. CNA A was beside her and assisted her as much as she could, down to the floor. CNA A called for help and two staff members came to the room to assist. At 12:35 PM, the resident was assessed by the nurse, and she complained of leg and knee pain, and an order was obtained for the resident to be sent to the hospital. Resident #1's family was notified, and she was transported via Emergency Services (EMS) to the hospital. At 6:30 PM, the facility was notified by the hospital that resident #1 had suffered a fibular head fracture to the left knee. The facility's failure to provide supervision and oversight for staff members during transfers to ensure residents who were physically impaired and dependent for transfers were being transferred safely, appropriately, and per their individual care plans, placed all physically impaired residents requiring total assistance and mechanical lifts at risk for serious harm or serious injury. This failure resulted in Immediate Jeopardy starting on 10/11/24 and was removed on 10/15/24. Findings: Resident #1, a [AGE] year old female, was readmitted to the facility on [DATE] from an acute care hospital. She had diagnoses that included congestive heart failure, oxygen dependence, severe morbid obesity, difficulty walking, generalized muscle weakness, and a history of traumatic fracture. A day after her admission on 9/27/24, resident #1 weighed 353.2 pounds by mechanical lift. Review of resident #1's reentry Minimum Data Set assessment with Assessment Reference Date of 10/02/24 revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 15/15. The assessment indicated she was dependent, meaning she required the assistance of 2 or more staff members with mechanical lift, for bed mobility, sit to stand, transfers from bed to chair/chair to bed, and toilet transfers. The assessment further indicated that resident #1 did not attempt to walk 10 feet due to medical conditions or safety concerns. The medical record for resident #1 revealed she received Physical Therapy (PT) from 9/28/24 to 10/02/24. The PT discharge note dated 10/03/24 indicated the therapist documented that resident #1 would require a mechanical lift if she wanted to get out of bed due to her dependent status. The therapist documentation included that on 10/02/24 transfer out of bed to chair and ambulation were not attempted due to medical conditions or safety concerns. The therapist concluded that the resident was no longer appropriate for therapy at that time due to her medical status and resident being dependent for mobility. The note indicated the resident status and recommendations were communicated to the facility staff. Review of resident #1's PT progress notes dated 10/07/24 therapy performed a quarterly PT screen and found no changes in the resident status of non-ambulatory, and the screen recommended the use of a mechanical lift for transfers. Resident #1 had a care plan for Activities of Daily Living (ADLs) initiated on 7/02/24. The care plan interventions included a three person assist with transfers using the mechanical lift for safety initiated on 8/10/24. This intervention was a shared task for CNAs, nursing, and therapy staff. Other interventions for ADLs and mobility included a two person assist with bathing and toilet transfers using a mechanical lift. A change in condition progress note dated 10/11/24 revealed resident #1 had sustained a fall when she stood and lost her balance. The note detailed resident #1 slid onto the floor causing injury to her left knee and was sent to the emergency room for further evaluation. A nursing note entered later on the same day further detailed the incident reporting that CNA A was assigned to resident #1 and was assisting her to stand so that she could transfer into the wheelchair. The resident had verbalized to the CNA that she was able to stand and transfer into chair without the mechanical lift. The note indicated the resident twisted her left knee when she fell and was sent to the emergency room related to increased pain to the knee. The Hospital Emergency Report dated 10/11/24 at 3:00 PM, revealed Computerized Tomography (CT) scan of resident #1's left knee without contrast showed she sustained a non-displaced fracture of the fibula. The fibula helps stabilize and support your leg, body, ankle and leg muscles. It runs parallel to the tibia, the larger bone that forms the shin and attaches to the ankle and knee. A fibular head fracture is a break in the fibula bone near the knee, (retrieved on 11/08/24 from www.healthline.com). The facility provided a timeline of the incident as it was reported to the facility's Risk Manager. On 10/11/24 at 11:45 AM, CNA A was in resident #1's room to assist her in the shower area. The resident requested to use her personal four-wheel walker for the transfer from bed to wheelchair. CNA A brought the walker over to the bedside and the resident attempted to stand with CNA A's assistance and use of the walker. Her legs became weak and CNA A lowered resident to the floor. At 12:35 PM, a nurse assessed the resident and contacted the physician who gave the order for the resident to be sent to the emergency room for evaluation due to resident complaint of knee/leg pain. The family was notified and were with her at the facility after the fall. The facility contacted the hospital at 6:30 PM, and it was revealed that a CT scan confirmed the resident had suffered a fibular fracture. On 10/30/24 at 11:04 AM, resident #1 was lying in bed talking to a visitor. She recalled that on the day she fell CNA A came to the room to get her out of bed for a shower and asked her how she was feeling. The resident explained she told the CNA that she was feeling strong and didn't want to use the mechanical lift. Resident #1 explained staff did not always use the mechanical lift because sometimes she had felt strong enough to use her walker. She recalled that on that day, CNA A was by herself in the room and no other staff members were present to assist with her transfer. She explained the CNA unlocked the bed to push it against the wall to allow for more room, then she attempted to stand up with the help of the walker and CNA A. She recalled when she stood up, she felt her legs were like stone, so she tried to sit back down, but the bed was not locked, and it moved away from her causing her to fall. In the process of falling, she twisted her left leg and hurt her knee. She said she was sent to the hospital and told that she had a fracture. She explained she received an order for pain medication and was told she would need to follow up with the doctor in two days. On 10/30/24 at 4:33 PM, a phone interview was conducted with CNA A. She said she worked the 7:00 AM to 3:00 PM shift on 10/11/24 and was assigned resident #1. It was resident #1's shower day so she went to ask the resident if she would like to shower, and the resident said yes. She recalled she told the resident she would be back in a little while to get her up. She explained she entered the room again after about an hour to get resident #1 up from the bed and noticed the resident had her four-wheel walker nearby, so she asked the resident if she was feeling strong enough to transfer without the mechanical lift. Resident #1 told her she was feeling well that day and agreed with CNA A to use her four-wheel walker and not the mechanical lift because she did not like using it. CNA A conveyed she then assisted the resident to sit up at the side of the bed and placed the walker in front of her as well as the wheelchair. Resident #1 stood up by holding on to the walker and CNA A assisted by standing next to her supporting her arm. Once resident #1 stood up she complained her knees were feeling heavy, and she could not keep standing. CNA A said she immediately moved behind the resident and assisted her to the floor as she fell sideways, twisting her left leg in the process. CNA A said she saw another CNA pass by the hallway and she screamed for help. She continued the resident was assessed and sent to the hospital because of pain to her left leg. She explained she knew resident #1 very well and had an understanding with her that if she was feeling strong, she would not use the mechanical lift. She said normally she would check the Kardex, which was in the resident's medical record and detailed the tasks assigned to the resident based on their care plan, but she only did that if the resident was new to her assignment. She acknowledged she knew resident#1 required two to three person staff assist with a mechanical lift because this was the way she had been transferred since her most recent admission to the facility. CNA A explained on the day of the incident she was surprised to see the walker in the room which led her to believe there had been a change in the resident's transfer status. She said that even after seeing the walker in the room, she did not confirm the transfer status in the Kardex but took the resident's word she was strong enough to transfer herself without the mechanical lift. She admitted that she had transferred the resident without assistance of the mechanical lift in the past because the resident disliked using it. CNA A said that looking back now she should have checked the Kardex and should have asked other staff for assistance with the transfer because it was her job to keep the resident safe. On 10/31/24 at 9:30 AM, the Director of Nursing (DON) and Administrator were interviewed jointly regarding resident #1's transfer status. They both agreed and acknowledged it was a therapy recommendation to have three people assist during transfers because the resident was severely, morbidly obese and totally dependent on staff for transfers. They explained the third person was an extra safety measure. The DON said that during morning Interdisciplinary Team (IDT) meetings they had previously discussed resident #1 and why it would be beneficial to have a third person during transfers. The third staff member would be in the room for support while the two others would be manning the mechanical lift. The Administrator stated that CNA A was aware of resident #1's transfer status and verified that in her statement. He said CNA A chose to honor the resident's wishes of not using the mechanical lift and failed to inform her immediate supervisor of the resident's refusal to use the mechanical lift as she was care planned for. Later at 10:30 AM, the DON said her expectation was for CNAs to check the Kardex at the beginning of their shifts. The DON explained she understood that staff got into a routine with their assigned residents, but confirmed they still needed to check the Kardex prior to caring for the residents at the beginning of their shifts because their status could change anytime. They explained the therapy department evaluated the residents' mobility and transfer status which was then communicated to the Care Plan coordinator and nursing staff. The care plan interventions were reflected in the Kardex for the CNAs to see. They stated that CNAs received mechanical lift training upon hire and then quarterly from the staff developer and risk managers. On 10/31/24 at 11:00 AM, a joint interview was conducted with the Director of Rehabilitation and the Physical Therapist that evaluated resident #1. The Physical Therapist said she had been working with resident #1 since she was readmitted to the facility on [DATE]. She explained the resident's medical status constantly changed and she was frequently in and out of the hospital. This required frequent PT evaluations to determine her mobility and transfer status. They said resident #1 often refused PT and would refuse to get out of bed, which prevented them from evaluating her ability to transfer from the bed to the wheelchair. The times she did agree to receive PT, it would require two therapists to assist her with the use of a therapy provided walker, but she had severe difficulty ambulating. They said she was discharged from PT on 10/02/24 with the recommendation that a mechanical lift be used for transfers because the resident was non-compliant. They confirmed therapy felt she was not safe to transfer without the lift. She further added that the therapy department only made the recommendation for use of the mechanical lift, but the facility assigned how many people assisted based on the facility's policies and procedures. The Director of Rehabilitation confirmed the policy was to have two people assist with mechanical lift transfers. She further explained that once an evaluation had been made by the therapy department, they provided a communication sheet with their recommendations to the Care Plan Coordinator for the care plan to be created. She said that they communicated with the Unit Managers and CNAs. She explained regarding the four-wheel walker in the resident's room on the day of the incident, they were aware the resident had it but it was not used by therapists during therapy sessions. They confirmed therapy was not responsible for checking if the walker was adequate for use by the resident and there was no facility policy requiring the walker be evaluated since it was personal property. They both agreed that resident #1 was able to make her needs known and was aware she needed the mechanical lift for transfers due to her declining physical health. Review of CNA A's Skills Competency Assessment for Mechanical Lifts revealed that on 7/20/24 the assessment was completed as part of the annual required competencies. The assessment indicated CNA A was found to be competent to perform the task per the Risk Manager who was the evaluator. A review of the CNA's job description document dated March 2023, was signed as completed. The document revealed CNAs were responsible for observing safety needs of residents as indicated in their care plans and to follow established safety policies and procedures. Furthermore, they were to assist with lifting, positioning, and transporting residents into and out of bed, chairs, bathtubs, wheelchairs, and lifts per specific resident safety needs. The facility's policy on positioning and moving residents titled, Safe Lifting and Movement of Residents with review date of 1/25/23, read, Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' need for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. The facility also had a second policy entitled, Lifting Machine, Using a Portable, with revision date 1/25/23. This policy directed staff to review the resident's care plan to assess for any special needs of the resident and required two trained staff members when using the mechanical lift. Review of the Facility Assessment Tool updated 8/05/24 revealed that the services and care offered was based on resident needs which included mobility and fall/fall with injury prevention. The assessment further revealed that the facility would provide person-centered care and would identify any hazards and risks to the resident. The immediate actions to remove the Immediate Jeopardy by the facility were reviewed and revealed the following which was verified by the survey team: *On 10/11/24 at 12:50 PM, resident #1 was transferred to the hospital. *On 10/11/24 at 6:30 PM, the facility was made aware that resident #1 sustained a left fibular fracture. *On 10/11/24 CNA A was removed from her assignment, interviewed about the incident, and then suspended pending investigation. At 7:00 PM, law enforcement was notified and at 8:00 PM, they reported the incident to Department of Children and Families. *On 10/11/24 all staff were in-serviced on following care plans for transfers, how to access information on the Kardex, and following appropriate transfer status for each resident. All 85 CNAs were either trained in-person or via Onshift messaging by 10/13/24 and all 48 nurses were trained by 10/15/24. Observations of mechanical lift transfers were completed with CNA groups to ensure transfers were completed correctly. *On 10/12/24 the facility reviewed all residents who required a mechanical lift for transfers, those who were interviewable, were questioned to determine if the care plan was being followed. *On 10/12/24 all staff involved were interviewed and witness statements were taken. A review of CNA A's personnel file was completed to ensure there was education and competencies related to transfers and mechanical lifts present. Competencies had been completed in July 2023 and July 2024. *On 10/14/24 a Quality Assurance and Performance Improvement meeting was held to discuss the event and adequate follow up. The Medical Director, Administrator, DON, Risk Manager, and other department heads attended the meeting. *On 10/15/24 CNA A was terminated and reported to the Board of Nursing due to her not following resident #1's care plan for transfers and admitting she was aware the resident required a mechanical lift, and three person assist but chose to not follow the care plan. On 10/31/24 from 10:37 AM to 11:45 AM interviews were conducted with five CNAs, one Licensed Practical Nurse (LPN), and one Registered Nurse regarding transfers, locating resident transfer status, and education received after the incident. Two of the seven staff members were able to identify where they could find the resident's transfer status. The other five staff members stated that they would ask another staff member about the resident's transfer status, or they would ask the resident. An interview was conducted with the facility's Staffing Developer and Risk Manager on 10/31/24 at 12:08 PM. They stated that they had recently provided education and training for all staff to ensure all nursing staff knew where to find the resident's transfer status. They educated staff on the facility policy of having two staff members assist during transfers with mechanical lift. They explained that CNAs were told that they needed to report a resident's refusal to use the mechanical lift to their immediate supervisor and explain to the resident that they must follow the care plan to keep the. In addition, other education provided included demonstration of how to safely use the mechanical lift, how to check the Kardex at the beginning of their shift, and how to update the CNA shift report sheet that indicated the care needs, including transfer status, of their assigned residents. The Staffing Developer was made aware by the survey team that only two staff members out of seven were able to identify where they must look for the resident's transfer status. Following the interview, at around 3:20 PM, six CNAs and one LPN from the 3:00 PM-11:00 PM shift were interviewed and there were no issues with their answers. Review of the in-service attendance sheets validated mechanical lift education accompanied by competencies and post-test were completed on the topics of safe transferring with mechanical lifts, checking the Kardex for transfer status, and following the facility's policies on transfers. As of 10/31/24 about 94% of staff had received the education. The resident sample was expanded to include four additional residents who were identified as requiring a mechanical lift for transfers. Observations, interviews, and record reviews revealed no concerns with their care plans or staff assistance during transfers.

Based on interview and record review, the facility failed to ensure Personal Care Attendant (PCA) A was knowledgeable of her scope of practice and competent in transfer procedures to prevent unauthorized and unsafe use of a full body mechanical lift, for 1 of 8 residents reviewed for accidents of a total sample of 27 residents, (#1). On 12/08/21 at approximately 12:25 PM, resident #1 fell during or soon after a transfer from her bed to a wheelchair with a full body mechanical lift. PCA A transferred resident #1 to a wheelchair instead of a recliner as noted in the care plan, and performed the transfer without assistance, which was prohibited by the facility's policy and the PCA's scope of practice. The facility's investigation failed to identify the causative factors for resident #1's fall, and the PCA continued to provide care for residents for 24 additional shifts before she was reassigned to non-clinical duties. The facility's failure to ensure staff competency placed all residents who required a mechanical lift for transfers at risk for serious harm from falls, fractures, head trauma and death. There were currently 27 residents who required a full body mechanical lift for transfers. This failure resulted in Immediate Jeopardy starting on 12/08/21. The Immediate Jeopardy was removed on 1/22/22. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: Cross Reference F835 Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated resident #1 had severely impaired cognition and was rarely or never understood. She was totally dependent on two staff persons for transfers and totally dependent on one person for eating. The MDS assessment revealed the resident was not steady during transfers and was only able to stabilize with staff assistance. Resident #1 had functional limitations in range of motion and had impairments of all extremities. Review of the medical record revealed a care plan for falls dated 6/04/19. The document indicated resident #1 was at risk for falls related to impaired mobility with transfers and non-ambulatory status with use of a mechanical lift. The goal noted resident #1 would not sustain significant injury from a fall. An intervention dated 2/03/21 directed staff to Assist with transfers / Use 2 person assist with mechanical lift (full body) to recliner chair. The fall care plan revealed that on 12/08/21 at 12:44 PM, resident #1 sustained a minor injury when staff lowered her to the floor as she slipped out of her wheelchair. Review of resident #1's care plan for activities of daily living dated 6/04/19 revealed an intervention dated 4/26/21 for two staff members to use a mechanical lift for transfers from bed to a recliner. The Agency rule making was not complete at the time of the survey however, the agency approved to extend the temporary approved Personal Care Attendant (PCA) program created by the Florida Health Care Association. According to Florida Statutes 400.141(1)(w), the Agency for Health Care Administration may adopt rules to implement this paragraph. (w) Be allowed to employ personal care attendants as defined in s. 400.211(2)(d), if such personal care attendants are participating in the personal care attendant training program developed by the agency, in accordance with 42 C.F.R. ss. 483.151-483.154, in consultation with the Board of Nursing. 1. The personal care attendant program must consist of a minimum of 16 hours of education and must include all of the topics and lessons specified in the program curriculum. 2. The program curriculum must include, but need not be limited to, training in all of the following content areas: a. Residents' rights. b. Confidentiality of residents' personal information and medical records. c. Control of contagious and infectious diseases. d. Emergency response measures. e. Assistance with activities of daily living. f. Measuring vital signs. g. Skin care and pressure sores prevention. h. Portable oxygen use and safety. i. Nutrition and hydration. j. Dementia care. 3 .A personal care attendant must complete the 16 hours of required education before having any direct contact with a resident. 4. A personal care attendant may not perform any task that requires clinical assessment, interpretation, or judgment The facility must notify certified and licensed staff of the PCAs' limited scope of practice and intervene if the PCA performs prohibited tasks. The program requirements include PCAs cannot feed residents nor perform any transfer that requires more than one person without assistance from a certified or licensed staff member (retrieved on 1/28/22 from www.LeadingAgeFlorida.org). The facility's policy and procedure for Safe Lifting and Movement of Residents revised on 1/07/20 revealed the facility would utilize appropriate techniques and equipment to transfer residents. The document read, . Staff will document resident transferring and lifting needs in the care plan . Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. On 1/19/22 at 2:00 PM, Licensed Practical Nurse (LPN) B recalled the day PCA A came out of resident #1's room and asked her for help. LPN B stated when she entered the room, the resident was on the floor in front of the wheelchair and the mechanical lift transfer pad under her. LPN B stated PCA A informed her she guided resident #1 to the floor as she was sliding down in her wheelchair. On 1/20/22 at 11:10 AM, PCA A stated she transferred resident #1 out of bed to the wheelchair using the mechanical lift. She confirmed she did not request assistance from another staff member because her assignment sheet indicated the resident required assistance of only one person for transfers. PCA A explained she was trained to rely on the assignment sheet. Review of the CNA Assignment Sheet for the 400 hall revealed resident #1 needed assistance with eating, used a recliner, was to be put back to bed after lunch, and required a mechanical lift and two persons for transfers. On 1/20/22 at 1:10 PM, PCA A stated she could not recall if she was educated and trained on the use of a mechanical lift. She said, I had so much education I can't remember everything, but on my assignment sheet the resident was a one-person transfer. When asked if she looked at the resident's care plan, she said, I don't look at care plans. Nobody looks at care plans. On 1/21/22 at 1:45 PM, in a telephone interview, PCA A stated she had used a mechanical lift by herself to transfer other residents in the past. She denied receiving hands-on training from a supervisor on use of the lift and reiterated that her assignment sheet specified resident #1 required assistance from one person for transfers. PCA A did not recall that the assignment sheet specified use of a recliner, and she explained she thought the recliner in the room belonged to resident #1's roommate. She stated the training period was disorganized and said, For our training we got random CNAs. Review of PCA A's Transfer from Bed to Chair/wheelchair/Use of Gait Belt Competency Check-Off form dated 9/13/21 revealed she demonstrated competency in this skill. The document read For anything beyond a one-person transfer, the PCA may only assist and must be directed by a certified / licensed staff member. The check off sheet was signed by PCA A and validated by the Assistant Director of Nursing (ADON). On 1/20/22 at 9:40 AM and 1/22/22 at 11:50 AM, Certified Nursing Assistant (CNA) D stated she was familiar with resident #1's care needs as she was regularly assigned to residents on the hallway. She stated resident #1 had always required two staff for transfers and she often assisted whoever was assigned to the resident. She said, I was shocked to see her on the floor because she had not had any falls. I did not help [PCA A] transfer the resident out of bed. CNA D confirmed all mechanical lift transfers required two people. She described PCA A as not really a good worker and recalled PCA A was frequently off the nursing unit socializing with other staff members. Although PCAs cannot feed residents, CNA D stated PCA A always fed another resident on her assignment but did not do it properly. She stated she rushed through the meal and quickly placed the unfinished tray back on the food cart. CNA D stated she reported her concerns to nurses. CNA D expressed concern that PCAs were not given adequate training and were not always placed with experienced CNAs who would be good preceptors. On 1/21/22 at 12:10 PM, during review of resident #1's Physical Therapy Discharge Summary dated 10/18/17 with the Assistant Director of Rehab, he confirmed the resident's indicated she had poor dynamic and static sitting balance. He was informed resident #1 fell from a wheelchair and not a recliner as indicated in her plan of care. He explained resident #1 would not have been able to maintain her balance without assistance if seated upright in a chair. The Assistant Director of Rehab acknowledged the resident would need an adjustable reclining chair as the back and leg rest would ensure she had adequate support and comfort. He confirmed mechanical lift transfers should always be performed by two people to ensure safety and proper positioning. On 1/21/22 at 1:35 PM, in a telephone interview, LPN B described resident #1 as bed bound and nonverbal. She stated the resident had one contracted hand, flaccid or floppy legs, and did not move independently. She explained mechanical lift transfers should always be conducted by two staff as one person would position the resident in the chair or bed while the other person operated the lift. LPN B confirmed when PCA A called her to the resident's room, there was no other staff member in the room. On 1/21/22 at 2:15 PM, CNA F stated resident #1 could not move her lower body and needed a recliner to prevent her knees and legs from sliding towards the floor. She recalled resident #1 had required a mechanical lift for transfers for many years. She stated the facility's policy was to utilize two people for all mechanical lift transfers. CNA F explained it would be very dangerous to attempt this type of transfer with only one person. She stated she overheard discussion about the incident and was aware PCA A continued to work afterwards. CNA F said, When I heard it, I said, 'Why is she still here?' I could not believe it. On 1/21/22 at 2:25 PM, CNA G stated she was shocked when she heard PCA A operated the mechanical lift, and then completed the transfer without assistance. On 1/22/22 at 9:20 AM, CNA H stated CNAs trained and supervised PCAs on the nursing units. She said, The CNA has the license. I am responsible for the PCA. I do not recall getting any kind of formal education on how to train the PCA. On 1/22/21 at 9:30 AM, CNA I stated he completed the facility's PCA program and recently became a CNA. CNA I stated after a four-day orientation on the unit he was given a full resident assignment and performed tasks including feeding residents. CNA I described classroom instruction at the start of the PCA program, but he did not recall ever discussing his progress with any supervisors or the Director of Nursing (DON) after classroom training was completed. On 1/22/22 at 9:50 AM, CNA C stated she assisted PCAs with their assigned residents if they asked for help, but she was not aware of all tasks they were not allowed to perform. CNA C said, When they have an assignment they have to feed their residents. They don't have a choice because everyone has their own people to feed. CNA C stated she had trained PCAs on the nursing unit but no member of administration ever asked her how the PCAs did. On 1/22/22 at 10:49 AM, the Weekend Nursing Supervisor stated she assumed responsibility for the PCA program in November 2021. She explained she evaluated competencies at the end of 16 hours of classroom training and PCAs would then shadow or work with a CNA for a minimum of five days. The Weekend Nursing Supervisor stated she did not evaluate PCAs during or at the end of the five-day period, but noted PCAs could request additional clinical orientation. She said, They let me know. The Weekend Nursing Supervisor stated she worked on Fridays, Saturdays and Sundays; therefore, she was not available to provide monitoring, supervision and oversight of PCAs from Monday through Thursday. She stated although she asked the Staffing Coordinator to pair PCAs with more experienced CNAs, it was not always possible. The Weekend Nursing Supervisor said, They just go with whoever is scheduled. I train but I do not schedule. The weakness of this method is that there is no structure in the scheduling or checking if they are okay. There is no structure after the two [classroom] days. On 1/21/22 at 2:50 PM, the Staffing Coordinator stated on the day of the incident, PCA A had a full assignment of nine residents. She confirmed her duties included ensuring the facility met minimum staffing requirements, not selecting appropriate assignments. The Staffing Coordinator explained she assigned CNAs and PCAs to designated hallway assignments and did not have to consider their scope of practice or abilities. On 1/22/22 at 3:34 PM, the DON acknowledged as head of the nursing department, she was ultimately responsible for oversight of the facility's PCA program. She explained the PCA program did not include scheduled evaluation and monitoring of PCAs after completion of the 16-hour class. The DON stated there were no official meetings to obtain feedback of PCAs' performance, or to discuss their progress, clinical competence, and compliance with the facility's policies and procedures. When asked how the facility ensured PCAs adhered to the requirements of the program and provided appropriate care and services to residents, the DON said, If we don't have issues of complaints by families and residents, then we know they are doing a good job. Review of PCA A's Personal Care Attendant job description signed on 8/23/21 revealed the purpose was to, Provides basic nursing care to residents within the scope of the Personal Care Attendant responsibilities. which included regular meetings with the supervisor to promote identification and correction of issues and to improve services. The document indicated the PCA would observe residents' safety needs as noted in the care plan and follow safety policies and procedures. The job description specified the PCA would perform transfers with Use of Gait belt-One person standby / transfer. The job description included a checklist for duties and responsibilities with one column titled Job-specific Orientation and six additional columns titled Evaluation. The areas for documentation of PCA A's performance level were blank and the job description was not signed by a supervisor, DON and/or Administrator. Review of the Facility Assessment Tool reviewed on 2/04/21 revealed the facility offered care and services including transfers, and prevention of falls, with or without injury. The document did not include PCAs in the facility's general staffing plan and there was no required training listed for these members of the nursing department. Review of immediate actions to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 12/11/21, education on Neglect was completed with 100% of staff including 6 Registered Nurses (RN), 19 LPNs, 35 CNAs, 14 PCAs, 4 laundry staff, 1 activities staff, 6 Social Services staff, 12 dietary staff, 2 maintenance staff, 8 housekeepers, 1 medical records staff, 8 administrative staff, 6 Physical Therapists, 6 Occupational Therapists and 1 Speech Therapist. Total 129 staff were educated. *On 1/20/22, education was initiated on use of mechanical lifts and that PCAs were prohibited to perform transfers with mechanical lifts. 100% compliance was achieved on 1/22/22 with 75/75 staff members educated including 6 RNs, 19 LPNS, 35 CNAs. 12 PCAs, 1 activities staff and 2 administrative staff. *On 1/22/22, the facility completed all-staff training on full disclosure and telling the truth during incident investigations; tasks PCAs were permitted to perform; and review of the resident's profile to obtain care directives. 43 staff who were in-serviced via phone must complete training with Staff Development prior to working next shift. *On 1/22/22, the facility reviewed the PCA job description and performance appraisal and the process for assigning PCAs to ensure they could safely and appropriately meet residents' care needs. PCAs will simulate and demonstrate competency in required procedures. During shift report, nurses will remind PCAs of their scope of practice. PCAs will report to the Charge Nurse or Nursing Supervisor. *On 1/22/22, the Chief Quality Officer trained the facility's administrative team on PCA training, competency check-off, continued on-the-job training with performance appraisal validation. *On 1/22/22, the facility-initiated review of concerns by the leadership team in daily clinical meetings so that corrective action can be identified / implemented. *On 1/22/22, a full-house audit of MDS assessments and care plans was completed and 26 residents were identified as requiring a full body mechanical lift for transfers. Care plans were updated to reflect current transfer needs. *On 12/17/21 and 1/22/22, the facility's Quality Assurance and Performance Improvement committee held ad hoc meeting to discuss the event involving resident #1 and conducted follow-up. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed on the facility's policies and procedures on Neglect, safe transfers with mechanical lifts and PCA program requirements. On 1/22/22, interviews conducted with 21 facility staff including 1 PCA, 15 CNAs, and 5 LPNs revealed all staff were knowledgeable of PCAs' scope of practice. All staff verbalized the importance of following residents' care plans and always using two persons for transfers with a mechanical lift. The sample was expanded to include 7 additional residents who required a full body mechanical lift for transfers. Interview and/or record review revealed these residents were assessed appropriately and had care plans that reflected their transfer status accurately.

Based on interview and record review, the facility failed to effectively use its resources to maintain a Personal Care Attendant (PCA) program with adequate supervision, monitoring and evaluation to ensure staff competency and promote safety for 1 of 8 residents reviewed for accidents, (#1), of a sample of 27 residents; and failed to develop, implement, and monitor corrective actions to ensure the safety of all residents who received care from PCAs. On 12/08/21 at approximately 12:25 PM, resident #1 fell during or soon after a transfer from her bed to a wheelchair with a full body mechanical lift. Personal Care Attendant (PCA) A transferred resident #1 to a wheelchair instead of a recliner chair as noted in the care plan, and performed the transfer without assistance, which was prohibited by the facility's policy and the PCA's scope of practice. The facility's investigation failed to identify the causative factors for resident #1's fall, and the PCA continued to provide care for residents for 24 additional shifts before she was reassigned to non-clinical duties. The facility's failure to provide adequate supervision, regular monitoring and periodic competency checks for PCAs during their training placed all residents who were assigned to PCAs at risk. This failure resulted in Immediate Jeopardy starting on 12/08/21. The Immediate Jeopardy was removed on 1/22/22. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: Cross reference F726 Review of a facility incident investigation revealed on 12/08/21 at approximately 12:25 PM, PCA A observed resident #1 sliding out of her wheelchair. The document revealed PCA A lowered the resident to the floor and notified the assigned nurse, Licensed Practical Nurse (LPN) B. The facility's investigative findings indicated PCA A was preparing to transfer resident #1 from her wheelchair to the bed with a full body mechanical lift at the time the incident occurred. The investigation showed the resident's wheelchair brakes were unlocked. On 1/20/22 at 1:10 PM, PCA A offered a conflicting statement. She stated the incident occurred immediately after she transferred resident #1 from the bed to the wheelchair. She explained she locked the brakes on the wheelchair, used the mechanical lift to perform the transfer by herself and placed resident #1 in the wheelchair. PCA A stated she placed the mechanical lift on the opposite side of the room and when she looked around, the resident was sliding out of the wheelchair. PCA A stated she never asked any other staff member to assist her with the transfer as her assignment sheet noted resident #1 required assistance of only one person for transfers. She explained she was trained by the Certified Nursing Assistants (CNAs) in the facility who instructed her to rely on the assignment sheet. She said, I don't look at care plans. Nobody looks at the care plans. We follow our assignment sheets. I got trained on so many things, I can't remember everything. On 1/22/22 at 10:00 AM, the facility's leadership team including the Administrator, Risk Manager (RM) and the Director of Nursing (DON) discussed resident #1's fall. On 1/22/22 at approximately 10:05 AM, the RM stated the facility's investigative findings regarding the fall were inconclusive, and the administrative team did not identify a root cause due to conflicting information and statements. The RM stated she did not ask PCA A who assisted her to transfer resident #1 from the bed to the wheelchair. She explained she did not pursue that path of questioning as PCA A told her the resident was already in the chair when the incident occurred. On 1/22/22 at approximately 10:10 AM, the Administrator stated the facility decided to implement the PCA program in about May 2020 to mitigate staffing shortages associated with the Corona Virus Disease 2019 (COVID 19) pandemic. She acknowledged this unique group of nursing staff had specialized training and a defined scope of practice. The Administrator stated the previous Assistant Director of Nursing (ADON) was in charge of the PCA program until she resigned in December 2021, and the program was reassigned to the Weekend Nursing Supervisor. She stated after completion of a 16-hour class provided by the facility, the ADON verified PCAs were competent in the tasks they were permitted to perform. The Administrator explained PCAs were then assigned to shadow and/or work alongside CNAs on the nursing units for five to ten days, under supervision of licensed nurses. She stated at the end of that period, if the PCA was comfortable, he/she was assigned to a group of residents. She stated PCAs received full assignments, comparable to certified staff, with the exception of residents on transmission-based precautions or those with COVID 2019. The Administrator confirmed although PCAs were not permitted to utilize a mechanical lift or feed residents they were assigned to residents who required these interventions. She explained nurses were educated regarding the tasks PCAs were permitted to perform and PCAs were expected to follow the residents' care plan instructions. When asked how the facility ensured PCAs practiced within their scope, avoided prohibited tasks, and followed plans of care, the Administrator said, [The ADON] was checking in with them. However, she was not aware of any specific frequency of monitoring, nor the extent of supervision provided once PCAs had their own resident assignments. The Administrator stated the facility had no documentation to show PCAs' progress was monitored or evaluated at any time after completion of the 16-hour class. On 1/22/22 at approximately 10:20 AM, the administrative team was informed that interviews with facility staff revealed that PCA A had been performing transfers with a mechanical lift without any assistance and also feeding residents; CNA I stated when he was a PCA he received only four days of orientation on the nursing unit and had a full assignment on the fifth day with duties which included feeding residents; CNA H did not recall any education regarding the PCA scope of practice and felt CNAs were responsible for supervising PCAs; CNA D was PCA A's hall partner and reported issues about performance of her duties. She expressed concern about training of PCAs and selection of CNA preceptors who were not good mentors; and CNA C was not aware of the PCA's scope of practice and reported PCAs fed their assigned residents. She stated she had never been asked to provide feedback regarding any PCAs she trained. On 1/22/22 at approximately 10:25 AM, the DON and the Administrator stated they were not aware PCA A was regularly assigned to care for two residents who required transfers with a mechanical lift although she was prohibited from performing this type of transfer. The DON stated PCAs were to follow residents' care plans and her expectation was they would ask for assistance from a certified or licensed staff member. The Administrator stated she was not aware of the issues identified regarding the PCA program. She was not aware PCAs were feeding their assigned residents and confirmed it was not permitted. On 1/22/22 at 10:49 AM, the Weekend Nursing Supervisor stated she assumed responsibility for the PCA program in November 2021. She explained she evaluated competencies at the end of 16 hours of classroom training and PCAs would then shadow or work with a licensed CNA for a minimum of five days. The Weekend Nursing Supervisor stated she did not evaluate PCAs during or at the end of the five-day period, but PCAs could request additional clinical orientation if they felt they needed it. The Weekend Nursing Supervisor stated she worked on Fridays, Saturdays, and Sundays; therefore, she was not available to provide monitoring, supervision, and oversight of PCAs from Monday through Thursday. She stated although she asked the Staffing Coordinator to pair PCAs with more experienced CNAs, it was not always possible. The Weekend Nursing Supervisor said, They just go with whoever is scheduled. I train but I do not schedule. The weakness of this method is that there is no structure in the scheduling or checking if they are okay. There is no structure after the two [classroom] days. She confirmed it would be problematic if CNAs assigned to mentor PCAs were not aware of what tasks and procedures were prohibited for PCAs. She acknowledged a checklist would be effective for obtaining and giving feedback on PCAs' performance throughout their training, but she was not aware any such document existed. On 1/22/22 at 3:34 PM, the DON acknowledged as head of the nursing department, she was ultimately responsible for oversight of the facility's PCA program. She explained the PCA program did not include scheduled evaluation and monitoring of PCAs after completion of the 16-hour class. The DON stated there were no official meetings to obtain feedback on PCAs' performance, or to discuss their progress, clinical competence, and compliance with the facility's policies and procedures. When asked how the facility ensured PCAs adhered to the requirements of the program and provided appropriate care and services to residents, the DON said, If we don't have issues of complaints by families and residents then we know they are doing a good job. She stated the facility's corporate office designed the program and the previous ADON implemented it. The DON stated she was familiar with PCA programs in many other facilities that operated successfully without any additional monitoring of PCAs after the 16-hour class. Review of the Personal Care Attendant job description dated 4/01/20 revealed there was a performance evaluation system for PCAs that was not known to the Administrator, Weekend Nursing Supervisor or DON. The document indicated PCAs would have regular meetings with a supervisor to promote identification and correction of issues and to improve services. The job description included a checklist for duties and responsibilities with one column titled Job-specific Orientation and six additional columns titled Evaluation to document on a PCAs' performance and progress in all areas during the training period. Review of the Facility Assessment Tool reviewed by the Quality Assurance and Performance Improvement (QAPI) committee on 2/04/21 revealed the type and number of qualified staff needed to meet residents' needs. The general staffing plan did not indicate the facility utilized PCAs as direct care staff and there was no required training, education or competencies listed for these members of the nursing department. The document read, As circumstances and regulations arise and changes occur within the facility, policy and procedures need to be reviewed and changed. The assessment revealed the QAPI team would approve changes and educate staff as indicated. On 1/22/22 at 1:35 PM, the Administrator validated the current Facility Assessment Tool did not include PCAs in the description of staff. Review of the job description for Administrator dated March 2018 revealed responsibilities and duties that included ensuring employees were adequately trained to perform their duties, and ensuring supervisors are trained in and implement facility policy and procedures. The job description for Director of Nursing Services dated 4/11/18 revealed a purpose to lead the nursing department and maintain quality care in the facility. The DON's responsibilities and duties included oversight of the nursing department and roles of each position, reviewing employee performance, evaluating clinical programs and ensuring .effective departmental orientation and ongoing on-the-job training for new nursing employees. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 1/22/22, the Chief Quality Officer trained the facility's Administrator, DON, and RM on the PCA program education and training. Topics included PCA Program Standards, Required Staff Instruction, Staff Competency Requirements, Job Description and Approved Job Duties for PCAs. *On 1/22/22, the facility implemented a feedback review system to provide enhanced monitoring of PCAs. *On 1/22/22, the facility involved the Staffing Coordinator, Charge Nurse and DON in reviewing and ensuring appropriate assignments for PCAs. The facility will utilize change of shift report with the nurse to remind PCAs of prohibited tasks. *On 1/22/22, the facility's Quality Assurance and Performance Improvement committee held ad hoc meeting to discuss the event involving resident #1 and conducted follow-up. Review of in-service attendance sheet validated education was completed by 3 of 3 administrative staff.

Based on observation, interview and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #28 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #28's Quarterly Minimum Data Set assessment with an assessment reference date of 2/12/21 revealed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The assessment indicated there were no skin impairments. On 4/19/21 at 10:17 AM, resident #28 was seated in a recliner in her room. Her lower legs were discolored and she had two dressings on her right lower leg which were not dated or initialed. On 4/20/21 at 11:37 AM, and again on 4/21/21 at 10:59 AM resident #28 was seated in a recliner in her room. The same dressings were in place to her right lower leg. They were not dated or initialed. On 4/21/21 at 11:40 AM, Certified Nursing Assistant (CNA) E stated she regularly cared for resident #28. She said resident #28 had periods of confusion and scratched her skin often. CNA E recalled on the previous Saturday, five days before, resident #28 had scratched her legs and the lacerations were bleeding. She stated a nurse then put dressings on resident #28's right lower leg. On 4/21/21 at 1:18 PM, Licensed Practical Nurse (LPN) F acknowledged resident #28 had dressings on her right lower leg. She recalled during shift change report, the off-going night nurse told her of an injury/scratch to resident #28's right leg. LPN F was not sure if an incident report was made and could not recall which day the injury happened. LPN F explained, after change of shift report, a CNA informed her there were no dressings on resident #28's lacerations. The CNA also informed her the resident continued to scratch the area. LPN F stated she cleaned the lacerations with normal saline, and applied a dry dressing to them. She validated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/21/21 at 1:25 PM, resident #28's right leg lacerations were observed with LPN F. She said the physician should have been notified of resident #28's lacerations and a treatment order obtained. LPN F stated the dressings should be dated so staff would know how long they had been there. On 4/21/21 at 1:34 PM, resident #28's right lower leg was observed with the North Wing Unit Manager (UM). The UM measured the lacerations at 0.5 centimeters (cm) x 0.2 cm on the right outer calf and 3.0 cm x 0.5 cm to the right shin. The right outer calf wound was partially scabbed. The wound to the right shin was not healed, and had a visible wound bed. The peri-wound area was red and the wound started bleeding during observation. The UM stated his expectation was that nurses would notify the physician of any skin injury, obtain an order, document the incident in a progress note and complete an incident report if indicated. He noted there were no standing orders for wound treatments, and said, there should absolutely be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's wound treatment order was discontinued on 4/11/21 for a resolved right lower leg skin tear. Review of the nursing progress notes revealed no documentation of new skin injuries, lacerations or treatments for resident #28 between 4/11/21 and 4/21/21. Review of the Observation Detail List Report revealed the Monthly Nursing Summary dated 4/11/21 showed no skin impairments. The Weekly Skin assessment dated [DATE] showed no skin impairments. No further skin impairments were documented from 4/11/21 to 4/21/21. Review of the medical record revealed resident #28 had a care plan dated 6/5/19 for skin integrity. Interventions directed nurses to see the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's incident reports for April 2021 revealed no documentation of skin impairment or scratches for resident #28 between 4/11/21 and 4/21/21. On 04/21/21 at 2:01 PM, the Wound Nurse stated any new skin issues or incidents should be reported to the UM. She said nurses should initiate an incident report, notify the physician and the family, even for a scratch. The Wound Nurse said, There is no such thing as not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/22/21 at 12:40 PM, resident #28's hospice physician stated she was never notified by the facility that resident #28 had lacerations to her right lower leg. The hospice physician said, I will have to look at it.

Based on observation, interview and record review, the facility failed to provide dressing changes for a Peripherally Inserted Central Catheter (PICC) according to current professional standards of practice for 1 of 4 residents with intravenous (IV) access sites, of a total sample of 51 residents, (#44). Findings: Resident #44 was admitted to the facility on [DATE] from an acute care hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] is a body's extreme response to an infection. It is a life-threatening medical emergency which without timely treatment can rapidly lead to tissue damage, organ failure and death. (retrieved 4/23/21 from www.cdc.gov). Review of the medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A peripherally inserted central catheter .is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart . It's generally used to give medications . A PICC line requires careful care and monitoring for complications, including infection and blood clots .(retrieved 4/26/21 from www.mayoclinic.org) On 4/19/21 at 10:00 AM, resident #44 stated she currently received IV antibiotics for a severe wound infection. Resident #44 had a PICC line in her left upper arm with a clear dressing dated 4/08/21. The dressing was loose on the bottom edge near the PICC line insertion point. Resident #44 stated she thought the dressing needed to be changed. A review of the Treatment Administration Record (TAR) dated 4/01/21 to 4/22/21 revealed that nurses documented every shift that the PICC site dressing was observed as ordered. The PICC dressing change scheduled every week on Mondays was initialed by nurses to verify it was completed as ordered on 4/05/21, 4/12/21, and 4/19/21. There was no documentation on the TAR of a dressing change on 4/08/21. Review of progress notes by the Advance Practice Registered Nurse dated 4/09/21, 4/12/21, and 4/16/21 revealed PICC line care was included in resident #44's plan of care. Review of the admission Minimum Data Set with assessment reference date of 2/23/21 revealed resident #44 had a Brief Interview for Mental Status score of 14 indicating she was cognitively intact. The assessment showed she was receiving IV medications. Resident #44 had a care plan dated 2/17/21 for risk of developing complications to the IV line. The care plan goal was for resident #44 not to develop signs or symptoms of complications related to the IV. Interventions directed nurses to change the IV dressing as ordered and as needed if loose or soiled, and to observe the IV site every shift. On 04/19/21 at 10:25 AM, the North Wing Unit Manager (UM) stated that IV dressings were ordered to be changed once a week. He stated that IV sites should be checked every shift, and the dressing changed as needed. On 4/19/21 at 10:32 AM, resident #44's PICC line dressing was observed with the North Wing UM. He validated the dressing was dated 11 days ago on 4/08/21. Resident #44 informed the UM that the dressing had not been changed in a while and she had asked the nurse to tape it down last night because the dressing was loose. The North Wing UM confirmed the dressing edge was rolled back leaving the insertion site partially exposed. He stated the IV dressing should be changed weekly and remain intact to prevent infection at the IV site. On 4/21/21 at 1:08 PM, Licensed Practical Nurse (LPN) F stated she checked resident #44's IV every shift. She said, I'm not IV certified. I looked at it but did not notice the date on it. LPN F explained she usually asked a nurse who was IV certified to perform care for her assigned residents with IV's. She did not recall who she asked to do resident #44's dressing change, and said she did not remember if she actually followed up. LPN F acknowledged she signed the TAR to indicate the dressing was changed. She said, I don't do anything with it. I was educated not to sign off on it since I am not IV certified. She stated she saw a piece of tape was placed to secure the loose edge of the dressing, but never reported it. On 4/22/21 at 12:17 PM, the North Wing UM confirmed LPN F documented the PICC line dressing change was performed on 4/05/21, 4/12/21, and 4/19/21, although she was not certified to care for the IV. He could not explain why she did what she did, and said the document is not accurate. He said the expectation was that a non-IV certified nurse should find someone who is certified to perform and document any IV care. He further clarified that all dressings should be initialed and accurately dated. He acknowledged resident #44's IV dressing dated 4/08/21 was not initialed. Review of the facility's policy and procedure, Midline Dressing Changes revised April 2016, read, The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. Guidelines included, change dressing every five to seven days or if wet, dirty, not intact or compromised in any way. The policy noted the dressing should be labeled with initials, date and time, to report any signs or symptoms and intervene as necessary.

Based on observation, interview and record review, the facility failed to ensure a physician's order was obtained for oxygen therapy for 1 of 1 resident reviewed for respiratory care of a total sample of 51 residents, (#164). Findings: Resident #164 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Certification For Medicaid Long-Term Services And Patient Transfer Form( AHCA Form 3008) revealed the resident was discharged from the hospital on 4/16/21 with Treatment Devices listed as, Oxygen 4% PRN (as needed). The resident's Observation Report dated 4/16/21 read, Respiratory equipment uses: Oxygen while at rest .Oxygen is delivered: Per nasal cannula. Nursing progress note dated 4/16/21 read, no c/o (complaint of ) pain/discomfort upon arrival via stretcher .O2 (oxygen) at 4 (Liters) NC (Nasal cannula). A review of the resident's progress note documented by the Advance Practiced Registered Nurse dated 4/19/2, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The APRN's plan included, oxygen via nasal cannula. Review of the resident's physician orders revealed no orders for O2 therapy. On 04/19/21 at 11:17 AM, resident #164 had O2 via NC at 4 liters per minute (LPM). On 04/21/21 at 1:31 PM, the Licensed Practical Nurse (LPN)/ Infection Preventionist (IP) stated she was working on a medication cart, and resident #164 was on her assignment. The LPN/IP stated resident #164 received O2 but was not sure of the LPM. The resident's physician orders were reviewed with LPN/IP. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/21/21 at 1:49 PM, observation conducted with LPN/IP showed resident #164 received O2 via NC at 3 LPM. The LPN/IP stated she would double check the resident's physician orders. She verbalized that O2 should only be administered by physician orders. She acknowledged that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/21/21 at 2:08 PM, the North Wing Unit Manager (UM) stated O2 could be placed in an emergent situation, if a resident was having respiratory distress, but a physician order had to be obtained for continued O2 therapy. The UM reviewed the resident's physician's orders, and verbalized that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/21/21 at 2:28 PM, the Interim Director of Nursing (DON) stated that O2 administration was by physician's orders. She noted that resident #164 had O2 on the 3008 transfer form and O2 should have been placed on the facility's physician's orders. On 04/22/21 at 12:55 PM, the LPN/IP indicated the resident's admitting nurse should have placed the order for O2 in the resident's clinical record. She added that nurses who cared for the resident should have ensured an order was in place for the resident's O2 therapy. On 04/22/21 at 12:57 PM, the North Wing UM said nurses should follow up to ensure orders for treatment were in place. He stated the Interdisciplinary Team reviewed the resident's physician orders and noted the oxygen orders fell through the cracks. The facility's policy Oxygen Administration revised 2/10/2019 read, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to store medications in appropriate and properly labeled containers on 1 of 2 medication carts of a total of 4 medication carts, (South Wing 200 hall). Findings: On 4/19/21 at 8:27 AM, Licensed Practical Nurse (LPN) G prepared to administer medications on the South Wing. LPN G did not have the medication Acidophilus in her medication cart and asked LPN A, who stood at a nearby medication cart if she had any. LPN A pulled a transparent plastic cup out of the drawer from the 200 hall medication cart and shook a pill out of the plastic cup into the medication cup held by LPN G. Acidophilus is a [MEDICATION(S)] supplement commonly used to promote the growth of good bacteria in the body (retrieved on 4/26/21 from www.Mayoclinic.org). On 4/19/21 at 8:29 AM, LPN A showed the container from which she had provided the Acidophilus capsule to LPN G. The clear plastic cup contained 5 capsules and read, [MEDICATION(S)], handwritten in black marker. LPN A acknowledged she poured a capsule from the clear plastic cup into the medication cup held by LPN G. LPN A said there was no bottle of Acidophilus in the 200 hall medication cart. She noted it was not good practice to store and administer any medication that was not in its original container as nurses could not be sure what the medication was. On 4/19/21 at 8:33 AM, the Risk Manager (RM) was informed Acidophilus capsules were stored in an uncovered clear plastic cup on the 200 hall medication cart. LPN A handed the plastic cup with the Acidophilus capsules to the RM. The RM said, No, the nurse should not give medications out of a cup. She said medications should only be stored and dispensed from their original containers. On 4/19/21 at 8:36 AM, LPN G said nurses should not administer medications stored in a clear plastic cup. She acknowledged she should not have taken the Acidophilus capsule that was dispensed from a cup by LPN A. LPN G could not explain why she did. On 4/19/21 at 12:45 PM, the Director of Nursing stated nurses should not have used medications that were stored in a plastic cup. She said medications were only to be dispensed from original containers. On 4/20/21 at 1:33 PM, the South Wing Unit Manager (UM) verbalized that capsules kept in a uncovered plastic cup were not properly stored. She explained that nurses could not be certain of what the medication was, and the medication could become contaminated if uncovered. The South Wing UM said, Medication stored in a cup shouldn't happen. Review of the policy and procedure Medication Storage in the Facility revised 2018, read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia (USP). The document revealed medications were to be kept in those containers and nurses may not transfer medications from one container to another.

Based on observation, interview and record review, the facility failed to follow proper infection control processes by not cleaning equipment used for a resident on transmission based precautions, (#211) and failed to wash/sanitize hands during a resident's wound care, (#30) for 2 of 4 residents sampled for infection control, (#211,#30). Findings: 1. Resident #211 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her 14-day minimum data set (MDS) assessment dated [DATE] indicated her brief interview for mental status (BIMS) was 13 which indicated she was cognitively intact. She required extensive assistance of 2 staff for bed mobility and transfers. She was total dependence for locomotion with wheelchair of one staff, total assistance for toilet use with one staff, and always incontinent of bowel and bladder. On 8/13/19 resident #211's urine was tested , and the results were reported to the facility on [DATE] showing, Escherichia coli, Extended Spectrum B-Lactamase (ESBL). The physician ordered Contact Isolation for ESBL, urinary tract infection [MEDICAL CONDITION] on 8/15/19. On 8/16/19 an antibiotic, [MEDICATION NAME] 100 milligrams (mg) 1 tablet twice a day for 10 days was ordered by the physician. On 8/19/19 at 9:47 AM, resident #211 was observed in bed watching television. There were isolation personal protective equipment (PPE) supplies hanging on the door along with a sign to see nurse before entering the resident's room. Resident #211's daughter was interviewed as resident only spoke Spanish. She stated my mother was put on isolation on Friday and someone explained to me that it was because she had a UTI. On 8/19/19 at 11:11 AM, certified nursing assistant (CNA) D brought a mechanical lift #1 into resident #211's room who was on isolation precautions and used it with the assistance of a therapy staff member to transfer the resident from the bed to a wheelchair. At 11:33 AM, CNA D was observed coming out of resident #211's room with the mechanical lift #1 and wheeled it down the hall by the nurse's station. The CNA D had not cleaned the lift prior to taking it out of the resident's room. The mechanical lift #1 was observed in the hall until 12:47 PM when CNA C took the lift #1 down another hall in preparation to use on another resident. On 8/19/19 at 12:49 PM, CNA C stated, after we use a lift in an isolation room it has to be wiped down with our bleach wipes before leaving the room so any infection doesn't get on anyone else. CNA C was made aware that the lift #1 was not cleaned after being used in an isolation room and needed to be cleaned prior to use. On 8/19/19 at 12:56 PM, CNA D stated that the lift needed to be cleaned with bleach wipes before taking it out of a room on isolation precautions. The CNA D verified that he had not cleaned the lift after using it for resident #211 who was on isolation precautions. He responded I should have cleaned it after I used it in the isolation room. On 8/20/19 at 3:35 PM, the director of nursing (DON) said the CNA should have cleaned and disinfected the lift prior to leaving a resident's room who was on isolation precautions. Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, dated, 11/01/18, read, Policy Statement 1. Standard Precautions shall always be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others . 7. Resident-Care Equipment b. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her quarterly minimal data set ((MDS) dated [DATE] indicated that her brief interview for mental status (BIMS) score was 0 which indicated severe cognitive impairment. She was totally dependent on staff for all her activities of daily living (ADL) care. She was always incontinent of bowel and bladder and required feedings via gastrostomy tube for all nutrition. A review of the medical record revealed a wound care physician evaluation summary note dated 8/14/19 which showed wound to left distal lateral foot- stage 4 for at least 147 days, moderate serosanguinous exudate, slough 25%, granulation 50% . A physician's order dated 7/22/19 read Iodosorb gel 0.9% amount 1 topical-Special instructions: clean left distal lateral foot with normal sterile saline (NSS), pat dry, apply skin prep peri wound, cover with silicone dressing once a day. On 8/21/19 at 3:41 PM, licensed practical nurse, (LPN) A was observed doing the resident's wound care dressing change. LPN A assembled her supplies, donned gloves and informed the resident of the procedure. She repositioned the resident with assistance of another staff. LPN A then took off her gloves, and washed her hands in the bathroom. She donned clean gloves and removed the soiled dressing from the resident's left lateral foot wound and disposed of the soiled dressing. She then removed her gloves and disposed of the gloves at the bedside. Without washing/sanitizing her hands, she donned another pair of clean gloves and proceeded to clean the wound. When she finished cleaning the wound, she removed and disposed of the gloves. She then donned another pair of gloves without washing or sanitizing her hands. She then applied skin prep around the wound and removed and disposed her gloves. She again donned another pair of clean gloves without washing/sanitizing her hands. She applied the Iodosorb gel to the silicone dressing and applied the dressing to the wound. LPN A washed her hands after the completion of the dressing change. At 4:14 PM, LPN A verified that she did not wash her hands after removing the soiled dressing, cleaning the wound and applying the new dressing. On 8/21/19 at 4:20 PM, the director of nursing (DON), stated, LPN A should have washed her hands during the dressing change between removing the soiled dressing and then applying sterile dressing to the wound. Review of the facility policy, Standard Precautions dated, 11/01/18, . Policy statement Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, bodily fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents Review of facility policy, Dressings, Dry/Clean dated, 2/10/19, read, . Steps in the procedure . 6. Put on gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly

Based on interview and record review, the facility failed to follow a resident's advance directive for DNR (Do Not Resuscitate) as documented in a Living Will Declaration Form signed by the resident for 1 of 2 residents reviewed for advance directives, (#1). Findings: Resident #1, a [AGE] year old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE], revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact and able to make his own decisions. Review of a facility initiated Living Will Declaration Form dated [DATE], signed by resident #1 and witnessed by the Social Worker (SW) and the Admissions Clerk (AC) indicated the resident wished to have a code status of DNR. The form also noted that resident #1 wished to Willingly and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that if at any time I am both mentally and physically incapacitated and have the following: a terminal condition, an end-state condition and am in a persistent vegetative state. All 3 conditions were initialed by the resident. The form further indicated, If my attending or treating physician and another consulting physician have determined that there is no reasonable medical 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 the performance of any medical procedure deemed necessary to provide me with comfort care to alleviate pain. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept consequences for such refusal. Review of the facility initiated Designation of Health Care Surrogate form dated [DATE], (the same day) witnessed by the SW and AC was initiated to name resident #1's daughter, who lived out of state as his health care surrogate. The above form read: My health care surrogate's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I initial either or both of the following boxes. If I initial this box, my health care surrogate's authority to receive my health information takes effect immediately. If I initial this box, my health care surrogate's authority to make health care decisions for me takes effect immediately. Pursuant to section 765.204(3), Florida States, any instructions of health care decisions I make, either verbally or in writing, while I possess capacity shall supercede any instructions or health care decisions made by my surrogate that are in material conflict with those made by me. Both boxes were initialed by the resident. Review of the recapitulation of physician orders [REDACTED]. Living Wills are legal advance directives that record an individual's decisions regarding medical care options in the event of incapacitation (www.medlineplus.gov) that can include a DO NOT RESUSCITATE (DNR) order that instructs providers not to initiate cardiopulmonary resuscitation (CPR) in the event an individual's heart or breathing stops. In contrast, a RESUSCITATE status refers to a wish for CPR which instructs staff to try cardiopulmonary resuscitation to keep the resident alive. Resident #1 was unable to be interviewed regarding his code status related to his declining cognitive status. On [DATE] at 12:35 PM, the SW stated that it was her understanding that resident #1's wishes were to be RESUSCITATED and stated that she would call the health care surrogate to verify the resident's code status. The SW was unable to explain why an order to RESUSCITATE the resident was in place despite the resident's Living Will indicating his wish to die without the use of life-prolonging procedures, The SW was also unable to explain why she interpreted the living will signed by the resident to provide CPR when in fact the form gave instructions not to provide CPR or any other life sustaining interventions if the resident's heart or breathing was to cease. On [DATE] at 2:08 PM, a call was placed by the SW to the health care surrogate, who stated she was not aware of the Living Will signed by resident #1, indicating a DNR code status and requested a conference call be conducted the following day with her father to confirm his wishes. On [DATE] at 3:35 PM, the AC stated she had sent the admission packet to the health care surrogate to complete following the resident's admission to the facility but never received the completed documents back confirming the code status wishes for resident #1. She could not explain why she did not follow up with the health care surrogate to request the completed admission papers. Since admission to the facility the above listed Living Will Declaration Form signed by the resident remained in the medical record representing the resident's DNR code status wishes which the healthcare surrogate was not aware of. Review of the policy and procedure, Do Not Resuscitate Order revised on ,[DATE], indicated the facility will not use cardiopulmonary and emergency measures (CPR) to maintain life functions on a resident when the resident has indicated wishes to not prolong their life with artificial measures.

Based on observation, interview and record review the facility failed to ensure the accurate reordering and administering of medications to meet the needs of 1 of 3 residents reviewed for medication administration, (#23). Findings: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His current medications included [MEDICATION NAME] 5 milligrams (mg) one tablet daily for high blood pressure, [MEDICATION NAME] 25 mg one tablet twice daily for high blood pressure, [MEDICATION NAME] 100 mg one tablet daily for diabetes and [MEDICATION NAME] 0.2% eye drops, one drop in both eyes daily for treatment of [REDACTED]. On 01/30/19 at 9:48 AM, during medication administration, the licensed practical nurse (LPN) C indicated that 4 of the resident's medications that were due to be given were not on the medication cart, [MEDICATION NAME] 5 milligrams (mg) one tablet daily, [MEDICATION NAME] 25 mg one tablet 2 times daily, [MEDICATION NAME] 100 mg one tablet daily, and [MEDICATION NAME] 0.2% eye drops 1 one drop to each eye daily. The LPN C stated that these 4 medications were not on the medication cart and would have to be reordered. She said, which ever nurse was working the cart should have reordered medications when they were getting low. We reorder right on the computer screen. On 1/30/19 at 10:57 AM, LPN C called the pharmacy. She was informed by pharmacy that the resident's [MEDICATION NAME] 5 mg medication card was delivered to the facility on [DATE]. The LPN C stated that she could not find the [MEDICATION NAME]. The medication [MEDICATION NAME] 100 mg was being reordered too early as it was not scheduled to be reordered until 02/01/19. The pharmacy did not have the medication orders on file for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 2% eye drops for resident #23. These medication had not been reordered after the resident returned from his leave of absence (LOA) on 09/16/18. Review of the progress notes revealed that resident #23 had a LOA with family on 09/03/18 and returned on 09/15/18. On 1/30/19 at 10:00 AM, Registered Nurse (RN) B stated when a resident goes out on a LOA, they are not discharged , the medications are put on hold, then started again when they return. Review of the resident's Medication Administration Record [REDACTED]. Further review of the MARs indicated that resident #23 continued to receive [MEDICATION NAME] and [MEDICATION NAME] 2% eye drops after return from LOA on 09/16/18 through 01/29/19. On 1/30/19 at 1:42 PM, the Director of Nursing (DON) stated every nurse was responsible to reorder medications as they get low and was not made aware that we had run out of medications for any resident. All medications have to be reordered manually and are not reordered automatically. On 01/31/19 at 3:30 PM the DON provided an email from the facility pharmacy consultant dated 01/30/19 at 3:16 PM which read, [MEDICATION NAME] was last filled by pharmacy in (MONTH) (YEAR) patient was discharged from our system on (MONTH) 10, (YEAR) and nothing was received in regards to [MEDICATION NAME] on readmission on (MONTH) 16th. [MEDICATION NAME] was last filled by the pharmacy in early (MONTH) (YEAR) (3 or 4th) and nothing has been filled after the readmission of the patient on (MONTH) 16th. [MEDICATION NAME] 100 mg was filled for 14 day supply on Saturday (MONTH) 19, 2019 and was due to for a refill on (MONTH) 2, 2019. (14 doses sent) and refill being sent out today after initial request was too soon to fill. She stated, [MEDICATION NAME] was sent from the pharmacy on Monday (MONTH) 28, 2019. She said she had spoken with the consultant pharmacist and could not find any indication that the medications for resident #23, the [MEDICATION NAME] and the [MEDICATION NAME] eye drops were ever reordered after (MONTH) (YEAR). When asked to provide any documentation for the pharmacy delivery receipts or reconciliation of received medications from the pharmacy, The DON could not provide any documentation. The DON stated I think it was a computer glitch, the medication orders were in place prior to the residents LOA and were in place after the resident returned. Review of facility policy, 4.5 Reordering, Changing, and Discontinuing Orders, dated, 05/01/10, read, . Procedure . 2.4.2.1 Facility staff should select needed refills orders from a list of residents and medications due for refill

Based on observation, interview and record review, the facility failed to ensure medication administration error rate of less than 5% for 1 of 3 residents reviewed for medication administration observation, (#23). The medication error rate was 16.13%. Findings: On 01/30/19 at 9:48 AM, medication administration was observed with Licensed practical nurse (LPN) C. LPN C stated, we have one hour before and one hour after the time the medication is due for it to be given. Among the medications given, LPN C administered [MEDICATION NAME] 20 milligrams (mg) one tablet by mouth to the resident. LPN C was also observed to be missing 4 other medications that were due to be given at 10:00 AM, [MEDICATION NAME] 5 mg one tablet daily, [MEDICATION NAME] 25 mg one tablet 2 times daily, [MEDICATION NAME] 100 mg one tablet daily, and [MEDICATION NAME] 0.2% eye drops 1 one drop to each eye daily. She stated that these medications were not on the cart and would have to be reordered. A review of the physician orders [REDACTED].#23. The order for [MEDICATION NAME] read 20 mg tablet x 2 to equal 40 mg daily but LPN C only administered 1 tablet of [MEDICATION NAME] 20 mg. Medication administration was reviewed with LPN C. She stated, I thought it said 20 mg only. Unfortunately I gave only half the dose ordered. The other four medications I could not give as ordered because they weren't on the cart and were not in our emergency drug kit (EDK). LPN C stated, I could not find the [MEDICATION NAME]. She added, which ever nurse is working the cart should have reordered medications when they were getting low. We reorder right on the computer screen. On 1/30/19 at 1:48 PM, LPN C confirmed that resident #23 had still not received [MEDICATION NAME] 5 mg one tablet, [MEDICATION NAME] 25 mg one tablet, [MEDICATION NAME] 100 mg one tablet, and [MEDICATION NAME] 0.2% eye drops 1 one drop to each eye as ordered by physician for the 10:00 AM medication pass. Review of resident's Medication Administration Record [REDACTED]. At 1:42 PM on 1/30/19, the Director of Nursing (DON) stated every nurse was responsible to reorder medications as they get low and was not made aware that we had run out of medications for any resident. All medications have to be reordered manually and are not reordered automatically. Review of facility policy, 6.0 General Dose Preparation and Medication Administration, dated, 5/01/10, read, . 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law .5.4 Administer medications within the timeframes specified by Facility policy

Based on observation, interview and record review, the facility failed to ensure clean linens were free from exposure to blood-borne pathogens in the laundry department and failed to use appropriate personal protective equipment (PPE), gloves, and did not disinfect a pulse oximeter used on a resident with a multi-drug resistant organism (MDRO) urinary infection, extended-spectrum B-lactamase producing Escherichia Coli (ESBL-EC), while receiving physical therapy in the therapy gym for 1 of 2 residents (#94) reviewed for urinary catheter or urinary tract infection [MEDICAL CONDITION] out of 41 sampled residents. Findings: 1. On 6/28/18 at 9:39 AM, an observation was conducted in the laundry department. The clean linen room door was propped open with a laundry cart. The soiled laundry room door, approximately 3 feet from the clean laundry room, was open. There were 3 uncovered, soiled linen barrels filled to the top with soiled linens. Directly adjacent to the soiled linen room door was the door to the employee break room. Several staff entered and exited the break room at that time. On 6/28/18 at 9:40 AM, Laundry Aide A stated that the clean and soiled room doors should not be open because of the mixing of clean and dirty linens. On 6/28/18 at 9:41 AM, the Director of Nursing (DON) confirmed that the doors to the clean and soiled rooms should not be left open. On 6/28/18 at 9:42 AM, the Housekeeping/Laundry Supervisor confirmed that the clean linen room door and the soiled linen room doors should always be kept closed to prevent cross contamination. On 6/28/18 at 2:18 PM, the Infection Control Preventionist stated that she does not conduct infection control rounds in the laundry department. She confirmed that having the clean and soiled laundry room doors open is an infection control issue and said, Both doors should be kept closed. Review of the facility Laundry Procedures read, A. Laundry Purpose: 1. The purpose of the Laundry Department is to provide an adequate supply of linen for the direct and indirect patient care and to operate an efficient and economically sound operation B. Laundry Standard 2. Sanitary linen will contribute to the comfort and well-being of the patient; it is essential to the sanitary condition of your center Laundry Factors 2. Clean linen and clothing must be stored in separate well-ventilated areas and should not be allowed to accumulate in the center. 3. Soiled linen and clothing are to be stored separately in suitable bags or containers Review of the Infection Control Guidelines read, The laundry and linens is the LARGEST single reservoir of bacteria in your center. Large stacks and bundles of bedding are teaming with millions of bacteria. Contamination Sources in Linen: Once soiled line has been deposited it can serve as a source of contamination to clean linen and center by: 1. air currents. 2. people who handle both soiled and clean linen 4. Careless handling Review of the facility Laundry and Bedding, Soiled Policy read, Policy Statement, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen 2. Per a physician's orders [REDACTED].#94 was placed on contact isolation precautions for a multi-drug resistant organism (MDRO) urinary tract infection [MEDICAL CONDITION]. Review of a urinary analysis with culture and sensitivity report, dated 6/07/18, revealed the organism to be ESBL-EC. She was currently receiving the antibiotic, [MEDICATION NAME] DS 800 milligrams (mg.)/160 mg. by mouth once a day for her UTI. On 6/25/18 at 12:45 PM, an isolation precaution sign was attached to her room's door and a PPE bin had been placed over the door. She resided in a single-occupancy room. The resident did not have an indwelling urinary catheter and required assistance for personal hygiene and toileting needs. She wore an adult incontinence brief. On 6/26/18 at 10:15 AM, resident #94 received physical therapy from physical therapist (PT) G in the therapy gym. PT G did not wear gloves as she touched the resident's hands, positioned her wheelchair into place, and held the resident's bare legs during assisted leg exercises. During therapy treatment, resident #94 received oxygen (O2) at 2 liters per minute via nasal cannula with a portable oxygen tank attached to the back of her wheelchair. Resident #94 became sleepy and closed her eyes during therapy. PT G walked over to an area in the gym counter tops and cabinets. She obtained a pulse oximeter hanging from the wall and then used the pulse oximeter to check the resident's oxygen saturation from a finger on the resident's left hand. The resident's oxygen saturation was 90%. PT G did not wash her hands or resident #94's hands prior to use of the oxygen saturation machine. After obtaining the O2 saturation level, PT G placed the pulse oximeter back into its place on the wall without cleaning or disinfecting it. PT G then assisted the resident back to her unit and informed her nurse of the resident's O2 saturation. At 10:30 AM, an interview was conducted with PT G and the director of nursing (DON). PT G stated that she knew the resident had a urinary tract infection and was on isolation precautions but did not know the name of the organism or that it was an MDRO. She validated that she had not worn gloves during therapy treatment and had not disinfected the pulse oximeter. PT G stated that she did not know if the resident's hands had been washed prior to coming into the therapy gym, and validated that she had not washed the resident's hands during therapy. The DON stated that while the resident's urine was contained in her adult brief, facility expectations to prevent the potential spread of resident #94's MDRO infection would be the following: The therapist would have ensured that the resident's hands were washed prior to coming into the gym for therapy. The therapist would have worn gloves during the resident's treatment. The therapist would have cleaned and disinfected the pulse oximeter machine with the approved facility disinfection wipes after use with the resident. Review of the facility's [MEDICAL CONDITION] policy and procedure included the following: Personal hygiene of the resident (e.g. handwashing, keeping hands away from infected/colonized areas the nursing staff and/infection preventionist will ensure that staff are aware of a resident with a MDRO infection so that appropriate transmission-based precautions can be utilized for residents with colonization or infection with MDRO's, non-critical resident-care items will be dedicated for individual use or decontaminated prior to use with another resident.

Based on observation, record review and interview, the facility failed to implement care plan approaches relating to Activities of Daily Living (ADLs) and Nutrition, to ensure the highest practicable physical, mental, and psychological well-being for 1 of 41 sampled residents (#90). Findings: Resident #90 is of advanced age with [DIAGNOSES REDACTED]. On 6/25/18 at 12:47 PM, the resident was in bed with his lunch tray in front of him, that was on the over-the-bed table. The head of the bed was elevated past 40 degrees. The resident's meal tray was set up but the resident had not eaten much. At that time, the resident had eaten less than 20% of the meal. There was no staff in the room cueing or assisting the resident with the lunch meal. On 6/26/18 at 12:02 PM, the resident was again observed in bed. There was a glass of orange juice on the over the bed table. The resident was asleep and half of the juice remained in the glass. Review of the Annual Minimum Data Set (MDS), dated [DATE], noted that the resident scored a 5 on the Brief Interview for Mental Status (BIMS). A BIMS score of 0 to 7 indicates severely impaired cognition. The MDS also noted that the resident was a 3/2 for eating. This means the resident requires extensive assistance by one staff person for eating. Review of the quarterly MDS, dated [DATE], noted that the resident's cognition was still severely impaired but his eating skills improved to a 1/1. This means the resident is able to feed himself and only needs staff supervision/cueing and meal set up help. Review of the ADL Care Plan, dated 3/09/18 and last reviewed on 6/13/18, instructs staff to set up food tray and encourage the resident to consume meal and feed self. The staff is also to assist as needed. The Nutrition Care Plan, dated 3/09/11 and last reviewed on 6/13/18, notes to set up the meal tray daily and assist to feed if the resident allows. Review of the most recent Quarterly MDS dated [DATE] noted that the resident's cognition remained at a 5 but the resident's eating skills regressed back to a 3/2, requiring extensive assistance from staff during meals. On 6/27/18 at 12:09 PM, the meal tray cart was observed in the 300 hallway and the Certified Nursing Assistants (CNAs) were passing out the meal trays to the residents. At 12:10 PM, CNA Z delivered a meal tray to resident #90's room. The CNA set up the meal tray, elevated the head of the resident's bed, then left the room and continued to pass out meal trays. At 12:28 PM, the resident was still in his room with the meal tray in front of him. Less then 5% of the meal had been eaten but the resident's eyes were closed as if were asleep. At that time, the staff on the 300 hallway had not engaged with resident #90 since his meal tray was delivered. At 12:31 PM, the resident's eyes were open and the meal tray remained untouched. The resident did not respond when asked if he liked his lunch. On 6/27/18 at 12:39 PM, an accounting of the staff on the 300 hallway was noted. There were 2 nurse at a medication cart having a conversation. CNA Y was in a room feeding resident #55. CNA X answered a call light for room [ROOM NUMBER] A bed, than a few minutes later began feeding the resident in the B bed. As other residents were receiving staff assistance with dining, no one entered resident #90's room to help him with his meal. At 12:50 PM, CNA C came to the 300 hallway and was begriming to pass out meal trays. CNA C stated she works on the 100 hallway and that she came to the 300 hallway to help. CNA C removed a meal tray from the cart and delivered it to room [ROOM NUMBER]. Approximately thirty seconds later, CNA C came out of room [ROOM NUMBER] and asked the staff in the hallway at the time, who was going to feed the resident in 309 A, resident #90. The staff did not discuss who among them was going to assist resident #90. The staff went to their respective rooms to assist other residents while resident #90 remained in his room and did not receive any supervision, cueing or assistance which are the approaches on his ADL and Nutritional Care plans.

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) for shaving (#98) and nail care (#361) for 2 of 3 residents reviewed for Activities of Daily Living out of 41 sampled residents. Findings: 1. Review of resident #98's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He has moderate impairment of his cognitive status and requires extensive assistance with personal hygiene. Review of the quarterly Minimum Data Set (MDS), dated [DATE], documented resident #98 requires extensive assistance of one person with personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands, excluding baths and showers. Review of resident #98 care plan for assistance needed with ADLs related to impaired mobility, impaired memory and cognitive skills reflected approaches to assist with bathing, dressing and grooming. On 6/26/18 at 10:13 AM, 6/26/18 at 12:25 PM , 6/26/18 at 5:07 PM, and 6/27/18 at 9:29 AM, observations of resident #98 revealed he was unshaven with long facial hair on his face, chin, and neck. On 6/25/18 at 4:30 PM, 6/26/18 at 5:07 PM, 6/27/18 at 9:29 AM , and 6/27/18 at 11:48 AM, interviews conducted with resident #98 revealed that he wanted to be shaved,and had spoken to the Certified Nursing Assistant (CNA) about being shaved. Resident #98 stated that the CNA told him that she would shave him but never did. On 6/28/18 at 8:31 AM, Licensed Practical Nurse (LPN) B confirmed that shaving is part of daily resident care and can be completed on any shift. On 6/27/18 at 1:45 PM, CNA B confirmed that resident #98's facial hair was long, and he needed to be shaved. On 6/27/18 at 1:47 PM, CNA C stated that shaving both men and women is part of daily resident care and can be completed on any shift. Review of resident #98's ADL 31 Day Look-Back documentation for personal hygiene revealed Self-Performance (what the resident actually did for himself and how much verbal or physical help was required by the staff) of limited assistance to extensive assistance. Review of the facility Shaving the Resident read, Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care. Preparation 1. Review the resident's care plan to assess for any special needs of the resident Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual(s) who performed the procedure . 5. If the resident refused the treatment, the reason(s) why and the intervention taken 2. On 6/26/18 at 11:49 AM, resident #361 was observed in bed in his room. The resident was very polite, with confusion and able to voice simple care needs. The resident's finger nails were long with some jagged edges. The resident agreed that his finger nails needed trimming and he could not recall the last time he received nail care. Review of the resident's Annual MDS dated [DATE] noted that the resident scored an 11 on the Brief Interview for Mental Status (BIMS). This means the resident's cognition is moderately impaired. The resident was noted to be a 1/1 for personal hygiene which means the resident able to perform this task with the supervision and set up help from staff. Review of the most recent Quarterly MDS dated [DATE] noted that the resident's BIMS was a 7, which mean his cognition is severely impaired. On 6/08/18, the resident transferred to the hospital and returned to the facility on [DATE]. On 6/27/18 at 11:49 AM, the MDS Coordinator stated the resident's MDS was due but the ADL section had not been completed. The MDS Coordinator provided ADL Flow Charts and the Dart Chart. The Coordinator stated the Dart Chart compiles the information on the ADL Flow Sheets, which helps with the MDS coding. Review of the ADL Flow Sheets and the Dart Chart noted that the resident would be coded as a 3/2 for personal hygiene. This means the resident requires extensive assist from staff for hygiene. On 6/28/18 at 4:31 PM, the resident was in his room and his finger nails had not been trimmed. The resident stated that he wanted his nails trimmed but did not know when the staff would trim them. Approximately 1-2 minutes later, his 3-11 shift direct care CNA U confirmed that the resident's nails needed to be trimmed but no one had informed her that the resident needed nail care.

Based on observation, interview and record review, the facility failed to obtain a physician's order for use of oxygen for 1 of 2 resident reviewed (#67). Findings: Resident #67 was admitted [DATE] with a [DIAGNOSES REDACTED]. On 6/26/18 at 10:21 AM, resident received continuous oxygen via nasal cannula at 2 liters per minute via an oxygen concentrator. At 12:37 PM, the resident's husband stated the resident had been on oxygen since the last month, (MONTH) (YEAR). At 5:01 PM, the resident was in bed with continuous oxygen. On 6/27/18 at 11:11 AM, the resident sat up in a wheelchair, and did not have oxygen in use. At 11:26 AM, nurse E stated that resident #67 always has her oxygen on. On 06/28/18 at 10:47 AM, nurse F stated, The nurse never got an order for [REDACTED]. Review progress note, dated 5/14/18, confirmed nurse F's statement. The resident's current physician orders dod not reveal an order for [REDACTED].>Review of facility's policy on oxygen administration under the heading of Preparation read, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or the facility protocol for the oxygen administration

Based on observation, interview and record review, the facility failed to ensure medication administration error rate of 7.41% for 2 of 27 medication opportunities, affecting 1 of 2 residents (#61). Findings: Medication administration was observed on 6/26/18 at 10:01 AM and on 6/27/18 at 11:38 AM with two nurses. There were a total of 27 medication opportunities. [MEDICATION NAME] 0.2% eye drops, 1 drop to both eyes and Calcium 500 milligrams (mg.) plus (+) D3 200 international units (iu) 1 tablet were given to resident #61. Current physician's orders [REDACTED]. Current physician's orders [REDACTED]. Current physician's orders [REDACTED]. + Vitamin D3 400 iu, one tablet 2 times a day. On 6/27/18 at 12:38 PM, the medication errors were reviewed with nurse E and she confirmed that 2 medication errors had occurred during her medication pass.

Based on observation, interview, and record review the facility failed to identify, document, and report a bruised area, for 1of 1 resident reviewed for non-pressure related skin condition (#82). Findings: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Medications included: ASA 81 milligram (mg) daily and [MEDICATION NAME] 10 mg daily. The minimum data set 14-day assessment dated [DATE] showed resident #82's brief interview for mental status (BIMS) score was 04/15 indicating that resident # 82's cognition was severely impaired. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and eating. The section for skin condition indicated the resident did not have any skin issues. On 01/08/18 at 1:33 PM resident #82 had 2 areas of reddish bruises/discoloration approximately 1.5 centimeters (cm) x 0.5 cm each to the top of her right hand. The resident did not give any response when she was addressed. On 01/10/18 at 10:14 AM the bruises/discolorations were observed and there was no change in character or size. On 01/11/18 at 02:28 PM an observation of resident # 82's skin was conducted with the resident's primary nurse, registered nurse (RN) G. The RN verified two bruises/discoloration to the top of the resident's right hand, and said she became aware of the bruises on Tuesday 1/09/17. RN G said she did not document the bruises. She reported that the facility's process for identifying bruises included: notifying the charge nurse, family, and medical doctor (MD), completion of an incident report, progress note, and documentation of the incident on the 24 hour report. RN G verbalized that this process was not followed. Review of the progress notes for resident #82 for the period 1/05/18 to 1/11/18 and review of the weekly skin assessment completed on 1/05/18, revealed no documentation regarding bruises to the resident's right hand. The care plan dated 10/18/17 for At risk for skin break down related to impaired mobility, use of ASA, and [MEDICATION NAME], listed the following approach, observe and inform MD of .increase bruising of skin. The Weekly skin assessment for resident #82 completed on 1/05/18 showed the resident's skin was intact. There was no documentation regarding any bruise/discoloration. On 01/11/18 at 02:45 PM the North Wing unit manager (UM) said resident # 82 had labs drawn on 1/02/18, and 1/07/18, however she could not say if the bruises were caused from the lab. The UM verified bruises to the top of the resident's right hand near the wrist area. She said the protocol was for any bruise/injury to document and complete an incident report. The UM verified that there was no documentation identifying the bruises to resident #82's right hand. Review of the facility's incident log showed no entry for resident #82. The policy and procedure Risk Management and quality Assurance revised 05/10/2017 read, Staff members are required to report incidents immediately and during the shift in which said incident occurred An incident report is completed for each incident during the shift in which the incident occurred .

Based on observation, interview and record review, the facility failed to adhere to proper infection control practices related to application of personal protective equipment (PPE) for contact isolation precautions (#58 & #61), failed to perform handwashing to prevent cross-contamination (#12), failed to prevent exposure to communicable disease (#38 & #62), and failed to discontinue transmission-based precautions in a timely manner (#58 & #61) for 5 of 30 sampled residents. Findings: 1. On 1/11/18 at 9:04 AM, persistent, loud coughing and repeated sniffling were heard in resident #38's room. From the doorway of the room, resident #38 was observed in bed with her breakfast on the overbed table. Certified nursing assistant (CNA) A stood at resident #38's bedside, coughing and sniffling as she cut the food into pieces. Each time she coughed, CNA A turned her head slightly to the left and coughed over her shoulder, towards resident #62 who lay in the adjacent bed. CNA A held resident #38's utensils and sniffled continuously during the meal set-up process. She then handed the utensils to resident #38, went into the bathroom and was again heard coughing loudly. CNA A had red, watery eyes and admitted she was coughing and sniffling. She explained she had a cold, but did not call off because she had no sick leave. CNA A verified she did not have environmental allergies and said, I'm sick. It's a cold. She explained the nurse, licensed practical nurse (LPN) B, noticed she was sick at the start of the shift and recommended she take echinacea. CNA A confirmed she told LPN B she had a cold. On 1/11/18 at 9:09 AM, LPN B stated she noted CNA A had a raspy voice, and said, I asked if she was sick. She told me she was sick, and had a cold for a few days. LPN B explained the facility's policy directed staff to call off if they were sick because most residents in the facility were elderly and had compromised immunity. LPN B confirmed she did not instruct CNA A to go home. On 1/11/18 at 9:15 AM, the director of nursing (DON) was informed CNA A was assisting with a resident's meal while showing cold symptoms, including coughing, sniffling and red, watery eyes. In an observation conducted with the DON from the doorway of the same room, CNA A was seated beside resident #38's roommate, resident #62, feeding her breakfast. CNA A continued to sniffle, and the DON asked her to leave the bedside. CNA A went to the bathroom to wash her hands and had another coughing episode that was heard and acknowledged by the DON. On 1/11/18 at 9:18 AM, an interview was conducted with CNA A and the DON. CNA A validated she knew the facility's policy required her to call off if she had a cold. When asked if she knew why she should have called off, CNA A stated she understood she could spread her illness to residents. CNA A said, It could be death for elderly residents. Resident #38 was [AGE] years old, and had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a lung condition that makes it hard to breathe. Catching a cold worsens a patient's ability to breathe, and the [MEDICAL CONDITION] increases the chance of getting a more serious respiratory tract infection. (www.webmd.com). Resident #38 had physician's orders [REDACTED]. In addition, resident #38 received Breo Ellipta 100 micrograms (mcg)-25 mcg/dose powder for inhalation, once daily for [MEDICAL CONDITION]. She had a care plan for Risk for ineffective breathing . due to a history of [MEDICAL CONDITION], with approaches including observe for shortness of breath and respiratory distress. The care plan for activities of daily living (ADLs) revealed resident #38 required assistance with set up of meals. Resident #62 was [AGE] years old, and had a [DIAGNOSES REDACTED]. Studies show patients who are elderly are at a higher risk for complications from upper respiratory infections, and efforts should be made to prevent these infections to limit morbidity. (www.clevelandclinicmeded.com). Review of the policy for Employee Infection and Vaccination Status revised August 2013, revealed employees were required to report acute upper respiratory infections, for decisions on restrictions regarding direct resident contact. Review of the Job Description - LPN (undated) revealed The LPN is considered to be a supervisor and is required to exercise supervisory authority over all non-licensed nurses. The job description indicated the LPN was expected to supervise and evaluate non-licensed nursing staff to ensure facility policies and accepted patient care practices were followed. 2. Resident #58 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the clinical record revealed resident #58 had a care plan for VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) in urine. The approaches directed staff to set up contact isolation, provide personal protective equipment (PPE) for staff and family, and Encourage meticulous handwashing and educate . on importance of compliance. VRE are antimicrobial-resistant bacteria that are resistant to [MEDICATION NAME], the drug often used to treat infections caused by [MEDICATION NAME], bacteria normally present in the human intestines, that can sometimes cause infections. (www.cdc.gov) Resident #58 had a urinalysis (UA) on 12/04/17, and received physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The follow up urinalysis was not ordered until 1/09/18, 25 days after completion of the antibiotic. The facility maintained contact isolation precautions for resident #58 from 12/08/17 until 1/11/18 when the result of the re-evaluation for infection was received. On 1/11/18 at 1:42 PM, the DON explained following a course of antibiotics, the physician would order labs to re-culture a specimen for verification treatment was effective against an organism. She stated isolation status was updated as appropriate based on the result. The DON validated resident #58 remained on contact isolation and had not been re-evaluated, even though she completed the antibiotic. The DON explained either a floor nurse or the infection control nurse was responsible for obtaining an order to do a re-culture after antibiotic therapy, if not already written by the physician. She acknowledged the infection control nurse should follow up to ensure re-cultures were done in a timely manner. A urine culture and sensitivity (C+S) is a test to find and identify germs that may cause a UTI and select the appropriate antibiotic. (www.webmd.com). On 1/11/18 at 2:15 PM, CNA I said, (Resident #58) has been on isolation for a while, something in her urine. On 1/11/18 at 2:18 PM, LPN D stated any nurse assigned to resident #58 was responsible for arranging any follow up labs. LPN D stated she left a note in the physician's communication binder regarding an order for [REDACTED]. I kept telling the night nurse and it stayed in the book. Review of the communication binder from 11/30/17 to 1/11/18 revealed an entry regarding resident #58 dated 1/05/18, that read, May we do a UA C+S to clear resident from VRE, is no longer on (antibiotic), still on isolation. On 1/11/18 at 5:16 PM, LPN E, the Infection Control nurse, acknowledged resident #58 should have been re-cultured after completion of her antibiotic order and contact isolation removed if appropriate. LPN E stated resident #58's contact isolation could have been discontinued a long time ago. She admitted , I really don't keep up with the antibiotics like I should. It just got carried way too long. She explained she was not required to, and did not attend daily clinical meetings. She explained she recorded data on current infections and labs in a logbook, and said, The weak area is in the follow up. LPN E stated if the physician did not request follow up labs after completion of an antibiotic, it was up to the nurses on the unit to follow up with the physician. LPN E, the Infection Control nurse, was unable to say who was ultimately responsible for monitoring lab results, re-cultures and implementing or discontinuing isolation precautions. On 1/11/18 at 5:24 PM, the DON acknowledged she was responsible for oversight of the facility's infection control program and all nursing activities in the facility. She explained although LPN E was the Infection Control nurse, there was no specific job description related to this role that listed requirements, duties and responsibilities. Review of the Job Description - Director of Nurses revealed she had .responsibility, and accountability for the functions, activities, and training of the nursing services' staff. 3. On 1/11/18 at 9:52 AM, in an observation conducted with licensed practical nurse (LPN) D, CNA C responded to a call light in a room that had a caddy containing PPE including gloves, gowns, masks and biohazard bags hanging over the door. CNA C walked through the doorway and approached resident #58's bed without donning any PPE. CNA C leaned across the bed, checked placement of resident #58's nasal cannula and adjusted the position of the bed. CNA C then turned towards resident #12 in the adjacent bed. Without washing her hands or donning PPE, CNA C pulled the privacy curtain back slightly. She proceeded to lean over resident #12's bed, then walked around the bed to adjust her position and lower the bed. Resident #12 was [AGE] years old. She received hospice services and had a terminal [DIAGNOSES REDACTED].#12 had a care plan for ADLs indicating she desires to stay in bed. The approaches included assist with bathing, dressing and grooming and positioning. On exiting the room, CNA C validated resident #58 was on contact precautions. She acknowledged she should have applied PPE, specifically gown and gloves, on entering the room. When asked about attending to resident #12 after resident #58, she said I should have worn gloves. CNA C confirmed she should have washed her hands between interactions with residents #58 and #12. On 1/11/18 at 9:57 AM, LPN D validated CNA C entered the room without applying PPE as ordered, and cared for both residents without performing hand hygiene in between. She said, I can't explain what happened. She should have worn gown and gloves. LPN D stated resident #58 was on contact precautions for VRE in her urine, had bladder incontinence and wore a brief. On 1/11/18 at 2:15 PM, CNA G confirmed she used PPE every time she entered the room. She explained CNAs were told to gown up once they entered resident #58's room. The care plan for activities of daily living revealed resident #58 needed assistance with positioning, transfers, toileting and incontinent care, and used oxygen at 2 liters/minute continuously. Review of the facility's policy for Standard Precautions revised in December 2007 revealed standard precautions should be used in the care of all residents. The practices included hand hygiene, and the use of gloves when in contact with resident-care equipment that is potentially contaminated or resident who is infected with an organism transmissible by contact. According to the Centers for Disease Control and Prevention (CDC), Contact Precautions require the use of gloves and gown .for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. (www.cdc.gov). 4. Resident #61 was admitted to the facility originally on 4/22/15, her most recent readmission was on 12/07/16. Her [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] (MRSA). The physician's orders [REDACTED]. ESBL is a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections Bacteria use ESBLs to become resistant to antibiotics (www.healthline.com) On 1/08/18 Signage on resident #61's door read, Please report to nurses station before entering room. An over door container with the necessary PPE (personal protective equipment) was in place. On 01/08/18 at 09:27 AM CNA F was assisting resident #61 in the bathroom. The CNA had on a pair of gloves, but no gown. At that time LPN J the resident's primary nurse, verified that CNA F was assisting the resident in the bathroom, wearing gloves, and no gown. LPN J said resident #61 was on contact isolation for ESBL in the urine, and the CNA should wear a gown and gloves when assisting the resident in the bathroom. On 01/08/18 at 09:29 AM, CNA F assisted the resident from the bathroom, guiding the resident from behind, hands on either side of resident, wearing gloves, no gown. The CNA assisted the resident to sit on the side of her bed, positioned on her back, placed the resident's legs on pillows, and positioned her tray table within reach. LPN J verified CNA F did not have on a gown, she said PPE should have been worn, since there was the potential for being in contact with the resident's care items, and linen. In an interview conducted on 1/08/18 at 09:33 AM CNA F said she did not know what type of isolation the resident was on. She verified that she had on gloves, no gown, and was assisting resident # 61 in the bathroom. On 01/08/18 at 02:58 PM, CNA K was assisting resident #61 from her recliner to her wheelchair. The CNA did not have PPE on. CNA K said the resident was on contact isolation for something in her urine and the procedure was to wear gown and gloves. CNA K said she did not put PPE on because she was transferring the resident. CNA K verified that there was the potential to be in contact with care items, linen, and the resident clothing, and she should have worn the proper PPE. On 01/09/18 at 09:24 AM the director of nursing (DON) said, usually staff did not have to use a gown, if they were just helping the resident from the rest room. The facility's policies and procedures, Isolation- Categories of Transmission- Based Precautions revised January 2012 was reviewed with the DON. It read, May wear a disposable gown upon entering the contact precaution room . if you anticipate contact with bodily fluids, linen, and or surfaces. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) last update October 2017, contact precautions read, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. On 01/09/18 at 09:39 AM resident #61 said she had some infection in her urine and facility was to do some more test. Resident # 61 said staff do not always wear gown and gloves when giving her care. In an interview conducted with the infection control nurse on 01/10/18 at 10:45 AM, she said if rendering care to residents on contact isolation, staff should wear proper PPE. 5. The physician's orders [REDACTED]. ESBL is a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections Bacteria use ESBLs to become resistant to antibiotics (www.healthline.com) Urine culture completed on 9/27/17 showed ESBL. Progress Notes dated 12/10/17 read, MD notified of abnormal UA C&S(urinalysis, culture and sensitivity) results. New order received for [MEDICATION NAME] 100mg bid x 10 days; contact isolation initiated for ESBL. [MEDICATION NAME] is an antibacterial. Care Plan created on 10/02/17 for ESBL in urine goal was, to resolve infection with tx(treatment) without adverse reactions. Approaches included, set up contact isolation and inform resident of purpose, provide PPE (Personal protective equipment) for all staff and family to use . encourage meticulous hand washing and educate resident, family and staff on importance of compliance. On 01/11/18 at 01:43 PM DON verified that resident #61 had been on contact isolation precautions since 12/10/17. The DON said the MD has to give order for re-culture, and she was not sure if resident #61 had a re-culture. The DON said nurses shared responsibility to follow-up regarding re- culture, and the infection control nurse should be following up to make sure cultures are done. On 01/11/18 at 05:16 PM the infection control nurse said, the facility's process was that the charge nurses notify the MD of lab results, and receive orders for antibiotic. After the period of the antibiotic therapy is over, usually a re-culture would be done. The infection control nurse said I really don't keep up with the abt (antibiotics) like I should. She said the weak area is in the follow up, and contact isolation for resident # 61 could have been discontinued. Review of the physician order [REDACTED]. Resident # 61 has been on contact isolation precautions since 12/10/17, she completed a ten day dose of [MEDICATION NAME] ordered on [DATE], but cultures were not ordered/repeated to ascertain that the contact isolation precautions were still required until 1/10/18.

Based on record review and interview, the facility failed to honor a resident's advance directives to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 15 sampled residents(#1) reviewed for advanced directives. Resident #1 had advance directives that did not include withholding of cardiopulmonary resuscitation (CPR) at admission. On [DATE] at 4:55 AM, the resident was found in bed unresponsive with absence of vital signs. The facility failed to verify the resident did not have an order for [REDACTED]. The failure to provide CPR per the resident's advance directives, physician orders, and per facility policy denied the resident's wishes for the chance for resuscitation. This resulted in substandard quality of care and immediate jeopardy starting on [DATE] and was determined to be ongoing at the exit date of [DATE]. Findings: Resident #1 was a [AGE] year-old female admitted to the facility from the hospital on [DATE] for short-term rehabilitation following a left below knee amputation. She had a history of [REDACTED]. The facility policy for Advance Directives for Clinical Social work Services revised [DATE], included a procedure for (Residents) who have advance directives: III. Advance directives belong to the (resident) and accompany the (resident) in whatever treatment setting he/she chooses. Upon transfer to another health care setting, a copy of any advance directive currently valid will be attached to the transfer form. The receiving provider will be responsible for whether the (resident) continues to wish the advance directive honored. The social services director (SSD) stated on [DATE] at 1:45 PM that resident #1 was alert and oriented to time, place, and person, and advance directives were discussed at admission on [DATE]. The SSD said that resident #1 stated she was a full code. Code status refers to the desire for resuscitative efforts should the need arise. Unless the patient specifically requests not to be resuscitated, i.e. DNR (do not resuscitate), CPR is performed. (www.medical-dictionary.com) The social services director said she reviewed advance directives with the resident on [DATE] and resident #1 did not make any changes to her advance directives. A physician's orders [REDACTED]. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (3008) dated [DATE] for Advance Care Planning read no DNR. A review of the interim care plan dated [DATE] noted that the resident was alert, oriented, and responsible for self and was a full code. The facility's policy, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2016 read, If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in cardiopulmonary resuscitation (CPR) shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order exists. Another policy was provided by the Administrator for Resuscitating a Patient with a Full code Status. This policy did not have a date. It read: .begin CPR when a patient has no DNR order and when circumstances necessitate the initiation of life saving measures. In addition to beginning CPR, 911 will be called. CPR will continue until relieved by Emergency Medical Staff. A nursing progress note dated [DATE] at 5:37 AM entered by licensed practical nurse (LPN) A read, CNA (certified nursing assistant) making her rounds. Went to check on resident to get her cleaned. Called to resident's room at 455a. Noted resident cool to touch with no pulse, respiration, or B/P. Had other nurse come in to check her and verify that there was no pulse, respiration or B/P. The nursing progress notes did not include any documentation regarding resident #1's DNR/code status, initiation of CPR, or any calls to 911. A nursing progress note on [DATE] at 7:36 AM by LPN A, 2 hours and 41 minutes after the resident was found without vital signs, read that doctor and family were notified that the resident had deceased . A telephone interview with LPN A on [DATE] at 4:49 PM revealed that she was the primary nurse for resident #1. She stated that on [DATE] at 4:55 AM, CNA C informed her that resident #1 had passed. She stated that she went to the resident's room and found the resident in bed with no pulse, no blood pressure and no respirations. She stated that she called RN B and she verified the findings. LPN A stated that her only thought at the time was that she had to call the family and tell them the resident was dead. She stated that the resident was not a DNR, but she said she was not thinking and did not initiate CPR. She stated that RN B did not suggest or initiate CPR. LPN A said she was familiar with the facility's CPR policy to initiate CPR for resident #1, but stated she did not know why she did not follow the procedure that night. A telephone interview with RN B on [DATE] at 4:56 PM, she stated LPN A asked her to come with her to resident #1's room because resident #1 had passed away. RN stated that she checked the resident's pulse and respirations and noted that the resident was cool to the touch. She stated that they did not start CPR or initiate any lifesaving measures. She stated she thought resident #1 was on hospice and she did not ask about the resident's code status. An interview with the director of nursing (DON) on [DATE] at 2:03 PM, confirmed that LPN A and RN B did not initiate CPR or call 911 as per facility policy. She said that code status is determined by looking in front of the medical record. If there is a yellow DNR form in front of the medical record, do not initiate CPR. If there is no yellow form in front of the medical record, initiate CPR. She stated that when she spoke to LPN A and RN B, they believed that the resident was cold and too far gone and that CPR would not have helped her. She stated that their inaction went against facility policy and procedure for Emergency Procedure-Cardiopulmonary Resuscitation. The DON said there was no break in the facility's system and it was a personal choice by the nurses not to initiate CPR. The facility procedure for CPR does not include the option to eliminate verification of code status. The policies for CPR do not include the option for nurses to decide whether or not to initiate CPR based on the temperature of the resident's skin or their assessment of how long the resident has gone without having vital signs.

Based on interview, record review, and facility policy and procedure review, the facility failed to protect residents from neglect. Neglect means, to disregard or ignore; to fail to perform a duty or to give due attention or care. (www.medical-dictionary.com).The facility failed to initiate cardiopulmonary resuscitation (CPR) and call 911 for 1 of 15 residents reviewed for Advance Directives after the resident was found unresponsive in her bed (resident #1). The facility failed to provide emergency treatment and services for resident #1. The resident had resuscitation orders, but CPR was not initiated when she was found unresponsive in her bed without pulse, respirations, and blood pressure (B/P). The facilty staff did not call 911 emergency response. Two nurses, licensed practical nurse (LPN) A and registered nurse (RN) B, both certified in CPR, did not initiate basic life support or any emergency care, and the resident died . Cross Reference F155, F281, F520 The failure to prevent neglect resulted in substandard quality of care and immediate jeopardy starting on [DATE] and was determined to be ongoing at exit date [DATE]. Findings: Review of the medical record revealed resident #1 was a [AGE] year old female admitted to the facility on [DATE] for short-term rehabilitation. Her [DIAGNOSES REDACTED]. The admission data dated [DATE] showed that resident #1 was a full code. Full code status refers to the desire for resuscitative efforts should the need arise. Unless the patient/residents specifically requests not to be resuscitated, i.e. DNR (Do not resuscitate), CPR is performed. (www.medical-dictionary.com). On [DATE] at 5:37 AM, licensed practical nurse (LPN) A wrote, CNA (certified nursing assistant) making her rounds. Went to check on resident to get her cleaned. Called to resident's room at 455a. Noted resident cool to touch with no pulse, respiration or B/P. Had other nurse come in to check her and verify that there was no pulse, respiration or B/P. There was no documentation regarding resident # 1's DNR/code status, initiation of CPR, or that emergency medical services (911) was called. The facility's policy and procedure Emergency Procedure-Cardiopulmonary Resuscitation, revised on [DATE], read, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless . It is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or . There are obvious signs of irreversible death (e.g., rigor mortis). Another facility's policy Resuscitating a patient with full code status states that in addition to beginning CPR, 911 will be called. Resident #1 did not have a DNR order and did not have any signs of rigor mortis. Her status was documented in the physician's orders [REDACTED]. The written statement by LPN A dated [DATE] showed she was called to resident #1's room by certified nursing assistant (CNA) C at 4:55 AM, and noted the resident was in bed with no B/P, pulse, and respirations. LPN A called registered nurse (RN) B, who also noted resident had no B/P, pulse and respirations. LPN A instructed CNA C to clean resident up. The statement showed the DNR/code status of resident #1 was never checked and there was no mention of initiating CPR and calling 911. The written statement by RN B dated [DATE] showed that about 5 AM she was called to resident # 1's room by LPN A. LPN A stated that the resident had passed away. RN B wrote that after she had verified that the resident had passed away and was going cold, LPN A told her the resident was a full code, meaning CPR was to be initiated. RN B's written statement read, We did not start CPR or call 911. In a telephone interview conducted with RN B on [DATE] at 4:56 PM, she said after 5 AM on [DATE] LPN A came, and said, I need you to come with me. She walked back with LPN A, who told her resident #1 had passed away. RN B said she checked the resident for pulse and respiration. When she placed her hand on the resident's chest, it was cold. RN B said they did not do anything, did not start CPR, and said the resident was blue/gray in color. RN B said she had in the back of her mind that resident #1 was a hospice resident, so she would be DNR. RN B said she did not ask about the resident's DNR/code status. Review of the record revealed RN B was incorrect regarding hospice. Resident #1 was not receiving hospice services. On [DATE] at 4:49 PM, a telephone interview was conducted with LPN A. She said she was the primary nurse for resident #1, and worked the 11PM -7AM shift from ,[DATE]-[DATE], the night the resident did not receive any CPR. LPN A said around 4:55 AM on [DATE], CNA C came and told her that resident # 1 had passed away. LPN A said she checked the resident. The resident had no pulse, no B/P, and no respirations. She said she called RN B who verified the findings. LPN A said her only thought at the time was that she had to call family, and tell them the resident was dead. She told CNA C to clean up the resident. LPN A said resident #1 was not a DNR. She said she was not thinking, and did not initiate CPR. RN B did not initiate CPR. When asked the facility's protocol for CPR, LPN A said, the nurse is to determine code status of resident. If resident is a full code, start CPR, and call 911. LPN A said looking back, she should have started CPR. She said, we check code status all the time and she said she does not know why she did not do CPR that night. A telephone interview was conducted with CNA C on [DATE] at 11:17 AM. CNA C said on [DATE] around 4:55 AM she went to check on resident # 1 and her roommate. She knocked on the door, there was no response, she turned the light on, called the resident, and there was no response. CNA C said she ran from the room, called LPN A, and told her the resident was unresponsive. LPN A came to the room and checked the resident, got the RN supervisor (RN B), both nurses checked the resident, then LPN A told her (CNA C) to clean up the resident. CNA C said usually the nurse would initiate CPR, call a code, and call for the crash cart. She said none of that happened for resident #1. On [DATE] at 2:03 PM, the director of nursing (DON) said LPN A and RN B did not initiate CPR, for resident #1. When she spoke with both staff members, they said they believed the resident was too far gone, and was so cold that CPR would not help her. Both nurses were suspended, when the incident was reported to the risk manager (RM) and the assistant director of nursing (ADON) on [DATE] at approximately ,[DATE]:30 AM. The DON said there was no failure in the facility's system. She said it was a personal choice by the nurses not to initiate CPR. On [DATE] at 2:22 PM, the RM said that around 8:10 AM on [DATE], LPN A came to her office and said resident #1 had passed away. LPN A said CNA C had checked the resident around 3 AM before going on break, and the resident appeared to be sleeping. When CNA C went back at 4:55 AM, she came and got her, and said resident #1 did not look right. LPN A said she went to the resident's room, she had no pulse, respiration, or B/P. Staff A got staff B who verified the findings of no pulse, respiration, or B/P. LPN A said she told RN B the resident was a full code, but CPR was not initiated and 911 was not called, because, per RN B, the resident was cool-cold to touch. The RM said she notified the administrator at 8:25 AM, and the ADON at 8:30 AM. The ADON spoke with both nurses. Both were suspended after written statements were obtained. CNA C came in 11:27 AM and verified the timeline of the occurrence. At 3:05 PM, the abuse hotline was called, and the report was accepted as medical neglect. A telephone interview was conducted with the ADON on [DATE] at 11:47 AM, and on [DATE] at 11:00AM. She said when she reported to work on [DATE] at 8:30 AM, the RM stopped her and informed her that resident #1 was found unresponsive, CPR was not initiated, and 911 was not called. The ADON said she spoke with both nurses involved, and asked why the MD orders were not followed. LPN A said she froze and RN B said the resident was cold and she did not want to do anything unnecessary. The ADON said she started re-educating the nursing staff on duty that day. She said the education included, if a resident has a DNR, do nothing; if full code, do CPR. The education did not address neglect and or any revision of the facility's system to prevent neglect. It did not include how the decision to initiate CPR is not a personal choice. The facility's policy and procedure Abuse, Neglect, Exploitation, and Misappropriation of Property Prevention, Protection and Response, revised [DATE], defines neglect as, The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and /or supervise the delivery of patient care and services to assure that care is provided as needed by the patient.

Based on interview and record review, the facility failed to meet professional nursing standards of quality by failing to adequately assess residents for signs/symptoms of death, failing to determine the DNR/code status, failing to follow physician orders [REDACTED].# 1). Resident # 1 was found unresponsive in her bed without pulse, respirations and blood pressure on [DATE]. The licensed practical nurse (LPN) A and registered nurse (RN) B, both certified in CPR, failed to initiate CPR and call 911, and the resident died . Cross Reference F155, F223, F520. This failure resulted in substandard quality of care and immediate jeopardy starting on [DATE], and was determined to be ongoing at exit date [DATE]. Findings: According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) State Statute, Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgement, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured or infirmed; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) Nursing [DIAGNOSES REDACTED]. (f) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. Practical nursing is defined as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance of health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, or a licensed dentist. According to the 2015 American Heart Association Handbook of Emergency Cardiovascular Care for Healthcare Providers, The following sequence is intended for a single healthcare provider rescuer. If additional rescuers are available, the first rescuer feels for a pulse for no more than 10 seconds and starts chest compressions if pulse is not definitely palpated. A second rescuer activates the emergency response number and obtains an automated external defibrillator (AED), and a third rescuer opens the airway and provides ventilation. Recognition: The victim is not responsive and not breathing or only gasping (i.e. not breathing normally). Check for breathing and pulse. Activation: Activate the emergency response system and send someone to retrieve emergency equipment. Pulse Check: Check pulse for no more than 10 seconds (carotid in adult). If pulse is absent provide CPR until advanced life support providers arrive. If pulse is present, but breathing is absent, open the airway and provide rescue breathing. Recheck the pulse every two minutes. Continue CPR until advanced life support providers arrive or the victim starts to move. The facility's policy and procedure Emergency Procedure-Cardiopulmonary Resuscitation, revised on [DATE], read, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless . It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. Cardiopulmonary resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: a. instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. A review of the medical record revealed resident #1 was a [AGE] year old female admitted to the facility on [DATE] for short-term rehabilitation. Her [DIAGNOSES REDACTED]. A physician order [REDACTED]. Interim care plan dated [DATE] read full code. Code status refers to the desire for resuscitative efforts should the need arise. Unless the patient/residents specifically requests not to be resuscitated, i.e. DNR, CPR is performed. (www.medical-dictionary.com) As per the director of nursing (DON) in an interview on [DATE] at 2:03 PM, a resident's code status is determined by looking in front of the medical record. If there is a yellow DNR form in front of the medical record, CPR is not initiated. If a yellow form is not in front of the medical record, CPR is initiated. Licensed practical nurse (LPN) A progress note dated [DATE] at 5:37 AM read, CNA making her rounds. Went to check on resident Called to residents' room at 455a. Noted resident cool to touch with no pulse, respiration or B/p (blood pressure). Had other nurse come in to check her and verify that there was no pulse, respiration or B/p. There was no documentation regarding resident #1's DNR/code status and no documentation that emergency medical service (911) was called. Nursing progress notes on [DATE] at 7:36 AM read, Doctor and family notified that resident was deceased There was no documentation to identify which medical doctor (MD) or family member was called, the time they were notified of the resident's death or the circumstances surrounding her death. Documentation did not show that the nurse informed the MD that resident # 1 was a full code, and CPR was not initiated. The written statement by LPN A dated [DATE] showed she was called to resident # 1's room by certified nursing assistant (CNA) C at 4:55 AM. She noted the resident in bed with no B/P, no pulse and no respirations. LPN A called registered nurse (RN) B, who also noted resident had no B/P, no pulse and no respirations. LPN A instructed CNA C to clean resident up. Documentation did not show DNR/code status of resident #1, and there was no mention of CPR and 911 being called. The written statement by RN B dated [DATE] showed, that about 5 AM she was called to resident #1's room by LPN A. LPN A stated that the resident had passed away. RN B wrote that after she had verified that the resident had passed away and was going cold, LPN A told her the resident was a full code. LPN A wrote, We did not start CPR or call 911. On [DATE] at 4:49 PM, a telephone interview was conducted with LPN A. She said she was the primary nurse for resident # 1, and worked the 11PM -7AM shift on ,[DATE]-[DATE]. LPN A said around 4:55 AM on [DATE], CNA C told her that resident # 1 had passed. LPN A said she went in to the resident's room, and checked the resident. She had no pulse, no blood pressure (B/P), and no respirations. She called RN B and she verified the findings. LPN A said, her only thought at the time, was that she had to call family, and tell them the resident was dead. When asked if resident #1 was a DNR, LPN A said she was not a DNR, she added, that she was not thinking, and did not initiate CPR. RN B did not initiate CPR. When asked the facility's protocol for CPR, LPN A said they determine the code status of the resident. If resident is a full code, start CPR, and call 911. LPN A said looking back, she should have started CPR. She said, we check code status all the time and did not know why she did not do it that night. In a telephone interview conducted with RN B on [DATE] at 4:56 PM, she said after 5 AM on [DATE] LPN A said, I need you to come with me. She walked back with LPN A, who told her resident #1 had passed away. RN B said she checked the resident's pulse and respirations, when she placed her hand on the resident's chest, it was cold. RN B said they did not do anything, did not start CPR. She said the resident was blue/gray in color. RN B said she had in the back of her mind that resident # 1 was a hospice resident, making her a DNR. She said she did not ask about the resident's DNR/code status. When asked if that was normal procedure, she said no, she was stressed and behind with her work. On [DATE] at 12:03 PM via telephone RN B said she pronounced the resident dead, since she was the RN. She stated that the MD was usually not present physically to pronounce deaths in the nursing home. The police case supplemental report dated [DATE], revealed that on [DATE] at around 5 PM law enforcement visited the facility in reference to a deceased person. The report read, I was informed that a resident, (name) passed away sometime between 0300 (3:00 AM) and 0530 (5:30 AM) on [DATE]. No notifications were made to Law Enforcement or Fire Rescue. There was no attending physician to pronounce her deceased The facility's policy Pronouncement of death of a patient signed by the medical director, dated [DATE], and reviewed at QA on [DATE] read, I hereby designate a licensed nurse to pronounce a patient dead in the absence of a physician. The practice of a licensed nurse pronouncing death is not supported by Florida Nurse Practice Act. Interviews conducted with the administrator on [DATE] at 11:06 AM, and with the director of nursing (DON) on [DATE] 12:15 PM revealed that they did not know who pronounced the death of resident #1. When asked if nurses could pronounce deaths, they were unable to provide an answer. On [DATE] at 11:54 AM, the Medical director (MD) said that neither he, nor his associate, pronounced the resident dead. On [DATE] at 2:03 PM, the director of nursing (DON) said LPN A and RN B did not initiate CPR, and did not call 911 for resident #1 as per physician's orders [REDACTED]. The actions of LPN A and RN B resulted in both nurses being reported to the Florida Board of Nursing on [DATE]. The Florida Board of Nursing licenses, monitors, disciplines, educates and, when appropriate, rehabilitates its licensees to assure their fitness and competence in providing health care services for the people of Florida (http://floridasnursing.gov/) LPN A and RN B failed to respond appropriately when resident # 1 was found unresponsive in her bed, and failed to provide CPR in accordance with the resident's wishes and physician's orders [REDACTED].

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for advanced directives, neglect, and standards of nursing practice to ensure that cardiopulmonary resuscitation (CPR) was initiated for 1 of 15 residents with cessation of pulse and respirations in accordance with her choice for CPR and physician orders [REDACTED]. Resident #1 was a [AGE] year-old female who had advance directives for cardiopulmonary resuscitation at admission on [DATE]. On [DATE] at 4:55 AM, the resident was found in bed with absence of blood pressure, pulse, respirations and was cool to the touch. The licensed practical nurse and the registered nurse, both certified in cardiopulmonary resuscitation failed to initiate CPR and call 911. Cross reference: F223, F281, F155 The facility's QAA committee failed to identify quality deficiencies by not identifying the root cause of the incident and failed to evaluate and analyze the risk once the incident had occurred. The facility failed to provide adequate education and failed to recognize that the facility's policy for cardiopulmonary resuscitation was unclear. This failure, resulted in immediate jeopardy starting on [DATE], and it was determined to be ongoing at the exit date of [DATE]. Findings: The facility policy on Emergency Procedure-Cardiopulmonary Resuscitation, dated 2016 read, If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in cardiopulmonary resuscitation (CPR) shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order exists; If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. An interview with the administrator, director of nursing (DON), risk manager and nurse consultant on [DATE] at 3:00 PM revealed that they identified failure to initiate CPR and resident #1's death as a serious event and held an emergency QAA meeting on [DATE]. The medical director was not present at this meeting. A telephone interview with the medical director on [DATE] at 3:10 PM revealed that he was not present during the emergency QAA meeting, but was kept informed by telephone calls after the meeting. He stated that he had many other facilities to, take care of and could not be at all QAA meetings. He said that he could not understand, why you (survey team) were jeopardizing the facility and all the residents for one incident. The risk manager stated that they started a performance improvement plan (PIP) which included audits of all medical records and care plans for advance directives, addition of a checklist for advance directives to the admission packet and the admission/readmission nursing data collection, review of the CPR policy, and re-education for all nursing staff of the resuscitation policy which began on [DATE]. The administrator stated that the policy for CPR was reviewed at the QAA meeting, but no changes were made. They could not provide an answer about the policy that read, if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. Resident #1's code status was clear in her medical record and her care plan. She wished CPR to be initiated, but the nurses determined she did not need CPR without checking her code status. The DON stated that the directive given to nursing staff during education included an undated instruction page which read, Policy: Resuscitating A Patient With A Full Code Status-It is the policy of Solaris Healthcare Osceola to begin Cardio-Pulmonary Resuscitation (CPR) when a patient has no DNR order and when circumstances necessitate the initiation of life saving measures. In addition to beginning CPR, 911 will be called. CPR will continue until relieved by Emergency Medical Staff. The DON was not able to provide an answer to clarify, the meaning of, when circumstances necessitate. Although the failure of not initiating CPR was serious, the facility failed to recognize the root cause of the incident. The facility did not focus on the incident as a system failure, but rather the nurses' personal choice not to initiate CPR. In an interview with the DON on [DATE] at 2:03 PM, she confirmed their conclusion was that there was no break in the facility's system and it was a personal choice by the nurses not to initiate CPR. On [DATE] at 3:00 PM, the risk manager stated that all licensed nurses were CPR certified every 2 years and all residents had a doctor's order for either CPR or DNR that is documented in the medical record. She stated that the first nurse, LPN A froze as she only thought of calling the family to inform them of the death. The second nurse, RN B noted the resident's body was cool to touch and did not, want to do anything unnecessarily. The DON stated that both nurses were experienced, we can't make decisions for them. She was asked what education and training was provided to licensed nurses to ensure confidence with knowing what to do when finding an unresponsive resident without vital signs. She stated that they had not provided any education to nurses about CPR except for advance directives on electronic learning system. She was asked if mock codes were done at the facility as per the facility CPR policy, Provide periodic Mock Codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. She stated that they had not done any mock codes previously, but had started this morning on [DATE]. She was not able to provide an answer as to a CPR team as per their CPR policy, Select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The DON stated that all staff have been educated that if they find an unresponsive resident without vital signs, the staff member must check the medical record. If there is no yellow DNR form in front of the chart, they are to initiate CPR, call 911 and continue CPR until relieved by emergency personnel. Interviews with staff, LPN E, LPN G, and RN F on [DATE] between 2:15 PM and 2:45 PM identified that regular mock codes would have been helpful to gain confidence in conducting CPR especially with defibrillator, so that people would not freeze. The medical director conducted mock codes on [DATE] at 8:30 AM and 9:30 AM. An interview with licensed practical nurse, (LPN) E on [DATE] at 2:45 PM revealed that she had attended the mock code in the morning on [DATE]. She stated that the mock code was held on the patio using a plant as the patient. She stated that she was confused, as the directive given by the medical director was to, err on the side of caution, and start CPR until a DNR is determined. The registered nurse (RN) F on [DATE] at 2:15 PM stated that her understanding after the mock code was to start CPR until DNR is determined. She said this was different from the direction given at education a few weeks ago. An interview with LPN G on [DATE] at 2:30 PM revealed that she was taught this morning at the mock code to, err on the side of caution, start CPR until DNR is determined. She stated that this was confusing and she would have to clarify this with the DON. On [DATE] at 3:45 PM, the DON stated that she had attended the mock code done by the medical director at 8:30 AM that day. She confirmed that the medical director had directed the nursing staff to start CPR until DNR was established, but this was contrary to what the facility had been instructing the staff to do. She stated that the staff had been instructed to verify the DNR or code status before doing anything. She could not provide an answer as to why she did not clarify the directives that the medical director was giving to the staff. She could not provide an answer when asked if the medical director had been involved in decision making of the CPR education to be provided to staff. She said that staff had questioned her after the mock code as they were confused and she corrected the process, but could not explain why she did not clarify the CPR process with the medical director. The purpose of a QAA committee is to continuously evaluate the facility's systems with the objective of maintaining current practice standards, preventing deviation from care processes, identifying issues and concerns and correcting inappropriate care processes. On [DATE], a [AGE] year-old resident was found unresponsive without vital signs. She had clear directives to initiate CPR including physician orders [REDACTED]. An emergency QAA meeting was held to address this failure, but did not include the medical director. The policies and procedures for CPR were reviewed, but no changes were made to address and eliminate any confusion about when to initiate CPR. The facility did not identify the root cause of the incident and arrived at the conclusion that it was the nurses' personal choice not to initiate CPR. Therefore, they failed to recognize a systems failure and their action plan was based on inaccurate analysis of the incident. The facility provided in-service to all nursing staff to determine DNR/code status first when finding an unresponsive resident absent of vital signs, but during the mock codes on [DATE], the medical director informed staff to, err on the side of caution, and do CPR until DNR can be determined. The medical director's education was contradictory to the directives given to the nursing staff by the facility and exemplified the importance of all members being included in the QAA meetings.

Based on observation, interview and record review, the facility failed to provide appropriate interventions and adequate supervision to prevent falls that resulted in injury and/or required transfer to a higher level of care for of 1 (#14) of 3 residents reviewed for accidents of 3 sampled residents with falls. The facility's actions resulted in actual harm to resident #14 due to sustained, repeated injuries from falls from 4/29/14 to 1/18/15. Resident #14 had a hospital transfer for a sprained ankle from a fall on 4/29/14, a right hip fracture that required surgical intervention from a fall which occurred on 7/13/14, and a head injury from a fall that occurred on 1/18/15 resulting in an emergency room transfer. Findings: Clinical record review indicated that resident # 14 was a long term resident of the facility. She was admitted to the facility on [DATE], with multiple admissions to an acute care hospital, and readmissions to the facility. Her most recent readmission from the hospital was on 01/18/2015. Resident # 14 [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] indicated the resident was severely impaired for cognitive skills for daily decision making. The functional status, the resident required extensive assistance with bed mobility and transfer, and needed two+ persons physical assist with bed mobility, and one person physical assist with transfer. The reentry MDS dated [DATE] indicated cognitive skills for daily decision making were severely impaired. Functional status was extensive assistance with one person physical assist for bed mobility, transfer, and walk in room. The quarterly MDS dated [DATE] revealed resident # 14 required extensive assistance with two + persons physical assist for bed mobility and transfer. The mobility device that was normally used was listed as a wheelchair (w/c). The quarterly MDS dated [DATE] showed no signs of inattention, disorganized thinking, or altered level of consciousness; no mood indicators. Cognitive skills for daily decision making were severely impaired. Behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming, disruptive sounds) occurred 1-3 days within the last 7 days of the assessment date. Rejection of care and wandering occurred 1 to 3 days within the last 7 days of the assessment date. Balance in moving from seated to standing position and balance during surface-to-surface transfer (between bed and chair or wheelchair) was not steady, only able to stabilize with human assistance. Transfer, walk in room, and bed mobility require extensive assistance with one person. The number of falls since last assessment, 10/23/14, listed one fall with injury and no other falls. Review of the admission fall risk assessment completed on 05/21/14 indicated, "falls 1-2 x' s, gait /balance: balance problem while standing, balance problem while walking, decreased muscular coordination, requires use of assistive devices( i.e., cane, w/c, walker, furniture), mobility: ambulation- 1 assist (limited assist), Balance: unsteady. " The assessment indicated resident fell on [DATE]. Record review of the fall risk assessment dated [DATE]=12 indicating the resident was assessed as high risk for falls. Review of the nursing progress notes dated 4/29/14 to 1/18/15 indicated the resident fell 8 times. Progress on the following dates read: 4/29/14, "....resident was found on the floor laying on her left side at the entrance to her room.... " 5/23/14, ".... pt (patient) on dining room floor...." 7/13/14, ".....resident unable to bear wt(weight), extend rt(right) leg, started crying in pain and rt hip deformity notified....physician notified. Order received to send to ER...." 7/17/14, " Resident returned from hospital via stretcher....MD notified, family notified of arrival S/P FX ( status [REDACTED]. " 9/21/14, "....X ray of left shoulder done, report received...slight widening of AC joint...no fracture. " 10/24/14, " Bed alarm heard sounding, CNA responded, patient noted hanging half off bed, torso and arms on fall mat, buttocks and legs on bed....no apparent injury." 11/7/14 for 11/6/14, "....nurses observed resident seated in an upright position on the floor mat next to her bed...no apparent injury" 12/19/14, "Patient noted kneeling on her mat on floor next to her bed, redness noted to knees, no other injuries noted...." 1/18/15," Residents' chair alarm heard going off, went to check on resident when notice her to be laying on the floor in the assisting dining room....bump noted to residents' right lateral forehead....resident was taken to the hospital for evaluation...." The resident returned to the facility on [DATE]. Hospital progress notes dated 1/18/15 indicated the resident had a computerized tomography (CT) scan of the head and cervical spine and both were negative. Three of the 8 falls resulted in transfers to the hospital. Record review of the "Nursing home to hospital transfer form" dated 05/01/14, indicated reason for transfer: "recent fall/fracture of ankle." The resident did not have a fracture, but sustained a sprained ankle. On 7/13/14 the transfer form listed " deformity of hip. " The transfer form for 1/18/15 included, " fell hit head. " Record review of the hospital history and physical dated 08/09/14 indicated resident#14 had a history (hx) of advance severe dementia, and was admitted to the hospital on [DATE] -7/18/14 with a right hip fracture, s/p open reduction internal fixation (ORIF). Documentation on the operative report from the hospital dated 7/14/14 read, "....patient with multiple medical problems including dementia and a fall in the nursing home, injuring her right hip with inability to get out of bed, sit and take the few steps that she was taking before.... " Preoperative [DIAGNOSES REDACTED]. A new care plan was initiated on 5/07/2014 for "At risk for falls as related to: hx (history) of falls, restless at times, poor safety awareness as evidenced by: exiting bed and w/c on her own constantly. She fidgets with her alarm devices until she breaks them, wanders at times, and possible risk of side effects due to medication use." Interventions included the following: assist her daily with transfer and mobility as needed, redirect when seen ambulating on own as needed, redirect in times of restless behaviors (toilet, feed, rest periods) and times of wandering and fidgeting with her alarm devices, keep call light in reach, check on while in room, resident does not usually use it due to cognition deficits. discourage self ambulation, 4/29/14 - issue a pressure seat alarm device, 5/23/14 discourage self transfers, continue with fall precautions daily.... 7/17/14 -continue with fall precautions, 9/20/14 x-ray left shoulder, 1:1 rotation on 3-11 shift, 10/24/14 continue with fall precautions, 11/6/14 continue low bed, mats + alarms, 12/19/14 issue perimeter mattress, continue with fall precautions, 1/18/15 sent to ER with return, do orthostatic blood pressure every shift, confer with MD (medical doctor) possible med review." Other care plans initiated on 5/07/14 with an updated date of 10/29/14 included: Assist needed with activities of daily living related to: "impaired memory and cognitive skills, impaired balance and weakness, decreased safety awareness, and unsteady gait...." and " Resident needs encouragement to attend out of room group. Resident prefers-doing her favorite activity which is talk with staff and other residents. " On 01/26/2015 at 02:14 PM an interview was conducted with resident #14's daughter. The resident was in her wheelchair being transported in the hallway by her daughter. During the interview with the resident's daughter, resident #14 was observed to be restless, as per her daughter, the resident was impulsive at times, and could not remain still for long, wanted to be moving. On 01/27/2015 at 9:34 AM, an interview was conducted with registered nurse (RN)-A regarding the resident ' s fall on 1/18/15. She said resident #14 was found on the floor in the assisted dining room on the South Wing on 1/18/15 at 3:30 PM. She said the resident sustained [REDACTED]. RN- A said at that time the resident had a chair alarm x 2, and when agitated, staff were to implement 1:1 observation. Review of the care plan revealed the 1:1 intervention read, " 1:1 rotation on 3-11 shift." It did not refer to agitation. On 01/27/2015 at 5:19 PM, certified nursing assistant (CNA) -L was observed standing at the foot of resident #14 s' bed. The certified nursing assistant (CNA) said she was doing 1:1 observation, because the resident was not able to put the call light on for assistance, and they wanted to prevent falls. An interview was conducted with the certified occupational therapy assistant (COTA)-D on 01/28/2015 at 2:08 PM. She said therapy received requests for screen for resident(s) who fall. The facility's process included, screening " as soon as possible " , interviews of nursing staff, interviews of CNAs, investigations to establish what the resident was doing when the fall occurred, screen resident, do evaluation, and recommendations as needed. COTA-D said resident #14 was not currently receiving therapy services. She said a therapy screen was completed for the resident on 10/27/14, and 01/20/15 and the resident did not qualify for therapy. As per COTA-D, they "would have discussed safety measures with nurses, bed alarm, chair alarm." She said if the resident had a decline, there was an open line of communication with nursing, and they could request a therapy screen again. On 1/28/2015 at 5:15 PM an interview was conducted with the director of nursing (DON). She said during the fall committee meeting, fall precaution interventions were discussed for resident #14. The DON said the resident was cognitively hard to rehab, physical therapy (PT) screen was done, resident was not cooperative with therapy, hit out at staff, was cognitively hard to retain instructions. She said when the resident gets agitated, they "try" to do 1:1 rotation with her. The DON said restraints would be unsafe, was not attempted, tried non pharmacological interventions such as, 1:1, activities, and call daughter to come in and sit with the resident. When asked if she believed the interventions in place were effective, the DON said she believed "we have done the best we could." In an interview with the risk manager (RM) on 01/29/2015 at 9:40 AM she said a full investigation was conducted on incident which occurred on 7/13/14, which resulted in resident #14 being sent out to the hospital, and a [DIAGNOSES REDACTED]. The RM said according to their investigation, the resident did not have any trauma to her body, had fall precautions in place, and was care planned. She said the facility had "everything in place." There was no identification of a fall, no trauma, and the resident's hip did not have bruising. When asked what fall precaution interventions were put in place from May 2014, after a fall resulting in a sprained ankle, to July 2014, the RM said care plan interventions we added on 5/23/14 for restorative for ambulation and transfer, continue fall precautions, low bed, and floor mats, however review of the care plan revealed those interventions were not listed. The incident/accident reports were reviewed with the RM 1/29/15 at 9:40 AM. The report dated 4/29/14 2:30 PM, "found lying on left side at entrance of room with w/c behind her." Intervention: pressure seat alarm, X-ray, right (rt) and left ankle, immobilize right ankle x 4 weeks, pain management, 2nd X-ray requested, resident did not want to wear immobilizer. X ray = "There is no fracture, no dislocation, no effusion... rt ankle - neg." The notes on the report read, Notes indicated the facility reviewed the incident and determined it was not within their control. The report from 7/13/14, 4:00 AM, "Sunday July 13, 2014 resident was reported to require transport to the ER (emergency room ) for evaluation due to possible hip dislocation.... DPOA (designated power of attorney) reports a dx (diagnosis) of a hip fx (fracture)." Due to this unknown origin and transfer to a higher level with confirmed fracture an investigation has been initiated..." the report dated 9/20/14 indicated at 6:45 PM FOF (found on floor) no injury. On 10/24/14 at 11:45 PM, transfer unattended. On 11/6/14, 8:15 PM FOF, 12/19/14, 7:30 AM FOF no injury, and 1/18/15 FOF- bump to forehead. Record review of the Five day Federal report completed on 7/17/14 for the fall that occurred on 7/13/14 read " ....Unable to confirm any fall or actual incident 24 hours prior. The time frame prior to the residents' transfer to the hospital was normal and typical, self-propelling with wheelchair throughout building, eating in dining room lunch and dinner.... agitated , wandering behaviors continued throughout day, but normal and care planned for the resident.....It is determined that a fracture may have occurred while agitated behaviors and walking, pushing her wheelchair...." Record review Federal report indicated, " CNA immediately responded and transferred with a bear hug method from a standing position to the bed also 2-3 feet away." The RM said she did not consider the resident ' s fracture within the facility ' s control and the facility made the determination that the event was unavoidable. The RM did not consider the incident in which the resident was unable to hold herself up while leaning against the wall a fall. She did not consider the type of transfer used by the CNA as a contributing to the resident's injury. In another interview with the RM at 6:57 PM on 1/29/15 regarding the incident on 7/13/14, she said on 7/13/14 the 11 PM-7 AM shift CNA checked on the resident at 4 AM, and found the resident was wet, the CNA went to get her supplies, pull back the bed clothes, tried to roll the resident, and the resident complained of pain. The statement from the 3 PM-11 PM CNA- J was reviewed with the RM. It read, "Between 7-8 PM (name of resident # 14) come to the room. she stand up and pull up the bed sheet, I try to put her down on the chair...she start yelling and push back the chair. try again to seat her down she wouldn't let me I leave alone and turn around continue with (Name of roommate). (name of resident # 14) was in the opposite side of bed, heard a noise, looked saw her leaning against the wall...." The RM said, while CNA- J was doing care for the B bed, resident #14 was in her wheelchair moving around, the CNA heard the noise, the chair hitting the dresser and responded. The RM said "they know that something occurred," and " believed" it was between the time frame of 7-8 PM, and said, if it was "felt" that someone had caused the incident, the facility would have filed a report and "owed" the incident. On 01/29/2015 at 7:39 PM in another interview with the RM and DON, they were asked if a "bear hug method" was standard for transfer, they said the bear hug move was not standard. The RM said the CNA stated this verbally, and demonstrated the move. The RM said, based on investigation the CNA did "the best she could at that time." They did not consider it within the facility ' s control in the fact that the CNA did not stop and assist resident #14 when she needed assistance and returned to providing care for the roommate while resident #14 was out of her sight, and then performed a transfer that was not per the plan of care. An interview was conducted with CNA- J on 01/30/2015 at 8:44 AM. She said she was a "float" and filled in for other CNAs. Staff J said resident #14 was a "bit confused and aggressive." She said on 7/13/14, she took resident from the B bed, resident #14's roommate, from the nursing station to put her to bed. She did not see resident #14 before taking her roommate to her room. CNA-J said the door to the room was closed. She heard the door open and when she looked, it was resident #14. The resident closed the door, self-propelled in her w/c and came between the beds. CNA- J said she asked the resident if she wanted to go to bed, but she did not answer. The CNA said she heard the alarm, the resident tried to stand up, and she said to resident "what are you trying to do". The resident was standing, and pulling on the bedsheet. CNA- J said she left the B bed resident, in the chair, and said to resident #14 "lets go to bed." She said resident # 14 did not want to go to bed, so she put her back in the chair. Staff J said she pulled the privacy curtain back "a bit", resident # 14 was "scooting" around in her w/c chair. She said she put the bed B resident to bed, was putting up her feet, could not see resident # 14, heard a "bang", resident # 14's w/c knocked into the closet door, when she looked resident # 14 was "crouched" on the wall, next to the door, close to her bed, her w/c was at the closet door. CNA- J said she ran, could not reach the call bell to call for assistance, hugged resident # 14 and turned and put her in the bed. She verbalized the resident did not "fight" her, but held on to her during transfer, did not complain of pain, or say "anything." CNA-J said she did not call for help, and no one came to help her when the bang was heard. She said both residents were in bed the nurse came in. On 01/30/2015 at 10:44 AM in an interview with the medical director (MD) he said he has been resident # 14 MD "for years." The MD said the resident was extremely demented, had significant behavioral problems, a [DIAGNOSES REDACTED]. He said the only "key" to services was to leave her alone, the more you interact with her, the more agitated she becomes. Review of the plan of care revealed the " key " to service was not included. The MD said the resident had "couple episodes of transfer issues from low bed", he said resident #14 had osteoporosis, diabetes, [DIAGNOSES REDACTED], was a high risk person, and the staff knew her "very well, staff knows what to do." When asked about the incident on 07/13/14 the MD said, in reviewing the resident's chart, the resident got agitated with the CNA and did what she always does, "push her w/c." He said she was found leaning against the wall, did not fall to the ground, w/c was against the wall. He said the resident did not verbalize anything, her vital signs were stable, pulse never got above 70, was 60-70bpm (beats per minute) all the time. The MD said the "suspicion of a fracture was very low." The MD said he did not think the incident was avoidable, the resident has condition you cannot predict, and was the type of person who did not respond to redirection all the time consistently, however none of this was included in the plan of care. When asked if the facility/ MD determined the root cause of the incident, he said, resident #14 got agitated, was not able to move her wheelchair as she would like, possibly lost her balance, and went against the wall. The MD said he "surmised" that episode against the wall caused the fracture. According to the Centers for Medicare and Medicaid Services MDS 3.0 Guidelines, "a fall is: the unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person - this is still considered a fall." Although the facility had developed a care plan for falls for resident # 14, the interventions did not prevent continued falls and the resident continued to sustain injuries. The lack of adequate supervision and intervention while the resident was in her room, self propelling in her w/c, resulted in the residents' w/c banging into the closet door, resident crouching against the wall, and admission to the hospital with a [DIAGNOSES REDACTED]. Although the care plan was updated on 9/20/14 with 1:1 rotation on 3-11 shift, two unwitnessed falls occurred on the 3-11 shift on 11/06/14 at 8:15 PM, and 1/18/15 at 3:30 PM. The incident log indicated found on floor. There was no documentation to indicate resident #14 was on "1:1 rotation" per care plan. Progress notes for both days, indicated resident was " observed ...on floor", "noticed....on floor." The last fall on 1/18/15 required further evaluation at the hospital because the resident hit her head when she fell .

Based on observation, interview, and record review, the facility failed to provide adequate staffing to prevent a fall with injury for resident (#14), give pain medication in a timely manner for resident (#221), provide wound care treatment as scheduled (#49), and failed to respond to call lights in a timely manner for resident #35, 98 and 117 out of 6 sampled residents, 3 who voiced concerns with staffing and 2 residents with poor care outcomes. The facility failure to provide adequate staffing to prevent falls caused actual harm to resident #14. Resident #14 had a hospital transfer for a sprained ankle from a fall on 4/29/14, a right [MEDICAL CONDITION] that required surgical intervention from a fall which occurred on 7/13/14, and a head injury from a fall that occurred on 1/18/15 resulting in an emergency room transfer. Cross reference to F323. Findings: 1. In an interview with resident #221 on 1/29/15 at 8:30 a.m., she stated last Saturday, 1/24/15, she received her pain medication over an hour after she requested it between 6:30 -7:00 p.m. The last pain medication was given at 2:00 p.m. She stated the pain medication was ordered every 6 hours, but it did not hold the pain and had been changed to every 4 hours as of 1/26/15. Initial physician's orders [REDACTED]. She added that she was able to tolerate the pain, on a scale of 0-10 it was an "8" at that time, but she felt uncomfortable. The numeric pain scale means 0 is no pain and 10 is worst possible pain. An 8 on the pain scale is severe pain She indicated the nurse must have been busy the evening of 1/24/15. She said her regular pills were given late, around 10:00 -11:00 p.m. The staff nurse-B was interviewed on 1/29/15 at approximately 8:45 a.m. She was the nurse that was on duty last Saturday, 1/24/15. She denied that she gave the medications late. Review of the Medication Administration Record [REDACTED]. Review of the medical records revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment indicated the resident was assessed as alert and oriented, able to make needs known and was assessed with [REDACTED]. A review of the staffing schedule for 1/24/15 indicated there were 2 licensed staff on the 7-3 shift and 3-11 shift for both wings, North and South wings. There were 5 certified nursing assistants (CNAs) on each wing. In an interview with the director of nursing (DON) on 1/29/15 at approximately 3:30 p.m., she stated they usually/normally would have 6 -7 CNAs on each wing. She indicated that the 600 hall in the north wing was always provided with an extra CNA because of the residents' conditions, sub acute stage post hospitalization and new admissions. She did not have an explanation on why last Saturday 1/24/15 there were only 5 CNAs on the schedule for each wing. 2. A wound care observation was conducted with resident #49 on 1/27/15 at 5:00 p.m. The 7-3 shift staff nurse-G conducted the wound care, but it was scheduled to be conducted in the 7-3 shift. In an interview with the staff nurse-G at that time, she stated she was busy and was not able to do the dressing. She said she passed the medications, respond to family inquiries, follow up on physician's orders [REDACTED]. 3. An interview was conducted with resident #35 on 1/26/15 at 2:30 p.m. he stated that he feels there is not enough staff available that when he uses the call bell it takes more than 30 minutes for staff to respond. He indicated this usually happens and he has to wait. He is unable to recall specific dates and times. The resident was assessed as alert and able to make needs known. He has slurred speech, but can also communicate in gestures what he desires. 4. On 1/26/15 at 1:59 PM resident # 98 said sometimes when she uses her call bell, she has to wait for up to 1/2 hour, 4 times a week. She said "maybe not enough staff," and she heard "somebody" saying it was "too much work." 5. On 1/26/15 at 4:07 PM in an interview with resident # 117, she said when she places her light on, she has to wait a"long" time. She was unable to give an estimated time and she believes there was not enough staff available. 6. Review of the progress notes dated 4/29/14 to 1/18/15 indicated resident #14 fell 8 times. All of the falls were unwitnessed. Nursing progress on the following dates read: 4/29/14, "....resident was found on the floor laying on her left side at the entrance to her room.... " 5/23/14, ".... pt (patient) on dining room floor...." 7/13/14, ".....resident unable to bear wt(weight), extend rt(right) leg, started crying in pain and rt hip deformity notified....physician notified. Order received to send to ER...." 7/17/14, " Resident returned from hospital via stretcher....MD notified, family notified of arrival S/P FX ( status [REDACTED]. " 9/21/14, "....X ray of left shoulder done, report received...slight widening of AC joint...no fracture. " 10/24/14, " Bed alarm heard sounding, CNA responded, patient noted hanging half off bed, torso and arms on fall mat, buttocks and legs on bed....no apparent injury." 11/7/14 for 11/6/14, "....nurses observed resident seated in an upright position on the floor mat next to her bed...no apparent injury" 12/19/14, " Patient noted kneeling on her mat on floor next to her bed, redness noted to knees, no other injuries noted...." 1/18/15, " Residents' chair alarm heard going off, went to check on resident when notice her to be laying on the floor in the assisting dining room....bump noted to residents' right lateral forehead....resident was taken to the hospital for evaluation...." An interview was conducted with CNA- J on 01/30/2015 at 8:44 AM. She said she was a "float" and filled in for other CNAs. Staff J said resident #14 was a "bit confused and aggressive." She said on 7/13/14, she was caring for resident #14's roommate when she heard the door open and when she looked, it was resident #14. The resident closed the door, self-propelled in her w/c and came between the beds. CNA- J said she asked the resident if she wanted to go to bed, but she did not answer. The CNA said she heard the alarm, the resident tried to stand up, and she said to resident "what are you trying to do." The resident was standing, and pulling on the bedsheet. CNA- J said she left the B bed resident, in the chair, and said to resident #14 "lets go to bed." She said resident # 14 did not want to go to bed, so she put her back in the chair. Staff J said she pulled the privacy curtain back "a bit", resident # 14 was "scooting" around in her w/c chair. She said she put the bed B resident to bed, was putting up her feet, could not see resident # 14, heard a "bang", resident # 14's w/c knocked into the closet door, when she looked resident # 14 was "crouched" on the wall, next to the door, close to her bed, her w/c was at the closet door. CNA- J said she ran, could not reach the call bell to call for assistance, hugged resident # 14 and turned and put her in the bed. She verbalized the resident did not "fight" her, but held on to her during transfer, did not complain of pain, or say "anything." CNA-J said she did not call for help, and no one came to help her when the bang was heard. On 01/29/2015 at 7:39 PM in another interview with the RM and DON, they were asked if a "bear hug method" was standard for transfer, they said the bear hug move was not standard. The RM said the CNA stated this verbally, and demonstrated the move. The RM said, based on investigation the CNA did "the best she could at that time." They did not consider it within the facility's control in the fact that the CNA did not stop and assist resident #14 when she needed assistance and returned to providing care for the roommate while resident #14 was out of her sight, and then performed a transfer that was not per the plan of care. The lack of adequate supervision and intervention while the resident was in her room, self propelling in her w/c, resulted in the residents' w/c banging into the closet door, resident crouching against the wall, and admission to the hospital with a [DIAGNOSES REDACTED]. Although the care plan was updated on 9/20/14 with 1:1 rotation on 3-11 shift, two unwitnessed falls occurred on the 3-11 shift on 11/06/14 at 8:15 PM, and 1/18/15 at 3:30 PM. The incident log indicated found on floor. There was no documentation to indicate resident #14 was on "1:1 rotation" per care plan. Progress notes for both days, indicated resident was " observed ...on floor", "noticed....on floor." The last fall on 1/18/15 required further evaluation at the hospital because the resident hit her head when she fell . An interview was conducted with the risk manager (RM) on 01/29/20 at 9:40 AM She said resident #14 fell in the resident lounge/assisted dining room on 1/18/15 at 3:30 PM. The RM said no staff was present at the time of the fall, the resident was in the room, with the door open, no one was standing in the room. Her wheelchair alarm went off at 3:30 PM during the change of shift. The RM said no one was in visual range of resident during shift change. The CNAs were usually giving report in the hall.