Every finding on record at Springs at Boca Ciega Bay

Based on record review and interviews, the facility failed to ensure an injury of unknown source-an acute right subcapital femoral neck fracture, was reported to the Agency for Healthcare Administration (AHCA), Adult Protective Services (APS), and local law enforcement within 24 hours of becoming aware of the X ray results, for one resident (#2) of six sampled residents. Findings included: Record review showed Resident #2 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included cerebrovascular disease, prior intracerebral hemorrhage, hypertension, dysphagia, hemiplegia following cerebral infarction, and a need for extensive assistance with personal care.A Brief Interview for Mental Status (BIMS) dated 08/29/2025 documented a score of 6, indicating severe cognitive impairment.Review of the facility's event log (03/01/2026-05/16/2026) showed:04/08/2026: Unwitnessed fall with a skin tear to the left elbow; no additional injuries documented.04/28/2026: Unwitnessed fall; nursing assessment documented no injuries. On 06/15/2026 at 3:30 p.m., the Director of Nursing (DON) confirmed these assessments.On 06/15/2026 at 10:01 a.m., a phone interview with the resident's family member/POA revealed: On 05/03/2026, the resident had extreme pain. Hospice was contacted to assess the resident. The family insisted on an X ray. Hospice crisis care evaluated him, provided pain management, and ordered an X ray. Hospice later informed the family that the X ray revealed a fracture in the upper right thigh. The family member reported the nursing home's demeanor changed following this discovery, becoming cold.Record review showed an X ray procedure (Hip unilateral with or without pelvis, 2-3 views) completed on 05/06/2026 at 23:17 and reported on 05/07/2026 at 4:39 a.m.Final Radiology Report Findings showed an Acute right subcapital femoral neck fracture, 1/2 shaft-width superior lateral displacement, Soft tissue swelling; no dislocation and Bony demineralization.On 06/15/2026 at approximately 3:30 p.m., interviews were conducted with the Nursing Home Administrator (NHA) and the DON. The DON stated the family reported the resident's pain on 05/04/2026, prompting hospice involvement on 05/04, 05/05, and 05/06/2026. The DON stated she physically assessed the resident on 05/06/2026 but did not document the assessment. The DON confirmed she reviewed the X ray results on 05/07/2026 in the morning. The physician reviewed the X ray at approximately 8:30 a.m. on 05/07/2026 and concluded the fracture was pathological. The NHA stated she became aware of the fracture on her way to work on 05/07/2026. She stated she did not report it because the physician believed the fracture was pathological and she had no indication of abuse or neglect.Record review and interviews showed despite the facility becoming aware of the acute fracture on 05/07/2026, there was no evidence the injury was reported to AHCA, APS, or law enforcement within 24 hours as required for injuries of unknown source.Review of the facility's undated Abuse, Neglect, Exploitation & Misappropriation policy showed: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and / or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. The Abuse Coordinator/ designee shall report any alleged violations of abuse or serious bodily injury immediately, but no later than 2 hours to the Agency for Health care Administration, the Adult Protective Services, and the local law enforcement if they feel a crime has occurred. If the alleged violation involves neglect, misappropriation of resident property, exploitation or injuries of an unknown source and involves no serious bodily injury, it must be reported no later than 24 hours.

Based on record review and interview, the facility failed to implement a care planned intervention for the use of floor mats for one resident (Resident #2) of six sampled residents. Resident #2's care plan included the use of floor mats when the resident was in bed; however, the intervention was not in place at the time of the resident's fall on 04/08/2026.Findings included: Record review showed Resident #2 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included, but were not limited to, cerebrovascular disease; urinary tract infection; nontraumatic intracerebral hemorrhage, unspecified; personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits; atherosclerotic heart disease of native coronary artery without angina pectoris; cervical spondylosis without myelopathy or radiculopathy; essential hypertension; dysphagia following cerebral infarction; hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side; need for assistance with personal care; and syncope and collapse.A review of the Brief Interview for Mental Status (BIMS) dated 08/29/2025 documented a score of 6, indicating severe cognitive impairment.The resident's care plan, initiated 08/29/2025, identified a problem of risk for falls or fall related injury related to deconditioning, gait and balance problems, dementia, and a history of falls. The goal, initiated 08/31/2025, stated the resident would not sustain serious injury through the review date. Interventions included the use of floor mats when the resident was in bed, initiated 09/29/2025.On 06/15/2026 at approximately 3:30 p.m., an interview was conducted with the Director of Nursing (DON), with the Nursing Home Administrator present. The DON reported Resident #2 had two falls in April 2026, on 04/08 and 04/28. During review of the 04/08/2026 fall event, the DON stated the fall occurred at 5:30 a.m., was unwitnessed, and occurred from the bed to the floor. The bed was in low position. The resident sustained a skin tear to the left elbow. The DON stated, He did not have mats.Review of the facility's Resident Assessment Instrument (RAI) Comprehensive Care Plan Policy, effective 09/2024, documented: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes.

Based on observation, record review, and interviews, the facility failed to provide adequate supervision to reduce the risk of accidents for one resident (#3) of six sampled residents. Resident #3 experienced six falls between 05/13/2026 and 06/06/2026. Only four of the falls were recorded in the facility's fall log, and the required post fall investigations and care plan revisions were not consistently completed.Findings included: On 06/15/2026 at 1:23 p.m., Resident #3 was observed seated in a wheelchair as family members prepared to take the resident on a leave of absence. Record review showed Resident #3 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, encephalopathy, paroxysmal atrial fibrillation, need for assistance with personal care, and a cognitive communication deficit. A Brief Interview for Mental Status (BIMS) dated 05/07/2026 documented a score of 1, indicating severe cognitive impairment.A review of the care plan revealed a problem area identifying the resident as being at risk for falls related to deconditioning, gait and balance problems, a history of falls, vertigo, and left side weakness, initiated on 05/06/2026. The goal stated the resident would not sustain serious injury through the review period.Interventions included:Encourage resident to remain in common areas while awake (05/13/2026).Medication adjustments for restlessness (05/25/2026).Clinical workup/treatment for UTI (urinary tract infection) (06/08/2026).Encourage participation in exercises/activities to improve mobility (05/14/2026).Psych services for medication review (05/15/2026).Call light within reach and encourage use (05/06/2026).Safety education to resident/family (05/14/2026).Encourage keeping bed in low position (05/14/2026).Ensure appropriate footwear/non skid socks (05/06/2026).Orientation to surroundings (05/06/2026).PT (physical therapy) evaluation/treatment as ordered (05/06/2026). A second care plan focus area identified an ADL(activity of daily living) self care deficit, including interventions for wheelchair locomotion, assistance with bed mobility, dressing, eating, hygiene, toileting assistance by one staff for toileting, transfer assistance by two staff, participation encouragement, and monitoring for changes in function; initiated on 05/06/2026.The facility's fall log dates (03/01/2026-06/15/2026) listed four falls for Resident #3: 05/13 at 3:31 p.m., unwitnessed 05/14 at 7:40 p.m., unwitnessed 05/15 at 3:06 p.m., witnessed 05/23 at 6:00 p.m., unwitnessedRecord review showed two additional falls, on 06/01/2026 and 06/06/2026, that were not recorded on the fall log.Record review of nursing documentation (05/01/2026-06/15/2026) revealed two documented falls:On 05/13/2026, 15:39: Resident found lying on left side on floor mat next to bed. Resident stated he was trying to get in bed. No injury. Provider and family notified.On 05/23/2026, 19:28: Resident found sitting on buttocks on floor mat next to bed with linens around legs. No injury. Provider and family notified.The record review revealed the following: No nursing note for 05/14/2026 at 7:40 p.m. fall. No nursing note for the 05/15/2026 fall at 3:00 p.m. No IDT (interdisciplinary) meeting note for the 05/23/2026 fall. No nursing notes for 06/01/2026 or 06/06/2026 falls. No IDT review documented for the 06/01/2026 or 06/06/2026 falls.Review of a progress note dated 05/15/2026, 9:04 a.m. entryshowed: IDT documented a review of a recent fall, but the note did not identify which fall (05/13 or the fall on 05/14). On 06/15/2026 at approximately 3:00 p.m., the Director of Nursing (DON), with the Nursing Home Administrator present, was interviewed regarding the fall investigations. The DON stated the 05/13/2026 fall occurred when the resident attempted to get into bed from his wheelchair, and the intervention added was encouraging the resident to remain in common areas when awake. The DON stated the 05/14/2026 fall occurred when the resident attempted to make his bed and sustained a skin tear. The DON stated the 05/15/2026 fall was witnessed by a nurse, but documentation did not indicate the bed height. The DON stated the 05/23/2026 fall had no documented bed height and that care planned interventions were expected to be in place. The DON stated the 06/01/2026 fall occurred when family attempted to transfer the resident without staff, and the intervention added was education for the family. The DON stated the 06/06/2026 fall occurred when the resident attempted to transfer from the wheelchair to the bed and stated the low bed height does not have anything to do with this fall, noting the only intervention implemented was treatment for a urinary tract infection.A review of the facility's Risk Management - Fall Risk Reduction Program policy, undated, documented that residents at risk for falls would be identified and individualized interventions implemented, underlying medical issues addressed, the effectiveness of interventions evaluated, and all resident falls reviewed by the interdisciplinary team. The procedure required documentation of circumstances of each fall, including resident position, environmental factors, condition prior to the fall, witness statements, and implementation of new strategies to prevent recurrence.

Based on record review and interviews, the facility failed to ensure a resident experiencing a new onset of significant pain was assessed, had pain characteristics documented, and the pain was reported to the physician and hospice in a timely manner for one resident (#2) of six sampled residents. Findings included:A review of Resident #2's clinical record showed a documented new onset of pain on 05/03/2026 at 5:57 p.m., rated 8/10, with no documented anatomical location and no documented physician notification. On 05/04/2026 at 5:01 p.m., pain was documented as 7/10, and on 05/05/2026 at 11:29 a.m., as 10/10, again with no anatomical location documented and no evidence of physician notification.Review of nursing documentation on 05/05/2026 at 11:29 a.m. showed communication with hospice. An X-ray was ordered on 05/06/2026, with results on 05/07/2026, identifying an acute right subcapital femoral neck fracture. A final Radiology Report Findings showed an Acute right subcapital femoral neck fracture, 1/2 shaft-width superior lateral displacement, Soft tissue swelling; no dislocation and Bony demineralization.A review of nursing notes from 04/01/2026 through 05/16/2026 revealed no nursing notes documented between: 04/01-04/09; 04/10-04/28 and 04/30-05/04.Additionally, there were no assessments documented in the Evaluation Record from 05/02/2026 through 05/14/2026.A review of the Medication Administration Record for May 2026 confirmed administration of as needed Oxycodone for documented pain levels ranging from 4-10 between 05/03/2026 and 05/13/2026. The pain levels were documented as follows:05/03 at 1957, with a pain level of 805/04 at 1701, with a pain level of 705/05 at 1615, with a pain level of 405/06 at 0021, with a pain level of 005/06 at 0431, with a pain level of 805/05 at 1129, with a pain level of 1005/06 at 1553, with a pain level of 6.05/07 at 0000, with a pain level of 805/07 at 0457, with a pain level of 805/08 at 0527, with a pain level of 1005/13 at 1542, with a pain level of 8The resident's Care Plan, initiated 08/31/2025 and 12/08/2025, directed staff to: Observe, document, and report pain characteristics (quality, severity, anatomical location, onset, duration, aggravating/relieving factors). Observe and report signs of non verbal pain. Notify the physician immediately for breakthrough pain.Record review showed these interventions were not followed, as documentation lacked to show the required pain characteristics were documented to include timely physician notifications.Review of progress notes dated 05/05/2026, 11:19 a.m. showed, met with resident's [family member], reports resident continues with pain. Requested Hospice visit to readdress chronic pain. Hospice notified will send nurse out. On 05/06/2026, 10:45 a.m. Resident with continued pain control, Hospice team making real time adjustments to around fluctuations in pain. A review of Resident #2's Evaluation record revealed there were no assessments documented for the reviewed periods of 04/30/2026 through 05/04/2026 and 05/02/2026 through 05/14/2026.During a phone interview on 06/15/2026 at 10:01 a.m., Resident #2's family member and health care power of attorney reported the resident was in extreme pain on 05/03/2026. The family contacted hospice and requested an X-ray. Hospice provided crisis care and pain management. The family reported the fracture was identified, and soon after, interactions with facility staff felt cold.On 06/15/2026 at approximately 3:30 p.m., the Director of Nursing (DON) reported the family informed her on 05/04/2026 of the resident's increased pain and requested hospice involvement. The DON stated hospice evaluated the resident on 05/04, 05/05, and 05/06, making adjustments to pain medication. She reported she completed a physical assessment on 05/06, though no documentation of this assessment was present in the record. The DON confirmed the physician did not see the resident until 05/07, when X-ray results were available.The facility did not provide a policy related to the stated concerns.

Based on observations, interviews, and record review, the facility failed to ensure advanced directive wishes and physician orders were followed for one resident (#1) out of six residents sampled for advanced directives.On [DATE], facility staff initiated cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) on Resident #1 after determining no pulse or respirations. The resident had wishes to not be resuscitated and had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. Paramedics ceased chest compressions and Resident #1 expired. Cardiac compressions were provided to Resident #1 for approximately twenty minutes. The facility staff failed to honor Resident #1's advanced directive wishes and physician signed DNR order, dated [DATE], which was uploaded into the resident's record. The failure to ensure staff honored Resident #1 advanced directive wishes caused unnecessary physical harm and pain and denied Resident #1 a peaceful death.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F600, F678, and F726.Findings Include: A review of Resident #1's admission record revealed an initial admission to the facility on [DATE], and a re-admission on [DATE] with diagnoses to include myasthenia gravis without (acute) exacerbation, immunodeficiency, unspecified, chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, peripheral vascular disease, unspecified, personal history of transient ischemic attack (tia), cerebral infarction without residual deficits, and adult failure to thrive. A review of Resident #1's physician orders included the following:Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE].Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE].Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, changed to DNR.Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, Resident is DNR status. The order was created on [DATE] at 3:04 p.m., by Staff A, Licensed Practical Nurse (LPN). The order was discontinued by Staff I, Registered Nurse (RN) on [DATE] at 7:31 a.m. A review of Resident #1's care plan revealed the following: Resident has the capacity to make health care decisions and has signed a DNR Date Initiated: [DATE] Revision on: [DATE], with interventions to include, Placed signed DNR under Advanced Directives tab in the MISC [miscellaneous] section of the Electric medical record. Date Initiated: [DATE] Revision on: [DATE]. A review of Resident #1's progress notes revealed the following: [DATE] encounter, .Patient wishes to change his CODE STATUS to DNR. DNR is documented in [hospital name] Type of care preferred: --Patient wishes to be transferred to the hospital in case of medical emergency. --Patient will appoint healthcare surrogate -- Patient's family will bring DNR paper but will communicate with social worker to follow.[DATE] nursing note, Notified By Social services that Resident Code Status Updated to DNR. Orders Updated.[DATE] change in condition note at 3:00 p.m., The Change In Condition/s reported . Abnormal vital signs (low/high BP [blood pressure], heart rate, respiratory rate, weight change) Respiratory arrest Shortness of breath At the time of evaluation resident/patient vital signs, weight and blood sugar were: . - Pulse: P 72 - [DATE] 03:12 Pulse Type: Regular - Pulse Oximetry: O2 55 % - [DATE] 15:00 [3:00 p.m.] Method: Oxygen via Nasal Cannula . Code Status: Do Not Resuscitate (DNR) . Nursing observations, evaluation, and recommendations are: hypoxic, transfer to ER [emergency room] . Primary Care Provider responded with the following feedback: A. Recommendations: transfer to ER .[DATE] nursing note at 4:40 p.m., Note Text: 1500 Writer called in to resident room for C/O [complaint of] cough, SOB [shortness of breath], resident noted in bed, awake looking unwell and c/o SOB, vitals measured, hypoxic, SPO2 [oxygen saturation] 55% highest, [Staff G, Nurse Practitioner (NP)] contacted and agrees to send to ER, paramedics arrived, resident expired during workup. Family, [Staff G, Nurse Practitioner] and funeral home contacted. Remains picked up at 1640. [4:40 p.m.] A review of Resident #1's evaluations/assessments revealed the following: [DATE] advance care planning discussion/review, b. readmission . 1. Code status b. Florida Do Not Resuscitate. A review of Resident #1's miscellaneous documents revealed the following:State of Florida DNR order, dated [DATE], with Resident #1 and the physician's signature was scanned into the electronic health record on [DATE] at 3:02 p.mXXX[DATE] inpatient hospitalist progress note, Internal Medicine Inpatient Note . Admission/Discharge [DATE] - Present . Admitting Diagnosis: SEVERE SEPSIS, PNA [pneumonia] . ***CODE STATUS DNR . Nutrition: Continue pureed diet. Patient cannot tolerate thickened liquids. on thin liquids for comfort care. Patient is aware of the risk of aspiration. He does not want PEG [percutaneous endoscopic gastrostomy] tube. NUTRITION REASSESSMENT . [DATE]: . Per inpatient hospitalist progress note dated [DATE], pt has opted to liberalize his diet for quality of life purposes. Pt agreed this date that this is still in line with his current preferences. On [DATE] at 12:03 p.m., an interview was conducted with Staff D, LPN. She said the most recent actual code blue was with Resident #1. She said on [DATE], she overheard a conversation that someone needed a non-rebreather mask. She said she was assisting another resident at the time, and a Certified Nursing Assistant (CNA) told her she was needed on the other side of the facility. She stated it, Made me think something was going on. Staff D, LPN said she went to the long-term care side of the facility and saw a crash cart outside the door of Resident #1's room. She said Staff A, LPN was doing chest compressions. Staff D, LPN said she gave the non-rebreather mask to Staff N, Registered Nurse (RN). She recalled connecting the mask to the oxygen tank, then heard Staff A, LPN say she needed to switch, and Staff D, LPN took over chest compressions. Staff D, LPN said Staff E, LPN relieved her and started doing chest compressions. She said a few minutes later, as Staff E, LPN was doing chest compressions, the paramedics arrived. She said Staff E, LPN continued chest compressions, per the paramedics' advisement, and she left the room. Staff D, LPN said she went to complete the transfer paperwork to include the face sheet, medication list, and transfer to hospital form. She said she noted Resident #1 was not a full code. She stated, When I noted he was a DNR, [Staff E, LPN] and [Staff N, RN] were coming out of the room, paramedics had taken over. Staff D, LPN stated she asked Staff N, RN, Why did we do CPR on a DNR. She said she asked Staff N, RN to talk to the paramedics, while Resident #1's DNR form was printed and provided to the paramedics. She stated, They would not stop until they had the physical DNR in hand. Staff D, LPN said she did not know who initiated compressions and assumed someone checked Resident #1's code status. She stated, The nurse was to check the code status, then to initiate or not to initiate. She said the assigned nurse is expected to check the resident's code status. On [DATE] at 12:52 p.m., an interview was conducted with Staff E, LPN. He said the last time there was an actual code blue was about a month ago, and confirmed it was for Resident #1. He said he went into Resident #1's room, observed he was not doing well, and called the provider for orders to transfer him to the hospital. Staff E, LPN confirmed on [DATE] he was Resident #1's assigned nurse. He said after he received orders from Staff G, NP to transfer him to the hospital, he prepared paperwork to include discharge documents, the face sheet, and the medication list. He stated, As I was going to my desk someone was getting the crash cart and going to my patient's room. Staff E, LPN stated the code blue was not called overhead and, It was a big to-do. He said he went to Resident #1's room, observed the resident was on the floor, and staff were doing compressions. He said Staff N, RN was in the room and Staff A, LPN was doing chest compressions. Staff E, LPN confirmed himself, Staff A, LPN, Staff D, LPN did chest compressions, and thought Staff N, RN did as well. He said the first person he observed doing chest compressions was Staff A, LPN, followed by Staff D, LPN, and then himself. He confirmed Resident #1 had physician orders for DNR but did not know at the time chest compressions were done. Staff E, LPN said he did not notice the resident was a DNR because it was not on the face sheet. He stated, Someone must have said something about the resident being a DNR, and could not recall who said that. He said when the paramedics arrived, they took over CPR. He stated, By that time it was known he was a DNR, they [paramedics] could not stop until they had the yellow DNR sheet. He said the resident passed away. On [DATE] at 1:23 p.m., an interview was conducted with Staff C, RN. She stated on [DATE] she was in her office and heard a commotion, then responded to Resident #1's room. She said when she arrived, Things were taking place. She said she saw a crash cart, staff present were suctioning Resident #1, and he was lowered to the ground. She stated her part in the code blue was minimal, Nothing at all. Staff C, RN stated the commotion she heard was staff saying, We need help, call 911. She said she observed Staff N, RN suctioning Resident #1, and was leading the code. Staff C, RN said Staff B, CNA were assisting and moving items out of the way, and Staff A, LPN was following guidance from Staff N, RN. She said Staff A, LPN started chest compressions, after being instructed by Staff N, RN. She said she did not hear a code blue was called. She confirmed Resident #1 was a DNR. Staff C, RN stated she knew his code status because Resident #1 was her, Customer service resident, and she was present during his care plan meetings and Minimum Data Set (MDS) admission assessments. She said she had not checked his code status that day and, It could have changed. On [DATE] at 4:29 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the facility's response and investigation related to Resident #1. She said on [DATE] Staff P, CNA answered Resident #1's call light and he expressed feeling shortness of breath (SOB). She said Staff P, CNA told Staff E, LPN who went to check Resident #1's vital signs and determined his oxygen saturation was low. The NHA said Staff E, LPN contacted the provider and received orders to transfer the resident to the hospital. She said Staff E, LPN told the Staffing Coordinator to tell the nurse manager at the time, Staff N, RN, that he was transferring the resident to the hospital. She said Staff N, RN went to Resident #1's room and checked his oxygen saturation twice with the same result, which was 73%. The NHA said Staff N, RN had taken the crash cart to the room with her. She said Staff E, LPN left Resident #1's room to prepare transfer paperwork to include the medication list, face sheet, and the hospital transfer form with the change in condition documented. The NHA said Staff N, RN started suctioning Resident #1 because he was drooling, while suctioning he had agonal breathing (Insufficient breathing that sounds like snorting, gasping, or labored breathing, and indicates that someone is suffering from a medical emergency. The person can appear to be choking or having an involuntary gasp reflex.), then stopped breathing. She said Staff A, LPN came into the room, checked Resident #1's pulse, did not find a pulse and Staff N, RN instructed Staff A, LPN and Staff B, CNA to transfer Resident #1 to the floor to start chest compressions. The NHA said Staff D, LPN came into the room and took over chest compressions from Staff A, LPN. She said Staff E, LPN came back to the room, while they were waiting for paramedics, and he took over chest compressions for Staff D, LPN. She said they switched to Staff A, LPN, who was doing the chest compressions when paramedics arrived. The NHA said after the paramedics took over, Staff C, RN had gone to Resident #1's room and left to confirm his code status. The NHA said Staff C, RN heard Staff E, LPN, Staff D, LPN, and Staff N, RN, who were at the nurse's station say, He's a DNR. She said Staff N, RN took the DNR paper to the paramedics who stopped compressions. She said at approximately 3:45 p.m., Staff C, RN informed her CPR had occurred. She said the facility policy is if a resident was unresponsive, staff should assess them and determine their code status. The NHA said if a resident had orders for a DNR, the expectation is not to do chest compressions and ensure they are comfortable. The NHA confirmed she interviewed all the staff involved and they confirmed they were instructed/directed by Staff N, RN to start compressions. She stated, Their thought process was the resident was a full code. She said it had always been the process for the nurse to verify the code status in the electronic health record in the physician orders and dashboard. The NHA said there had been no changes implemented to following orders for advance directives and code blue response process after the incident with Resident #1. On [DATE] at 8:31 a.m., a telephone interview was conducted with Staff A, LPN. On [DATE], she said a CNA came and told her Staff N, RN needed assistance. She said the code blue was not called overhead. Staff A, LPN stated when she arrived to Resident #1's room a, Code was in progress, as the crash cart was there. She said she checked Resident #1's pulse. She said Staff N, RN was in the room at that time along with other CNAs, who she could not recall their names. She said Staff N, RN instructed her to put Resident #1 on a back board, then to put him on floor with the assistance of three CNAs. Staff A, LPN said Staff N, RN told her to start chest compressions. She said Staff N, RN was directing everyone during the code. She said she did not confirm Resident #1's code status as Staff N, RN had sent a CNA specifically asking for a nurse, therefore she started chest compressions as directed. Staff A, LPN said Staff D, LPN came in and relieved her, then Staff E, LPN continued chest compressions. She said she did not remember who was doing chest compressions when paramedics arrived and could not recall how many rounds she completed. She said she switched out once. On [DATE] at 9:42 a.m., a follow-up interview was conducted with Staff D, LPN. She said the facility does not keep a code status book at the nurse's station. She stated, Everything is on the computer. On [DATE] at 10:24 a.m., a follow-up interview was conducted with the NHA, Regional Director of Operations, and Regional Director of Clinical Services. The NHA reviewed the facility's investigation file and read witness statements that revealed Resident #1 was observed earlier in the day on [DATE] wearing oxygen, sounded congested, and was alert/talking. Later in the shift, the resident complained of difficulty breathing and was noted to remove his oxygen, as he expressed it was not helping. Staff Q, CNA and Staff P, CNA both reported notifying Staff E, LPN of the Resident #1's respiratory distress, after which nursing staff responded. Staff N, RN reported responding to the room at approximately 3:10 p.m., after being notified that assistance was needed. Upon her arrival, the resident was drooling and appeared to be in respiratory distress. Staff N, RN directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, lowered to the floor, and chest compressions were initiated. Staff N, RN said the resident's code status was not verified prior to initiating compressions and could not recall who checked for a pulse. Paramedics arrived and compressions were discontinued once documentation confirmed the resident had DNR orders. Staff P, CNA corroborated that Staff N, RN was directing care in the room and that multiple nurses were present when the resident was placed on the floor. Staff C, RN reported arriving during the event, observing the crash cart and suction equipment in use, and questioning the resident's code status. She verified on the computer that the resident had a DNR order and heard a paramedic state Resident #1 was a DNR. Further review of the facility's investigation with the NHA, Regional Director of Operations, and Regional Director of Clinical Services revealed the NHA read a timeline that showed chest compressions were initiated at 3:18 p.m. by Staff A, LPN. EMTs arrived at 3:23 p.m. and instructed staff to continue compressions. EMTs took control of the code at 3:30 p.m. At 3:35 p.m., the resident's DNR status was identified. At 3:38 p.m., Staff N, RN provided the DNR documentation to the EMTs, and chest compressions were discontinued. Chest compressions were performed from 3:18 p.m. to 3:38 p.m., totaling approximately 20 minutes. An interview with the Regional Director of Clinical Services revealed before a code blue or initiating CPR, nurses needed to ask for the residents' code status and determine if that information had been checked. The Regional Director of Clinical Services stated, Everybody walking in should ask, was code status checked? She confirmed that two nurses verifying the resident's code status was not the process/protocol before Resident #1's code blue event. On [DATE] at 11:51 a.m., a telephone interview was conducted with Staff F, Medical Doctor (MD). She confirmed Resident #1 was re-admitted to the facility on [DATE], but she was not the admitting provider or on call. She said a few days after the re-admission, she was called by Staff G, NP who was getting ready to transfer him to the hospital, then Resident #1 passed away. Staff F, MD said she thought Resident #1 had DNR orders. She stated, He did not want anything aggressive, no feeding tube done. Staff F, MD stated, He did not want anything artificial, did not want anything invasive. She said he had myasthenia gravis and he started deteriorating. She said she sent him to hospital on [DATE], to be seen by a neurologist and to determine if the symptoms he was having was related to myasthenia gravis, or something else. She stated he had DNR orders, 99% sure I can tell you. She said if Resident #1's code status had not changed during the admission at the hospital, and his wishes were for DNR, the facility should not have resuscitated him. On [DATE] at 12:13 p.m., a telephone interview was conducted with Staff G, Nurse Practitioner (NP). She said when Resident #1 was re-admitted on [DATE] the nurse called her to let her know the resident was back and they verified admission orders. Staff G, NP said she did not discuss advanced directives but told the nurse to continue whatever orders the resident had from the hospital. She stated, After the hospitalization, whatever wishes he wanted in the hospital it was for the nursing home to follow. She stated she could not remember his code status. She said she recalled a second interaction, when the nurse called and said Resident #1 was in respiratory distress and was doing all possible measures at bedside. She said she told the nurse to call 911 and transfer him to the hospital based on symptoms he was having. Staff G, NP said she did not recall a follow up call after the initial communication with the nurse. She stated, Not sure they mentioned chest compressions during call. Staff G, NP said by the standards of care if a resident had signed orders for DNR, then chest compressions should not be started. A review of the facility policy titled Nursing Policies- Emergency Care (CPR), revealed the following: Policy . The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures, and Florida State law. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order., Procedure . 2. The resident or legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. 3. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident, . 7. Should a resident experience cardiac emergency, staff will refer to the presence of the yellow form signed by the resident and physician, and/or the physicians order to determine if CPR should be performed. A review of the facility policy titled Admission/Social Services - Advance Directives, revealed the following: .Procedure. 5. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident. A review of the facility policy titled Admission/Social Services - Advance Directives - Resident's Right to Make Decision, revealed the following: Purpose . The facility respects the resident's or legal representative's right to make medical treatment decisions and be provided the appropriate information as required under State and Federal Rules and Regulations., A review of the facility policy titled Resident Rights, revealed the following, All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input. The facility's immediate actions to remove the Immediate Jeopardy included: - Disciplinary action/suspension was initiated for two nurses. RN was terminated and reported to Board of Nursing. - Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses. - Ad hoc quality assurance performance improvement (QAPI) meetings held on [DATE] and [DATE] to discuss concern and correction plan. [DATE] Ad hoc meeting held to review IJ citations. Ad Hoc [unplanned/spontaneous] meeting on [DATE] at 1:06 p.m. to discuss additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE) reviewed, approved a code blue worksheet, reviewed and approved an abuse posttest to reinforce prior education. [DATE] Ad hoc at 4:31 p.m. to review, revise and approve code blue worksheet. - [DATE] Post ad hoc- took revised code blue worksheet to units and initiated review of the worksheet with staff. Anyone can complete the code blue worksheet. - Education 100% of nurses on advance directives, resident right to make a decision and emergency care (CPR) and ANE by [DATE]. New licensed staff were educated on abuse and code status upon hire. - 100% of resident medical records were reviewed- code status orders were verified. Audit was conducted of residents who expired in facility in past 90 days with no concerns found related to honoring code status. - Mock code drills were initiated on [DATE] at 4:30 p.m. and continued through current date [DATE] on varying shifts and days. - Code status for all new admissions after [DATE] were reviewed and verified. - [DATE] 23 of 23 nurses received reinforcement of prior education to verify and document code status orders. - [DATE] began implementation of the code drill worksheet and feedback received to add a box for full code/ DNR that can be checked. - [DATE] 69 of 104 non-licensed staff received additional education to evaluate and reinforce prior education on code status, who can perform CPR and emergency care, advance directives and ANE and their role during a code blue. - Education initiated on [DATE] and [DATE] is ongoing and staff will complete reinforcement education prior to working next shift. Verification of the facility's removal plan was conducted by the survey team on [DATE]. - Interviews were conducted with twelve out of twenty-three licensed nursing staff and fifteen out of fifty-one licensed CNA's who worked across all shifts. Interviews were conducted with twenty-four staff members who were considered other licensed clinical (dietitian, social work, therapy) and non-clinical staff. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A review of in-service documentation revealed 100% of staff currently working had completed education and training related advanced directives policy/procedure, identification and responding to change in condition and order evaluation with competency, verifying code status completed by licensed nursing staff, abuse/neglect/exploitation and participation in code blue drills. - On [DATE] at 2:59 p.m., the facility was asked to conduct a blue code drill. Staff were observed promptly announcing overhead, Code blue, after assessing the resident and verifying their code status. Multiple clinical and non-clinical staff responded without delay. The Director of Nursing (DON) was observed leading the drill. Staff arrived with two crash carts, laptops, and one individual scribed the event on the code blue form/timeline. Multiple staff asked about and confirmed the resident's code status demonstrating awareness of the protocol/understanding their roles and responsibilities. Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews, and record review, the facility failed to ensure the residents were free from abuse by performing Cardiopulmonary Resuscitation (CPR) against the resident's wishes for one resident (#1) out of six residents sampled for Advance Directives.On [DATE], Resident #1 experienced a change of status when his oxygen saturation levels dropped to 55% (Normal oxygen saturation levels range from 95%-100%). Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) were initiated by staff. Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the documentation to the paramedics. Paramedics discontinued cardiac compressions. Cardiac compressions were provided to Resident #1 for approximately twenty minutes. The CPR provided for Resident #1 against his wishes, denied him the right to a peaceful death and caused unnecessary physical harm and pain.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F578, F678, and F726.Findings Include: A review of Resident #1's admission record revealed an initial admission to the facility on [DATE], and a re-admission on [DATE] with diagnoses to include myasthenia gravis without (acute) exacerbation, immunodeficiency, unspecified, chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, peripheral vascular disease, unspecified, personal history of transient ischemic attack (tia), cerebral infarction without residual deficits, and adult failure to thrive. A review of Resident #1's physician orders included the following: - Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE]. - Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE]. - Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, changed to DNR. - Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, Resident is DNR status. The order was created on [DATE] at 3:04 p.m., by Staff A, Licensed Practical Nurse (LPN). The order was discontinued by Staff I, Registered Nurse (RN) on [DATE] at 7:31 a.m. A review of Resident #1's care plan revealed the following: - Resident has the capacity to make health care decisions and has signed a DNR Date Initiated: [DATE] Revision on: [DATE], with interventions to include, Placed signed DNR under Advanced Directives tab in the MISC [miscellaneous] section of the Electric medical record. Date Initiated: [DATE] Revision on: [DATE]. A review of Resident #1's progress notes revealed the following: - [DATE] nursing note, PT [patient] received from [hospital name] to room [number] via [by] [vendor name] Ambulance on stretcher. PT alert/oriented x 3 [awake, alert, and oriented by three] able to sign admission documents. PT oriented to room and staff. PT DX [diagnosis] acute cystitis. PT code status full CPR. - [DATE] encounter, .Patient wishes to change his CODE STATUS to DNR. DNR is documented in [hospital name] Type of care preferred: --Patient wishes to be transferred to the hospital in case of medical emergency. --Patient will appoint healthcare surrogate -- Patient's family will bring DNR paper but will communicate with social worker to follow. - [DATE] nursing note, Notified By Social services that Resident Code Status Updated to DNR. Orders Updated. - [DATE] nursing note, Verbal orders received from [Staff F, Medical Doctor (MD)] to contact [medical provider name] at [hospital name] for urgent neurology consult within 7 days for myasthenia gravis flare up. Writer placed call to [hospital name] and requested consult as ordered. - [DATE] nursing note, [hospital name] notified writer that resident unable to be seen by neurology as requested by [Staff F, MD] for several weeks. Provider notified and requested that other neurologists be contacted for referral. - [DATE] nursing note, Resident currently discharged to [hospital name] on [DATE]. - [DATE] nursing note, Resident arrived to the facility via stretcher with an admitting dx of diarrhea Full code. AAO x 4 [awake, alert, and oriented by four] and able to make needs known. Incont of b/b. [incontinent of bowel and bladder] MD and family aware of arrival. - [DATE] change in condition note at 3:00 p.m., The Change In Condition/s reported . Abnormal vital signs (low/high BP [blood pressure], heart rate, respiratory rate, weight change) Respiratory arrest Shortness of breath At the time of evaluation resident/patient vital signs, weight and blood sugar were: . - Pulse: P 72 - [DATE] 03:12 Pulse Type: Regular - Pulse Oximetry: O2 55 % - [DATE] 15:00 [3:00 p.m.] Method: Oxygen via Nasal Cannula . Code Status: Do Not Resuscitate (DNR) . Nursing observations, evaluation, and recommendations are: hypoxic, transfer to ER [emergency room] . Primary Care Provider responded with the following feedback: A. Recommendations: transfer to ER . - [DATE] nursing note at 4:40 p.m., Note Text: 1500 Writer called in to resident room for C/O [complaint of] cough, SOB [shortness of breath], resident noted in bed, awake looking unwell and c/o SOB, vitals measured, hypoxic, SPO2 [oxygen saturation] 55% highest, [Staff G, Nurse Practitioner (NP)] contacted and agrees to send to ER, paramedics arrived, resident expired during workup. Family, [Staff G, NP] and funeral home contacted. Remains picked up at 1640. [4:40 p.m.] A review of Resident #1's evaluations/assessments revealed the following: - [DATE] advance care planning discussion/review, a. admission . Resident Physician Ordered Code Status 1. Code status b. Florida Do Not Resuscitate . He said the [hospital name] has his living will and advanced directives. - [DATE] advance care planning discussion/review, b. readmission . 1. Code status b. Florida Do Not Resuscitate. A review of Resident #1's miscellaneous documents revealed the following: - State of Florida DNR order, dated [DATE], with Resident #1 and the physician's signature was scanned into the electronic health record on [DATE] at 3:02 p.m. - [DATE] inpatient hospitalist progress note, Internal Medicine Inpatient Note . Admission/Discharge [DATE] - Present . Admitting Diagnosis: SEVERE SEPSIS, PNA [pneumonia] . ***CODE STATUS DNR . Nutrition: Continue pureed diet. Patient cannot tolerate thickened liquids. on thin liquids for comfort care. Patient is aware of the risk of aspiration. He does not want PEG [percutaneous endoscopic gastrostomy] tube. NUTRITION REASSESSMENT . [DATE]: . Per inpatient hospitalist progress note dated [DATE], pt has opted to liberalize his diet for quality of life purposes. Pt agreed this date that this is still in line with his current preferences. - The long-term care services and patient transfer form/Agency for Healthcare Administration (AHCA) 3008 form, dated [DATE], did not show any advance directives under section H-advanced care planning. On [DATE] at 12:03 p.m., an interview was conducted with Staff D, LPN. She said the most recent actual code blue was with Resident #1. She said on [DATE], she overheard a conversation that someone needed a non-rebreather mask. She said she was assisting another resident at the time, and a Certified Nursing Assistant (CNA) told her she was needed on the other side of the facility. She stated it, Made me think something was going on. Staff D, LPN said she went to the long-term care side of the facility and saw a crash cart outside the door of Resident #1's room. She said Staff A, LPN was doing chest compressions. Staff D, LPN said she gave the non-rebreather mask to Staff N, Registered Nurse (RN). She recalled connecting the mask to the oxygen tank, then heard Staff A, LPN say she needed to switch, and Staff D, LPN took over chest compressions. She said Staff E, LPN relieved her and started doing chest compressions. She said a few minutes later, as Staff E, LPN was doing chest compressions, the paramedics arrived. She said Staff E, LPN continued chest compressions, per the paramedics' advisement, and she left the room. Staff D, LPN said she went to complete the transfer paperwork to include the face sheet, medication list, and transfer to hospital form. She said she noted Resident #1 was not a full code. She stated, When I noted he was a DNR, [Staff E, LPN] and [Staff N, RN] were coming out of the room, paramedics had taken over. Staff D, LPN stated she asked Staff N, RN, Why did we do CPR on a DNR. She said she asked Staff N, RN to talk to the paramedics, while Resident #1's DNR form was printed and provided to the paramedics. She stated, They would not stop until they had the physical DNR in hand. Staff D, LPN said she did not know who initiated compressions and assumed someone checked Resident #1's code status. She stated, The nurse was to check the code status, then to initiate or not to initiate. She said the assigned nurse is expected to check the resident's code status. Staff D, LPN said the code blue sheets are on the crash cart and they are a new process. She said prior to Resident #1's code blue, the facility did not fill out the code blue sheets. She said a code blue is supposed to be announced, prior to and after, over the facility's intercom system. On [DATE] at 12:52 p.m., an interview was conducted with Staff E, LPN. He said the last time there was an actual code blue was about a month ago, and confirmed it was for Resident #1. He said he went into Resident #1's room, observed he was not doing well, and called the provider for orders to transfer him to the hospital. Staff E, LPN confirmed on [DATE] he was Resident #1's assigned nurse. He said after he received orders from Staff G, NP to transfer him to the hospital, he prepared paperwork to include discharge documents, the face sheet, and the medication list. He stated, As I was going to my desk someone was getting the crash cart and going to my patient's room. Staff E, LPN stated the code blue was not called overhead and, It was a big to-do. He said he went to Resident #1's room, observed the resident was on the floor, and staff were doing compressions. He said Staff N, RN was in the room and Staff A, LPN was doing chest compressions. Staff E, LPN confirmed himself, Staff A, LPN, Staff D, LPN did chest compressions, and thought Staff N, RN did as well. He said the first person he observed doing chest compressions was Staff A, LPN, followed by Staff D, LPN, and then himself. He confirmed Resident #1 had physician orders for DNR but did not know at the time chest compressions were done. Staff E, LPN said he did not notice the resident was a DNR because it was not on the face sheet. He stated, Someone must have said something about the resident being a DNR, and could not recall who said that. He said when the paramedics arrived, they took over CPR. He stated, By that time it was known he was a DNR, they [paramedics] could not stop until they had the yellow DNR sheet. He said the resident passed away. He said the process for a resident who is unresponsive has not changed from prior to Resident #1's code blue event. He said the facility staff are, Just doing more drills. Staff E, LPN said he had never seen a code blue log previously or currently. On [DATE] at 1:23 p.m., an interview was conducted with Staff C, RN. She stated on [DATE] she was in her office and heard a commotion, then responded to Resident #1's room. She said when she arrived, Things were taking place. She said she saw a crash cart, staff present were suctioning Resident #1, and he was lowered to the ground. She stated her part in the code blue was minimal, Nothing at all. Staff C, RN stated the commotion she heard was staff saying, We need help, call 911. She said she observed Staff N, RN suctioning Resident #1, and was leading the code. Staff C, RN said Staff B, CNA were assisting and moving items out of the way, and Staff A, LPN was following guidance from Staff N, RN. She said Staff A, LPN started chest compressions, after being instructed by Staff N, RN. She said she did not hear a code blue was called. She said in response to a resident's change in condition she would use her nursing judgment, which is to check their code status, call code blue over the intercom, and grab the crash cart if it was appropriate. She confirmed Resident #1 was a DNR. Staff C, RN stated she knew his code status because Resident #1 was her, Customer service resident, and she was present during his care plan meetings and Minimum Data Set (MDS) admission assessments. She said she had not checked his code status that day and, It could have changed. She did not think there were code blue sheets currently and they were not part of the process prior to Resident #1's code blue event. Staff C, RN stated, No, I have not seen that here as far as code blue sheets. On [DATE] at 2:05 p.m., an interview was conducted with the Central Supply/Staffing Coordinator. The Coordinator said on [DATE], she was walking down the hall to go back to her office. She said Staff E, LPN, was coming out of Resident #1's room and told her to get another nurse. The Central Supply/Staffing Coordinator said she told Staff N, RN she was needed in Resident #1's room. She said Staff E, LPN was getting ready to send Resident #1 to the hospital and thought he was on the telephone with emergency services. The Central Supply/Staffing Coordinator said Staff E, LPN did not tell her why he needed a nurse. She said approximately five to ten minutes later, she walked back down the hallway and observed multiple people in Resident #1's room. She said she did not hear code blue being called. She said she assisted with getting Resident #1 off the floor to the bed. She said she recalled Staff A, LPN and Staff N, RN being in the room, as well as paramedics who were getting ready to leave. She said she had never participated in an actual code blue, but her role would be to get the crash cart and/or call emergency services. The Central Supply/Staffing Coordinator initially stated, I can verify code status in the book, but not in the computer. She said to her understanding there was a code status book and code status could also be found in the Kardex. She said she could not confirm if her role was to check the code status book, but she would find out. On [DATE] at 4:29 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the facility's response and investigation related to Resident #1. She said on [DATE] Staff P, CNA answered Resident #1's call light and he expressed feeling shortness of breath (SOB). She said Staff P, CNA told Staff E, LPN who went to check Resident #1's vital signs and determined his oxygen saturation was low. The NHA said Staff E, LPN contacted the provider and received orders to transfer the resident to the hospital. She said Staff E, LPN told the Staffing Coordinator to tell the nurse manager at the time, Staff N, RN, that he was transferring the resident to the hospital. She said Staff N, RN went to Resident #1's room and checked his oxygen saturation twice with the same result, which was 73%. The NHA said Staff N, RN had taken the crash cart to the room with her. She said Staff E, LPN left Resident #1's room to prepare transfer paperwork to include the medication list, face sheet, and the hospital transfer form with the change in condition documented. The NHA said Staff N, RN started suctioning Resident #1 because he was drooling, while suctioning he had agonal breathing [insufficient breathing that sounds like snorting, gasping, or labored breathing, and indicates that someone is suffering from a medical emergency. The person can appear to be choking or having an involuntary gasp reflex.], then stopped breathing. She said Staff A, LPN came into the room, checked Resident #1's pulse, did not find a pulse and Staff N, RN instructed Staff A, LPN and Staff B, CNA to transfer Resident #1 to the floor to start chest compressions. The NHA said Staff D, LPN came into the room and took over chest compressions from Staff A, LPN. She said Staff E, LPN came back to the room, while they were waiting for paramedics, and he took over chest compressions for Staff D, LPN. She said they switched to Staff A, LPN, who was doing the chest compressions when paramedics arrived. The NHA said after the paramedics took over, Staff C, RN had gone to Resident #1's room and left to confirm his code status. The NHA said Staff C, RN heard Staff E, LPN, Staff D, LPN, and Staff N, RN, who were at the nurse's station say, He's a DNR. She said Staff N, RN took the DNR paper to the paramedics who stopped compressions. She said Staff B, CNA and the staffing coordinator completed post-mortem care. She said at approximately 3:45 p.m., Staff C, RN informed her CPR had occurred. The NHA stated, That's when I notified the Regional Director of Operations of the incident, and started the facility's investigation. She said the facility policy is if a resident was unresponsive, staff should assess them and determine their code status. The NHA said if a resident had orders for a DNR, the expectation is not to do chest compressions and ensure they are comfortable. The NHA confirmed she interviewed all the staff involved and they confirmed they were instructed/directed by Staff N, RN to start compressions. She stated, Their thought process was the resident was a full code. She said it had always been the process for the nurse to verify the code status in the electronic health record in the physician orders and dashboard. The NHA confirmed CNAs are not allowed to do CPR. She said there is a paper attached to the crash cart where staff take notes, she said that it had always been part of the code blue process. She confirmed the code blue form/timeline was not completed for Resident #1. The NHA said there had been no change to the code blue response process after the incident with Resident #1. On [DATE] at 8:31 a.m., a telephone interview was conducted with Staff A, LPN. On [DATE], she said a CNA came and told her Staff N, RN needed assistance. She said the code blue was not called overhead. Staff A, LPN stated when she arrived to Resident #1's room a, Code was in progress, as the crash cart was there. She said she checked Resident #1's pulse. She said Staff N, RN was in the room at that time along with other CNAs, who she could not recall their names. She said Staff N, RN instructed her to put Resident #1 on a back board, then to put him on floor with the assistance of three CNAs. Staff A, LPN said Staff N, RN told her to start chest compressions. She said Staff N, RN was directing everyone during the code. She said she did not confirm Resident #1's code status as Staff N, RN had sent a CNA specifically asking for a nurse, therefore she started chest compressions as directed. Staff A, LPN said Staff D, LPN came in and relieved her, then Staff E, LPN continued chest compressions. She said she did not remember who was doing chest compressions when paramedics arrived and could not recall how many rounds she completed. She said she switched out once. She stated, Usually if a code is called, I grab the computer and look at the face sheet. Staff A, LPN said the facility does not have a code status book, with physical copies of the yellow DNR form, at the nurse's station. She confirmed there is a clipboard with blank pages of paper on the crash cart where notes could be taken. She said typically the first staff member who arrived completed the notes, whoever is leading the code. On [DATE] at 9:42 a.m., a follow-up interview was conducted with Staff D, LPN. She said the facility does not keep a code status book at the nurse's station. She stated, Everything is on the computer. On [DATE] at 10:24 a.m., a follow-up interview was conducted with the NHA, Regional Director of Operations, and Regional Director of Clinical Services. The NHA reviewed the facility's investigation file and read witness statements that revealed Resident #1 was observed earlier in the day on [DATE] wearing oxygen, sounded congested, and was alert/talking. Later in the shift, the resident complained of difficulty breathing and was noted to remove his oxygen, as he expressed it was not helping. Staff Q, CNA and Staff P, CNA both reported notifying Staff E, LPN of the Resident #1's respiratory distress, after which nursing staff responded. Staff N, RN reported responding to the room at approximately 3:10 p.m., after being notified that assistance was needed. Upon her arrival, the resident was drooling and appeared to be in respiratory distress. Staff N, RN directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, lowered to the floor, and chest compressions were initiated. Staff N, RN said the resident's code status was not verified prior to initiating compressions and could not recall who checked for a pulse. Paramedics arrived and compressions were discontinued once documentation confirmed the resident had DNR orders. Staff P, CNA corroborated that Staff N, RN was directing care in the room and that multiple nurses were present when the resident was placed on the floor. Staff R, Medical Records, reported hearing staff say, call 911, at approximately 3:11 p.m. she called, and observed paramedics arrived shortly after. Staff C, RN reported arriving during the event, observing the crash cart and suction equipment in use, and questioning the resident's code status. She verified on the computer that the resident had a DNR order, heard a paramedic state Resident #1 was a DNR, and afterward informed the NHA of the incident as she was not aware there was a code. Further review of the facility's investigation with the NHA, Regional Director of Operations, and Regional Director of Clinical Services revealed the NHA read a timeline that showed chest compressions were initiated at 3:18 p.m. by Staff A, LPN. EMTs arrived at 3:23 p.m. and instructed staff to continue compressions while they prepared equipment and gathered information. EMTs took control of the code at 3:30 p.m. At 3:35 p.m., the resident's DNR status was identified. At 3:38 p.m., Staff N, RN provided the DNR documentation to the EMTs, and chest compressions were discontinued. Chest compressions were performed from 3:18 p.m. to 3:38 p.m., totaling 20 minutes. An interview with the Regional Director of Clinical Services revealed before a code blue or initiating CPR, nurses needed to ask for the residents' code status and determine if that information had been checked. The Regional Director of Clinical Services stated, Everybody walking in should ask, was code status checked? She confirmed that two nurses verifying the resident's code status was not the process/protocol before Resident #1's code blue event. The Regional Director of Clinical Services and the Regional Director of Operations said the leader or whoever is designated should be taking notes on a clipboard found on the crash cart. The NHA stated, Probably not, when asked about notes being documented on the code blue event for Resident #1. She said she was not sure if staff were aware of the expectation to take notes during a code blue, but now it was being emphasized during education and the mock drills. On [DATE] at 11:51 a.m., a telephone interview was conducted with Staff F, Medical Doctor (MD). She confirmed Resident #1 was re-admitted to the facility on [DATE], but she was not the admitting provider or on call. She said a few days after the re-admission, she was called by Staff G, NP who was getting ready to transfer him to the hospital, then Resident #1 passed away. She said Staff G, NP told her she was on the telephone with Staff E, LPN who said, [Resident #1] got bad. Staff F, MD said she thought Resident #1 had DNR orders. She stated, He did not want anything aggressive, no feeding tube done. Staff F, MD stated, He did not want anything artificial, did not want anything invasive. She said he had myasthenia gravis and he started deteriorating, eating less, and had swallowing issues. She said she sent him to hospital on [DATE], to be seen by a neurologist and to determine if the symptoms he was having was related to myasthenia gravis, or something else. Staff F, MD said she thought he was diagnosed with pneumonia while at the hospital as he was sent back with treatment. She stated he had DNR orders, 99% sure I can tell you. She said if Resident #1's code status had not changed during the admission at the hospital, and his wishes were for DNR, the facility should not have resuscitated him. On [DATE] at 12:13 p.m., a telephone interview was conducted with Staff G, Nurse Practitioner (NP). She said when Resident #1 was re-admitted on [DATE] the nurse called her to let her know the resident was back and they verified admission orders. Staff G, NP said she did not discuss advanced directives but told the nurse to continue whatever orders the resident had from the hospital. She stated, After the hospitalization, whatever wishes he wanted in the hospital it was for the nursing home to follow. She stated she could not remember his code status. She said she recalled a second interaction, when the nurse called and said Resident #1 was in respiratory distress and was doing all possible measures at bedside. She said she told the nurse to call 911 and transfer him to the hospital based on symptoms he was having. Staff G, NP said she did not recall a follow up call after the initial communication with the nurse about sending Resident #1 to the hospital. She stated, Not sure they mentioned chest compressions during call. Staff G, NP said by the standards of care if a resident had signed orders for DNR, then chest compressions should not be started. On [DATE] at 2:31 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She said on [DATE] at approximately 3:00 p.m. there was a call light on for Resident #1's room. She said she helped Staff A, LPN move Resident #1 to the floor as instructed by Staff N, RN. Staff B, CNA said it was only her and Staff A, LPN who moved the resident. She said she informed Staff N, RN that CNAs were not allowed to do CPR and left the room. When she left the room, she said she informed one of the Minimum Data Set (MDS) nurses to call 911. A review of the facility policy titled Abuse, Neglect, Exploitation & [and] Misappropriation, revealed the following: Policy . It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and / or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and The Director of Nursing., .5. Protection . 2) If the suspected perpetrator is an employee, the Administrator or their designee shall place the employee on immediate suspension, pending the outcome of the investigation. c. The DON/designee shall notify the attending physician regarding the alleged violation and findings and document that the physician was notified and follow any orders received. A review of the facility policy titled Nursing Policies- Emergency Care (CPR), revealed the following: Policy . The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures, and Florida State law. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order., Procedure . 2. The resident or legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. 3. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident, . 7. Should a resident experience cardiac emergency, staff will refer to the presence of the yellow form signed by the resident and physician, and/or the physicians order to determine if CPR should be performed. A review of the facility policy titled Admission/Social Services - Advance Directives, revealed the following: .Procedure. 5. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident. A review of the facility policy titled Admission/Social Services - Advance Directives - Resident's Right to Make Decision, revealed the following: Purpose . The facility respects the resident's or legal representative's right to make medical treatment decisions and be provided the appropriate information as required under State and Federal Rules and Regulations., A review of the facility policy titled Resident Rights, revealed the following: All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input. The facility's immediate actions to remove the Immediate Jeopardy included: - Disciplinary action/suspension was initiated for two nurses. RN was terminated and reported to Board of Nursing. - Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses. - Ad hoc [unplanned/spontaneous] quality assurance performance improvement (QAPI) meetings held on [DATE] and [DATE] to discuss concern and correction plan. [DATE] Ad hoc meeting held to review IJ citations. Ad Hoc meeting on [DATE] at 1:06 p.m. to discuss additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE) reviewed, approved a code blue worksheet, reviewed and approved an abuse posttest to reinforce prior education. [DATE] Ad hoc at 4:31 p.m. to review, revise and approve code blue worksheet. - [DATE] Post ad hoc- took revised code blue worksheet to units and initiated review of the worksheet with staff. Anyone can complete the code blue worksheet. - Education 100% of nurses on advance directives, resident right to make a decision and emergency care (CPR) and ANE by [DATE]. New licensed staff were educated on abuse and code status upon hire. - 100%

Based on observations, interviews, and record review, the facility failed to honor a Do Not Resuscitate (DNR) order for one resident (#1) out of three residents sampled. Facility staff unnecessarily provided chest compressions for twenty minutes causing physical harm and a traumatic end of life. On [DATE], Resident #1 was found unresponsive by facility staff. Facility staff performed Cardiopulmonary Resuscitation (CPR), including chest compressions, without confirming Resident #1's preferred resuscitation status. The resident had a physician order for DNR, dated [DATE]. Emergency Medical Services (EMS) were called to the facility, and paramedics took over chest compressions. After twenty minutes of CPR, facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. Paramedics ceased chest compressions and Resident #1 expired. By providing CPR, the facility staff failed to honor Resident #1's advance directive wishes and physician signed DNR form which caused unnecessary physical harm and pain and denied Resident #1 a peaceful death.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F578, F600, and F726.Findings Include: A review of Resident #1's admission record revealed an initial admission to the facility on [DATE], and a re-admission on [DATE] with diagnoses to include myasthenia gravis without (acute) exacerbation, immunodeficiency, unspecified, chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, peripheral vascular disease, unspecified, personal history of transient ischemic attack (tia), cerebral infarction without residual deficits, and adult failure to thrive. A review of Resident #1's physician orders included the following:Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE].Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE].Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, changed to DNR.Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, Resident is DNR status. The order was created on [DATE] at 3:04 p.m., by Staff A, Licensed Practical Nurse (LPN). The order was discontinued by Staff I, Registered Nurse (RN) on [DATE] at 7:31 a.m. A review of Resident #1's care plan revealed the following: Resident has the capacity to make health care decisions and has signed a DNR Date Initiated: [DATE] Revision on: [DATE], with interventions to include, Placed signed DNR under Advanced Directives tab in the MISC [miscellaneous] section of the Electric medical record. Date Initiated: [DATE] Revision on: [DATE]. A review of Resident #1's progress notes revealed the following:[DATE] encounter, .Patient wishes to change his CODE STATUS to DNR. DNR is documented in [hospital name] Type of care preferred: --Patient wishes to be transferred to the hospital in case of medical emergency. --Patient will appoint healthcare surrogate -- Patient's family will bring DNR paper but will communicate with social worker to follow.[DATE] nursing note, Notified By Social services that Resident Code Status Updated to DNR. Orders Updated.[DATE] change in condition note at 3:00 p.m., The Change In Condition/s reported . Abnormal vital signs (low/high BP [blood pressure], heart rate, respiratory rate, weight change) Respiratory arrest Shortness of breath At the time of evaluation resident/patient vital signs, weight and blood sugar were: . - Pulse: P 72 - [DATE] 03:12 Pulse Type: Regular - Pulse Oximetry: O2 55 % - [DATE] 15:00 [3:00 p.m.] Method: Oxygen via Nasal Cannula . Code Status: Do Not Resuscitate (DNR) . Nursing observations, evaluation, and recommendations are: hypoxic, transfer to ER [emergency room] . Primary Care Provider responded with the following feedback: A. Recommendations: transfer to ER .[DATE] nursing note at 4:40 p.m., Note Text: 1500 Writer called in to resident room for C/O [complaint of] cough, SOB [shortness of breath], resident noted in bed, awake looking unwell and c/o SOB, vitals measured, hypoxic, SPO2 [oxygen saturation] 55% highest, [Staff G, Nurse Practitioner (NP)] contacted and agrees to send to ER, paramedics arrived, resident expired during workup. Family, [Staff G, Nurse Practitioner] and funeral home contacted. Remains picked up at 1640. [4:40 p.m.] A review of Resident #1's evaluations/assessments revealed the following:[DATE] advance care planning discussion/review, a. admission . Resident Physician Ordered Code Status 1. Code status b. Florida Do Not Resuscitate . He said the [hospital name] has his living will and advanced directives.[DATE] advance care planning discussion/review, b. readmission . 1. Code status b. Florida Do Not Resuscitate. A review of Resident #1's miscellaneous documents revealed the following:State of Florida DNR order, dated [DATE], with Resident #1 and the physician's signature was scanned into the electronic health record on [DATE] at 3:02 p.mXXX[DATE] inpatient hospitalist progress note, Internal Medicine Inpatient Note . Admission/Discharge [DATE] - Present . Admitting Diagnosis: SEVERE SEPSIS, PNA [pneumonia] . ***CODE STATUS DNR . Nutrition: Continue pureed diet. Patient cannot tolerate thickened liquids. on thin liquids for comfort care. Patient is aware of the risk of aspiration. He does not want PEG [percutaneous endoscopic gastrostomy] tube. NUTRITION REASSESSMENT . [DATE]: . Per inpatient hospitalist progress note dated [DATE], pt [patient] has opted to liberalize his diet for quality of life purposes. Pt agreed this date that this is still in line with his current preferences. On [DATE] at 12:03 p.m., an interview was conducted with Staff D, LPN. She said the most recent actual code blue was with Resident #1. She said on [DATE], she overheard a conversation that someone needed a non-rebreather mask. She said she was assisting another resident at the time, and a Certified Nursing Assistant (CNA) told her she was needed on the other side of the facility. She stated it, Made me think something was going on. Staff D, LPN said she went to the long-term care side of the facility and saw a crash cart outside the door of Resident #1's room. She said Staff A, LPN was doing chest compressions. Staff D, LPN said she gave the non-rebreather mask to Staff N, Registered Nurse (RN). She recalled connecting the mask to the oxygen tank, then heard Staff A, LPN say she needed to switch, and Staff D, LPN took over chest compressions. Staff D, LPN said Staff E, LPN relieved her and started doing chest compressions. She said a few minutes later, as Staff E, LPN was doing chest compressions, the paramedics arrived. She said Staff E, LPN continued chest compressions, per the paramedics' advisement, and she left the room. Staff D, LPN said she went to complete the transfer paperwork when she noted Resident #1 was not a full code. She stated, When I noted he was a DNR, [Staff E, LPN] and [Staff N, RN] were coming out of the room, paramedics had taken over. Staff D, LPN stated she asked Staff N, RN, Why did we do CPR on a DNR. She stated, They [paramedics] would not stop until they had the physical DNR in hand. Staff D, LPN said she did not know who initiated compressions and assumed someone checked Resident #1's code status. She stated, The nurse was to check the code status, then to initiate or not to initiate. She said the assigned nurse is expected to check the resident's code status. On [DATE] at 12:52 p.m., an interview was conducted with Staff E, LPN. He said the last time there was an actual code blue was about a month ago, and confirmed it was for Resident #1. He said he went into Resident #1's room, observed he was not doing well, and called the provider for orders to transfer him to the hospital. Staff E, LPN confirmed on [DATE] he was Resident #1's assigned nurse. He said after he received orders from Staff G, NP to transfer him to the hospital, he prepared paperwork to include discharge documents, the face sheet, and the medication list. He stated, As I was going to my desk someone was getting the crash cart and going to my patient's room. He said he went to Resident #1's room, observed the resident was on the floor, and staff were doing compressions. He said Staff N, RN was in the room and Staff A, LPN was doing chest compressions. Staff E, LPN confirmed himself, Staff A, LPN, Staff D, LPN did chest compressions, and thought Staff N, RN did as well. He confirmed Resident #1 had physician orders for DNR but did not know at the time chest compressions were done. Staff E, LPN said he did not notice the resident was a DNR because it was not on the face sheet. He stated, Someone must have said something about the resident being a DNR. He said when the paramedics arrived, they took over CPR. He stated, By that time it was known he was a DNR, they [paramedics] could not stop until they had the yellow DNR sheet. He said the resident passed away. On [DATE] at 1:23 p.m., an interview was conducted with Staff C, RN. She stated on [DATE] she was in her office and heard a commotion, then responded to Resident #1's room. She said when she arrived there was a crash cart, staff present were suctioning Resident #1, and he was lowered to the ground. Staff C, RN stated the commotion she heard was staff saying, We need help, call 911. She said she observed Staff N, RN suctioning Resident #1, and was leading the code. She said Staff A, LPN started chest compressions, after being instructed by Staff N, RN. She confirmed Resident #1 was a DNR. Staff C, RN stated she knew his code status because Resident #1 was her, Customer service resident, and she was present during his care plan meetings and Minimum Data Set (MDS) admission assessments. She said she had not checked his code status that day and, It could have changed. On [DATE] at 4:29 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the facility's response and investigation related to Resident #1. She said on [DATE] Staff P, CNA answered Resident #1's call light and he expressed feeling shortness of breath (SOB). She said Staff P, CNA told Staff E, LPN who went to check Resident #1's vital signs and determined his oxygen saturation was low at 55% (normal oxygen saturation levels range from 95%-100%). The NHA said Staff E, LPN contacted the provider and received orders to transfer the resident to the hospital. She said Staff E, LPN told the Staffing Coordinator to tell the nurse manager at the time, Staff N, RN, that he was transferring the resident to the hospital. She said Staff N, RN went to Resident #1's room and checked his oxygen saturation twice with the same result, which was 73%. The NHA said Staff N, RN had taken the crash cart to the room with her. She said Staff E, LPN left Resident #1's room to prepare transfer paperwork to include the medication list, face sheet, and the hospital transfer form. The NHA said Staff N, RN started suctioning Resident #1 because he was drooling, while suctioning he had agonal breathing (Insufficient breathing that sounds like snorting, gasping, or labored breathing, and indicates that someone is suffering from a medical emergency. The person can appear to be choking or having an involuntary gasp reflex.), then stopped breathing. She said Staff A, LPN came into the room, checked Resident #1's pulse, did not find a pulse and Staff N, RN instructed Staff A, LPN and Staff B, CNA to transfer Resident #1 to the floor to start chest compressions. The NHA said Staff D, LPN came into the room and took over chest compressions from Staff A, LPN. She said Staff E, LPN came back to the room, while they were waiting for paramedics, and he took over chest compressions for Staff D, LPN. She said they switched to Staff A, LPN, who was doing the chest compressions when paramedics arrived. The NHA said after the paramedics took over, Staff C, RN had gone to Resident #1's room and left to confirm his code status. The NHA said Staff C, RN heard Staff E, LPN, Staff D, LPN, and Staff N, RN say, He's a DNR. The NHA said Staff N, RN took the yellow DNR form to the paramedics who stopped compressions. She said at approximately 3:45 p.m., Staff C, RN informed her CPR had occurred. She said the facility policy is if a resident was unresponsive, staff should assess them and determine their code status. The NHA said if a resident had orders for a DNR, the expectation is not to do chest compressions and ensure they are comfortable. The NHA confirmed she interviewed all the staff involved and they confirmed they were instructed/directed by Staff N, RN to start compressions. She stated, Their thought process was the resident was a full code. She said it had always been the process for the nurse to verify the code status in the electronic health record in the physician orders and dashboard. On [DATE] at 8:31 a.m., a telephone interview was conducted with Staff A, LPN. On [DATE], she said a CNA came and told her Staff N, RN needed assistance. She said the code blue was not called overhead. Staff A, LPN stated when she arrived to Resident #1's room a, Code was in progress, as the crash cart was there. She said she checked Resident #1's pulse. She said Staff N, RN was in the room at that time along with other CNAs. She said Staff N, RN instructed her to put Resident #1 on a back board, then to put him on floor with the assistance of three CNAs. Staff A, LPN said Staff N, RN told her to start chest compressions. She said Staff N, RN was directing everyone during the code. She said she did not confirm Resident #1's code status as Staff N, RN had sent a CNA specifically asking for a nurse, therefore she started chest compressions as directed. Staff A, LPN said Staff D, LPN came in and relieved her, then Staff E, LPN continued chest compressions. She said she did not remember who was doing chest compressions when paramedics arrived and could not recall how many rounds she completed. She said she switched out once. On [DATE] at 10:24 a.m., a follow-up interview was conducted with the NHA, Regional Director of Operations, and Regional Director of Clinical Services. The NHA reviewed the facility's investigation file and read witness statements that revealed Resident #1 was observed earlier in the day on [DATE] wearing oxygen, sounded congested, and was alert/talking. Later in the shift, the resident complained of difficulty breathing and was noted to remove his oxygen, as he expressed it was not helping. Staff Q, CNA and Staff P, CNA both reported notifying Staff E, LPN of the Resident #1's respiratory distress, after which nursing staff responded. Staff N, RN reported responding to the room at approximately 3:10 p.m., after being notified that assistance was needed. Upon her arrival, the resident was drooling and appeared to be in respiratory distress. Staff N, RN directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, lowered to the floor, and chest compressions were initiated. Staff N, RN said the resident's code status was not verified prior to initiating compressions and could not recall who checked for a pulse. Paramedics arrived and compressions were discontinued once documentation confirmed the resident had DNR orders. Staff P, CNA corroborated that Staff N, RN was directing care in the room and that multiple nurses were present when the resident was placed on the floor. Staff C, RN reported arriving during the event, observing the crash cart and suction equipment in use, and questioning the resident's code status. She verified on the computer that the resident had a DNR order and heard a paramedic state Resident #1 was a DNR. Further review of the facility's investigation with the NHA, Regional Director of Operations, and Regional Director of Clinical Services revealed the NHA read a timeline that showed chest compressions were initiated at 3:18 p.m. by Staff A, LPN. EMTs arrived at 3:23 p.m. and instructed staff to continue compressions. EMTs took control of the code at 3:30 p.m. At 3:35 p.m., the resident's DNR status was identified. At 3:38 p.m., Staff N, RN provided the DNR documentation to the EMTs, and chest compressions were discontinued. Chest compressions were performed from 3:18 p.m. to 3:38 p.m., totaling approximately 20 minutes. An interview with the Regional Director of Clinical Services revealed before a code blue or initiating CPR, nurses needed to ask for the residents' code status and determine if that information had been checked. The Regional Director of Clinical Services stated, Everybody walking in should ask, was code status checked? She confirmed that two nurses verifying the resident's code status was not the process/protocol before Resident #1's code blue event. On [DATE] at 11:51 a.m., a telephone interview was conducted with Staff F, Medical Doctor (MD). She confirmed Resident #1 was re-admitted to the facility on [DATE], but she was not the admitting provider or on call. She said a few days after the re-admission, she was called by Staff G, NP who was getting ready to transfer him to the hospital, then Resident #1 passed away. Staff F, MD stated, He did not want anything aggressive, no feeding tube done. She stated, He did not want anything artificial, did not want anything invasive. She said he had myasthenia gravis and he started deteriorating. She said she sent him to hospital on [DATE], to be seen by a neurologist and to determine if the symptoms he was having was related to myasthenia gravis, or something else. Staff F, MD stated she thought he had DNR orders, 99% sure I can tell you. She said if Resident #1's code status had not changed during the admission at the hospital, and his wishes were for DNR, the facility should not have resuscitated him. On [DATE] at 12:13 p.m., a telephone interview was conducted with Staff G, Nurse Practitioner (NP). She said when Resident #1 was re-admitted on [DATE] the nurse called her to let her know the resident was back and they verified admission orders. Staff G, NP said she did not discuss advanced directives but told the nurse to continue whatever orders the resident had from the hospital. She stated, After the hospitalization, whatever wishes he wanted in the hospital it was for the nursing home to follow. Staff G, NP said she could not remember his code status. She said she recalled a second interaction, when the nurse called and said Resident #1 was in respiratory distress and was doing all possible measures at bedside. She said she told the nurse to call 911 and transfer him to the hospital based on symptoms he was having. Staff G, NP said she did not recall a follow up call after the initial communication with the nurse. She stated, Not sure they mentioned chest compressions during call. Staff G, NP said by the standards of care if a resident had signed orders for DNR, then chest compressions should not be started. A review of the facility policy titled Nursing Policies- Emergency Care (CPR), revealed the following: Policy . The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures, and Florida State law. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order., Procedure . 2. The resident or legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. 3. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident, . 7. Should a resident experience cardiac emergency, staff will refer to the presence of the yellow form signed by the resident and physician, and/or the physicians order to determine if CPR should be performed. A review of the facility policy titled Admission/Social Services - Advance Directives, revealed the following: .Procedure. 5. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident. A review of the facility policy titled Admission/Social Services - Advance Directives - Resident's Right to Make Decision, revealed the following: Purpose . The facility respects the resident's or legal representative's right to make medical treatment decisions and be provided the appropriate information as required under State and Federal Rules and Regulations., A review of the facility policy titled Resident Rights, revealed the following, All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input. The facility's immediate actions to remove the Immediate Jeopardy included: - Disciplinary action/suspension was initiated for two nurses. RN was terminated and reported to Board of Nursing. - Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses. - Ad hoc [unplanned/spontaneous] quality assurance performance improvement (QAPI) meetings held on [DATE] and [DATE] to discuss concern and correction plan. [DATE] Ad hoc meeting held to review IJ citations. Ad Hoc meeting on [DATE] at 1:06 p.m. to discuss additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE) reviewed, approved a code blue worksheet, reviewed and approved an abuse posttest to reinforce prior education. [DATE] Ad hoc at 4:31 p.m. to review, revise and approve code blue worksheet. - [DATE] Post ad hoc- took revised code blue worksheet to units and initiated review of the worksheet with staff. Anyone can complete the code blue worksheet. - Education 100% of nurses on advance directives, resident right to make a decision and emergency care (CPR) and ANE by [DATE]. New licensed staff were educated on abuse and code status upon hire. - 100% of resident medical records were reviewed- code status orders were verified. Audit was conducted of residents who expired in facility in past 90 days with no concerns found related to honoring code status. - Mock code drills were initiated on [DATE] at 4:30 p.m. and continued through current date [DATE] on varying shifts and days. - Code status for all new admissions after [DATE] were reviewed and verified. - [DATE] 23 of 23 nurses received reinforcement of prior education to verify and document code status orders. - [DATE] began implementation of the code drill worksheet and feedback received to add a box for full code/ DNR that can be checked. - [DATE] 69 of 104 non-licensed staff received additional education to evaluate and reinforce prior education on code status, who can perform CPR and emergency care, advance directives and ANE and their role during a code blue. - Education initiated on [DATE] and [DATE] is ongoing and staff will complete reinforcement education prior to working next shift. Verification of the facility's removal plan was conducted by the survey team on [DATE]. - Interviews were conducted with twelve out of twenty-three licensed nursing staff and fifteen out of fifty-one licensed CNA's who worked across all shifts. Interviews were conducted with twenty-four staff members who were considered other licensed clinical (dietitian, social work, therapy) and non-clinical staff. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A review of in-service documentation revealed 100% of staff currently working had completed education and training related advanced directives policy/procedure, identification and responding to change in condition and order evaluation with competency, verifying code status completed by licensed nursing staff, abuse/neglect/exploitation and participation in code blue drills. - On [DATE] at 2:59 p.m., the facility was asked to conduct a blue code drill. Staff were observed promptly announcing overhead, Code blue, after assessing the resident and verifying their code status. Multiple clinical and non-clinical staff responded without delay. The Director of Nursing (DON) was observed leading the drill. Staff arrived with two crash carts, laptops, and one individual scribed the event on the code blue form/timeline. Multiple staff asked about and confirmed the resident's code status demonstrating awareness of the protocol/understanding their roles and responsibilities. Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews, and record review, the facility failed to ensure nursing staff were competent in identifying residents code status and following physician orders for Do Not Resuscitate (DNR) for one resident (#1) out of six residents sampled.On [DATE], Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions were initiated by staff (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly caused physical damage including fractured ribs or sternum, bruising, and internal organ injury). Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the documentation to the paramedics. Paramedics discontinued compressions. Cardiac compressions were provided to Resident #1 for approximately twenty minutes. The CPR provided for Resident #1 denied him the right to a peaceful death and caused unnecessary physical harm and pain.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F578, F600, and F678.Findings Include: A review of Resident #1's admission record revealed an initial admission to the facility on [DATE], and a re-admission on [DATE] with diagnoses to include myasthenia gravis without (acute) exacerbation, immunodeficiency, unspecified, chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, peripheral vascular disease, unspecified, personal history of transient ischemic attack (tia), cerebral infarction without residual deficits, and adult failure to thrive. A review of Resident #1's physician orders included the following: - Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE]. - Do Not Resuscitate (DNR), with an ordered/created date of [DATE] and an end date of [DATE]. - Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, changed to DNR. - Full Cardiopulmonary Resuscitation (CPR), with an ordered/created date of [DATE] and an end date of [DATE]. Further review of the order had notes with the following, Resident is DNR status. The order was created on [DATE] at 3:04 p.m., by Staff A, Licensed Practical Nurse (LPN). The order was discontinued by Staff I, Registered Nurse (RN) on [DATE] at 7:31 a.m. A review of Resident #1's miscellaneous documents revealed the following: - State of Florida DNR order, dated [DATE], with Resident #1 and the physician's signature was scanned into the electronic health record on [DATE] at 3:02 p.m. On [DATE] at 12:03 p.m., an interview was conducted with Staff D, LPN. She said the most recent actual code blue was with Resident #1. She said on [DATE], she overheard a conversation that someone needed a non-rebreather mask. She said she was assisting another resident at the time, and a Certified Nursing Assistant (CNA) told her she was needed on the other side of the facility. She stated it, Made me think something was going on. Staff D, LPN said she went to the long-term care side of the facility and saw a crash cart outside the door of Resident #1's room. She said Staff A, LPN was doing chest compressions. Staff D, LPN said she gave the non-rebreather mask to Staff N, Registered Nurse (RN). She recalled connecting the mask to the oxygen tank, then heard Staff A, LPN say she needed to switch, and Staff D, LPN took over chest compressions. Staff D, LPN said Staff E, LPN relieved her and started doing chest compressions. She said a few minutes later, as Staff E, LPN was doing chest compressions, the paramedics arrived. She said Staff E, LPN continued chest compressions, per the paramedics' advisement, and she left the room. Staff D, LPN said she went to complete the transfer paperwork to include the face sheet, medication list, and transfer to hospital form. She said she noted Resident #1 was not a full code. She stated, When I noted he was a DNR, [Staff E, LPN] and [Staff N, RN] were coming out of the room, paramedics had taken over. Staff D, LPN stated she asked Staff N, RN, Why did we do CPR on a DNR. She said she asked Staff N, RN to talk to the paramedics, while Resident #1's DNR form was printed and provided to the paramedics. She stated, They would not stop until they had the physical DNR in hand. Staff D, LPN said she did not know who initiated compressions and assumed someone checked Resident #1's code status. She stated, The nurse was to check the code status, then to initiate or not to initiate. She said the assigned nurse is expected to check the resident's code status. Staff D, LPN said the code blue sheets are on the crash cart and they are a new process. She said prior to Resident #1's code blue, the facility did not fill out the code blue sheets. She said a code blue is supposed to be announced, prior to and after, over the facility's intercom system. On [DATE] at 12:52 p.m., an interview was conducted with Staff E, LPN. He said the last time there was an actual code blue was about a month ago, and confirmed it was for Resident #1. He said he went into Resident #1's room, observed he was not doing well, and called the provider for orders to transfer him to the hospital. Staff E, LPN confirmed on [DATE] he was Resident #1's assigned nurse. He said he prepared paperwork to include discharge documents, the face sheet, and the medication list. He stated, As I was going to my desk someone was getting the crash cart and going to my patient's room. Staff E, LPN stated the code blue was not called overhead and, It was a big to-do. He said he went to Resident #1's room, observed the resident was on the floor, and staff were doing compressions. He said Staff N, RN was in the room and Staff A, LPN was doing chest compressions. Staff E, LPN confirmed himself, Staff A, LPN, Staff D, LPN did chest compressions, and thought Staff N, RN did as well. He said the first person he observed doing chest compressions was Staff A, LPN, followed by Staff D, LPN, and then himself. He confirmed Resident #1 had physician orders for DNR but did not know at the time chest compressions were done. Staff E, LPN said he did not notice the resident was a DNR because it was not on the face sheet. He stated, Someone must have said something about the resident being a DNR, and could not recall who said that. He said when the paramedics arrived, they took over CPR. He stated, By that time it was known he was a DNR, they [paramedics] could not stop until they had the yellow DNR sheet. He said the resident passed away. He said the process for a resident who is unresponsive has not changed from prior to Resident #1's code blue event. He said the facility staff are, Just doing more drills. Staff E, LPN said he had never seen a code blue log previously or currently. On [DATE] at 1:23 p.m., an interview was conducted with Staff C, RN. She stated on [DATE] she was in her office and heard a commotion, then responded to Resident #1's room. She said when she arrived, Things were taking place. She said she saw a crash cart, staff present were suctioning Resident #1, and he was lowered to the ground. She stated her part in the code blue was minimal, Nothing at all. Staff C, RN stated the commotion she heard was staff saying, We need help, call 911. She said she observed Staff N, RN suctioning Resident #1, and was leading the code. Staff C, RN said Staff B, CNA were assisting and moving items out of the way, and Staff A, LPN was following guidance from Staff N, RN. She said Staff A, LPN started chest compressions, after being instructed by Staff N, RN. She said she did not hear a code blue was called. She said in response to a resident's change in condition she would use her nursing judgment, which is to check their code status, call code blue over the intercom, and grab the crash cart if it was appropriate. She confirmed Resident #1 was a DNR. Staff C, RN stated she knew his code status because Resident #1 was her, Customer service resident, and she was present during his care plan meetings and Minimum Data Set (MDS) admission assessments. She said she had not checked his code status that day and, It could have changed. She did not think there were code blue sheets currently and they were not part of the process prior to Resident #1's code blue event. Staff C, RN stated, No, I have not seen that here as far as code blue sheets. On [DATE] at 2:05 p.m., an interview was conducted with the Central Supply/Staffing Coordinator. The Coordinator said on [DATE], she was walking down the hall to go back to her office. She said Staff E, LPN, was coming out of Resident #1's room and told her to get another nurse. The Central Supply/Staffing Coordinator said she told Staff N, RN she was needed in Resident #1's room. She said Staff E, LPN was getting ready to send Resident #1 to the hospital and thought he was on the telephone with emergency services. The Central Supply/Staffing Coordinator said Staff E, LPN did not tell her why he needed a nurse. She said approximately five to ten minutes later, she walked back down the hallway and observed multiple people in Resident #1's room. She said she did not hear code blue being called. She said she assisted with getting Resident #1 off the floor to the bed. She said she recalled Staff A, LPN and Staff N, RN being in the room, as well as paramedics who were getting ready to leave. She said she had never participated in an actual code blue, but her role would be to get the crash cart and/or call emergency services. The Central Supply/Staffing Coordinator initially stated, I can verify code status in the book, but not in the computer. She said to her understanding there was a code status book and code status could also be found in the Kardex. She said she could not confirm if her role was to check the code status book, but she would find out. On [DATE] at 3:01 p.m., an interview was conducted with Staff I, RN. She confirmed she was not present during the event on [DATE] but was told a nurse started resuscitation. She stated the code blue response process, Hasn't changed, the regulation never changes. Staff I, RN said the facility completed a timeline of what happened during a code. She said the timeline had always been protocol at the facility. She said in a code blue, her role was the person in charge. Staff I, RN stated, The first person is to check the computer for status. She said she would first check the code status in the computer and would not touch a resident without knowing that information. She said the code blue sheets/timeline should be on the crash cart and confirmed they were not at the time of interview. A follow-up interview and observation was conducted at 3:18 p.m., Staff I, RN said the facility does not keep a book of the residents' code status as they are found in the electronic health record. The crash cart was observed, and the code blue sheets/timelines were not present. Staff I, RN verified the sheets were not on the crash cart and could not provide an explanation as to where they were. On [DATE] at 3:12 p.m., an interview was conducted with Staff J, CNA. She said her role in a code blue is to come in with other staff and attend to anything going on. She stated, I basically don't know if I can do CPR here, but I am CPR certified. She stated, I guess I can do it, why else would they ask for it. On [DATE] at 3:16 p.m., an interview was conducted with Staff K, CNA. She said she was not working on [DATE]. She stated, Code blue was called on one of our residents, and confirmed she had been Resident #1's assigned CNA. Staff K, CNA said the facility had a book that listed the residents' code status and the Kardex also had code status information. On [DATE] at 3:21 p.m., an interview was conducted with Staff L, LPN. She said she was not present for the code blue on [DATE] and did not hear anything about it. Staff L, LPN said the facility staff do not complete a code blue sheet or timeline. She stated, Not that I'm aware of. On [DATE] at 3:26 p.m., an interview was conducted with Staff M, CNA. She said during a code blue, she may check the resident for a pulse. Staff M, CNA said if a nurse was not present, she could start chest compressions. She confirmed she could do CPR and every three months she completed a CPR refresher. On [DATE] at 4:29 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the facility's response and investigation related to Resident #1. She said on [DATE] Staff P, CNA answered Resident #1's call light and he expressed feeling shortness of breath (SOB). She said Staff P, CNA told Staff E, LPN who went to check Resident #1's vital signs and determined his oxygen saturation was low. The NHA said Staff E, LPN contacted the provider and received orders to transfer the resident to the hospital. She said Staff N, RN, nurse manager at that time, was informed by the Staffing Coordinator she was needed in Resident #1's room. Staff N, RN went and checked Resident #1's oxygen saturation twice with the same result, which was 73%. The NHA said Staff N, RN had taken the crash cart to the room with her. She said Staff E, LPN left Resident #1's room to prepare transfer paperwork. The NHA said Staff N, RN started suctioning Resident #1 because he was drooling, while suctioning he had agonal breathing (Insufficient breathing that sounds like snorting, gasping, or labored breathing, and indicates that someone is suffering from a medical emergency. The person can appear to be choking or having an involuntary gasp reflex.), then stopped breathing. She said Staff A, LPN came into the room, checked Resident #1's pulse, did not find a pulse. Staff N, RN instructed Staff A, LPN and Staff B, CNA to transfer Resident #1 to the floor to start chest compressions. The NHA said Staff D, LPN came into the room and took over chest compressions from Staff A, LPN. She said Staff E, LPN came back to the room, while they were waiting for paramedics, and he took over chest compressions for Staff D, LPN. She said they switched to Staff A, LPN, who was doing the chest compressions when paramedics arrived. The NHA said after the paramedics took over, Staff C, RN went to Resident #1's room and left to confirm his code status. The NHA said Staff C, RN heard Staff E, LPN, Staff D, LPN, and Staff N, RN say, He's a DNR. She said Staff N, RN took the DNR paper to the paramedics who stopped compressions. She said at approximately 3:45 p.m., Staff C, RN informed her CPR had occurred. She said the facility policy is if a resident was unresponsive, staff should assess them and determine their code status. The NHA said if a resident had orders for a DNR, the expectation is not to do chest compressions and ensure they are comfortable. The NHA confirmed she interviewed all the staff involved and they confirmed they were instructed/directed by Staff N, RN to start compressions. She stated, Their thought process was the resident was a full code. She said it had always been the process for the nurse to verify the code status in the electronic health record in the physician orders and dashboard. The NHA confirmed CNAs are not allowed to do CPR. She said there is a paper attached to the crash cart where staff take notes, she said that it had always been part of the code blue process. She confirmed the code blue form/timeline was not completed for Resident #1. The NHA said there had been no change to the code blue response process after the incident with Resident #1. On [DATE] at 8:31 a.m., a telephone interview was conducted with Staff A, LPN. On [DATE], she said a CNA came and told her Staff N, RN needed assistance. She said the code blue was not called overhead. Staff A, LPN stated when she arrived to Resident #1's room a, Code was in progress, as the crash cart was there. She said she checked Resident #1's pulse. She said Staff N, RN was in the room at that time along with other CNAs, who she could not recall their names. She said Staff N, RN instructed her to put Resident #1 on a back board, then to put him on floor with the assistance of three CNAs. Staff A, LPN said Staff N, RN told her to start chest compressions. She said Staff N, RN was directing everyone during the code. She said she did not confirm Resident #1's code status as Staff N, RN had sent a CNA specifically asking for a nurse, therefore she started chest compressions as directed. Staff A, LPN said Staff D, LPN came in and relieved her, then Staff E, LPN continued chest compressions. She said she did not remember who was doing chest compressions when paramedics arrived and could not recall how many rounds she completed. She said she switched out once. She stated, Usually if a code is called, I grab the computer and look at the face sheet. Staff A, LPN said the facility does not have a code status book, with physical copies of the yellow DNR form, at the nurse's station. She confirmed there is a clipboard with blank pages of paper on the crash cart where notes could be taken. She said typically the first staff member who arrived completed the notes, whoever is leading the code. On [DATE] at 9:42 a.m., a follow-up interview was conducted with Staff D, LPN. She said the facility does not keep a code status book at the nurse's station. She stated, Everything is on the computer. On [DATE] at 10:24 a.m., a follow-up interview was conducted with the NHA, Regional Director of Operations, and Regional Director of Clinical Services. The NHA reviewed the facility's investigation file and read witness statements that revealed Resident #1 was observed earlier in the day on [DATE] wearing oxygen, sounded congested, and was alert/talking. Later in the shift, the resident complained of difficulty breathing and was noted to remove his oxygen, as he expressed it was not helping. Staff Q, CNA and Staff P, CNA both reported notifying Staff E, LPN of the Resident #1's respiratory distress, after which nursing staff responded. Staff N, RN reported responding to the room at approximately 3:10 p.m., after being notified that assistance was needed. Upon her arrival, the resident was drooling and appeared to be in respiratory distress. Staff N, RN directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, lowered to the floor, and chest compressions were initiated. Staff N, RN said the resident's code status was not verified prior to initiating compressions and could not recall who checked for a pulse. Paramedics arrived and compressions were discontinued once documentation confirmed the resident had DNR orders. Staff P, CNA corroborated that Staff N, RN was directing care in the room and that multiple nurses were present when the resident was placed on the floor. Staff R, Medical Records, reported hearing staff say, call 911, at approximately 3:11 p.m. she called, and observed paramedics arrived shortly after. Staff C, RN reported arriving during the event, observing the crash cart and suction equipment in use, and questioning the resident's code status. She verified on the computer that the resident had a DNR order, heard a paramedic state Resident #1 was a DNR, and afterward informed the NHA of the incident as she was not aware there was a code. Further review of the facility's investigation with the NHA, Regional Director of Operations, and Regional Director of Clinical Services revealed the NHA read a timeline that showed chest compressions were initiated at 3:18 p.m. by Staff A, LPN. EMTs arrived at 3:23 p.m. and instructed staff to continue compressions while they prepared equipment and gathered information. EMTs took control of the code at 3:30 p.m. At 3:35 p.m., the resident's DNR status was identified. At 3:38 p.m., Staff N, RN provided the DNR documentation to the EMTs, and chest compressions were discontinued. Chest compressions were performed from 3:18 p.m. to 3:38 p.m., totaling approximately 20 minutes. An interview with the Regional Director of Clinical Services revealed before a code blue or initiating CPR, nurses needed to ask for the residents' code status and determine if that information had been checked. The Regional Director of Clinical Services stated, Everybody walking in should ask, was code status checked? She confirmed that two nurses verifying the resident's code status was not the process/protocol before Resident #1's code blue event. The Regional Director of Clinical Services and the Regional Director of Operations said the leader or whoever is designated should be taking notes on a clipboard found on the crash cart. The NHA stated, Probably not, when asked about notes being documented on the code blue event for Resident #1. She said she was not sure if staff were aware of the expectation to take notes during a code blue, but now it was being emphasized during education and the mock drills. On [DATE] at 11:51 a.m., a telephone interview was conducted with Staff F, Medical Doctor (MD). She confirmed Resident #1 was re-admitted to the facility on [DATE], but she was not the admitting provider or on call. She said a few days after the re-admission, she was called by Staff G, NP who was getting ready to transfer him to the hospital, then Resident #1 passed away. She said Staff G, NP told her she was on the phone with Staff E, LPN who said, [Resident #1] got bad. She stated, He did not want anything aggressive, no feeding tube done. She stated, He did not want anything artificial, did not want anything invasive. She said he had myasthenia gravis and he started deteriorating, eating less, and had swallowing issues. She said she sent him to hospital on [DATE], to be seen by a neurologist and to determine if the symptoms he was having was related to myasthenia gravis, or something else. Staff F, MD said she thought he was diagnosed with pneumonia while at the hospital as he was sent back with treatment. She stated she thought he had DNR orders, 99% sure I can tell you. She said if Resident #1's code status had not changed during the admission at the hospital, and his wishes were for DNR, the facility should not have resuscitated him. On [DATE] at 12:13 p.m., a telephone interview was conducted with Staff G, Nurse Practitioner (NP). She said when Resident #1 was re-admitted on [DATE] the nurse called her to let her know the resident was back and they verified admission orders. Staff G, NP said she did not discuss advanced directives but told the nurse to continue whatever orders the resident had from the hospital. She stated, After the hospitalization, whatever wishes he wanted in the hospital it was for the nursing home to follow. She stated she could not remember his code status. She said she recalled a second interaction, when the nurse called and said Resident #1 was in respiratory distress and was doing all possible measures at bedside. She said she told the nurse to call 911 and transfer him to the hospital based on symptoms he was having. Staff G, NP said she did not recall a follow up call after the initial communication with the nurse about sending Resident #1 to the hospital. She stated, Not sure they mentioned chest compressions during call. Staff G, NP said by the standards of care if a resident had signed orders for DNR, then chest compressions should not be started. On [DATE] at 2:31 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She said on [DATE] at approximately 3:00 p.m. there was a call light on for Resident #1's room. She said she helped Staff A, LPN move Resident #1 to the floor as instructed by Staff N, RN. Staff B, CNA said it was only her and Staff A, LPN who moved the resident. She said she informed Staff N, RN that CNAs were not allowed to do CPR and left the room. When she left the room, she said she informed one of the Minimum Data Set (MDS) nurses to call 911. A review of the position description for licensed practical nurses revealed the following: .Essential Functions 1. Works under direct supervision using the Nurse Practice Act, Policies and Procedures and nursing judgement. 4. Implements the resident plan of care and evaluates the resident response. 12. Initiates the emergency support measures (i.e. CPR, protects patients/residents from injury). General Patient/Resident Care . 8. Emergency situations are recognized and appropriate action is instituted. A review of the position description for registered nurses revealed the following: .Essential Functions 1. Works using the guidelines established from the Nurse Practice Act, COMPANY Standards, Policies and Procedures and nursing judgement. 4. Implements the patient/resident plan of care and evaluates the patient/resident response. 13. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury). A review of the position description for the unit supervisor-LPN revealed the following: .Knowledge/Skills/Abilities . 3. Knowledge of medical principles (symptoms, treatment alternatives, drug properties and interactions, and preventive health care). 4. Knowledge of applicable federal, state, and local regulations. A review of the facility policy titled Nursing Policies- Emergency Care (CPR), revealed the following: Policy . The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures, and Florida State law. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's advance directive or Do-Not-Resuscitate (DNR) order., Procedure . 2. The resident or legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. 3. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident, . 7. Should a resident experience cardiac emergency, staff will refer to the presence of the yellow form signed by the resident and physician, and/or the physicians order to determine if CPR should be performed. A review of the facility policy titled Admission/Social Services - Advance Directives, revealed the following: .Procedure. 5. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative. Once the resident or resident's legal representative and physician, autonomous advanced practice registered nurse or physician assistant have signed the Yellow DNR form, it will serve as the physician order concerning CPR for the resident. A review of the facility policy titled Admission/Social Services - Advance Directives - Resident's Right to Make Decision, revealed the following: Purpose . The facility respects the resident's or legal representative's right to make medical treatment decisions and be provided the appropriate information as required under State and Federal Rules and Regulations., A review of the facility policy titled Nursing - Admitting/Readmitting a Resident, revealed the following: Procedure The admission / readmission Procedure is initiated upon the resident's arrival to the facility. The nursing department, at a minimum will complete the following: . 2. Verify that transfer documentation is received and includes: . Codes status/Advance Directives . 5. Obtain additional physician orders as indicated and verify the following: . Code status/Advance Directives . 6. Accurately and completely transcribe verified physician orders onto the POS [point of service], MAR [medication administration record], TAR [treatment administration record], ADL [activities of daily living] sheets and/or other necessary locations and note when completed. A review of the facility policy titled Resident Rights, revealed the following: All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input. The facility's immediate actions to remove the Immediate Jeopardy included: - Disciplinary action/suspension was initiated for two nurses. RN was terminated and reported to Board of Nursing. - Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses. - Ad hoc [unplanned/spontaneous] quality assurance performance improvement (QAPI) meetings held on [DATE] and [DATE] to discuss concern and correction plan. [DATE] Ad hoc meeting held to review IJ citations. Ad Hoc meeting on [DATE] at 1:06 p.m. to discuss additional education to evaluate and reinforce education previously provided on code status, ANE reviewed, approved a code blue worksheet, reviewed and approved an abuse posttest to reinforce prior education. [DATE] Ad hoc at 4:31 p.m. to review, revise and approve code blue worksheet. - [DATE] Post ad hoc- took revised code blue worksheet to units and initiated review of the worksheet with staff. Anyone can complete the code blue worksheet. - Education 100% of nurses on advance directives, resident right to make a decision and emergency care (CPR) and ANE by [DATE]. New licensed staff were educated on abuse and code status upon hire. - 100% of resident medical records were reviewed- code status orders were verified. Audit was conducted of residents who expired in facility in past 90 days with no concerns found related to honoring code status. - Mock code drills were initiated on [DATE] at 4:30 p.m. and continued through current date [DATE] on varying shifts and days. - Code status for all new admissions after [DATE] were reviewed and verified. - [DATE] 23 of 23 nurses received reinforcement of prior education to verify and document code status orders. - [DATE] began implementation of the code drill worksheet and feedback received to add a box for full code/ DNR that can be checked. - [DATE] 69 of 104 non-licensed staff received additional education to evaluate and reinforce prior education on code status, who can perform CPR and emergency care, advance directives and abuse, neglect, and exploitation (ANE) and their role during a code blue. - Education initiated on [DATE] and [DATE] is ongoing and staff will complete reinforcement education prior to working next shift. Verification of the facility's removal plan was conducted by the survey team on [DATE]. - Interviews were conducted with twelve out of twenty-three licensed nursing staff and fifteen out of fifty-one licensed CNA's who worked across all shifts. Interviews were conducted with twenty-four staff members who were considered other licensed clinical (dietitian, social work, therapy) and non-clinical staff. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A review of in-service documentation revealed 100% of staff currently working had completed education and training related advanced directives policy/procedure, identification and respondin

Based on record reviews, policy reviews, Quality Assurance Performance Improvement (QAPI) documentation, and interviews the facility failed to ensure staff were educated and had the tools to respond to a resident's change in condition related to knowing if the Certified Nursing Assistant's (CNA) were allowed to perform cardiopulmonary resuscitation (CPR) and if code blue forms were utilized during a code.Findings included:Review of Resident #1's record showed signed Do Not Resuscitation Order (DNRO) on [DATE]. Review of Resident #1's hospital records (found in the facility's uploaded miscellaneous documents for the resident) showed the acute care facility, had noted on 12/24 and [DATE] the resident's code status was Do Not Resuscitate (DNR). The uploaded documents did not reveal the order had been rescinded. Review of Resident #1's physician orders showed a DNR order was initiated on [DATE]. Review of Resident #1's progress notes showed the resident suffered a change in condition while at the facility on [DATE]. While Staff N, Registered Nurse (RN), was assessing the resident, the resident stopped breathing and had no pulse as reported by Staff A, Licensed Practical Nurse (LPN). Staff N, RN directed Staff A, LPN and Staff B, Certified Nursing Assistant (CNA) to place resident on the floor and begin chest compressions. Staff B informed Staff N that CNA's were not allowed to perform CPR at the facility. Staff D (LPN) and Staff E (LPN) continued CPR until Emergency Medical Services (EMS) arrived and took over. Interviews on 1/20, 1/21, and [DATE] with staff, including the Nursing Home Administrator (NHA), the Regional Nurse Consultant, Regional Director of Operations, that Staff A, Staff B, Staff D, and Staff E did not verify Resident #41's code status prior to performing CPR on Resident #1 whose wishes were not to resuscitated. During an interview on [DATE] at 4:29 p.m. the NHA stated recalling the event with Resident #1. The NHA said if staff discovered a resident to be unresponsive, the staff would assess the resident and determine code status. If a resident has a DNR then staff should not start chest compressions. The NHA stated CNAs are not allowed to perform CPR. The NHA stated if CPR is started, the code should be documented. The facility has attached blank paper to the crash cart for staff to take notes of vital signs, code status, who was involved, was 911 called and then following the code was the physician and family notified. The NHA confirmed the process was not new and had been in place at the time of the incident. The NHA stated staff had not used the blank paper to note the actions taken during Resident #1s event. The NHA stated the code status is verified by the physician order (electronic). The NHA said on [DATE] staff education occurred regarding abuse and neglect, mock (code) drills were started and continued for 7 days on each shift. The NHA stated all nurses have participated in these drills. The NHA stated no change in the process was needed based on the results of the mock drills. An interview was conducted on [DATE] at 12:03 p.m. with Staff D, LPN. Staff D reported participating in the chest compressions of Resident #1. The staff member reported the code sheets are on the crash cart and the process was not new. Staff D stated CNAs are not allowed to perform CPR, they can take direction from the nurse and grab the computer. An interview was conducted on [DATE] at 12:52 p.m. with Staff E, LPN. Staff E confirmed performing chest compressions on Resident #1. The staff member reported Resident #1s code was not paged overhead, it was a big to do, the process hasn't changed just doing more drills and had never see a code blue log (form) until now. An interview was conducted on [DATE] at 2:45 p.m. with Staff H, LPN. The staff member reported thinking the facility used code sheets (forms), thought they were on the crash cart, Aren't they standard?. An interview was conducted on [DATE] at 3:01 p.m. with Staff I, Registered Nurse (RN). Staff I reported being educated on code blues and does the mock codes on the weekends. The staff member stated the process hadn't changed, the regulation never changes, the facility does a timeline of what happens during a code, and the timeline has always been the protocol. The staff member stated the code sheets/timeline should be on the crash cart but wasn't. An interview was conducted on [DATE] at 3:12 p.m. with Staff J, CNA. The CNA reported not knowing if CNAs allowed to do CPR. If the CNA is CPR certified, then guess they could do it why else would they [the facility] have asked for it [the CPR certification]. An interview was conducted on [DATE] at 3:16 p.m. with Staff K, CNA. The staff member reported being educated on a code blue, and the CNA role is to call 911, and anything else the nurse requests. Staff K stated the facility has a book listing resident's code statuses at the desk. An interview was conducted on [DATE] at 3:21 p.m. with Staff L, LPN. The staff member reported the facility doesn't do a code timeline, not that I'm aware of. A review of the policy - Quality Management, undated, revealed This facility will create a caring and nutrient environment, focused on professionalism and excellence in service delivery. The facility strives to be the provider of choice as well as the employer of choice in our community. The facilities mission statement is to provide quality focused care, one resident at a time. Through quality assurance and performance improvement (QAPI), the facility will take a proactive approach to continually improving care and services to our residents. The facility will involve residents, staff, and other partners to realize our vision of being both the provider and the employer of choice in this community. To do this, all employees will participate in ongoing QAPI efforts to support our mission of providing quality focused care, one resident at a time. The guiding principles included: The facility will use QAPI to make decisions and improve the day-to-day operationsQAPI will include all employees, every department, and all services providedQAPI focuses on systems and processes, rather than individuals.The facility will support performance improvement by encouraging our staff to support each other as well as to be accountable for their own professional performance and practice.The facility we'll make decisions based on data, which will include the input and experiences of caregivers, residents, health care partners, families, and other stakeholders.The desired outcome of QAPI in the facility is the improved quality of care in the enhanced quality of life for our residents. The administrator is responsible for the quality assessment and assurance committee for the facility. The facility will have an internal quality assurance and performance improvement program designed to provide a comprehensive approach to high ensuring high quality care and services. The QA&A Committee referred to as the QAPI committee, we'll meet at least monthly and we'll utilize the five elements of QAPI which are: Design and ScopeGovernance and LeadershipFeedback, Data Systems, and MonitoringPerformance Improvement Projects (PIPs)Systemic Analysis and Systemic Action The composition and duties of the QAPI committee included: 2. The Committee Will identify opportunities for improvement as well as recommend, implement, monitor, and evaluate changes. The committee will address all systems of care and management practices, immune for safety and high quality while emphasizing an autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals.3. The Committee will obtain data from multiple sources, including performance indicators which are benchmarked, and will incorporate input from staff, residents, families, and others as appropriate.4. The Committee will charter performance improvement projects (PIPs) to provide concentrated efforts to address a particular problem areas identified in one part of a facility or facility wide. The facility conducts PIPs to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement.6. Once the root cause has been established, changes or corrective actions tightly linked to the root cause will be implemented. These changes are corrective measures should offer long term solutions to the problem, and must be achievable, objective, and measurable.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as indicated by the following: - Refrigerated, ready-to-eat, Time/temperature Control for Safety foods were stored too long under refrigeration and not date-marked to indicate when the food must be consumed or discarded. - The kitchen area was not protected from contamination from unauthorized employees entering the area and not wearing hair restraints. - Stored packaged food was not protected from potential cleaning chemical contamination in the food storage room. - The surface material of equipment was not kept in good condition and was not smooth and easily cleanable. - Clean eating equipment was not stored in a manner to prevent contamination of the mouth/food contact surfaces. - Clean equipment was not stored to protect from contamination from the outside environment and wildlife. - Food was not labeled to its identity. - Staff did not know how to calibrate the food thermometer and did not calibrate the thermometer before use. - Food contact and non-food contact surfaces of equipment were not visibly clean to sight and touch. - Food service staff did not properly wash their hands before donning clean gloves. - Exposed food was not protected from contamination. - Exposed food and clean equipment and utensils were not protected from contamination in that trash cans were not covered during meal service. - The automatic paper towel dispenser above the hand sink located in the Island View dining room kitchen did not function. - The freezer compartment of the refrigerator in the 1 & 2 Nourishment Room was not maintaining temperature to keep frozen food frozen. These practices have the potential to cause foodborne illness to 104 of 104 residents in the facility, who consume the facility's food. Findings included: During the Initial Kitchen Tour in the nursing home warming kitchen on 02/19/24 at 9:44 AM, there was a block of sliced American pasteurized cheese wrapped in plastic wrap (not the original packaging) with a hand written date of 2/8/24, stored in the white Hotpoint refrigerator/freezer unit. There also was no label on the cheese packaging. Photographic evidence obtained. The American cheese was stored more than 7 days under refrigeration (American cheese is not exempt from date-marking). At 10:01 AM, there was an insect electrocution device mounted on the kitchen wall behind the juice dispenser and above a preparation counter, which was not conducive to preventing dead insects and insect fragments from being impelled onto or falling on exposed food and clean equipment. Photographic evidence obtained. At 10:05 AM an unauthorized nursing staff with long hair entered kitchen without a hair restraint to get a cup of coffee. Continuing the Initial Kitchen Tour at 10:03 AM, in the room where the hand washing sink was located, there were cleaning chemicals stored with canned sodas in this area. Photographic evidence obtained. At 10:07 AM, during the Initial Kitchen Tour, the drawer face (or front) of the left drawer of the white kitchen counter cabinet was missing, exposing the unfinished wood, which was not easily cleanable. Photographic evidence obtained. At 10:09 AM, there were 2 stacks of 13 maroon colored insulated plate bases that had multiple scratched and gouged edges on the surface on each of them. Additionally, there was a silverware caddy with multiple knives and forks stored in it, that were positioned with the mouth/food contact surface upright. Photographic evidence obtained. At 10:15 PM, There was a bag of dry cereal that was stored on a counter that was not labeled to its identity. Photographic evidence obtained. During the Initial Tour, at 10:12 AM, there was a rusted white wire shelf in the Artic Air double door refrigerator unit. Photographic evidence obtained. During a follow up visit to the kitchen on 2/21/24 at 11:59 AM, Dietary Aide, Staff H (a contract employee) was taking temperatures of hot food held on the steam table before the lunch meal service. He kept putting his thermometer in a Styrofoam cup with cold water (no ice) after he took the temperature. He said he did this to bring down the temperature of the thermometer. He was recording these temperatures in the temperature log. At 12:16 PM, Dietary Aide, Staff H was asked how he calibrated his thermometer and he said, what's that? The facility Registered Dietitian, who was standing nearby said that they use ice water to calibrate the thermometers. Dietary Aide, Staff H said he uses water (without ice). He did not calibrate the thermometer to check its accuracy before taking hot food holding temperatures. The surveyor asked for a cup of ice water to check the accuracy of the facility thermometer and the surveyor's thermometer. The facility thermometer read 34 degrees Fahrenheit (F), and not 32 degrees F. During this time a mobile plastic open side standard service cart with packaged food stored on top of it, had a buildup of soil on one side of the cart. The cart was stored next to the steam table. Photographic evidence obtained. Additionally, all the metal steam table pans were dented on the edges and were not flush to the steam table wells (these were property of the off-site kitchen). Photographic evidence obtained. There were multiple insulated dome plate covers with the surfaces scratched and gouged stored on a shelf. Photographic evidence taken. On 2/21/24 at 12:18 PM during the lunch meal service, Dietary Aide, Staff H used hand sanitizer from a dispenser on the wall in the kitchen before donning his gloves. He was told he must use soap and water to wash his hands. The Dietary Manager (a contract employee) said a few minutes later that ServSafe [food safety training and certification program that was developed and run by the National Restaurant Association] says you can use hand sanitizer for changing gloves. During a follow up visit to the warming kitchen on 2/21/24 at 02:12 PM, after the lunch meal service was completed, there were 4 plates of plated food from lunch stored on the shelf above the steam table. The exposed food was not covered or held in temperature control. Photographic evidence obtained. There was a shelf over the steam table in which there was an accumulation of black food matter underneath the shelf. Photographic evidence obtained. There was a white powdery/flake-like substance on the milk crates used to store cases of carbonated beverages in the room where the hand sink is located. Photographic evidence obtained. There were 2 clean enclosed tray delivery carts stored outside of the kitchen when not in use. The Dietary Manager said one cart was broken. The area outside was not screened in and not protected from contamination. Photographic evidence obtained. There were clean insulated dome plate covers that in which the outer surface was scratched, worn, and gouged. These were no longer a smooth, easily cleanable surface. During follow up visit to the warming kitchen on 2/22/24 at 8:50 AM, there was no trash can available to dispose of used paper towels after using the hand sink. The only trash can in the kitchen was across on the other side. There was no cover on the trash can and the breakfast meal service was in process. Photographic evidence obtained. During the lunch service on 2/22/24 at 12:23 PM in the independent Island View dining room, there were several insulated dome plate covers that had worn surfaces. Photographic evidence obtained. There was silverware stored with food/lip surface positioned up in a caddy. Photographic evidence obtained. The automatic paper towel dispenser did not work, so staff used napkins to dry their hands after washing them at the hand sink in the dining room kitchen area. There was a block of wrapped American pasteurized cheese slices wrapped in plastic wrap that was stored in the [NAME] refrigerator/freezer unit in the dining room kitchen area. The date handwritten on the American cheese packaging was illegible. Photographic evidence obtained. At 12:34 PM, the trash can in the Island View dining room near the kitchen serving line had no cover on it and the lunch meal service was in progress. There were several nursing staff who were not wearing hairnets who entered the Island View Kitchen area with clean equipment and clean utensils present. On 02/22/24 at 8:59 AM, in the Warming kitchen, there was a squirrel observed eating food from soiled eatingware that was stored a mobile sheet pan rack cart located in the area outside the kitchen. This is the area where clean enclosed tray delivery carts were observed to be stored on 2/21/24. Photographic evidence obtained. A few minutes later, the cart was taken by a kitchen staff member to the off-site kitchen. On 2/21/24 at 2:02 PM, the refrigerator compartment of the Insignia refrigerator/freezer unit in the Station 3 Nourishment Room had a container of a Thick and Easy supplement that was opened and not date marked. The temperature on the dial thermometer located in the freezer compartment of the Insignia refrigerator/freezer unit in the Station 1 & 2 Nourishment Room on 2/21/24 at 2:29 PM read (+) 12 degrees F. The freezer compartment had a box of individual 4 ounce containers of ice cream stored in it. The individual ice cream containers were not firm to touch. Photographic evidence obtained.

Based on interviews and record review, the facility failed to develop and implement appropriate plans of actions to correct identified quality concerns related to resident falls. This concern has the potential to affect all residents in the facility. The findings include: On 2/22/24 at approximately 12:39 PM, an interview was conducted with the Risk Manager in the presence of the Regional Nurse Consultant. During the interview the Risk Manager stated that he has been in is position since September 2023 and that part of his position was quality improvement. He stated that as part of his performance improvement efforts he tracks falls in the facility by nursing station. At this time he presented a graph titled Falls by Unit that included the number of falls that had occurred in each month of 2023 for Station 1 (25 falls), Station 2 (26 falls), and Station 3 (181 falls). The graph demonstrated that 87% of the falls that had occurred in the facility in 2023 had occurred on Station 3. The graph also supported that Station 3 had 25 falls in the month of November while stations 1 and 2 had zero. When asked if he had investigated why station 3 had such a large number of falls he stated that station 3 was the short term rehabilitation unit and he expected there to be more falls. When asked if he had offered training to staff on fall prevention, observed staff for care concerns or developed a performance improvement plan (PIP) to address fall concerns he stated No. A review of the job description for Director of Risk Management revealed, Responsible for the facility Risk Management program, functioning under the direction of the facility Administrator. Under essential functions was included Plans develops, organizes, evaluates and directs the facility safety programs, including the evaluation and establishment of safety objectives. Performs routine chart audits in order to analyze and identify areas of improvement. Uses this information to structure and accomplish targeted staff training as indicated. Prepares written weekly Risk Management Report designed to identify risk and report on preventive action plans. Reviews with the Administrator and establishes goals. Serves as a liaison with the Director of Nursing to ensure nursing department involvement of risk identified and awareness of goals established for quality improvement. A review of the Policy for Quality Management revealed that the facility will have an internal Quality Assurance and Performance Improvement (QAPI) Program designed to provide a comprehensive approach to ensure high quality care and services. The policy identifies that QAPI is an ongoing program that is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily lift for residents. It utilizes the best available evidence to define and measure goals. Feedback, data systems and monitoring includes the facility will put systems in place to monitor care and services through the use of multiple sources. Performance Indicators will monitor a wide range for care and outcomes and findings will be compared to benchmarks or targets established for performance. Performance Improvement Projects (PIPs) involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. Systemic analysis and systemic action the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level.

Based on interviews and record reviews, the facility failed to provide resident centered restorative services to maintain or improve mobility for three residents (#62, #47, and #46) of three residents sampled for restorative services. Findings included: A review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the left hip and bilateral knees, muscle weakness, need for assistance with personal care, and reduced mobility. A review of Resident #62's physician's orders revealed an order, dated 1/30/2024 for restorative services for active range of motion (AROM) to bilateral lower extremities (BLE), wheel chair mobility, and active range of motion to bilateral upper extremities (BUE). The order did not reveal a frequency of how often Resident #62 was to receive restorative services. An interview was conducted on 2/19/24 at 4:13 PM with Resident #62 in the resident's room. Resident #62 was observed up in her wheelchair near her bed. Resident #62 stated she was supposed to be receiving restorative therapy and she was not receiving restorative services on a consistent basis. A review of Resident #62's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/5/2024, revealed under section O - Special Treatments, Procedures, and Programs, Resident #62 received Range of motion (active) under the Restorative Nursing Program for one session of at least 15 minutes during the past 7 calendar days. A review of Resident #62's Physical Therapy Discharge Summary revealed Resident #62 received therapy from 12/14/2023 to 1/17/2024 and was discharged to the facility's Restorative Program on 1/17/2024 for range of motion (ROM). The summary also revealed under the section titled Functional Maintenance Prognosis Resident #62's prognosis to maintain current level of functioning (CLOF) was excellent with consistent staff support. A review of the facility's Restorative Program record revealed the following: - Resident #62 did not receive restorative services during the week of 1/22/2024 to 1/28/2024. No refusal of services were documented. - Resident #62 received restorative services one time during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. - Resident #62 received restorative services one time during the week of 2/12/2024 to 2/18/2024. No refusal of services were documented. A review of Resident #62's Point of Care (POC) history for the dates of 1/21/2024 to 2/20/2024 revealed the following for the task Restorative: ROM (Active) and AROM to BLE/BUE: - 1/29/2024 at 2:59 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:58 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/18/2024 at 2:17 AM: 2 minutes. No refusals were documented in the record. The POC history also revealed for the dates of 1/21/2024 to 2/20/2024 the following for the task Restorative: wheelchair mobility using BUE: - 1/29/2024 at 2:59 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:58 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/18/2024 at 2:18 AM: 2 minutes. No refusals were documented in the record. A review of Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following non-traumatic subarachnoid hemorrhage affecting right dominant side, difficulty walking, and muscle weakness. A review of Resident #46's physician's orders revealed an order, dated 1/4/2024 for restorative services for AROM to BUE/BLE and ambulation with rollator walker (RW) at facility level. The order did not reveal a frequency of how often Resident #46 was to receive restorative services. A review of Resident #46's quarterly MDS assessment, with an ARD of 2/13/2024, revealed under section O - Special Treatments, Procedures, and Programs, Resident #46 received Range of motion (active) under the Restorative Nursing Program for three sessions of at least 15 minutes during the past 7 calendar days. A review of Resident #46's Physical Therapy Discharge Summary revealed Resident #46 received therapy from 11/11/2023 to 12/4/2023 and was discharged to the facility's Restorative Program on 12/4/2023 for ambulation and ROM. The summary also revealed under the section titled Functional Maintenance Prognosis Resident #46's prognosis to maintain CLOF was excellent with consistent staff support. A review of the facility's Restorative Program record revealed the following: - Resident #46 received restorative services two times during the week of 1/22/2024 to 1/28/2024. An entry for 1/24/2024 was marked bed. - Resident #46 received restorative services one time during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. A review of Resident #46's POC history for the dates of 1/22/2024 to 2/21/2024 revealed the following for the task Restorative: Ambulation with RW at facility level: - 1/23/2024 at 4:05 PM: 15 minutes. - 1/24/2024 at 2:59 PM: Resident not available. - 1/28/2024 at 2:40 AM: 2 minutes. - 1/30/2024 at 6:07 PM: Not applicable. - 2/6/2024 at 4:15 PM: Not applicable. - 2/7/2024 at 4:57 PM: 15 minutes. - 2/9/2024 at 1:55 PM: 15 minutes. - 2/13/2024 at 1:07 PM: 15 minutes. - 2/14/2024 at 5:31 PM: 15 minutes. - 2/20/2024 at 5:57 PM: 15 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. No refusals were documented in the record. The POC history also revealed for the dates of 1/22/2024 to 2/21/2024 the following for the task ROM (Active)to BUE/BLE: - 1/23/2024 at 4:05 PM: 15 minutes. - 1/24/2024 at 2:59 PM: Resident not available. - 1/28/2024 at 2:40 AM: 2 minutes. - 1/30/2024 at 6:08 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:57 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/13/2024 at 1:07 PM: 15 minutes. - 2/14/2024 at 5:31 PM: 15 minutes. - 2/20/2024 at 5:57 PM: 15 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 3:52 PM: 15 minutes No refusals were documented in the record. A review of Resident #47's medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, muscle weakness, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A review of Resident #47's physician's orders revealed an order, dated 1/26/2024 for restorative services for ambulation and AROM to BLE. The order did not reveal a frequency of how often Resident #47 was to receive restorative services. A review of Resident #47's Physical Therapy Discharge Summary revealed Resident #47 received therapy from 11/20/2023 to 1/24/2024 and was discharged to the facility's Restorative Program on 1/24/2024 for gait and therapeutic exercise. The summary also revealed under the section titled Functional Maintenance Prognosis Resident #47's prognosis to maintain CLOF was good with consistent staff follow-through. A review of the facility's Restorative Program record revealed the following: - Resident #47 did not receive restorative services during the week of 1/22/2024 to 1/28/2024. No refusal of services were documented. - Resident #47 did not receive restorative services during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. - Resident #47 received restorative services two times during the week of 2/12/2024 to 2/18/2024. No refusal of services were documented. A review of Resident #47's POC history for the dates of 1/23/2024 to 2/22/2024 revealed the following for the task Ambulation with RW with contact guard assist (CGA) of 1: - 1/26/2024 at 4:25 PM: 3 minutes. - 1/27/2024 at 4:28 PM: 2 minutes. - 1/28/2024 at 2:25 AM: 2 minutes. - 1/29/2024 at 9:08 PM: 2 minutes. - 1/30/2024 at 7:16 PM: 2 minutes. - 2/2/2024 at 6:59 PM: 2 minutes. - 2/3/2024 at 7:08 PM: 2 minutes. - 2/4/2024 at 5:19 PM: 2 minutes. - 2/5/2024 at 7:25 PM: 2 minutes. - 2/6/2024 at 4:16 PM: 15 minutes. - 2/7/2024 at 4:58 PM: Refused. - 2/8/2024 at 4:56 PM: 2 minutes. - 2/9/2024 at 3:38 PM: 2 minutes. - 2/12/2024 at 8:59 PM: 2 minutes. - 2/13/2024 at 5:09 PM: 2 minutes. - 2/14/2024 at 5:32 PM: Refused. - 2/15/2024 at 5:43 PM: 15 minutes. - 2/16/2024 at 9:03 PM: 2 minutes. - 2/17/2024 at 4:33 PM: 2 minutes. - 2/18/2024 at 4:19 PM: 2 minutes. - 2/19/2024 at 8:55 PM: 3 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 9:22 PM: 2 minutes. The POC history also revealed for the dates of 1/23/2024 to 2/22/2024 the following for the task ROM (Active)to BLE: - 1/26/2024 at 4:25 PM: 3 minutes. - 1/27/2024 at 4:28 PM: 2 minutes. - 1/28/2024 at 2:25 AM: 2 minutes. - 1/29/2024 at 9:08 PM: 2 minutes. - 1/30/2024 at 7:16 PM: 2 minutes. - 2/2/2024 at 6:59 PM: 2 minutes. - 2/3/2024 at 7:08 PM: 2 minutes. - 2/4/2024 at 5:19 PM: 2 minutes. - 2/5/2024 at 7:25 PM: 2 minutes. - 2/6/2024 at 4:16 PM: 15 minutes. - 2/7/2024 at 4:58 PM: Refused. - 2/8/2024 at 4:56 PM: 2 minutes. - 2/9/2024 at 3:38 PM: 2 minutes. - 2/12/2024 at 9:00 PM: 2 minutes. - 2/13/2024 at 5:09 PM: 2 minutes. - 2/14/2024 at 5:32 PM: Refused. - 2/15/2024 at 5:43 PM: 15 minutes. - 2/16/2024 at 9:03 PM: 2 minutes. - 2/17/2024 at 4:33 PM: 2 minutes. - 2/18/2024 at 4:19 PM: 2 minutes. - 2/19/2024 at 8:55 PM: 3 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 9:23 PM: 2 minutes. An interview was conducted on 2/21/2024 at 11:06 AM with Staff A, Assistant Director of Nursing (ADON). Staff A, ADON stated the facility had 16 total residents on the restorative program and the program was offered to the residents three times a week. Staff A, ADON also stated residents refused the services at times and refusals would be documented in the resident's record. During a follow up interview at 12:15 PM, Staff A, ADON reviewed Resident #62's restorative therapy documentation and was not able to state why the resident was not offered restorative services three times a week. Staff A, ADON stated the documentation showing Resident #62 was offered restorative therapy should be in the resident's medical record. An interview was conducted on 2/21/2024 at 12:18 PM with Staff B, Restorative Certified Nursing Assistant (RCNA). Staff B, RCNA stated residents on restorative therapy are offered services three times a week, which is documented in the electronic medical record and on the restorative therapy record. Staff B, RCNA also stated only 16 residents can participate in the restorative program at a time and resident's waiting for restorative services could be waiting for up to a month before they receive restorative therapy due to the facility on ly having one restorative aide. An interview was conducted on 2/21/2024 at 1:50 PM with Staff A, ADON. Staff A, ADON stated the facility has a waiting list for residents who are ordered restorative therapy and they are only able to assist 16 residents at a time with restorative therapy. Staff A, ADON also stated she was not aware certain residents were only being offered therapy one or two times a week and stated she should be notified of any residents who refuse restorative therapy or if the resident is offered less than three times a week. An interview was conducted on 2/21/2024 at 2:27 PM with the facility's Director of Nursing (DON) and Staff A, ADON. The DON stated orders are received when a resident discharges from therapy for restorative therapy which indicate the focus area and amount of repetitions the resident is to perform during therapy. Staff A, ADON stated they were instructed by their corporate team to not have instructions related to the duration of therapy put into the resident's order for restorative therapy or a how often the resident is to receive the services. The DON stated the facility process is to only take 16 residents at one time for restorative services and they rarely have residents who have orders for restorative therapy who do not receive restorative therapy. An interview was conducted on 2/22/2024 at 8:47 AM with Staff C, Physical Therapist (PT). Staff C, PT stated restorative therapy is limited to 16 residents in the facility at any given time and the nursing staff determine which resident's continue to receive restorative therapy based on the resident's goals. Staff C, PT also stated the goal of restorative therapy is to ensure the resident does not decline after receiving therapy services and for the resident to maintain ROM and the ability to ambulate. Staff C, PT stated after a resident receives physical therapy, they place a referral to the restorative nursing program into the referral bin, which is then picked up by the restorative CNA. The therapy department will review the resident's program and train the RCNA on the restorative needs of the specific resident. Staff C, PT stated residents should receive restorative therapy as much as they are able to tolerate and the restorative nurse should ask the resident how often they would like to participate in the therapy. Staff C, PT also stated it would take the RCNA longer than 2 or 3 minutes to complete a restorative session and there is a difference between normal ROM performed during care and the specific restorative therapy routine the resident is to receive. A review of the facility policy titled Restorative Nursing, with no effective date, revealed restorative nursing programming refers to a formal nursing program which includes interventions that serve to assist the resident in restoring or attaining the ability to live as independently and as safely as possible. The program focuses on achieving optimal physical, mental, and psychosocial functioning. The Restorative Nursing Program is individualized and goal oriented based on the resident's identified strength and needs. It includes measurable objectives and interventions that are documented in the resident's medical record and outlined in the plan of care.

Based on record review and staff interview, the facility failed to provide the appropriate transfer/discharge notice to the resident and their responsible party and failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge for one resident (#98) of two sampled residents reviewed for transfer and hospitalization . The findings included: A record review was conducted for Resident #98 which revealed a pink form titled SNF (Skilled Nursing Facility) to ED (Emergency Department) Handoff dated 12/29/23. The form indicated the resident was being transferred to the ED for abnormal vital signs and altered mental status. Review of the record revealed the resident did not return to the facility. Review of the Agency for Health Care Administration (AHCA) Nursing Home Transfer and Discharge Notice, form 3120-0002, listed Resident #98's name, the facility name, address, facility contact person and telephone number, and the signature of the Unit Manager (UM). All other areas of the form were blank to include the resident's representative contact information, date the notice was given, the effective date and the reason for the discharge. A review of the AHCA form Long Term Ombudsman Program Request for Review of Nursing Home Discharge or Transfer Form, form 3120-0004, revealed the form contained no resident information and was completely blank in all areas except for a check mark indicating check if this involves an emergency discharge or transfer. The form was signed by the UM and the words verbal consent were written in the resident or resident representative area. Review of the Fair Hearing Request for Transfer or Discharge from Nursing Home was completely blank of all resident information, was signed by the UM and offered that verbal residents written above the resident/representative signature line. A review of Resident #98's admitting diagnoses included: Unspecified Fall, Subsequent Encounter Unspecified Injury of Head, Abnormalities of Gait and Mobility, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. A review of progress notes for Resident #98 revealed the following: 12/21/23 Admission Note Text: admitted from the hospital via wheelchair and 1 transporter. No complaints of pain or discomfort. Skin assessment completed. Dressings to right and left arm changed. Daughter in to sign consents 12/22/23 Note Text: Monitoring device placed to right ankle for an elopement risk of 9. 12/22/23 Note Text: Monitoring device expiration date 09/20/26. right ankle. 12/27/23 Late Entry: Note Text: Plan of Care meeting: Team Members present: Therapy, Social Services, Resident declined, Family Member present via phone. Advance Directive: DNR (Do Not Resuscitate); Discharge plan: Resident lives at an assisted living facility (ALF). Resident was assisted prior with showers and dressing as needed. Family Member is looking into Memory Care if needed. Declined consult services at this time. No concerns at this time. Resident/representative has reviewed medication list and care plan with nurse. Resident has not displayed exit seeking behaviors prior to admission per the resident representative. 12/28/23 Late Entry: Note Text: Attendees: Director of Nursing (DON), Risk Manager, Unit Manager, Registered Dietician, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator, Wound Care Nurse, Activities Director, and Rehab Director. Discussion about Accidents and Incidents: None, Weight/Diet/Adaptive Equipment, Skin Condition, Bowel and Bladder, Psychotropic Medications, Therapy to include Physical, Occupational and Speech, Fall Interventions, and Monitoring Device with Exit Seeking Behaviors. 12/29/23 Family Member and Medical Doctor made aware of resident being transferred to hospital for 140 heart rate and 44 respiration transferred to hospital. Did not return to facility. Family requested a locked unit for resident. On 02/22/24 at approximately 11:34 AM, an interview was conducted with the DON during which she stated when a resident is transferred to the ED (Emergency Department) there are usually two or three nurses working to complete the required transfer/discharge forms. She stated if the resident is transferred before the forms are completed, they will fax them to the ED. At this time, she was shown the blank forms that were signed by the Unit Manager she stated, Oh this is not good. She verified the forms should be completely filled out and stated, This is unacceptable. On 2/22/24 at approximately 1:00 PM, the SSD stated she sends a fax to the Office of the State Long-Term Care Ombudsman on the first of each month with a list of residents who had been discharged from the facility for the preceding month. She provided a copy of a fax confirmation dated 1/1/24 at 9:52 AM. Attached to the fax confirmation page was a Discharge Report for the dates 12/1/23 to 12/31/23. Resident #98's name was not included on the list. The SSD confirmed Resident #98's name was not on the list that was faxed to the Ombudsman's office on 1/1/24. The SSD proceeded to run the Discharge Report again for the same dates and the resident's name appeared. The SSD was not sure why the resident's name did not appear in the original report but stated she would fax it to the ombudsman again today (2/22/24).

Based on observation, interview and record review, the facility failed to revise the care plan for one resident (#13) of 20 sampled residents whose care plans were reviewed, to reflect the current interventions to manage healing and prevention of pressure ulcers. Findings included: Resident #13 was originally admitted on [DATE] and the most recent admission was 1/20/23. The resident was hospitalized on [DATE] with no pressure ulcer present upon transfer to the hospital Resident #13's pertinent diagnoses included Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness and tremors); Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); severe protein-calorie malnutrition; hypo-osmolality (increased body fluid volume and decreased solute volumes in the blood) and hyponatremia (abnormally low sodium levels in the blood); oropharyngeal phase dysphasia (swallowing disorder); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; hypertension (high blood pressure), orthostatic hypotension (a medical condition wherein a person's blood pressure drops when standing up or sitting down); hyperkalemia (below normal blood potassium level); legal blindness; muscle weakness; Vitamin B12 deficiency; benign paroxysmal vertigo (an inner ear disorder that causes a spinning sensation); Vitamin D deficiency; unspecified glaucoma (a group of eye conditions that damage the optic nerve); spinal stenosis, cervical region (the narrowing of one or more spaces within the spinal canal in the neck); anxiety disorder; unspecified macular degeneration (a vision impairment resulting from deterioration of the central part of retina). According to Resident #13's Minimum Data Set (MDS) Significant Change in Status Assessment, with an Assessment Reference Date (ARD) of 8/29/23, the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed Resident #13 required extensive assistance with bed mobility, transfer, eating, toilet use, personal hygiene with one person assist. For walking in room and on corridor, this activity did not occur and she required limited assistance with locomotion on and off the unit. Resident #13 was occasionally incontinent with urine and always continent with bowel. The MDS indicated that she had no prognosis of a condition or chronic disease that may result in life expectancy of less than 6 months. The resident had no swallowing disorder, her height was 60, there was no weight documented (due to hospice) and there was no weight loss or gain or it was unknown in last month or 6 months. Resident #13's assessment indicated she had no pressure ulcer; was at risk for developing a pressure ulcer, had no unhealed pressure ulcers. In addition, the MDS indicated that the resident had a pressure reducing chair device and bed; no turning/repositioning program; no nutrition or hydration interventions related to pressure ulcer management; and ointments/medications were applied to her skin other than to feet. According to Resident #13's Quarterly MDS, with an ARD of 11/29/23, the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed resident #13's interim performance for self-care included substantial/maximal assistance with toilet hygiene, personal hygiene; dependent with eating; putting on/taking off footwear; partial/moderate assistance with rolling left and right in bed, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The assessment indicated it was not applicable for the resident to walk 10 feet; the resident could wheel 50 feet with 2 turns in a wheelchair and wheel 150 feet with partial/moderate assistance. Resident #13 was occasionally incontinent with urine and always continent with bowel. The MDS indicated she had no prognosis of a condition or chronic disease that may result in life expectancy of less than 6 months. The resident had no swallowing disorder, her height was 60, she weighed 107 lbs., and there was no weight loss or gain or it was unknown in last month or 6 months. Resident #13's assessment indicated she had no pressure ulcer; was at risk for developing a pressure ulcer, had no unhealed pressure ulcers. In addition, the MDS indicated the resident had a pressure reducing chair device and bed; no turning/repositioning program; no nutrition or hydration interventions related to pressure ulcer management; and ointments/medications were applied to her skin other than to feet. Resident #13's care plan initiated on 5/4/23 and revised on 11/27/23, included a focus related to pressure ulcer management - resident was at risk for impairment to skin integrity related to impaired physical mobility, fragile skin, incontinent of bowel and bladder, need for assistance with bed/functional mobility, circulatory deficiencies, end stage disease process. The care plan included two goals: The resident's will have no complications related to skin injury type through the review date. Among the many care plan interventions included, there was an intervention for The resident needs pressure reducing mattress, pillows, padding etc., to protect the skin while in bed/chair. There was a physician's order on the February 2024 Treatment Administration Record for use of pillow under legs to suspend heels off of bed - every shift for pressure ulcer management, left heel. According to the most recent Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #1 - left posterior heel, documented the following: acquired during admission on 1/30/24, which was a pressure ulcer; SDTI [suspected deep tissue injury]; improving; dry, intact non blanching dark maroon discolored tissue; no drainage, no odor, length 2.0 cm x width 2.6 cm x depth 0 cm; peri-wound tissue is pink, firm blanching tissue, no erythema; well defined wound border; no infection; skin prep to area every shift, no dressings; showing improvement, no erythema at peri tissue. The Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #2 - left buttock wound, documented the following; acquired during admission on 1/30/24; pressure ulcer; SDTI; improving; epithelial tissue present; dry, 100% pink exposed tissue; no drainage, no odor, length 1.0 cm x width 0.4 cm x depth 0.1 cm; peri-wound tissue is pink, blanching tissue intact; well defined wound, improved; no infection; nurses to apply Baza protect 12% moisture barrier cream to area every shift, no dressings. improved, healing. The Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #3 - right buttock, documented the following; acquired during admission on 1/30/24; pressure ulcer; SDTI; healed; dry, 100% intact closed tissue; no drainage, no odor, intact pink, blanching, no swelling; no open wound; no inflammation; nurses to apply Baza protect 12% moisture barrier cream to area every shift, no dressings. closed intact tissue; nursing continues to apply Baza Protect cream, follow up often. During an observation on 2/21/24 at 8:24 AM, Resident #13 was lying in her bed awake. She had a blanket over her and her legs and feet were angled toward her right. There was no pillow under her feet to offload and she was wearing socks on her feet. She had a scoop mattress on her bed. She is a very thin female with no fat tissue over her bony prominences. On 2/21/24 at 8:40 AM, Resident #13 had finished her breakfast. She said she ate half of her breakfast sandwich. She had enough to eat. She said she hasn't got her appetite back. She was lying in bed on her back with her knees bent and angled toward her right. There was no pillow under her feet to off load her feet. She was asked if she had a pillow under her feet and she said no and doesn't want a pillow. Resident #13 was asked if she had any bed sores and she said yes - on her foot. She was asked if she would like a pillow under her feet to make the sore better and she said no. During a wound care observation with the facility Wound Care Licensed Practical Nurse (LPN) on 2/21/24 at 10:15 AM, the LPN washed hands and put on gloves, explained procedure to the resident, removed resident's brief (noted to be clean/not soiled), right buttock noted to have a small area (approximately 2 inch x 2 inch) with 2 small dry skin/scabbed areas. Left buttock intact small area of very light redness. Interview with the Wound Care LPN during the observation revealed that she had a deep tissue injury and they have been applying barrier cream with zinc every shift. The LPN applied the barrier cream and checked with the resident again regarding discomfort and she denied any discomfort. The LPN explained the resident is on a scope mattress due to some falls and the special overlay mattress does not work. He further explained that Resident #13 is on scoop mattress and she really has improved. She had been on hospice but was discharged from their care at some point. Normally she is up during the day and is able to self-propel her wheelchair. The LPN uncovered her feet, and there was a small plaid blanket at foot of bed, per resident sometimes staff put that under her feet. The LPN removed the left foot sock and the heel noted to have a small 1 inch x 1 inch light maroon colored area blanchable skin around and the LPN indicated Resident #13 had a Deep Tissue Injury and now is improving to point the center is much lighter. The wound care LPN commented that resident appears to have good perfusion to her extremities which has allowed for healing. The left heel was intact and no redness and the LPN applied skin prep to areas, allowed to dry and reapplied socks on both feet. The LPN placed a pillow between knees and the right foot was noted floating, while the resident was lying on the right side. During an observation on 2/22/24 at 9:12 AM, Resident #13 was in bed positioned on her right side and her knees were bent. She said she needed to use the bathroom. The surveyor pushed the call bell for her and the Unit 3 Secretary came in. The Unit 3 Secretary was told Resident #13 needed to use the bathroom. The Unit 3 Secretary was asked if Resident #13 had a pillow offloading her heels and she lifted the resident's blanket and there was a folded wool blanket between her legs and her heels were not offloaded. The side of her heels was touching the mattress. An interview with Staff I, LPN at 9:13 AM, the surveyor reported the resident doesn't have a pillow under her feet and the resident said yesterday that she didn't like the pillow under her feet. Staff I, LPN was told the resident's feet were not offloaded during observations for two days. She said she would look into it. Interview with Certified Nursing Assistant (CNA), Staff G on 2/22/24 at 12:58 PM, revealed that for the Resident #13's pressure ulcers, the resident's feet should be floated with the pillow between her legs; however the resident doesn't like it and doesn't like a pillow on her back. She said that the Wound Care LPN would put a blanket between the resident's legs. Interview with the facility Wound Care Nurse, LPN, on 2/22/24 at 1:18 PM revealed that Resident #13 has 3 wounds - all deep tissue injury. The bilateral buttocks are fragile healed and he will continue to monitor until resolved. The resident is still getting the moisture barrier cream. The left heel should have a pillow to offload. He stated the resident is more mobile now and she kicks off her pillow. They have been using a blanket for the last 3 days to offload her feet. The pillow is used under left leg, as tolerated. The heel is improving and as she becomes more mobile, they will discontinue it.

Based on observation, interview, record review, and meal tray identification, the facility failed to provide the correct therapeutic diet to one resident (#55) of two residents reviewed for nutritional status who was at nutritional risk. Findings included: Resident # 55 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident #55's pertinent diagnoses included: encephalopathy (diffuse disease of the brain that alters brain function or structure that causes altered mental state and confusion), cerebral infarction [a brain lesion in which a cluster of brain cells die when they don't get enough blood] due to occlusion or stenosis of small artery; post COVID-19; dysphagia [swallowing difficulty] following cerebral infarction; acute respiratory failure with hypoxia [low levels of oxygen in your body tissues]; Type 2 Diabetes Mellitus with diabetic neuropathy [A group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet]; muscle weakness; cerebral ischemia (acute brain injury that results from impaired blood flow to the brain); oropharyngeal dysphagia; delusional disorders (maintaining fixed false beliefs even when confronted with facts, usually as a result of mental illness); unspecified dementia without behavioral disturbance, mood disturbance and anxiety; disorder of kidney; hyperlipidemia (high cholesterol); hypo osmolality [increased body fluid volume and decreased solute volumes in the blood] and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues); Cardiomegaly (enlarged heart); major depressive disorder; paranoid personality disorder; essential hypertension (high blood pressure); spinal stenosis (the narrowing of one or more spaces within the spinal canal). The resident developed a Stage III pressure ulcer on the left sacrum/coccyx. The resident's current diet order was a No Added Salt, pureed texture, honey thickened consistency liquids, fortified foods each meal. This was ordered on 1/3/2024. Additionally, a Magic Cup [a nutritional supplement for added calories and protein, that can be eaten as a pudding or frozen as an ice cream] three times a day on each meal tray was ordered on 11/20/23. According to Resident #55's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/23, the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating that she had severely impaired cognitive status and had no indicators of delirium. The resident's mood symptoms indicated that the resident had no poor appetite or overeating. The resident required extensive assistance with eating with one person physical assist. The assessment revealed that the resident had no swallowing disorder, weight was 157 lbs., Height was 62, the resident had no weight loss or gain or it was unknown and the resident was receiving a mechanically altered diet and therapeutic diet while a resident. Resident #55 did not have any oral/dental issues and the resident had received Speech Therapy and Occupational Therapy services. According to Resident #55's Quarterly MDS with an ARD of 12/18/23, the resident had a BIMS score of 2, indicating that she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed resident #55's interim performance for self-care showed dependence with eating. The assessment revealed that the resident had loss of liquids/solids from mouth when eating, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing. The resident weighed 154 lbs., Height was 62, the resident had no weight loss or gain or it was unknown. Resident #55 did not have any no broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) or mouth or facial pain, discomfort or difficulty with chewing. Resident #55's care plan initiated on 3/8/23 and revised on 12/18/23, included a focus related to nutrition - the resident has nutritional problem or potential nutritional problem related desirable weight loss in 6 months, dependent upon staff at meals, Type 2 Diabetes Mellitus; hypertension, depression, history of cerebral vascular accident, spinal stenosis, anxiety, medication changes and paranoia. The care plan included two goals: Be able to control what resident has in mouth. Loss of control of food or liquid in mouth can result in aspiration/choking. The resident will maintain adequate nutritional status as evidenced by maintaining weight with less than 5% weight gain in 30 days, less than 7.5% weight gain in 90 days and less than 10% weight gain in 180 days. Among the many care plan interventions included, there was an intervention to provide, serve diet as ordered. Monitor intake and record each meal. Pureed [consistency food], honey [thickened] liquids, no straws. On 02/20/24 at 6:13 PM, Resident #55 was observed with her evening meal. The Certified Nursing Assistant (CNA) positioned the resident upright in the bed. The tray ticket showed Resident #55 was served a Pureed, CCHO [Controlled Carbohydrate], low cholesterol, small portion diet with honey thickened juice and water. The ticket also indicated that Resident #55 liked a Magic Cup. On 02/22/24 at 9:07 AM, Resident #55 was lying in bed and her breakfast tray was on the over the bed table. The resident was waiting for staff to feed her. The tray ticket showed the resident was served a Pureed, CCHO [Controlled Carbohydrate], low cholesterol, small portion diet with honey thickened juice and water. Photographic evidence obtained. The 9/15/23 Nutrition Screening & Data Collection for Skilled Nursing Facilities SCii, included a Registered Dietitian (RD) note that documented, Weight has been trending up and was greater than 10% gain in 6 months. She is dependent upon staff at meals and consumes 76 to 100% of meals. Tolerates diet as ordered. Intact skin. Receives daily multivitamin/minerals with Januvia [anti-diabetic medication used to treat Type 2 Diabetes], Levemir [long-acting insulin], Humalog [fast acting insulin] provided for glucose control. A statin [a medication that lowers cholesterol levels in the blood] for HDL [High Density Lipoprotein, a type of fat in the blood] provided as well as daily multivitamin/minerals. Recommend to continue plan of care. Follow as needed. The 11/20/23 Nutrition Assessment indicated Resident #55 lost weight while at the hospital. This included an RD note that documented, Dysphagia diagnosis, she attends the dependent dining room at meals and consumes variable portions. Communicates needs at times and is often confused. Receives Januvia for glucose control. On 11/20/23, a Mini Nutritional Assessment was conducted and the score was 7, indicating that the resident was possibly malnourished. A Nutrition/Dietary Note (Summit) dated 1/23/24, documented, Weight note and wound note: Current weight is 152.6 lbs. and stable. NAS diet, pureed consistency, honey thickened liquids, and fortified foods each meal. Supplements of Magic Cup three times a day with all meals and Magic Cup three times daily between meals. Skin: Left sacral/coccyx stage 3 ulcer is fragile healed. Since wound is healed, suggest to decrease Magic Cups to only three times a day at meals. Also the fact that her weight has been fluctuating may be explained by her going out to the hospital. Her oral intake is usually averaging 50% or more of meals. Will follow as needed. The following is Resident #55's weight history for the past 6 months: 1/2/2024 17:02, 152.6 lbs., Mechanical Lift 12/11/2023 14:51, 153.6 lbs., Mechanical Lift 12/1/2023 14:38, 162.2 lbs., Mechanical Lift 11/20/2023 10:54, 158.6 lbs. Mechanical Lift 11/19/2023 15:32, 158.0 lbs., Mechanical Lift 11/17/2023 15:54, 158.2 lbs., Mechanical Lift 11/1/2023 16:34, 176.6 lbs., Wheelchair 10/1/2023 10:43, 177.8 lbs., Wheelchair 9/1/2023 13:00, 170.8 lbs., Wheelchair 8/1/2023 17:48, 160.6 lbs., Wheelchair The resident's height was 62 and her Body Mass Index was 27.9, which was in an acceptable range for elderly individuals. Based on the resident's weight history, on 12/01/23, the resident weighed 162.2 lbs. On 01/02/2024, the resident weighed 152.6 pounds which is a (-)5.92 % significant weight loss in a month. On 10/01/2023, the resident weighed 177.8 lbs. On 1/02/24, the resident weighed 152.6 pounds which is a (-)14.17 % weight loss in 3 months. According to Resident #55's medical record, the resident's last hospitalization was 11/9/23 and the resident had pneumonia in December 2023. On 2/22/24 at 9:45 AM, during an interview with the facility RD, Resident #55's diet order was discussed and the RD was informed that the diet order on the tray ticket did not match the diet order that was prescribed. The RD said she would look into that. The RD stated that the resident was not receiving fortified foods, because the off-site kitchen did not prepare fortified foods.

Based on observations, interviews, and record reviews, the facility failed to document observed wandering behaviors to ensure an accurate medical record for one (Resident #46) of one resident observed with wandering behaviors. Findings included: A review of Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following non-traumatic subarachnoid hemorrhage affecting right dominant side, difficulty walking, and cognitive communication deficit. A review of Resident #46's physician's orders revealed an order, dated 11/14/2023 for a wander management bracelet to the resident's left wrist. A review of Resident #46's care plan revealed a Focus area, initiated 11/14/2023, Resident #46 is an elopement risk related to being disoriented to place. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book and observe the wander management device for proper placement and function as ordered. A review of Resident #46's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/13/2024, revealed under Section C - Cognitive Patterns, a Brief Interview for Cognitive Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS assessment also revealed under Section E - Behaviors, Resident #46 did not display wandering behaviors during the assessment period. An observation was conducted on 2/19/2024 at 1:07 PM of Resident #46 propelling herself in her wheelchair into another resident's room. Resident #46 was observed crawling into another resident's empty bed and covering herself with a blanket. Resident #46 was redirected by staff back into the unit hallway. An observation was conducted on 2/20/2024 at 12:07 PM of Resident #46 propelling herself in her wheelchair down a unit hallway opposite of where the resident's room was located. Resident #46 was observed propelling herself into another resident's room and stopping in the entrance to the room before being redirected by facility staff. An observation was conducted 2/21/2024 at 1:45 PM of Resident #46 propelling herself in her wheelchair down a unit hallway opposite of where the resident's room was located. Resident #46 continued to propel herself aimlessly down the length of the unit hallway. An interview was conducted on 2/21/2024 at 4:24 PM with Staff D, Registered Nurse (RN). Staff D, RN stated Resident #46 wandered throughout the facility and often went into other resident's room, but was easily redirected by facility staff. An interview was conducted on 2/22/2024 at 9:54 AM with Staff E, Certified Nursing Assistant, who was sitting behind the nurses station with Resident #46. Staff E, CNA stated Resident #46 was pleasantly confused and normally wanders around the facility. Staff E, CNA also stated she informs the nurse on duty of any of Resident #46's wandering behaviors so it can be documented. An interview was also conducted with Staff F, Licensed Practical Nurse (LPN), who was also behind the nurse's station with Staff E, CNA and Resident #46. Staff F, LPN stated Resident #46 would often wander into other resident's rooms and climb into empty beds, but was easily redirected by facility staff. Staff F, LPN also stated the resident had a behavior folder in her medical record where any behaviors are documented. A review of Resident #46's Point of Care (POC) response history for the dates of 1/22/2024 to 2/21/2024 revealed under the task Behavior Monitoring & Interventions no observations of Resident #46's wandering behaviors were documented. An interview was conducted on 2/22/2024 with the facility's Director of Nursing (DON). The DON stated any behaviors a resident displays are to be documented every shift in the resident's behavior monitoring record. During the interview, Resident #46 was observed propelling herself past the DON's office, located in the hallway on the opposite side of the facility to Resident #46's room. The DON stated Resident #46 wandered the facility often and the resident's wandering behaviors should be documented in the resident's record.

Based on observations interviews and record reviews the facility failed to ensure necessary services to maintain a rehabilitation device in a sanitary manner for four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22) for one resident (#34) out of 29 sampled residents. Findings included: Review of the Admission Record for Resident #34 showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) for Resident #34, dated 11/09/21, Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment. Section G Functional Status showed Resident #34 required extensive assistance for activities of daily living (ADLs) including bed mobility, transfers, locomotion in and off unit, eating, toilet use and personal hygiene. Review of the current physician orders for Resident #34 printed on 01/06/22 showed Resident #34 wears a clavicle neck brace with active orders dated 08/03/21. The physician orders included the following: *Rigid collar on neck on at all times, check skin around and under collar every shift for monitoring. *Apply [name of product] dressings to L (left) clavicle under neck brace for patient comfort. Change on shower days, every evening shift every Tuesday and Friday. The physician orders did not indicate the process for care, cleaning, or replacement of the cervical collar brace and brace pads. On 01/04/22 at 1:20 p.m., an observation was made of Resident #34 in his room. Resident #34 was having lunch and was noted with soup spilling in his neck collar as he ate his lunch. On 01/05/22 at 12:26 p.m., an observation was made of Resident #34's cervical neck collar with food and residue from his meal. The neck padding was noted with an orange color from the soup he had been drinking. Resident #34 was observed spilling soup on himself during the meal. The neck brace pads inserted on the inside of the cervical collar were noted with a wet sponge like material from the soup. On 01/05/22 at 1:57 p.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C stated he worked closely with the resident. Staff C stated Resident #34 does not require assistance with ADLs and typically requires cueing and supervision for meals only. On 01/05/22 at 2:00 p.m., Resident #34 was observed in his room, neck collar observed with food residue. An immediate interview was conducted with Resident #34. Resident #34 was asked if he had received assistance with cleaning his neck collar after meals. Resident #34 stated that Staff C, CNA had wiped it down with a towel. When asked if the neck padding was wet, Resident #34 said, Yes, a little. It gets wet when I drink anything. On 01/06/22 at 09:12 a.m., Resident #34 was observed having finished breakfast meal. Resident #34's neck collar was observed with food residue and an appearance of heavily stained brown marks. On 01/06/22 at 09:12 a.m., an interview was conducted with Staff C. Staff C made an observation of Resident #34's neck collar with food remnants and food stains on the cervical collar and padding. Staff C stated he would wipe it down. When asked how often the cervical collar brace and pads was cleaned, Staff C said, I wipe it down with a washcloth after meals. Staff C was observed with a wet towel and wiped down the collar. Staff C said, I don't know when it is supposed to be changed. Maybe the nurse does it. Staff C confirmed he had not noted the cervical collar padding being washed. On 01/07/22 at 10:59 a.m. Resident #34 was observed in his room. Resident #34's neck collar padding was noted with brown and orange stains. Resident #34 stated he heard they have ordered a new padding for him. Resident #34 said, It will be nice to have it changed. It will get rid of the smell. Sometimes it [cervical collar padding] smells like the food I ate. Review of a Treatment Administration Record (TAR) dated 12/1/21 to 12/31/21 showed an order to apply [name of product] dressing to L clavicle under neck brace for patient comfort every evening shift every Tuesday and Friday with missing documentation on 12/3, 12/7, 12/10, 12/14, 12/17, 12/21 and 12/24. The TAR did not show documentation related to process for care, cleaning, or replacement of the cervical collar brace and brace pads. A care plan for Resident #34 showed an ADL Focus initiated on 08/18/21. The Focus stated Resident #34 has a self-care performance deficit related to dementia, impaired balance, limited range of motion, (ROM) pain, fracture, cardiac deficits, arthritis, [CONDITION(S)], spondylolysis, and incontinence. The goal indicated the resident would improve current level of function through the next review. Interventions included to adjust provisions for ADLs to compensate for resident's changing abilities, encourage participation, wear collar as ordered, encourage to use bell for assistance, monitor for changes as needed, praise all efforts at self-care and Physical Therapy (PT)/ Occupational Therapy (OT) to eval and treat per doctor's orders. The care plan did not indicate expectations for care, cleaning or replacement of cervical collar brace and brace pads. On 01/06/22 at 1:45 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D stated the nurses are supposed to apply [name of product] dressing twice a week. Staff D confirmed there was no process to clean or replace the collar padding. Staff D said, We kind of just wipe it off as needed, we sponge wash. When asked who was responsible for ensuring the collar was clean and sanitary, Staff D stated anyone can do it. Staff D stated usually the aides wipe it off after meals. Staff D said she would expect the collar to be changed or cleaned especially if it looks soiled. Staff D said, It should be clean and sanitary. An interview was conducted on 01/06/22 at 1:58 p.m. with Staff B, Registered Nurse (RN)/Unit Manager. Staff B stated Resident #34 used to be in therapy, and they would clean and maintain the neck brace. Staff B stated Resident #34 used to have a second padding for replacement, but she did not know what happened to it. Staff B confirmed it had been months since the padding was replaced or washed. Staff B said, It has to be months since he was in therapy. Staff B stated she spoke to the Director of Rehabilitation (DOR) about ordering a replacement. Staff B stated the expectation would be to maintain the collar in a clean manner. Staff B said, .it should be cleaned more often especially if he is spilling food on himself. It does not look good. We will fix that. A follow-up was conducted on 01/06/22 at 2:36 p.m. with the DOR. The DOR stated Resident #34 was no longer on therapy case load and was discharged around August 2021. The DOR stated Resident #34 had a spare neck brace padding that was changed and laundered when he was in therapy. The DOR stated during meals they used to place a washcloth on the padding to absorb the food spills. DOR stated Resident #34 was put on a restorative program for ROM. When asked who should be caring for the neck brace and padding, the DOR stated nursing should be caring for braces or splints. The DOR said, There was definitely a break down on the process. The expectation would have been that the brace replacements pads are laundered. The DOR stated wearing a wet or stained neck brace was a dignity issue. The DOR said, It is not sanitary. The DOR stated central supply had ordered replacement padding for the cervical neck brace. An interview was conducted on 01/07/22 at 9:53 a.m. with the Director of Nursing. (DON). The DON said, I looked at the resident's orders. There should be an order to care for the collar. DON stated when Resident #34 was transferred to restorative nursing they should have picked him up. The DON said, I agree, we dropped the ball. He should not be in a wet collar after meals. Review of an undated facility policy titled, Restorative nursing - ADL's assistance (bathing, dressing, and grooming), showed the facility will provide restorative programming to assist residents in attaining and maintaining the highest practicable level of function. The benefits of restorative ADL programming may include increased resident self-esteem as well as improve cognition, social acceptance, strength, balance, and coordination. Under the procedure the policy section, it stated #1. (c.) grooming includes maintaining personal hygiene or use of adaptive equipment. #8. The dressing and grooming programs should be carried out at least 6 days a week with daily being optimal. Review of the job description titled, Licensed Practical Nurse, revised 03/02, showed the basic function is to deliver nursing care to residents of the facility. Essential functions noted to include: #2 Delivers nursing care to patients/ resident. #3. Makes observations and reports pertinent information related to the care of the resident. #4. Implements the resident plan of care and evaluates the resident responses.

Based on of observations, interview and policy review the facility failed to ensure a clean and sanitary homelike environment related to a spot on the wall and baseboard in two places for one resident room (48) of twenty-six rooms observed on Station 3 for three days (01/04/22, 01/05/22 and 01/06/22) of four days. Findings included: On 01/04/22 at 9:15 a.m., an initial observation was conducted of resident room 48 on the hall of Station 3. During the observation a spot was seen on the wall in the middle of the room, which extended down to the baseboard in two places. (Photographic Evidence Obtained) A subsequent observation was conducted on 01/04/22 at 12:47 p.m. During the observation a family member in the room visiting the resident was interviewed. The family member indicated the resident was admitted on the evening of 12/31/21, and further revealed he never sees anyone cleaning the room. The family member stated, The housekeeping could be better. During the interview the family member revealed he had not spoken to anyone in the facility regarding the spot on the wall that extended down to the baseboard and could be seen in two places. He further revealed since he had complained about other housekeeping issues since the resident's admission, he did not want to continue to complain to the facility and stated, I am tired of talking to them. On 01/05/22 at 9:00 a.m., an observation was conducted of Resident Room 48 which revealed the spot on the wall and on the baseboard in two places. During a follow-up observation and interview, on 01/05/22 at 3:11 p.m., of Resident Room 48, the spot was observed on the wall and baseboard, and the resident's family member indicated he had not mentioned to the facility the dirty spot on the wall. On 01/06/22 at 10:18 a.m. an observation was made of the resident room and a chair was placed in front of the spot on the wall and baseboard. The resident was not in the room at the time. On 01/06/22 at 11:55 a.m., another subsequent interview and observation was conducted in Resident Room 48. The resident's visitor stated, I am upset by the spot on the wall. I called him (the resident's spouse) and he told me its been here ever since she came. During an interview with the Nursing Home Administrator (NHA) on 01/06/22 at 12:03 p.m., she confirmed the spot on the wall that extended down to the baseboard in two places, while the resident's visitor was in the room. The NHA indicated she would have housekeeping address the spot and the visitor in the room told the NHA the spot on the wall, and the two on the baseboard were not from the present resident in the room. The NHA acknowledged the visitor and stated Ok. On 01/06/22 at 12:51 p.m., an interview was conducted with the Environmental Services Director (EVS) who revealed the floors, and bathrooms should be cleaned every day. He further indicated if the housekeeping staff see the spot, they should clean it, its part of the cleaning process. A review of facility policy titled, Environmental Services-Cleaning Schedules Respiratory, read under Policy: Cleaning Schedules shall be developed and implemented to ensure that our health center is maintained in a clean and comfortable manner.

Based on observation, record review, and interviews, the facility failed to ensure appropriate and sanitary storage of respiratory equipment of an oxygen nasal cannula for one resident (#193) of sixteen residents who use oxygen for four of four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22). Findings included: On 01/04/22 at 11:38 a.m., an observation was conducted of Resident #193's room. During the observation the oxygen nasal cannula and tubing was located on top of the oxygen concentrator and not stored appropriately in a storage bag. (Photographic Evidence Obtained) On 01/05/22 at 9:44 a.m. an observation was conducted of Resident #193's nasal cannula and tubing to be on top of the concentrator. Resident #193, who was sitting in a wheelchair and watching television, indicated she put it there when she was done wearing it because there wasn't a plastic storage bag by the concentrator to put it in. An observation was conducted on 01/06/22 at 10:17 a.m., of Resident #193's oxygen tubing and nasal cannula wrapped around the top of the unit. The resident was not in the room at the time. The plastic storage bag used to store the nasal cannula and tubing was not on or near the oxygen concentrator. A subsequent observation was conducted on 01/06/22 at 3:16 p.m. of Resident #193's oxygen tubing and nasal cannula to be located on top of the oxygen concentrator, and there was no plastic storage bag located on or near the oxygen concentrator. On 01/07/22 at 9:15 a.m. an observation was made of Resident #193 sitting in a wheelchair watching television. The oxygen tubing and nasal cannula was seen draped over the resident's bed and stored appropriately a plastic storage bag. The resident was asked if the staff place her oxygen tubing in a plastic storage bag after she was done wearing it since she has been admitted , and Resident #193 pleasantly stated, No, never seen one. Record review of Resident #193's Admission Record indicated she was admitted on [DATE] and readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an active physician order, dated 12/27/21, for Resident #193 read: Oxygen@ (at) 1-2 Liters/Minute (L/Min) via Nasal Cannula (NC) continuous inhalation at night to keep Saturation (Sats) >92% every evening and night shift for low O2 Sats at night. Review of the Minimum Data Set (MDS), dated [DATE], identified in Section C, Cognitive Patterns that Resident #193's Brief Interview for Mental Status (BIMS) score was 14, on a 15 point scale, indicating the resident was cognitively intact. Further record review of Resident #193's care plan, dated 01/04/22, revealed she was care planned to wear oxygen NC as ordered and tolerated. On 01/07/22 at 9:23 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager (UM) for Station Three. During the interview Staff B confirmed the presence of the nasal cannula and tubing on top of the oxygen concentrator, in Resident #193's room. Staff B stated, It is the nurse's responsibility to store the oxygen tubing in the plastic bag. Staff B revealed she would obtain a new nasal cannula, and a plastic storage bag from the supply room, and change the present nasal cannula. An interview was conducted with the Director of Nursing (DON) on 01/07/22 at 9:40 a.m. The DON stated, When it's not being used, and is PRN (as needed) or used overnight, it has to be stored in the plastic storage bag to be protected. A review of facility policy titled, Respiratory Therapy Equipment, Page 01 of Page 02, read as follows: Oxygen Administration 7. Keep Oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.

Based on interview and record review, the facility failed to ensure a PRN (as needed) [CONDITION(S)] medication order was limited to a 14 day duration for one resident (#26) of five residents reviewed. Findings included: Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, and anxiety disorder according to the resident face sheet. Continued review of the Physician's Order Summary revealed an order for [MEDICATION(S)] ([MEDICATION(S)]) 0.25 milligram (mg) 1 tab orally (PO) every 4 hours as needed for anxiety, with a start date of 11/24/21; the end date was listed as 'indefinite.' On 01/05/22 at 12:35 p.m. Resident #26 was observed sitting upright in bed and eating lunch. The resident was groomed and paying attention to the television. An interview was attempted; however, the resident was not interviewable. In an interview with Staff A, Licensed Practical Nurse (LPN) on 01/05/22 at 12:58 p.m., the LPN confirmed the resident was on PRN [MEDICATION(S)] and gets it occasionally. The LPN stated the resident will occasionally get 'shaky' and that is when she gives her the [MEDICATION(S)]. Staff A, LPN confirmed the medication does help sometimes, and the resident has been on the PRN [MEDICATION(S)] for a while. Review of the Medication Administration Record (MAR) revealed [MEDICATION(S)] was administered as follows: November 2021: -11/24/21, 11/25/21, 11/26/21, 11/29/21, and 11/30/21. December 2021: -12/01/21, 12/03/21, 12/06/21, 12/07/21, 12/09/21, 12/11/21 (2 doses), 12/24/21, and 12/27/21. -January 2022 (to date): 01/03/22, and 01/06/22. Review of the Pharmacy Medication Regime Reviews revealed a recommendation dated 11/30/2021, which read: -This resident is currently receiving the following [CONDITION(S)] (non-antipsychotic) medication on a PRN basis: [MEDICATION(S)] 0.25 mg every 4 hours as needed for anxiety. Please evaluate the resident for the appropriateness of this medication. If it is to be extended, please document the rationale in the resident's medical record and indicate the duration of the PRN order. The recommendation was signed by an unreadable signature with a note that read: - okayed to cont [continue] on tel [telephone] 12/2/21 at 11pm. There were no pharmacy recommendations for December 2021. On 01/07/22 at 10:33 a.m. in an interview with the Director of Nursing (DON), she confirmed the November 2021 pharmacy recommendation was received and the physician was informed. The DON confirmed there was no rationale documented in the record for continuation of the medication, nor was there an end date on the order. On 01/07/21 at 10:47 a.m. an interview was conducted with the facility's Consultant Pharmacist via telephone. She confirmed she issued a pharmacy recommendation in November 2021 related to the PRN [MEDICATION(S)] order, and stated it was the expectation the order have a justification for continuation and an end date documented in the medical record. Review of a facility-provided policy titled, Behavior Monitoring and Psychoactive Medication Management, undated, did not address the use of PRN [CONDITION(S)] medications.