Every finding on record at Southern Pines Nursing Center

Based on observations, interviews, and record review, the facility failed to provide supervision to a known wandering resident resulting in an incident of potential sexual abuse for two residents (#8 and #9) out of three residents sampled. On 05/30/2026, facility staff became aware that Resident #9, who was cognitively impaired, had entered Resident #8's bed while both residents were fully unclothed. The facility did not implement immediate protective measures consistent with their policy. Findings included: On 06/24/2026 at 02:36 PM, Resident #9 was observed self propelling through D Hall without staff present. Resident #9 did not answer questions, and continued past her own room, and approached the threshold of another resident's room. At 02:48 PM the same day, Resident #9 was observed self propelling from the dining room toward the area between A Hall and B Hall, without staff supervision. During an interview on 06/24/2026 at 02:12 PM, Resident #8 stated that on 05/30/2026, Resident #9 came into his room, removed her clothing, and got into his bed. He reported that both he and Resident #9 were fully unclothed and lying together for approximately half an hour before staff entered the room and removed Resident #9. Resident #8 reported that a staff member then sat in a chair next to his bed and would not allow him to leave the bed for about 15 minutes. During an interview on 06/24/2026 at 02:28 PM, Staff A Certified Nursing Assistant (CNA) stated Resident #9 was ambulatory with minimal assistance and frequently self propelled around the facility. Staff A stated Resident #9 entered any random room all the time, attempted to enter other rooms almost daily, and that she had received no direction regarding increased supervision since the incident on 05/30/2026. During an interview on 06/24/2026 at 02:43 PM, Staff B, CNA stated Resident #9 piddles around everywhere, had wandered into rooms on a different wing, and had attempted to get into another resident's bed previously. During an interview on 06/24/2026 at 02:47 PM, Staff C, CNA stated that Resident #9 wandered around the facility. During an interview on 06/24/2026 at 03:06 PM, Staff D Licensed Practical Nurse (LPN) stated Resident #9 was very confused, had dementia, frequently propelled herself up and down halls, entered other residents' rooms, and attempted to exit the building. Staff D stated redirection was sometimes ineffective. Staff D confirmed Resident #9 did end up in the bed with [Resident #8] and was not clothed. Staff D also stated staff were not allowed to enter certain information into the medical record and added, this place has a habit of sweeping things under the rug. An interview on 06/24/2026 at 03:54 PM, with Staff E, LPN revealed Resident #9 wandered frequently and on 05/30/2026 she got into [Resident #8's] bed. Staff E reported when Staff F called for assistance, she found Resident #9 lying on the right side of Resident #8's bed, unclothed from the waist down, with her head at the head of the bed and back toward Resident #8's roommates. Resident #8 was in the bed with a blanket wrapped around his genital area and no other clothing visible. Staff E reported she had been in the room [ROOM NUMBER] to 30 minutes prior and did not know how long Resident #9 had been in the bed. She stated Resident #9 frequently entered other residents' beds and rooms. Staff E stated Staff F had previously reported Resident #8 made sexually inappropriate comments. During an interview on 06/24/2026 at 05:23 PM, Staff F, CNA) stated that on 05/30/2026 at approximately 09:00 PM, she returned from a 30 minute break and observed Resident #8's curtain closed, which was unusual. Upon opening the curtain, she found Resident #8 and Resident #9 completely naked in Resident #8's bed. Resident #9 was lying flat on her back with all body parts exposed, and her clothing, including her adult briefs were placed on her wheelchair. Resident #8 was sitting at the foot of the bed with his back to Resident #9. Staff F stated she removed Resident #9 from the room and assisted Resident #8 with incontinence care. She reported that supervision of Resident #9 involved redirection, one on one monitoring for short periods, and 15 minute checks, but stated that sometimes it could slip and she did not know who supervised her residents while she was on break. On 06/24/2026 at 05:52 PM, an interview was conducted with the Nurse Practitioner for both residents who stated she was informed by facility staff that the residents had been found together briefly and fully clothed. She stated that had she known they were unclothed and together for approximately 30 minutes, she would have conducted a more extensive assessment and obtained additional history. She stated a reasonable person could have experienced emotional harm, stress, anxiety, or confusion as a result of the incident. During an interview on 06/24/2026 at 09:37 PM, the Social Services Director (SSD) stated she contacted the NP and reported Resident #9 had briefly gotten into Resident #8's bed and admitted she did not provide additional details. During an interview on 06/24/2026 at 08:06 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) stated the DON was notified at 08:55 PM on 05/30/2026 that Resident #9 had been found in Resident #8's room. They confirmed Resident #9 was completely unclothed below the waist and Resident #8 had only a brief on. They stated they did not know how long they had been together, did not know who was supervising the residents while Staff F was on break. They stated they did not interview Resident #9's roommates. They confirmed the investigation did not begin until 06/02/2026. They stated they implemented interventions for 15 minute checks for Resident #9. They stated there was a possibility a reasonable person would have had a negative outcome. They stated supervision was performed through staff members but not directly assigned to specific residents. The NHA stated there was not adequate supervision. Record review revealed that Resident #8 had moderate cognitive impairment and a history of sexually inappropriate behaviors, while Resident #9 had severe cognitive impairment, dementia related wandering, and required increased supervision as outlined in her care plan. Documentation from 05/30/2026 did not reflect monitoring consistent with the resident's needs or facility policy. Review of a facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatments, and Injury, revised 03/2025, revealed (2.) Neglect means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observations, interviews and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed and two errors were identified for one resident (#118) out of seven residents observed. These errors constituted a 5.56% medication error rate.Findings included:On 5/20/2026 at 9:00 AM, an observation was made of Staff G, Licensed Practical Nurse (LPN) pull the following medication for Resident #118:Omeprazole 20 mg (milligrams) one tabletGuaifenesin 400 mg one tabletA record review of Resident #118's current physician orders showed the following:Pantoprazole Sodium oral packet 40 mg , give 40 mg by mouth two times a day for GERD (Gastroesophageal reflux disease), ordered 5/13/2026Guaifenesin ER (extended release) 12 hour 600 mg, give one tablet by mouth two times a day for chest congestion for 10 days, ordered 5/13/2026On 5/20/2026 at 9:30 AM, Staff G, LPN confirmed she gave one tablet of the Omeprazole 20 mg and Guaifenesin 400 mg. Staff G, LPN opened her assigned medication cart and presented each over the counter bottle to review the milligrams and medications. On 5/20/2026 at 4:30 PM, an interview was conducted with the Director of Nursing (DON). The DON was notified of the medication error rate. A review of the facility's policy titled, Standards and Guidelines: Medication Administration, issued 10/2020 and revised on 01/2024 showed the following standard statement: Medications are ordered and administered safely and as prescribedProcedure:.9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified, monitored, and sustained corrective actions related to food storage, food preparation, and sanitary practices. This failure resulted in the recurrence of previously identified sanitation concerns in one of one kitchen observed.Findings included: The facility's Plan of Correction for F812, completed on 06/20/2026, included cleaning the kitchen, educating dietary staff, performing routine sanitation audits, and reporting findings through QAPI until compliance was achieved. Despite these measures, similar deficiencies were again observed.On 05/17/2026 at 9:31 AM, the kitchen handwashing sink area was observed with debris on the cabinet face, countertop, faucet, and wall backsplash. Pink dried liquid was present on the countertop, brown residue was on the cabinet door, and paper trash was sitting on the faucet fixture. The wall behind the sink had visible brown buildup. On 05/19/2026 at 11:49 AM, debris was observed on pipes and light fixtures directly above the food preparation area.During interviews on 05/17/2026 and 05/19/2026, the Senior Certified Dietary Manager (SCDM) stated that daily and monthly cleaning schedules existed but acknowledged areas needing improvement. The Certified Dietary Manager (CDM) reported limited storage space for chemicals. On 05/20/2026 at 2:36 PM, the Nursing Home Administrator (NHA) stated that concerns should have been identified earlier and that kitchen staff were responsible for maintaining cleanliness of the handwashing sink, the mop bucket area, and overhead surfaces.During a tour of the kitchen on 06/24/2026 at 9:42 AM, observations and interviews with Certified Dietary Manager (CDM) and the Senior Certified Dietary Manager (SCDM) revealed on-going sanitation concerns. Dust and debris was observed on pipes and light fixtures above the food preparation station. They stated maintenance cleans pipping and light fixtures once a month. They stated debris should not be on pipes and/or light fixtures as it could fall on foods. The juice machine was observed with visible buildup and residue. The CDM stated he had not identified the build-up in the juice machine prior to today's observation. She acknowledged she should be more observant and communicate with staff more frequently regarding cleaning expectations and follow up. Observations of personal staff beverages were observed on and around the food preparation area. A staff's cell phone was observed on the rack where cups were stored. The CDM stated staff have shown improvement but reported ongoing concerns with cleanliness and stated she frequently reminds staff to address debris and maintain a clean environment. An observation was made of cups with clear and colored liquids inside a cooler. The tray of fluids were unlabeled and undated without prepared on/use by dates. The CDM stated the beverages should have been labeled and dated. A bright pink note posted on the juice cooler/refrigerator revealed the following, Attention dietary staff!! Anything going in this refrigerator must have a label date prepared and a used by date.During an interview on 06/24/2026 at 7:36 PM, the NHA stated that dietary management was responsible for sanitation monitoring and acknowledged concerns presented with photographic evidence. The NHA reported the facility had previously been cited for similar issues and stated education and deep cleaning were completed following the previous survey; however, based on the concerns identified during today's observation, additional monitoring and cleaning may be needed to ensure ongoing compliance. She stated she was not aware the identified concerns had reoccurred until they were brought to her attention.Review of a facility policy titled, Chapter 2: Kitchen Operations Standards and Guidelines: Sanitization, dated 07/2023 revealed requirements for maintaining all kitchen areas, equipment, and food-contact surfaces in a clean and sanitary condition.Review of the undated facility's QAPI policy revealed requirements to identify areas needing improvement, implement performance improvement projects, and monitor corrective actions. The recurrence of sanitation deficiencies demonstrated the facility failed to effectively implement and sustain QAPI processes related to dietary sanitation.

Based on observations, interviews, and review of facility policy, the facility failed to maintain the garbage storage area in a sanitary manner creating unsanitary conditions and increasing the risk of attracting pests.Findings included: A tour of the facility's garbage storage area was conducted immediately following the kitchen tour initiated on 06/24/2026 at 9:42 AM with the Certified Dietary Manager (CDM) and the Senior CDM. During this tour, approximately 14 used plastic gloves were observed scattered around the trash receptacles. In addition, a clear trash bag filled with trash was lying on the ground outside of the trash receptacle rather than inside the designated container. Upon observing these conditions, the manager stated, in reference to the gloves on the ground around the dumpster, I'll get on it now, I'll pick that stuff up. The Senior CDM stated the items would be picked up and discarded. One of the dumpster lid was observed opened. The CDM stated during staff meetings they had mentioned this concern as multiple departments use the dumpster area. The CDM stated the administrators were aware of the concern. On 06/24/2026 at 7:36 PM, an interview was conducted with the Nursing Home Administrator (NHA). After reviewing the photographic evidence, the NHA stated that the conditions observed in the dumpster area were unacceptable, unsanitary, and could attract pests. Review of the facility's policy titled Food Related Garbage and Refuse Disposal, revised October 2017, revealed that food related garbage and refuse are to be disposed of in accordance with state laws. Under the policy's interpretation and implementation section, it states that all food waste shall be kept in containers and that outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. [Photographic Evidence Obtained]

Based on observations, interviews, and record review, the facility failed to ensure kitchen sanitation requirements were maintained, for one of one kitchen.Findings Included: On 05/17/2026 at 09:31AM, during a tour of the kitchen, an observation was made of the kitchen hand washing sink. The kitchen sink was white with debris in various areas to include the face of the cabinet, countertop, faucet, and the area where the backsplash of the countertop made contact with the wall behind it. There was a pink dried liquid, on the left rear side of the countertop. The cabinet door face had a dried brown substance streak from the middle for about two inches. [NAME] buildup surrounded the faucet fixture and paper trash was sitting on the fixture. [NAME] buildup of debris on the wall behind the sink. On 05/19/2026 at 11:49 AM, during a tour of the kitchen, an observation was made of the kitchen food prep area. The food preparation area was in the middle of the kitchen. The ceiling area above the food preparation area revealed black debris, on the pipes and light fixtures. On 05/17/2026 at 09:31 AM, during a tour of the kitchen, the Senior Certified Dietary Manager (SCDM) stated the staff had a daily cleaning schedule with monthly deep cleanings. The SCDM stated, maintenance not doing a very good job. On 05/19/2026 at 11:15 AM, during a tour of the kitchen with the SCDM and Certified Dietary Manager (CDM), the SCDM stated absolutely, there are some things that could be worked. The CDM stated, I don't have enough room to store my chemicals properly. On 05/20/2026 at 2:36 PM, during an interview, the Nursing Home Administrator (NHA), stated if any concerns are identified, the kitchen staff should tell maintenance or the maintenance director, or any other leaders. The NHA stated the debris build-up in various areas of the kitchen should have been identified sooner. The NHA stated for the kitchen, I don't feel were clean enough for the standards. The NHA stated the kitchen staff were responsible for cleaning the outside mop bucket area, the kitchen sink for hand washing, and the area above the food preparation table. Review of a facility policy titled, Chapter 2: Kitchen Operations Standards and Guidelines: Sanitization, dated 07/2023 revealed:Policy Statement:The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and ImplementationAll kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners shall be kept in good repair.All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Photographic evidence obtained.

Based on observations, interviews and record review, the facility failed to ensure that a current/correct copy of a resident's advance directive was in the resident's medical record for two residents (#2 and #80) of two residents sampled for advanced directives. Findings included:During an observation and interview on 05/18/2026 at 1:45 PM the Regional Nurse Educator (RNE) stated Resident #80's Do Not Resuscitate (DNR) form in the nurses binder at the A wing nurses station, should be on yellow paper and verified that the DNR binder contained a DNR on white paper.During a review on 05/19/2026 at 2:28 PM of Resident #80's medical record it was noted that the DNR was on white paper in both the Electronic Health Record (EHR) and in the DNR binder in the A wing nurses station.Review of Resident #80's EHR showed the advanced directive consent signed on 11/26/25, the DNR order put in on 4/28/26 and the DNR signed on 6/13/26.During an observation on 05/19/2026 at 1:34 PM a review of the A wing nurses stations DNR binder, it was noted that Resident #2's DNR was not found in the DNR binder.During an interview on 05/19/2026 at 1:35 PM the RNE stated Resident #2's DNR form was in the binder but couldn't find it.Review of Resident #2's EHR showed the resident signed an advanced directive discussion document on 1/11/26.Review of Resident #2's EHR showed an order for a DNR from the medical director dated 4/7/26.Review of a facility order listing report, dated 5/18/26, shows 34 Residents who are labeled as DNR's with two residents who have been corrected, Resident #2 and Resident #80.During an interview on 05/19/2026 at 1:37 PM, the Regional Nurse Consultant (RNC) stated Resident #2's DNR was in the binder, but it's not in there now.During an interview on 05/19/2026 at 1:39 PM, Staff C, Certified Nursing Assistant (CNA), stated, if a resident codes {becomes unresponsive}, I look for their status in the binder at the nurses station.During an interview on 05/19/2026 at 1:45 PM Staff E, CNA stated she would look at the (advanced directive) binder at the nursing station to determine code status.During an interview on 05/19/2026 at 1:47 PM Staff F, CNA, stated if a resident codes (becomes unresponsive) she would look at the (advanced directive binder at the nurses station to determine code statusDuring an interview on 05/19/2026 at 1:41 PM Staff D, Licensed Practical Nurse (LPN), stated that if a resident codes (becomes unresponsive) she would look in the electronic record and the code (advanced directive) book at the nurses station.During an interview on 5/20/26 at 10:00 AM, the Director of Nursing (DON), stated if they have a code blue (unresponsive resident) they respond to the resident and check their code status. She stated they check advanced directives in the binder and in the EHR for the resident's code status. She stated they validate with two nurses and keep binders at the nurses station and the yellow DNR form (advanced directive order form) is in the binder. She stated residents with a DNR are audited by social services every week.During an interview on 5/20/26 at 10:11 AM the Social Services Director (SSD) stated when residents are admitted , she reviews the DNR for accuracy and lets the nursing team know if she doesn't see a code status. She stated she puts the DNR into the EHR or medical records will upload. She stated in the admission packet there is a form that is reviewed with the resident called the advanced directive consent and she was trained to recognize a properly filled out document. She stated she does weekly audits but doesn't write down the results. She stated she reviews it for accuracy, and after printing out a code status review of our residents, checks the names against the (advanced directive) book. Review of a facility policy named Advanced Directives Code Status, Dated 09/2025, unsigned. Policy: It is the policy of the facility to honor advanced directives, code status and do not resuscitate orders in accordance with the state and federal regulations. Admission/Readmission, Code Status verified upon admission with Resident/Representative by admitting nurse. Nurse reviews code status with the resident/representative and confirms decision with the attending physician. DNR Initiates yellow DNR form. Yellow DNR form will be signed by the resident/representative and the two nurses who obtained the order from the physician. Yellow DNR form will be copied and social services notified of new DNR. DNR form will be expedited to physician for final signature. Yellow DNR form is placed in a Binder at Nurses' station.

Based on observations, interviews and record review, the facility did not ensure physician orders were followed for enteral nutrition for one resident (#39) out of one resident reviewed. On 5/17/2026 at 9:18 AM., an observation was made of Resident #39 in his room. Resident #39's enteral (tube feeding) pump was alarming and enteral nutrition was not instilling nutrition. Resident #39 could not state when the alarm started. On 5/18/2026 at 11:05 AM, an observation was made of Resident #39's tube feeding bag hung on a pole but not connected to the resident to instill nutrition. On 5/18/2026 at 3:04 PM, an observation was made of Resident #39's tube feeding bag hung on a pole but not connected to the resident to instill nutrition.On 5/18/2026 at 3:31 PM, an observation was made of Resident #39's tube feeding bag hung on a pole, connected to the resident but audibly alarming downstream occlusion. On 5/18/2026 at 3:57 PM, an observation was made of Resident #39's tube feeding pump audibly alarming. On 5/18/2026 at 4:19 PM, an observation was made of Resident #39's tube feeding pump audibly alarming. On 5/18/2026 at 4:41 PM, an observation was made of Resident #39's tube feeding pump audibly alarming. On 5/19/2026 at 8:19 AM, an observation was made of Resident #39's room of no enteral feedings and/or associated tubing for enteral nutrition hanging from the pole. On 5/19/2026 at 8:30 AM, an interview was conducted with Staff G, Licensed Practical Nurse (LPN). Staff G, LPN stated she had discussed her concerns with Resident #39 not having his enteral tube feedings instilling upon her shift with the Director of Nursing. Staff G, LPN stated this was not the first time she has had Resident #39 without his tube feedings instilling. On 5/19/2026 at 9:56 AM, an observation was made of Resident #39's tube feeding instilling. On 5/19/2026 at 11:53 AM, an observation was made of Resident #39's tube feeding pump audibly alarming. An observation was made of the DON entering the resident's room. The DON stated she would reprogram the entire pump machine and start the whole process over per a new order where the resident will receive 40 ml (milliliters)/hour of water every hour and Jevity 75ml/hour for a total of Jevity for 1500 ml. A record review of Resident #39's weights showed the following:02/26/2026: 200.0 pounds4/06/2026: 203.0 pounds4/20/2026: 184.0 pounds5/07/2026: 181.1 poundsA record review of the Registered Dietician's (RD) progress notes dated 4/09/2026 showed the following: Current weight: W203.0 lb (pounds) - 4/06/2026Ideal Body weight: 192A review of the Registered Dietician's progress notes dated 5/16/2026 showed the following:Note Text: Weight loss note and TF (tube feed) note:Resident is NPO (nothing to eat or drink by mouth) and on TF (tube feeding). Enteral tube: continuous tube feedings of: Jevity 1.5 at 75 ml/hr (20 hours 0 with water flush of auto- flush of 45 ml/hr. This provides 1500 ml volume and 2250 kcal (total calories) which is adequate to promote weight gain. A review of Resident #39's admission Record showed an admit date of 02/26/2026 to 3/227/2026 with a readmission date of 3/29/2026 and diagnoses to include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gastrostomy status, muscle weakness, and dysphagia.A review of the physician orders showed the following orders:Continues feeding of: Jevity 1.5 at 75 ml/hr with water flush of 45 ml/hr per shift for peg tube supplement per shift for enteral feeding off at 10am and on at 2 pm, ordered on 3/29/2026 and discontinued on 5/18/2026A review of Resident #39's care plan showed a focus area of alteration in nutrition/hydration related to dysphagia, has weight fluctuations, refuses to wear dentures, significant weight change, is NPO and receives tube feeding for nutritional support initiated 5/19/2026A focus area of requires tube feeding related to NPO and dysphagia initiated 02/27/2026 with interventions to include but not limited to:Follow physician orders regarding nutrition order and flushes.On 5/19/2026 at 11:49 AM, a telephone interview was conducted with the Registered Dietician (RD). The RD stated at first the resident was on continuous tube feedings when he arrived at the facility but was changed to a total infused of over 20 hours to allow the resident the opportunity for physical therapy or to participate in activities. The RD acknowledged the weight loss but attributed it to his recent hospital stay and/or the scales could be wrong. The RD stated the following month the resident was down again by three pounds. The RD stated she did not want to see him lose anymore weight. The RD stated the pump will let you know how much was infused over the 20 hour time frame the ordered total volume should be infused. The RD stated there are times where the tube feedings are paused for resident care. The RD was concerned with the increased time intervals the resident had not received his ordered enteral tube feedings. The RD stated the nurse should dial the total volume to infuse in order to infuse the total ordered volume given to the resident. The RD stated a resident could lose a pound a week minimum if not provided the appropriate calculated and ordered enteral tube feeding nutrition. On 5/19/2026 at 12:50 PM, an interview was conducted with the DON. The DON stated she arrived at the facility early this morning and was notified by the night shift nurse assigned to Resident #39 she was missing the appropriate equipment to hang the enteral feedings. The DON stated she was able to acquire the missing tubing/bag to hang the tube feeding and acknowledged the resident's feeding went up after 8:30 AM.On 5/20/2026 at 4:35 PM, an interview was conducted with the DON who stated the pump was exchanged and education had started for the clinical team. A review of the facility's policy titled: Standards and Guidelines: Enteral Nutrition, on 10/2020 and revised on 9/2024 showed the following standard statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advanced directives, treatment goals and facility policies.Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary.5. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings6. Through feedings are scheduled to try to optimize resident independence whenever possible ( e.g., at night or during hours that do not interfere with their resident's ability to participate in facility activities).7. The nurse confirms that orders for enteral nutrition are complete.8. Staff caring for residents with feeding tubes are trained on managing enteral tubes and enteral nutrition.A review of the facility's policy titled, Standards and Guidelines: Weight Assessment, issued on 9/2022 and revised on 8/2023 showed the following guideline statement:To determine a baseline and an ongoing record of the resident's body weight.Weight Assessment With the residence permission the nursing staff will measure the resident's weight within 72 hours of admission, weekly for three weeks and monthly thereafter or as determined by the physician or per the resident's preference. Weight variance changes that are undesired or unplanned since the last weight assessment will be retaken as soon as practical for confirmation. If the weight is verified, nursing will communicate with the dietician and/ or the physician.Weight variances will be addressed by the registered dietitian as soon as practicable, typically within 7 to 14 days of weight being obtained. If the weight change is desirable or planned, this will be documented and no change in the care plan will be necessary.A review of the facility's policy titled, Standards and Guidelines: Physician Orders, issued on 10/2020 and revised on 01/2024, showed the following guideline statement:Orders and administration of medication and treatment will be consistent with principles of safe and effective order writing.Procedure:.9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.

Based on observations, interviews and review of facility's policy, the facility did not ensure proper infection control practices and standards of care were followed related to 1. a (peripherally inserted central catheter) PICC dressing was not changed per standard of care for one resident (#80) of one resident reviewed for central catheters; 2. proper hand hygiene during a medication administration for one resident (#118) of seven residents observed for medication administrations; and 3. failed to ensure resident daily reusable equipment was maintained with cleanable surface for one resident's (#65) wheelchair out of 3 wheelchairs observed.Findings included:1. On 5/17/2026 at 10:15 AM, an observation was made during initial tour of Resident #80's PICC line dressing dated 5-7-26. Resident #80 stated she was on antibiotic for an infection. A review of Resident #80's physician orders showed the following:PICC line LUE (left upper extremity): Change dressing within 24 hours of admission, insertion, or reinsertion and q7 days (every 7 days) and PRN (as needed) thereafter using sterile technique. Measure arm circumference and external length of the catheter every day shift every 7 day(s), ordered 4/30/2026.2. On 5/20/2026 at 9:00 AM, an observation was made during Resident #118's morning medication administration. Staff G, Licensed Practical Nurse (LPN) pulled the morning medications for Resident #118, entered room, and handed the medication cup to the resident. Resident #118 picked one pill out of the medication cup but placed it on her bedside table and requested her muscle relaxant medication first before taking any of her morning scheduled medications. Staff G, LPN picked up the pill with her bare hands and placed the pill back in the medication cup along with the other pills pulled for Resident #118. Staff G, LPN returned to her medication cart, pulled the requested medication and placed it in a separate medication cup, returned with the two medication cups to begin administration. Resident #118 took all medications but two when the resident began a coughing event. Staff G, LPN was observed reaching for the resident's nasal cannula laying on the side of the bed and place on the resident. Staff G, LPN was observed attempting to get behind the resident sitting in a wheelchair, picking up an item from the ground to reach the oxygen concentrator to turn on oxygen for the resident. Staff G, LPN offered a nebulizer treatment for the resident in which the resident agreed. Staff G, LPN stated we do this every morning. Staff G, LPN retrieved albuterol 2.5 mg/3 ml (milliliters) to be administered via nebulizer. Staff G, LPN was observed rinsing the nebulizer with water and placing directly in the bag post treatment. An observation was made of a box of disposable gloves above the sink approximately five feet away from the resident. Staff G, LPN did not don (apply) gloves or use hand hygiene at any point placing oxygen tubing not properly contained, picking up items from the floor, administering a nebulizer treatment and cleaning the nebulizer. On 5/20/2026 at 4:35 PM, an interview was conducted with the Director of Nursing (DON). The DON was aware of Resident #80's PICC line dressing and stated she personally changed the dressing later on 5/17/2026. The DON was aware of the medication administration for Resident #118 and the lack of donning gloves/hand hygiene during medication administration and potential cross-contamination. 3. On 5/18/2026 at 9:14 AM and 5/19/2026 at 9:20 AM, an observation of a Resident #65's wheelchair had two large cracks in excess of six inches in the middle to the edge of the sitting area. The inside of the wheelchair was viewable, revealing the inside fabric, a beige colored foam material. The surface area was of a non-cleanable material due to the break in material. On 5/19/2026 at 5:26 PM, during an interview with the Director of Rehab (DOR), and Maintenance Director, the DOR stated wheelchairs are verified appropriate for the user and in sound condition before being given to a resident. The DOR stated if during a residents' stay something is wrong with the wheelchair, whoever identifies the issue should put in a work order for repair. The DOR stated at that point it would be maintenance responsibility to fix the wheelchair. The DOR and Maintenance Director stated the condition for the wheelchair for Resident #65 was unacceptable. Record review for Resident #65 revealed Resident #65 was admitted into the facility on [DATE]. The medical diagnosis for Resident #65 included: Parkinson's disease, dementia, and dysphagia. During an interview on 5/20/2026 at 2:36 PM, the Nursing Home Administrator (NHA) stated Resident #65's wheelchair was in disrepair and should have been fixed. Review of a facility policy titled, Standards and Guidelines: Maintenance of Resident-Care Items and Equipment, dated 03/2024, revealed:Standard: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. Guideline: 1. The Semi-critical items consist of items that may come in contact with mucous membranes or non- intact skin (e.g., respiratory therapy equipment). Such devices should be free from microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time (e.g., hydrotherapy tanks, bed side rails) are usually considered non-critical surfaces and are disinfected with intermediate- level disinfectants.)2. Non-critical items are those that come in contact with intact skin but not mucous membranes.Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers.Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location).Most non-critical reusable items need to be in good condition to properly decontaminated3. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).5. Durable medical equipment (DME) is cleaned and disinfected before re-use by another resident. Photographic evidence obtained. A review of the facility's policy titled, Standards and Guidelines: Medication Administration, issued 10/2020 and revised on 01/2024 showed the following standard statement: Medications are ordered and administered safely and as prescribedProcedure:.19. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.A review of the facility's policy titled: Standards and Guidelines: Central lines, issued 10/2020 and revised 5/2024 showed the following guideline statement:Maintain central line care that is consistent with professional standards of practice an in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preference. Procedure: .2. Ensure infection control standards are maintained during the care of the central line including but not limited to: a. change dressing routinely and per physician orders

Based on interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) was accurate for one (Resident #51) out of six residents reviewed.Review of Resident #51's admission record revealed an admission date of 3/08/25, with an initial admission date of 1/08/25, with diagnosis to include but not limited to: generalized anxiety disorder (onset 1/08/25), depression unspecified (3/08/25), and bipolar disorder, current episode depressed, mild (onset 3/08/25).Review of Resident #51's Preadmission Screening and Resident Review (PASRR) dated 2/03/26 revealed bipolar disorder and depressive disorder were marked under Section A. Mental Illness or Suspected Mental Illness (MI). Anxiety disorder was not marked.On 5/20/26 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). She stated when a resident is admitted to the facility, the admissions department is responsible for ensuring the resident has a Preadmission Screening and Resident Review (PASRR). If the resident does not have a PASRR at the time of admission, one will be submitted for the resident through a care management system. She stated after admission, she would review the resident's chart daily with the Interdisciplinary Team (IDT Team) to determine if the resident had any new MI diagnosis. She stated if a resident experiences a change of condition or has a new MI, a new PASRR submission would be triggered. She stated Level 2 PASRR's are triggered based on if the resident has a major mental illness. The DON reviewed Resident #51's health chart and acknowledged that anxiety was not marked under Section A. She stated she would re submit the PASRR to include anxiety.On 5/20/26 at 1:52 PM, the DON stated the facility does not have a PASRR policy.

3. Review of Resident #3's admission Record revealed the resident was admitted on [DATE] from an acute care hospital. The record included diagnoses not limited to other idiopathic peripheral autonomic neuropathy, unspecified chronic obstructive pulmonary disease, unspecified cord compression, and generalized muscle weakness. The resident discharged to a private home on 3/13/25. An interview was conducted on 6/11/25 at 1:57 p.m. with the Director of Rehab (DOR). The DOR stated all new admissions are evaluated or screened by therapy. The DOR reported remembering Resident #3 did participate in physical and occupational therapies. A review of the therapy notes for both disciplines revealed the resident did not miss any scheduled visits. Review of Resident #3's assessments did not reveal any Daily Skilled Nursing notes were completed for the resident.Review of Resident #3's progress notes showed no nursing notes had been completed after the residents' admission. The progress notes showed Physician/Practitioner notes were written on 3/8/25, 3/7/25, and 3/5/25, a pharmacy note was written by pharmacy on 3/3/25, a nutritional evaluation was conducted on 2/27/25, and the Admission/readmission Nursing Evaluation on 2/27/25. Review of Resident #3's bowel management tasks showed from 3/2/25 to 3/13/25 staff had documented 2 no bowel movement, NA no applicable, RR resident refused, or did not document the task. The documentation showed the resident had no bowel movement for 10 days between 3/2/25 to 3/13/25. An interview was conducted on 6/11/25 at 4:19 p.m. with the DON. The DON reviewed Resident #3's insurance and stated she thought it was skilled nursing. She reviewed the resident's record and confirmed not seeing any skilled nursing or nursing progress notes. The DON reviewed the bowel management task documentation and confirmed the facility had a Certified Nursing Assistant (CNA) documentation issue. 4. Review of Resident #5's admission Record showed the resident was admitted on [DATE] from an acute care hospital. The record included diagnoses not limited to, thoracic region spinal stenosis, unspecified paraplegia, and not elsewhere classified post-laminectomy syndrome. Review of Resident #5's progress notes showed on 5/19/25 the Physical Medicine and Rehabilitation Practitioner noted the resident was admitted to the facility to receive subacute rehabilitation with the goal to maximize functional level/independence. The note revealed the resident was seen at bedside and had increased pain upon being moved related to the bed pad was making contact with her thoracic incision from surgery. Looking at the site, patient's dressing had peeled up exposing a few of (pronoun) staples .Review of Resident #5's progress notes revealed from the day of the resident's admission on [DATE] to 5/21/25 staff had not completed a progress note or Skilled Nursing note for this resident. The note on 5/21/25 revealed the resident complied with treatment orders, an indwelling catheter was removed and on 5/22/25 staff noted the resident was voiding sufficient quantity. The resident had an episode of a behavior as noted on 5/24/25 and a fall on 5/26/25. The record did not include any nursing documentation related to the resident's condition from 5/26/25 to 5/29/25 when a Summary of Skilled Service note was completed showing the resident continued on oral antibiotic for an infectious process to surgical incision. The next nursing note was a late entry note dated 6/4/25 regarding redness and warmth to the resident's surgical incision and left lower leg swelling. The last Summary of Skilled Service progress note from nursing staff was completed on 6/5/25. Review of the facility census dated 6/11/25 at 8:48 a.m. revealed Resident #5 was on therapeutic unpaid leave. Review of a Change in Condition evaluation, dated 6/4/25 showed on 6/11/25 at 5:07 p.m. the document was In Progress. The record did not reveal a transfer form, or a Change of Condition evaluation was completed for the resident's transfer. The progress notes did not reveal information regarding the resident's transfer. Review of Resident #5's assessments showed nursing had completed skilled documentation on 5/21/25, 5/29/25, and 6/5/25. Review of the Daily Skilled Documentation list, updated 5/20/25 revealed the 7:00 a.m. - 7:00 p.m. shift was responsible for the Daily Skilled documentation of Resident #5. Review of the clinical policy - Medical Records, revised 1/2024 revealed Services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. The procedure outlined:1. Documentation in the medical record may be electronic, manual, or a combination.2. The following information is to be documented in the resident medical record:- a) Objective observation;- b) Medications administered;- c) Treatments or services performed; stop- d) Changes in the residence condition;3. Documentation in the medical record is required as updates/ changes in the residents plan of care are made.4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.8. Documentation of procedures and treatments will include care specific details, including:- a) the date and time the procedure/ treatment was provided;- b) the name and title of the individual(s) who provided the care;- c) the assessment data and/ or any unusual findings obtained during the procedure/ treatment;- d) whether the resident refused the procedure/ treatment;- e) notification of the family, physician or other staff, if indicated; and- f) the signature and title of the individual documenting.Review of the facility's policy, Standards and Guidelines: Documentation, revised 01/2024 showed services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure: 1. Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Treatments or services performed; d. Changes in the resident's condition. Documentation in the medical record is required as updates / changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective, complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure / treatment was provided; b. The name and title of the individual (s) who provided the care; c. The assessment data and / or any unusual findings obtained during the procedure / treatment; d. Whether the resident refused the procedure / treatment; e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documenting. Based on interview and record review the facility failed to maintain medical records according to standards of practices related to skilled nursing notes, change inconditon notes, transfer notes, activities of daily living notes, for residents receiving skilled services were documented for four residents (#1, #3, #4, and #5) of four sampled residents. Finding included: 1. Resident #4 was admitted on [DATE] and discharged on 04/16/2025. Review of the admission Record showed diagnoses included but not limited to fracture of the left femur, history of falling, hypertension, anemia, urine retention, and weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 09 or moderately impaired. Review of the physician orders showed to admit the resident to the facility for skilled services. Occupational Therapy services five times a week times 30 days as of 04/04/2025. Physical Therapy services five times a week times 30 days as of 04/07/2025. Review of the progress notes showed no Skilled Notes documentation. Review of the medical record showed no Skilled Nurses notes in the assessment section of the chart. During an interview on 06/11/2025 at 3:18 p.m. the Director of Nursing (DON) stated skilled services entails, nursing services are needed in a facility and not at home. These services can include IV (intravenous) therapy, wound care, vital signs monitoring, physical therapy, nurses need to oversee the resident. The DON stated there should either be a Skilled Nurses Note, or a Skilled Progress Note in the progress notes every day the resident was on Skilled Services. The DON verified there were no Skilled Nursing Notes in the assessment section. The DON reviewed the progress notes and found no Skilled Notes from the nurse in the progress notes either. The DON stated she would expect to see the Skilled Notes. 2. Resident #1 was admitted on [DATE] and discharged on 12/24/2024. Review of the admission Record showed diagnoses included but were not limited to metabolic encephalopathy, contusion of scalp, history of falling, necrotizing enterocolitis, dementia with mood disturbance, disorder of brain, orthostatic hypotension, hypertension, muscle weakness, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Brief Interview for Mental Status (BIMS) score of 03 or severe impairment. Review of the physician orders showed admit the resident to the facility for skilled services as of 12/11/2024. Occupational Therapy services four times a week times 30 days as of 12/12/2024. Physical Therapy services four times a week times 30 days as of 12/12/2024 and increased to five times a week for 30 days as of 12/17/2024. Speech Therapy services three times a week for 30 days as of 12/12/2024. Review of the Skilled Documentation showed notes dated 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024 only. Review of the progress notes showed no Skilled Notes after 12/15/2024. Progress notes lacked any documentation regarding his skin. During an interview on 06/11/2025 at 3:18 p.m. the DON stated Resident #1 had a couple of Skilled Documentation notes but not the whole time. The DON stated they were now reviewing for Skilled Service Notes during the morning meetings.

Based on interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice related to performing weekly skin checks for four residents (#1, #3, #5, #6) out of five sampled residents. Findings included: 1. Review of Resident #3s admission Record showed the resident was admitted on [DATE] and discharged to the community on 3/13/25, residing at the facility for a total of 15 days. The record revealed diagnoses not limited to prediabetes, morbid (severe) obesity due to excess calories, and generalized muscle weakness. Review of Resident #3s nursing assessments showed the resident was evaluated on 2/27/25 for an admission/readmission. The clinical record did not reveal a skin evaluation/check was completed during the fifteen days the resident resided at the facility. The admission/readmission evaluation revealed the resident had redness to buttocks. The progress notes did not reveal licensed nursing had completed a weekly skin evaluation/check for the resident. An interview was conducted with the Director of Nursing (DON) on 6/11/25 at 4:19 p.m. The DON reviewed Resident #3's record confirming there were no skilled nursing notes or any nursing progress notes. 2. Review of Resident #5's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to post-laminectomy syndrome not elsewhere classified, unspecified paraplegia, and thoracic region spinal stenosis. Review of Resident #5's Order Summary Report showed the resident did not have an order for weekly skin checks by licensed nursing staff. Review of an Advanced Practitioner Registered Nurse (APRN) note dated 5/19/25 showed the resident had increased pain seeming like it was due to the location of bed pad was making contact with (pronoun) thoracic incision from surgery. Looking at the site, patient's dressing had peeled up exposing a few of (pronoun) staples which remained intact with no redness or bleeding. The practitioner noted Resident #5 was status post (s/p) T10=T11 laminectomy and was at high risk for skin breakdown that can lead to infections/sepsis that may require admission to the hospital for debridement. Review of Resident #5's assessments showed a Skin Check - Weekly or Other was completed on 5/26/25, showing no new concerns at this time. The evaluation did not reveal the resident had any previous skin conditions. Review of a Summary for Providers change in condition evaluation, dated 5/26/25 at 8:00 p.m. showed no physician recommendations after Resident #5 had fallen and a skin evaluation was not completed. Review of Resident #5's progress notes did not show nursing staff had evaluated the resident's body for any new skin impairments or the status of the post-laminectomy incision until a note on 6/4/25 at 4:42 p.m. revealed a late entry regarding notifying the physician of left lower leg swelling and redness and warmth to the surgical incision. Review of Resident #5's record showed one Skin Check Weekly or Other assessment was completed on 5/26/25 at 8:00 p.m., twelve days after the resident was admitted and eleven days before the resident was transferred to an acute care facility. 3. Review of Resident #6's admission Record revealed the resident was admitted on [DATE] with a most recent readmission on [DATE] following a 4-day (5/22/25) hospital stay. The record included diagnoses not limited to unspecified peripheral vascular disease and unspecified type 2 diabetes mellitus with diabetic neuropathy. The record showed the resident was discharged on 3/3/25 and returned on 3/24/25. On 6/11/25 at approximately 9:35 a.m. Resident #6 was observed lying in bed, face covered with a sheet, knees bent and uncovered. The observation showed multiple abrasions/ discolorations of reddish/purple coloration to the resident's right knee. An interview was conducted on 6/11/25 at 2:17 p.m. with Resident #6. The resident reported having a wound on the right heel which is dressed daily. Review of Resident #6's care plan revealed the following focuses and related interventions:- At risk for adverse effects of hyper/hypo glycemia related to (r/t) diagnosis of diabetes. The interventions instructed nursing to monitor feet for open areas, sores, pressure areas, blisters, edema, or redness and to report to medical doctor (MD) as indicated. - On anticoagulant/antiplatelet therapy r/t cardiac prophylaxis (ppx). The interventions instructed nursing and Certified Nursing Assistant (CNA) staff to monitor skin for abnormalities and report to nurse/Medical Doctor (MD) as indicated. - Has impaired skin: right (R) heel wound, R great toe wound, (and) R dorsal 3rd toe wound (revised on 1/28/25). The interventions instructed nursing staff to Complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for signs/symptoms (s/s) of infection. Report changes to MD as indicated. Review of Resident #6's clinical record revealed an Unavoidable Skin Condition evaluation was signed by the physician on 4/15/25. The evaluation showed the resident had conditions of peripheral vascular disease (PVD)/peripheral arterial disease, continuous urinary incontinence, diabetes mellitus, and cellulitis. Other risk factors were limitation of range of motion and muscle wasting. The preventative interventions showed a licensed nurse was to complete weekly skin integrity checks. Review of a previous Unavoidable Skin Condition evaluation dated 2/19/25 revealed licensed nursing was to perform weekly skin integrity checks as a preventative intervention. Review of Resident #6's physician orders showed an order dated 1/15/25 for a Skin Assessment to be completed every Wednesday. Review of Resident #6's Skin Check - Weekly or Other assessments showed staff did not complete skin assessment on Wednesday 3/26/25, Wednesday 4/2/25, Wednesday 4/16/25, Wednesday 4/30/25, Wednesday 5/7/25, Wednesday 5/14/25, Wednesday 5/21/25, or Wednesday 6/4/25. An interview was conducted on 6/11/25 at 4:00 p.m. with the Director of Nursing (DON). The DON reviewed the record and stated Resident #6 should be receiving weekly skin checks but was seen weekly by wound care then confirmed the wound physician did not check the entire skin. Review of an in-service roster, dated 5/1/25, revealed the wound care manager (WCI), Certified Nursing Assistants (CNA), and Patient Care Assistants (PCA) were educated on detailed skin assessment on admission (and) schedule weekly. In the upper right-hand corner of the in-service was written all staff. On 6/3/25 licensed nursing staff were educated on Assessments - Increase nurse awareness of the importance of timely completion of assessments upon admission, discharge, transfer (return to hospital (RTH)), and risk events. The DON provided a Cheat Sheet for Assessments, undated, the cheat sheet did not address the timeliness of weekly skin assessments. 4. Resident #1 was admitted on [DATE] and discharged on 12/24/2024. Review of the admission Record showed diagnoses included but were not limited to metabolic encephalopathy, contusion of scalp, history of falling, necrotizing enterocolitis, dementia with mood disturbance, disorder of brain, orthostatic hypotension, Hypertension, muscle weakness, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Brief Interview for Mental Status (BIMS) score of 03 or severe impairment. Review of the admission / readmission Nursing Evaluation dated 12/11/2024 showed Skin Evaluation: top of his scalp was left parietal area secondary to ground level fall, scabbing 4 cm [centimeters] x 3 cm both right and left antecubital areas with multiple bruises from hospital IV/blood draws Review of the Skilled Documentation dated 12/12/2024 showed resident had hematoma to head, bilateral upper extremity bruises present on admission.Review of the Skilled Documentation dated 12/13/2024 showed resident had hematoma to head, bilateral upper extremity bruises present on admission.Review of the Skilled Documentation dated 12/14/2024 showed resident had hematoma to head, bilateral upper extremity bruises present on admission.Review of the Skilled Documentation dated 12/15/2024 showed resident had hematoma to head, bilateral upper extremity bruises present on admission.Review of the progress notes showed no skilled notes after 12/15/2024. Progress notes lacked any documentation regarding his skin. Review of the medical record showed no weekly skin checks performed after 12/15/2024. Review of the care plans showed:Resident #1 was at risk for skin impairment related to weakness/decreased mobility as of 12/12/2-24. Interventions included but not limited to monitor/observe skin while providing routine care. Notify nurse for any concern as indicated. During an interview on 06/11/2025 at 3:18 p.m. the Director of Nursing (DON) stated Resident #1 had a couple of skilled documentation notes but not the whole time. DON stated they were now reviewing for Skilled Service Notes during the morning meetings. The DON stated Resident #1 had a scab on top of his scalp per the admission assessment. The DON stated they did not do a further assessment / skin check on the resident. The DON stated they should have been doing skin checks on Resident #1. 5. Review of the facility's policy, Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, revised 01/2024 showed the purpose of this policy is to provide information regarding identification of skin wound risk factors and interventions for specific risk factors. Risk Assessment: 1. Assess the resident on admission for existing wounds risk factors. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity-any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or activities of daily living (ADL's). a. Identify any signs of developing skin wound. B. Inspect pressure points c. Wash the skin after episodes of incontinence d. repositioned resident as indicated on the care plan. Monitoring / Documenting 1. Evaluate, report, and document potential changes in the skin. 2. Notify the physician and the resident / resident representative of changes in the skin. 3. Review the interventions and strategies for effectiveness on an ongoing basis. 4. Evaluate open areas per physician orders.Review of the facility's policy, Standards and Guidelines: Documentation, revised 01/2024 showed services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure: 1. Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Treatments or services performed; d. Changes in the resident's condition. 3. Documentation in the medical record is required as updates / changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective, complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure / treatment was provided; b. The name and title of the individual (s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. Whether the resident refused the procedure / treatment; e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documenting.

Based on observations and interviews, the facility failed to provide a clean, comfortable, sanitary, and homelike environment in four halls (A, B, C, D) of four hallways and one of one dining room. Findings included: The following observations were made on 6/11/25: - At 9:20 a.m. a treatment cart parked in the dining room beside the exit door to the courtyard. The cart was empty and unlocked, on top of the cart were crumbs of an unknown substance, a piece of black fabric, and the front of the cart was stained with brown and black substances, the cart appeared to be unclean and unsanitary. On the floor next to the cart was a piece of white paper and a plastic domed lid with a brown liquid attached to it. The floor surrounding the cart was unclean and scuffed. The observation revealed a white piece of paper and a clear piece of plastic against the wall opposite of where the cart was parked in the dining room. The floor was unclean. At the time of the observation no residents were eating a meal in the dining room. Staff B, Certified Nursing Assistant (CNA) reported being unsure how long the cart had been parked there. - At approximately 9:23 a.m. an observation was conducted of room D4. The closet doors to be not hanging correctly, not perpendicular to the floor, on the top right hand outside corner of the closet was an unfinished patch, the wall beside the in-room sink was multiple small patches unpainted, the room was painted a bright green however an area behind a box of gloves (above the sink) was a cream color. The ceiling tile was white except for the tile above the sink was outlined with a dark tan color while the inner area of the tile was a cream color. The wall behind the first bed was gouged revealing an unpainted, uncleanable surface. - At approximately 9:46 a.m. the bathroom was shared between rooms D6 and D7 where 6 residents resided, a strong pungent urine smell was emitting from the room, prior to opening the door from room D7. The observation showed the flooring did not meet up with the toilet and the approximate 1.5-to-2-inch gap was filled with cracked white silicone-looking substance and tapered along the side of toilet. A green microfiber-looking cloth was observed on the sink, and a white towel with a brown substance was observed lying across the only toilet paper dispenser. The floor was stained and unclean. - At 9:32 a.m. an observation revealed on the floor of room C16, to the side of the bathroom door was half a circular item attached to the floor, next to the item was an unmovable upside-down bolt. Resident #8 stated the circular item was a door stop. The floor next to the doorstop and bolt was stained black. - At 9:32 a.m. an observation was made of the floor under the window of room C1. The window sill held multiple potted plants and on the floor was 3 small piles of black dirt. - At 9:35 an observation showed an unfinished patch approximately two feet by three feet section of wall behind and beside the entry door of room C7. - At 9:36 a.m. an observation of room C8 revealed an air conditioning unit was observed with a disconnected accordion-style hose lying on the floor at the end of the resident's bed. One of two closet doors was not on its track. The bathroom shared by room C7 and C8 was odorous of bowel. A gray wash basin, unlabeled, was sitting on the floor beside the back of the toilet, the trash can contained an incontinent brief with a brown substance attached to it, and a piece of paper littered the floor. Resident #8 reported using the bathroom with staff assistance. - At 9:40 a.m. an observation was made of room C13. The bathroom was odorous of urine. A toilet plunger was observed sitting on top of an opaque plastic bag on the floor and an upside down gradient clear plastic container was observed sitting on a brown paper towel on the back of toilet. On 6/11/25 at approximately 9:45 a.m., an observation showed two housekeepers were in the dining room, each with a housekeeping cart. - At 9:51 a.m. an observation of the bathroom of room A8 revealed the room was very odorous of urine and a liquid was on the floor surrounding the toilet. The toilet bowl was filled with a yellow liquid and liquid splattered the toilet seat. The flooring was scuffed and dirty looking. - At 9:55 a.m. an observation of room A1 revealed one of two closet doors was off its track and leaning into the closet and an unfinished and uncleanable surface was noted behind and to the right side of the second beds. The bathroom revealed the floor grout was stained, the caulking around toilet and back wall were missing and the tiles on the wall behind the toilet were stained brown. - At 10:08 a.m. an observation was conducted of the treatment cart parked next to the courtyard door in the dining room. The observation showed the domed plastic lid continued to lie next to the cart and the cart continued with splatters of unknown substances. The floor was scuffed and stained. In the lobby area, in front of the half wall looking into the dining room was an area stained with an unknown black substance. - At 10:12 a.m. an observation of room B8 revealed an overturned medication cup was on the floor in front of a trash can which contained unwanted items, a black stain was observed on the floor in front of room's vanity area, and the privacy curtain of B-bed was askew and not fully hooked. The toilet contained a brown-colored substance with crumb-looking material and feces. The bathroom was very odorous. On top of the dresser were piles of different items, specifically an unprotected toothbrush lying on items, and an emesis basin containing an unprotected toothbrush. A bottle of antiseptic oral rinse was observed on top of the dresser. On 6/11/25 at 5:23 p.m. observations were conducted with the Senior Administrator (SA). The SA observed the black stain on the floor next to lobby's half wall and stated he would take care of that. The following observations were made, and some were discussed with the SA: - Observation of the plastic domed lid lying in between the treatment cart and another similar cart in the dining room next to the courtyard exit door. The SA picked it up and threw it away, stating housekeeping should be moving the carts. - Observation of the D6-D7 bathroom, which the SA confirmed, the bathroom continued to be odorous. The washcloth and towel had been removed. Resident #9 was lying on bed and reported thinking there were only 2 of the 6 residents using the bathroom. - Observed the plunger in the bathroom of C13 continued to sit on an opaque plastic bag next to the toilet and the gradient container continued to be upside down on the back of the toilet. The SA reviewed photos taken at 9:40 a.m. showed the items were in the same positions. - Observed the half circular doorstop attached to the floor of room C16, the SA stated it should be removed. The bolt was moveable slightly and the SA stated it should be removed. Immediately following the above observations, the SA reviewed photo taken of the closet doors in room C8 and the unfinished wall in room C7 and stated yes. Additional photos were reviewed with the SA and the NHA and the SA stated it was the expectation that the residents were to be provided with a clean and homelike environment. Review of the Environmental policy - Cleaning, revised 01/2024 revealed the purpose was To maintain a clean, safe, and sanitary environment for residents, staff, and visitors by outlining the procedures and standards for effective housekeeping in accordance with federal, state, and local health regulations including Centers for Medicare and Medicaid Services (CMS) and Centers for Disease control and prevention (CDC) guidelines. The policy statement showed it is the policy of the facility to ensure that all areas of the facility are maintained in a clear, sanitary, and orderly condition. The housekeeping department is responsible for daily and scheduled cleaning and sanitation services, promoting infection control safety for all residents and staff. The procedures outlined daily cleaning tasks: 1. Resident Rooms: - Empty trash and replace liners. - Sweep/ vacuum and mop floors. - Wipe and disinfect high-touch surfaces (bed rails, tables, doorknobs). - Clean bathroom sinks, toilets, and floors with EPA- registered disinfectants. - Restart toilet paper, paper towels, soap. 2. Common Areas (lounges, hallways, dining rooms) - Vacuum carpets and mop floors. - Dust furniture and fixtures. - Sanitize door handles, elevator buttons, and hand rails. - Clean windows and glass surfaces as needed. B. Weekly/Deep Cleaning Tasks: - Strip and wax floors as scheduled. - Wash walls and ceilings. - Clean light fixtures and vents. - Perform terminal cleaning of vacated rooms before new admissions. - Clean behind and under beds and furniture. C. Infection Control Protocols: - Follow color-coded cleaning cloth system (e.g., red for bathrooms, green for general). The responsibility of the Housekeeping Supervisor was to: - Develop cleaning schedules and assign tasks. - Train staff in cleaning techniques and infection control. - Perform quality checks and audits. The Housekeepers' responsibility was to: - Follow assigned duties. - Use equipment safely and according to protocol. - Report damage, hazards, or unusual conditions. - Maintain supply inventory and request restocking when needed.

Based on observation, interview, and record review the facility failed to follow standard infection control practices related to hand hygiene and cleaning of resident care multi-use equipment. Findings included: On 06/11/2025 at 9:55 a.m. Staff A, Licensed Practical Nurse (LPN) was observed entering room A-3 which had Contact Precaution signage on the outside of the door. Staff A placed a blood pressure cuff on Bed A's, Resident #8's lower right arm. While waiting for the blood pressure to be performed Staff A placed her right hand on the footboard of the bed. Staff A removed the blood pressure cuff, exited the room and placed it on the medication cart. Staff A did not hand hygiene nor clean the blood pressure cuff. Staff A documented the blood pressure on her paperwork. Staff A moved the medication cart across the hall to room A-11. Staff A was approached by another staff member, and she went down the hall with the staff member. Staff A opened the wound care cart and removed items and returned to the medication cart without performing hand hygiene. Staff A started performing medication administration for Resident #9 in room A-11 without hand hygiene. Staff A moved the blood pressure cuff which was on top of the medication cart to another spot. Staff A applied gloves without hand hygiene. Staff A opened the medication cart and removed a glucometer machine, a strip, and an alcohol wipe. Staff A entered A-11 and went to the other side of the bed to get a cup of water. Staff A performed the blood glucose monitoring and then returned to the medication cart. Staff A removed her gloves and did not perform hand hygiene. Staff A replaced her gloves and opened the medication cart. She removed Resident #9's insulin pen and drew up the insulin. Staff A reentered room A-11 and administered the insulin. Staff A removed her gloves and returned to the medication cart. Staff A did not perform hand hygiene. Staff A placed the blood pressure cuff inside a bag which was on the medication cart. Staff A moved the medication cart to room A-2 and began medication administration. During an interview on 06/11/2025 at 3:47 p.m. the Director of Nursing (DON) stated hand hygiene was to be performed upon removal of gloves, before going into a resident room, when exiting a resident room, between passing of meal trays, before and after resident care. The DON stated items like blood pressure cuffs should be cleaned after use with wipes. The DON stated Resident #8 was on enhanced barriers for c-aureus (candida- aureus). The DON stated she would have to check regarding Resident #8's roommate as to why the contact isolation signage was on the door. The DON stated the roommate was on contact isolation due to an infection in her urine. Review of the facility's policy, Hand Hygiene Infection Control, revised 6.2023 showed hand hygiene is the single most important measure for preventing the spread of infection. The facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Procedure: the facility acknowledges the CDC guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC (Centers for Disease Control and Prevention) strategy to reduce infections in health care settings to promote resident safety. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by healthcare personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Situations that require hand hygiene include, but are not limited to: before and after direct contact (for which hand hygiene is indicated by acceptable professional practice) before and after performing any invasive procedure (for example finger stick blood sampling) before and after entering isolation precaution settings upon and after coming in contact with the resident's intact skin (for example when taking a pulse your blood pressure) after removing gloves or aprons Review of the facility's policy, Infection Control-Infection Prevention and Control Program, dated 1/2024 showed an infection prevention and control program are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention of Infection 1. Important facets of infection prevention include: C. Educating staff and ensuring that they adhere to proper techniques and procedures; G. Implementing appropriate isolation precautions when necessary; and H. Following established general and disease specific guidelines such as those of the Centers for Disease control (CDC). Review of the facility's policy, Standards and Guidelines: Maintenance of Resident Care Items and Equipment, revised 3/2024 showed resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogen standard. 2. Non-critical items are those that come in contact with intact skin but not mucous membranes. A. non-critical resident care items include bed pans, blood pressure cuffs, crutches and computers. B. Most non-critical reusable items can be decontaminated where they are used. 3. reusable items are cleaned and disinfected or sterilized between residents.

Based on interview and record review the facility failed to promptly notify the resident representative of a room change for one resident (#4) of three sampled residents. Findings included: Resident #4 was admitted on [DATE] and discharged on 04/16/2025. Review of the admission Record showed diagnoses included but not limited to fracture of the left femur, history of falling, hypertension, anemia, urine retention, and weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 09 or moderately impaired. Review Resident #4's progress notes lacked any documentation regarding the room change that occurred on 04/09/2025 from room A2A to A5A. Review of a Social Services Director's (SSD) progress note read: On 04/11/2025 at 10:12 a.m. Resident #4 will be moving from A5A to A3A due to family request. Resident was notified of the room change on 04/11/2025. The resident representative was notified, the family member requested the move in person. Resident was agreeable to a room change. Resident's representative was agreeable to a room change at this time. Review of Resident #4's medical record revealed a Room Change Notification for the room change on 04/09/2025 was not documented. Review of Room Change Notification dated 04/11/2025 showed appropriate documentation: Date of room change: 04/11/2025; Moving from A5A to room A3A Reason for room change: family request Was resident notified of room change: yes on 4/11/2025 Resident representative (family member) was notified of room change Review of the Interdisciplinary Plan of Care Plan Meeting (IPOC) dated 04/08/2025 showed Resident #4 attended, family member attended via phone. New resident at facility. Active family involvement, family representative actively involved. Family member felt resident was not compatible with current roommate. Possible placement at another facility close to caregiver. Discussion with room change per family member. During an interview on 6/11/25 at 3:18 p.m. with the Social Service Director (SSD) and the Director of Nursing (DON) the SSD stated if a resident requested a room change we look for an empty room of their liking. SSD stated we show it (the room) and proceed. The SSD stated they document the room change on the Room Change Notification form in the assessment section. The SSD verified the 04/09/2025 room change was not documented on a Room Change Notification form nor in the progress notes. SSD stated If she did not change the room, someone else may have and not performed the notification. SSD stated we have to make sure both SSD and admissions know of the bed changes. SSD verified there was no documentation regarding the room change for 04/09/2025. SSD stated she moved Resident #4 due to the family member requested Resident #4 to be moved. SSD stated she could not remember why the family member wanted the resident moved. Review of the facility's policy, Standards and Guidelines: Room Changes, revised 1/2024 showed changes in room or roommate assignment are made when the facility deems it necessary to meet the needs of current residents or when the resident requests a change. Policy Interpretation and Implementation 1. Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 2. Residents have the right to share a room with their roommate of choice, including a spouse, domestic partner, or friend, as long as both parties live in the same facility, and consent to the arrangement. 3. Prior to changing a room or roommate assignment parties involved in the change / assignment (for example residents and their representatives) are given advance notice of such change. 4. Documentation of a room change is recorded in the residence medical record.

Based on observation, interview, and record review, the facility failed to maintain and implement an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to prevent the development and transmission of communicable diseases and infections as evidenced by: 1. five staff members (P, Q, N, T, U) not donning and doffing personal protective equipment (PPE) when entering and exiting resident rooms on contact isolation; 2. one staff member (G) not following infection control guidelines during medication administration; 3. a mechanical lift used for multiple residents not being cleaned and disinfected after each use; and 4. one staff member (U) not effectively cleaning and disinfecting environmental surfaces and tools used for cleaning to mitigate the transmission of communicable diseases for a sample of four resident rooms (B-wing rooms 3, and 5 and A-wing rooms 2, and 5) out of five resident rooms designated as transmission-based precautions. Findings included: 1. On 10/16/23 at 1:22 p.m. Staff P, Physical Therapist (PT) and Staff Q, Certified Occupational Therapist Assistant (COTA) were observed entering room [ROOM NUMBER] on the B Wing. A Contact Precautions sign was observed hanging beside the door that read, STOP EVERYONE MUST: clean their hands, including before entering the room and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. (Photographic Evidence Obtained) Staff P, PT and Staff Q, COTA were observed walking into the room without donning a gown or gloves and then assisted a resident in this room out of bed and down the hall to the therapy department. During an interview on 10/16/23 at 1:46 p.m. Staff P, PT confirmed room [ROOM NUMBER] B Wing was on contact precautions due to a foot infection. Staff P, PT confirmed she did not don a gown prior to entering room [ROOM NUMBER] B Wing and she assisted the resident to the therapy department. Staff P, PT stated the therapy department had permission from the nurse to assist this resident to the therapy department. Staff P, PT reviewed the Contact Precautions sign located on the wall next to room [ROOM NUMBER] B Wing and stated, in the other facility I work for we follow what all the signs say. During an interview on 10/16/23 at 1:54 p.m. Staff Q, COTA stated I was aware room [ROOM NUMBER] B Wing was on Contact Precautions. Staff Q, COTA stated a couple of weeks ago Staff S, Licensed Practical Nurse (LPN)/Unit Manager (UM) gave permission for therapy to enter room [ROOM NUMBER] B Wing and assist this resident down to the gym for therapy. Staff Q, COTA stated the resident's wound was covered so the therapy department only used gloves. Staff Q, COTA reviewed the Contact Precautions sign and stated, We use gloves depending on the patient. During an interview on 10/16/23 at 2:05 p.m. Staff S, LPN/UM stated when a room was under Contact Precautions all staff needed to don a gown and gloves before entering the room and doff prior to exiting the designated contact precaution room. On 10/18/23 at 1:04 p.m., Staff N, Registered Nurse (RN) was observed entering room [ROOM NUMBER] B Wing, that still had the Contact Precautions sign, with gloves only. Staff N, RN was touching and investigating the resident's Intravenous Therapy (IV) pump and tubing that was beeping. During an interview on 10/18/23 at 1:10 p.m. Staff N, RN stated, I did not put on a gown because I did not provide direct care. Staff N, RN stated he only checked on the IV that was beeping. Staff N stated when a room was under Enhanced Precautions You wear a gown and gloves no matter what. Staff N, RN stated when a room was under Contact Precautions; You wear gloves, but gown and gloves when doing patient care. Review of the facility policy titled, Contact Precautions sign, revealed the following: STOP CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Used dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of the facility policy titled, Enhanced Precautions sign, revealed the following: STOP ENHANCED PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheotomy. Wound Care: any skin opening requiring dressing. During an interview on 10/19/23 at 6:29 p.m. the Infection Preventionist (IP) stated she was just hired last week and was still learning the job from Staff S, LPN/Unit Manager and the previous IP. During an interview on 10/19/23 at 6:29 p.m. Staff S, LPN/UM and the previous IP stated the facility was currently looking for Contact Precautions signs that fit the facility's policy. Staff S, LPN/UM stated the Contact Precautions signs the facility had now were from the Centers for Disease Control and Prevention (CDC) and stated, We are trying to find signs that match our policy. Staff S, LPN/UM stated for Contact Precaution rooms, You definitely need gloves if you're just going into the room and if you're not going to be in contact with anything else. Staff S, LPN/UM stated the nurse should wear gowns and gloves when the nurse was providing care and when providing care to residents with Intravenous Therapy (IV). Staff S, LPN/UM stated, Housekeeping needs to gown up as well. Staff S, LPN/UM stated residents under Contact Precautions should not come out of their rooms unless a surgical wound has been resolved. Staff S, LPN/UM stated, If it is something that is a wound that has a lot of excoriate and someone can come in contact with that they are encouraged to stay in their rooms. An interview was conducted with the Director of Nursing (DON) on 10/19/2023 at 6:34 p.m. The DON stated she has been in contact with the local Department of Health (DOH) infection specialist regarding Candida Auris (C-Auris). The DON stated the facility has implemented isolation precautions based on the DOH and Center for Disease Control (CDC) recommendations. The DON stated the residents who are currently on Enhanced Barrier Precautions do not have active infections. The residents are all colonized. If the resident has a change and has signs and symptoms of an active infection, their isolation would be increased to Contact Precautions. The DON reported she decided the placement of new resident admissions. She stated they try to cohort residents with colonized C-Auris together. She stated Enhanced Precautions require gown and gloves only when you are giving direct care. She stated Contact Isolation requires a gown and gloves when entering the room. 37999 2. During an observation of medication administration on 10/18/23 at 8:21 a.m. with Staff G, LPN the following medications were dispensed for Resident #37: -Buspirone 10 milligram (mg) tablet -Folic Acid 1 mg tablet -Diltiazem 120 mg tablet -Montelukast 10 mg tablet -Spirolactone 50 mg tablet -Xifaxan 550 mg tablet -Potassium 20 milliequivalents (meq) Extended Release (ER) tablet -Omeprazole 20 mg over the counter (otc) tablet -Iron 325 mg otc tablet -Magnesium oxide 400 mg tablet otc. Staff G, LPN placed the tablets in a medication cup while dispensing and when asked to confirm there were 10 tablets, Staff G poured the tablets out of the cup and onto an 8x11 piece of paper lying on the medication cup. Staff G put the tablets back into the cup with bare hands including a couple that had rolled off the paper and onto the top of the medication cart. Staff G confirmed 10 tablets and turned toward the doorway of Resident #37's room. 48223 3. On 10/17/2023 at 10:40 a.m., Staff H, Certified Nursing Assistant (CNA) was observed in room [ROOM NUMBER] on B wing, with a resident care lift. Staff H, CNA was observed exiting the room with a resident care lift covered in a clear bag and in her other hand, a clear bag with soiled linen enclosed. Staff H, CNA placed the resident care lift against the handrail and proceeded to discard the linen bag in the appropriate location. An interview was conducted with Staff H, CNA on 10/17/2023 at 10:46 a.m. Staff H, CNA stated they are instructed to bag the resident care lift after each use. This indicates the lift is clean and ready for the next use. We don't wipe the lift down after each use, just bag it. We only wipe the patient lift down with alcohol wipes after utilizing the lift with a resident who is in isolation. Staff H, CNA stated when entering a contact isolation room, you only need to wear gloves. You only need to don a gown if you are going to be providing care. Enhanced isolation means you don gown and gloves when entering the room. During an interview on 10/17/2023 at 4:30 p.m. Staff H, CNA confirmed alcohol wipes are not kept in resident rooms and the patient lift was not wiped down upon exiting room [ROOM NUMBER] on B wing earlier in the day as this was not the process. On 10/18/2023 at 9:53 a.m. Staff T, Plant Ops (PO) was observed approaching the door of room [ROOM NUMBER] on B wing. An isolation cart was observed beside the door and a Contact Isolation sign was posted in the middle of the door instructing staff to don gown and gloves prior to entering the room. Staff T, PO knocked on the door and entered the room. No personal protective equipment (PPE) was donned. Staff T, PO proceeded to work on the closet door. At 9:56 a.m. Staff T, PO exited the room and completed hand hygiene with an alcohol-based hand sanitizer (ABHS). At 10:00 a.m. Staff T, PO entered room [ROOM NUMBER] on B wing, donned gloves, proceeded to the bathroom, completed a task, doffed gloves, exited the bathroom, and proceeded to exit to the hallway. Staff T, PO completed hand hygiene with ABHS after exiting the room. An interview was conducted with Staff T, PO on 10/18/2023 at 10:05 a.m. Staff T, PO stated when entering isolation rooms you only need PPE when going near the resident bed. On 10/18/2023 at 10:20 a.m., Staff U, Housekeeping Aide (HA) was observed in room [ROOM NUMBER] on A Wing, with gown and gloves. room [ROOM NUMBER] had 4 beds in the room. At the time of the survey, three residents resided in room [ROOM NUMBER] on A wing. All three residents were colonized for C-Auris. Staff U, HA was observed cleaning multiple residents' surfaces with the same rag. Staff U, HA changed the rag throughout the room, just not between residents' sections. On 10/18/2023 at 10:39 a.m., Staff U, (HA) was observed in room [ROOM NUMBER] on A wing and a Contact Isolation sign was observed in the middle of door, and an isolation cart sitting next to the door. Staff U, HA donned a gown and gloves. At 10:44 a.m. Staff U, HA was observed exiting room [ROOM NUMBER] on A Wing. Staff U, HA placed the used mop, with the microfiber cloth still attached directly on the cleaning cart between the center console and the clean microfiber mop head bucket. Staff U, HA exited the room, in full PPE (gown and gloves). Staff U, HA proceeded to walk around the cleaning cart. Doffed the gown, draped it on the side of the cleaning cart, the trash receptacle was on. Doffed the gloves, and disposed of them in the trash receptacle, on the cleaning cart. A resident approached Staff U, HA and they hugged. Staff U, HA proceeded to complete hand hygiene with ABHS. An interview was conducted with Staff U, HA on 10/18/2023 at 10:59 a.m. outside of the Speech Therapy (ST) room. The ST room was at the end of B hall. room [ROOM NUMBER] on A wing was on another wing. The soiled mop had not been moved. Staff U, HA stated they treat all isolation rooms the same. They don/doff gown and gloves upon entering/exiting the rooms. Staff U stated they plan for the items they will need in the isolation room to minimize the trips to the cart. She stated they utilize individual rags and microfiber mops to clean and complete hand hygiene by utilizing ABHS. She stated they don't need to utilize soap and water unless their hands get soiled. They need to go to the bathroom or at the end of the day. Staff U, HA confirmed she did not utilize soap and water prior to exiting room [ROOM NUMBER] on A Wing, and the microfiber mop was left to rest on the cleaning cart until getting ready to enter the next room. She stated once she exits the isolation room, she does not touch the mop until she arrives at the next room and puts gloves on. She stated she then removes the dirty microfiber mob head, and places the dirty one in a plastic bag. She then places the mop in the microfiber mop head bucket for a new pad. Staff U, HA confirmed she utilized multiple rags to clean resident rooms but does not change rags in between resident beds (sections). An interview was conducted with Staff D, Environmental Supervisor (EVS) on 10/18/2023 at 11:25 a.m. Staff D, EVS confirmed responsibility of overseeing Housekeeping and Laundry Services. Staff D, EVS stated isolation rooms should have the microfiber mop head removed prior to doffing PPE and placing the used mop head in the bag for appropriate cleaning. He stated the staff should doff the PPE they have on and place the gown and gloves in the trash can inside the room door. He stated they have placed larger trash cans in all isolation rooms to ensure appropriate hygiene practice occurs. Staff D, EVS stated the resident rooms do not have sinks by the door, so the staff only utilize ABHS. Staff D, EVS confirmed Staff U, HA did not practice the correct process, listed above. Review of the facility policy titled, Isolation Precautions, Categories of, dated 2/23/23, revealed the following: Policy: Transmission-based isolation precautions will be used for residents who are documented or suspected to have infections or communicable diseases that can be transmitted by droplet transmission or by contact with dry skin or contaminated surfaces. Transmission-based isolation precautions are to be used in addition to standard precautions. Enhanced barrier precautions are to be used with multidrug-resistant organisms. Policy Interpretation and Implementation: 1. Transmission-based isolation precautions have been established in order to ensure the appropriate isolation techniques are implemented in this center when necessary. 2. Isolation should be the least restrictive possible for the resident under the circumstances. Contact Precautions: Gown/Gloves Enhanced Barrier Precautions: Gowns/Gloves-during high resident care activities Review of a policy titled, Candida Auris, dated September 2023, revealed the following: Policy: Fungal infections caused by candida auris (C-Auris) are resistant to commonly used antifungal medications and are difficult to treat. C-Auris is associated with a high mortality rate and has the potential to cause outbreaks in facilities. Facility will follow CDC guidelines to manage C-Auris: Currently CDC defines the following targeted organisms for use in Enhanced Barrier Precautions (EBP): C-Auris Facility will place the resident in either contact or enhanced barrier precautions for the duration of their stay . Residents with colonized infection will be placed on EBP . Having health care personnel change their PPE including gloves and performing hand hygiene before and after interaction with each patient. Alcohol based sanitizers are okay for use as C-Auris does not produce any spores . When patients are placed in shared rooms, facility must implement strategies to help minimize transmission between roommates. Clean and disinfect as if each bed area were a different room. For example: Clean and disinfect any shared or reusable equipment. Change mop heads, cleaning clothes, and other cleaning equipment between bed areas . Gowns and gloves must be worn when providing direct resident care/high contact care . Residents are permitted to leave their rooms for activities, dining, etc. EBP will remain in place for the duration of the admission for residents with colonization .

Based on observations, interviews, and record review, the facility failed to ensure 1) medications on one medication cart (A-wing cart) were secured while unattended, 2) insulin pens and vials were dated in one medication cart (B-wing cart), 3) bottles of ophthalmic solutions were dated and internal/external medications were not stored in the same compartments on one medication cart (C-wing cart) of four medication carts observed. Findings included: An observation was made on 10/18/23 at 8:19 a.m. of medication administration with Staff G, Licensed Practical Nurse (LPN) for Resident #33. The nurse dispensed one Multivitamin over the counter (otc) tablet, one Vitamin C otc tablet, and one Zinc otc tablet from separate bottles. The staff member left the three otc medication bottles sitting on the unlocked and unattended medication cart (A-wing cart) as the medications were administered in the resident's room. The medication cart was parked in the hallway and to the side of the doorway to the resident's room. An observation was conducted with Staff N, Registered Nurse (RN) on 10/18/23 at 11:42 a.m. of the B-wing medication cart. The observation revealed the following: - Lantus insulin pen. Storage bag dated 10/13/23, pen was not dated. A label attached to the pen allowed for the medication to be dated with an open date. -An opened undated Levemir insulin vial, storage bag dated as opened on 10/13 and another date of 10/2/23 was written on another label. -An opened undated Insulin Aspart vial, storage bag dated as opened on 10/12/23. -An opened undated vial of Insulin Lispro. The storage bag was dated with both 10/1/23 and 10/13. -An opened undated bottle of Olopatadine 0.2% solution, storage bag dated 9/29/23. An observation was conducted with Staff O, LPN on 10/18/23 at 12:11 p.m. of the C-wing medication cart. The observation revealed the following: -An opened undated bottle of Latanoprost 0.005% ophthalmic drops. The storage bag was dated 9/20/23. -An opened undated bottle of Brimonidine 0.2% ophthalmic drops, neither the box nor the label attached to the bottle was dated. The storage bag was dated 10/16/23. -An opened undated bottle of Artificial Tears, the box was dated 7/23/23. -An opened undated bottle of Artificial Tears, the box was dated 3/19/23. -An opened undated bottle of Artificial Tears, the box was dated 4/26/23. -A bottle of Saline Nasal spray, was stored with a box of rectal Bisacodyl suppositories, and multiple respiratory inhalers. -An opened, undated bottle of ProStat liquid protein. Staff O, LPN tipped the bottle over to identify the manufacturer's expiration date. The label of the bottle instructed to Discard 3 months after opening. An interview on 10/18/23 at 1:48 p.m. was conducted with the Regional Director of [Pharmacy Name]. The Director stated dates of insulin could be on the package (storage bag) or the pen/vial as staff could not reuse the storage bag, and they should be using the (storage) bag that comes from the pharmacy. She stated the policy was the same for eye drops, dates did not need to be on the bottle itself, the Prostat needed to be discarded after three months, and the pharmacy recommended separating external and internal products. During an observation, on 10/19/23 at 5:45 p.m. the Director of Nursing (DON) stated open dates should be on the vials, bottles, and pens. The DON stated the expectation would be all medications were put away and carts locked before leaving them unattended, external, and internal medications should be stored separately. A review of the he facility policy titled, Storage of Medications, dated April 2022, revealed the following: Drugs and biologicals should be stored in a safe, secure, and orderly manner. The Interpretation and Implementation identified the following: -1. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing. -3. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this Center. All such drugs are destroyed. -6. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) -7. Drugs are stored in an orderly manner in cabinets, drawers, or carts. These compartments are sufficient size to prevent crowding. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug from one resident being given to another resident. According to Cleveland Clinic, (located at https://my.clevelandclinic.org/health/drugs/18710-artificial-tears-eye-solution) Most experts recommend discarding the product (Artificial Tears eye solution) after 30 days. According to Mayo Clinic, (located at https://www.mayoclinic.org/drugs-supplements/latanoprost-ophthalmic-route/proper-use/drg-20064474) identified an opened bottle of Latanoprost (Xalatan) can be stored in the refrigerator or at room temperature for 6 weeks. (Photographic Evidence Obtained)

Based on observation, record review and interview the facility failed to accurately reflect each resident's status at the time of assessment on the minimum data set assessment (MDS) for three residents (#3, #40, and #33) out of thirty three sampled residents. Findings included: 1. A review of Resident #3's Admission Record showed Resident# 3 was admitted to the facility on [DATE] with diagnoses of spinal bifida, paraplegia and atherosclerotic heart disease of native coronary artery with unspecified angina. A review of the Quarterly MDS, dated [DATE], Section N Medications, showed Resident #3 received anticoagulants for six days during the seven-day look back period. A review of Resident #3's current and discontinued physician orders showed no anticoagulant therapy. During an interview on 10/19/23 at 1:30 p.m. the Registered Nurse (RN) MDS Coordinator stated she reviewed anticoagulants on the Medication Administration Record (MAR) to ensure the medication was given. The RN MDS Coordinator reviewed Resident #3's MAR and stated she did not see an anticoagulant on the MAR. The RN MDS Coordinator reviewed Resident #3's current and discontinued physician orders and stated Resident #3 was never ordered or administered anticoagulants and the MDS was marked in error. 2. A review of Resident #40's Admission Record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and dysphasia. A review of Resident #40's Modification to Annual MDS, dated [DATE], Section K Swallowing Nutrition Status showed Yes was marked for weight loss. A review of Resident #40's weights and summary report as of 10/19/23 showed: 6/5/2023 - 106.5 pounds (Lbs) 7/4/2023- 111.5 Lbs 8/11/2023- 111.0 Lbs 9/13/2023- 114.2 Lbs 10/5/2023- 115.2 Lbs On 06/05/2023, Resident #40 weighed 106.5 lbs. On 07/04/2023, Resident #40 weighed 111.5 pounds which was a 4.69 % gain. During an interview on 10/19/23 at 1:28 p.m. the RN MDS Coordinator reviewed Resident #40's Modification to Annual MDS, dated [DATE], Section K Swallowing Nutrition Status and weights. The RN MDS Coordinator stated that usually the Dietitian completes the MDS Section K but stated, I was the one who modified [Resident #40's] MDS to show weight loss. The RN MDS Coordinator stated, I looked at the dates wrong and modified the Dietitian's answer of weight gain to weight loss and that was an error as Resident #40 did not have weight loss. 48223 3. A review of the Admission Record for Resident #33 showed an admitted [DATE] with diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCP aka knuckles). During an interview on 10/17/2023 at 2:30 p.m. Resident #33 stated my hands have been like this for a while. The facility has not been working with me on moving them. Resident #33 continued to state; I can open my hands. At this time Resident #33 was able to bilaterally move his fingers from the MCP joints only, however, his middle to pinkie finger remained bent. Resident #33's second finger (pointer) and thumb moved up and down to touch each other and both hands were observed moving in this manner. During an interview on 10/18/2023 at 4:49 p.m. with Staff B, Certified Nursing Assistant (CNA) stated Resident #33's hands have been like that for a while now. Staff B, CNA stated I clean underneath the fingers and the palm the best I can as they are hard to move. I do not complete range of motion (ROM) with him. Resident #33 does not refuse care for me. During an interview on 10/18/2023 at 12:49 p.m. Staff G, Licensed Practical Nurse (LPN) stated Resident #33's right and left hands are contracted. I clean Resident #33's hands and clip the nails as this is hard for the CNA to complete due to the rigidity in the fingers. Resident #33 is very sweet and compliant with care for me. A review of Resident #33's physician order, dated 4/25/2023, revealed: May have restorative/maintenance programs as indicated. During an interview on 10/17/2023 at 2:36 p.m. the Regional Director of Rehabilitation (RDOR) stated he has been functioning as the Director of Rehabilitation at the facility. The RDOR stated therapy routinely screens residents on a quarterly basis, based on the MDS calendar. The RDOR was not able to provide a screening form completed on Resident #33, whose MDS was completed on 8/14/2023. The RDOR stated, I have not received a calendar for a while now. The RDOR stated I am unsure when Resident #33 was screened last, we don't have any documentation prior to July 1, 2023. An interview was conducted on 10/17/2023 at 2:41 p.m. with the RN MDS Coordinator and the Regional MDS Director. The RN MDS Coordinator stated the Inter Disciplinary Team is made aware of when the MDS for the residents are due by utilizing the computer software we have. The RN MDS Coordinator stated, I don't know why the screen would not have been completed. An interview on 10/18/23 at 12:59 p.m. was conducted with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The DON stated Resident #33 is not compliant with care and maybe this is the reason no screening was performed. During an interview on 10/19/2023 at 1:20 p.m. the RN MDS Coordinator stated she was responsible for completing the section of the MDS that would indicate the resident's functional status. The RN MDS Coordinator verified Resident #33's functional status did not have any impairments noted. The RN MDS Coordinator stated there was no documentation of impairment in range of motion. No Policy and Procedure for Resident Assessments was provided to the survey team upon exit on 10/19/23.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances and progress toward a resolution for concerns expressed in Resident Council Meetings by three residents (#63, #52, and #23) of 36 sampled residents. Findings included: A review of the facility's the Resident Council Minutes from 9/12/2023 at 10:00 a.m. revealed the residents were voicing complaints regarding receiving clothing back from the laundry. (Photographic Evidence Obtained) An interview was conducted with Resident #63 on 10/16/23 at 10:10 a.m. During the interview Resident #63 stated, I had a lot of expensive stuff, now it's gone. They told me to write my name on my stuff, I did, and it didn't make a difference. Yes, I told them, and they said I needed to go to the clothing drive. I told them what's that got to do with my missing stuff. I don't trust them. I don't trust them when it comes to my clothes. An interview was conducted with Resident #52 on 10/16/23 at 11:35 a.m. During the interview Resident #52 stated, Oh, it's bad. You can ask anybody . They just keep saying that they are behind. This has been going on since I've been here .It's frustrating. As a woman it's frustrating because I have to wear the same thing every day. A Resident Council Meeting, conducted on 10/18/23 at 3:18 p.m., revealed residents voicing additional concerns regarding the facility's laundry service. During the meeting Resident #23 stated, It takes 6 weeks to get my laundry back. These findings were discussed and confirmed during an interview with Staff D, Environmental Supervisor, on 10/19/23 at 11:04 a.m. During the interview Staff E stated, The way personal laundry works is that when we get a new resident in the building, the CNAs ( Certified Nursing Assistants) are supposed to bag all their clothing , bring it to us and we label it. The issue that we are having is that clothing is not being brought to us to be labeled. I'm in the process of changing out this process .Yes, it's been bad but it's definitely getting better. It's been an ongoing issue.

Based on observations, record reviews, and interviews the facility failed to develop and implement a care plan related to: 1. smoking for one resident (#82), 2. lack of range of motion for one resident (#33), and 3. related to the changes in one resident's (#78) mood, behavior and new medications for depression and anxiety out of thirty-three sampled residents. Findings included: 1. An observation and interview was conducted on 10/16/23 at 10:51 a.m. with Resident #82. The resident confirmed he smoked while at the facility. The resident stated staff members are always with the residents while smoking and the facility keep all cigarettes and lighters. On 10/18/23 at 10:49 a.m. Resident #82 was observed walking the facility's hallway. A review of the Admission Record for Resident #82 revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record showed the resident had diagnoses not limited to other encephalopathy, fracture of unspecified part of neck of unspecified femur subsequent encounter for closed fracture with routine healing, uncomplicated alcohol abuse, and unspecified nutritional anemia. Review of Resident #82's Minimum Data Set, dated dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. Section J Health Conditions revealed the resident did not use tobacco. A review of a Smoking Evaluation, dated 9/5/23, for Resident #82 identified the resident did smoke, was determined a safe smoker, and supervision was not needed. Review of Resident #82's Smoking Evaluation, dated 9/21/23, identified the resident did smoke and was determined to be a safe smoker. The evaluation did not reveal if the resident needed supervision while smoking. Review of Resident #82's active care plan with the last review date of 10/16/23 revealed there was no focus, goal, or intervention regarding the resident's choice to smoke. An interview was conducted with the Registered Nurse Minimum Data Set Coordinator (RN MDS Coordinator) on 10/19/23 at 1:52 p.m. The RN MDS Coordinator stated residents should absolutely have a care plan for smoking if they had gotten to their comprehensive assessment. The RN MDS Coordinator reviewed Resident #82's care plan, the options available, and confirmed the resident did not have a care plan for smoking. The staff member stated she must have been unaware Resident #82 was smoking and finds out if a resident was a smoker generally there is a smoking assessment in the electronic clinical record. On 10/19/23 at 2:03 p.m. Resident #82 confirmed smoking and being out there (smoking patio) every day. 48223 2. A review of the Admission Record for Resident #33 showed an admitted [DATE] with diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCP aka knuckles). During an interview on 10/17/2023 at 2:30 p.m. Resident #33 stated my hands have been like this for a while. The facility has not been working with me on moving them. Resident #33 continued to state; I can open my hands. At this time Resident #33 was able to bilaterally move his fingers from the MCP joints only, however, his middle to pinkie finger remained bent. Resident #33's second finger (pointer) and thumb moved up and down to touch each other and both hands were observed moving in this manner. During an interview on 10/18/2023 at 4:49 p.m. with Staff B, Certified Nursing Assistant (CNA) stated Resident #33's hands have been like that for a while now. Staff B, CNA stated I clean underneath the fingers and the palm the best I can as they are hard to move. I do not complete range of motion (ROM) with him. Resident #33 does not refuse care for me. During an interview on 10/18/2023 at 12:49 p.m. Staff G, Licensed Practical Nurse (LPN) stated Resident #33's right and left hands are contracted. I clean Resident #33's hands and clip the nails as this is hard for the CNA to complete due to the rigidity in the fingers. Resident #33 is very sweet and compliant with care for me. A review of Resident #33's physician order, dated 4/25/2023, revealed: May have restorative/maintenance programs as indicated. A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. During an interview on 10/17/2023 at 2:36 p.m. the Regional Director of Rehabilitation (RDOR) stated he has been functioning as the Director of Rehabilitation at the facility. The RDOR stated therapy routinely screens residents on a quarterly basis, based on the MDS calendar. The RDOR was not able to provide a screening form completed on Resident #33, whose MDS was completed on 8/14/2023. The RDOR stated, I have not received a calendar for a while now. The RDOR stated I am unsure when Resident #33 was screened last, we don't have any documentation prior to July 1, 2023. An interview was conducted on 10/17/2023 at 2:41 p.m. with the RN MDS Coordinator and the Regional MDS Director. The RN MDS Coordinator stated the Inter Disciplinary Team is made aware of when the MDS for the residents are due by utilizing the computer software we have. The RN MDS Coordinator stated, I don't know why the screen would not have been completed. An interview on 10/18/23 at 12:59 p.m. was conducted with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The RCN stated we do have a restorative maintenance program. Residents are placed on the program by either a therapy or nursing referral. Residents stay on this program for about 6-8 weeks. Resident #33 is not on restorative. The DON stated Resident #33 is not compliant with care and maybe this is the reason no screening was performed. During an interview on 10/19/2023 at 1:20 p.m. the RN MDS Coordinator stated she was responsible for completing the section of the MDS that would indicate the resident's functional status. The RN MDS Coordinator verified Resident #33's functional status did not have any impairments noted. The RN MDS Coordinator stated there was no documentation of impairment in range of motion. The RN MDS Coordinator stated Resident #33 refused to speak with me. A review of Resident #33's care plan with last care plan review completed 8/29/2023 showed: *Focus: [Resident #33] has an Activity of Daily Living self-care deficit related to muscle weakness, decreased mobility, obsessive compulsive disorder, depression, bipolar, cerebral vascular disease, adult failure to thrive. [Resident #33] prefers to stay in bed and declines staff request to transfer out of bed and into the wheelchair. [Resident #33] has a history of refusing care, declining showers, and declining to be weighed. Goal: The resident will maintain current level of function through next review date. Interventions: Bathing/Showering: assist of one staff. Bathing/Showering: check nail length and trim and clean on bath day as necessary, report any changes to the nurse. Bed mobility: assist of two staff. Bed fast: the resident is bed fast all or most of the time per his preference. Dressing: assist of one staff. Eating: the resident is able to feed self with setup. Personal hygiene: assist of one staff. Toilet use: assist of one staff. Transfer: requires mechanical lift [name brand] with two staff assistance for transfers. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use the call bell for assistance. Praise all efforts at self-care. Physical Therapy and Occupational Therapy evaluation and treatment as per Medical Doctor orders. *Focus: [Resident #33] prefers to stay in bed and declines staff request to transfer out of bed and into the wheelchair. [Resident #33] has a history of refusing care, wound care, declining showers and/or bed baths, refuses nail care, declining to reposition and declining to be weighed. Goal: The resident will cooperate with care through the next review date. Interventions: Allow the resident to make decisions about treatment regimen, to provide sense of control. Arrange for psych evaluation if resident continues to decline care on a consistent basis, and the root cause of resident's decline for assistance cannot be determined. Educate resident/resident's representative/caregivers of possible outcome(s) of not complying with treatment care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all activities prior to and as they occur during each contact. If resident does not cooperate with ADL's (activities of daily living), reassure the resident, leave, and return later and try again. Notify physician as needed of frequent denials to assist with care. Praise the resident when behavior is appropriate. Provide consistency and care to promote comfort with ADLs. Maintain consistency and timing of ADLs, caregivers, and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Resident #33's care plan was silent of a focus, goal or interventions related to the lack of range of motion for the resident's hands. 3. Review of Resident #78's Minimum Data Set (MDS) assessments showed the resident returned to the facility on [DATE], had an unplanned transfer to the hospital on 9/30/2023, and was readmitted to the facility a 3rd time on 10/10/2023. Review of Resident #78's Nursing Progress notes dated 9/30/2023 at 5:45 AM (just prior to the most recent hospitalization ) showed, Resident #78 called a family member and stated I am giving up. Review of the Admission Record showed new diagnoses in October of 2023 to include major depressive disorder and anxiety. On 10/16/2023 at 9:53 AM, Resident #78 was observed in bed under the blankets with the lights off. Resident #78 stated I just don't want to get up. On 10/17/2023 at 3:30 PM, Resident #78 was observed in bed under the blankets with the lights off, and on 10/18/2023 at 11:36 AM, Resident #78 was observed a third time in the same state. During the 10/18/2023 observation, Resident #78 stated I went to therapy today. Outside of that, I am going to stay in bed with the lights off. I don't feel like doing anything. Interview on 10/18/2023 at 11:40 AM with Staff E, Certified Nursing Assistant (CNA) revealed Resident #78's only goes to therapy and then lays in the bed with the lights off. Interview on 10/18/2023 at 12:52 PM with Staff G, Licensed Practical Nurse (LPN) revealed it was the resident's choice to stay in bed. Staff G reported Resident #78 was not like this on her prior admissions. Review of Resident #78's physician orders revealed the resident was receiving: Mirtazapine oral tablet 15 mg - give one tablet at bedtime for depression with appetite loss (order and start date 10/10/2023) Paroxetine HCI oral tablet 20 mg - give 1 capsule one time a day for depression related to major depressive disorder, single episode, unspecified (order date 10/4/2023, start date 10/5/2023) Alprazolam oral tablet 0.5 mg - give 1 tablet every 8 hours as needed 3 times daily for anxiety disorder, unspecified for 14 days (order and start date 10/12/2023) Review of Resident #78's care plan revealed no plan of care was developed related to the changes in the resident's mood, behavior and new medications for depression and anxiety. On 10/18/2023 at 3:05 PM, the Social Services Director (SSD) reported Resident #78 should have been care planned for depression, especially since the resident doesn't come out of her room. On 10/18/2023 at 3:15 PM, the Director of Nursing (DON) stated the expectation is medications for mood and behavior receive a care plan. Review of the policy and procedure titled, Care Plans, dated 8/2022, revealed: Intent: it is the policy of the facility to create care plans in accordance with state and federal regulations. Definition: Resident care plan means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident, the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being, a listing of services provided within or outside the facility to meet those needs, and an explanation of service goals. Procedure: 1. Each resident admitted to the nursing home facility shall have a plan of care. 2. The plan of care must consist of: a. Physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential. 3. A preliminary nursing evaluation with physician's orders for immediate care, completed upon admission. 4. A complete, comprehensive, accurate, and reproducible assessment of each resident's functional capacity which is standardized in the facility and is completed within 14 days of the resident's admission to the facility, and every 12 months thereafter. 5. The assessment must be: a. Reviewed no less than once every three months, b. Reviewed promptly after a significant change, which is in need to stop a form of treatment because of adverse consequences (e. g., an adverse drug reaction), or commence a new form of treatment to deal with a problem in the resident's physical or mental condition; and c. Revised as appropriate to assure the continued accuracy of the assessment. 6. The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. 7. The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. 8. The care plan will be completed within seven days after completion of the resident's assessment. 9. At the resident's option, every effort must be made to include the resident and family or responsible party, including private duty nurse or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident's plan of care. 10. All staff personnel who provide care, and at the resident's option, private duty nurses or personnel who are not employees of the facility, will be knowledgeable of, and have access to, the resident's plan of care. 11. A summary of the residence plan of care and a copy of any advanced directives must accompany each resident discharge or transferred to another healthcare facility, licensed under chapter 395 or 400, F. S., or must be forwarded to the receiving facility as soon as possible consistent with good medical practice.

Based on interview and record review, the facility failed to honor a resident preference to have medication administered at a later time in the morning for one resident (#75) of five residents sampled. Findings included: An interview was conducted with Resident #75 on 10/16/2023 at 1:18 PM. Resident #75 stated, I didn't sleep well last night as the facility insists on giving me my medication before the sun is up. I keep telling them, I don't want to be woken up until after 7:00 AM. They don't listen, I have told them numerous times and continue to tell them not to wake me up. A review of Resident #75's electronic Medication Administration Record (eMAR) revealed a note, dated 8/22/2023 at 5:00 AM that showed, resident does not want to be woke up for meds this early. A review of Resident #75's progress note, dated 8/24/2023 at 11:14 AM, revealed APRN [APRN] (advanced practice registered nurse) in to see resident, new orders for different time on hydralazine due to resident refusals of the 6:00 AM dose. Resident is agreeable. A review of Resident #75's Admission Record revealed the resident was admitted on [DATE], with diagnoses of hypertension and hyperlipidemia among other co-morbidities. A review of the Minimum Data Set (MDS), Section C Cognitive Patterns, dated 9/20/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident is cognitively intact. A review of Resident #75's Order Summary Report for October 2023 revealed physician orders for Hydralazine HCL oral tablet 50 milligrams (mg) with the following instructions: Give one tablet by mouth three times a day for HTN (hypertension) hold if systolic blood pressure (SBP) less than 100 millimeters of Mercury (mmHg) or diastolic blood pressure (DBP) less than 50 mmHg, ordered on 9/26/2023. An additional physician order, dated 9/26/2023, revealed Hydralazine HCL 50 mg as an as needed (PRN) every eight hours if resident systolic blood pressure is greater than 160 mmHg. A review of the electronic Medication Administration Record (eMAR) for the month of October 2023 for Resident #75 revealed the Hydralazine administration regimen as every day at 6:00 AM, 2:00PM and 10:00PM. Resident #75 received Hydralazine on all days but refused the morning 6:00 AM dose on 10/18/2023. A review of the electronic Medication Administration Record (eMAR) for the month of September 2023 for Resident #75 revealed the Hydralazine administration regimen as every day at 9:00 AM, 1:00PM and 8:00PM until the new order for 9/26/2023 with Resident #75 compliant with regimen. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 10/18/2023 at 12:49 PM. Staff G, LPN stated there is medication Resident #75 refuses to take in the morning, as Resident #75 does not want to be awoken early. Staff G, LPN stated we did not change the orders as it would not matter the timing, as the order is for every 8 hours. Therefore, the resident would have to be woken up in the evening. Staff G, LPN confirmed the medication times were never altered. A review of the facility's Grievance Logs revealed no grievances were filed for a change in medication times for Resident #75, during the months of July, August, September, or October 2023. An interview was conducted with the Social Service Director (SSD) on 10/18/2023 at 3:02 PM. The SSD confirmed there were no grievances filed for Resident #75 regarding medication administration times. The SSD stated the resident requests should be honored, if possible and be care planned. An interview was conducted with the Director of Nursing (DON) on 10/18/2023 at 3:15 PM. The DON stated she did not know the resident was refusing medications, due to the timing. Nor was she aware Resident #75 did not want to be woken up early. The DON continued to state, she did not know why the Resident's request was not facilitated. A policy for choices or accommodation of need was requested. No policies were produced upon exit of the survey team on 10/19/2023.

Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review, the facility failed to provide competent staff, which ensured residents reviewed for insulin administration received medication as ordered and follow-up monitoring occurred after a medication error. The facility failed to ensure one (Resident #1) of five residents were assessed and monitored for approximately five hours following identification of an insulin medication error and failed to notify the provider of a medication error in a timely manner as evidenced by a lapse of approximately two hours after the medication error occurred. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 3/12/23. After surveyor review and verification, it was determined the actions implemented by the facility achieved compliance on 3/17/23. Findings included: Reference citation F600 A review of Resident #1's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes Mellitus without complications, Neurocognitive disorder with Lewy bodies, and Metabolic encephalopathy (primary.) A review of Resident #1's Minimum Data Set (MDS) Five Day Assessment Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status Score (BIMS) score of 99, indicating he was unable to complete the interview. The assessment also showed the resident had short- and long-term memory problems and his cognitive skills for daily decision making was severely impaired. Section I, Active Diagnoses showed the resident had Diabetes Mellitus and Non-Alzheimer's Dementia but did not have a seizure disorder or epilepsy. The MDS was dated 3/10/23. A review of Resident #1's physician orders related to diabetes revealed: -1/18/23 Insulin aspart (Novolog) 100 unit (u)/milliliter (ml) (70-30) per sliding scale: If blood sugar is less than 70, call MD. If blood sugar is 141-180, give 3 units. If blood sugar is 181-220, give 5 units. If blood sugar Is 221-260, give 8 units. If blood sugar is 261-300, give 10 units. If blood sugar is 301-350, give 12 units. If blood sugar is greater than 350, give 14 units. Subcutaneous. Before meals and at bedtime. 6:00 a.m., 11:15 a.m., 5:00 p.m., 9:00 p.m. -1/18/23 Levemir U-100 Insulin solution; 100 u/ml; amt: 5 units subcutaneous 1 time daily. Give 5 units subcutaneous once per day for Type II Diabetes Mellitus without complications. Once in morning, 9:00 a.m. -1/18/23 Glucagon (HCL) Emergency Kit. 1 milligram (mg) IM (intramuscular) injection as directed PRN (as needed) for hypoglycemia. -3/6/23 Side Effects: Hyperglycemia/Insulin Medication Use. Observe resident closely for side effects: confusion, sweating, SOB (shortness of breath), fruity breath, weakness, fatigue, increased thirst, increased urination, shakiness, pale skin, lethargy. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. -3/6/23 Side Effects: Monitor resident for s/s (signs/symptoms) of hypoglycemia. Monitor for shaking/trembling, fast heart rate, increased hunger, sweating, confusion/difficulty concentrating, dizziness. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. A review of Resident #1's Medication Administration Record (MAR) showed the residents blood glucose levels and insulin administered were as follows: 3/11/23 6:00 a.m. blood glucose was 212 milligram (mg)/deciliter (dL) with 5 units of Novolog insulin administered per sliding scale order. 3/11/23 between 7:00-11:00 a.m. Levemir U-100, 5 units was administered as ordered. 3/11/23 11:15 a.m. blood glucose was 99 mg/dL with no Novolog insulin administered per sliding scale order. 3/11/23 5:00 p.m. blood glucose was 114 mg/dL with no Novolog insulin administered per sliding scale order. 3/12/23 6:00 a.m. blood glucose was 327 mg/dL with 12 units of Novolog insulin administered per sliding scale. (Documented on 3/12/23 at 5:20 a.m.) 3/12/23 11:15 a.m. blood glucose was 58 mg/dL with no Novolog insulin administered per sliding scale order. (Documented on 3/12/23 at 1:01 p.m.) A review of Resident #1's medical record revealed the following care plan: Category: Health Related Complications Resident #1 has a diagnosis of Diabetes and is at risk for unstable blood glucose as evidenced by hyperglycemia with signs and symptoms of increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss, blood sugars >180 mg/dl and hypoglycemia with signs and symptoms of shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Interventions include blood glucose monitoring as ordered, document non-compliance of diet recommendations, medications as ordered, notify MD with significant changes in signs and symptoms, and observe for/report signs and symptoms of hypoglycemia: shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Created 1/18/23. A review of Resident #1's medication record showed the following progress notes: A Nursing Note dated 3/12/23 5:45 a.m. (Recorded as late entry on 3/12/23 at 7:36 p.m.) showed Resident's BS [blood sugar] at 0545 am med pass recorded 327. Both Levemir 12u and Novolog 12 units given. Levemir order is for 5u to be given between 7-11 a.m. Rechecked in 1 hour and BS 84. Medication error and BS levels reported to on call nurse manager [Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM)] and ARNP for Medical Director. Received order to hold am dose of Levemir, monitor resident and have glucagon on standby if needed. New orders and BS checks reported to oncoming nurse [Staff B, Registered Nurse (RN).] Resident is awake and alert without s/s [signs and symptoms] of hypoglycemia. Dietary trays on hall and trays passing at this time. The Nursing note was entered by Staff A, Registered Nurse (RN). A Nursing Note dated 3/12/23 1:20 p.m. showed Client observed in bed resting with eyes closed. Blood glucose checked: 58. Rechecked to verify BG [Blood Glucose]: 56, 52. Glucagon 1g injected subq [subcutaneously]. Client breathing was regular at 14 respirations per min [minute]. Sternal rub performed and patient continued to be unresponsive. Pupils pinpoint and BG dropped to 38. Another nurse called 911 while I stayed with the patient. Blood pressure measured manually: BP 70/30 pulse 66. The reading was lower than in the early AM which was 116/60 pulse 70. BG went up to 68 and then back down to 54. Paramedics arrived at 12:55 and patient left at 1300. Client was cool to touch and unresponsive when the paramedics arrived but continued to have steady respiration at 14 bpm. MD notified at 1300 gave ok to send to ER for eval and tx [treatment], and family notified at 1305. The Nursing Note was entered by Staff B, RN. A review of the facility documentation, dated 3/12/23, described the medication error as Nurse mistakenly administered Levemir 12U instead of Novolog 12U, nurse administered Novolog 12U after realizing she gave Levemir 12U. After administering both insulins, nurse contacted MD on call. It showed the correct order was sliding scale Novolog 12u. The type of error was listed as incorrect dose and incorrect medication. The report showed the resident became hypotensive and hypoglycemic around 12:45 p.m., resident was unresponsive but maintained respirations and heart rate. The immediate interventions were described as Glucagon 1g injected subq as ordered. Res [resident] blood sugar rechecked. Resident remained unresponsive. 911 activated and res transported to ER [emergency room ] via stretcher around 12:55. The report shows the following blood sugar levels: 3/12/23 5:15 a.m. Blood sugar 327 mg/dL 3/12/23 12:04 p.m. Blood sugar 58 mg/dL A phone interview was conducted with Staff A, RN on 4/10/23 at 8:48 a.m. She confirmed she was taking care of Resident #1 the morning of 3/12/23 and made a medication error. She said the resident had been on her wing for a while and she was familiar with him. She said the resident was confused but could converse, saying hello and talking some. She said he did not always recognize family; he was incontinent and needed full care. She added the resident was able to self-propel in his wheelchair with his feet once he had help getting up. Staff A, RN said during her shift running from 3/11/23 7:00 p.m. to 3/12/23 7:00 a.m., the resident had stayed up very late, until 2:00 a.m. She said he did not want to stay in bed and was restless. She said there was no increased confusion, the resident was at his baseline. She said he had a history of falls, so she got him up to a wheelchair for a couple of hours, then put him back to bed. Staff A, RN said when insulin comes from the pharmacy, the vial is in the insulin box with a label on it and it is in a plastic bag that also has a label. Those bags are placed in the medication cart. She said when she pulled the bag out of the drawer, she read the bag, name, and checked everything. She confirmed she did not check the label on the box, she only checked the bag. After she administered the first insulin based on the sliding scale, she came back to the cart to put the vial in the box and bag, she realized she had given the wrong insulin. Staff A, RN said she gave the resident 12u of Levemir long-acting insulin instead of Novolog short-acting insulin. She said she panicked and stated, in my mind his blood sugar was still 327. The long acting was not going to bring down his blood sugar now. She said she went ahead and administered the Novolog within a couple of minutes of the Levemir. Staff A, RN said it was 5:30 a.m. and she could not call the doctor yet as she thought it was too early. She said, that is my error, I gave both. She said right after change of shift, approximately 7:15 a.m., she called and talked to the Nurse Practitioner (NP) for the Medical Director and the on-call manager, Staff C, LPN/UM Staff A, RN said the NP told her to monitor the resident closely, hold the morning dose of Levemir and have Glucagon on hand. An interview was conducted with Staff C, LPN/UM. on 4/17/23 at 12:29 p.m. Staff C, LPN/UM confirmed she was the on-call manager on 3/12/23. She said Staff A, RN called her about 7:20 a.m. and informed her she gave the wrong insulin to Resident #1. Staff C, LPN/UM said she asked Staff A, RN if she had talked to the doctor and Staff A, RN told her no. She said she told Staff A, RN to contact the doctor and follow his orders. She said Staff A, RN only told her she gave the resident long-acting insulin. She said she was not told the resident was also given short-acting insulin at the same time. Staff C, LPN/UM said she then received a call about 2:30 p.m. from Staff B, RN (the nurse caring for Resident #1 on the day shift 3/12/23) saying Resident #1's blood sugar had dropped. Staff B, RN asked her if she was aware of the extra insulin and Staff C, LPN/UM told her she was not aware. Staff B, RN notified her they gave Resident #1 Glucagon, and he was sent to the hospital. Staff C, LPN/UM said she notified the Director of Nursing (DON), and the DON notified the administrator. Staff C, LPN/UM said around 5:00 p.m. the day the error was made (3/12/23) she, along with other management, came in and began doing medication cart audits. During an interview with the DON on 4/18/23 at 4:31 p.m. she confirmed she came to the facility on [DATE] to complete medication cart audits with Staff C, LPN/UM. An interview was conducted with Staff B, RN on 4/5/23 at 2:50 p.m. She said she came on shift at 6:45 on 3/12/23 and received shift report from Staff A, RN between 7:00-7:15 a.m. She said Staff A, RN informed her she gave Resident #1 both long-acting and short-acting insulin that morning. She said Staff A, RN had not called the doctor at that point. Staff B, RN said Staff A, RN called the provider for the first time after she gave her report, approximately 7:15 a.m. She said Staff A, RN told her the NP gave orders to monitor the resident and have glucagon ready. Staff B, RN said she found out later that day Staff A, RN did not inform the NP she gave both the long and short-acting insulin; she only told her about the incorrect dose of Levemir. Staff B, RN said she checked Resident #1's blood glucose level between 8:30-9:00 a.m. and it was in the 90's. She said she did not document the blood glucose check in the resident's medical record because there was no place to enter it. Staff B, RN did say she could have documented it under vitals, but she did not think about that at the time. She said right before lunch trays came out, which is around 12, she rechecked Resident #1s' blood glucose and it was 58. She said she had another nurse (Staff D, LPN) come in and they verified again, it was 56 then 52. Staff B, RN said she administered Glucagon to the resident then checked his blood glucose again. She said it was then 38, so they called 911. She said she continually checked blood glucose levels until paramedics arrived. She said he went up to 68 then dropped back down in the 50's. When asked about monitoring the resident between 9:00 a.m. and 11:45 a.m., she said she was giving all of her other residents their medication. She said she looked in the room a couple of times and the resident was sleeping. She said he was snoring but arousable. A review of records did not reveal any documentation showing Resident #1 was assessed or monitored from 9:00 a.m. until 11:45 a.m. An interview was conducted with Staff D, LPN on 4/18/23 at 1:50 p.m. Staff D, LPN stated I did not know [Resident #1] very well but I do know he was very confused and a fall risk, very impulsive. That day he was sent out I helped the nurse. She came to me and said she checked his sugar [blood glucose] and it was low. She said she couldn't get him to take anything by mouth and I told her well give him the sugar s*** (expletive) [glucagon] we have in our medication carts, so she did that, and she came to me and said it's even lower now and I don't know what to do. I told her you need to call 911 and get them here. They couldn't even bring him back either. He was breathing and his heart was beating but he was just unresponsive. An interview was conducted with Staff E, Nurse Practitioner (NP) on 4/12/23 at 8:42 a.m. The NP stated she does not physically go to this facility and did not know this resident, but she was covering on-call the morning of 3/12/23. She said she does not recall exactly when the nurse called or what she told her specifically. She said she was told Resident #1 had received the wrong dose of insulin and had gotten double what he should have. The NP said she told the nurse to have Glucagon ready to go, monitor the resident and if his blood glucose drops low and you cannot get him out of it, to call her back. The NP said she never heard anything else from the facility. She said Staff A, RN just told her she gave too much insulin; she did not get into details. She said she does not believe Staff A, RN mentioned giving both insulins at the same time. She said she does not remember if she gave specific monitoring parameters, but her standard with low or high blood sugar is they should be checked at least every 2 hours. When asked if it was okay that the resident's blood glucose level was only checked between 8:30/9:00 a.m. then again at 11:45/12:00 p.m. she said, absolutely not. The NP said she did not have any notes related to this call. An interview was conducted with the Regional Consultant Pharmacist on 4/17/23 at 10:33 a.m. She said the onset of action for Levemir is between 3-4 hours after administration and the duration of action can range from 5/6 hours up to 18 hours depending on body weight and other factors specific to the resident. She said the onset of action for Novolog is around 12-18 minutes and the duration of action is between 3-7 hours depending on body weight, age, and other factors specific to the resident. The pharmacist said around 3-4 hours after both insulins were administered to the resident would have most likely been the point, they were at the highest effect together and the blood sugar could drop low. The pharmacist said 12u of Levemir is not an unusual dose, however because insulin is so dependent, for Resident #1 individually it may have been. She said typically the Novolog and Levemir are not administered at the same time, there would be some spacing. The pharmacist said in the incidence of an insulin overdose, the resident's blood glucose should be checked every 15 minutes and if it is below 70, interventions should have been implemented, such as giving Glucagon or IV glucose. She said the onset of Glucagon is 5-20 minutes and most protocols show that if Glucagon is given and the blood glucose is still below 70 you proceed to the next step, in this case send resident to the hospital. The pharmacist said the consultant pharmacist that visited the facility had not identified anything unusual in the facility regarding insulins or other medications. The pharmacist had previously conducted medication cart audits and did not find any issues. An interview was conducted with the facility Medical Director on 4/10/23 at 11:43 a.m. He said the nurse gave Resident #1 12u of rapid acting insulin and 12u or long-acting insulin. He confirmed he was not called that morning. He said the NP told the nurse to monitor the resident and have Glucagon ready. The doctor said he did not have any notes showing he saw Resident #1 and stated, It is very weird. (The Medical Director and NHA both confirmed there was no documentation to show the resident was seen in the facility by a primary provider.) The doctor said when a medication error is made the nurse should let the provider and their immediate supervisor know right then. He said he or the on-call should have been called that morning when the error happened. A review of the local Fire Rescue Patient Care Report showed the 911 call for Resident #1 was received on 3/12/23 at 12:38 p.m. Emergency Medical Services (EMS) arrived at the patient at 12:50 p.m. The reports showed the chief complaint for Resident #1 was Diabetic-Hypoglycemia and the primary symptom was altered mental status. The resident's blood glucose was 48 and his blood pressure was 119/68 at 12:56 p.m. The Fire Rescue Narrative note showed found 77 yom [year old male] lying in his hospital bed. Pt [patient] responded to painful stimuli, Pt equal chest rise and fall, ABC's [airway, breathing, circulation] intact, skin WNL [within normal limits,] lung sounds clear, and perrl [pupils equal, round, reactive to light.] Staff stated pt was assessed and BGL [blood glucose level] was 39. Staff stated they gave 1g of Glucagon with no improvement leading them to call [Fire rescue.] Pt was carried to the stretcher and secured with all appropriate straps, rails x 2 and semi fowlers [position] for pt comfort and safety. Pt. further assessed and vitals WNL. Pt. BGL 48. Pt IV established and 250ml of D10 [Dextrose 10% solution] given with an improved response. Staff stated pt has Lewy Body dementia and only has a verbal response as his baseline. Pt continued to improve throughout the entire call. Pt transported to [local hospital] per request. Pt monitored enroute with no notable changes. Fire Rescue arrived at the hospital at 1:13 p.m. on 3/12/23. A review of hospital records, dated 3/12/23, for Resident #1 showed the Chief Complaint as From [facility]: Pt found to be hypoglycemic this morning, given 1 g of glucagon by staff, pt blood sugar in the 40's for EMS given 250ml of D10. Pt hx: dementia. The History or Present Illness revealed Patient presents to the emergency department acutely altered. Patient presents from [facility] with report from EMS indicated the patient was hypoglycemic. He was given glucagon, but this did not improve his blood sugar. When EMS arrived his blood sugar was in the 40s. They subsequently gave D10. He was unresponsive for them the entirety of their time with the patient. I subsequently called patient's emergency contact, [family member.] She states the patient does have Lewy body dementia. However, normally is not unresponsive and is alert. Patient does arrive with a DO NOT RESUSCITATE order and I specifically clarified with the [family member] if he would want to be intubated [have a breathing tube placed down the throat into the windpipe to allow a machine to assist with breathing.] She thinks that that [sic] would be in accordance with his wishes and he would be amenable to intubation. She does not know of any seizure history, which I asked because the patient did have rhythmic eye movements and contracted positioning that made me concerned for possible seizures. I did also call the facility and discussed with the nurse taking care of him. She does confirm that patient is normally able to push himself around in wheelchair and is typically alert. She does state that this morning was an acute change for patient. Patient was unresponsive for her the entire time as well. Patient on arrival unresponsive and unable to answer any questions for me. The record also revealed the resident had recurrent episodes of hypoglycemia on arrival and was again given D50 and a D10 drip was started. Despite the correction of the hypoglycemia, the patient continued to be altered. There was a strong suspicion for possible seizure in the setting of rhythmic movements of the eyes and contracted positioning. The patient was hypothermic on arrival and a forced air warming blanket was used. An intubation was performed and completed without any hypoxia. A continued review of hospital records showed an assessment performed on Resident #1 on 3/12/23 at 1:40 p.m. The assessment showed the resident's level of consciousness as obtunded, meaning he had a lessened interest in the environment and slowed response to stimulation. The Coma Scale showed Resident #1 has no eye-opening response and no verbal response. The resident did have a motor response of flexion withdrawal. His overall coma score was a 6. According to the Centre for Neuro Skills, the Glasgow Coma Scale provides an assessment of coma and impaired consciousness. The total scores were explained as follows: 90% less than or equal to 8 are in a coma, greater than or equal to 9 not in coma, 8 is the critical score, 9-12= moderate severity, and greater than or equal to 13=minor injury. (Accessed on 4/20/23 at https://www.neuroskills.com/education-and-resources/glasgow-coma-scale/) The hospital records, dated 3/12/23 showed after reexamination in the emergency room Resident #1 was found to have a urinary tract infection which could potentially be contributory but does not truthfully explain why the patient was seizing. Following intubation and paralysis wearing off, patient without further rhythmic activity of his eyes and no longer posturing his upper extremities leading me to believe that his seizure likely is stopped. Patient was admitted to the Intensive Care Unit. The hospital Discharge Summary, dated 3/20/23, showed Patient was weaned off sedation, however patient was not waking up and minimally responsive. Therefore, he remained intubated due to concerns of ability to protect airway. Palliative care consulted. Patient was discharged to inpatient hospice facility pending bed availability. The discharge diagnoses included acute hypoxic respiratory failure, requiring mechanical ventilation, acute encephalopathy, likely multifactorial secondary to hypoglycemia, UTI (Urinary tract infection,) possible seizure with underlying Lew body dementia. Low suspicion of meningitis and possible seizure secondary to hypoglycemia. The patient's overall prognosis is terminal with no meaningful recovery. A review of the in-patient Hospice record showed the resident arrived to their facility on 3/20/23 at 1:30 p.m. He was non-responsive to spoken name, his eyes were wide open with no track, and his facial features were relaxed. A hospice note dated 3/20/23 at 4:58 p.m. showed Provider ordering ME [medical examiner] Reportable Death: Patient has been deemed ME case per [medical doctor] for reported medical error of inappropriate insulin at a nursing facility leading to profound hypoglycemia. The record revealed Resident #1's time of death at 12:16 p.m. on 3/27/23. An interview was conducted on 4/17/23 at 12:17 p.m. with a family member of Resident #1. The family member confirmed the resident passed away at the in-patient Hospice facility but was unable to discuss any further details at the time. A facility policy titled Administration of Drugs, dated April 2022, was reviewed. The following showed the following: Policy Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. 2. Drugs must be administered in accordance with the written orders of the attending physician. 3. All current drugs and dosage schedules must be recorded on the resident's Electronic Medication Administration Record (eMAR). 7. Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. 11. When PRN drugs are administered, the nurse should record: a. The date and time administered inside eMAR displays; b. Any complaints or symptoms for which the drug was administered; and c. Any results achieved from administering the drug and the time such results were observed. 13. The nurse should enter an explanatory note in the progress notes for eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and or repeated refusal of drugs. 15. Prior to administering the resident's drug, the nurse should compare the drug and dosage schedule on the resident's eMAR with the drug label. A facility policy titled Diabetes Care-Insulin Administration, dated April 2022 was reviewed. The policy showed the following: Policy Special precautions should be followed when administering insulin. Policy Interpretation and Implementation 1. Special precautions should be followed in the administration of insulin. 2. Insulin dosage should be drawn only by personnel licensed to administer such drug and must be administered by the person drawing the injection. 3. The type of insulin, dosage requirements, strength, and method of administration should be verified to assure that it corresponds with the order on the medication sheet and the physician's order. 4. Any discrepancies should be reported to the Charge Nurse or designee. 5. The resident's physician should be notified of any discrepancies or adverse drug reactions. A facility policy titled Medication Errors and Adverse Reactions, undated, was reviewed. The policy showed the following: Policy Drug errors and adverse drug reactions should be reported to the resident's attending physician. Policy Interpretation and Implementation 1. Adverse drug reactions and drug errors with adverse clinical consequences should be reported to the resident's attending physician or physician designee. 2. Nursing services should implement and follow the physician's orders. The resident's condition should be closely observed for seventy-two (72) hours or as may be directed. 3. A detailed account of the incident should be recorded on a medication error report. 4. Documentation of the residence condition and response to treatment should be recorded during the observation period. 5. The Medical Director and Director of Nursing Services should be informed of all drug errors and adverse reactions. 6. If the reaction is allergic in nature, the chart will be labeled to inform all parties of the drug that the resident is allergic to. A facility job description titled Registered Nurse, dated 8/16/19 was reviewed. The job description listed the following: Overview Under the direction of the Director of Nursing, supervises the nursing personnel and the day-to-day nursing activities of the facility during an assigned tour of duty. Such supervision must be in accordance with accepted professional standards and current federal, state and local regulations to ensure the highest degree of quality care is always maintained. Responsibilities: -Monitor the daily delivery of nursing care and nursing staff performance as they deliver nursing care to the patients/residents in accordance with established policies and procedures -Identify problems or potential problems in the delivery of nursing care to residents and implement corrective action immediately -Oversee the nursing care to patients/residents to ensure safe, efficient and customer-oriented services are delivered at all times. -Visit resident on report daily in order to observe and evaluate each resident's physical and emotional status -Provide direct nursing care as necessary -Ensure the staff refer to the resident's care plan prior to administering care to the resident -Assist the staff nurses in monitoring seriously ill resident -Ensure that all nurses on your shift comply with the written procedures for the administration, storage and control of medications and supplies -Monitor medication passes and treatments to ensure compliance with physician orders and facility policy -Review medication administration records (MAR) for completeness of information, accuracy in the transcription of physician orders -Report all accident and incidents to Supervisor immediately upon occurrence -Conduct all activities within established safety, security and infection control procedures and guidelines Conducts all activities within established corporate compliance policies and procedures -Ensure residents safety in accordance with resident safety program. An article titled Hypoglycemia (Nursing,) dated January 2023, was reviewed. The article showed the following: Nursing Diagnosis According to the North American Nursing Diagnosis Association International 9 ([NAME]-I), the nursing diagnosis of risk for unstable blood glucose level poses many additional risks and additional nursing diagnoses for the patient. The nurse's responsibility is to diagnose human responses within the nurse's scope and level of competency. It is vital that critical thinking is used to identify and understand the risk factors of unstable blood glucose levels, particularly low levels for the sake of this topic, and the accompanying signs and symptoms upon presentation of the patient. Medical Management Identification of a hypoglycemic patient is critical due to potential adverse effects including coma and/or death. Severe hypoglycemia can be treated with intravenous (IV) dextrose followed by infusion of glucose. For conscious patients able to take oral (PO) medications, readily absorbable carbohydrate sources (such as fruit juice) should be given. For patients unable to take oral agents, a 1-mg intramuscular (IM) injection of glucagon can be administered. Once the patient is more awake, a complex carbohydrate food source should be given to the patient to achieve sustained euglycemia. More frequent blood glucose monitoring should occur to rule out further drops in blood sugar. Nursing Management Nursing management of hypoglycemic episodes may consist of pharmacologic and non-pharmacologic actions. Immediate and frequent glucose monitoring is vital for any patient presenting with symptoms of unstable blood glucose, particularly with hypoglycemia. Risk Management Patient safety remains the priority in any event. The nurse should monitor the patient closely during and following a hypoglycemic episode. It is important to avoid leaving the patient unattended, due to the risks of worsening symptoms and the potential for falls. In addition to patient safety, documentation is a key responsibility of the nurse with regard to reducing liability risks. Documentation should always be specific and clear to the reader. Following a hypoglycemic episode, the nurse should document glucose levels, signs and symptoms, actions performed, the patient's response to th[TRUNCATED]

Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review the facility failed to ensure one (Resident #1) of five residents reviewed for insulin administration was free from a significant medication error as evidenced by the wrong dose and wrong type of insulin being administered a diabetic resident. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 3/12/23. After surveyor review and verification, it was determined the actions implemented by the facility achieved compliance on 3/17/23. Findings included: Reference citation F600 A review of Resident #1's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes Mellitus without complications, Neurocognitive disorder with Lewy bodies, and Metabolic encephalopathy (primary.) A review of Resident #1's Minimum Data Set (MDS) Five Day Assessment Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status Score (BIMS) score of 99, indicating he was unable to complete the interview. The assessment also showed the resident had short- and long-term memory problems and his cognitive skills for daily decision making was severely impaired. Section I, Active Diagnoses showed the resident had Diabetes Mellitus and Non-Alzheimer's Dementia but did not have a seizure disorder or epilepsy. The MDS was dated 3/10/23. A review of Resident #1's physician orders related to diabetes revealed: -1/18/23 Insulin aspart (Novolog) 100 unit (u)/milliliter (ml) (70-30) per sliding scale: If blood sugar is less than 70, call MD. If blood sugar is 141-180, give 3 units. If blood sugar is 181-220, give 5 units. If blood sugar Is 221-260, give 8 units. If blood sugar is 261-300, give 10 units. If blood sugar is 301-350, give 12 units. If blood sugar is greater than 350, give 14 units. Subcutaneous. Before meals and at bedtime. 6:00 a.m., 11:15 a.m., 5:00 p.m., 9:00 p.m. -1/18/23 Levemir U-100 Insulin solution; 100 u/ml; amt: 5 units subcutaneous 1 time daily. Give 5 units subcutaneous once per day for Type II Diabetes Mellitus without complications. Once in morning, 9:00 a.m. -1/18/23 Glucagon (HCL) Emergency Kit. 1 milligram (mg) IM (intramuscular) injection as directed PRN (as needed) for hypoglycemia. -3/6/23 Side Effects: Hyperglycemia/Insulin Medication Use. Observe resident closely for side effects: confusion, sweating, SOB (shortness of breath), fruity breath, weakness, fatigue, increased thirst, increased urination, shakiness, pale skin, lethargy. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. -3/6/23 Side Effects: Monitor resident for s/s (signs/symptoms) of hypoglycemia. Monitor for shaking/trembling, fast heart rate, increased hunger, sweating, confusion/difficulty concentrating, dizziness. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. A review of Resident #1's Medication Administration Record (MAR) showed the residents blood glucose levels and insulin administered were as follows: 3/11/23 6:00 a.m. blood glucose was 212 milligram (mg)/deciliter (dL) with 5 units of Novolog insulin administered per sliding scale order. 3/11/23 between 7:00-11:00 a.m. Levemir U-100, 5 units was administered as ordered. 3/11/23 11:15 a.m. blood glucose was 99 mg/dL with no Novolog insulin administered per sliding scale order. 3/11/23 5:00 p.m. blood glucose was 114 mg/dL with no Novolog insulin administered per sliding scale order. 3/12/23 6:00 a.m. blood glucose was 327 mg/dL with 12 units of Novolog insulin administered per sliding scale. (Documented on 3/12/23 at 5:20 a.m.) 3/12/23 11:15 a.m. blood glucose was 58 mg/dL with no Novolog insulin administered per sliding scale order. (Documented on 3/12/23 at 1:01 p.m.) A review of Resident #1's medical record revealed the following care plan: Category: Health Related Complications Resident #1 has a diagnosis of Diabetes and is at risk for unstable blood glucose as evidenced by hyperglycemia with signs and symptoms of increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss, blood sugars >180 mg/dl and hypoglycemia with signs and symptoms of shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Interventions include blood glucose monitoring as ordered, document non-compliance of diet recommendations, medications as ordered, notify MD with significant changes in signs and symptoms, and observe for/report signs and symptoms of hypoglycemia: shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Created 1/18/23. A review of Resident #1's medication record showed the following progress notes: A Nursing Note dated 3/12/23 5:45 a.m. (Recorded as late entry on 3/12/23 at 7:36 p.m.) showed Resident's BS [blood sugar] at 0545 am med pass recorded 327. Both Levemir 12u and Novolog 12 units given. Levemir order is for 5u to be given between 7-11 a.m. Rechecked in 1 hour and BS 84. Medication error and BS levels reported to on call nurse manager [Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM)] and ARNP for Medical Director. Received order to hold am dose of Levemir, monitor resident and have glucagon on standby if needed. New orders and BS checks reported to oncoming nurse [Staff B, Registered Nurse (RN).] Resident is awake and alert without s/s [signs and symptoms] of hypoglycemia. Dietary trays on hall and trays passing at this time. The Nursing note was entered by Staff A, Registered Nurse (RN). A Nursing Note dated 3/12/23 1:20 p.m. showed Client observed in bed resting with eyes closed. Blood glucose checked: 58. Rechecked to verify BG [Blood Glucose]: 56, 52. Glucagon 1g injected subq [subcutaneously]. Client breathing was regular at 14 respirations per min [minute]. Sternal rub performed and patient continued to be unresponsive. Pupils pinpoint and BG dropped to 38. Another nurse called 911 while I stayed with the patient. Blood pressure measured manually: BP 70/30 pulse 66. The reading was lower than in the early AM which was 116/60 pulse 70. BG went up to 68 and then back down to 54. Paramedics arrived at 12:55 and patient left at 1300. Client was cool to touch and unresponsive when the paramedics arrived but continued to have steady respiration at 14 bpm. MD notified at 1300 gave ok to send to ER for eval and tx [treatment], and family notified at 1305. The Nursing Note was entered by Staff B, RN. A review of the facility documentation, dated 3/12/23, described the medication error as Nurse mistakenly administered Levemir 12U instead of Novolog 12U, nurse administered Novolog 12U after realizing she gave Levemir 12U. After administering both insulins, nurse contacted MD on call. It showed the correct order was sliding scale Novolog 12u. The type of error was listed as incorrect dose and incorrect medication. The report showed the resident became hypotensive and hypoglycemic around 12:45, resident was unresponsive but maintained respirations and heart rate. The immediate interventions were described as Glucagon 1g injected subq as ordered. Res [resident] blood sugar rechecked. Resident remained unresponsive. 911 activated and res transported to ER [emergency room ] via stretcher around 12:55. The report shows the following blood sugar levels: 3/12/23 5:15 a.m. Blood sugar 327 mg/dL 3/12/23 12:04 p.m. Blood sugar 58 mg/dL A phone interview was conducted with Staff A, RN on 4/10/23 at 8:48 a.m. She confirmed she was taking care of Resident #1 the morning of 3/12/23 and made a medication error. She said the resident had been on her wing for a while and she was familiar with him. She said the resident was confused but could converse, saying hello and talking some. She said he did not always recognize family; he was incontinent and needed full care. She added the resident was able to self-propel in his wheelchair with his feet once he had help getting up. Staff A, RN said during her shift running from 3/11/23 7:00 p.m. to 3/12/23 7:00 a.m., the resident had stayed up very late, until 2:00 a.m. She said he did not want to stay in bed and was restless. She said there was no increased confusion, the resident was at his baseline. She said he had a history of falls, so she got him up to a wheelchair for a couple of hours, then put him back to bed. Staff A, RN said when insulin comes from the pharmacy, the vial is in the insulin box with a label on it and it is in a plastic bag that also has a label. Those bags are placed in the medication cart. She said when she pulled the bag out of the drawer, she read the bag, name, and checked everything. She confirmed she did not check the label on the box, she only checked the bag. After she administered the first insulin based on the sliding scale, she came back to the cart to put the vial in the box and bag, she realized she had given the wrong insulin. Staff A, RN said she gave the resident 12u of Levemir long-acting insulin instead of Novolog short-acting insulin. She said she panicked and stated, in my mind his blood sugar was still 327. The long acting was not going to bring down his blood sugar now. She said she went ahead and administered the Novolog within a couple of minutes of the Levemir. Staff A, RN said it was 5:30 a.m. and she could not call the doctor yet as she thought it was too early. She said, that is my error, I gave both. She said right after change of shift, approximately 7:15 a.m., she called and talked to the Nurse Practitioner (NP) for the Medical Director and the on-call manager, Staff C, LPN/UM Staff A, RN said the NP told her to monitor the resident closely, hold the morning dose of Levemir and have Glucagon on hand. An interview was conducted with Staff C, LPN/UM. on 4/17/23 at 12:29 p.m. Staff C, LPN/UM confirmed she was the on-call manager on 3/12/23. She said Staff A, RN called her about 7:20 a.m. and informed her she gave the wrong insulin to Resident #1. Staff C, LPN/UM said she asked Staff A, RN if she had talked to the doctor and Staff A, RN told her no. She said she told Staff A, RN to contact the doctor and follow his orders. She said Staff A, RN only told her she gave the resident long-acting insulin. She said she was not told the resident was also given short-acting insulin at the same time. Staff C, LPN/UM said she then received a call about 2:30 p.m. from Staff B, RN (the nurse caring for Resident #1 on the day shift 3/12/23) saying Resident #1's blood sugar had dropped. Staff B, RN asked her if she was aware of the extra insulin and Staff C, LPN/UM told her she was not aware. Staff B, RN notified her they gave Resident #1 Glucagon, and he was sent to the hospital. Staff C, LPN/UM said she notified the Director of Nursing (DON), and the DON notified the administrator. Staff C, LPN/UM said around 5:00 p.m. the day the error was made (3/12/23) she, along with other management, came in and began doing medication cart audits. During an interview with the DON on 4/18/23 at 4:31 p.m. she confirmed she came to the facility on [DATE] to complete medication cart audits with Staff C, LPN/UM. An interview was conducted with Staff B, RN on 4/5/23 at 2:50 p.m. She said she came on shift at 6:45 on 3/12/23 and received shift report from Staff A, RN between 7:00-7:15 a.m. She said Staff A, RN informed her she gave Resident #1 both long-acting and short-acting insulin that morning. She said Staff A, RN had not called the doctor at that point. Staff B, RN said Staff A, RN called the provider for the first time after she gave her report, approximately 7:15 a.m. She said Staff A, RN told her the NP gave orders to monitor the resident and have glucagon ready. Staff B, RN said she found out later that day Staff A, RN did not inform the NP she gave both the long and short-acting insulin; she only told her about the incorrect dose of Levemir. Staff B, RN said she checked Resident #1's blood glucose level between 8:30-9:00 a.m. and it was in the 90's. She said she did not document the blood glucose check in the resident's medical record because there was no place to enter it. B, RN did say she could have documented it under vitals, but she did not think about that at the time. She said right before lunch trays came out, which is around 12, she rechecked Resident #1s' blood glucose and it was 58. She said she had another nurse (Staff D, LPN) come in and they verified again, it was 56 then 52. Staff B, RN said she administered Glucagon to the resident then checked his blood glucose again. She said it was then 38, so they called 911. She said she continually checked blood glucose levels until paramedics arrived. She said he went up to 68 then dropped back down in the 50's. When asked about monitoring the resident between 9:00 a.m. and 11:45 a.m., she said she was giving all of her other residents their medication. She said she looked in the room a couple of times and the resident was sleeping. She said he was snoring but arousable. A review of records did not reveal any documentation showing Resident #1 was assessed or monitored from 9:00 a.m. until 11:45 a.m. An interview was conducted with Staff D, LPN on 4/18/23 at 1:50 p.m. Staff D, LPN stated I did not know [Resident #1] very well but I do know he was very confused and a fall risk, very impulsive. That day he was sent out I helped the nurse. She came to me and said she checked his sugar [blood glucose] and it was low. She said she couldn't get him to take anything by mouth and I told her well give him the sugar s*** (expletive) [glucagon] we have in our medication carts, so she did that, and she came to me and said it's even lower now and I don't know what to do. I told her you need to call 911 and get them here. They couldn't even bring him back either. He was breathing and his heart was beating but he was just unresponsive. An interview was conducted with Staff E, Nurse Practitioner (NP) on 4/12/23 at 8:42 a.m. The NP stated she does not physically go to this facility and did not know this resident, but she was covering on-call the morning of 3/12/23. She said she does not recall exactly when the nurse called or what she told her specifically. She said she was told Resident #1 had received the wrong dose of insulin and had gotten double what he should have. The NP said she told the nurse to have Glucagon ready to go, monitor the resident and if his blood glucose drops low and you cannot get him out of it, to call her back. The NP said she never heard anything else from the facility. She said Staff A, RN just told her she gave too much insulin; she did not get into details. She said she does not believe Staff A, RN mentioned giving both insulins at the same time. She said she does not remember if she gave specific monitoring parameters, but her standard with low or high blood sugar is they should be checked at least every 2 hours. When asked if it was okay that the resident's blood glucose level was only checked between 8:30/9:00 a.m. then again at 11:45/12:00 p.m. she said, absolutely not. The NP said she did not have any notes related to this call. An interview was conducted with the Regional Consultant Pharmacist on 4/17/23 at 10:33 a.m. She said the onset of action for Levemir is between 3-4 hours after administration and the duration of action can range from 5/6 hours up to 18 hours depending on body weight and other factors specific to the resident. She said the onset of action for Novolog is around 12-18 minutes and the duration of action is between 3-7 hours depending on body weight, age, and other factors specific to the resident. The pharmacist said around 3-4 hours after both insulins were administered to the resident would have most likely been the point, they were at the highest effect together and the blood sugar could drop low. The pharmacist said 12u of Levemir is not an unusual dose, however because insulin is so dependent, for Resident #1 individually it may have been. She said typically the Novolog and Levemir are not administered at the same time, there would be some spacing. The pharmacist said in the incidence of an insulin overdose, the resident's blood glucose should be checked every 15 minutes and if it is below 70, interventions should have been implemented, such as giving Glucagon or IV glucose. She said the onset of Glucagon is 5-20 minutes and most protocols show that if Glucagon is given and the blood glucose is still below 70 you proceed to the next step, in this case send resident to the hospital. The pharmacist said the consultant pharmacist that visited the facility had not identified anything unusual in the facility regarding insulins or other medications. The pharmacist had previously conducted medication cart audits and did not find any issues. An interview was conducted with the facility Medical Director on 4/10/23 at 11:43 a.m. He said the nurse gave Resident #1 12u of rapid acting insulin and 12u or long-acting insulin. He confirmed he was not called that morning. He said the NP told the nurse to monitor the resident and have Glucagon ready. The doctor said he did not have any notes showing he saw Resident #1 and stated, It is very weird. (The Medical Director and NHA both confirmed there was no documentation to show the resident was seen in the facility by a primary provider.) The doctor said when a medication error is made the nurse should let the provider and their immediate supervisor know right then. He said he or the on-call should have been called that morning when the error happened. A review of the local Fire Rescue Patient Care Report showed the 911 call for Resident #1 was received on 3/12/23 at 12:38 p.m. Emergency Medical Services (EMS) arrived at the patient at 12:50 p.m. The reports showed the chief complaint for Resident #1 was Diabetic-Hypoglycemia and the primary symptom was altered mental status. The resident's blood glucose was 48 and his blood pressure was 119/68 at 12:56 p.m. The Fire Rescue Narrative note showed found 77 yom [year old male] lying in his hospital bed. Pt [patient] responded to painful stimuli, Pt equal chest rise and fall, ABC's [airway, breathing, circulation] intact, skin WNL [within normal limits,] lung sounds clear, and perrl [pupils equal, round, reactive to light.] Staff stated pt was assessed and BGL [blood glucose level] was 39. Staff stated they gave 1g of Glucagon with no improvement leading them to call [Fire rescue.] Pt was carried to the stretcher and secured with all appropriate straps, rails x 2 and semi fowlers [position] for pt comfort and safety. Pt. further assessed and vitals WNL. Pt. BGL 48. Pt IV established and 250ml of D10 [Dextrose 10% solution] given with an improved response. Staff stated pt has Lewy Body dementia and only has a verbal response as his baseline. Pt continued to improve throughout the entire call. Pt transported to [local hospital] per request. Pt monitored enroute with no notable changes. Fire Rescue arrived at the hospital at 1:13 p.m. on 3/12/23. A review of hospital records, dated 3/12/23, for Resident #1 showed the Chief Complaint as From [facility]: Pt found to be hypoglycemic this morning, given 1 g of glucagon by staff, pt blood sugar in the 40's for EMS given 250ml of D10. Pt hx: dementia. The History or Present Illness revealed Patient presents to the emergency department acutely altered. Patient presents from [facility] with report from EMS indicated the patient was hypoglycemic. He was given glucagon, but this did not improve his blood sugar. When EMS arrived his blood sugar was in the 40s. They subsequently gave D10. He was unresponsive for them the entirety of their time with the patient. I subsequently called patient's emergency contact, [family member.] She states the patient does have Lewy body dementia. However, normally is not unresponsive and is alert. Patient does arrive with a DO NOT RESUSCITATE order and I specifically clarified with the [family member] if he would want to be intubated [have a breathing tube placed down the throat into the windpipe to allow a machine to assist with breathing.] She thinks that that [sic] would be in accordance with his wishes and he would be amenable to intubation. She does not know of any seizure history, which I asked because the patient did have rhythmic eye movements and contracted positioning that made me concerned for possible seizures. I did also call the facility and discussed with the nurse taking care of him. She does confirm that patient is normally able to push himself around in wheelchair and is typically alert. She does state that this morning was an acute change for patient. Patient was unresponsive for her the entire time as well. Patient on arrival unresponsive and unable to answer any questions for me. The record also revealed the resident had recurrent episodes of hypoglycemia on arrival and was again given D50 and a D10 drip was started. Despite the correction of the hypoglycemia, the patient continued to be altered. There was a strong suspicion for possible seizure in the setting of rhythmic movements of the eyes and contracted positioning. The patient was hypothermic on arrival and a forced air warming blanket was used. An intubation was performed and completed without any hypoxia. A continued review of hospital records showed an assessment performed on Resident #1 on 3/12/23 at 1:40 p.m. The assessment showed the resident's level of consciousness as obtunded, meaning he had a lessened interest in the environment and slowed response to stimulation. The Coma Scale showed Resident #1 has no eye-opening response and no verbal response. The resident did have a motor response of flexion withdrawal. His overall coma score was a 6. According to the Centre for Neuro Skills, the Glasgow Coma Scale provides an assessment of coma and impaired consciousness. The total scores were explained as follows: 90% less than or equal to 8 are in a coma, greater than or equal to 9 not in coma, 8 is the critical score, 9-12= moderate severity, and greater than or equal to 13=minor injury. (Accessed on 4/20/23 at https://www.neuroskills.com/education-and-resources/glasgow-coma-scale/) The hospital records, dated 3/12/23 showed after reexamination in the emergency room Resident #1 was found to have a urinary tract infection which could potentially be contributory but does not truthfully explain why the patient was seizing. Following intubation and paralysis wearing off, patient without further rhythmic activity of his eyes and no longer posturing his upper extremities leading me to believe that his seizure likely is stopped. Patient was admitted to the Intensive Care Unit. The hospital Discharge Summary, dated 3/20/23, showed Patient was weaned off sedation, however patient was not waking up and minimally responsive. Therefore, he remained intubated due to concerns of ability to protect airway. Palliative care consulted. Patient was discharged to inpatient hospice facility pending bed availability. The discharge diagnoses included acute hypoxic respiratory failure, requiring mechanical ventilation, acute encephalopathy, likely multifactorial secondary to hypoglycemia, UTI (Urinary tract infection,) possible seizure with underlying Lew body dementia. Low suspicion of meningitis and possible seizure secondary to hypoglycemia. The patient's overall prognosis is terminal with no meaningful recovery. A review of the in-patient Hospice record showed the resident arrived to their facility on 3/20/23 at 1:30 p.m. He was non-responsive to spoken name, his eyes were wide open with no track, and his facial features were relaxed. A hospice note dated 3/20/23 at 4:58 p.m. showed Provider ordering ME [medical examiner] Reportable Death: Patient has been deemed ME case per [medical doctor] for reported medical error of inappropriate insulin at a nursing facility leading to profound hypoglycemia. The record revealed Resident #1's time of death at 12:16 p.m. on 3/27/23. An interview was conducted on 4/17/23 at 12:17 p.m. with a family member of Resident #1. The family member confirmed the resident passed away at the in-patient Hospice facility but was unable to discuss any further details at the time. A facility policy titled Administration of Drugs, dated April 2022, was reviewed. The following showed the following: Policy Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. 2. Drugs must be administered in accordance with the written orders of the attending physician. 3. All current drugs and dosage schedules must be recorded on the resident's Electronic Medication Administration Record (eMAR). 7. Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. 11. When PRN drugs are administered, the nurse should record: a. The date and time administered inside eMAR displays; b. Any complaints or symptoms for which the drug was administered; and c. Any results achieved from administering the drug and the time such results were observed. 13. The nurse should enter an explanatory note in the progress notes for eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and or repeated refusal of drugs. 15. Prior to administering the resident's drug, the nurse should compare the drug and dosage schedule on the resident's eMAR with the drug label. A facility policy titled Diabetes Care-Insulin Administration, dated April 2022 was reviewed. The policy showed the following: Policy Special precautions should be followed when administering insulin. Policy Interpretation and Implementation 1. Special precautions should be followed in the administration of insulin. 2. Insulin dosage should be drawn only by personnel licensed to administer such drug and must be administered by the person drawing the injection. 3. The type of insulin, dosage requirements, strength, and method of administration should be verified to assure that it corresponds with the order on the medication sheet and the physician's order. 4. Any discrepancies should be reported to the Charge Nurse or designee. 5. The resident's physician should be notified of any discrepancies or adverse drug reactions. A facility policy titled Medication Errors and Adverse Reactions, undated, was reviewed. The policy showed the following: Policy Drug errors and adverse drug reactions should be reported to the resident's attending physician. Policy Interpretation and Implementation 1. Adverse drug reactions and drug errors with adverse clinical consequences should be reported to the resident's attending physician or physician designee. 2. Nursing services should implement and follow the physician's orders. The resident's condition should be closely observed for seventy-two (72) hours or as may be directed. 3. A detailed account of the incident should be recorded on a medication error report. 4. Documentation of the residence condition and response to treatment should be recorded during the observation period. 5. The Medical Director and Director of Nursing Services should be informed of all drug errors and adverse reactions. 6. If the reaction is allergic in nature, the chart will be labeled to inform all parties of the drug that the resident is allergic to. A facility job description titled Registered Nurse, dated 8/16/19 was reviewed. The job description listed the following: Overview Under the direction of the Director of Nursing, supervises the nursing personnel and the day-to-day nursing activities of the facility during an assigned tour of duty. Such supervision must be in accordance with accepted professional standards and current federal, state and local regulations to ensure the highest degree of quality care is always maintained. Responsibilities: -Monitor the daily delivery of nursing care and nursing staff performance as they deliver nursing care to the patients/residents in accordance with established policies and procedures -Identify problems or potential problems in the delivery of nursing care to residents and implement corrective action immediately -Oversee the nursing care to patients/residents to ensure safe, efficient and customer-oriented services are delivered at all times. -Visit resident on report daily in order to observe and evaluate each resident's physical and emotional status -Provide direct nursing care as necessary -Ensure the staff refer to the resident's care plan prior to administering care to the resident -Assist the staff nurses in monitoring seriously ill resident -Ensure that all nurses on your shift comply with the written procedures for the administration, storage and control of medications and supplies -Monitor medication passes and treatments to ensure compliance with physician orders and facility policy -Review medication administration records (MAR) for completeness of information, accuracy in the transcription of physician orders -Report all accident and incidents to Supervisor immediately upon occurrence -Conduct all activities within established safety, security and infection control procedures and guidelines Conducts all activities within established corporate compliance policies and procedures -Ensure residents safety in accordance with resident safety program. According to the Food and Drug Administration Levemir injection label, Levemir is a long-acting (up to 24-hour duration of action) human insulin analog used to improve glycemic control in adults and children with diabetes mellitus. Warnings and Precautions included: -Dose adjustment and monitoring: Monitor blood glucose in all patients treated with insulin. Insulin regiments should be modified cautiously and only under medical supervision. -Hypoglycemia is the most common adverse reaction to insulin therapy and may be life-threatening. 5.3 Hypoglycemia Hypoglycemia is the most common adverse reaction of insulin therapy, including LEVEMIR. The risk of hypoglycemia increases with intensive glycemic control. Patients must be educated to recognize and manage hypoglycemia. Severe hypoglycemia can lead to unconsciousness or convulsions and may result in temporary or permanent impairment of brain function or death. Severe hypoglycemia requiring the assistance of another person or parental glucose infusion, or glucagon administration has been observed in clinical trials with insulin, including trials with LEVEMIR. 8.5 Geriatric Use In elderly patients with diabetes, the initial dosing, dose increments and maintenance dosage should be conservative to avoid hypoglycemia. 10. Overdosage An excess of insulin relative to food intake, energy expenditure, or both may lead to severe and sometimes prolonged and life-threatening hypoglycemia. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns or exercise may be needed. More severe episode with coma, seizure, or neurological impairment may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose. (Accessed on 4/21/23 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021536s037lbl.pdf) Facility immediate actions to correct deficient practice and remove the Immediate Jeopardy included: On 3/12/2023: The DON/designee completed cart audit of all insulin to ensure all insulin is labeled and stored appropriately. The physician and family notified and Medication error. Statements were obtained from Staff who were working at the time of the event. 100% [26] of licensed staff were educated on the 5 rights of medication administration. 100% [26] of licensed staff were educated on notifying MD of medication prior to administering any other medications. On 3/13/2023 AD HOC Quality Assurance & Performance Improvement Meeting- Review of event medication error. Held with Administrator, Medical Director[TRUNCATED]

Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review, the facility failed to ensure one (Resident #1) of five residents reviewed for insulin administration was free from neglect as evidenced by neglecting to give insulin per physician orders, neglecting to notify the provider immediately after an insulin overdose, and neglecting to monitor the resident after a medication error. Resident #1 had Diabetes Mellitus Type II and had physician orders for Levemir U-100 (long-acting) insulin, 5 units (u) to be given one time daily at 9:00 a.m. He also had orders for Novolog 100 unit (u)/milliliter (ml) (short-acting) insulin to be given per a sliding scale (based on blood glucose measurement) before each meal and at bedtime. On 3/12/23 at 5:20 a.m. Staff A, Registered Nurse (RN) checked Resident #1's blood glucose level and charted it was 327. Per the sliding scale, this called for the administration of 12u of Novolog. The nurse neglected to check the medication label on the insulin vial and instead administered 12u of Levemir insulin to Resident #1. Staff A, RN did not notify the physician of this medication error immediately and she proceeded to administer Resident #1 12u of Novolog insulin. Staff A, RN did not notify a provider of the medication error until after finishing her shift, at 7:15 a.m., approximately 2 hours after the resident was administered an overdose of insulin. The Nurse Practitioner told the nurse to monitor the resident closely and have Glucagon (a medication that raises blood glucose levels and is used to treat hypoglycemia) ready if needed. A late entry progress note written recorded on 3/12/23 at 7:36 p.m. by Staff A, RN showed she checked the blood glucose level of Resident #1 approximately 1 hour after the insulin overdose and the reading was 84. The next documented blood glucose level was not until approximately 11:45 a.m. when the resident was found to be unresponsive by Staff B, RN with a blood glucose level of 58. During an interview with Staff B, RN on 4/5/23 at 2:50 p.m., she confirmed she took over care of Resident #1 at 7:00 a.m. She said she had to give her other assigned residents their medications, but she stuck her head in the room of Resident #1 a couple of times and he was sleeping but arousable. There was no documentation showing Resident #1 had vital signs or blood glucose monitored from approximately 6:20 a.m. until 11:45 a.m. Resident #1 was sent to the hospital where he was found to be hypoglycemic (having blood glucose levels less than 70 milligrams (mg)/deciliter(dL)) and having seizure like activity secondary (caused by) to hypoglycemia. The resident was intubated (had a breathing tube placed down the throat into the windpipe to allow a machine to assist with breathing,) placed on life support, and admitted to the Intensive Care Unit. He was later transferred to an in-patient Hospice, where he passed away on 3/27/23. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 3/12/23. After surveyor review and verification, it was determined the actions implemented by the facility achieved compliance on 3/17/23. The findings of Immediate Jeopardy were determined to be corrected on 3/17/23. Findings included: A review of Resident #1's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes Mellitus without complications, Neurocognitive disorder with Lewy bodies, and Metabolic encephalopathy (primary.) A review of Resident #1's Minimum Data Set (MDS) Five Day Assessment Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status Score (BIMS) score of 99, indicating he was unable to complete the interview. The assessment showed the resident had short- and long-term memory problems and his cognitive skills for daily decision making was severely impaired. Section I, Active Diagnoses showed the resident had Diabetes Mellitus and Non-Alzheimer's Dementia but did not have a seizure disorder or epilepsy. The MDS was dated 3/10/23. A review of Resident #1's physician orders related to diabetes revealed: -1/18/23 Insulin aspart (Novolog) 100 unit (u)/milliliter (ml) (70-30) per sliding scale: If blood sugar is less than 70, call MD. If blood sugar is 141-180, give 3 units. If blood sugar is 181-220, give 5 units. If blood sugar Is 221-260, give 8 units. If blood sugar is 261-300, give 10 units. If blood sugar is 301-350, give 12 units. If blood sugar is greater than 350, give 14 units. Subcutaneous. Before meals and at bedtime. 6:00 a.m., 11:15 a.m., 5:00 p.m., 9:00 p.m. -1/18/23 Levemir U-100 Insulin solution; 100 u/ml; amt: 5 units subcutaneous 1 time daily. Give 5 units subcutaneous once per day for Type II Diabetes Mellitus without complications. Once in morning, 9:00 a.m. -1/18/23 Glucagon (HCL) Emergency Kit. 1 milligram (mg) IM (intramuscular) injection as directed PRN (as needed) for hypoglycemia. -3/6/23 Side Effects: Hyperglycemia/Insulin Medication Use. Observe resident closely for side effects: confusion, sweating, SOB (shortness of breath), fruity breath, weakness, fatigue, increased thirst, increased urination, shakiness, pale skin, lethargy. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. -3/6/23 Side Effects: Monitor resident for s/s (signs/symptoms) of hypoglycemia. Monitor for shaking/trembling, fast heart rate, increased hunger, sweating, confusion/difficulty concentrating, dizziness. Every shift: Days 7:00 a.m.-7:00 p.m. Nights 7:00 p.m.-7:00 a.m. A review of Resident #1's Medication Administration Record (MAR) showed the residents blood glucose levels and insulin administered were as follows: 3/11/23 6:00 a.m. blood glucose was 212 milligram (mg)/deciliter (dL) with 5 units of Novolog insulin administered per sliding scale order. 3/11/23 between 7:00-11:00 a.m. Levemir U-100, 5 units was administered as ordered. 3/11/23 11:15 a.m. blood glucose was 99 mg/dL with no Novolog insulin administered per sliding scale order. 3/11/23 5:00 p.m. blood glucose was 114 mg/dL with no Novolog insulin administered per sliding scale order. 3/12/23 6:00 a.m. blood glucose was 327 mg/dL with 12 units of Novolog insulin administered per sliding scale. (Documented on 3/12/23 at 5:20 a.m.) 3/12/23 11:15 a.m. blood glucose was 58 mg/dL with no Novolog insulin administered per sliding scale order. (Documented on 3/12/23 at 1:01 p.m.) A review of Resident #1's medical record revealed the following care plan: Category: Health Related Complications Resident #1 has a diagnosis of Diabetes and is at risk for unstable blood glucose as evidenced by hyperglycemia with signs and symptoms of increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss, blood sugars >180 mg/dl and hypoglycemia with signs and symptoms of shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Interventions include blood glucose monitoring as ordered, document non-compliance of diet recommendations, medications as ordered, notify MD with significant changes in signs and symptoms, and observe for/report signs and symptoms of hypoglycemia: shakiness, dizziness, sweating, intense hunger, irritability, anxiety, decreased level of consciousness, headache. Created 1/18/23. A review of Resident #1's medication record showed the following progress notes: A Nursing Note dated 3/12/23 5:45 a.m. (Recorded as late entry on 3/12/23 at 7:36 p.m.) showed Resident's BS [blood sugar] at 0545 am med pass recorded 327. Both Levemir 12u and Novolog 12 units given. Levemir order is for 5u to be given between 7-11 a.m. Rechecked in 1 hour and BS 84. Medication error and BS levels reported to on call nurse manager [Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM)] and ARNP for Medical Director. Received order to hold am dose of Levemir, monitor resident and have glucagon on standby if needed. New orders and BS checks reported to oncoming nurse [Staff B, Registered Nurse (RN).] Resident is awake and alert without s/s [signs and symptoms] of hypoglycemia. Dietary trays on hall and trays passing at this time. The Nursing note was entered by Staff A, Registered Nurse (RN). A Nursing Note dated 3/12/23 1:20 p.m. showed Client observed in bed resting with eyes closed. Blood glucose checked: 58. Rechecked to verify BG [Blood Glucose]: 56, 52. Glucagon 1g injected subq [subcutaneously]. Client breathing was regular at 14 respirations per min [minute]. Sternal rub performed and patient continued to be unresponsive. Pupils pinpoint and BG dropped to 38. Another nurse called 911 while I stayed with the patient. Blood pressure measured manually: BP 70/30 pulse 66. The reading was lower than in the early AM which was 116/60 pulse 70. BG went up to 68 and then back down to 54. Paramedics arrived at 12:55 and patient left at 1300. Client was cool to touch and unresponsive when the paramedics arrived but continued to have steady respiration at 14 bpm. MD notified at 1300 gave ok to send to ER for eval and tx [treatment], and family notified at 1305. The Nursing Note was entered by Staff B, RN. A review of the facility documentation, dated 3/12/23, described the medication error as Nurse mistakenly administered Levemir 12U instead of Novolog 12U, nurse administered Novolog 12U after realizing she gave Levemir 12U. After administering both insulins, nurse contacted MD on call. It showed the correct order was sliding scale Novolog 12u. The type of error was listed as incorrect dose and incorrect medication. The report showed the resident became hypotensive and hypoglycemic around 12:45, resident was unresponsive but maintained respirations and heart rate. The immediate interventions were described as Glucagon 1g injected subq as ordered. Res [resident] blood sugar rechecked. Resident remained unresponsive. 911 activated and res transported to ER [emergency room ] via stretcher around 12:55. The report shows the following blood sugar levels: 3/12/23 5:15 a.m. Blood sugar 327 mg/dL 3/12/23 12:04 p.m. Blood sugar 58 mg/dL A phone interview was conducted with Staff A, RN on 4/10/23 at 8:48 a.m. She confirmed she was taking care of Resident #1 the morning of 3/12/23 and made a medication error. She said the resident had been on her wing for a while and she was familiar with him. She said the resident was confused but could converse, saying hello and talking some. She said he did not always recognize family; he was incontinent and needed full care. She added the resident was able to self-propel in his wheelchair with his feet once he had help getting up. Staff A, RN said during her shift running from 3/11/23 7:00 p.m. to 3/12/23 7:00 a.m., the resident had stayed up very late, until 2:00 a.m. She said he did not want to stay in bed and was restless. She said there was no increased confusion, the resident was at his baseline. She said he had a history of falls, so she got him up to a wheelchair for a couple of hours, then put him back to bed. Staff A, RN said when insulin comes from the pharmacy, the vial is in the insulin box with a label on it and it is in a plastic bag that also has a label. Those bags are placed in the medication cart. She said when she pulled the bag out of the drawer, she read the bag, name, and checked everything. She confirmed she did not check the label on the box, she only checked the bag. After she administered the first insulin based on the sliding scale, she came back to the cart to put the vial in the box and bag, she realized she had given the wrong insulin. Staff A, RN said she gave the resident 12u of Levemir long-acting insulin instead of Novolog short-acting insulin. She said she panicked and stated, in my mind his blood sugar was still 327. The long acting was not going to bring down his blood sugar now. She said she went ahead and administered the Novolog within a couple of minutes of the Levemir. Staff A, RN said it was 5:30 a.m. and she could not call the doctor yet as she thought it was too early. She said, that is my error, I gave both. She said right after change of shift, approximately 7:15 a.m., she called and talked to the Nurse Practitioner (NP) for the Medical Director and the on-call manager, Staff C, LPN/UM Staff A, RN said the NP told her to monitor the resident closely, hold the morning dose of Levemir and have Glucagon on hand. An interview was conducted with Staff C, LPN/UM. on 4/17/23 at 12:29 p.m. Staff C, LPN/UM confirmed she was the on-call manager on 3/12/23. She said Staff A, RN called her about 7:20 a.m. and informed her she gave the wrong insulin to Resident #1. Staff C, LPN/UM said she asked Staff A, RN if she had talked to the doctor and Staff A, RN told her no. She said she told Staff A, RN to contact the doctor and follow his orders. She said Staff A, RN only told her she gave the resident long-acting insulin. She said she was not told the resident was also given short-acting insulin at the same time. Staff C, LPN/UM said she then received a call about 2:30 p.m. from Staff B, RN (the nurse caring for Resident #1 on the day shift 3/12/23) saying Resident #1's blood sugar had dropped. Staff B, RN asked her if she was aware of the extra insulin and Staff C, LPN/UM told her she was not aware. Staff B, RN notified her they gave Resident #1 Glucagon, and he was sent to the hospital. Staff C, LPN/UM said she notified the Director of Nursing (DON), and the DON notified the administrator. Staff C, LPN/UM said around 5:00 p.m. the day the error was made (3/12/23) she, along with other management, came in and began doing medication cart audits. During an interview with the DON on 4/18/23 at 4:31 p.m. she confirmed she came to the facility on [DATE] to complete medication cart audits with Staff C, LPN/UM. An interview was conducted with Staff B, RN on 4/5/23 at 2:50 p.m. She said she came on shift at 6:45 a.m. on 3/12/23 and received shift report from Staff A, RN between 7:00-7:15 a.m. She said Staff A, RN informed her she gave Resident #1 both long-acting and short-acting insulin that morning. She said Staff A, RN had not called the doctor at that point. Staff B, RN said Staff A, RN called the provider for the first time after she gave her report, approximately 7:15 a.m. She said Staff A, RN told her the NP gave orders to monitor the resident and have glucagon ready. Staff B, RN said she found out later that day Staff A, RN did not inform the NP she gave both the long and short-acting insulin; she only told her about the incorrect dose of Levemir. Staff B, RN said she checked Resident #1's blood glucose level between 8:30-9:00 a.m. and it was in the 90's. She said she did not document the blood glucose check in the resident's medical record because there was no place to enter it. Staff B, RN did say she could have documented it under vitals, but she did not think about that at the time. She said right before lunch trays came out, which is around 12, she rechecked Resident #1s' blood glucose and it was 58. She said she had another nurse (Staff D, LPN) come in and they verified again, it was 56 then 52. Staff B, RN said she administered Glucagon to the resident then checked his blood glucose again. She said it was then 38, so they called 911. She said she continually checked blood glucose levels until paramedics arrived. She said he went up to 68 then dropped back down in the 50's. When asked about monitoring the resident between 9:00 a.m. and 11:45 a.m., she said she was giving all of her other residents their medication. She said she looked in the room a couple of times and the resident was sleeping. She said he was snoring but arousable. A review of records did not reveal any documentation showing Resident #1 was assessed or monitored from 9:00 a.m. until 11:45 a.m. An interview was conducted with Staff D, LPN on 4/18/23 at 1:50 p.m. Staff D, LPN stated I did not know [Resident #1] very well but I do know he was very confused and a fall risk, very impulsive. That day he was sent out I helped the nurse. She came to me and said she checked his sugar [blood glucose] and it was low. She said she couldn't get him to take anything by mouth and I told her well give him the sugar s*** (expletive) [glucagon] we have in our medication carts, so she did that, and she came to me and said it's even lower now and I don't know what to do. I told her you need to call 911 and get them here. They couldn't even bring him back either. He was breathing and his heart was beating but he was just unresponsive. An interview was conducted with Staff E, Nurse Practitioner (NP) on 4/12/23 at 8:42 a.m. The NP stated she does not physically go to this facility and did not know this resident, but she was covering on-call the morning of 3/12/23. She said she does not recall exactly when the nurse called or what she told her specifically. She said she was told Resident #1 had received the wrong dose of insulin and had gotten double what he should have. The NP said she told the nurse to have Glucagon ready to go, monitor the resident and if his blood glucose drops low and you cannot get him out of it, to call her back. The NP said she never heard anything else from the facility. She said Staff A, RN just told her she gave too much insulin; she did not get into details. She said she does not believe Staff A, RN mentioned giving both insulins at the same time. She said she does not remember if she gave specific monitoring parameters, but her standard with low or high blood sugar is they should be checked at least every 2 hours. When asked if it was okay that the resident's blood glucose level was only checked between 8:30/9:00 a.m. then again at 11:45/12:00 p.m. she said, absolutely not. The NP said she did not have any notes related to this call. An interview was conducted with the Regional Consultant Pharmacist on 4/17/23 at 10:33 a.m. She said the onset of action for Levemir is between 3-4 hours after administration and the duration of action can range from 5/6 hours up to 18 hours depending on body weight and other factors specific to the resident. She said the onset of action for Novolog is around 12-18 minutes and the duration of action is between 3-7 hours depending on body weight, age, and other factors specific to the resident. The pharmacist said around 3-4 hours after both insulins were administered to the resident would have most likely been the point, they were at the highest effect together and the blood sugar could drop low. The pharmacist said 12u of Levemir is not an unusual dose, however because insulin is so dependent, for Resident #1 individually it may have been. She said typically the Novolog and Levemir are not administered at the same time, there would be some spacing. The pharmacist said in the incidence of an insulin overdose, the resident's blood glucose should be checked every 15 minutes and if it is below 70, interventions should have been implemented, such as giving Glucagon or IV glucose. She said the onset of Glucagon is 5-20 minutes and most protocols show that if Glucagon is given and the blood glucose is still below 70 you proceed to the next step, in this case send resident to the hospital. The pharmacist said the consultant pharmacist that visited the facility had not identified anything unusual in the facility regarding insulins or other medications. The pharmacist had previously conducted medication cart audits and did not find any issues. An interview was conducted with the facility Medical Director on 4/10/23 at 11:43 a.m. He said the nurse gave Resident #1 12u of rapid acting insulin and 12u or long-acting insulin. He confirmed he was not called that morning. He said the NP told the nurse to monitor the resident and have Glucagon ready. The doctor said he not did have any notes showing he saw Resident #1 and stated, It is very weird. (The Medical Director and NHA both confirmed there was no documentation to show the resident was seen in the facility by a primary provider.) The doctor said when a medication error is made the nurse should let the provider and their immediate supervisor know right then. He said he or the on-call should have been called that morning when the error happened. A review of the local Fire Rescue Patient Care Report showed the 911 call for Resident #1 was received on 3/12/23 at 12:38 p.m. Emergency Medical Services (EMS) arrived at the patient at 12:50 p.m. The reports showed the chief complaint for Resident #1 was Diabetic-Hypoglycemia and the primary symptom was altered mental status. The resident's blood glucose was 48 and his blood pressure was 119/68 at 12:56 p.m. The Fire Rescue Narrative note showed found 77 yom [year old male] lying in his hospital bed. Pt [patient] responded to painful stimuli, Pt equal chest rise and fall, ABC's [airway, breathing, circulation] intact, skin WNL [within normal limits,] lung sounds clear, and perrl [pupils equal, round, reactive to light.] Staff stated pt was assessed and BGL [blood glucose level] was 39. Staff stated they gave 1g of Glucagon with no improvement leading them to call [Fire rescue.] Pt was carried to the stretcher and secured with all appropriate straps, rails x 2 and semi fowlers [position] for pt comfort and safety. Pt. further assessed and vitals WNL. Pt. BGL 48. Pt IV established and 250ml of D10 [Dextrose 10% solution] given with an improved response. Staff stated pt has Lewy Body dementia and only has a verbal response as his baseline. Pt continued to improve throughout the entire call. Pt transported to [local hospital] per request. Pt monitored enroute with no notable changes. Fire Rescue arrived at the hospital at 1:13 p.m. on 3/12/23. A review of hospital records, dated 3/12/23, for Resident #1 showed the Chief Complaint as From [facility]: Pt found to be hypoglycemic this morning, given 1 g of glucagon by staff, pt blood sugar in the 40's for EMS given 250ml of D10. Pt hx: dementia. The History or Present Illness revealed Patient presents to the emergency department acutely altered. Patient presents from [facility] with report from EMS indicated the patient was hypoglycemic. He was given glucagon, but this did not improve his blood sugar. When EMS arrived his blood sugar was in the 40s. They subsequently gave D10. He was unresponsive for them the entirety of their time with the patient. I subsequently called patient's emergency contact, [family member.] She states the patient does have Lewy body dementia. However, normally is not unresponsive and is alert. Patient does arrive with a DO NOT RESUSCITATE order and I specifically clarified with the [family member] if he would want to be intubated [have a breathing tube placed down the throat into the windpipe to allow a machine to assist with breathing.] She thinks that that [sic] would be in accordance with his wishes and he would be amenable to intubation. She does not know of any seizure history, which I asked because the patient did have rhythmic eye movements and contracted positioning that made me concerned for possible seizures. I did also call the facility and discussed with the nurse taking care of him. She does confirm that patient is normally able to push himself around in wheelchair and is typically alert. She does state that this morning was an acute change for patient. Patient was unresponsive for her the entire time as well. Patient on arrival unresponsive and unable to answer any questions for me. The record also revealed the resident had recurrent episodes of hypoglycemia on arrival and was again given D50 and a D10 drip was started. Despite the correction of the hypoglycemia, the patient continued to be altered. There was a strong suspicion for possible seizure in the setting of rhythmic movements of the eyes and contracted positioning. The patient was hypothermic on arrival and a forced air warming blanket was used. An intubation was performed and completed without any hypoxia. A continued review of hospital records showed an assessment performed on Resident #1 on 3/12/23 at 1:40 p.m. The assessment showed the resident's level of consciousness as obtunded, meaning he had a lessened interest in the environment and slowed response to stimulation. The Coma Scale showed Resident #1 has no eye-opening response and no verbal response. The resident did have a motor response of flexion withdrawal. His overall coma score was a 6. According to the Centre for Neuro Skills, the Glasgow Coma Scale provides an assessment of coma and impaired consciousness. The total scores were explained as follows: 90% less than or equal to 8 are in a coma, greater than or equal to 9 not in coma, 8 is the critical score, 9-12= moderate severity, and greater than or equal to 13=minor injury. (Accessed on 4/20/23 at https://www.neuroskills.com/education-and-resources/glasgow-coma-scale/) The hospital records, dated 3/12/23 showed after reexamination in the emergency room Resident #1 was found to have a urinary tract infection which could potentially be contributory but does not truthfully explain why the patient was seizing. Following intubation and paralysis wearing off, patient without further rhythmic activity of his eyes and no longer posturing his upper extremities leading me to believe that his seizure likely is stopped. Patient was admitted to the Intensive Care Unit. The hospital Discharge Summary, dated 3/20/23, showed Patient was weaned off sedation, however patient was not waking up and minimally responsive. Therefore, he remained intubated due to concerns of ability to protect airway. Palliative care consulted. Patient was discharged to inpatient hospice facility pending bed availability. The discharge diagnoses included acute hypoxic respiratory failure, requiring mechanical ventilation, acute encephalopathy, likely multifactorial secondary to hypoglycemia, UTI (Urinary tract infection,) possible seizure with underlying Lew body dementia. Low suspicion of meningitis and possible seizure secondary to hypoglycemia. The patient's overall prognosis is terminal with no meaningful recovery. A review of the in-patient Hospice record showed the resident arrived to their facility on 3/20/23 at 1:30 p.m. He was non-responsive to spoken name, his eyes were wide open with no track, and his facial features were relaxed. A hospice note dated 3/20/23 at 4:58 p.m. showed Provider ordering ME [medical examiner] Reportable Death: Patient has been deemed ME case per [medical doctor] for reported medical error of inappropriate insulin at a nursing facility leading to profound hypoglycemia. The record revealed Resident #1's time of death at 12:16 p.m. on 3/27/23. An interview was conducted on 4/17/23 at 12:17 p.m. with a family member of Resident #1. The family member confirmed the resident passed away at the in-patient Hospice facility but was unable to discuss any further details at the time. A facility policy titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property, and Injury of Unknown Source Prevention (ANEMMI), undated, was reviewed. The policy showed the following: Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences and protect its residents. Procedure: I. Screening: -Screen potential employees for a history of abuse, neglect, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. -The facility must not employ or otherwise engage individuals who: i. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; ii. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment or residents or misappropriation of their property; or iii. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. -The facility will report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. II. Training: -Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as: *Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; *Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; *Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators; *Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; *Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: 1. Aggressive and/or catastrophic reactions of residents; 2. Wandering or elopement-type behaviors; 3. Resistance to care; 4. Outbursts or yelling out; and 5. Difficulty in adjusting to new routines or staff. *How to recognize signs of burnout, frustration and stress that may lead to abuse; *In addition to the freedom from abuse, neglect, and exploitation requirements in S 483.12, facilities must also provide training to their staff that at a minimum educates staff on: 1. S 483.95(c) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at S 483.12. 2. S 493.95(c) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. 3. S493.95(c) Dementia management and resident abuse prevention. III. Prevention: -Provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. -Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; -Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. This includes the implementation of policies that address the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. -Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently; -The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict, such as: *Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; *Physically aggressive behavior, such as hitting[TRUNCATED]

Based on interviews with the Nursing Home Administrator, the Director of Nursing, the Medical Director, the Business Office Manager, the Admissions Director, nursing staff, residents and review of medical records, job descriptions, and policies and procedures it was determined that the facility 1. failed to provide competent and sufficient nursing staff to provide nursing, and related services safely to nine (Resident #3, #6, #7, #10, #11, #12, #13, #14, and #15) of 20 sampled residents. Five of 24 sampled residents (#6, #10, #13, #14, and #15), who were able to participate in interviews, expressed concerns about insufficient staff to address all resident care needs. Further, the facility failed to ensure that two of two (Staff P and Staff Q) CNAs, who were pulled from resident care to staff the kitchen, had received the training and competence to complete dietary tasks. Eight of thirty sampled staff, who rendered care directly to residents (Staff C, RN, Staff D, CNA, Staff A, LPN, Staff U, LPN, Staff T, LPN, Staff P, CNA, Staff Y, CNA, and Staff Q, CNA) and two of nine sampled Management staff (Admissions Director and Dietary Director) expressed concerns about staffing ratios or being pulled from the floor to staff the Dietary Department. Resident #6, an alert and oriented resident with a Brief Interview for Mental Status (BI[CONDITION]) score of 15, reported that a CNA flushed his Peripherally Inserted Central Catheter (PICC) line and that a CNA administered narcotic medication to him. Residents # 13, #14, and #15 complained that there were not enough staff to take care of all resident needs. A CNA conducted blood glucose monitoring for Resident #10, Resident #11, Resident #12, and one unidentified resident. The CNA also administered oral medication to Resident #3 and Resident #7. The CNAs performed job duties outside of their professional scope of practice which they were not legally able to perform. The nurses delegated job duties, which were legally required to be performed by a nurse, to CNAs. The facility failure to ensure staff who provided medication administration, management of a central intravenous line and performed blood glucose monitoring had the necessary training, competence, knowledge and skills placed the residents at risk for potentially serious errors and complications. The CNA staff lacked the training, experience and knowledge to perform administration of medications, manage intravenous lines and perform blood glucose testing. CNA staff in the facility were not trained or expected to perform at a nursing level in the areas of observation, assessment and evaluation of care based on clinical nursing judgement to ensure patient safety while carrying out tasks that have potential for serious complications if not performed correctly or a resident's condition has changed. Additionally, based on interviews, record reviews, and review of facility policy the facility 2. failed to ensure that 1 (Resident #1) of 24 sampled residents were free of significant medication errors. The resident arrived at the facility with a list of discharge medications from the hospital. The facility did not order nine of the resident's medications including [MED] to be given daily, an oral diabetic medication to be given twice daily and an antibiotic to be given twice daily. The facility did not provide the medications for 2 days and learned of the mistake when the resident's blood sugar rose, the resident became unstable and the resident required transfer to the hospital. This resulted in findings of Immediate Jeopardy, occurring on [DATE] and removed at 06:17 PM on [DATE] with Scope and Severity reduced to a D. Findings included: 1. A review of the Facility Assessment, dated [DATE] through [DATE], indicated under the heading B.1. Acuity-Sufficiency Analysis Summary #2. Staff are trained upon hire, annually and as needed regarding resident population and healthcare needs. General competencies are performed related to disease or task specific competencies. Ancillary departments also have competencies relevant to their specific area- i.e. housekeeping, dietary and therapy. The Resident Census and Conditions of Residents, completed on [DATE], reflected a census of 89 residents. Of those, [AGE] percent needed some form of assistance with bathing; 87 percent needed assistance or more in dressing; [AGE] percent needed assistance with transferring; 67% needed assistance with toilet use; and 12% needed assistance with eating. Of those needing assistance with toilet use, forty-six were occasionally or frequently incontinent. Under the category of Special Care, three received hospice care; one received [MEDICAL TREATMENT]; three were on intravenous therapy/IV nutrition; seventeen received respiratory treatment; and three received ostomy care. As to mobility, sixty residents were included as being in a chair all or most of the time. Thirteen residents were identified with pressure sores and sixty-five were receiving preventive skin care. An interview was conducted on [DATE] at 10:15 AM with Resident #6. Resident #6 stated that he reported to Staff G, LPN that a CNA flushed his PICC line on the 11 PM to 7 AM shift on [DATE] going into [DATE]. Resident #6 stated that he used his call light in order to receive pain medication but had to wait for over an hour to get staff to bring it. Resident #6 stated that he got out of his bed and walked down the hall to discover that all of the staff were outside smoking. Resident #6 stated that Staff C, RN saw him, came back into the facility, and asked him what he needed. Resident #6 stated to Staff C, RN that he needed a pain pill and that his pain pill was an hour and a half late. Resident #6 stated that Staff C, RN told him that he would be given a pain pill as soon as possible and that Staff C, RN had been very busy. Resident #6 stated that around 01:30 AM to 02:00 AM, Staff D, CNA came to his room and gave him his [MEDICATION NAME]. Resident #6 also stated that Staff D, CNA disconnected his PICC line, flushed it, and left the old bag and tubing on the machine. Resident #6 stated that he informed Staff G, LPN of the incident the next morning. A review of Resident #6's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #6's admission Minimum Data Set (MDS) assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, indicating intact cognition. A review of Resident #6's care plan revealed a problem, dated [DATE] that Resident #6 had a PICC line with an intervention for nursing to check the site every 8 hours for signs and symptoms of inflammation/infection. Resident #6's care plan also revealed a problem, dated [DATE] that Resident #6 is at risk for uncontrolled pain related to osteo[DIAGNOSES REDACTED] of the [MEDICATION NAME] spine and vertebra with an intervention for nursing to administer pain medications per physician's orders [REDACTED].#6's Medication Administration Record [REDACTED]. Staff C, RN documented her initials for the [DATE] evening dose of Normal Saline. Resident #6's MAR indicated [REDACTED]. Staff C, RN documented her initials on [DATE] at 01:24 AM for a dose of [MEDICATION NAME]. Resident #6's MAR indicated [REDACTED]. A review of Resident #6's Progress Notes revealed a Nursing Note, dated on [DATE] at 06:42 PM, documented by the facility's DON which stated Writer assessed resident's PICC line site for any signs of redness, inflammation, or heat which insertion site for PICC line was clear of. Dressing was intact. Resident voiced no complaints. A peripherally inserted central catheter also called a PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart. A PICC line requires careful care and monitoring for complications, including infection and blood clots. PICC line complications can include: Bleeding, nerve injury, irregular heartbeat, damage to veins in your arm, blood clots, infection, and a blocked or broken PICC line, according to https://www.mayoclinic.org/tests-procedures/picc-line/about/pac- 748 A review of the facility Log revealed an allegation dated [DATE]. The allegation appeared on the log as Nurses and CNA med pass. The Log also indicated that the allegation was substantiated by the facility. An interview was conducted on [DATE] at 03:56 PM with the Nursing Home Administrator (NHA) and the facility's Director of Nursing (DON) regarding the [DATE] allegation on the facility's Log. The NHA stated that on [DATE] Resident #6 reported to Staff G, LPN that on Friday [DATE] during the 11 PM to 7 AM shift, Staff C, RN, Staff Developer instructed Staff D, CNA to give Resident #6 a narcotic medication and to flush the resident's PICC line. The DON stated that she interviewed Resident #6 and gathered that the incident occurred around midnight going into Saturday [DATE]. The DON also stated that upon discovery, she interviewed Staff D, CNA who confirmed that she did administer a narcotic medication to Resident #6 and flushed the resident's PICC line. The DON stated that she informed the NHA and both staff members were suspended pending an investigation. During the investigation, she also discovered that on [DATE] on the 11 AM to 7 PM shift between 5 AM and 7 AM, Staff B, CNA was instructed by Staff A, LPN to perform blood glucose monitoring on 4 residents and to administer oral medications to Resident #3 and Resident #7. Staff B, CNA told the DON that she administered a liquid medication [MEDICATION NAME] to Resident #3 and a pill form of [MEDICATION NAME] to Resident #7. The DON stated that she conducted telephone interview with Staff A, LPN on [DATE] who confirmed that she instructed Staff B, CNA to perform blood glucose monitoring on 4 residents but denied allowing Staff B, CNA to administer medications to Resident #3 and Resident #7. The NHA stated that Staff A, B, C, and D were suspended on [DATE] and later on [DATE] terminated from employment following a meeting with their corporate team. The NHA also stated that the state licensing board was notified of the allegation. The DON stated that further resident interviews were being conducted as well as staff education and interviews regarding nursing staff performing job duties within their scope of practice. The DON also stated that Resident's #3, #6, and #7 were assessed for adverse effects and physicians were notified on [DATE]. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgement, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others and the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Review of the Florida Administrative Code Rule 64B,[DATE].002, effective on [DATE], documents CNA Authorized Duties as: (1) A certified nursing assistant shall provide care and assist residents with the following tasks related to the activities of daily living only under the general supervision of a registered nurse or licensed practical nurse: (a) Tasks associated with personal care: 1. Bathing, 2. Dressing, 3. [NAME]ing, 4. Shaving, 5. Shampooing and caring for hair, 6. Providing and assisting with oral hygiene and denture care, 7. Caring for the skin, 8. Caring for the feet, 9. Caring for the nails, 10. Providing peri care, 11. Bed making and handling linen, 12. Maintaining a clean environment. (b) Tasks associated with maintaining mobility: 1. Ambulating, 2. Transferring, 3. Transporting, 4. positioning, 5. Turning, 6. Lifting, 7. Performing range of motion exercises, 8. Maintaining body alignment. (c) Tasks associated with nutrition and hydration: 1. Feeding and assisting the resident with eating, 2. Assisting the resident with drinking. (d) Tasks associated with elimination: 1. Toileting, 2. Assisting with the use of the bedpan and urinal, 3. Providing catheter care, 4. Collecting specimens, 5. Emptying ostomy bags, or changing bags that do not adhere to the skin, 6. Bowel and bladder training. (e) Tasks associated with the use of assistive devices: 1. Caring for dentures, eyeglasses, contact lenses, and hearing aids, 2. Applying or donning established or previously fitted and adjusted prosthetic and orthotic devices, 3. Applying or donning previously fitted and adjusted orthotic braces, 4. Applying previously fitted ant [MEDICAL CONDITION] stockings, 5. Assisting with wheelchairs, walkers, or crutches, 6. Using comfort devices such as pillows, cradles, footboards, wedges, and boots, 7. Assisting with and encouraging the use of self-help devices for eating, grooming, and other personal care tasks, 8. Utilizing and assisting residents with devices for transferring, ambulation, alignment, and positioning, 9. Using restraints. (f) Tasks associated with maintaining environment and resident safety, including handling of blood and body fluid and cleaning resident care areas. (g) Tasks associated with data gathering: 1. Measuring temperature, pulse, respiration, and blood pressure, 2. Measuring height and weight, 3. Measuring and recording oral intake, 4. Measuring and recording urinary output, both voided and from urinary drainage systems, 5. Measuring and recording emesis, 6. Measuring and recording liquid stool. (h) Recognition of and reporting of abnormal resident findings, signs, and symptoms. (i) Postmortem care. (j) Tasks associated with resident socialization, leisure activities, reality orientation, and validation techniques. (k) Tasks associated with end of life care. (l) Tasks associated with basic first aid, CPR skills, and emergency care. (m) Tasks associated with compliance with resident's/patient's rights. (n) Tasks associated with daily documentation of certified nursing assistant services provided to the resident. (2) A certified nursing assistant shall perform all tasks with knowledge of and awareness of a resident's/patient's rights and developmental level. (3) A certified nursing assistant shall not perform any task which requires specialized nursing knowledge, judgment, or skills. (4) A certified nursing assistant may receive additional training beyond that required for initial certification and upon validation of competence in the skill by a registered nurse may perform such skills as authorized by the facility. (5) A certified nursing assistant shall not work independently without the supervision of a registered nurse or a licensed practical nurse. A review of the facility's job description for the position of Charge Nurse (LPN or RN), last updated in ,[DATE], provided a summary of the position: Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality of care at all times. Under the section titled Essential Duties & Responsibilities of the job description for the position of Charge Nurse (LPN or RN) are job duties that include: Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry, confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility, verify that all nursing service personnel are in compliance with their respective job descriptions, prepare and administer medications as ordered by the physician, verify the identity of the resident before administering the medication/treatment, verify that prescribed medication for one resident is not administered to another, and deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. A telephone interview was conducted on [DATE] at 03:58 PM with Staff C, RN. Staff C, RN was assigned as charge nurse on A and B halls on [DATE]. Staff C, RN stated that she was terminated and that her licensed was reported to the board. Staff C, RN stated that on the date of the incident, she was on the phone with pharmacy, getting and ordering labs, dealing with patients requesting pain medications, and wound care. Staff C, RN also stated that there were 38 residents for 1 nurse and 2 CNA's on her shift. Staff C, RN stated that she was overwhelmed with everything and that she asked Staff D, CNA for any kind of help. Staff C, RN stated that she asked Staff D, CNA to flush a PICC line and administer medications. Staff C, RN also stated that she signed off on Resident #6's MAR indicated [REDACTED]. Staff C, RN stated that she made a bad judgement call in asking Staff D, CNA to administer medication but she did not know what else to do because the residents need their medications. In regard to staffing, Staff C, RN stated that she worked 22 hours on [DATE] into [DATE], but since she was a salaried employee the hours were not tracked. Staff C, RN stated that she also functioned as the facility's Staff Developer. Staff C, RN stated that the NHA and the DON were both aware of the lack of staff, but the Assistant Director of Nursing (ADON) was on vacation and the DON could not help because her hours wouldn't count if she was on a cart, so the NHA told her that she was going to have to figure it out. Staff C, RN stated that she was aware of multiple instances of CNAs performing job duties out of their scope of practice due to the nurses at the facility being overwhelmed by the lack of staff. A telephone interview was conducted on [DATE] at 01:40 PM with Staff D, CNA. Staff D, CNA was assigned to B wing on [DATE]. Staff D, CNA stated that she was told by Staff C, RN, who was also her supervisor, to flush Resident #6's PICC line and to administer a pain pill to Resident #6. Staff D, CNA also stated that Staff C, RN asked her to perform blood glucose monitoring for 4 residents on B wing but was unable to identify the 4 residents during the interview. Staff D, CNA stated that she told the facility's NHA about 2 or 3 weeks ago about what happened and that she was sorry that she did not get many residents up out of bed before she left in the morning. Staff D, CNA also stated to the NHA that she had 36 residents in her assignment and that the NHA responded by telling her to do the best she could. Staff D, CNA stated that she was only doing what she was told and that many other nights she had done the same things. Staff D, CNA also stated that she now knows that she is not supposed to perform those duties and that the nurse is supposed to. An interview was conducted on [DATE] at 09:31 AM with Resident #3. Resident #3 stated that he received [MEDICATION NAME] liquid from Staff B, CNA after being directed to by Staff A, LPN. Resident #3 was unable to recall why Staff B, CNA provided him with the medication. A review of Resident #3's medical record revealed admission to the facility on [DATE]. A review of Resident #3's Quarterly MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, indicating intact cognition. A review of Resident #3's MAR indicated [REDACTED]. Staff A, LPN documented her initials on [DATE] for the 06:00 AM dose of [MEDICATION NAME]. A review of Resident #3's Progress Notes revealed a Nursing Note, dated on [DATE] at 06:53 PM, documented by the facility's DON which stated Resident was assessed for side effects of medication. Resident denies and does not show any s/sx (signs and symptoms) of adverse effects at this time. A review of Resident #7's medical record revealed admission to the facility on [DATE]. A review of Resident #7's Admission MDS assessment, dated [DATE], under Section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, indicating intact cognition. A review of Resident #7's MAR indicated [REDACTED]. Staff A documented her initials on [DATE] for the daily dose of [MEDICATION NAME]. A review of Resident #7's Progress Notes revealed a Nursing Note, dated [DATE] at 06:48 PM, documented by the facility's DON which stated Resident was assessed for side effects of medications. Resident does not show any adverse s/sx (signs and symptoms) of medications at this time. A telephone interview was conducted on [DATE] at 10:45 AM with Staff A, LPN. Staff A, LPN was assigned as charge nurse for A and B wings on [DATE]. Staff A, LPN stated that she was terminated from employment at the facility for something that she did not do. Staff A, LPN stated that the facility accused her of asking Staff B, CNA to administer a medication to Resident #3 and that the allegation was not true. Staff A, LPN stated that she poured the [MEDICATION NAME] solution to prepare for administration to Resident #3 as ordered and Staff B, CNA accompanied her into Resident #3's room to encourage Resident #3 to take it. Staff A, LPN stated that sometimes the CNAs can encourage residents to take their medications if they refuse. Staff A, LPN stated that during her shift on [DATE] she was caring for 40 residents on 2 separate units, which she identified as the A and B halls. Staff A, LPN also stated that she had asked CNAs to assist her with blood glucose monitoring in the past and that Staff B, CNA assisted her with blood glucose monitoring on the 11 PM to 7 AM shift on [DATE] while she was completing charting on other residents. Staff A, LPN stated that she had brought up concerns of the facility being short staffed to the facility's NHA and DON on multiple occasions and that on some occasions they would have to work with 1 nurse and 1 CNA for an assignment of 40 residents. A telephone interview was conducted on [DATE] at 12:52 PM with Staff B, CNA. Staff B, CNA was assigned as Community CNA on [DATE]. Staff B, CNA stated that she was terminated from employment at the facility on [DATE] for administering medications but denied that she administered any medications to residents. Staff B, CNA stated that she conducted blood glucose monitoring on 4 residents after being told to do so by Staff A, LPN. Staff B, CNA was able to identify 3 (Resident #10, #11, and #12) of the 4 residents that she performed blood glucose monitoring on. Staff B, CNA stated that she performed the blood glucose monitoring in order to help Staff A, LPN, who had 40 residents in her assignment on the 11 PM to 7 AM shift on [DATE]. Staff B, CNA also stated that she will seldom conduct blood glucose monitoring for a nurse but was not aware that it was against the facility's policy. An interview was conducted on [DATE] at 09:10 AM with Resident #10. Resident #10 stated I can tell you that there is definitely not enough staff here. A review of Resident #10's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #10's Admission MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #10's MAR indicated [REDACTED] If Blood Sugar is less than [AGE], call MD. If Blood Sugar is 150 to 200, give 2 units. If Blood Sugar is 201 to 250, give 4 units. If Blood Sugar is 251 to 300, give 6 units. If Blood Sugar is 301 to 350, give 8 units. If Blood Sugar is 351 to 400, give 10 units. If Blood Sugar is greater than 401, call MD. Staff A, LPN initialed an entry on [DATE] at 05:00 AM with a blood glucose reading of 200 milligrams per deciliter (mg/dl). A review of Resident #11's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #11's Annual MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, indicating intact cognition. A review of Resident #11's MAR indicated [REDACTED] If Blood Sugar is less than 71, call MD. If Blood Sugar is 71 to 140, give 0 units. If Blood Sugar is 141 to 1[AGE], give 3 units. If Blood Sugar is 181 to 220, give 5 units. If Blood Sugar is 221 to 2[AGE], give 8 units. If Blood Sugar is 261 to 300, give 10 units. If Blood Sugar is 301 to 350, give 12 units. If Blood Sugar is greater than 350, give 14 units and call MD. Staff A, LPN initialed an entry on [DATE] at 06:00 AM with a blood glucose reading of 210 mg/dl. An interview was conducted on [DATE] at 01:34 PM with Resident #12. Resident #12 stated that the nurse primarily performs blood glucose monitoring, but also stated that maybe one time a CNA has performed blood glucose monitoring for him. A review of Resident #12's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #12's Quarterly MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 14, indicating intact cognition. A review of Resident #12's MAR indicated [REDACTED] If Blood Sugar is less than [AGE], call MD. If Blood Sugar is 150 to 200, give 1 units. If Blood Sugar is 201 to 250, give 2 units. If Blood Sugar is 251 to 300, give 3 units. If Blood Sugar is 301 to 350, give 4 units. If Blood Sugar is 351 to 400, give 5 units. If Blood Sugar is greater than 400, call MD. Staff A, LPN initialed an entry on [DATE] at 06:00 AM with a blood glucose reading of 258 mg/dl. An interview was conducted on [DATE] at 04:55 PM with Staff T, LPN, charge nurse assigned to C wing on the 3 PM to 11 PM shift, regarding allowing CNAs to perform duties outside of their scope of practice. Staff T, LPN stated that a couple of CNAs reported that they had been asked by a nurse to administer medications, perform blood glucose monitoring, or perform treatments, but none of them had actually performed any of those actions. The CNAs were identified as Staff V, CNA, Staff W, CNA, and Staff X, CNA. The nurse was identified as Staff U, LPN, charge nurse assigned to D Wing. An interview was conducted on [DATE] at 05:29 PM with Staff W, CNA, assigned to C Wing on the 3 PM to 11 PM shift, regarding being asked to perform job duties outside of a CNAs scope of practice. Staff W, CNA stated that she usually is able to assist the nurse's with vital signs monitoring as part of daily assignment but did not perform blood glucose monitoring. Staff W, CNA also stated that she had not been asked by a nurse to perform blood glucose monitoring or administer medications but has been asked by a nurse to apply a medicated cream to a resident's shoulders. Staff W, CNA did not state what resident she applied the cream to, what cream was administered, or the date that she administered the cream to the resident. Staff W, CNA stated that she had not witnessed any CNA performing job duties outside of their scope of practice. Staff W, CNA also stated that if she was asked to perform job duties outside of her scope of practice, she would tell the nurse no. An interview was conducted on [DATE] at 05:40 PM with Staff V, CNA, assigned to C Wing on the 3 PM to 11 PM shift, regarding being asked to perform job duties outside of a CNAs scope of practice. Staff V, CNA stated that she assists the nurse with vital signs monitoring as requested but does not administer any type of medication or perform blood glucose monitoring. Staff V, CNA stated that a while back, Staff U, LPN had asked her to administer a medication to a resident, to which she refused. Staff V, CNA also stated that she was taught very strictly not to do the nurse's job and that the only treatment that she provides is barrier cream. Staff V, CNA stated that she did not report Staff U, LPN for asking her to administer a medication to a resident but addressed that she should have reported the incident. Staff V, CNA stated that she has not observed any CNAs performing duties outside of their scope of practice. An interview was conducted on [DATE] at 05:45 PM with Staff U, LPN, charge nurse assigned to D wing on the 3 PM to 11 PM shift. Staff U, LPN stated that he left the facility around midnight last night due to having 3 re-admissions from the hospital on his unit. Staff U, LPN also stated that he had a hard time completing his job duties and that he feels like he does not have enough time to complete all of his job duties. Staff U, LPN stated that he had to leave some of the work for the 11 PM to 7 AM shift to complete, but that he was able to complete all of his blood glucose monitoring, medication administration, and treatments as ordered. Staff U, LPN stated that CNAs assist him with applying barrier cream or skin prep to residents and also assist if he needs help holding a resident's arm to administer an intramuscular (IM) injection, but the CNAs are not allowed to apply any treatment that requires a physician's prescription. Staff U, LPN also stated that he would not allow a CNA to administer a medication to a resident or perform blood glucose monitoring because it is not in the CNAs scope of practice to do so. Staff U, LPN stated that he has not witnessed a CNA performing blood glucose monitoring or administering a medication, but he would report the observation to the facility's NHA or DON if witnessed. An interview was conducted on [DATE] at 5:55 AM with the facility's NHA. The NHA stated that another immediate report was filed last night on [DATE] related to Staff W, CNA reporting that she administered a medicated cream to a resident but could not recollect a date or time of the incident. Staff W, CNA was instructed by Staff U, LPN to administer the medicated cream to a resident. Staff W, CNA and Staff U, LPN were both suspended pending the investigation and the facility continued to educate staff regarding scope of practice, resident interviews, and were collecting written statements. A review of Staff W, CNA's written statement, dated on [DATE] revealed that Staff W, CNA was instructed by Staff U, LPN to apply a cream to a resident's shoulders after the resident was given a shower. The statement als

Based on interviews with the Nursing Home Administrator, the Director of Nursing, the Medical Director, nursing staff, residents and review of State Nurse Practice Act, State Laws governing practice of Certified Nurse's Aides (CNAs), medical records, job descriptions, and policies and procedures it was determined that the facility 1. failed to provide care and services in accordance with professional standards of practice to 6 (Resident #3, #6, #7, #10, #11, and #12) of 24 sampled residents. Resident #6, an alert and oriented resident with a Brief Interview for Mental Status (BI[CONDITION]) score of 15, reported that a CNA flushed his Peripherally Inserted Central Catheter (PICC) line and that a CNA administered narcotic medication to him. A CNA conducted blood glucose monitoring for Resident #10, Resident #11, Resident #12, and one unidentified resident. The CNA administered oral medication to Resident #3 and Resident #7. The CNAs performed job duties outside of their professional scope of practice which they were not legally able to perform. The nurses delegated job duties, which were legally required to be performed by a licensed nurse. The facility failure to ensure staff who provided medication administration, management of a central intravenous line and performed blood glucose monitoring had the necessary training, knowledge and skills placed the residents at risk for potentially serious errors and complications. The CNA staff lacked the training, experience and knowledge to perform administration of medications, manage intravenous lines and perform blood glucose testing. CNA staff in the facility were not trained or expected to perform at a licensed nursing level in the areas of observation, assessment and evaluation based on clinical judgement to ensure patient safety while carrying out tasks that have potential for serious complications if not performed correctly or a resident's condition has changed. Additionally, based on interviews, record reviews, and review of facility policy the facility 2. failed to ensure that 1 (Resident #1) of 24 sampled residents were free of significant medication errors. The resident arrived at the facility with a list of discharge medications from the hospital. The facility did not order nine of the resident's medications including [MED] to be given daily, an oral diabetic medication to be given twice daily and an antibiotic to be given twice daily. The facility did not provide the medications for 2 days and learned of the mistake when the resident's blood sugar rose, the resident became unstable and the resident required transfer to the hospital. This resulted in findings of Immediate Jeopardy, occurring on [DATE] and removed at 06:17 PM on [DATE] with Scope and Severity reduced to a D. Findings included: 1. An interview was conducted on [DATE] at 10:15 AM with Resident #6. Resident #6 stated that he reported to Staff G, LPN (Licensed Practical Nurse) that a CNA flushed his PICC line on the 11 PM to 7 AM shift on [DATE] going into [DATE]. Resident #6 stated that he used his call light in order to receive pain medication but had to wait for over an hour to get staff to bring it. Resident #6 stated that he got out of his bed and walked down the hall to discover that all of the staff were outside smoking. Resident #6 stated that Staff C, RN (Registered Nurse) saw him, came back into the facility, and asked him what he needed. Resident #6 stated to Staff C, RN that he needed a pain pill and that his pain pill was an hour and a half late. Resident #6 stated that Staff C, RN told him that he would be given a pain pill as soon as possible and that Staff C, RN had been very busy. Resident #6 stated that around 01:30 AM to 02:00 AM, Staff D, CNA came to his room and gave him his [MEDICATION NAME] (a schedule II narcotic controlled medication). Resident #6 stated that Staff D, CNA disconnected his PICC line, flushed it, and left the old bag and tubing on the machine. Resident #6 stated that he informed Staff G, LPN of the incident the next morning. A review of Resident #6's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #6's admission Minimum Data Set (MDS) assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #6's care plan revealed a problem, dated [DATE] that Resident #6 had a PICC line with an intervention for nursing to check the site every 8 hours for signs and symptoms of inflammation/infection. Resident #6's care plan also revealed a problem, dated [DATE] that Resident #6 is at risk for uncontrolled pain related to osteo[DIAGNOSES REDACTED] of the [MEDICATION NAME] spine and vertebra with an intervention for nursing to administer pain medications per physician's orders. A review of Resident #6's Medication Administration Record [REDACTED]. Staff C, RN documented her initials for the [DATE] evening dose of Normal Saline. Resident #6's MAR indicated [REDACTED]. Staff C, RN documented her initials on [DATE] at 01:24 AM for a dose of [MEDICATION NAME]. Resident #6's MAR indicated [REDACTED]. A review of Resident #6's Progress Notes revealed a Nursing Note, dated on [DATE] at 06:42 PM, documented by the facility's DON which stated Writer assessed resident's PICC line site for any signs of redness, inflammation, or heat which insertion site for PICC line was clear of. Dressing was intact. Resident voiced no complaints. A peripherally inserted central catheter also called a PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart. A PICC line requires careful care and monitoring for complications, including infection and blood clots. PICC line complications can include: Bleeding, nerve injury, irregular heartbeat, damage to veins in your arm, blood clots, infection, and a blocked or broken PICC line, according to https://www.mayoclinic.org/tests-procedures/picc-line/about/pac- 748 A review of the facility Log revealed an allegation dated [DATE]. The allegation appeared on the log as Nurses and CNA med pass. The Log also indicated that the allegation was substantiated by the facility. An interview was conducted on [DATE] at 03:56 PM with the Nursing Home Administrator (NHA) and the facility's Director of Nursing (DON) regarding the [DATE] allegation on the facility's Log. The NHA stated that on [DATE] Resident #6 reported to Staff G, LPN that on Friday [DATE] during the 11 PM to 7 AM shift, Staff C, RN, Staff Developer instructed Staff D, CNA to give Resident #6 a narcotic medication and to flush the resident's PICC line. The DON stated that she interviewed Resident #6 and gathered that the incident occurred around midnight going into Saturday [DATE]. The DON also stated that upon discovery, she interviewed Staff D, CNA who confirmed that she did administer a narcotic medication to Resident #6 and flushed the resident's PICC line. The DON stated that she informed the NHA and both staff members were suspended pending an investigation. During the investigation, she also discovered on [DATE] on the 11 AM to 7 PM shift between 5 AM and 7 AM, Staff B, CNA was instructed by Staff A, LPN to perform blood glucose monitoring on 4 residents and to administer oral medications to Resident #3 and Resident #7. Staff B, CNA told the DON that she administered a liquid medication [MEDICATION NAME] to Resident #3 and a pill form of [MEDICATION NAME] to Resident #7. The DON stated that she conducted a telephone interview with Staff A, LPN on [DATE] who confirmed that she instructed Staff B, CNA to perform blood glucose monitoring on 4 residents but denied allowing Staff B, CNA to administer medications to Resident #3 and Resident #7. The NHA stated that Staff A, B, C, and D were suspended on [DATE] and later on [DATE] terminated from employment following a meeting with their corporate team. The NHA also stated that the state licensing board was notified of the allegation. The DON stated that further resident interviews were being conducted as well as staff education and interviews regarding nursing staff performing job duties within their scope of practice. The DON also stated that Resident's #3, #6, and #7 were assessed for adverse effects and physicians were notified on [DATE]. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgement, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others and the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Review of the Florida Administrative Code Rule 64B,[DATE].002, effective on [DATE], documents CNA Authorized Duties as: (1) A certified nursing assistant shall provide care and assist residents with the following tasks related to the activities of daily living only under the general supervision of a registered nurse or licensed practical nurse: (a) Tasks associated with personal care: 1. Bathing, 2. Dressing, 3. [NAME]ing, 4. Shaving, 5. Shampooing and caring for hair, 6. Providing and assisting with oral hygiene and denture care, 7. Caring for the skin, 8. Caring for the feet, 9. Caring for the nails, 10. Providing peri care, 11. Bed making and handling linen, 12. Maintaining a clean environment. (b) Tasks associated with maintaining mobility: 1. Ambulating, 2. Transferring, 3. Transporting, 4. positioning, 5. Turning, 6. Lifting, 7. Performing range of motion exercises, 8. Maintaining body alignment. (c) Tasks associated with nutrition and hydration: 1. Feeding and assisting the resident with eating, 2. Assisting the resident with drinking. (d) Tasks associated with elimination: 1. Toileting, 2. Assisting with the use of the bedpan and urinal, 3. Providing catheter care, 4. Collecting specimens, 5. Emptying ostomy bags, or changing bags that do not adhere to the skin, 6. Bowel and bladder training. (e) Tasks associated with the use of assistive devices: 1. Caring for dentures, eyeglasses, contact lenses, and hearing aids, 2. Applying or donning established or previously fitted and adjusted prosthetic and orthotic devices, 3. Applying or donning previously fitted and adjusted orthotic braces, 4. Applying previously fitted ant [MEDICAL CONDITION] stockings, 5. Assisting with wheelchairs, walkers, or crutches, 6. Using comfort devices such as pillows, cradles, footboards, wedges, and boots, 7. Assisting with and encouraging the use of self-help devices for eating, grooming, and other personal care tasks, 8. Utilizing and assisting residents with devices for transferring, ambulation, alignment, and positioning, 9. Using restraints. (f) Tasks associated with maintaining environment and resident safety, including handling of blood and body fluid and cleaning resident care areas. (g) Tasks associated with data gathering: 1. Measuring temperature, pulse, respiration, and blood pressure, 2. Measuring height and weight, 3. Measuring and recording oral intake, 4. Measuring and recording urinary output, both voided and from urinary drainage systems, 5. Measuring and recording emesis, 6. Measuring and recording liquid stool. (h) Recognition of and reporting of abnormal resident findings, signs, and symptoms. (i) Postmortem care. (j) Tasks associated with resident socialization, leisure activities, reality orientation, and validation techniques. (k) Tasks associated with end of life care. (l) Tasks associated with basic first aid, CPR skills, and emergency care. (m) Tasks associated with compliance with resident's/patient's rights. (n) Tasks associated with daily documentation of certified nursing assistant services provided to the resident. (2) A certified nursing assistant shall perform all tasks with knowledge of and awareness of a resident's/patient's rights and developmental level. (3) A certified nursing assistant shall not perform any task which requires specialized nursing knowledge, judgment, or skills. (4) A certified nursing assistant may receive additional training beyond that required for initial certification and upon validation of competence in the skill by a registered nurse may perform such skills as authorized by the facility. (5) A certified nursing assistant shall not work independently without the supervision of a registered nurse or a licensed practical nurse. A review of the facility's job description for the position of Charge Nurse (LPN or RN), last updated in ,[DATE], provided a summary of the position: Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality of care at all times. Under the section titled Essential Duties & Responsibilities of the job description for the position of Charge Nurse (LPN or RN) are job duties that include: Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry, confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility, verify that all nursing service personnel are in compliance with their respective job descriptions, prepare and administer medications as ordered by the physician, verify the identity of the resident before administering the medication/treatment, verify that prescribed medication for one resident is not administered to another, and deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. A telephone interview was conducted on [DATE] at 03:58 PM with Staff C, RN. Staff C, RN was assigned as charge nurse on A and B halls on [DATE]. Staff C, RN stated that she was terminated and that her licensed was reported to the board. Staff C, RN stated that on the date of the incident, she was on the phone with pharmacy, getting and ordering labs, dealing with patients requesting pain medications, and wound care. Staff C, RN also stated that there were 38 residents for 1 nurse and 2 CNA's on her shift. Staff C, RN stated that she was overwhelmed with everything and that she asked Staff D, CNA for any kind of help. Staff C, RN stated that she asked Staff D, CNA to flush a PICC line and administer medications. Staff C, RN also stated that she signed off on Resident #6's MAR indicated [REDACTED]. Staff C, RN stated that she made a bad judgement call in asking Staff D, CNA to administer medication but she did not know what else to do because the residents need their medications. In regard to staffing, Staff C, RN stated that she worked 22 hours on [DATE] into [DATE], but since she was a salaried employee the hours were not tracked. Staff C, RN stated that she also functioned as the facility's Staff Developer. Staff C, RN stated that the NHA and the DON were both aware of the lack of staff, but the Assistant Director of Nursing (ADON) was on vacation and the DON could not help because her hours wouldn't count if she was on a cart, so the NHA told her that she was going to have to figure it out. Staff C, RN stated that she was aware of multiple instances of CNAs performing job duties out of their scope of practice due to the nurses at the facility being overwhelmed by the lack of staff. A telephone interview was conducted on [DATE] at 01:40 PM with Staff D, CNA. Staff D, CNA was assigned to B wing on [DATE]. Staff D, CNA stated that she was told by Staff C, RN, who was also her supervisor, to flush Resident #6's PICC line and to administer a pain pill to Resident #6. Staff D, CNA also stated that Staff C, RN asked her to perform blood glucose monitoring for 4 residents on B wing but was unable to identify the 4 residents during the interview. Staff D, CNA stated that she told the facility's NHA about 2 or 3 weeks ago about what happened and that she was sorry that she did not get many residents up out of bed before she left in the morning. Staff D, CNA also stated to the NHA that she had 36 residents in her assignment and that the NHA responded by telling her to do the best she could. Staff D, CNA stated that she was only doing what she was told and that many other nights she had done the same things. Staff D, CNA also stated that she now knows that she is not supposed to perform those duties and that the nurse is supposed to. An interview was conducted on [DATE] at 09:31 AM with Resident #3. Resident #3 stated that he received [MEDICATION NAME] liquid from Staff B, CNA after being directed to by Staff A, LPN. Resident #3 was unable to recall why Staff B, CNA provided him with the medication. A review of Resident #3's medical record revealed that Resident #3 was admitted to the facility on [DATE]. A review of Resident #3's Quarterly MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #3's MAR indicated [REDACTED]. Staff A, LPN documented her initials on [DATE] for the 06:00 AM dose of [MEDICATION NAME]. A review of Resident #3's Progress Notes revealed a Nursing Note, dated on [DATE] at 06:53 PM, documented by the facility's DON which stated Resident was assessed for side effects of medication. Resident denies and does not show any s/sx (signs and symptoms) of adverse effects at this time. A review of Resident #7's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #7's Admission MDS assessment, dated [DATE], under Section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #7's MAR indicated [REDACTED]. Staff A documented her initials on [DATE] for the daily dose of [MEDICATION NAME]. A review of Resident #7's Progress Notes revealed a Nursing Note, dated [DATE] at 06:48 PM, documented by the facility's DON which stated Resident was assessed for side effects of medications. Resident does not show any adverse s/sx (signs and symptoms) of medications at this time. A telephone interview was conducted on [DATE] at 10:45 AM with Staff A, LPN. Staff A, LPN was assigned as charge nurse for A and B wings on [DATE]. Staff A, LPN stated that she was terminated from employment at the facility for something that she did not do. Staff A, LPN stated that the facility accused her of asking Staff B, CNA to administer a medication to Resident #3 and that the allegation was not true. Staff A, LPN stated that she poured the [MEDICATION NAME] solution to prepare for administration to Resident #3 as ordered and Staff B, CNA accompanied her into Resident #3's room to encourage Resident #3 to take it. Staff A, LPN stated that sometimes the CNAs can encourage residents to take their medications if they refuse. Staff A, LPN stated that during her shift on [DATE] she was caring for 40 residents on 2 separate units, which she identified as the A and B halls. Staff A, LPN also stated that she had asked CNAs to assist her with blood glucose monitoring in the past and that Staff B, CNA assisted her with blood glucose monitoring on the 11 PM to 7 AM shift on [DATE] while she was completing charting on other residents. Staff A, LPN stated that she had brought up concerns of the facility being short staffed to the facility's NHA and DON on multiple occasions and that on some occasions they would have to work with 1 nurse and 1 CNA for an assignment of 40 residents. A telephone interview was conducted on [DATE] at 12:52 PM with Staff B, CNA. Staff B, CNA was assigned as Community CNA on [DATE]. Staff B, CNA stated that she was terminated from employment at the facility on [DATE] for administering medications but denied that she administered any medications to residents. Staff B, CNA stated that she conducted blood glucose monitoring on 4 residents after being told to do so by Staff A, LPN. Staff B, CNA was able to identify 3 (Resident #10, #11, and #12) of the 4 residents that she performed blood glucose monitoring on. Staff B, CNA stated that she performed the blood glucose monitoring in order to help Staff A, LPN, who had 40 residents in her assignment on the 11 PM to 7 AM shift on [DATE]. Staff B, CNA also stated that she will seldom conduct blood glucose monitoring for a nurse but was not aware that it was against the facility's policy. A review of Resident #10's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #10's Admission MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #10's MAR indicated [REDACTED] If Blood Sugar is less than [AGE], call MD. If Blood Sugar is 150 to 200, give 2 units. If Blood Sugar is 201 to 250, give 4 units. If Blood Sugar is 251 to 300, give 6 units. If Blood Sugar is 301 to 350, give 8 units. If Blood Sugar is 351 to 400, give 10 units. If Blood Sugar is greater than 401, call MD. Staff A, LPN initialed an entry on [DATE] at 05:00 AM with a blood glucose reading of 200 milligrams per deciliter (mg/dl). A review of Resident #11's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #11's Annual MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 15, which would indicate intact cognition. A review of Resident #11's MAR indicated [REDACTED] If Blood Sugar is less than 71, call MD. If Blood Sugar is 71 to 140, give 0 units. If Blood Sugar is 141 to 1[AGE], give 3 units. If Blood Sugar is 181 to 220, give 5 units. If Blood Sugar is 221 to 2[AGE], give 8 units. If Blood Sugar is 261 to 300, give 10 units. If Blood Sugar is 301 to 350, give 12 units. If Blood Sugar is greater than 350, give 14 units and call MD. Staff A, LPN initialed an entry on [DATE] at 06:00 AM with a blood glucose reading of 210 mg/dl. An interview was conducted on [DATE] at 01:34 PM with Resident #12. Resident #12 stated that the nurse primarily performs blood glucose monitoring, but also stated that maybe one time a CNA has performed blood glucose monitoring for him. A review of Resident #12's medical record revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #12's Quarterly MDS assessment, dated [DATE], under section C: Cognitive Patterns revealed a BI[CONDITION] Summary Score of 14, which would indicate intact cognition. A review of Resident #12's MAR indicated [REDACTED] If Blood Sugar is less than [AGE], call MD. If Blood Sugar is 150 to 200, give 1 units. If Blood Sugar is 201 to 250, give 2 units. If Blood Sugar is 251 to 300, give 3 units. If Blood Sugar is 301 to 350, give 4 units. If Blood Sugar is 351 to 400, give 5 units. If Blood Sugar is greater than 400, call MD. Staff A, LPN initialed an entry on [DATE] at 06:00 AM with a blood glucose reading of 258 mg/dl. An interview was conducted on [DATE] at 04:55 PM with Staff T, LPN, charge nurse assigned to C wing on the 3 PM to 11 PM shift, regarding allowing CNAs to perform duties outside of their scope of practice. Staff T, LPN stated that a couple of CNAs reported that they had been asked by a nurse to administer medications, perform blood glucose monitoring, or perform treatments, but none of them had actually performed any of those actions. The CNAs were identified as Staff V, CNA, Staff W, CNA, and Staff X, CNA. The nurse was identified as Staff U, LPN, charge nurse assigned to D Wing. An interview was conducted on [DATE] at 05:29 PM with Staff W, CNA, assigned to C Wing on the 3 PM to 11 PM shift, regarding being asked to perform job duties outside of a CNAs scope of practice. Staff W, CNA stated that she usually is able to assist the nurse's with vital signs monitoring as part of daily assignment but did not perform blood glucose monitoring. Staff W, CNA also stated that she had not been asked by a nurse to perform blood glucose monitoring or administer medications but has been asked by a nurse to apply a medicated cream to a resident's shoulders. Staff W, CNA did not state what resident she applied the cream to, what cream was administered, or the date that she administered the cream to the resident. Staff W, CNA stated that she had not witnessed any CNA performing job duties outside of their scope of practice. Staff W, CNA also stated that if she was asked to perform job duties outside of her scope of practice, she would tell the nurse no. An interview was conducted on [DATE] at 05:40 PM with Staff V, CNA, assigned to C Wing on the 3 PM to 11 PM shift, regarding being asked to perform job duties outside of a CNAs scope of practice. Staff V, CNA stated that she assists the nurse with vital signs monitoring as requested but does not administer any type of medication or perform blood glucose monitoring. Staff V, CNA stated that a while back, Staff U, LPN had asked her to administer a medication to a resident, to which she refused. Staff V, CNA also stated that she was taught very strictly not to do the nurse's job and that the only treatment that she provides is barrier cream. Staff V, CNA stated that she did not report Staff U, LPN for asking her to administer a medication to a resident but addressed that she should have reported the incident. Staff V, CNA stated that she has not observed any CNAs performing duties outside of their scope of practice. An interview was conducted on [DATE] at 05:45 PM with Staff U, LPN, charge nurse assigned to D wing on the 3 PM to 11 PM shift. Staff U, LPN stated that he left the facility around midnight last night due to having 3 re-admissions from the hospital on his unit. Staff U, LPN also stated that he had a hard time completing his job duties and that he feels like he does not have enough time to complete all of his job duties. Staff U, LPN stated that he had to leave some of the work for the 11 PM to 7 AM shift to complete, but that he was able to complete all of his blood glucose monitoring, medication administration, and treatments as ordered. Staff U, LPN stated that CNAs assist him with applying barrier cream or skin prep to residents and also assist if he needs help holding a resident's arm to administer an intramuscular (IM) injection, but the CNAs are not allowed to apply any treatment that requires a physician's prescription. Staff U, LPN also stated that he would not allow a CNA to administer a medication to a resident or perform blood glucose monitoring because it is not in the CNAs scope of practice to do so. Staff U, LPN stated that he has not witnessed a CNA performing blood glucose monitoring or administering a medication, but he would report the observation to the facility's NHA or DON if witnessed. An interview was conducted on [DATE] at 5:55 AM with the facility's NHA. The NHA stated that another immediate report was filed last night on [DATE] related to Staff W, CNA reporting that she administered a medicated cream to a resident but could not recollect a date or time of the incident. Staff W, CNA and Staff U, LPN were both suspended pending the investigation and the facility continued to educate staff regarding scope of practice, resident interviews, and were collecting written statements. A review of Staff W, CNA's written statement, dated on [DATE] revealed that Staff W, CNA was instructed by Staff U, LPN to apply a cream to a resident's shoulders after the resident was given a shower. The statement also revealed that Staff U, LPN put something in a cup and told Staff W, CNA to put it on a resident's shoulders and that she did not know that it was a treatment. Staff W, CNA signed the statement on [DATE]. A review of Staff U, LPN's written statement, dated on [DATE] documented Staff U, LPN stated, I have not given a CNA cream medicated to put on a resident, just skin prep and periguard. The statement was signed by Staff U, LPN on [DATE]. The facility's Business Office Manager, Social Services Director, and the Assistance Director of Nursing interviewed residents, who could participate, on [DATE] regarding if a CNA's are administering a medication or performing blood glucose monitoring for them. A telephone interview was conducted on [DATE] at 10:05 AM with the facility's Medical Director. The Medical Director confirmed he was aware of the incident of a CNA flushing a PICC line, administering medications, and conducting blood glucose monitoring. A Performance Improvement Plan (PIP) meeting was held on [DATE] to address the issues of staff members performing job duties outside of their scope of practice. The Medical Director stated that he was livid when he was informed that CNAs were performing job duties outside of their scope of practice. A review of the facility policy titled Medication Administration: General Guidelines, dated ,[DATE], under the section titled Policy revealed that medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The section titled Medication Preparation of the policy revealed that medications are prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state regulations to prepare medications. The section titled Medication Administration of the policy under step 5 revealed that the person who prepares the dose for administration is the person who administers the dose. The section of the facility policy titled Doc

Based on interview with the facility ' s nursing staff, and review of the resident ' s medical record, facility policy, and documented statements from facility staff, it was determined that the facility failed to protect the rights for one (#1) of 39 residents with a Full Code status, according to the midnight census of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation when the resident was found unresponsive, with no pulse or respirations. The facility staff did not begin the administration of CPR and did not call 911 for medical aide in accordance with their policy and procedure (Resuscitation (Cardio-Pulmonary)/Emergency Procedures revised [DATE], page 2R-1, and Cardio [MEDICAL CONDITION] Resuscitation (CPR), page 1 & 2 with an effective date of [DATE]). The facility did not honor the advanced directives expressed by the resident and his health care surrogate/spouse. Failure of the facility staff to correctly implement advance directives resulted in findings of immediate jeopardy which was removed on [DATE] at 10:30 p.m. Findings include: 1. Telephone interview with the resident ' s spouse on [DATE] at 12:56 p.m., revealed she had been married to resident #1 for [AGE] years. She recalled someone from the facility calling her around 6:30 a.m. on [DATE]. They said they were sorry, but her husband had passed in his sleep. She stated her spouse was okay when she left him Wednesday afternoon, the day prior to his death, so she really didn ' t expect to receive that phone call. He had been making some progress in therapy but it was hard to tell due to dementia and weakness in his legs. The staff encouraged him to walk and he was, but he couldn ' t get out of the chair by himself. The staff did not mention that they didn ' t attempt CPR on him. He did not have any orders to withhold CPR. She stated she had power of attorney for the resident with an understanding of health care surrogate but not a separate document as far as she can remember. She does not recall facility staff discussing a do not resuscitate (DNR) order with her. 2. Interview with the administrator on [DATE] at 8:32 a.m. revealed the facility ' s social services director (SSD) had been terminated about a week prior to [DATE]. Part of the reason the SSD had been terminated was related to her not following up with advance directives. Residents and families were receiving the information on admission, but the SSD was not following up with them to receive the information for their records and to formulate new advance directives. At the time of this survey, the administrator was acting as the SSD. The administrator was in the process of auditing resident records for advanced directives. According to the administrator, long term care residents have the information contained in their records, and the focus was new admissions. 3. Review of resident #1 ' s clinical record revealed an Admission Record Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. A review of the physician orders [REDACTED]. Review of the facility ' s Advance Directives/Informed Consent form revealed the resident ' s spouse had signed this acknowledgement form on [DATE] on behalf of the resident and indicated that the resident had a living will, durable power of attorney (POA), and designation of health care surrogate. These documents were present in the clinical record. No other advance directives were checked off on this form including do not resuscitate. Continued review of the clinical record revealed the following nurses note entries on [DATE]: 2:00 a.m. quietly resting with eyes closed. No complaint of pain or discomfort reported. Vital signs ,[DATE] (blood pressure), 72 (pulse), 24 (respirations), 98.9 (temperature). (Signed by LPN#1) 6:15 a.m. Patient pronounced without respirations, no blood pressure, no heartbeat. (Signed by RN #2) 6:30 a.m. Wife informed and National Cremation Society notified. This writer was informed from lab tech that patient was unresponsive and she was unable to draw labs. This writer went to patient ' s room to find patient lying on his back with mouth open and eyes closed. Patient ' s skin was pale. Cold to touch with mottling noted throughout. Patient was extremely rigid. Vital signs were unobtainable at this time. Doctor was notified of patient ' s condition and history. Orders were received to pronounce and release body at this time. (Signed by LPN #2) Review of the physician's order [REDACTED]. 4. Interview with the facility ' s Director of Nursing (DON) on [DATE] at 1:17 p.m. revealed it is her normal procedure to review the clinical record for any death occurring in the facility. At approximately 8:30 a.m. on [DATE] she reviewed the record of resident #1 who had expired in the facility on [DATE] at approximately 6:15 a.m. Upon review of this record, the DON realized the facility did not have the appropriate documentation to withhold CPR for resident #1. The DON informed her administrator and they initiated an investigation into the events surrounding the death of resident #1. 5. Review of the facility ' s policy, " Advance Directives " dated [DATE] page ,[DATE] revealed " Advance directives will be respected in accordance with state law and faciity policy. " A review was made of the facility ' s policy, " Emergencies " dated [DATE] page E-11a. This policy states it is the intent of this faciity to respond to emergencies in accordance with our procedures and Standards of Practice. The procedures portion of this policy includes the following relevant bullet points: (1) Resuscitation Nursing Services P&P Manual 2R-1 (3) Call 911 for services of life threatening issues Review of the " Resuscitation (Cardio-Pulmonary) " policy and procedure referenced above in bullet #1 (revised [DATE], page 2R-1) documented " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resusciation (DNR) for the issuance of an order not to resuscitate. " A review of the Do Not Resuscitate (DNR) policy labeled " Nursing Services Policy & Procedure Manual Advance Directives-Florida " page 2A-7 revealed the following statement: " Regardless of whether the resident is in a persisitent vegetative state or has a terminal conditon, all facility ' s residents shall receive full resuscitative measures unless a DNR directive is written in the resident ' s medical record and is identified in the resident ' s Advance Directive. " Further investigation and review of the " Cardio [MEDICAL CONDITION] Resusciation (CPR) policy and procedure with an effective date of [DATE], Policy No: N.C-077 revealed the following " essential points " on page 2 of 2: " Once CPR is initiated, it must be continued until help arrives. 6. Interview with the administrator and director of nursing on [DATE] at 8:32 a.m. revealed facility ' s investigation found licensed practical nurse (LPN #1) had been assigned to resident #1 on the 11:00 p.m. - 7:00 a.m. shift on [DATE]. At around 6:00 a.m. on [DATE] the LPN found resident #1 unresponsive with no pulse and no respirations. The LPN proceeded to get the Registered Nurse (RN #2) supervisor to assess the resident. The RN determined that rigor mortis had set in, the resident was mottled all over, and ice cold. The LPN then called the resident ' s physician and provided him with the resident ' s history. The physician gave permission to pronounce the resident and release the body. The spouse of the resident was also notified. The resident was originally admitted for rehab with the hopes of returning back to an assisted living facility (ALF). However, after a couple of weeks in the facility it became apparent that the resident ' s dementia was advanced and he was declining. The administrator and the resident ' s spouse had discussed long term placement in the facility the same week this incident occurred. The resident was a full code and CPR was not started and 911 were not called. The facility immediately suspended RN #2 pending investigation and ultimately terminated her employment following this incident. The DON and administrator stated that every nurse in the building has received re-in-service training on CPR policies and procedures and DNR status since the incident occurred. 7. Interview on [DATE] at 9:39 a.m. with LPN #1 revealed that around 6 a.m. on [DATE] a lab technician was here to draw blood on resident #1. The lab tech came to this nurse and informed her she could not arouse resident #1 and could not perform the procedure unless she spoke to the resident. The LPN then went down to see the resident and upon observation indicated he had obviously expired. He was very stiff, had no pulse, no respirations, and was mottled all over. The LPN then went across the building to nurses ' station 2 which is where the crash cart is kept. Along the way the RN supervisor stopped her and asked what was going on. The LPN informed the RN and the RN locked her medication cart up and went with a stethoscope to assess the resident. The RN stated to her there ' s no need for CPR, he is more than expired. The LPN then proceeded to call the resident ' s physician and inform him of what was going on. She gave the doctor the resident ' s medical history but could not recall the specifics of what was discussed. The LPN stated the doctor said they can pronounce and release the body. She then phoned the wife and informed her of what had transpired. The LPN was aware that resident #1 was a full code and stated she was going to start CPR but when stopped by the RN supervisor she went with the RN ' s conclusion that no CPR needed to be done. 8. Review of a written statement by RN #2 dated [DATE] revealed the following: At about 6 AM - 6:30 AM, as I was giving out my 6 AM medications, the nurse from Station I came over to me with her stethoscope around her neck and stated the lab tech was unable to arouse a patient. The nurse stated that he had passed away but was a full code. I went over and the patient was cold, mottled from the thighs to feet and total arm mottled, mouth opened, mouth, lips, and nail beds purplish-mouth opened and dry. Up to this point no CPR or 911 had not been called. I felt the patient and he was rigid and had no respirations and no apical heartbeat. " I pronounced the patient. " Doctor and family were called. Telephone interview with RN #2 on [DATE] at 2:36 p.m. revealed between 6 and 6:30 a.m. on [DATE] she was on station 2 passing meds. Nurse from station one told me resident had passed away, he ' s a full code. I looked at him; he was cyanotic from fingers to arm pits, toes to thighs. He was cold. I couldn ' t see performing CPR on a dead person. He had no pulse, no respirations. His mouth was open, gaped, and dried. His nail beds were cyanotic. The doctor was called and gave permission to pronounce and the wife was called and said she had already said her goodbyes. RN #2 went on to state I didn ' t start CPR like I should have and CPR had not been started either. What happened was the lab could not arouse him. The LPN checked him and then came to me as the RN supervisor. 9. Interview with the resident ' s physician on [DATE] at 12:37 p.m. revealed he recalled the LPN calling him on the day of the incident and informing him they found resident #1 dead. He was familiar with the resident ' s history but could not remember if at the time the facility called him they had informed him of the resident ' s code status. He was under the assumption initially that he was a DNR but didn ' t ask the nurse at that time. Because the resident did not have a DNR order the expectation would be to start CPR and call paramedics. He signed the resident ' s death certificate and believed the death was due to natural causes. This doctor also serves as the medical director of the facility. He was not aware of any other similar cases at this facility of failure to give CPR. He was present in the facility on [DATE] for the Continuous Quality Improvement (CQI) meeting and stated he would make sure they discussed this matter in the meeting. 10. Interview with the staff education coordinator on [DATE] at 2:49 p.m. revealed emergency procedures to include proper response to an unresponsive resident without vital signs has always been part of the orientation and annual review for direct care staff to include licensed nurses and certified nursing assistants. A review of the facility ' s orientation check list verified that this information is covered during orientation/annual review as part of CPR and First-Aide. This procedure includes a mock test to ensure staff understands the subject matter discussed. Prior to this incident on [DATE], staff did not always attend classroom training prior to working on the floor, however, interview with the administrator on [DATE] at approximately 10:30 a.m. reviewed this will change effective immediately to ensure all direct care staff receive classroom orientation to include emergency procedures prior to working on the floor. 11. Review of the facility ' s licensed nurse schedules from [DATE] - [DATE] and the current employee roster revealed the facility has 21 nurses who work at the facility on a regular basis. The LPN involved in the incident received individual coaching and retraining on the CPR policy on [DATE]. Review of the in-service sign in records revealed 11 additional nurses were in-service trained on [DATE], seven received in-service training on [DATE], one was trained on [DATE], and the final nurse was re-in serviced on [DATE] at 10:30 p.m. Random interviews with nurses were conducted on [DATE] to validate that they had received training and would respond appropriately in the event of a similar incident. 12. Interview with the administrator on [DATE] at approximately 10:30 a.m. revealed the facility held a CQI committee meeting on [DATE] at 1:00 p.m. and is putting the following system in place: Advanced directives will be addressed with the resident upon admission by the nurse, social services or admissions coordinator; advanced directive information to be given upon admission. Resident will be addressed about any advanced directive change within 14 days of admission. Resident will be addressed about any advanced directive changes quarterly. Yellow dots will be added to the residents charts who have a DNR. Residents with DNR ' s will have a yellow wrist band. In-servicing to be provided to licensed staff upon hire during class room orientation prior to working on the floor and annually. Based on the facility ' s systems process, the IJ was abated on [DATE] at 10:30 p.m. and the severity and scope was reduced to D.

Based on interview with the facility ' s nursing staff, and review of the resident ' s medical record and documented statements from facility staff, it was determined that the facility failed to ensure services for resuscitation were provided in accordance with professional standards for one (#1) of 39 residents identified as full code, according to the midnight census of [DATE]. The registered nurse supervisor did not initiate Cardio-Pulmonary Resuscitation for a full code resident after performing an assessment and identifying the resident to be without pulse or respirations. In addition, the registered nurse supervisor acted outside the scope of her nursing license when pronouncing the death of resident #1. Failure of the facility to ensure nurses meet professional standards and act in accordance with the Nurse Practice Act as defined in the Florida Statutes, Chapter 464, resulted in findings of immediate jeopardy which was removed on [DATE] at 10:30 p.m. Findings include: 1. The "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: a. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. b. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. c. The supervision and teaching of other personnel in the theory and performance of any of the above acts. The professional nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. " 2. Review of the resident #1 ' s clinical record revealed an Admission Record Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. A review of the physician orders [REDACTED]. Review of the facility ' s Advance Directives/Informed Consent form revealed the resident ' s spouse had signed this acknowledgement form on [DATE] on behalf of the resident. This consent form documented the resident as having a living will, durable power of attorney (POA), and designation of health care surrogate. These documents were present in the clinical record. No additional advance directives were on file. 3. Continued review of the clinical record revealed the following nurses note entries on [DATE]: 2:00 a.m. quietly resting with eyes closed. No complaint of pain or discomfort reported. Vital signs ,[DATE] (blood pressure), 72 (pulse), 24 (respirations), 98.9 (temperature). (Signed by LPN#1) 6:15 a.m. Patient pronounced without respirations, no blood pressure, no heartbeat. (Signed by RN #2) 6:30 a.m. Wife informed and National Cremation Society notified. This writer was informed from lab tech that patient was unresponsive and she was unable to draw labs. This writer went to patient ' s room to find patient lying on his back with mouth open and eyes closed. Patient ' s skin was pale. Cold to touch with mottling noted throughout. Patient was extremely rigid. Vital signs were unobtainable at this time. Doctor was notified of patient ' s condition and history. Orders were received to pronounce and release body at this time. (Signed by LPN #1) Review of the physician's order [REDACTED]. 4. Interview with the facility ' s Director of Nursing (DON) on [DATE] at 1:17 p.m. revealed it is her normal procedure to review the clinical record for any death occurring in the facility. At approximately 8:30 a.m. on [DATE] she reviewed the record of resident #1 who had expired in the facility on [DATE] at approximately 6:15 a.m. Upon review of this record, the DON realized the facility did not have the appropriate documentation to withhold CPR for resident #1. The DON informed her administrator and they initiated an investigation into the events surrounding the death of resident #1. 5. Interview with the Administrator and Director of Nursing on [DATE] at 8:32 a.m. revealed the licensed practical nurse (LPN #1) assigned to resident #1 on the 11:00 p.m. - 7:00 a.m. shift on [DATE] found resident #1 unresponsive with no pulse and no respirations around 6:00 a.m. on [DATE]. The LPN proceeded to get the Registered Nurse (RN #2) supervisor to assess the resident. The RN determined that rigor mortis had set in, the resident was mottled all over, and ice cold. The LPN then called the resident ' s physician and provided him with the resident ' s history. The physician gave permission to pronounce the resident and release the body. The spouse of the resident was also notified. The resident was originally admitted for rehab with the hopes of returning back to an assisted living facility (ALF). However, after a couple of weeks in the facility it became apparent that the resident ' s dementia was advanced and he was declining. The administrator and the resident ' s spouse had discussed long term placement in the facility the same week this incident occurred. The resident was a full code and CPR was not started and 911 were not called. 6. Interview on [DATE] at 9:39 a.m. with LPN #1 revealed that around 6 a.m. on [DATE] a lab technician was here to draw blood on resident #1. The lab tech came to this nurse and informed her she could not arouse resident #1 and could not perform the procedure unless she spoke to the resident. The LPN then went down to see the resident and upon observation indicated he had obviously expired. He was very stiff, had no pulse, no respirations, and was mottled all over. The LPN then went across the building to nurses ' station 2 which is where the crash cart is kept. Along the way the RN supervisor stopped her and asked what was going on. The LPN informed the RN, and the RN locked her medication cart up and went with a stethoscope to assess the resident. The RN stated to her there ' s no need for CPR, he is more than expired. The LPN then proceeded to call the resident ' s physician and inform him of what was going on. She gave the doctor the resident ' s medical history but could not recall the specifics of what was discussed. The LPN stated the doctor said they can pronounce and release the body. She then phoned the wife and informed her of what had transpired. The LPN was aware that resident #1 was a full code and stated she was going to start CPR but when stopped by the RN supervisor she went with the RN ' s conclusion that no CPR needed to be done. 7. Subsequent interview with LPN #1 on [DATE] at 12:45 p.m. revealed she had checked resident ' s #1 chart for a DNR order right after she found the resident unresponsive without vital signs. When she saw the resident was a full code she immediately headed for the crash cart when she was stopped by RN #2. The LPN stated she had received training on emergency procedures in the facility in the past as this was part of their normal in-servicing they had a couple of times a year. Since the time of this incident the facility has changed their training and policy to state that no one can stop a code and CPR must be administered when the resident is a full code regardless of direction by other staff members. LPN#1 stated that the RN did pronounce the resident. She stated that as an LPN she is not allowed to pronounce or release a body. 8. Review of a written statement by RN #2, dated [DATE], revealed the following: At about 6 AM - 6:30 AM, as I was giving out my 6 AM medications, the nurse from Station I came over to me with her stethoscope around her neck and stated the lab tech was unable to arouse a patient. The nurse stated that he had passed away but was a full code. I went over and the patient was cold, mottled from the thighs to feet and total arm mottled, mouth opened, mouth, lips, and nail beds purplish-mouth opened and dry. Up to this point no CPR or 911 had not been called. I felt the patient and he was rigid and had no respirations and no apical heartbeat. " I pronounced the patient. " Doctor and family were called. Telephone interview with RN #2 on [DATE] at 2:36 p.m. revealed between 6 and 6:30 a.m. on [DATE] she was on station 2 passing meds. Nurse from station one told me resident had passed away, he ' s a full code. I looked at him; he was cyanotic from fingers to arm pits, toes to thighs. He was cold. I couldn ' t see performing CPR on a dead person. He had no pulse, no respirations. His mouth was open, gaped, and dried. His nail beds were cyanotic. The doctor was called and gave permission to pronounce and the wife was called and said she had already said her goodbyes. RN #2 went on to state I didn ' t start CPR like I should have and CPR had not been started either. What happened was the lab could not arouse him. The LPN checked him and then came to me as the RN supervisor. Further investigation and subsequent interview with RN#2 on [DATE] at 11:25 a.m. revealed she had participated in CPR drills at the facility in the past and was aware of the proper procedure for a resident with a full code. However, she admitted that she did not perform CPR like she should have because the resident appeared to have been down for a while. The RN stated " I was wrong. I realize that. " 9. Interview with the resident ' s physician on [DATE] at 12:37 p.m. revealed he recalled the LPN calling him on the day of the incident and informing him they found the resident dead. He was familiar with the resident ' s history but could not recall if at the time the facility contacted him they informed him of the resident ' s code status. He was under the assumption initially that he was a DNR but didn ' t ask the nurse at that time. Because the resident did not have a DNR order the expectation would be to start CPR and call paramedics. He signed the resident ' s death certificate and believed the death was due to natural causes. This doctor also serves as the medical director of the facility. He was not aware of any other similar cases at this facility of failure to give CPR. He was present in the facility on [DATE] for the Continuous Quality Improvement (CQI) meeting and stated he would make sure they discussed this matter in the meeting. 10. Interview with the administrator and DON on [DATE] at 8:32 a.m. revealed the facility immediately suspended RN #2 and ultimately terminated her employment following this incident. The DON and administrator stated that every nurse in the building has received re-in-service training on CPR policies and procedures and DNR status. 11. Review of the facility ' s licensed nurse schedules from [DATE] - [DATE] and the current employee roster revealed the facility has 21 nurses who work at the facility on a regular basis. The LPN involved in the incident received individual coaching and retraining on the CPR policy on [DATE]. Review of the in-service sign in records revealed 11 additional nurses were in-service trained on [DATE], seven received in-service training on [DATE], one was trained on [DATE], and the final one was re-in serviced on [DATE] at 10:30 p.m. Random interviews with nurses were conducted on [DATE] to validate that they had received training and would respond appropriately in the event of a similar incident. Interview with the administrator on [DATE] at approximately 10:30 a.m. revealed the facility held a CQI committee meeting on [DATE] at 1:00 p.m. and is putting the following system in place: Advanced directives will be addressed with the resident upon admission by the nurse, social services or admissions coordinator; advanced directive information to be given upon admission. Resident will be addressed about any advanced directive change within 14 days of admission. Resident will be addressed about any advanced directive changes quarterly. Yellow dots will be added to the residents charts who have a DNR. Residents with DNR ' s will have a yellow wrist band. In-servicing to be provided to licensed staff upon hire during class room orientation prior to working on the floor and annually. Based on the facility ' s systems process, the IJ was abated on [DATE] at 10:30 p.m. and the severity and scope reduced to D.

Based on interview with the facility ' s nursing staff, and review of the resident ' s medical record, facility policy, and documented statements from facility staff, it was determined that the facility failed to ensure that needed services for resuscitation were initiated for one (#1) of 39 residents identified as full code, according to the midnight census of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation when the resident was found unresponsive, with no pulse or respirations. The facility did not implement their policy and procedure (Resuscitation (Cardio-Pulmonary)/Emergency Procedures revised [DATE], page 2R-1, and Cardio [MEDICAL CONDITION] Resuscitation (CPR), page 1 & 2 with an effective date of [DATE]) as staff did not begin the administration of CPR and did not call 911 for medical aide. The facility did not honor the expressed wishes of the resident and his health care surrogate/spouse. Failure of the facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy which was removed on [DATE] at 10:30 p.m. Findings include: 1.During the visit beginning on [DATE], a review was made of the facility ' s policy, " Emergencies " dated [DATE] page E-11a. This policy states it is the intent of this faciity to respond to emergencies in accordance with our procedures and Standards of Practice. The procedures portion of this policy includes the following relevant bullet points: 1. Resuscitation Nursing Services P&P Manual 2R-1 3. Call 911 for services of life threatening issues Review of the " Resuscitation (Cardio-Pulmonary) " policy and procedure referenced above in bullet #1 (revised [DATE], page 2R-1) documented " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resusciation (DNR) for the issuance of an order not to resuscitate. " A review of the Do Not Resuscitate (DNR) policy labeled " Nursing Services Policy & Procedure Manual Advance Directives-Florida " page 2A-7 revealed the following statement: " Regardless of whether the resident is in a persisitent vegetative state or has a terminal conditon, all facility ' s residents shall receive full resuscitative measures unless a DNR directive is written in the resident ' s medical record and is identified in the resident ' s Advance Directive. " Further investigation and review of the " Cardio [MEDICAL CONDITION] Resusciation (CPR) policy and procedure with an effective date of [DATE], Policy No: N.C-077 revealed the following " essential points " on page 2 of 2: " Once CPR is initiated, it must be continued until help arrives. 2.Interview with the facility ' s Director of Nursing (DON) on [DATE] at 1:17 p.m. revealed it is her normal procedure to review the clinical record for any death occurring in the facility. At approximately 8:30 a.m. on [DATE] she reviewed the record of resident #1 who had expired in the facility on [DATE] at approximately 6:15 a.m. Upon review of this record, the DON realized the facility did not have the appropriate documentation to withhold CPR for resident #1. The DON informed her administrator and they initiated an investigation into the events surrounding the death of resident #1. 3.Interview with the administrator and director of nursing on [DATE] at 8:32 a.m. revealed the licensed practical nurse (LPN #1) assigned to resident #1 on the 11:00 p.m. - 7:00 a.m. shift on [DATE] found resident #1 unresponsive with no pulse and no respirations around 6:00 a.m. on [DATE]. The LPN proceeded to get the Registered Nurse (RN #2) supervisor to assess the resident. The RN determined that rigor mortis had set in, the resident was mottled all over, and ice cold. The LPN then called the resident ' s physician and provided him with the resident ' s history. The physician gave permission to pronounce the resident and release the body. The spouse of the resident was also notified. The resident was originally admitted for rehab with the hopes of returning back to an assisted living facility (ALF). However, after a couple of weeks in the facility it became apparent that the resident ' s dementia was advanced and he was declining. The administrator and the resident ' s spouse had discussed long term placement in the facility the same week this incident occurred. The resident was a full code and CPR was not started and 911 were not called. 4. Interview on [DATE] at 9:39 a.m. with LPN #1 revealed that around 6 a.m. on [DATE] a lab technician was here to draw blood on resident #1. The lab tech came to this nurse and informed her she could not arouse resident #1 and could not perform the procedure unless she spoke to the resident. The LPN then went down to see the resident and upon observation indicated he had obviously expired. He was very stiff, had no pulse, no respirations, and was mottled all over. The LPN then went across the building to nurses ' station 2 which is where the crash cart is kept. Along the way the RN supervisor stopped her and asked what was going on. The LPN informed the RN and the RN locked her medication cart up and went with a stethoscope to assess the resident. The RN stated to her there ' s no need for CPR, he is more than expired. The LPN then proceeded to call the resident ' s physician and inform him of what was going on. She gave the doctor the resident ' s medical history but could not recall the specifics of what was discussed. The LPN stated the doctor said they can pronounce and release the body. She then phoned the wife and informed her of what had transpired. The LPN was aware that resident #1 was a full code and stated she was going to start CPR but when stopped by the RN supervisor she went with the RN ' s conclusion that no CPR needed to be done. 5. Review of a written statement by RN #2 dated [DATE] revealed the following: At about 6 AM - 6:30 AM, as I was giving out my 6 AM medications, the nurse from Station I came over to me with her stethoscope around her neck and stated the lab tech was unable to arouse a patient. The nurse stated that he had passed away but was a full code. I went over and the patient was cold, mottled from the thighs to feet and total arm mottled, mouth opened, mouth, lips, and nail beds purplish-mouth opened and dry. Up to this point no CPR or 911 had not been called. I felt the patient and he was rigid and had no respirations and no apical heartbeat. " I pronounced the patient. " Doctor and family were called. Telephone interview with RN #2 on [DATE] at 2:36 p.m. revealed between 6 and 6:30 a.m. on [DATE] she was on station 2 passing meds. Nurse from station one told me resident had passed away, he ' s a full code. I looked at him; he was cyanotic from fingers to arm pits, toes to thighs. He was cold. I couldn ' t see performing CPR on a dead person. He had no pulse, no respirations. His mouth was open, gaped, and dried. His nail beds were cyanotic. The doctor was called and gave permission to pronounce and the wife was called and said she had already said her goodbyes. RN #2 went on to state I didn ' t start CPR like I should have and CPR had not been started either. What happened was the lab could not arouse him. The LPN checked him and then came to me as the RN supervisor. 6. Interview with the resident ' s physician on [DATE] at 12:37 p.m. revealed he recalled the LPN calling him on the day of the incident and informing him they found him dead. He was familiar with the resident ' s history but could not remember if at the time the facility called him they had informed him of the resident ' s code status. He was under the assumption initially that he was a DNR but didn ' t ask the nurse at that time. Because the resident did not have a DNR order the expectation would be to start CPR and call paramedics. He signed the resident ' s death certificate and believed the death was due to natural causes. This doctor also serves as the medical director of the facility. He was not aware of any other similar cases at this facility of failure to give CPR. He was present in the facility on [DATE] for the Continuous Quality Improvement (CQI) meeting and stated he would make sure they discussed this matter in the meeting. 7. Telephone interview with the resident ' s spouse on [DATE] at 12:56 p.m. revealed she had been married to resident #1 for [AGE] years. She stated her husband was okay when she left him Wednesday afternoon ([DATE]) so she really didn ' t expect the call on [DATE]. He had been making some progress in therapy but it was hard to tell due to dementia and weakness in his legs. The staff encouraged him to walk and he was, but he couldn ' t get out of the chair by himself. She recalled someone from the facility calling her around 6:30 a.m. on [DATE]. They said they were sorry but he had passed in his sleep. The staff did not mention that they didn ' t attempt CPR on him. He did not have any orders to withhold CPR. She stated she had power of attorney for the resident with an understanding of health care surrogate but not a separate document as far as she can remember. She does not recall facility staff discussing a do not resuscitate (DNR) order with her. 8. Review of the resident ' s clinical record revealed an Admission Record Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. A review of the physician orders [REDACTED]. Review of the facility ' s Advance Directives/Informed Consent form revealed the resident ' s spouse had signed this acknowledgement form on [DATE] on behalf of the resident and indicated that the resident had a living will, durable power of attorney (POA), and designation of health care surrogate. No other advance directives were checked off on this form including do not resuscitate. Continued review of the clinical record revealed the following nurses note entries on [DATE]: 2:00 a.m. quietly resting with eyes closed. No complaint of pain or discomfort reported. Vital signs ,[DATE] (blood pressure), 72 (pulse), 24 (respirations), 98.9 (temperature). (Signed by LPN#1) 6:15 a.m. Patient pronounced without respirations, no blood pressure, no heartbeat. (Signed by RN #2) 6:30 a.m. Wife informed and National Cremation Society notified. This writer was informed from lab tech that patient was unresponsive and she was unable to draw labs. This writer went to patient ' s room to find patient lying on his back with mouth open and eyes closed. Patient ' s skin was pale. Cold to touch with mottling noted throughout. Patient was extremely rigid. Vital signs were unobtainable at this time. Doctor was notified of patient ' s condition and history. Orders were received to pronounce and release body at this time. Review of the physician's order [REDACTED]. 9.Interview with the administrator and DON on [DATE] at 8:32 a.m. revealed the facility immediately suspended RN #2 and ultimately terminated her employment following this incident. The DON and administrator stated that every nurse in the building has received re-in-service training on CPR policies and procedures and DNR status. 10. Interview with the staff education coordinator on [DATE] at 2:49 p.m. revealed emergency procedures to include proper response to an unresponsive resident without vital signs has always been part of the orientation and annual review for direct care staff to include licensed nurses and certified nursing assistants. A review of the facility ' s orientation check list verified that this information is covered during orientation/annual review as part of CPR and First-Aide. This procedure includes a mock test to ensure staff understands the subject matter discussed. Prior to this incident on [DATE], staff did not always attend classroom training prior to working on the floor, however, interview with the administrator on [DATE] at approximately 10:30 a.m. reviewed this will change effective immediately to ensure all direct care staff receive classroom orientation to include emergency procedures prior to working on the floor. 11. Review of the facility ' s licensed nurse schedules from [DATE] - [DATE] and the current employee roster revealed the facility has 21 nurses who work at the facility on a regular basis. The LPN involved in the incident received individual coaching and retraining on the CPR policy on [DATE]. Review of the in-service sign in records revealed 11 additional nurses were in-service trained on [DATE], seven received in-service training on [DATE], one was trained on [DATE], and the final one was re-in serviced on [DATE] at 10:30 p.m. Random interviews with nurses were conducted on [DATE] to validate that they had received training and would respond appropriately in the event of a similar incident. Interview with the administrator on [DATE] at approximately 10:30 a.m. revealed the facility held a CQI committee meeting on [DATE] at 1:00 p.m. and is putting the following system in place: Advanced directives will be addressed with the resident upon admission by the nurse, social services or admissions coordinator; advanced directive information to be given upon admission. Resident will be addressed about any advanced directive change within 14 days of admission. Resident will be addressed about any advanced directive changes quarterly. Yellow dots will be added to the residents charts who have a DNR. Residents with DNR ' s will have a yellow wrist band. In-servicing to be provided to licensed staff upon hire during class room orientation prior to working on the floor and annually. Based on the facility ' s systems process, the IJ was abated on [DATE] and the severity and scope reduced to D.

Based on clinical record review, review of policies and procedures for cardio-pulmonary resuscitation, review of statements and from facility staff, and interviews with facility staff, it was determined that administration failed to provide resource management to meet the needs for one (#1) of 39 facility wide residents who were full code according to the [DATE] midnight census. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. This related to not implementing policies and procedures for advanced directives and failure to administer CPR. Failure to ensure that staff would properly implement training on emergency policies and procedures led to neglect of one resident when staff did not perform CPR and call for Emergency Medical Services (EMS/911). These actions resulted in findings of immediate jeopardy, which were removed on [DATE] at 10:30 p.m. Findings included: 1. Review of the job description for the Administrator, signed by the administrator with no date but with an updated form date of [DATE] revealed the following " Summary: " " To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility ' s business objectives. " The following relevant " Essential Duties & Responsibilities: " were also documented as follows: *Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff as deemed necessary. *Monitor each department ' s activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. *Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed. *Maintain a working knowledge of and confirm compliance with all governmental regulations. 2. Review of resident #1 ' s clinical record revealed an Admission Record Face Sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. A review of the physician orders [REDACTED]. Review of the facility ' s Advance Directives/Informed Consent form revealed the resident ' s spouse/responsible party had signed this acknowledgement form on [DATE] on behalf of the resident. The form was checked to indicate the following advance directives were in place: living will, durable power of attorney (POA), and designation of health care surrogate. These advance directives were present in the clinical record; however, no other advance directives were checked off on this form or found in the clinical record. No orders to withhold cardio-pulmonary resuscitation were expressed or documented. No do not resuscitate orders (DNR) were present. Continued review of the clinical record revealed the following nurses note entries on [DATE]: 2:00 a.m. quietly resting with eyes closed. No complaint of pain or discomfort reported. Vital signs ,[DATE] (blood pressure), 72 (pulse), 24 (respirations), 98.9 (temperature). (Signed by LPN#1) 6:15 a.m. Patient pronounced without respirations, no blood pressure, no heartbeat. (Signed by RN #2) 6:30 a.m. Wife informed and National Cremation Society notified. This writer was informed from lab tech that patient was unresponsive and she was unable to draw labs. This writer went to patient ' s room to find patient lying on his back with mouth open and eyes closed. Patient ' s skin was pale. Cold to touch with mottling noted throughout. Patient was extremely rigid. Vital signs were unobtainable at this time. Doctor was notified of patient ' s condition and history. Orders were received to pronounce and release body at this time. (Signed by LPN #1) Review of the physician's order [REDACTED]. 3. Telephone interview with the resident ' s spouse on [DATE] at 12:56 p.m., revealed she had been married to resident #1 for [AGE] years. She stated her husband was okay when she left him Wednesday afternoon ([DATE]) so she really didn ' t expect the call on [DATE]. He had been making some progress in therapy but it was hard to tell due to dementia and weakness in his legs. The staff encouraged him to walk and he was, but he couldn ' t get out of the chair by himself. She recalled someone from the facility calling her around 6:30 a.m. on [DATE]. They said they were sorry but he had passed in his sleep. The staff did not mention that they didn ' t attempt CPR on him. He did not have any orders to withhold CPR. She stated she had power of attorney for the resident with an understanding of health care surrogate but not a separate document as far as she can remember. She could not recall facility staff discussing a do not resuscitate (DNR) order with her. 4. Interview with the facility ' s director of nursing (DON) on [DATE] at 1:17 p.m. revealed it is her normal procedure to review the clinical record for any death occurring in the facility. At approximately 8:30 a.m. on [DATE] she reviewed the record of resident #1 who had expired in the facility on [DATE] at approximately 6:15 a.m. Upon review of this record, the DON realized the facility did not have the appropriate documentation to withhold CPR for resident #1. The DON informed her administrator and they initiated an investigation into the events surrounding the death of resident #1. 5. Interview with the administrator and director of nursing on [DATE] at 8:32 a.m. revealed the following information was found during their investigation: The licensed practical nurse (LPN #1) assigned to resident #1 on the 11:00 p.m. - 7:00 a.m. shift on [DATE] found resident #1 unresponsive with no pulse and no respirations around 6:00 a.m. on [DATE]. The LPN proceeded to get the Registered Nurse (RN #2) supervisor to assess the resident. The RN determined that rigor mortis had set in, the resident was mottled all over, and ice cold. The LPN then called the resident ' s physician and provided him with the resident ' s history. The physician gave permission to pronounce the resident and release the body. The spouse of the resident was also notified. The resident was originally admitted for rehab with the hopes of returning back to an assisted living facility (ALF). However, after a couple of weeks in the facility it became apparent that the resident ' s dementia was advanced and he was declining. The administrator and the resident ' s spouse had discussed long term placement in the facility the same week this incident occurred. The resident was a full code and CPR was not started and 911 were not called. 6. A review was made of the facility ' s policy, " Emergencies " dated [DATE] page E-11a. This policy states it is the intent of this faciity to respond to emergencies in accordance with our procedures and Standards of Practice. The procedures portion of this policy included the following relevant bullet points: 1. Resuscitation Nursing Services P&P Manual 2R-1 3. Call 911 for services of life threatening issues Review of the " Resuscitation (Cardio-Pulmonary) " policy and procedure referenced above in bullet #1 (revised [DATE], page 2R-1) documented " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resusciation (DNR) for the issuance of an order not to resuscitate. " A review of the Do Not Resuscitate (DNR) policy labeled " Nursing Services Policy & Procedure Manual Advance Directives-Florida " page 2A-7 revealed the following statement: " Regardless of whether the resident is in a persisitent vegetative state or has a terminal conditon, all facility ' s residents shall receive full resuscitative measures unless a DNR directive is written in the resident ' s medical record and is identified in the resident ' s Advance Directive. " Continued investigation and review of the " Cardio [MEDICAL CONDITION] Resusciation (CPR) policy and procedure with an effective date of [DATE], Policy No: N.C-077 revealed the following " essential points " on page 2 of 2: " Once CPR is initiated, it must be continued until help arrives. 7. Further investigation and interview on [DATE] at 9:39 a.m. with LPN #1 revealed that around 6:00 a.m. on [DATE] a lab technician was here to draw blood on resident #1. The lab tech came to this nurse and informed her she could not arouse resident #1 and could not perform the procedure unless she spoke to the resident. The LPN then went down to see the resident and upon observation indicated he had obviously expired. He was very stiff, had no pulse, no respirations, and was mottled all over. The LPN then went across the building to nurses ' station 2 which is where the crash cart is kept. Along the way the RN supervisor stopped her and asked what was going on. The LPN informed the RN, and the RN locked her medication cart up and went with a stethoscope to assess the resident. The RN stated to her there ' s no need for CPR, he is more than expired. The LPN then proceeded to call the resident ' s physician and inform him of what was going on. She gave the doctor the resident ' s medical history but could not recall the specifics of what was discussed. The LPN stated the doctor said they can pronounce and release the body. She then phoned the wife and informed her of what had transpired. The LPN was aware that resident #1 was a full code, as she checked his chart, and stated she was going to start CPR but when stopped by the RN supervisor she went with the RN ' s conclusion that no CPR needed to be done. 8. Review of a written statement by RN #2 dated [DATE] revealed the following: At about 6 AM - 6:30 AM, as I was giving out my 6 AM medications, the nurse from Station I came over to me with her stethoscope around her neck and stated the lab tech was unable to arouse a patient. The nurse stated that he had passed away but was a full code. I went over and the patient was cold, mottled from the thighs to feet and total arm mottled, mouth opened, mouth, lips, and nail beds purplish-mouth opened and dry. Up to this point no CPR or 911 had not been called. I felt the patient and he was rigid and had no respirations and no apical heartbeat. " I pronounced the patient. " Doctor and family were called. Telephone interview with RN #2 on [DATE] at 2:36 p.m. revealed between 6 and 6:30 a.m. on [DATE] she was on station 2 passing meds. Nurse from station one told me resident had passed away, he ' s a full code. I looked at him; he was cyanotic from fingers to arm pits, toes to thighs. He was cold. I couldn ' t see performing CPR on a dead person. He had no pulse, no respirations. His mouth was open, gaped, and dried. His nail beds were cyanotic. The doctor was called and gave permission to pronounce and the wife was called and said she had already said her goodbyes. RN #2 went on to state I didn ' t start CPR like I should have and CPR had not been started either. What happened was the lab could not arouse him. The LPN checked him and then came to me as the RN supervisor. 9. Interview with the resident ' s physician on [DATE] at 12:37 p.m. revealed he recalled the LPN calling him on the day of the incident and informing him they found the resident dead. He was familiar with the resident ' s history but could not remember if the facility staff had informed him of the resident ' s code status when they initially called. He was under the assumption at that time that the resident was a DNR but he didn ' t ask the nurse. Because the resident did not have a DNR order the expectation would be to start CPR and call paramedics. He signed the resident ' s death certificate and believed the death was due to natural causes. This doctor also serves as the medical director of the facility. He was not aware of any other similar cases at this facility of failure to perform CPR. He was present in the facility on [DATE] for the Continuous Quality Improvement (CQI) meeting and stated he would make sure they discussed this matter in the meeting. 10. Interview with the administrator and DON on [DATE] at 8:32 a.m. revealed the facility immediately suspended RN #2 and ultimately terminated her employment following this incident. Review of a statement prepared by the director of nursing on [DATE] relating to the termination of RN#2 revealed that on [DATE] the facility concluded their investigation involving resident #1 and determined that this nurse acted prudent in her decision making and exercised good judgment in the care provided to this resident at the time she was called to the room. The facility did not identify this action as neglect. A review of the resident ' s medical record and conversation with the medical doctor determined that the outcome would have been the same for the resident. RN#2 was terminated based on interview with other staff present at the time of the incident and her lack of cooperation during the investigation. The DON and administrator stated on [DATE] at 8:32 a.m. that every nurse in the building had received re-in-service training on CPR policies and procedures and DNR status. 11. Verification of the re-in-service records was made through review of the facility ' s licensed nurse schedules from [DATE] - [DATE] and the current employee roster. This information revealed the facility has 21 nurses who work at the facility on a regular basis. The LPN involved in the incident received individual coaching and retraining on the CPR policy on [DATE]. Review of the in-service sign in records revealed 11 additional nurses were in-service trained on [DATE], seven received in-service training on [DATE], one was trained on [DATE], and the final one was re-in serviced on [DATE] at 10:30 p.m. . The final nurse receiving the training had worked 6 shifts from 11:00 p.m. - 7:00 a.m. prior to receiving the re-in-service training. Specifically, this nurse was documented as working on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Random interviews with nurses were conducted on [DATE] to ensure they had received the re-in-service training and would respond appropriately in the event of a similar incident. No problems or discrepancies were identified during these interviews. Interview with the administrator on [DATE] at approximately 10:30 a.m. revealed the facility held a CQI committee meeting on [DATE] at 1:00 p.m. and is putting the following system in place: Advanced directives will be addressed with the resident upon admission by the nurse, social services or admissions coordinator; advanced directive information to be given upon admission. Resident will be addressed about any advanced directive change within 14 days of admission. Resident will be addressed about any advanced directive changes quarterly. Yellow dots will be added to the residents charts who have a DNR. Residents with DNR ' s will have a yellow wrist band. In-servicing to be provided to licensed staff upon hire during class room orientation prior to working on the floor and annually. Based on the facility ' s systems process, the IJ was abated on [DATE] at 10:30 p.m. and the severity and scope reduced to D.