Every finding on record at Solaris Healthcare Waterman

Based on observation, interview, and record review, the facility failed to ensure infection control and prevention measures were followed for hand hygiene during wound care for 2 (Resident #3 and Resident #5) of 5 residents reviewed for wounds.Findings include: 1. Review of Resident #3's admission record revealed he was admitted on [DATE] with medical diagnoses that included rhabdomyolysis and methicillin resistant staphylococcus aureus infection. Review of Resident #3's physicians' orders dated 3/27/2026 read, Left Lateral Calf: cleanse wound with normal saline, pat dry, apply hydrogel saturated gauze, and cover with dry dressing daily and as needed: every day shift AND as needed for saturated, soiled, and dislodged dressing.Review of Resident #3's Physicians' Orders dated 3/25/2026 read, Left Hip Reddened Area: cleanse with soap and water, pat dry, apply house zinc every shift and as needed: every shift for redness AND as needed for redness.During an observation on 4/03/2026 at 11:40 AM, the Wound Care Nurse performed wound care on three separate wounds for Resident #3. The Wound Care Nurse failed to perform hand hygiene after removing each of the soiled dressings and her soiled gloves. She donned clean gloves, without performing hand hygiene and administered treatment and applied new dressings. 2. Review of Resident #5's admission record revealed she was admitted on [DATE] with medical diagnoses that included fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, anemia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness. Review of Resident #5's physicians' orders dated 3/24/2026 read, Skin Tear: cleanse with normal saline, pat dry, apply xeroform, and cover with a dry dressing daily and as needed: every day shift for wound care AND as needed for saturated, soiled, or dislodged dressing.Review of Resident #5's physicians' orders dated 3/23/2026 read, Coccyx Wound: cleanse with normal saline, pat dry, apply hydrogel gauze, and cover with dry dressing every shift and as needed: every shift for wound care AND as needed for saturated, soiled, or dislodged dressing.Review of Resident #5's physicians' orders dated 3/05/2026 read, Left Heel: cleanse with normal saline, apply betadine, left dry and leave open to air daily and as needed: every day shift for DTI AND as needed. During an observation on 4/03/2026 at 12:55 PM, the Wound Care Nurse performed wound care on two separate wounds for Resident #5. The Wound Care Nurse failed to perform hand hygiene after removing each soiled dressing and her soiled gloves. She donned clean gloves, without performing hand hygiene and administered treatment and applied new dressings. During an interview on 4/03/2026 at 1:00 PM, the Wound Care Nurse stated that she should have performed hand hygiene each time she removed her gloves, before applying clean gloves during wound care. During an interview on 4/03/2026 at 1:05 PM the DON (Director of Nursing) stated that the expectation was for nurses to perform hand hygiene when changing gloves during wound care especially after cleaning a wound prior to applying treatment and/or a clean dressing.

Based on observation, interview, and record review, the facility failed to provide respiratory services consistent with professional standards of practice for 3 of 4 residents reviewed for oxygen therapy (Residents #46, #136, and #139). Findings include: 1. During an observation on 7/28/2025 at 10:30 AM, Resident #46 was sitting in the recliner, receiving oxygen via nasal cannula at 3.5 liters per minute (LPM). During an observation on 7/29/2025 at 10:11 AM, Resident #46 was receiving oxygen via nasal cannula at 3.5 LPM. Review of Resident #46's physician orders showed an order dated 7/1/2025 for administration of oxygen at 2 LPM every shift. During an interview on 7/29/2025 at 10:11 AM, Resident #46, stated, I never touch the setting on the concentrator. I do not know how or where to adjust. 2. During an observation on 7/28/2025 at 9:16 AM, Resident #147’s nebulizer mask was clipped on the nebulizer machine sitting on the resident’s bedside table. The mask was not bagged. The resident was receiving oxygen at 4.5 LPM with humidification (Photographic evidence obtained). During an observation on 7/29/2025 at approximately 8:54 AM, Resident #147 was receiving oxygen at 4 LPM with humidification. Review of Resident #147’s physician orders showed an order dated 7/24/2025 for continuous administration of oxygen at 5 LPM via nasal cannula. Review of Resident #147’s physician orders showed an order dated 7/24/2025 for Levalbuterol 0.63 MG (milligram)/3ML (milliliter) nebulization solution; 3 ml inhale orally via nebulizer every 8 hours for hypoxia. Review of Resident #147’s physician orders showed an order dated 7/24/2025 for Budesonide Inhalation Suspension 0.5 MG/2ML; 1 vial inhale orally in the morning for shortness of breath, rinse mouth after. During an interview on 7/29/2025 at approximately 8:54 AM, Resident #147 stated, I do not touch the oxygen concentrator, or the mask. Nurses come in and work on it and tell me what to do. During an interview on 7/31/2025 at 8:40 AM, the Director of Nursing (DON) stated, “My expectation is the oxygen settings to be correct.” 3. During an observation on 7/28/2025 at 9:42 AM, Resident #139 was sitting in a wheelchair in his room. There was a nebulizer mask sitting on top of the nebulizer machine on the bedside table unbagged. During an interview on 7/28/2025 at 9:58 AM, Staff C, Registered Nurse (RN), stated that Resident #139's nebulizer mask should have been stored in a plastic bag with a date written on the bag. During an interview on 7/28/2025 at 11:30 AM, the Director of Nursing (DON) confirmed that nebulizer masks should be stored in a plastic bag when not in use. Review of Resident #139's physician orders showed an order dated 7/9/2025 for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate); 3 ML inhale orally via nebulizer every 6 hours as needed for shortness of breath or wheezing.

Based on observation, interview, and record review, the facility failed to ensure residents' preference for shower date and time was honored for 1 of 4 residents reviewed (Resident #107). Findings include: During an observation on 7/30/2025 at 8:50 AM, the communication board in Resident #107's room showed that the resident was scheduled to have two showers weekly on Wednesday and Sundays. During an interview on 7/30/2025 at 8:45 AM, Resident #107 stated that her usual shower days were Sundays and Wednesdays. This past Sunday (7/27/2025), she requested a shower, and the aide informed her that she could not have a shower, only a bed bath. The resident informed the aide that she did not want a bed bath, she wanted a shower, but the aide refused and informed her she would give a bed bath. The resident stated that she was never given a bed bath or a shower on 7/27/2025. During an interview on 7/30/2025 at 12:23 PM, Staff A, Certified Nursing Assistant (CNA), stated that she was the aide providing care for Resident #107 on the evening of 7/27/2025. Staff A stated, It was [Resident #107's name]'s shower day, but by the time I got to her, she said it was too late, and to just put her to bed, so I did. [Resident #107's name] asked to have her peri-area washed, and did not want her gown changed, as it was still clean. I asked if she was sure, but she said just wash my peri area. This occurred around 8:00 PM. She likes to shower right after dinner. If I remember right, we only had two CNAs that night. Normally, we have three, so it took longer for me to get to her. During an interview on 7/31/2025 at 9:08 AM, the Director of Nursing (DON) stated, I interviewed [Resident #107's name] and [Staff A, CNA's name]. [Staff A's name] should have documented the bed bath for [Resident #107's name] as refused if the bed bath was not completed. During an interview on 7/31/2025 at 10:10 AM, Staff B, Registered Nurse (RN), stated, I was the nurse on shift for [Resident #107's name] on the evening of 7/27/25. I review and sign the shower sheets at the end of the shift. [Staff A, CNA's name] never informed me that [Resident #107's name] refused a shower or a bed bath. I expect the CNAs to inform me when a resident refuses a shower or bed bath. Review of Resident #107's ADL (Activities of Daily Living) task records showed the resident preferred Wednesdays and Sundays at 3-11 shift for bathing. Review of Resident #107's Minimum Data Set (MDS) assessment dated [DATE] showed the resident was dependent for showering and bathing under Section GG- Functional Status. Review of Resident #107's care plan dated 5/22/2025 read, Focus: Resident has specific preferences r/t [related to] day to day activities. Goal: Staff need to be aware of resident preferences and incorporate them into daily care. Review of the facility policy and procedure titled Activities of Daily Living (ADL), Supporting with the last review date of 12/10/2024 read, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and policy and procedure review, the facility failed to prevent the possible spread of infection and communicable diseases when failing to place a resident on contact precaution during testing for possible C-Diff (Clostridium difficile) toxin (Resident #94), and failing to ensure staff donned appropriate personal protective equipment (PPE) and performed appropriate hand hygiene upon entering and exiting the resident's room. Findings include: During an observation on 7/28/2025 at 11:13 AM, there was no isolation signage on Resident #94's room door and there was no PPE available. During an interview on 7/28/2025 at 11:13 AM, Resident #94 stated, I have been having loose stool, and they did a test on it for me. I had that C. diff before. Review of Resident #94's physician orders dated 7/28/2025 read, Need Stool r/o (rule out) possible recurrent C-diff one time only for check for possible recurrent C-diff for 3 Days. During an observation on 7/29/2025 at 9:18 AM, Staff F, Certified Nursing Assistant (CNA), entered Resident #94's room, used hand sanitizer, exited room after 3 minutes, and used hand sanitizer. There was no isolation signage or PPE supplies on door of the room. During an observation on 7/30/2025 at 9:30 AM, Staff F, CNA, entered Resident #94's room, used hand sanitizer, exited the residents room after 3 minutes, used hand sanitizer, and entered a different resident's room. There was no isolation signage or PPE supplies on the door of the room. During an observation on 7/30/2025 at 10:32 AM, Staff D, Licensed Practical Nurse (LPN), entered Resident #94's room, used hand sanitizer on entry, and exited 3 minutes later and used hand sanitizer. Staff D returned to the medication cart. Review of Resident #94's infectious disease consult note dated 7/30/2025 read, Patient is a 95 y/o [year old] male who was admitted into [Name of a local hospital] back in May 2025 for weakness. Patient has had hx [history of] C-diff in the past. He now resides at Solaris skilled nursing facility; he was recently treated for C-diff and stool was normally formed. Now reported patient is having ongoing watery stools and C-diff was positive. ID [Infectious disease] consulted for antibiotics management. Seen today up in the chair awake responsive. He reports watery stools. Denies abdominal pain, no tenderness or distention noted. During an interview on 7/30/2025 at 12:15 PM, Staff E, Registered Nurse (RN), stated, He [Resident #94] was positive for C diff, and we need to place him on isolation. He should have been placed on isolation on the 28th when we got the order. We always do that. The nurse, that day, forgot to do it. During an interview on 7/30/2025 at 12:45 PM, Staff F, CNA, stated, I did not know until now that he has C diff. We should wash our hands and not use the sanitizer. I know a resident on precautions when I see the signs. During an interview on 7/31/2025 at 7:15 AM, the Director of Nursing (DON) stated, We should have placed him [Resident #94] on precautions right away when we got the order. Review of the facility policy and procedure titled Clostridium Difficile with the last approval date of 12/17/2024 read, Policy Statement: Preventive measures will be taken to prevent the occurrence of Clostridium difficile infections among residents and precautions will be taken while caring for residents with C. Difficile (to prevent the transmission of C. Difficile to others). Policy Interpretation and Implementation: 1. Clostridium Difficile infection will be considered in residents with acute onset of diarrhea (three or more unformed stools within 24 hours) or abdominal pain. 2. Residents considered at high risk for developing symptoms associated with C. Difficile include those with: a. Advanced age. c. Previous gastrointestinal illness caused by C. Difficile. 10. Residents with diarrhea associated with C. Difficile will be placed on Contact Precautions. D. Residents with diarrhea and suspected C. Difficile while awaiting laboratory results. 11. When caring for residents with diarrhea or fecal incontinence caused by C. Difficile, staff will maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR (alcohol-based hand rub) for the mechanical removal of C. Difficile spores from hands.

Based on observation, interview, and record review, the facility failed to utilize appropriate isolation precaution signages to help prevent the possible transmission of communicable diseases and infections for Residents #19, #82, and #85 (Photographic evidence obtained), and failed to ensure the staff used appropriate PPE (Personal Protective Equipment) while providing direct care to the residents on isolation precautions for Resident #418. Findings include: 1. Review of Resident #19's physician order dated 4/21/2024 read, COVID-19: Strict Isolation: Resident require strict isolation for positive COVID-19 every shift for COVID positive for 10 days. Review of Resident #19's care plan dated 4/22/2024 read, Focus: Resident is diagnosed with COVID-19 infection. Date Initiated: 04/22/2024 . Interventions . Droplet Isolation Precautions. During an observation on 4/22/2024 at 9:48 AM, Resident #19's door had a sign reading Enhanced Barrier Precautions on the door. Review of Resident #82's physician order dated 4/19/2024 read, COVID-19: Strict Isolation: Resident require strict isolation for positive COVID-19 every shift for COVID positive for 10 days. Review of Resident #82's care plan dated 4/20/2024 read, Focus: Resident is diagnosed with COVID-19 infection. Date Initiated: 04/20/2024 . Interventions . Droplet Isolation Precautions. During an observation on 4/22/2024 at 9:55 AM, Resident #82's door had a sign reading Enhanced Barrier Precautions on the door. During an interview on 4/22/2024 at 10:05 AM, the Infection Preventionist confirmed Residents #19 and #82 had inaccurate isolation precaution signs on their doors, and stated, They should have droplet precaution signs on their doors due to their COVID positive status. Review of the facility policy and procedure titled, Isolation- Notices of Transmission-Based Precautions revised on 10/16/2023 read, Policy Statement: Appropriate isolation notices will be used to alert staff of the implementation of Transmission-Based Precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation: 1. When Transmission-Based Precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of Transmission-Based Precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy. 46523 2. During an observation on 4/22/2024 at 9:40 AM, Resident #418 was sitting in a recliner in his room, receiving IV (intravenous) medication via PICC (Peripherally Inserted Central Catheter) line located on RUE (Right Upper Extremity). During an observation on 4/22/2024 at 9:41 AM, Staff A, License Practical Nurse (LPN), was disconnecting Resident #418's IV tubing. Staff A did not have a gown. During an interview on 4/22/2024 at 9:48 AM, Staff A, LPN, stated, I wear gloves because it was just the removal of IV tubing. Every room will have signs and PPE depending on why you are going in the room. I am the nurse for this unit. I know every resident and what I need to wear when going into the rooms. Review of Resident #418's physician order dated 4/4/2024 read, Enhanced Barrier Precautions for picc line every shift for precautions for picc line. During an observation on 4/22/2024 at 10:06 AM, Staff B, Occupational Therapist, was in Resident #85's room assisting with direct care. Staff B did not have a gown. There was no enhanced barrier precaution signage or personal protective equipment noted outside of room. During an interview on 4/22/2024 at 2:38 PM, Staff B, Occupational Therapist, stated, I am the Occupational Therapist for [Resident #85's name]. She was wet and I was changing her and assisting her with peri care. I did not know she was on enhanced barrier precautions. Normally, there would be a sign posted outside of the room and that is how we know what precautions to take. The room did not have any signs posted when I entered. Review of Resident #85 physician order dated 4/4/2024 read, Enhanced Barrier Precautions for MRSA Hx [Methicillin-Resistant Staphylococcus Aureus History] and wound every shift for precautions for MRSA Hx and wound. Review of Resident #85's physician order dated 4/19/2024 read, Enhanced Barrier Precautions: surgical wound every shift for foley and surgical wound. During an interview on 4/24/2024 at 1:30 PM, the Director of Nursing stated, Staff should be gowning when providing direct care. They have orders in the system as well as signage posted. During an interview on 4/25/2024 at 8:55 AM, the Infection Preventionist stated, There are orders set in the system and message will pop up. [Resident #85's name] had covid and then signs were taken down and enhance barrier was not put back up. Head of departments get a listing who is on precautions every day. Staff should 100% wear gown when in direct patient contact. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/16/2024 read, Policy Statement: This facility follows recommended CDC [Centers for Disease Control and Prevention] enhanced barrier precautions, to interrupt the spread of multidrug resistant organisms (MDROs) within the facility. For the purposes of this guidance, the MDROs for which the use of EBP [Enhanced Barrier Precautions] applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDROs. Policy Interpretation and Implementation: 1. While in the building, employees are required to strictly adhere to established infection prevention and control policies, including . c. Appropriate use of PPE [Personal Protective Equipment].

Based on record review and interview, the facility failed to ensure residents received medication as per physician order for 1 of 6 residents reviewed for blood pressure medication, Resident #106. Findings include: Review of Resident #106's physician order dated 3/15/2024 read, Midodrine HCl Oral Tablet 5 MG [milligram] (Midodrine HCl) Give 1 tablet by mouth every 8 hours for hypertension hold if SBP [Systolic Blood Pressure] greater than 130. Review of Resident #106's Medication Administration Record for April 2024 showed the resident received Midodrine 5 mg on 4/1/2024 at 2:00 PM with the blood pressure of 150/91, on 4/4/2024 at 2:00 PM with the blood pressure of 164/94 and at 10:00 PM with the blood pressure of 160/90, on 4/8/2024 at 10:00 PM with the blood pressure of 150/67, on 4/13/2024 at 10:00 PM with the blood pressure of 146/93, on 4/14/2024 at 6:00 AM with the blood pressure of 146/93, and on 4/22/2024 at 2:00 PM with the blood pressure of 138/83. During an interview on 4/24/2024 at 9:21 AM, the Director of Nursing stated, It was a medication error. I spoke with the doctor and the resident. Doctor stated we need to continue with the medication and resident had no adverse effects. During an interview on 4/24/2024 at 9:35 AM, Physician #1 provided no comment on possible side effects of administration of Midodrine 5 mg to Resident #106 when the blood pressure is greater than 130. During an interview on 4/24/2024 at 11:05 AM, Physician #2, Cardiologist, stated, Midodrine 5 mg is a very low dose. In cardiology, we do not use it. It is very insufficient. I spoke to the resident [Resident #106] and she had no side effects. Extra 5 mg of Midodrine is not going to have any major impact overall. It is not a very good vasopressor, but sometimes it is all we got. Review of the facility policy and procedure titled Medication Administration- General Guidelines with the last review date of 1/16/2024 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Procedures . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to ensure residents were not served known allergen food items for 1 of 6 residents reviewed for nutrition, Resident #419. Findings include: During an interview on 4/22/2024 at 10:12 AM, Resident #419 stated, I have been here in the facility for a few days. The food is not good. They give chicken twice a day. If you do not like it, they give you either a peanut butter sandwich which I am allergic to or turkey sandwich. During an observation on 4/22/2024 at 12:30 PM, Resident #419 was eating lunch in her room. The tray included a ham sandwich wrapped in plastic with a piece of lettuce and tomato garnish on the plate (Photographic evidence obtained). During an interview on 4/22/2024 at 12:30 PM, Resident #419 stated, If I had tomato, I would swell up. If it would have been on the sandwich, I would not be able to eat it. The sandwich came wrapped individually from the tomato. Review of Resident #419's admission record showed the resident was allergic to to Lisinopril, sulfa antibiotics, almond oil, peanuts, and tomato. Review of Resident #419's hospital records provided from the discharging hospital documented, intolerance to tomato. Review of Resident #419's meal ticket read, Allergies: Peanuts, Tomato/Almond Oil. During an interview on 4/24/2024 at 12:28 PM, Staff C, Certified Nursing Assistant (CNA), stated, Allergies are on the meal ticket. The resident tells us what they want, and we go and get it from the kitchen. We will lift the plate lid and see that it is appropriate for the resident. During an interview on 4/24/2024 at 12:43 PM, the Regional Dietary Manager stated, It was definitely an overlook. We have a system in place. The meals get checked three times and then also checked by the CNA. If they request an alternative, the CNA goes back and checks at that point. Review of the facility policy and procedure titled Tray Identification with the last review date of 1/16/2024 read, Policy Statement: Appropriate identification/coding shall be used to identify various diets. Policy Interpretation and Implementation . 2. The Food Services Manager or designee will check trays for correct diets before the food carts or meal trays are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of the facility policy and procedure titled Food Allergies and Intolerances with the last review date of 1/16/2024 read, Policy Statement: Residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergens.

Based on observation, interview, and record review, the facility failed to ensure residents received the appropriate enteral feed for 1 of 3 residents reviewed for enteral feed administration, Resident #170. Findings include: Review of Resident #170's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, dementia, and gastrostomy status. During an observation on 4/23/2024 at 1:45 PM, Resident #170's enteral feed pump was running at 70 ml/hr (milliliters/hour) (Photographic evidence obtained). Review of Resident #170's physician order dated 4/18/2024 read, Enteral Feed Order two times a day Enteral Glucerna 1.5 cal/ml [calorie/ milliliter] @ [at] 80 ml/hr x 20 hours. Off at 10 am and On at 2 pm (total volume 1600 ml). Review of Resident #170's care plan dated 4/17/2024 read, Focus: Resident requires enteral tube feeding for nutrition . Interventions . Enteral feeding as ordered. During an interview on 4/23/2024 at 2:00 PM, Staff E, licensed Practical Nurse (LPN), stated, I see his pump is running at 70 ml/hr. His order reads 80 ml/hr. The rate needs to be changed. During an interview on 4/25/2024 at 10:00 AM, the Director of Nursing stated his expectation for nurses when initiating enteral feed was to verify the order and set the pump to the administration rate in the current order. Review of the facility policy and procedure titled, Enteral Tube Feeding via Continuous Pump dated 1/25/2023 and last reviewed on 1/16/24 read, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Preparation: 1. Verify that there is a physician's order for this procedure . General Guidelines . 3. Check the enteral nutrition label against the order before administration. Check the following information . g. rate of administration ml/hour.

Based on observation, interview, and record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 1 of 4 nourishment rooms. Findings include: During an observation while conducting a tour of the facility's nourishment rooms with the Certified Dietary Manager on [DATE] beginning at 9:38 AM, there were an unlabeled and undated plastic grocery bag with 2 containers of unidentifiable food on the top shelf of the refrigerator, an unlabeled Taco Bell bag containing one Taco with the date of [DATE], an unlabeled Burger King bag containing a cheese burger and French fries with the date of [DATE], and an unlabeled and undated Wendy's bag containing a burger and side salad in the right side drawer of the refrigerator, and four pieces of celery wrapped in saran wrap with a date of [DATE] in the butter tray of the refrigerator in the 400 hall nourishment room. During an interview on [DATE] approximately at 9:40 AM, the Certified Dietary Manager acknowledged the expired and/or undated and unlabeled foods in the refrigerator and stated, Everything should be labeled with the resident's room number and the dates marked on it. I have posted the policies and there seems to be a problem with this hall only. Review of the facility policy and procedure titled Storage of Foods Brought to Residents by Family/Visitors dated [DATE] and last reviewed on [DATE] read, Policy Interpretation and Implementation . 6. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name and dated. 7. The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first.

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 2 residents sampled for oxygen therapy, Resident #417. Findings include: During an observation on 4/22/2024 at 9:31 AM, Resident #417 was sitting up in a recliner in his room, receiving oxygen via nasal cannula at 2 liters per minute. During an observation on 4/23/2024 at 1:30 PM, Resident #417 was sitting up in a recliner in his room, receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #417's physician order dated 4/11/2023 read, (ACC-OXYGEN) Oxygen (Specify L/Min [liter/minute] and via device) every shift for COPD [Chronic obstructive pulmonary disease] and SOB [Shortness of breath]. During an interview on 4/23/2024 at 2:05 PM, the Director of Nursing stated, Initially we go by the 3008 form and then input orders in the system. The order is incomplete and should include the rate and the device. Review of the facility policy and procedure titled Documentation with the last reviewed date of 1/16/2024 read, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.

Based on observation, record review, and interview, the facility failed to ensure the Minimum Dat Set (MDS) assessment accurately reflected the resident's status for 1 of 2 residents reviewed for oxygen therapy, Resident #420, and 1 of 3 residents reviewed for discharge, Resident #115. Findings include: 1. During an observation on 4/22/2024 at 9:26 AM, Resident #420 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. Review of Resident #420's physician order dated 4/5/2024 read, Oxygen (2L/nc prn) [liters via nasal canula as needed] as needed. Review of Resident #420's weights and vitals summary showed that the resident was receiving oxygen via nasal cannula on 4/4/2024, 4/6/2024, and 4/7/2024. Review of Resident #420's 5-Day MDS dated [DATE] did not show oxygen coded as in use while being a resident in the facility. During an interview on 4/24/2024 at 1:07 PM, the MDS Director stated, I do not look at the vitals CNAs [Certified Nursing Assistants] put in. I trust the nurse documentation. The nurse documents as not being done. Sometimes CNA documents as being done, and it is not so. I like to see nurse documentation to back it up. During an interview on 4/24/2024 at 1:37 PM, the Director of Nursing stated, CNA documentation should be considered accurate. 48708 2. Review of Resident #115's Discharge MDS dated [DATE] under Section A, Subsection A2105 showed the resident was discharged to short term general hospital. Review of Resident #115's progress note dated 3/15/2024 read, Resident was d/c [discharged ] home today about 1650 [4:50 PM]. She has not been seen by the doctor and family is aware. During an interview on 4/23/2024 at 2:14 PM, the Regional Director of Clinical Reimbursement and MDS Director stated that discharge status for Resident #115 was coded inaccurately. Review of the facility policy and procedure titled Resident Assessment Instrument with the last review date of 1/16/2024 read, Policy Statement: A comprehensive assessment of a resident's needs shall be made using the most recent version of the Resident Assessment Instrument. Policy Interpretation and Implementation: The assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conducts timely resident assessment and reviews according to the most recent RAI [Resident Assessment Instrument] manual specifications.

Based on observation, interview, and record review the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in the main kitchen and in 8 of 8 nourishment areas. Findings include: A tour of the facility main kitchen was completed with the Certified Dietary Manager on 12/19/2022 beginning at 9:30 AM. There was an undated bag of French fries, an undated opened bag of chicken nuggets, an undated opened bag of onion rings, 3 undated and unlabeled bags of pizza crust and an undated bag of hash brown potatoes stored in the reach in freezer. During an interview on 12/19/2022 beginning at 9:30 AM, the Certified Dietary Manager acknowledged the open, undated, and unlabeled food items were stored in the reach in freezer. A tour of the facility nourishment rooms was completed on 12/19/2022 beginning at 9:48 AM with the Certified Dietary Manager. On 12/19/2022 at 9:48 AM in the Low 200 Hall nourishment room, there was an undated, unlabeled container of takeout food stored in the microwave oven. On 12/19/2022 at 9:51 AM in the High 200 Hall nourishment room, there were brown and red substances splattered on the interior base of the freezer. On 12/19/2022 at 9:55 AM in the Low 400 Hall nourishment room, there was a brown substance splattered in the freezer, there was no thermometer in the freezer, there was food built up on the microwave oven plate and opaque splatters on the exterior front glass of the microwave oven. On 12/19/2022 at 9:59 AM in the High 400 Hall nourishment room, there were 3 thawed nutritional supplements with no thawed-on date stored in the refrigerator, there was a brown substance splattered on the lower side shelf of the refrigerator and a yellow substance splattered on the interior base of the freezer. On 12/19/2022 at 10:04 AM in High 300 Hall nourishment room, there was a sticky substance on the interior base of the refrigerator, there were 2 undated bagged slices of pizza in the refrigerator, 1 undated and unlabeled Styrofoam container stored in the refrigerator, and there was a brown built up sticky substance on the interior base of the freezer. On 12/19/2022 at 10:07 AM in the Low 300 Hall nourishment room, there was a sticky tan and pink substance splattered in the refrigerator, there was a thawed nutritional supplement with no thawed-on date stored in the refrigerator, and there was a sticky brown substance along the groove of the freezer rubber seal. On 12/19/2022 at 10:15 AM in the Activities Bistro, there was an undated, unlabeled squeeze bottle of a brown liquid and an undated, unlabeled squeeze bottle of yellow liquid stored in the refrigerator, there was an undated, unlabeled quarter full coffee carafe and an undated, unlabeled carafe of pink liquid stored with the open top of the carafe wedged against a shelf stored in the refrigerator and there were oyster colored flakes scattered on the base of the freezer. On 12/19/2022 at 10:17 AM in the High 100 Hall nourishment room, there were 2 thawed nutritional supplements with no thawed-on date stored in the refrigerator, there were 2 undated pocket sandwiches stored in the refrigerator and there was an opaque substance on the microwave oven glass plate. On 12/19/2022 at 10:20 AM in the Low 100 Hall nourishment room, there were 2 thawed nutritional supplements with no thawed-on date stored in the refrigerator. There was a loose plastic seal hanging from the lower edge of the refrigerator. There were 2 undated breakfast sandwiches stored in the refrigerator and there was a pooled and splattered amber substance on the interior base of the freezer. During an interview on 12/19/2022 beginning at 9:30 AM, the Certified Dietary Manager acknowledged open, undated, and unlabeled food items were stored in the nourishment room refrigerators and freezers, he confirmed the nourishment rooms were in need of cleaning and he confirmed the thawed nutritional supplements stored in the refrigerators did not have a thawed-on date. Review of the nutritional supplement use instructions displayed on the nutritional supplement carton showed the use instructions read STORE FROZEN THAW AT OR BELOW 40 [degrees Fahrenheit] USE THAWED PRODUCT WITHIN 14 DAYS. Review of the policy titled Dietary Sanitation, last reviewed 1/22/2022, read Policy: The facility will store, prepare, distribute and serve food in accordance with professional standards for food service safety and Procedure: 1. Food service staff follow procedures that reduce potential for food borne pathogens, in storing, preparing and serving food 3. All refrigerators and freezers are equipped with a thermometer and regular scheduled readings are monitored by a staff member and written on the log for the corresponding location .4. Opened food packages and left over foods stored in the refrigerators are sealed and dated Cleaning and Maintenance: 1. Cleaning schedules for all equipment and areas of the dietary department are posted with completion of cleaning recorded by the staff member assigned. Review of the policy titled Food Brought in By Others, last reviewed 1/22/2022, read Policy: It is the policy of this facility to ensure the safety of the residents and to prevent foodborne illness and contamination. PROCEDURE: .2. Food brought in by family/visitors for residents will be stored accordingly to prevent the potential for food borne illnesses. 3. The facility will provide safe handling of the food once it is brought to the staff at the facility 2. Food brought in by visitors and families will be dated and stored in refrigerators on the units or in the residents rooms that are only for resident items. Prior to placing in the refrigerators the food containers will be inspected by facility staff for any leakage or odors or signs of spoilage.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection during intravenous (IV) medication administration and by not performing hand hygiene for 3 of 6 medication administration observations. Findings include: During an observation of IV medication administration for Resident #226 on 12/21/22 at 8:04 AM, Staff D, Registered Nurse (RN), removed medication from medication cart, donned PPE (personal protective equipment) and entered Resident #226's room, turned on light and put gloves on with no hand hygiene performed. Staff D doffed PPE and exited room. Staff D went to get IV tubing from medication room, returned to med cart, unlocked med cart, and retrieved medication without hand hygiene. Staff D donned PPE and grabbed gloves, entered the room, and applied hand sanitizer. Staff D placed IV medication and supplies on top of night table without cleaning table or placing a barrier. Staff D connected the medication to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff D cleaned the needleless connector with alcohol and uncapped the 10 milliliters (ml) syringe of normal saline and removed the air. Staff D administered the 10 milliliters of normal saline without checking for blood return to verify placement of the line. Staff D removed the syringe and connected the IV tubing to the Peripherally Inserted Central Catheter (PICC) line needleless connector without cleaning the needless connector. During an interview on 12/21/22 at 8:17 AM, Staff D, RN stated, I should have done hand hygiene when returning from the medication room and cleaned the needleless connector after flushing before connecting the IV tubing. During an observation of medication administration on 12/21/22 at 8:22 AM, Staff K, Licensed Practical Nurse (LPN), exited a resident room, returned to the medication cart and without performing hand hygiene prepared medications for Resident #426. Staff K took medication with her to the medication room to retrieve medication which was missing from medication cart. No hand hygiene performed upon return. Staff K opened and labeled medication. Staff K entered the resident's room without performing hand hygiene, administered medications to Resident #426. Staff K administered nasal spray to Resident #426 without wearing gloves. During an interview on 12/21/2022 at 8:41 AM, Staff K, stated, I should have performed hand hygiene. I brought gloves inside the room with me to use them but forgot. I got nervous. During an observation of medication administration on 12/21/22 at 8:45 AM, Staff F, LPN, exited a resident room, returned to the medication cart, and prepared medications for Resident #6. Staff F entered the resident's room without performing hand hygiene and placed gloves on. Staff F exited the room with gloves on and retrieved a spoon from medication cart. Staff F entered the resident room without performing hand hygiene. Staff F administered medications to Resident #6 . During an interview on 12/21/2022 at 8:55 AM, Staff F, LPN, stated, I should have performed hand hygiene when I entered the room and removed my gloves and performed hand hygiene when exiting and re-entering residents room. During an observation of IV medication and oral medication administration for Resident #91 on 12/21/22 at 9:48 AM, Staff G, LPN, removed medication from medication cart, donned PPE, and entered Resident #91's room, performed hand hygiene, and placed on gloves. Staff G placed IV medication and supplies on top of side table without cleaning table or placing a barrier. Staff G handed oral medication to the resident. Staff G removed IV fluids and supplies from resident bedside table and placed it on the resident's recliner. Staff G connected the fluids to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff G cleaned the needleless connector with alcohol and uncapped the 10 ml syringe of normal saline and removed the air. Staff G administered the 10 ml of normal saline without checking for blood return to verify placement of the line. Staff G removed the syringe and needless connector came in to contact with resident bedrail. Staff G connected the IV tubing to the midline needleless connector without cleaning the needleless connector. During an interview on 12/21/22 at 10:08 AM, Staff G, LPN, stated, I should have cleaned the needleless connector before connecting the tubing to the needleless connector. During an interview on 12/21/022 at 10:52 AM, the Director of Nursing stated, Staff are expected to perform hand hygiene before and after they touch the medication and in between if needed. Staff are expected to clean the needleless port before flushing. Review of the facility policy titled Hand Hygiene, last reviewed on 1/22/2022 reads: 5. Hand Hygiene shall be performed for the following situations: before preparing or handling medications .7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Review of the facility policy titled Administration of an Intermittent Infusion, last reviewed on 1/22/2022 reads: Procedure: . 4. Perform hand hygiene, 5. Assemble equipment and supplies on a clean work surface . 16. Maintain asepsis, attach flush syringe to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe. 17. Perform a vigorous mechanical scrub to manually disinfect the needleless connector. Allow to air dry. Attach administration set to needleless connector . 24. Perform hand hygiene.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents receiving IV (Intravenous) medications (Residents #91, #226) and 1 of 4 residents receiving dialysis treatments (Residents #73). Findings include: 1. Review of the admission record documented Resident #91 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, bradycardia, chronic kidney disease, lipoprotein deficiency, type II diabetes mellitus, atherosclerotic heart disease, dehydration, chronic osteomyelitis, and infection following a procedure. During an observation on 12/20/22 at 9:30 AM, Resident #91 had a midline catheter dressing that was initialed and dated 12/15/22. A 4 by 4 [4 inch by 4 inch] gauze pad was observed folded in half under the clear bandage covering the catheter insertion site. Review of Resident #91's physician orders dated 12/19/22 read, midline dressing and injection cap change every day shift every Thurs [Thursday] for midline care and on 12/15/22 midline site analysis (right upper arm) every shift midline site analysis. During an interview on 12/20/22 at 9:40 AM the Director of Nursing (DON) confirmed the dressing was dated 12/15/22 and that his expectation was that the dressing should have been changed after two days due to having gauze under the dressing. Review of facility policy dated 1/15/04 and reviewed on 01/22/22 titled, Midline Catheter Dressing Change read Guidance: .2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 2.1 Upon admission 2.2 Every two days . 23. Label dressing with: 23.1 Date and time 23.2 Nurse's initials. 46523 2. Review of the admission record for Resident #73 documented the resident was admitted on [DATE] with diagnosis including but not limited to end stage renal disease, displaced trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, dependence on renal dialysis, acute on [sic] chronic diastolic heart failure, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, and essential hypertension. Review of the physician order dated 6/17/22 read complete COMS-post dialysis evaluation one time a day every Mon, Wed, Fri [Monday, Wednesday, Friday]. Review of the COMS-Pre/Post Dialysis Evaluation for Resident #73 revealed missing post dialysis evaluations for the following dates: 12/14/22, 12/9/22, 12/07/22, 11/30/22, 11/28/22, 11/25/22, 11/04/22, and 11/02/22. During an interview on 12/22/22 at 7:45 AM Staff K, Licensed Practical Nurse (LPN) stated, [Resident #73's Name] goes to dialysis on Monday, Wednesday, and Friday, is on fluid restrictions, and is sometimes noncompliant. The nursing staff do the pre-dialysis evaluation and send her [to dialysis center] with a dialysis book and a snack. When she returns, we do the post dialysis evaluation. At times, the dialysis facility will not send the required information. The nurse will try to call and get the information. The post evaluation will be done even if we do not get information from the dialysis center to assess resident and make sure blood pressure is stable. Especially since dialysis patients are sometimes not stable. During an interview on 12/22/22 at 9:30 AM the DON confirmed Resident #73 had missing pre/post dialysis evaluations on some days. Review of the facility policy titled, Documentation Standards revised 1/22/22 reads,3. Nursing staff should chart by exception, as often as necessary, in addition to scheduled charting. 3. During an observation of IV medication administration for Resident #226 on 12/21/22 at 8:04 AM Staff D, Registered Nurse (RN) removed medication from medication cart, donned PPE (personal protective equipment) and entered Resident #226's room, turned on light and put gloves on with no hand hygiene performed. Staff D doffed PPE and exited room. Staff D went to get IV tubing from medication room, returned to med cart, unlocked med cart, and retrieved medication without hand hygiene. Staff D donned PPE and grabbed gloves, enter room, and applied hand sanitizer. Placed IV medication and supplies on top of night table without cleaning table or placing a barrier. Staff D connected the medication to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff D cleaned the needleless connector with alcohol and uncapped the 10 milliliters (ml) syringe of normal saline, removed the air. Staff D administered the 10 milliliters of normal saline without checking for blood return to verify placement of the line. Staff D removed the syringe and connected the IV tubing to the PICC line needleless connector without cleaning the needless connector. During an interview on 10:08 AM Staff D, RN stated, I am not sure if I need to check for blood return. 4. During an observation of IV (intravenous) medication and oral medication administration for Resident #91 on 12/21/22 at 9:48 AM Staff G, LPN removed medication from medication cart, donned PPE, and entered Resident #91's room, performed hand hygiene, and placed on gloves. Staff G placed IV medication and supplies on top of side table without cleaning table or placing a barrier. Staff G handed oral medication to resident. Staff G removed IV fluids and supplies from resident bedside table and placed it on resident's recliner. Staff G connected the fluids to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff cleaned the needleless connector with alcohol and uncapped the 10 ml syringe of normal saline and removed the air. Staff administered the 10 ml of normal saline without checking for blood return to verify placement of the line. Staff G removed syringe and needless connector came in to contact with resident bedrail. Staff G connected the IV tubing to the midline needleless connector without cleaning the needleless connector. During an interview on 12/21/22 at 3:50 PM Staff G stated, I did not check for blood return. I was never informed to pull back. I haven't been in a hospital setting in a long time, and not aware if the new guidelines. During an interview on 12/21/22 at 2:59 PM the DON stated that the staff are expected to draw blood to verify placement of the line. Review of the facility policy titled Administration of an Intermittent Infusion last reviewed 1/22/22, reads: Procedure .4. Perform hand hygiene. 5. Assemble equipment and supplies on a clean work surface 16. Maintain asepsis, attach flush syringe to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe. 17. Perform a vigorous mechanical scrub to manually disinfect the needleless connector. Allow to air dry. Attach administration set to needless connector .24. Perform hand hygiene.

Based on observation, interview, and record review , the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 8 medication carts. Findings include: During an observation of medication cart #4 with Staff A, Licensed Practical Nurse (LPN), there were two bottles of artificial tears with no date opened or expiration date. During an interview on [DATE] at 9:50 AM Staff A, LPN, stated medication should be labeled with the date that it is opened and an expiration date as well. During an observation of medication cart #5 on [DATE] at 9:56 AM with Staff B, LPN, there was a bottle of Gentamicin 0.3% eye drops and Prednisolone AC 1% eye drops with no date opened or expiration date and a bottle of B Complex Vitamins with an expiration date ,d+[DATE]. During an interview on [DATE] at 10:04 AM Staff B, LPN, stated expired medication should be thrown away and eye drops should be dated. During an observation of medication cart #6 on [DATE] at 10:07 AM with Staff C, Registered Nurse, (RN), there was a bottle of Fexofenadine with expiration date of ,d+[DATE] and a bottle of artificial tears with no date opened or expiration date. During an interview on [DATE] at 10:12 AM with Staff C, RN stated expired medication should be removed from medication cart and all medications should be dated with an opened and expire date. During an interview on [DATE] at 10:49 AM with Director of Nursing (DON) stated all medications should be labeled upon being opened. Expired medication should be tossed. Staff are expected to check their medication carts every day. Review of the facility policy titled Storage and Expiration Dating of Medications , Biologicals last reviewed [DATE] reads: .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or return to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened 5.4 When an ophthalmic solution or suspension has a manufacturer's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container.

Based on interview, and record review the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for pressure ulcers (Resident #42) and 1 of 5 residents reviewed for IV (Intravenous) therapy (Resident #91). Findings include: 1. Review of the admission record for Resident #42 documented the resident was admitted to facility on 6/10/2022 with diagnosis that included but not limited to multiple sclerosis, essential hypertension, functional quadriplegia, dysphagia, neuromuscular dysfunction of bladder, and pressure ulcer of sacral region stage 3. Record review of the physician orders dated 11/21/2022 reads: Dakins (1/2 strength) solution 0.25 % (sodium hypochlorite) apply to sacrum topically every day shift for wound on sacrum apply Dakins wet to dry to dry to sacrum with 4x4's and cover with calcium alginate and foam dressin [sic] daily. Review of the skin and wound evaluation dated 12/20/2022 reads: A. Describe: 1. Type: 15. Pressure. 15a. Stage: 3. Stage 3: Full Thickness skin loss. Review of skin and wound evaluation dated 11/21/2022 reads: A. Describe: 1. Type: 15. Pressure. 15a. Stage: 3. Stage 3: Full Thickness skin loss. Review of skin and wound evaluation dated 11/14/2022 reads: A. Describe: 1. Type: 15. Pressure. 15a. Stage: 3. Stage 3: Full Thickness skin loss. Review of the specialty physician wound evaluation and management summary dated 12/15/2022 for Resident #42 reads: Chief Complaint: Patient presents with a wound on her sacrum. History of present illness: At the request of the referring provider, [providers name], a thorough wound care assessment and evaluation was performed today. She [Resident #42] has a stage 4 wound sacrum for at least 174 days duration. There is moderate serous exudate. There is no indication of pain associated with this condition. Review of the specialty physician wound evaluation and management summary dated 11/17/2022 for Resident #42 reads: Chief Complaint: Patient presents with a wound on her sacrum. History of present illness: At the request of the referring provider, [providers name], a thorough wound care assessment and evaluation was performed today. She [Resident #42] has a stage 4 wound sacrum for at least 167 days duration. There is moderate serous exudate. There is no indication of pain associated with this condition. During an interview on 12/21/2022 at 11:47 AM the Director of Nursing (DON) stated once a pressure sore is staged by [the specialty physicians] that is what we will consider the stage to be. We have meetings on Tuesday, and we review all wounds. [The specialty physicians] will have report with the wound care nurse. During an interview on 12/21/022 at 10:17 AM Staff H, Licensed Practical Nurse (LPN), stated that [Resident #42 name] has a stage 3 pressure ulcer which was staged by [the specialty physicians] and has improved. When Staff H, LPN reviewed [the specialty physicians] notes, Staff H confirmed [the specialty physicians] notes stated the wound was a stage 4. Staff H stated I do not know why I said stage 3. I got confused due to the report saying MDS 3. During an interview on 12/22/2022 at 9:25 AM the DON confirmed [Resident #42's name] pressure ulcer was documented as a stage 3 incorrectly. The DON stated [Resident #42's name] has a stage 4 pressure ulcer, not a stage 3. Review of the facility policy titled Documentation Standards last reviewed on 1/22/2022 reads: Policy: It is the policy of this facility that documentation will reflect medical presence, team approach, and clinical decision making to promote quality of care. Documentation standards will follow established professional ethics and practices Guidelines 4. Documentation content should be clinically pertinent. 5. Charting should contain specific and accurate details to inform staff, demonstrate awareness of resident's condition, and/or problems, and facilitate quality of care. Record significant changes in the resident changes in the resident's condition, response to treatment/medications follow-up with physician/allied health professionals, and notification of resident /representative. 40559 2. Review of the admission record documented Resident #91 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, bradycardia, chronic kidney disease, lipoprotein deficiency, type II diabetes mellitus, atherosclerotic heart disease, dehydration, chronic osteomyelitis, and infection following a procedure. Review of Resident #91's Medication Administration Record for the month of December 2022 showed Staff J, Licensed Practical Nurse (LPN) administered Sodium Chloride Solution 5% - Use 1000 milliliters (ml) intravenously every shift for hydration infused 3 liters continuously on December 16th, 2022 during the day shift. Review of Written Statement from Staff J, LPN, reads, I get another certified nurse to handle them (intravenous medications) for me. Upon the beginning of my shift on 12/16/22, there was already IV (intravenous) fluids running on my patient in room [ROOM NUMBER] (Resident #91's Room). I only monitored throughout my shift. Review of written statement from Staff E, LPN reads, I am a Nurse Supervisor at [Name of Facility] and have been hanging and flushing IV medications for [Staff J's Name] .She has not been hanging them. Review of written statement from Staff I, LPN reads, I'm the Nurse Supervisor on the 3PM to 11PM shift at [Name of Facility] and have been hanging and flushing IV medications in assistance for IV administration. I assist [Staff J's Name] with regards to IV administration and flushing. During the interview on 12/20/22 at 1:15 PM the DON confirmed Staff J, LPN, was documented as administering the IV fluids on Resident #91 Medication Administration Record.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #126, Resident #127 and Resident #226, of 3 residents reviewed explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and explicitly stated that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission or as a requirement to continue to receive care at the facility. Findings include: Review of the facility Voluntary Binding Arbitration Agreements presented to Resident #126 on 12/14/2022, presented to Resident #127 on 12/16/2022 and presented to Resident #226 on 12/16/2022 failed to explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and failed to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to or as a requirement to continue to receive care at the facility. During interview on 12/21/2022 at or about 12:07 PM, the Administrator reported the facility had revised the arbitration form to include explicitly granting the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to or as a requirement to continue to receive care at the facility, but facility staff had not used the revised form.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services that is in accordance with professional standards of practice for 3 of 6 residents reviewed for respiratory care, Residents #25, #38 and #59, out of a total sample of 36 residents. Findings: 1. Review of Resident #25's records revealed the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's physician orders dated 11/8/2020 read, Oxygen at 2 liters via nasal cannula with humidification. On 6/15/2021 at 8:10 AM, Resident #25 was observed resting quietly on an air mattress with oxygen being administered at 3 liters via nasal cannula. On 6/15/2021 at 12:15 PM, Resident #25 was observed resting in bed quietly, with oxygen being administered at 3.5 liters via nasal cannula. During an interview on 6/15/2021 at 1:28 PM, Staff B, Registered Nurse (RN), verified oxygen was being administered between 3.5 to 4 liters per minute to the resident. Staff B stated, It is too high. It is only ordered for 2 liters. [Resident #25's name] cannot get to it and change it herself. I don't know how it was that high. We should assess that when we administer medications because oxygen is a medication. I did not check it this morning, but I always do usually. During an interview on 6/15/2021 at 1:51 PM, the Director of Nursing (DON) stated, I expect our nurses to verify that the oxygen is being administered at the correct liter flow per minute, that the tubing is properly positioned on the resident and the tubing is changed per our policy and procedure. I expect the nurses to assess this. Oxygen should be considered a medication. 2. On 6/14/2021 at 10:29 AM, Resident #38 was observed being administered oxygen at 3 liters per minute. Review of the physician's order dated 3/31/2021 for Resident #38 revealed oxygen at 2 liters per minute as needed. On 6/15/2021 at 8:27 AM, Resident #38 was observed being administered oxygen at 3 liters per minute. During an interview on 6/15/2021 at 8:27 AM, Resident #38 stated she couldn't get up on her own. When asked about the settings for her oxygen, the resident stated she would never touch the machine and that staff took care of that. On 6/15/2021 at 9:09 AM, Staff A, Registered Nurse (RN), entered Resident #38's room to pass medications. Staff A exited the resident's room. Oxygen was observed being administered at 3 liters per minute during the medication pass. During an interview on 6/15/2021 at 2:08 PM, Staff A, RN, confirmed that the oxygen was set on 3 liters per minute for Resident #38. She further confirmed that the physician's order is for 2 liters per minute. During an interview on 6/15/2021 at 2:15 PM, the Director of Nursing (DON) stated that the expectation was for the oxygen concentrator to be set according to the physician's order. 3. On 6/14/2021 at 11:47 AM, Resident #59 was observed sitting in bed with oxygen being administered via nasal cannula at 3 liters per minute, with a humidification bottle attached dated 6/18/2021. On 6/15/2021 at 11:23 AM, Resident #59 was observed sitting in bed with oxygen being administered via nasal cannula at 3 liters per minute with a humidification bottle attached dated 6/18/2021. Review of Resident #59's physician's orders revealed there was no documentation in the record of a physician's order to administer oxygen to Resident #59. During an interview on 6/15/2021 at 12:23 PM, Staff C, LPN, verified Resident #59 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy # 6.0, titled General Dose Preparation and Medication Administration, with last revision date of 1/1/2013, and last approval date of 1/29/2021, reads, Procedure: 1. Facility staff should comply with facility policy, applicable law, and the State Operations Manual when administering medications . 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards, including proper refrigeration and expiration dates for four (4) out of four (4) medication carts observed out of eight (8) total medication carts. Findings: During an observation of the 100 Hallway medication cart with Staff A, Licensed Practical Nurse (LPN) on [DATE] at 9:35 AM, an unopened Humalog insulin pen for Resident #38 was observed in the medication cart, not refrigerated per pharmacy recommendations. During an interview conducted on (MONTH) 4, 2019 at 9:40 AM with Staff A LPN, she stated, Oh, that should be in the refrigerator because we have an opened unexpired Humalog Insulin pen for Resident #38. During an observation on the 300 Hallway medication cart conducted on (MONTH) 4, 2019 at 10:12 AM with Staff B, Registered Nurse, two (2) bottles of Latanoprost 0.05% eye drops for Residents #5 and #26 were observed in the medication cart with no open dates or expiration dates. During an interview conducted on (MONTH) 4, 2019 at 10:20 AM Staff B, Registered Nurse, she stated They should have the dates that they were opened on them. I don't know why they don't. During an observation on the 400 hallway medication cart on (MONTH) 4, 2019 at 11:10 AM with Staff C, LPN, a bottle of [MEDICATION NAME] Lubricant eye drops had no open date on the box or the bottle, and one (1) opened bottle of Ketotifen [MEDICATION NAME] eye drops that was labeled with an open date of (MONTH) 17, 2019 for Resident #33. During an Interview conducted on (MONTH) 4, 2019 at 11:15 AM Staff C, LPN stated, All eye drops should have the date we open them written on the box or the eye drop bottle. The Ketotifen [MEDICATION NAME] drops expire 30 days after they are opened and should have been discarded. During an observation on the 200 hallway medication cart on (MONTH) 4, 2019 at 11:35 AM with Staff D, LPN two (2) bottles of [MEDICATION NAME] Lubricant eye drops were observed with room [ROOM NUMBER] and room [ROOM NUMBER] written on the outside of the box. There were no resident names or open dates on either box or bottle. There was one (1) [MEDICATION NAME] 1% solution 200 milligrams in 20 milliliter vial with no resident name, open date, or expiration date on the bottle. During an interview on (MONTH) 4, 2019 at 11:40 PM, Staff D, LPN stated We should have residents' names on these eye drops. Our residents move frequently. It is never acceptable to label medications with only a room number. The [MEDICATION NAME] 1% solution should have been discarded and not available for resident use. It also should have been labeled with the resident's name and the date it was opened. During an interview on (MONTH) 4, 2019 at 1:15 PM the Director of Nursing stated, I expect all staff to review their medication carts daily for outdated medications. All staff should label eye drops with the resident's name and date it was opened. All insulin pens should be refrigerated until the day we open them. During an interview with the Assistant Director of Nursing on (MONTH) 4, 2019 at 2:00 PM she stated, When opening eye drops we need to put the resident's name and the date the medication was opened. We move residents all the time so having simply a room number is unacceptable. The multi dose vial of [MEDICATION NAME] should have had a date and resident's name on it. Review of Policy titled, #5.3 Storage and expiration dating of medications, biologicals, syringes and needles read 5. Once any medication or biological package is opened facility should follow manufacturer/supplier recommendations with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 5.3 If a multi-dose vial of injectable medication has been opened or accessed (Needle punctured), the vial should be dated and discarded within twenty eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that open vial. 5.4 When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within twenty eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that open vial. 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.

Based on record review and interview the facility failed to provide 3 of 3 residents, Residents #30, #58, and #331, who were transferred from the facility to the hospital, a written notice of the facility bed hold policy at the time of transfer to the hospital or within 24 hours of transfer to the hospital, in a total sample of 34 residents. Findings: Record review of the facility policy titled Bed Hold and Therapeutic Leave revealed the facility standard of practice, At admission, the resident and/or responsible party will be given a copy of the Bed Hold policy. When the resident leaves the facility with an anticipated return, written notification of the bed hold policy will be provided to the resident and responsible party in one of the following ways: Provide written document to both resident and responsible party prior to transfer. Provide responsible party with written notice within 24 hours of an emergency transfer and include resident's notice with documents accompanying the resident at time of transfer. The notice should include the number of allowable Medicaid days, if applicable, or include the number of days authorized by the resident and/or the responsible party. A copy of the notice will be retained in the medical record. Record review of Resident #30's clinical record revealed Resident #30 had been transferred from the facility to the hospital emergency department for evaluation and treatment on 09/15/2019 and 10/12/2019. Record review of Resident #30's clinical record failed to reveal documentation the facility had provided Resident #30 or his representative written notice of the facility bed hold policy at the time of transfer or within 24 hours of his transfer to the hospital for evaluation and treatment. Record review of Resident #58's clinical record revealed Resident #58 had been transferred from the facility to the hospital emergency department for evaluation and treatment on 10/30/2019. Record review of Resident #58's clinical record failed to reveal documentation the facility had provided Resident #58 or her representative written notice of the facility bed hold policy at the time of transfer or within 24 hours of her transfer to the hospital for evaluation and treatment. Record review of Resident #331's clinical record revealed Resident #331 had been transferred from the facility to the hospital emergency department for evaluation and treatment on 08/31/2019. Record review of Resident #331's clinical record failed to reveal documentation the facility had provided Resident #331 or his representative written notice of the facility bed hold policy at the time of transfer or within 24 hours of his transfer to the hospital for evaluation and treatment. During interview on 11/06/2019 at 11:56 AM, the facility Administrator stated that the facility verbally called families or residents at the time of the resident's transfer to the hospital to inform them of the facility bed hold policy. She stated that the facility was not providing residents, or their families written notice of the facility bed hold policy when the resident was transferred from the facility to the hospital for evaluation and treatment. She stated that the facility did not always document the telephone notifications of the facility bed hold policy to residents or the resident's family.

Based on resident record review, staff interview and review of the policies and procedures, the facility failed to prevent neglect by failing to ensure structures and processes were in place to provide needed care and services to one of one resident reviewed for a full code status. (Resident #2) The facility failed to honor Resident #2's Full Code Status order. The facility failed to honor Resident #2's expressed and written wishes to have cardiopulmonary resuscitation implemented in the event of [MEDICAL CONDITION]. The facility failed to ensure that nursing staff had competencies to implement cardiopulmonary resuscitation (CPR). The facility's failure to prevent neglect of Resident #2 by omission of services needed to honor her wishes represented a system wide failure. This failure resulted in findings of Immediate Jeopardy past non-compliance beginning on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. The findings included: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The imbalance is caused by an illness or organs that are not working as well as they should), [DIAGNOSES REDACTED] (an infection in the bone, a rare but serious condition), [MEDICAL CONDITION] (a condition where the heart does not pump blood as well as it should), [MEDICAL CONDITION] (symptoms of a brain problem that happen because of sudden, abnormal electrical activity in the brain), [MEDICAL CONDITION] Fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), Chronic Obstruction [MEDICAL CONDITION] Disease (a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs), and Acute Embolism and [MEDICAL CONDITION] (Thrombus is a blood clot that forms in a vein. An [MEDICAL CONDITION] is anything that travels through the blood vessels until it reaches a vessel that is too small to let it pass). Review of the Clinical Notes dated [DATE] at 9:28 p.m. for Resident #2 revealed: Patient found unresponsive by CNA, (Staff D) (Certified Nursing Assistant). CNA called nurse into room, patient with no pulse, no respirations, pupils fixed and dilated. Patient FULL CODE, code announced. at 9:33 p.m. cardiopulmonary resuscitation (CPR) started. 911 called at 9:41 p.m. CPR continued until EMS (Emergency Medical Service) arrived at 9:50 p.m. and took over CPR and placed patient on EKG monitor. Code was called by EMS at 9:55 p.m. (EMS called the time of death). Review of the resident's code status revealed: Full Code (The patient wants resuscitation measures taken). Review of the facility's Investigation Verification Form revealed: Brief Description Of Occurrence/Incident: On [DATE] around 9:30 p.m. the resident who was a full code, coded. Both the CNA (Staff D) who discovered her and the assigned Nurse (Staff A) failed to initiate CPR immediately. The nurse (Staff A) left the room to grab another nurse (Staff B) to help her run the code. The CNA (Staff D) also left the room in confusion. Staff B, LPN (Licensed Practical Nurse) Interview Date: [DATE] Nurse (Staff B) was approached by other assigned nurse (Staff A) asking her to come help her with a resident who expired. Nurse (Staff B) thought she was needed for a second opinion, but when she arrived in the room she realized the resident was a full code and initiated CPR with assigned nurse (Staff A). Staff A, LPN/attending nurse, Interview Date: [DATE] Nurse (Staff A) and CNA (Staff D) were present in hallway when they both heard the resident's audible respirations stop. Both Nurse (Staff A) and CNA (Staff D) panicked. This was nurse's (Staff A) 1st code in her career. Nurse (Staff A) left resident room to get her stethoscope and get assistance from another nurse (Staff B) on the opposite hallway. When nurses (Staff A and B) returned to resident room CPR was initiated and continued until EMS arrived and called the time of death. During an interview on [DATE] at 3:58 PM with the Administrator and the DON (Director of Nursing), the DON stated, The nurse left the room, and went to the other side of the facility to get a nurse to assist her. This was this nurses' first code. When asked if there was a time delay the DON stated, Yes, there was. The time it took the nurse to go and get the other nurse to start CPR. During an interview on [DATE] at 8:08 p.m. via telephone with Staff A, LPN/Attending nurse she stated, As far as training prior to this event, it was the CPR training you go through every two years. That is all the training I had. When I started to work at the facility my card was valid so they didn't do any training prior to my hire or after I was hired. If you find a resident non-responsive there is a button you can push in the resident's room, I did that. There is a light that is flashing. When I worked at the hospital there were codes. When I found a patient that was having trouble I called the code and rapid response comes in and takes over. The CNA (Staff D) was in the hallway charting. I was down the hall a little and I was getting my medication ready for her. Her respirations were very audible from the hallway. They got quiet. The CNA (Staff D) was closer to the room then I was. The CNA (Staff D) was back at the door and said I needed to come. Resident #2 was slumped over to the right side, she was very limp, you could tell she was gone. I went up to her, I put my hand on her. I knew she wasn't breathing. I did not start CPR. My first thought was to get help, and to get my stethoscope to see if she was breathing or not. I got my stethoscope and grabbed another nurse (Staff B) because I knew I needed help. When we got to the room that is when we started CPR. The other nurse (Staff B) I went to get help from was over on the other hall. When asked how long it was before CPR was started Staff A stated, A couple of minutes; maybe three minutes. When asked the policy and procedure for starting CPR Staff A stated, You start CPR and get help. When asked if she was properly trained on how to perform CPR, Staff A stated, At this facility I don't think they trained or prepared me on how to respond to a code or to give CPR. I had no experience on how to do a code. I never did one before. It was not covered in orientation. During an interview on [DATE] at 9:00 AM with the DON (Director of Nursing) when asked when the nurse was in room, and she pushed the button why didn't anyone respond, why did the nurse leave the area to find another nurse for assistance? The DON stated, That is when we found an issue with the system. It was only going on, on that hall and not the entire floor. We had to call the alarm company to get it fixed. During an interview on [DATE] at 12:15 PM with the Administrator and the DON when asked if there was a system in place to check to see if the code blue light system was functioning properly prior to the incident, the DON stated, I don't know if there was anything in place to check them. I will have to check into that and get back with you. No additional information was provided. The Administrator was informed of the immediate jeopardy on [DATE] at 2:58 p.m. Cross reference F607 and F726. During an interview on [DATE] at 1:30 PM via telephone with the Medical Director (MD) when asked regarding a resident who is found unresponsive he stated, I would feel if you find a patient unresponsive and they are a full code you are to start CPR immediately, right then and there. That would be my expectation. Review of the policy and procedure titled, Cardiopulmonary Resuscitation last reviewed and approved [DATE] revealed: It is the policy of this facility to provide an efficient and organized team approach in response to a medical emergency requiring Cardiopulmonary Resuscitation (CPR). The facility recognizes that the use of Automated External Defibrillator (AED) along with Cardiopulmonary Resuscitation (CPR) methods may increase resident's chance for survival. Procedures: 3. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Review of the Cardiopulmonary Resuscitation - Clinical Practice Guidelines revealed 5. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status if not IMMEDIATELY known. The practice of hiring staff and not verifying their competencies and skill sets for the implementation of the policy and procedures related to cardiopulmonary resuscitation placed the residents at risk for neglect. The staff failure to immediately implement CPR placed the resident at risk for death and other residents were at risk of death or serious injury. Review of the facility's Plan of Action/Correction revealed: 1. Nursing staff educated on CPR/AED (Cardiopulmonary Resuscitation/Automated External Defibrillator) policy and steps when coding a resident. Expected Date of Completion [DATE]. 2. Assigned Nurse will have 1:1 education on coding full code residents, crash cart, documentation of code timeliness. Expected Date of Completion: [DATE]. 3. Mock code blue drills will be conducted on going until nurse competencies completed. Expected Date of Completion [DATE]. The date of review for the completion of the Plan of Action/Correction revealed: [DATE]. Review of the Plan of Action/Correction documentation for implementation dated [DATE] and [DATE], revealed a total of 23 current employees signed as having attended mock CPR drills from a total of 63 currently employed staff. Review of the in-service titled CPR/AED Policy Review dated [DATE] revealed 43 current employees signed as having attended. Review of the sign in sheet for the assigned nurse (Staff A) having attended 1:1 training in coding full code residents, crash cart, and documentation of code timeliness revealed the nurse signed as having completed the training on [DATE]. Review of the Orientation Packet showed Cardiopulmonary Resuscitation/AED was added to the curriculum on [DATE]. During an interview on [DATE] at 11:03 AM with the DON she stated, The policy has not changed related to CPR/AED. What has changed is the CPR/AED training is now being provided during orientation in the orientation packet. Review of the orientation provided to employees hired after [DATE] revealed 18 employees signed as having received training in the policy and procedure titled, CPR/AED. Review of the agency staffing scheduled in the facility revealed a total of 36 agency staff, 12 LPNs and 23 CNAs were listed from [DATE] to [DATE]. Seven agency staff were interviewed to reveal they received and/or participated in a Mock CPR drills. Review of the in-service sign in sheets dated [DATE] titled, Facility Policy and Procedure and Use of AED Objectives: Knowledge and use of AdventHealth Policy and procedure regarding use of AED revealed 44 staff signed as having received the training. Review of the in-service dated [DATE] titled, Code Blue - CPR/AED Drill Objective: Code Blue - CPR/AED drill revealed 11 staff signed as having received the training.

Based on resident record review, staff interview and review of policies and procedures, the facility failed to implement written policies and procedures to prevent neglect by failing to ensure that structures and processes were in place to provide needed care and services to one of one resident reviewed for a full code status. (Resident #2) The facility failed to honor Resident #2's Full Code Status order. The facility failed to honor Resident #2's expressed and written wishes to have cardiopulmonary resuscitation implemented in the event of [MEDICAL CONDITION]. The facility nursing staff failed to follow policies and procedures for Cardiopulmonary Resuscitation (CPR) and failed to ensure that nursing staff had competencies to implement CPR. The facility's failure to prevent neglect of Resident #2 by omission of services needed to honor her wishes represented a system wide failure. This failure resulted in findings of Immediate Jeopardy past non-compliance beginning on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. The findings included: Review of the policy and procedure titled, Cardiopulmonary Resuscitation last reviewed and approved [DATE] revealed: It is the policy of this facility to provide an efficient and organized team approach in response to a medical emergency requiring Cardiopulmonary Resuscitation (CPR). The facility recognizes that the use of Automated External Defibrillator (AED) along with Cardiopulmonary Resuscitation (CPR) methods may increase resident's chance for survival. Procedures: 3. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Review of the Cardiopulmonary Resuscitation - Clinical Practice Guidelines revealed 5. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The imbalance is caused by an illness or organs that are not working as well as they should), [DIAGNOSES REDACTED] (an infection in the bone, a rare but serious condition), [MEDICAL CONDITION] (a condition where the heart does not pump blood as well as it should), [MEDICAL CONDITION] (symptoms of a brain problem that happen because of sudden, abnormal electrical activity in the brain), [MEDICAL CONDITION] Fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), Chronic Obstruction [MEDICAL CONDITION] Disease (a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs), and Acute Embolism and [MEDICAL CONDITION] (Thrombus is a blood clot that forms in a vein. An [MEDICAL CONDITION] is anything that travels through the blood vessels until it reaches a vessel that is too small to let it pass). Review of the Clinical Notes dated [DATE] at 9:28 p.m. for Resident #2 revealed: Patient found unresponsive by CNA (Certified Nursing Assistant). CNA called nurse into room, patient with no pulse, no respirations, pupils fixed and dilated. Patient FULL CODE, code announced. at 9:33 p.m. cardiopulmonary resuscitation (CPR) started. 911 called at 9:41 p.m. CPR continued until EMS (Emergency Medical Service) arrived at 9:50 p.m. and took over CPR and placed patient on EKG monitor. Death was called by EMS at 9:55 p.m. Review of the resident's code status revealed: Full Code (The patient wants resuscitation measures taken). Review of the facility's Investigation Verification Form revealed: Brief Description of Occurrence/Incident: On [DATE] around 9:30 p.m. the resident who was a full code, coded. Both the CNA who discovered her and the assigned Nurse failed to initiate CPR immediately. The nurse left the room to grab another nurse to help her run the code. The CNA also left the room in confusion. Staff B, LPN (Licensed Practical Nurse) Interview Date: [DATE] Nurse was approached by other assigned nurse asking her to come help her with a resident who expired. Nurse thought she was needed for a second opinion, but when she arrived in the room she realized the resident was a full code and initiated CPR with assigned nurse. Staff A, LPN (the attending nurse), Interview Date: [DATE] Nurse and CNA were present in hallway when they both heard the resident's audible respirations stop. Both Nurse and CNA panicked. This was nurse's 1st code in her career. Nurse left resident room to get her stethoscope and get assistance from another nurse on the opposite hallway. When nurses returned to resident room CPR was initiated and continued until EMS arrived and called the time of death. The Administrator was informed of the immediate jeopardy on [DATE] at 2:58 p.m. Cross reference F600 and F726. During an interview on [DATE] at 3:58 PM with the Administrator and the DON (Director of Nursing), the DON stated, The nurse left the room, and went to the other side of the facility to get a nurse to assist her. This was this nurses' first code. When asked if there was a time delay the DON stated, Yes, there was. The time it took the nurse to go and get the other nurse to start CPR. During an interview on [DATE] at 8:08 p.m. via telephone with Staff A, LPN/Attending nurse she stated, As far as training prior to this event, it was the CPR training you go through every two years. That is all the training I had. When I started to work at the facility my card was valid so they didn't do any training prior to my hire or after I was hired. If you find a resident non-responsive there is a button you can push in the resident's room, I did that. There is a light that is flashing. When I worked at the hospital there were codes. When I found a patient that was having trouble I called the code and rapid response comes in and takes over. The CNA was in the hallway charting. I was down the hall a little and I was getting my medication ready for her. Her respirations were very audible from the hallway. They got quiet. The CNA was closer to the room then I was. The CNA was back at the door and said I needed to come. Resident #2 was slumped over to the right side, she was very limp, you could tell she was gone. I went up to her, I put my hand on her. I knew she wasn't breathing. She was a full code. I knew she was a full code. I did not start CPR. I should have started CPR, I know that is the policy and procedure but, my first thought was to get help, and to get my stethoscope to see if she was breathing or not. I got my stethoscope and grabbed another nurse because I knew I needed help. When we got to the room that is when we started CPR. The other nurse I went to get for help was over on the other hall. When asked how long it was before CPR was started the nurse stated, A couple of minutes maybe three minutes. When asked the policy and procedure regarding starting CPR she stated, You start CPR and get help. When asked if she was properly trained on how to perform CPR she stated, At this facility I don't think they trained or prepared me on how to respond to a code or to give CPR. I had no experience on how to do a code. I never did one before. It was not covered in orientation. During an interview on [DATE] at 9:00 AM with the DON when asked the policy and procedure regarding a resident with a full code status the DON stated, When you find someone who is unresponsive you check for a purple band, push the code blue light, and I would probably be yelling At that point if someone was a full code we would start CPR. During an interview on [DATE] at 1:30 PM via telephone with the Medical Director (MD) when asked regarding a resident who is found unresponsive he stated, I would feel if you find a patient unresponsive and they are a full code you are to start CPR immediately, right then and there. That would be my expectation. The practice of hiring staff and not verifying their competencies and skill sets for the implementation of the policy and procedures related to cardiopulmonary resuscitation placed the residents at risk for neglect. During an interview on [DATE] at 10:34 AM with the Administrator, the DON, the Director of Clinical Education, and the Chief Operating Officer (COO) it revealed the facility has 63 current direct care employees. The COO stated, The intent of our education, when we develop a QA (Quality Assurance) there is no regulation as to how you develop the education. What we try to do is to see how best we do that education. In our view when the P[NAME] (Plan of Correction) was developed it was that we would accomplish the same thing to go through the education and understand the policy and understand the procedure behind it, which is our policy. To offer an opportunity to do that training through a different format. When we developed a plan we know that people learn in different ways. We did one to one (1:1) education with the nurse (Staff A) who was present at the time. She was the nurse involved. We did drills, and we did in-services. We did more education yesterday. We provided the same information with review of the policy and procedure, and the AED. Of our 63 employees we in one way or the other educated 62 of the employees. We missed one CNA and we educated 100% of the nurses. We did miss one CNA. We did 62 of the staff. Review of the facility's Plan of Action/Correction revealed: 1. Nursing staff educated on CPR/AED (Cardiopulmonary Resuscitation/Automated External Defibrillator) policy and steps when coding a resident. Expected Date of Completion [DATE]. 2. Assigned Nurse will have 1:1 education on coding full code residents, crash cart, documentation of code timeliness. Expected Date of Completion: [DATE]. 3. Mock code blue drills will be conducted on going until nurse competencies completed. Expected Date of Completion [DATE]. The date of review for the completion of the Plan of Action/Correction revealed: [DATE]. Review of the Plan of Action/Correction documentation for implementation dated [DATE] and [DATE] revealed a total of 23 current employees signed as having attended mock CPR drills from a total of 63 currently employed staff. Review of the in-service titled CPR/AED Policy Review dated [DATE] revealed 43 current employees signed as having attended. Review of the sign in sheet for the assigned nurse (Staff A) having attended 1:1 training in coding full code residents, crash cart, and documentation of code timeliness revealed the nurse signed as having completed the training on [DATE]. Review of the Orientation Packet showed Cardiopulmonary Resuscitation/AED was added to the curriculum on [DATE]. During an interview on [DATE] at 11:03 AM with the DON she stated, The policy has not changed related to CPR/AED. What has changed is the CPR/AED training is now being provided during orientation in the orientation packet. Review of the orientation provided to employees hired after [DATE] revealed 18 employees signed as having received training in the policy and procedure titled, CPR/AED. Review of the agency staffing scheduled in the facility revealed a total of 36 agency staff, 12 LPNs and 23 CNAs were listed from [DATE] to [DATE]. Seven agency staff were interviewed to reveal they received and/or participated in a Mock CPR drills. Review of the in-service sign in sheets dated [DATE] titled, Facility Policy and Procedure and Use of AED Objectives: Knowledge and use of AdventHealth Policy and procedure regarding use of AED revealed 44 staff signed as having received the training. Review of the in-service dated [DATE] titled, Code Blue - CPR/AED Drill Objective: Code Blue - CPR/AED drill revealed 11 staff signed as having received the training.

Based on resident record review, staff interview and review of policies and procedures, the facility failed to ensure nursing staff had the appropriate competencies and skills sets necessary to meet residents' needs for one of one resident reviewed for a full code status (Resident #2). The facility also failed to ensure staff were able to demonstrate competency in skills and techniques necessary to care for residents' needs for cardiopulmonary resuscitation for Staff A, Licensed Practical Nurse (LPN) and Staff D, Certified Nursing Assistant (CNA). The facility nursing staff failed to follow policies and procedures for Cardiopulmonary Resuscitation (CPR). The facility's failure to ensure staff competencies represented a system wide failure. This failure resulted in findings of Immediate Jeopardy past non-compliance beginning on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. The findings included: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The imbalance is caused by an illness or organs that are not working as well as they should), [DIAGNOSES REDACTED] (an infection in the bone, a rare but serious condition), [MEDICAL CONDITION] (a condition where the heart does not pump blood as well as it should), [MEDICAL CONDITION] (symptoms of a brain problem that happen because of sudden, abnormal electrical activity in the brain), [MEDICAL CONDITION] Fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), Chronic Obstruction [MEDICAL CONDITION] Disease (a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs), and Acute Embolism and [MEDICAL CONDITION] (Thrombus is a blood clot that forms in a vein. An [MEDICAL CONDITION] is anything that travels through the blood vessels until it reaches a vessel that is too small to let it pass). Review of the Clinical Notes dated [DATE] at 9:28 p.m. for Resident #2 revealed: Patient found unresponsive by CNA (Certified Nursing Assistant) (Staff D). CNA called nurse into room, patient with no pulse, no respirations, pupils fixed and dilated. Patient FULL CODE, code announced. at 9:33 p.m. cardiopulmonary resuscitation (CPR) started. 911 called at 9:41 p.m. CPR continued until EMS (Emergency Medical Service) arrived at 9:50 p.m. and took over CPR. Death was called by EMS at 9:55 p.m. Review of the resident's code status revealed: Full Code (The patient wants resuscitation measures taken). Review of the facility's Investigation Verification Form revealed: Brief Description Of Occurrence/Incident: On [DATE] around 9:30 p.m. the resident (Resident #2) who was a full code, coded. Both the CNA (Staff D) who discovered her and the assigned Nurse (Staff A) failed to initiate CPR immediately. The nurse (Staff A) left the room to grab another nurse (Staff B) to help her run the code. The CNA (Staff D) also left the room in confusion. Staff B, LPN (Licensed Practical Nurse) Interview Date: [DATE] Nurse (Staff B) was approached by other assigned nurse (Staff A) asking her to come help her with a resident who expired. Nurse (Staff B) thought she was needed for a 2nd opinion but when she arrived in the room she realized the resident was a full code and initiated CPR with assigned nurse (Staff A). Staff A, LPN/attending nurse, Interview Date: [DATE] Nurse (Staff A) and CNA (Staff D) were present in hallway when they both heard the resident's audible respirations stop. Both Nurse (Staff A) and CNA (Staff D) panicked. This was nurse's (Staff A) 1st code in her career. Nurse (Staff A) left resident room to get her stethoscope and get assistance from another nurse (Staff B) on the opposite hallway. When nurses (Staff A and Staff B) returned to resident room CPR was initiated and continued until EMS arrived and called the time of death. The Administrator was informed of the immediate jeopardy on [DATE] at 2:58 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the survey. Cross reference F 600 and F607. During an interview on [DATE] at 3:58 PM with the Administrator and the DON (Director of Nursing), the DON stated, The nurse left the room, and went to the other side of the facility to get a nurse to assist her. This was this nurses' first code. When asked if there was a time delay the DON stated, Yes, there was. The time it took the nurse to go and get the other nurse to start CPR. During an interview on [DATE] at 8:08 p.m. via telephone with Staff A, LPN/attending nurse she stated, As far as training prior to this event, it was the CPR training you go through every two years. That is all the training I had. When I started to work at the facility my card was valid so they didn't do any training prior to my hire or after I was hired. If you find a resident non-responsive there is a button you can push in the resident's room, I did that. There is a light that is flashing. When I worked at the hospital there were codes. When I found a patient that was having trouble I called the code and rapid response comes in and takes over. The CNA was in the hallway charting. I was down the hall a little and I was getting my medication ready for her. Her respirations were very audible from the hallway. They got quiet. The CNA was closer to the room then I was. The CNA was back at the door and said I needed to come. Resident #2 was slumped over to the right side, she was very limp, you could tell she was gone. I went up to her, I put my hand on her. I knew she wasn't breathing. She was a full code. I knew she was a full code. I did not start CPR. I should have started CPR, I know that is the policy and procedure but, my first thought was to get help, and to get my stethoscope to see if she was breathing or not. I got my stethoscope and grabbed another nurse because I knew I needed help. When we got to the room that is when we started CPR. The other nurse I went to get for help was over on the other hall. When asked how long it was before CPR was started the nurse stated, A couple of minutes maybe three minutes. When asked the policy and procedure for starting CPR she stated, You start CPR and get help. When asked if she was properly trained on how to perform CPR she stated, At this facility I don't think they trained or prepared me on how to respond to a code or to give CPR. I had no experience on how to do a code. I never did one before. It was not covered in orientation. During an interview on [DATE] at 1:30 PM via telephone with the Medical Director (MD) when asked regarding a resident who is found unresponsive he stated, I would feel if you find a patient unresponsive and they are a full code you are to start CPR immediately, right then and there. That would be my expectation. Review of the Plan of Action and Follow-up Record - Subject Area Identified: Advance Directives/Abuse/Neglect/Resident Safety, dated [DATE] revealed Problem: A resident who coded and was full code had a 3 to 5 minute delay before CPR was initiated due to staff panic and an inaccurately documented timeline. Plan of Action/Correction: 1. Nursing staff education on CPR/AED policy and steps when coding a resident. 2. Assigned Nurse will have 1:1 education on coding full code residents, crash cart, documentation of code timelines. 3. Mock code blue drills will be conducted on going until nurse competencies completed. Review of the facility's Plan of Action/Correction revealed: 1. Nursing staff educated on CPR/AED (Cardiopulmonary Resuscitation/Automated External Defibrillator) policy and steps when coding a resident. Expected Date of Completion [DATE]. 2. Assigned Nurse will have 1:1 education on coding full code residents, crash cart, documentation of code timeliness. Expected Date of Completion: [DATE]. 3. Mock code blue drills will be conducted on going until nurse competencies completed. Expected Date of Completion [DATE]. The date of review for the completion of the Plan of Action/Correction revealed: [DATE]. Review of the Plan of Action/Correction documentation for implementation dated [DATE] and [DATE] revealed a total of 23 current employees signed as having attended mock CPR drills from a total of 63 currently employed staff. Review of the in-service titled CPR/AED Policy Review dated [DATE] revealed 43 current employees signed as having attended. Review of the sign in sheet for the assigned nurse (Staff A) having attended 1:1 training in coding full code residents, crash cart, and documentation of code timeliness revealed the nurse signed as having completed the training on [DATE]. Review of the Orientation Packet showed Cardiopulmonary Resuscitation/AED was added to the curriculum on [DATE]. During an interview on [DATE] at 11:03 AM with the DON she stated, The policy has not changed related to CPR/AED. What has changed is the CPR/AED training is now being provided during orientation in the orientation packet. Review of the orientation provided to employees hired after [DATE] revealed 18 employees signed as having received training in the policy and procedure titled, CPR/AED. Review of the agency staffing scheduled in the facility revealed a total of 36 agency staff, 12 LPNs and 23 CNAs were listed from [DATE] to [DATE]. Seven agency staff were interviewed to reveal they received and/or participated in a Mock CPR drills. Review of the in-service sign in sheets dated [DATE] titled, Facility Policy and Procedure and Use of AED Objectives: Knowledge and use of AdventHealth Policy and procedure regarding use of AED revealed 44 staff signed as having received the training. Review of the in-service dated [DATE] titled, Code Blue - CPR/AED Drill Objective: Code Blue - CPR/AED drill revealed 11 staff signed as having received the training. During an interview on [DATE] at 2:53 PM with the DON the sign in sheets were reviewed for the nursing staff education and mock code blue drills. When asked regarding 43 staff of the 63 total direct care staff having attended the in-service training and not all staff the DON stated, Our plan was to provide education to the nurses. When asked regarding mock drills being provided twice on [DATE] and once on [DATE] with only 23 different employees receiving the training the DON stated, The training was provided by two different RNs and they didn't sign in as having attended. Some people who were here for both of those shifts when we did the drills. When asked regarding additional staff training in mock drills the DON stated, Our plan shows that it is ongoing. The Plan of Action and Follow-Up Record was reviewed and the DON stated, We didn't put how often we were going to do the drills. We are planning on doing them every thirty days. We just haven't done anymore yet. During an interview on [DATE] at 10:30 AM with Staff E, LPN she stated, I have worked here since (MONTH) of last year. I did not receive training when I was hired in code blue or the AED use. I did it in my CPR course. I have never had to do CPR on a person, and haven't had anyone code on me, and haven't ever been involved in a code. I have been updated on the Code Blue policy, but have not been involved in any Mock code. I want to have the opportunity to be involved in them. It's hard to say what I would do in a code, and I really don't feel comfortable at all. Sometimes we have supervisors that don't have very much experience, and they have to take a medication cart so they aren't available to us. I am a hands on learner, so getting more training would be great. No one ever asked me about my experience when I was hired really about anything, but definitely not my experience with CPR. I know someone panicked and didn't start CPR, and I am afraid I would freeze. I hope I won't, but I think I could have been that nurse, any of us could have. I feel so awful about that incident and it is on my mind a lot. I really don't think about that before this happened, I never thought about whether I was prepared for a code, but now, I can say I don't think that they have prepared me adequately in an emergency, especially when there is so much change in staff. We always seem to have new people. During an interview on [DATE] at 11:45 AM with Staff F, CNA she stated, 'I have worked here since (MONTH) or (MONTH) of last year. I was CPR certified before I came to work here. I have never had to do CPR. I hope I wouldn't get frazzled. I would start CPR immediately if I didn't see a purple wristband. I was trained last month on the policy and they did a mock code. During the mock, they demonstrated how to call a code, where to find the code cart and defibrillator, and how to page overhead. I did not return demonstrate CPR or how to place the defibrillator pads on. I still don't feel comfortable. We had a CNA and a Nurse last month panic and not start CPR. After that incident I think it made me think. Before that happened I really don't think they prepared us for codes, and we need a lot more hands on training. I was never asked about my experience in performing CPR, and what I might like more training in at the time I was hired. During an interview on [DATE] at 12:55 PM with Staff G, CNA she stated, I've worked here since (MONTH) of this year; it's been okay. I did not get any training on codes or where to find the defibrillator or how to use it. I got my CPR card at my last job. I'm not very comfortable with what to do in an emergency, and I haven't ever done CPR on a real person. I was at the policy in-service, but did not do any mock code. I wish I had. It's scary to think about really doing it. I am not comfortable at all. I hope I can do the right thing when the time comes, but I'm not really prepared for that day. I was not asked about any education or training I would like to get when I was hired. Three to four weeks ago I was in serviced on the policy and they answered any questions we had, it took about 15 minutes. I have not had a mock code where they do a real code as training, but I want to be in one. I hope they do them every month. We get a lot of new people, new CNAs and new nurses so I think it would make us all feel better. During an interview on [DATE] at 1:45 PM with Staff H, LPN she stated, I have worked here about four months now. I never received training in orientation about CPR, but last month we had a resident that didn't get CPR done immediately. I think the nurse and the aide didn't know what to do. The aide pushed the code button, but the nurse shut it off and went to get another nurse to check the patient. After that we reviewed the policy in an in-service and they did a mock code. The in-service just explained the policy, and how we call a code blue, the mock code was about ,[DATE] minutes long and I did not use the defibrillator or do CPR in that. I have not had a code here and have never done CPR. I would like to hope I am prepared. I wasn't asked about what additional training or classes I would like. When I was hired I wasn't asked about my experience with CPR. During an interview on [DATE] at 3:15 PM with Staff I, CNA she stated, I just started working here in January. I did not get any training in orientation on codes. I have not done the practice codes that some people have done. I just had an in-service to review the policy and tell us how to call for assistance. I have never had to do CPR, and am not at all comfortable doing it. I pray someone else will find any problems before I do. I would hope that I can react quickly. I want to do those practice codes, and actually do CPR and put on the pads for the defibrillator. Until the in-service I had no idea where to find the defibrillator. I knew the cart was at the nurses station, but didn't know the machine to defibrillate was on the wall. I thought it was on the cart. I want more training so I can feel more comfortable. No one had ever asked if I needed any more training for anything. During an interview on [DATE] at 3:35 PM with Staff J, CNA she stated, I started here in January. I had no training in orientation on Code Blue or on the defibrillator. I did get an in-service a few weeks ago, I can't remember when, on the code policy. They read it to us and answered some questions we had. I have not done the mock codes. I hope to do them. I have never done CPR, but I hope I wouldn't panic and would just start it. I have never done CPR on a real person, and have never been involved in a code here or anywhere else. No one asked when I was hired if I wanted or needed any training for my job. During an interview on [DATE] at 3:55 PM with Staff K, CNA she stated, I just started working here two weeks ago. We reviewed the code policy during my orientation, but we went over so much I can't remember much. I now know where the code cart and defibrillator are. I have never done CPR at all except in my class to get my card. I am not comfortable doing CPR, but I hope I would start it until someone else got there. I have not received any other training, but I know they did some practice with some staff. No one asked me when I was hired if I was comfortable with codes or any training I might think would help me do a better job, or improve my performance. Review of the policy and procedure titled, Cardiopulmonary Resuscitation last reviewed and approved [DATE] revealed: It is the policy of this facility to provide an efficient and organized team approach in response to a medical emergency requiring Cardiopulmonary Resuscitation (CPR). The facility recognizes that the use of Automated External Defibrillator (AED) along with Cardiopulmonary Resuscitation (CPR) methods may increase resident's chance for survival. Procedures: 3. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Review of the Cardiopulmonary Resuscitation - Clinical Practice Guidelines revealed 5. If a resident experiences a cardiac or respiratory arrest, Cardiopulmonary Resuscitation (CPR) will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status if not IMMEDIATELY known. The practice of hiring staff and not verifying their competencies and skill sets for the implementation of the policy and procedures related to cardiopulmonary resuscitation placed the residents at risk for neglect.