Every finding on record at Springs at Lake Pointe Woods

Based on observations, review of facility's policy and procedure, and staff interviews, the facility failed to store and distribute food in accordance with professional standards for food service safety. This has the potential to affect 91 residents who consume the food made on the premises.The findings Included:Review of the facility policy on Food Receiving and Storage dated 6/2025 revealed that all foods stored in the refrigerator or freezer will be covered, labeled and dated.On 4/20/26 at 9:35 a.m., observations during the initial tour of the kitchen revealed:The following food items in the reach in refrigerator were not date-marked to indicate when the food must be consumed or discarded: 5 Apple Juice cups; 12 Cranberry Juice cups; 23 Orange Juice cups; a plate of tomato slices; a dish of an unknown white food item; a cup of fresh fruit; a container of Oat milk. The date on what appeared to be tapioca pudding was not legible and read either 4/4/ or 4/14; a dish of a white food item was dated 4/4; a container of (brand name) vanilla nutritional drink with an opened date of 3/2.Observation of the walk-in refrigerator revealed: A container of shredded cheese with a label that was illegible; 2 zip lock bags of sliced cheese that were not sealed; a bag of grated cheese that was opened, sealed, but not dated; a partially used block of butter or margarine that was sealed, but not dated; a container of maraschino cherries that was undated; a beverage pitcher that was undated with what appeared to be tea; a pastry bag with an unidentified substance partially used was stored in a plastic bag, with a label indicating it was opened on 4/5; an unlabeled and undated filled beverage pitcher; a beverage pitcher with fruit punch that had a prep date of 4/11 and disposal date of 4/15; a beverage pitcher with what appeared to be orange juice that was undated; an undated beverage pitcher with what appeared to be fruit punch; an opened and undated carton of (brand name) thickened lemon water; 2 cartons of (brand name) thickened cranberry juice dated 4/13/26; a tray of cups with a pudding consistency food item and cups of pineapple chunks that were undated; Observation of the walk-in freezer revealed: An open bag of what appeared to be individual sized, pre-prepared cookie dough that was not dated or properly sealed; 2 trays of biscuits that were not dated; 2 opened sleeves of waffles that were not dated.Observation of the food preparation area revealed: A bin of thickener that was dated 2/23 and disposal date of 3/23; a container of brown sugar that was dated 3/11 with a dispose of date of 4/11; an opened and undated container of ground oregano.On 4/20/26 at 10:00 a.m., in an interview the Dietary Manager verified the observation of the unlabeled, undated food items in the refrigerators, the freezer and the food preparation area. He said that all food items should be sealed, resealed, labeled and dated with a receipt date, an open date, and a dispose of date.On 4/20/26 at approximately 10:05 a.m., Dietary Staff O provided a list of food items specifying that all labels must include product name, open date, expiration date, and initials of person making the label. All wrapped items must be wrapped tight. The list specified the days given for the following food items: Prepared and leftover food, 3 days; Opened product (Mayo, BBQ, Peanut Butter), 30 days; Dry product (Sugar, flour, rice) 90 days, cut fruit and vegetables, 3 days, dairy (cottage cheese, sour cream, milk), 7 days, cheese products, 7 days; spices on food station, 1 year.On 4/20/26 at 12:20 p.m., observation of the assisted dining room lunch food cart on the [NAME] Unit revealed a tray of a resident's leftover breakfast food items stored on the bottom rack of the cart of, underneath the residents' lunch trays to be served. Photographic evidence obtainedOn 4/23/26 at 1:51 p.m., in an interview, the Dietary Manager said that left over breakfast trays should not be stored with fresh lunch trays. He said that it was crossing clean with dirty/contaminated and it should not occur.

Based on observation, interview and record review the facility failed to ensure garbage and refuse were properly contained in dumpsters and failed to ensure the surrounding area was maintained in a sanitary condition, free of trash and debris.The findings included:On 4/20/26 at 10:15 a.m., observation of the surrounding ground of the facility with the Dietary Manager revealed four dumpsters used for disposal of the facility trash and refuse. Each dumpster had two lids. Two of the dumpsters were not fully closed with one of the lids opened. A plastic bag of food waste, a Styrofoam container, loose trash, including used gloves and plastic utensils were observed scattered on the ground surrounding the dumpsters. In an interview during the observation, the Dietary Manager said that the lids of the dumpsters were supposed to remain closed. Photographic evidence obtained

Based on observations, record review, review of facility policies and procedures, residents and staff interviews, the facility failed to ensure that 2 (Residents #11 and #74) of 3 residents reviewed for non-pressure wounds received appropriate care and services in accordance with physician's orders. The facility failed to ensure that 1 (Resident #48) of 3 residents reviewed had preventive measures in place to prevent new skin injuries. The findings included:1. Review of the undated Facility Policy, Skin Care & Wound Management- Manage Wound Care revealed: The interdisciplinary team will develop a Care Plan to address identified skin impairment(s) which will include at a minimum, effort to stabilize, reduce or remove risk factors and describes treatment protocol. Interventions will be communicated to the caregiving team. The policy noted that treatment will be changed based on physician order and documented. On 4/20/26 at 9:52 a.m., Resident #48 was observed in bed with a wound vac (a medical device that uses negative pressure to promote healing in acute, chronic, and complex wounds) connected to the resident's back. In an interview, Resident #48 said that she developed a wound on her back at the facility but did not remember how she got it. Review of the clinical record for Resident #48 revealed an admission date of 10/17/23. Diagnoses included unspecified dementia, hypertensive heart disease, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 3/20/26 revealed that Resident #48 scored 05 of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The resident required substantial/maximal assist with toileting, bathing and transfers. A nursing progress note dated 2/17/26 documented that during a routine skin sweep, a skin abrasion was noted on the resident's right buttock with superficial skin loss, scant drainage and no active bleeding. The surrounding skin was intact with no erythema (redness), warmth, swelling, or signs of infection. An Interdisciplinary Team (IDT) note dated 2/20/26 revealed that the IDT met to discuss the resident's abrasion to her right buttocks. The note documented that the wound appears to be trauma possibly from bedside commode over the toilet for lift and safety. The recommendation was that the resident would benefit from a bariatric bedside commode so that the resident has room to sit. The plan included to consult wound care for treatment and Physical Therapy (PT) and Occupational Therapy (OT) for evaluation of a bedside commode. A Wound Physician Progress Note dated 2/24/26 revealed that the wound appeared to be a large area of ecchymosis (bruising), possibly trauma from the commode seat. The tissue type by percentage is 90% epithelial tissue (layer of cells covering body surface) and 10% dermal. The size was 6 centimeters(cm) by 6 cm with a depth of 0.1cm and a total wound area of 36 square cm. A Nursing Progress Note dated 3/2/26 documented that a Certified Nursing Assistant (CNA) was toileting Resident #48 when she noticed a change to the resident's right buttock wound and notified the nurse. Black necrotic (dead) tissue was noted to coccyx with surrounding erythema and the area was warm and tender to touch with some scant blood drainage noted. The wound care physician was notified and ordered antibiotics. A Wound Physician Progress Note dated 4/14/26 revealed that the wound had declined with excessive exudate (secretion) and a foul odor. A wound VAC was recommended. A Nursing Progress Note dated 4/14/26 at 5:03 p.m., revealed that a wound vac was applied to the right buttock wound per physician's order. On 4/21/26 at 10:00 a.m., in an interview, Wound Care Nurse, Staff A said that Resident #48's wound to the right buttock started as a trauma. She said that Resident #48 was sitting sideways on a commode and cut herself on the commode. The wound opened up a week later. Wound Care Nurse Staff A said that Physical Therapy evaluated the resident a week after the wound opened. On 4/23/26 at 11:17a.m., in an interview, the Risk Manager said that her investigation showed the wound occurred when the resident was being placed onto the commode in the bathroom. She said Resident #48 would regularly flop to one side as she was sitting on the commode. She said that she did not know how long the resident was on the commode, it was not timed or noted. She did not ask the CNA how long the Resident had been on the commode. She said Physical Therapy evaluated her for a new commode and for positioning onto the commode. They tried a larger commode, but the resident was very short and it was not a good fit for her. Physical Therapy spoke with the CNAs about how to position the resident on the commode. She said Resident #48 was still using the same commode. The Risk Manager said her investigation showed that the injury was not caused by the commode but how she was positioned on the commode. On 4/23/26 at 11:32 a.m., in an interview, the Director of Rehabilitation (DOR) said she was unable to provide documentation showing that the Resident was seen by Physical or Occupational Therapy at any time after the wound occurred or that Resident #48 was evaluated for a new commode. She said she had no documentation that training was provided to the CNAs on how to position the resident on the commode to prevent injury. Review of Resident #48's care plan revealed that on 3/3/26, a care plan was initiated for a trauma wound to the resident's right buttock. The goal was for the wound to show signs of healing by the next review date. The interventions did not include necessary precautions to prevent further skin injuries or worsening of the existing wound from improper positioning of the resident on the commode. 2. Review of the clinical record for Resident #11 revealed an admission date of 11/24/25. Diagnoses included peripheral vascular disease (blood vessels become blocked), venous insufficiency (poor circulation), and hypertensive (high blood pressure) heart disease with heart failure. Review of the Quarterly MDS Assessment with an Assessment Reference Date of 2/2/26 revealed that Resident #11 required substantial/maximal assistance to dependent on staff for Activities of Daily Living (ADLs). The MDS documented the resident's cognitive status moderately impaired. The care plan initiated on 12/1/25 and revised on 2/2/25 documented Resident #11 was at risk for further impairment to skin integrity related to generalized weakness, decreased mobility, incontinence, fragile skin and advanced age. The goal was for the resident to have interventions in place to minimize the risk of skin breakdown. The intervention initiated on 2/23/26 and revised on 4/9/26 included treatment to right upper arm malignant (cancerous) neoplasm growth (abnormal growth) as ordered. Review of the Progress Note dated 3/5/26 revealed that Resident #11 was seen by dermatology 3/5/26 for right upper arm. New order obtained. Review of the Dermatology Consult dated 3/5/26 revealed that Resident #11 was seen for a growth: unspecified malignant neoplasm of skin. Location: Right medial tricep (large muscles on the back of the upper arm). The note documented an Electronic Prescription for Efudex (fluorouracil 5% topical cream. A paper prescription was left with the nurse to enter into Medication Administration Record. The Skin/Wound Weekly Evaluation dated 3/11/26 documented Resident #11 had other wound to right proximal medial arm. Following Dermatology, received topical fluorouracil daily. Calcium Alginate and dry dressing. Review of the Treatment Administration Record for March 2026 revealed: An order dated 3/10/26 for fluorouracil external cream 5% (topical). Apply to right inner tricep topically one time a day for malignant neoplasm growth cover with dry dressing. An order dated 3/5/26 to clean the right proximal medial arm with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with dry dressing one time a day. The treatment was discontinued on 4/1/26. Review of the Dermatology Consult dated 4/2/26 revealed that Resident #11 was seen for unspecified malignant neoplasm of skin. Location: right middle mid medial tricep. Electronic prescription: Electronic Prescription: Efudex (fluorouracil 5% topical cream. Paper prescription left with nurse to enter into Medication Administration Record. Dermatologist documented that the wound care nurse said the order was never given to her and medication was never applied. She will get order in today. 3. Review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease without heart failure, unspecified dementia, and encephalopathy (brain dysfunction). Review of the Quarterly MDS Assessment with an Assessment Reference Date of 3/24/26 revealed that Resident #74 required substantial/maximal staff assistance for Activities of Daily Living (ADLs). The MDS documented that the resident's cognitive status was intact. The care plan initiated 9/18/24, revised on 1/3/25 documented Resident #74 is at risk for skin breakdown related to decreased mobility, incontinence, and fragile skin due to advanced age, admitted with a cancer lesion. Intervention initiated 12/2/24 included treatments as orders. The Dermatology Consult dated 2/5/26 documented Resident #74 was diagnosed with malignant neoplasm to the left buttock. Prescription: Mupirocin (antibiotic) 2% ointment. Apply topically to left gluteus (buttock) and cover with bandage. Review of the Progress note dated 2/12/26 revealed that Resident #74 was reviewed for wound care to cancerous lesion left buttock. Treatment is Mupirocin. Followed by dermatologist. Review of the Dermatology Consult dated 3/5/26 revealed that Resident #74 was seen for growth follow-up. Unspecified malignant neoplasm of skin left superior gluteus maximus (the upper, outer portion of the largest buttock muscle). Electronic prescription: Bactroban (mupirocin 2% topical ointment). Paper prescription left with nurse to enter into Medication Administration Record. Dermatologist documented that staff continued to use Efudex even though mupirocin was ordered last month. Nurse will make sure wound care nurse knows to apply mupirocin. Review of the Progress Note dated 3/5/26 revealed that Resident #74 was reviewed for wound care to cancerous lesion on left buttock. Treatment changes as of 3/3/26 to Santyl (prescription ointment to remove dead tissue) /dry dressing. Resident is also followed by Dermatologist. Review of the Skin/Wound Weekly Evaluation dated 3/13/26 revealed the wound did not appear infected at this time. Santyl and dry dressing. Review of the Dermatology Consult dated 4/2/26 revealed that Resident #74 was seen for Unspecified malignant neoplasm of skin left superior lateral gluteus maximus. Electronic prescription: Bactroban (mupirocin 2% topical ointment. Paper prescription left with nurse to enter into Medication Administration Record. Dermatologist documented wound care nurse said order was never given to her and medication was never applied. She will get order in today. Review of the Treatment Administration Record (TAR) for February 2026 for Resident #74 revealed that the treatment order to the left gluteus to cleanse the wound, pat dry, apply fluorouracil external cream 5% to the left gluteus topically every night shift was discontinued on 2/5/26. No other treatment was entered for the wound to the left gluteus for February 2026. Review of the TAR for March 2026 revealed the treatment to Resident #74's left buttock to cleanse with normal saline or wound cleanser, pat dry, apply Santyl and cover with dry dressing one time a day for wound care started on 3/5/26 and was discontinued on 4/1/26. Review of the TAR for April 2026 for Resident #74 revealed the treatment to cleanse the cancerous lesion to the left buttock with normal saline/wound cleanser, pat dry, apply mupirocin ointment, cover with dry dressing one time a day was not signed as completed on 4/9/26, 4/14/26, and 4/17/26. On 4/23/26 at 10:00 a.m., in an interview, Licensed Practical Nurse (LPN) Staff B said that the Dermatologist saw Residents #11 and #74 once a month for cancerous lesions. LPN Staff B, said they receive orders from the dermatologist monthly and enter them into the Treatment Administration Record. On 4/23/26 at 11:43 a.m., in an interview, LPN Staff A, said she no longer did wound care for Residents #11 and #74 since they were being followed by the dermatologist. LPN Staff A said she did not remember seeing the Dermatologist in March 2026 and could not explain why the orders were not entered. She said Residents #11 and #74 should have received the treatments ordered by the Dermatologist. LPN Staff A said the blank for wound care because they are being followed by the dermatologist. She said she does not remember seeing the dermatologist is March 2026. Staff B, LPN could not explain why the orders were not entered. Staff A, LPN said the residents should have been receiving the treatments ordered by the dermatologist. She said blanks on the TAR for Resident #74 for 4/9/26, 4/14/26, and 4/17/26 meant that the nurse did not sign off the treatment was done. On 4/23/26 at 1:06 p.m. in an interview, the Director of Nursing (DON) said the nurses should enter any new orders from the physician into the electronic medical record. The DON could not explain why the Dermatologist's orders were not entered in the electronic medical record for Residents #11 and #74. She said she could not explain what happened to the paper prescriptions the Dermatologist gave to the nurse. She said she would have to follow up with the Dermatologist.

Based on observation, review of facility's policy and procedure and staff interviews, the facility failed to provide necessary repair and store residents' personal care items in a sanitary manner in 7 (Rooms 101, 104, 106, 107, 108, 110 and 111) of 17 rooms of the [NAME] Unit observed.The findings included: Review of the undated facility policy and procedure titled, Environmental Services - Safe Environment revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely . Orderly is defined as an uncluttered physical environment that is neat and well kept. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living .On 4/20/26 at 9:37 a.m., during an initial tour of the [NAME] Unit (rooms 100 to 116), the following was observed:1. room [ROOM NUMBER] shared bathroom: 2 emesis basins containing residents' care items were stored uncovered on the sink with personal items in each.An unlabeled bed pan was stored unbagged behind the shared toilet.Photographic evidence obtained.2. room [ROOM NUMBER] shared bathroom: An unbagged urinal labeled 101-1 was hanging on the handrail next to a towel. An unlabeled and unbagged urinal was observed hanging from the handrail in the shared shower.Two unbagged bed pans, a towel and a bedside commode bucket were stacked on the shower seat.Photographic evidence obtained. 3. Private room [ROOM NUMBER]: An unlabeled and uncovered bedpan was stored on the floor under the toilet.Photographic evidence obtained.4. room [ROOM NUMBER] shared bathroom: An unlabeled and unbagged urinal was hanging from the arm rest of a bedside commode in the shared shower. A wash basin, a used towel and an unlabeled deodorant stick were stored on the shared shower seat. A large crawling insect was observed in the bathroom.Photographic evidence obtained.5. room [ROOM NUMBER] shared bathroom: An unlabeled and unbagged cup containing a toothbrush and toothpaste was observed stored on the shared sink. An unlabeled and unbagged washbasin containing resident care items, a bottle of mouth wash, a bottle of aftershave, a pack of wipes and other residents' care items were stored unlabeled and unbagged on the shower seat. Photographic evidence obtained.6. room [ROOM NUMBER] shared bathroom: 2 unlabeled and unbagged washed basins were stacked and stored on the shared sink. Photographic evidence obtained.7. room [ROOM NUMBER] shared bathroom: An unlabeled and unbagged wash basin was stored on the floor under the sink. Scuff marks were observed on the wall next to the sink with peeling paint and discoloration. Photographic evidence obtained.On 4/22/26 at 8:30 a.m., in an interview, when asked about the storage of residents' personal care items, such as urinals, the Director of Nursing replied, Is it in a private or shared bathroom?

Based on observations, record review, review of facility's policy and procedures, and staff interviews, the facility failed to implement the comprehensive person-centered care plan to meet the needs for communication for 1 (Resident #5) of 3 residents reviewed for implementation of care plan interventions.The findings included:Review of the facility policy for Resident Assessment Instrument Comprehensive Care Plan Policy with an effective date of September 2024 revealed:Developing the Care Plan:The care plan will address physical, emotional, social, and cognitive needs, as well as any other relevant areas (e.g., nutritional, safety, mobility, medication management).Interdisciplinary Team (IDT) Collaboration:The IDT, consisting of nursing, dietary, therapy, social services, and other relevant staff, will collaborate to create and review the care plan.Family members and resident will be involved in care planning to the greatest extent possible, ensuring their preferences and choices are reflected in the plan.Review of the clinical record for Resident #5 revealed an admission date of 1/17/25. Diagnoses included: Cerebral Infarction (a stroke caused by a blocked blood vessel); Hemiplegia and Hemiparesis of right side (paralysis and weakness on one side of the body); Dementia; and Cognitive Communication Deficit.Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/16/26 revealed Resident #5 scored 3 of 15 in the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS noted that the resident was sometimes understood and her ability to express ideas and wants was limited to making concrete requests. Resident #5's ability to understand others was Sometimes understands-responds adequately to simple, direct communication only. Review of Resident #5's Care Plan with a review date of 3/19/26 revealed:Resident #5 was alert and oriented, able to make needs and wants known. A communication book was at bedside and in the activity room. The goal was for the resident to maintain involvement in cognitive stimulation and social activities as desired through review date.The care plan noted that Resident #5 had a communication problem related to Spanish speaking and neurological symptoms. The goal was for the resident to maintain current level of communication function and be able to make basic needs known on a daily basis.On 4/21/26 at 11:16 a.m., Resident #5 was observed in the activity room. In an interview, Registered Nurse (RN) Staff G, stated that Resident #5 only spoke Spanish. RN Staff G said she was not aware that Resident #5 used a communication book.On 4/21/26 at 10:30 a.m., and at 1:32 p.m., Resident #5 was observed in her room without a communication book at bedside. On 4/21/26 at 10:35 a.m., Resident #5 was observed in an activity. No communication book was observed with the resident or available to the resident in the activity room. On 4/21/26 at 1:35 p.m., Resident #5 was observed in the small activity room. No communication book was observed available to the resident.On 4/22/26 at 10:02 a.m. Resident #5 was observed in her bed. No communication book was visible in room.On 4/22/26 at 12:30 p.m., in an interview, Certified Nursing Assistant (CNA) Staff N stated that lately, she has not seen a communication book in Resident #5's room. She said she didn't see the communication book yesterday or today. On 4/22/26 at 12:35 p.m., in an interview, CNA Staff J stated that he wasn't aware that Resident #5 used a communication book and has not seen one. He said that he did not work directly with the resident but does help to supervise the activity room while she is present. He stated that he does not speak Spanish.On 4/22/26 at 3:10 p.m., in an interview, CNA Staff L said he did not take care of Resident #5 except when he is supervising the activity room. He said he didn't know that Resident #5 used a communication book. He said that he didn't speak Spanish, but there were staff who spoke Spanish.On 4/22/26 at 3:13 p.m., in an interview, Licensed Practical Nurse (LPN) Staff M stated that Resident #5 had a communication book in her room when she first came, but she had not seen it recently and did not know if she still had it. LPN Staff M said she spoke Spanish and was able to communicate with Resident #5.On 4/23/26 at 9:45 a.m., in an interview, the Director of Nursing (DON) said that she was not aware Resident #5 used a communication book. The DON said they usually assigned a staff member who speaks Spanish to the resident. The DON did not answer when asked how staff communicated with Resident #5 when she's in the activity room and the staff assigned to supervise the residents did not speak Spanish.On 4/23/26 at 10:02 a.m., the DON brought in a communication book which she said belonged to Resident #5. She said that she found the book in the resident's closet. She said she did not know the specific locations for the communication book listed in the resident's care plan.

Based on observation, review of clinical records and resident and staff interviews the facility failed to provide the necessary care to maintain personal hygiene for 2 (Resident #86 and #56) of 5 residents who required staff assistance with activities of daily living (ADLs).The findings included:1. Review of the clinical record for Resident #86 revealed an admission date of 8/20/25. Diagnoses included dementia, repeated falls, anxiety and major depressive disorder.Review of the Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/05/26 revealed Resident #86 scored 09 of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment for daily decision making.Review of the care plan revealed that Resident #86 required assistance with Activities of Daily Living (ADLs) related to decreased mobility, generalized weakness and impaired cognition.The goal was for Resident #86 to have his ADL needs met as evidence by presenting in a clean, well-groomed manner. The interventions included to check nail length, trim and clean them on bath day and as necessary. Report any changes to the nurse. Provide sponge bath when a full bath or shower cannot be tolerated.Review of the CNA Kardex (contains instructions for care) revealed to keep Resident #86's fingernails short.On 4/20/26 at 2:10 p.m., Resident #86 was observed with 3 to 4 days of facial growth. The resident's fingernails extended approximately 1/2 inch with a brown substance underneath the nails. The resident's hair was not combed and looked greasy.On 4/21/26 at 11:28 a.m., Resident #86 remained unshaven. His fingernails remained untrimmed with a black substance under the nails. Resident #86 was not able to answer interview questions.Review of the shower schedule revealed that Resident #86's shower days were on Tuesdays and Fridays during the day shift. The shower schedule noted, Shower sheets MUST be turned in to nurse before end of shift!Review of the Certified Nursing Assistants (CNAs) logbook revealed individual shower sheets to be completed on shower days by the CNAs. The instructions on the form specified to turn in the form to the Unit Manager daily for shower confirmation.On 4/22/26, review of the shower sheets for Resident #86 revealed the resident had a shower on 4/1/26 and a bed bath on 4/8/26 and 4/15/26. On 4/8/26, Resident #86 refused a shower. Each shower sheet was signed by a licensed nurse. No other shower sheets were found for Resident #86 in the logbook. The shower sheets did not include documentation of nail care. Review of the electronic health record revealed that the CNA documentation for bathing for Resident #86 differed from the information entered in the shower sheets. The CNA documentation in the electronic health record documented that Resident #86 received a bed bath on 4/1/26 and 4/18/26 and a shower on 4/8/26. On 4/4/26 and 4/11/26, the CNA documented N/A (Not applicable) for bathing. Review of the nursing progress notes failed to provide documentation for the bed bath documented on shower days.2. Review of the clinical record for Resident #56 revealed and admission date of 3/27/26. Diagnoses included severe protein calorie malnutrition, anxiety disorder and difficulty walking.Review of the care plan initiated on 7/30/25 revealed that Resident #56 required assistance with ADLs related to decreased mobility and generalized weakness. The goal was for the resident to continue to have his ADL needs met as evidenced by presenting in a clean, well-groomed manner.The interventions specified that Resident #56 required assistance of 1 staff member with bathing/showering and dressing.The care plan initiated on 7/25/25 revealed that Resident #56 had a behavior problem related to refusing care and speaking inappropriately, yelling at staff. The goal was for the resident to have fewer episodes of refusing care, yelling at staff daily/weekly.Review of the CNA Kardex revealed Resident #56 required assistance of 1 staff member with bathing/showering.On 4/20/26 at 9:48 a.m., Resident #56 was observed in bed. He had approximately 4 days of facial hair growth. His fingernails extended approximately 1/2 inch with a brown substance under the nails.In an interview during the observation, Resident #56 said that he needed to see a podiatrist to have his toenails cut. He removed his socks. The resident's toenails were thick and beginning to curl over his toes. A brown substance was observed under the resident's nails. On 4/21/26 at 10:30 a.m., Resident #56 was observed in his bed. Resident #56 was wearing the same shirt he had on the day before. He remained unshaven and his nails remained untrimmed with an accumulation of a brown substance under the nails.On 4/22/26 at 9:48 a.m., in an interview, Unit Manager Registered Nurse (RN) Staff G said Resident #56 was alert and oriented and did a lot of his own care. RN Staff G said that Resident #56 refuses care. The CNA's shave the men and do nail care on shower days and when needed.On 4/22/26 at 8:30 a.m., in an interview, the Director of Nursing (DON) said, We do not have a specific time to do nail care, I can't say it is done weekly or on this day. It should be once a week and men should be shaved. If you see it, you should do it.On 4/22/26 at 9:30 a.m., in an interview, CNA Staff H said nail care is completed daily, nails are cut and cleaned. The CNA said, If a resident refuses a shower, I try to encourage them and if they still refuse, I let the nurse know. If the resident continues to refuse, I tell the nurse, document it and give a bed bath.Review of the shower schedule documented revealed that Resident #56 showers were scheduled on Wednesdays and Saturdays on the day shift.Review of the CNA documentation for April 2026 revealed N/A (Not applicable) was documented on the scheduled shower days on 4/2/26, 4/6/26, 4/9/26, 4/13/26, 4/16/26, and 4/20/26. There was no documentation of nail care.On 4/22/26 at 3:20 p.m., in an interview, Unit Manager RN Staff G said she did not know what the CNAs meant by documenting N/A for showers. On 4/22/26 at 9:36 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said the CNAs clean and file the residents' nails on shower days. Activities also do nail care.

Based on observations, resident and staff interviews, the facility failed to ensure the safe storage of medications for 3 (Residents #56, #24, and #97) of 3 residents observed with unsecured medications at the bedside. The findings included: On 4/20/26 at 9:48 a.m., a prefilled syringe of normal saline was observed in Resident #56' bed. In an interview, Resident #56 said that the nurse was in his room and had left the syringe of saline on his bed. On 4/20/26 at 11:52 a.m., observation of Resident #24's room revealed a bottle of nasal spray, 1 tube of anti-fungal cream and 2 bottles of eye lubricant stored unsecured at the resident's bedside. Photographic evidence obtained.On 4/20/26 at 12:01 p.m., a bottle of salicylic acid 17% (wart remover) was observed stored unsecured at Resident #97's bedside. Photographic evidence obtained.On 4/21/26 at 10:23 a.m., in an interview, Licensed Practical Nurse (LPN) Staff K verified the unsafe and unsecured storage of the medications at Residents #24, #97, and #56's bedside.

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from neglect by failing to follow safety precautions specified in the care plan to prevent avoidable accident with injury for 1 (Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Abuse, Neglect, Exploitation, Misappropriation, not dated, indicated: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm. Review of facility Policy titled Mechanical Lifts, not dated, indicated: The facility will encourage the use of mechanical lifts with resident transfers. Using mechanical lifts helps to minimize the risk of injury to the resident due to mishandling and serves to reduce the risk of injury to the caregiver as well. Policy also indicates: 3. The resident's level of assistance needed with transfers and repositioning along with lift type and sling size when applicable should be included in the resident's plan of care. Review of medical records revealed Resident #1 was admitted to the facility on [DATE] for short term rehab with diagnosis including Chronic Obstructive Pulmonary Disease, kidney disease and neuropathy (damage or disease to the nerves). Skin assessment noted resident had fragile skin. The admission Minimum Data Set (MDS) with a target date of 4/30/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the care plan revealed Resident #1 required assistance with Activities of Daily Living (ADL) related to decreased mobility and generalized weakness. Resident #1 required Full-body lift for transfers with 2 staff Hoyer (mechanical lift for transfer) and had Bilateral 1/4 assist bars to promote independence and mobility. Review of Kardex (an electronic system used to summarize resident information) revealed Resident #1 required full body mechanical lift with assist of 2 staff for transfers. Review of Change in Condition Form dated 4/8/25 indicated Resident #1 obtained a skin tear to the left lateral leg during transfer, steri-strips applied. A Physician Progress note dated 4/9/25 indicated: called last night, laceration left leg. Patient refused emergency room (ER). A Nursing progress note on 4/9/25 indicated Deep laceration to left lower extremity, steri-strips in place. A Nursing progress notes on 4/10/25 indicated Resident #1 previously refused to go to ER, was now agreeable to go to ER and was sent out. Patient returned the same day with 7 sutures to close left leg wound. On 6/26/25 at 12:00 p.m., Resident #1 said she had received a cut to her leg from the transfer. She said they didn't use the Hoyer to transfer. She said Staff B had put her arms around her with her leg between her knees to transfer her, but it wasn't far enough away from the enabler bar and when they turned, her leg scraped against it and caused the injury. Resident #1 said the enabler bar had a gap in it which was rough and caused the tear and she had needed 7 stitches to close the wound. She said there were 2 people in the room at the time, but Staff B chose to do it herself. She said since the injury, she had continued working with physical therapy and no longer required the Hoyer lift to transfer. Record Review of Resident #3's Kardex indicated she was a full body mechanical lift for transfers with 2 assist. On 6/26/25 at 12:19 p.m., the Resident said she is transferred using a Hoyer lift. She said they use 2 people to transfer with the Hoyer, but not always, especially on the evening shift. She said it hurt and was not safe. She said she had not sustained any injuries during transfers. Record review of Resident #2 Kardex indicated she requires full body mechanical lift with assist of 2 staff. On 6/26/25 at 2:20 p.m., Resident #2 said she is transferred using a Hoyer lift. She said they don't use 2 people, it's always one person, and it was not safe. Resident #2 said she felt they needed more help. She said she had not sustained any injuries during transfer. On 6/26/25 at 2:28 p.m., Staff A Certified Nurse Assistant (CNA) said on 4/8/25 Resident #1 wanted to go back to bed. Staff A said she went to get Staff B (CNA) to assist. Staff A said she noticed the Hoyer pad wasn't under Resident #1 and she told Resident #1 they would scoot the pad under her to transfer her. Resident #1 told us we didn't have to because therapy had gotten her up without it. Staff A said she said to Staff B let's get her up together, but Staff B said No, I got it. And positioned herself in front of Resident #1, put her arms around her waist and stood her up to guide her to the bed. Resident #1 said ouch and they looked down and saw blood on her leg. There was some kind of thing on the side that wasn't covered, and her leg had scraped across and caused the injury. Staff A said now the first thing she does is check the Kardex and see if the person is a Hoyer lift and always uses 2 people. Per the facility investigation, Staff B said Staff A had asked for help to transfer Resident #1. Staff B said Resident #1 didn't have the Hoyer pad underneath because therapy had gotten her up, so they put her in bed. On 6/26/25 at 3:44 p.m., Staff C Licensed Practical Nurse (LPN) evening supervisor said Staff A came to her upset about Resident #1, saying Staff B came in to assist to transfer, but moved her out of the way and transferred Resident #1 by herself and caused an injury. Staff C said she went to Resident #1's room and Resident #1 was screaming that she was not going to the hospital. Staff C said she tried to calm Resident #1 down and explained she may need stitches. Resident #1 was adamant about not going, so the wound was cleaned and steri-stripped. Staff C said she saw the Hoyer pad and asked about it and Resident #1 said therapy had got her up that morning and never put it in the chair. Staff C said she then asked why the staff didn't put the pad back under her and Resident #1 said she told them not to and started saying again she would not go to the hospital. Staff A was saying Staff B had just moved her out of the way and said I got it and lifted Resident #1 and Staff B kept saying there were 2 people in the room. Staff C said she asked Staff A and Staff B to leave the room. Staff C said as Resident#1 was talking she said she didn't want to get anyone in trouble and that Staff B had moved her by herself. On 6/26/25 at 3:50 p.m., the Director of Nursing said the staff had not followed Resident #1's Plan of Care for transfer. She said staff re-education had been in process and provided documentation of what they are trained. The documentation provided indicated: Kardex must be verified for all transfer status, any full body lift transfer must have the mechanical lift utilized for transfers and 2-person assistance for all full body lift transfers.

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from accidents by failing to follow safety precautions specified in the care plan resulting in an injury for 1 (Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Abuse, Neglect, Exploitation, Misappropriation, not dated, indicated: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm. Review of facility Policy titled Mechanical Lifts, not dated, indicated: The facility will encourage the use of mechanical lifts with resident transfers. Using mechanical lifts helps to minimize the risk of injury to the resident due to mishandling and serves to reduce the risk of injury to the caregiver as well. Policy also indicates: 3. The resident's level of assistance needed with transfers and repositioning along with lift type and sling size when applicable should be included in the resident's plan of care. Review of medical records revealed Resident #1 was admitted to the facility on [DATE] for short term rehab with diagnosis including Chronic Obstructive Pulmonary Disease, kidney disease and neuropathy (damage or disease to the nerves). Skin assessment noted resident had fragile skin. The admission Minimum Data Set (MDS) with a target date of 4/30/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the care plan revealed Resident #1 required assistance with Activities of Daily Living (ADL) related to decreased mobility and generalized weakness. Resident #1 required Full-body lift for transfers with 2 staff Hoyer (mechanical lift for transfer) and had Bilateral 1/4 assist bars to promote independence and mobility. Review of Kardex (an electronic system used to summarize resident information) revealed Resident #1 required full body mechanical lift with assist of 2 staff for transfers. Review of Change in Condition Form dated 4/8/25 indicated Resident #1 obtained a skin tear to the left lateral leg during transfer, steri-strips applied. A Physician Progress note dated 4/9/25 indicated: called last night, laceration left leg. Patient refused emergency room (ER). A Nursing progress note on 4/9/25 indicated Deep laceration to left lower extremity, steri-strips in place. A Nursing progress notes on 4/10/25 indicated Resident #1 previously refused to go to ER, was now agreeable to go to ER and was sent out. Patient returned the same day with 7 sutures to close left leg wound. On 6/26/25 at 12:00 p.m., Resident #1 said she had received a cut to her leg from the transfer. She said they didn't use the Hoyer to transfer. She said Staff B had put her arms around her with her leg between her knees to transfer her, but it wasn't far enough away from the enabler bar and when they turned, her leg scraped against it and caused the injury. Resident #1 said the enabler bar had a gap in it which was rough and caused the tear and she had needed 7 stitches to close the wound. She said there were 2 people in the room at the time, but Staff B chose to do it herself. She said since the injury, she had continued working with physical therapy and no longer required the Hoyer lift to transfer. Record Review of Resident #3's Kardex indicated she was a full body mechanical lift for transfers with 2 assist. On 6/26/25 at 12:19 p.m., the Resident said she is transferred using a Hoyer lift. She said they use 2 people to transfer with the Hoyer, but not always, especially on the evening shift. She said it hurt and was not safe. She said she had not sustained any injuries during transfers. Record review of Resident #2 Kardex indicated she requires full body mechanical lift with assist of 2 staff. On 6/26/25 at 2:20 p.m., Resident #2 said she is transferred using a Hoyer lift. She said they don't use 2 people, it's always one person, and it was not safe. Resident #2 said she felt they needed more help. She said she had not sustained any injuries during transfer. On 6/26/25 at 2:28 p.m., Staff A Certified Nurse Assistant (CNA) said on 4/8/25 Resident #1 wanted to go back to bed. Staff A said she went to get Staff B (CNA) to assist. Staff A said she noticed the Hoyer pad wasn't under Resident #1 and she told Resident #1 they would scoot the pad under her to transfer her. Resident #1 told us we didn't have to because therapy had gotten her up without it. Staff A said she said to Staff B let's get her up together, but Staff B said No, I got it. And positioned herself in front of Resident #1, put her arms around her waist and stood her up to guide her to the bed. Resident #1 said ouch and they looked down and saw blood on her leg. There was some kind of thing on the side that wasn't covered, and her leg had scraped across and caused the injury. Staff A said now the first thing she does is check the Kardex and see if the person is a Hoyer lift and always uses 2 people. Per the facility investigation, Staff B said Staff A had asked for help to transfer Resident #1. Staff B said Resident #1 didn't have the Hoyer pad underneath because therapy had gotten her up, so they put her in bed. On 6/26/25 at 3:44 p.m., Staff C Licensed Practical Nurse (LPN) evening supervisor said Staff A came to her upset about Resident #1, saying Staff B came in to assist to transfer, but moved her out of the way and transferred Resident #1 by herself and caused an injury. Staff C said she went to Resident #1's room and Resident #1 was screaming that she was not going to the hospital. Staff C said she tried to calm Resident #1 down and explained she may need stitches. Resident #1 was adamant about not going, so the wound was cleaned and steri-stripped. Staff C said she saw the Hoyer pad and asked about it and Resident #1 said therapy had got her up that morning and never put it in the chair. Staff C said she then asked why the staff didn't put the pad back under her and Resident #1 said she told them not to and started saying again she would not go to the hospital. Staff A was saying Staff B had just moved her out of the way and said I got it and lifted Resident #1 and Staff B kept saying there were 2 people in the room. Staff C said she asked Staff A and Staff B to leave the room. Staff C said as Resident#1 was talking she said she didn't want to get anyone in trouble and that Staff B had moved her by herself. On 6/26/25 at 3:50 p.m., the Director of Nursing said the staff had not followed Resident #1's Plan of Care for transfer. She said staff re-education had been in process and provided documentation of what they are trained. The documentation provided indicated: Kardex must be verified for all transfer status, any full body lift transfer must have the mechanical lift utilized for transfers and 2-person assistance for all full body lift transfers.

Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to provide adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #1) of 1 newly admitted cognitively impaired, confused resident exhibiting exit seeking behaviors. On 8/20/24 shortly after 4:15 a.m., Resident #1 who was confused, wandered and had documented exit seeking behaviors walked out of the facility through the front lobby. Staff was not aware of the resident's exit until 8/20/24 at 4:40 a.m. Resident #1 walked approximately half a mile through the parking lot, down a private road with a nearby unfenced pond, to a busy four lane main road. Resident #1 could have been hit by a car, assaulted, or fallen into the pond and drowned. The facility failure to implement adequate supervision to prevent unsafe wandering and elopement of cognitively impaired, and confused residents created a likelihood of avoidable accidents for Resident #1 and other cognitively impaired and confused residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy. The Immediate Jeopardy began on 8/20/24. On 9/19/24 after verification of an acceptable removal plan, the Immediate Jeopardy was removed as of 8/23/24. The findings included: The facility's Risk Management/Nursing Policies-Elopement Risk (undated) included, . An elopement risk evaluation will be completed as part of screening upon admission to the facility . If the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Facility staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] following hospitalization for a traumatic subdural hemorrhage (bleeding near the brain). Diagnoses included encephalopathy (disorder that can affect the function of the brain), and alcohol use. The Nursing Admission Note documented Resident #1 was alert, oriented with short term memory loss, and occasional confusion. The resident's daughter said it was her normal since the injury. The elopement risk evaluation used by the facility consisted in six questions. A score of 7 or higher is considered at risk. The Elopement Risk evaluation dated 8/19/24 at 6:27 p.m., showed question 1 (Mood/Mental Status), question 3 (Relationships), and question 6 (Elopement history) were not answered, resulting in a score of 2, indicating the resident was not an elopement risk. A Nursing Progress note dated 8/20/24 at 6:42 a.m., noted Resident #1 was exhibiting exit seeking behavior, going to doors and attempting to leave. The resident stated her daughter was here to pick her up and bring her home. Verbal redirection was initially effective. However, due to the resident's cognitive deficits, she forgets and attempts to leave shortly after. Review of the facility's incident investigations revealed that Resident #1 was last seen in bed on 8/20/24 at approximately 4:00 a.m. On 8/20/24 at approximately 4:30 a.m., the laboratory technician arrived at the facility and was not able to locate the resident on Unit C where she resided to draw her blood. Staff began to search for the resident at that time. Licensed Practical Nurse (LPN) Staff A said on 9/20/24 at approximately 4:15 a.m., she saw Resident #1 on Unit B. The resident asked LPN Staff A to direct her to the lobby. She said she had been visiting and needed to wait in the lobby for her daughter to pick her up. Resident #1 was dressed in sweatpants, tennis shoes, a shirt and a jacket covering her arms, so an arm band would not have been seen. She was carrying a purse. Staff A escorted Resident #1 to the front lobby where she said she would sit and wait for her daughter. LPN Staff A returned to her unit. The investigation noted, Unwitnessed, (Resident #1) pushed the lobby's door's red release button and left the facility for a walk. While searching for the resident, the laboratory technician mentioned he observed a woman in the driveway on his way to the facility. Facility staff, and the laboratory technician exited the facility to search for the resident. The laboratory technician located Resident #1 and the facility staff returned her to the facility at approximately 5:10 a.m. On 9/16/24 at 9:45 a.m., in an interview the Administrator said Resident #1 eloped from the facility in the early morning hours of 8/20/24. The Administrator provided the investigation, and actions taken to prevent recurrence. On 9/16/24 at 6:15 p.m., in an interview Licensed Practical Nurse (LPN) Staff C said she was working the night Resident #1 eloped. She said she saw Resident #1 walking by with a pillow and bags and thought maybe she was a dialysis resident. She said they began looking for the resident when the laboratory technician could not locate Resident #1 to draw her blood. LPN Staff C said the laboratory technician and her got in their car to search for the resident. The laboratory technician found her. Staff C said she brought the resident back to the facility. Resident #1 was pleasant and had no visible injuries. On 9/16/24 at 3:00 p.m., in an interview the Director of Nursing (DON) said she interviewed staff on duty the night Resident #1 eloped. She said when Resident #1 approached LPN Staff A, said she was a visitor and asked for assistance to exit the facility, Staff A did not verify the resident's identity. The DON said staff needed to be aware of new admissions and verify whether they are a visitor or resident before allowing them to leave. The DON said Staff A and Staff B (Charge nurse on Unit C where Resident #1 resided) were no longer employed at the facility. On 9/18/24 at 10:20 a.m., in a meeting with the DON and Administrator they said after Resident #1 eloped, she was fitted with a wander alert bracelet (wearable device that alerts staff when a resident leaves a designated safe area). Resident #1 was also placed on checks every 15 minutes until she was safely discharged to a secured facility on 8/22/24. The DON and Administrator said they in-serviced staff on elopement policies, conducted numerous elopement drills on all shifts and continued to audit to prevent further elopement incidents. The facility submitted an acceptable Immediate Jeopardy Removal Plan on 9/19/24, and the Immediate Actions implemented by the facility and verified by the surveyor included: All exterior doors were checked by the Director of Nursing, Administrator, and Maintenance Technician. All were in good working order with no deficiencies noted. The maintenance department conducts routine door inspections during their work shifts. On 9/16/24 at 12:20 p.m., the surveyor conducted a tour with the DON and verified all doors were functioning properly. Resident #1 was placed on enhanced monitoring on 8/20/24 with continuous 15-minute checks for supervision in addition to wander management bracelet until discharge date of [DATE]. On 9/16/24 the surveyor verified through review of the monitoring documentation beginning on 8/20/24 at 6:00 a.m., until 8/22/24 at 2:15 p.m., when Resident #1 was discharged to a secured facility. Exit button used by Resident #1 in front lobby to exit front door was disabled by the Administrator. Secured lock box was placed over exit button. A sign was placed on the lock box to see nurse to exit facility after hours on 8/20/24. The front door is monitored by the receptionist from 8 AM to 6:30 PM. The front door automatically locks at 6:30 PM and automatically unlocks at 8 AM. On 9/16/24 the surveyor verified through observation of the sign located over the exit button. On 9/16/24 a receptionist was observed at the desk during the day. On 9/16/24 after 6:30 p.m., the door was locked. A staff member had to open the door for the surveyor to exit the facility. Elopement education for staff began on 8/20/24 with 6:00 a.m., to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and subsequent shifts on elopement policy and procedure, wander management devices, identifying residents at risk for elopement, and steps to identify a resident versus a visitor. Education was completed with 100% participation of current staff on 8/23/24. There were 173 staff members trained out of 173 current staff members. On 9/19/24 the surveyor verified participation through review of the sign-in sheets for the education provided. On 9/19/24, interviews with staff member corroborated trainings. Ninety-one of 99 direct care staff have participated in one of more elopement drills. Staff members have participated in one or more elopement drills related to performance improvement plan initiated by this resident event. Elopement drills were conducted by the Assistant Director of Nursing, RN Unit Supervisors, the Administrator, and the Infection Preventionist. Those staff members who did not participate in an elopement drill will not work until participation in an elopement drill is completed. On 9/19/24 the surveyor verified through review of sign-in sheets for elopement drills. On 9/19/24 interviews with staff corroborated multiple elopement drills held on all shifts. QAPI (Quality Assurance and Performance Improvement) meeting was held with QAPI committee members on 8/20/24 at 10:00 a.m., to review resident elopement performance improvement plan. The Medical Director participated in the QAPI meeting as well as all facility members. All members approved the performance improvement plan as written. On 9/16/24 the surveyor verified through review of minutes from the QAPI meeting held on 8/20/24 and ad hoc (unplanned) follow up held on 9/16/24. Root Cause Analysis (RCA) was completed on 8/20/24. RCA determined the individual nurse did not follow facility practice in identifying residents. Facility nurse was educated on elopement procedure prior to the event. On 9/16/24 the surveyor verified through review of the education on elopement procedure prior to 8/20/24. All residents currently identified at risk for elopement were verified to have their wander management device in place and was functioning properly on 8/20/24. Residents who are at risk for elopement are audited twice daily by nurses for device placement and function. Nurses document in the resident Treatment Administration Record (TAR) that device is present and functioning. Elopement books are brought to clinical meeting to verify list of residents are correct, all resident sheets are in the book, and device placement is correct. On 9/16/24 the surveyor verified through observation of residents at risk for elopement wearing a wander alarm band during tour with the DON and documentation of placement and function of the wander alert band in the Treatment Administration Record. Elopement books were reviewed and contained the current information. The elopement risk binders located at nurses' stations, front desk, and risk manager office were verified as current and accurate on 8/20/24. Audits conducted weekly by Risk Manager with no identified areas of concern noted. On 9/16/24 the surveyor verified through review of the information in the elopement books for accuracy. Current residents were re-evaluated for elopement risk and documented in PCC (Point Click Care) electronic clinical record by nurse managers. All evaluations were found to be accurate with no changes indicated on 8/21/24. On 9/16/24 the surveyor verified through review of the elopement risk re-evaluation. Staff Elopement drills were initiated on the 6:00 a.m. to 2:00 p.m. shift on 8/20/24. They continued every eight hours for the next seven days. These drills were completed by nurse managers and Administrator. After the initial seven days, elopement drills have been conducted weekly and will continue weekly until 9/27/24. After 9/27 they will be completed twice monthly per facility protocol. On 9/16/24 the surveyor verified through review of the elopement drills. Director of nursing/designee has been auditing elopement evaluations in morning clinical meeting daily on new/readmission residents. No new residents have been identified at risk since the incident. On 9/16/24 the surveyor verified through review of the completed audits. Twenty-three of 25 licensed nurses were educated on 8/23/24 regarding taking new admission photos and uploading them into Point Click Care upon admission. This is verified in morning clinical meeting audits by nurse leadership and/or Administrator. Those PRN (as needed) nurses who have not been educated will not work until education is completed. On 9/19/24 the surveyor verified through review of the documentation of the education. A total of 26 nurses have been educated. On 8/28/24, a 15 day Adverse Incident was completed by DON and submitted to AHCA (Agency for Health Care Administration), (State Survey Agency). On 9/16/24 the surveyor verified through review of the Adverse Incident submitted. New staff are educated/oriented to elopement/missing resident policy and procedures upon general orientation which occurs prior to working in their assigned department. On 9/18/24 the surveyor verified through review of eight personnel files. All eight randomly selected staff received training. Employees receive education annually on elopement/missing resident policy and procedures. On 9/18/24 the surveyor verified through review of eight personnel files. All eight staff selected received training. Residents at risk for elopement are supervised by multiple interventions: Encouraged to participate in activities offered on units in Avalon rooms. These rooms are monitored by staff assigned to area for increased supervision. Encouraged to eat in Avalon rooms with other residents or in the main dining room for a higher level of supervision. Encouraged to attend group activities in supervised areas provided by the activity department. On off hour shifts, increased supervision is provided for those residents at risk by nurses during room rounds, medication pass, wound care treatments. Increased supervision is also provided by Certified Nursing Assistants (CNAs) by increased room rounds and monitoring. Staff are encouraged to provide 1:1 (one to one) or group activities if needed for residents with wandering behaviors. CNAs have Kardex (Provides instructions for care) and pocket care guides to have information on residents at risk for elopement. On 9/16/24 through 9/18/24 the surveyor verified through observation of residents at risk for elopement and review of Kardex and pocket care guides.

Based on record review and interview, the facility failed to protect the right to be free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse. The findings included: Review of the undated Facility policy titled Abuse, Neglect, Exploitation and Misappropriation noted, Abuse is the willful infliction of injury . with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Record review of Resident #2's clinical chart revealed a progress note dated 3/19/24 that indicated she had areas of bruising to her left forearm and complained of pain to the area. On 4/8/24 at 11:29 a.m., in an interview Certified Nurse Assistant (CNA) Staff A said he had tried to provide incontinent care to Resident #2. He said he was providing care alone without anyone to assist. He said Resident #2 became resistive to care and he had to grab her because he didn't want her to fall from the bed. He said he always called someone to help with her as she is often resistant to care, but that night he tried to do it by himself, because the other people were busy. On 4/8/24 at 12:41 p.m., an attempt to interview Resident #2 was made. Resident #2 is aphasic (difficulty communicating), however, when asked her how she felt the care was, she became restless, pointed to her left arm and appeared to be trying to communicate something. On 4/9/24 at 9:30 a.m., in an interview Resident #2's sister said Resident #2 indicated a staff member had been rough with her during care. The sister said she did not feel it was an accident but deliberate manipulation of her arm and that Resident #2 had been very upset at the time. On 4/9/24 at 11:17 a.m., the Director of Nursing (DON) said they had done an investigation into this incident, however they did not find the incident to be abuse as there was no intent to cause harm. The DON said Staff A had been holding Resident #2's arm so she would not put her hand in the bowel movement during incontinent care. The DON said at the time of the incident Resident #2 had been care planned for one person assist, but the care plan had been adjusted now to two people assist due to the resistive behaviors. Review of the care plan at this time revealed it had not been updated to two person assist with Activities of Daily Living. The DON agreed the care plan still indicated one person assist and it should be two.

Based on observation interview and record review the facility failed to maintain a comfortable safe temperature within the facility. The findings included: On 12/11/23 at 9:30 a.m., air temperatures were obtained from the conference room at the entrance of the building, the 200 hall nursing station, and in the halls and rooms of the 200 hall. The temperatures obtained in theses areas ranged from 69.4 to 69.8 degrees Fahrenheit. On 12/11/23 at 1:52 p.m., Resident #1 said the thermostat in his room was not working and it was either to hot or too cold. Most of the time it is too cold. The resident said the heat had not been working in his room for more than a month. On 12/12/23 at 1:52 p.m., Resident #19 said the thermostat in her room was not working. She said the facility staff keep telling her they are working on the heat. Resident #19 said she had problems with the temperature almost since she was admitted to the facility. Resident #19 said she had no heat in her room, and she had to use three blankets to stay warm. On 12/13/23 at 9:38 a.m., Resident #82's husband said it was very cold in his wife's room. The staff had to get an extra blanket for his wife. On 12/14/23 at 10:44 a.m., the Maintence Director said the main issue with the heat not functioning properly was the thermostats in the resident's rooms. There was not enough pressure in the lines. The Maintenance Director said the heat in the building had not been working properly for about three months. A subcontractor had been in the building working on the problem for about a month. The Maintenance Director said the rooms are below 71 degrees first thing in the morning in the morning when he takes the temperatures. If I know it's cool he tries to leave the air handlers off to quit blowing the air in the building. He said it had been very difficult to maintain appropriate temperatures in the building over the last three months due to the colder weather. The Maintence Director provided documentation of temperatures being obtained once a day in 66 rooms in the facility from 10/2/23 through 12/12/23. There were 13 days in which temperatures were documented in October of 2023. There were no days where all of the rooms were documented as being 71 degrees or higher. On 10/27/23 there were 28 of the 66 rooms documented with temperatures below 71 degrees. There were documented temperatures as low as 64 degrees noted on some of the days in some of the rooms. There were 7 days documented in November where temperatures were obtained. There were no days where all of the rooms were 71 degrees or above. On 11/13/23 there were 36 rooms documented as being below 71 degrees. room [ROOM NUMBER] was documented at 65 degrees. room [ROOM NUMBER] was 63 degrees, room [ROOM NUMBER] was 64 degrees, and room [ROOM NUMBER] was 65 degrees. There was no documentation of follow up temperatures or documentation the heaters in the rooms were not working. There were 5 days documented in December of 2023 were temperatures were documented. None of the days documented showed all 66 rooms with temperatures at 71 degrees or greater. On 12/12/23 there were 48 of the 66 rooms documented as being below 71 degrees. 25 of the rooms were documented at 69 degrees or lower. Two rooms were documented as being 66 degrees. There was no documentation found of any follow-up temperatures or any actions the facility took to maintain comfortable temperatures in the residents rooms. On 12/14/23 at 11:30 a.m., the Administrator said they had given residents extra blankets and in-serviced staff members who were instructed to call maintenance with any issues with the room temperatures. The Administrator verified there was only one temperature being obtained and many of the temperatures were below an exceptable temperature, and no documented follow-up as to what interventions were in place to ensure patient comfort and safety.

Based on record review and staff interview, the facility neglected to protect the resident's right to be free from neglect. The facility failed to provide physician ordered treatment of pressure ulcers for 1 (Resident #244) of 3 sampled residents surveyed for prevention and treatment of pressure ulcer. The findings included: The facility policy Abuse, Neglect, Exploitation and Misappropriation documented 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 any injury of unknown source and to ensure that all lead 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 facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. The facility policy Skin Care and Wound Management - Manage Wound Care documented The facility will manage wound care based upon current standards of practice. The nurse will document the identification of impaired skin, resident representative notification, physician notification and initiation of ordered treatment in the residence medical record. Review of Resident #244's clinical record revealed Resident #244 had an admitted [DATE] with diagnoses including dementia, cerebrovascular disease, hemiplegia, and hemiparesis affecting the left side, anemia, and hypertensive heart disease. The clinical record documented Resident #244 was admitted with bi-lateral pressure wounds to the heels. The physician order at admission documented cleanse bilateral heels with normal saline, apply silver alginate, and cover with foam dressing daily/prn (as needed) every day shift for wound care. The wound care was scheduled to be completed on the 6 a.m., to 6 p.m., shift. Review of the nursing progress note dated 2/4/23 documented Resident #244's niece reported to the charge nurse, the dressings on Resident #244's heels were dated 2/1/23. The Charge Nurse then provided the wound care to bi-lateral heels and contacted the physician. A new order was received from the physician for Doxycycline Hyclate Oral Tablet 100 milligram (mg) give 100 mg by mouth two times a day for Wound Prophylaxis for 10 Days. Review of the treatment administration record (TAR) documented the wound care to both heels was completed on 2/2/23 and 2/3/23 as ordered by the physician. On 12/13/23 at 1:15 p.m., in an interview, the Director of Nursing (DON) confirmed Resident #244's wound care was signed as completed on the TAR on 2/2/23 and 2/3/23 but the treatment was not rendered as ordered by the physician. The DON said the root cause of the wound care not being provided was an agency nurse. The DON confirmed she did not do audits of the wounds in house to ensure the wound care was being completed. She said she had someone looking daily at Resident #244's wound but had nothing in writing. The DON said the root cause of the event was an agency nurse and the facility no longer has agency staff. I did not substantiate the investigation because the wound was unchanged so there was no neglect.

Based on record review, staff interviews, and review of facility policy the facility failed to ensure the accuracy of a Pre-Admission Screening and Resident Review (PASARR), and make the necessary corrections for 1(Resident #73) of 2 residents reviewed for PASARR. The findings included: The facility policy Pre-Admission Screening and Resident Review (PASRR) with no date of implementation stated: The purpose of PASRR is to ensure individuals who are being considered for placement in a Nursing Facility are evaluated for serious mental illness and/or intellectual disability and are offered the most integrated setting appropriate for their long term care needs including determining whether a Nursing Facility is appropriate. All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for possible mental illness or the presence of an intellectual disability or both (Level 1). If a mental illness or intellectual disability appears to exist, the person must be referred for further evaluation (Level II) before Nursing Facility admission. Review of the clinical record for Resident #73 revealed an admitted [DATE]. The documented medical history at the time of admission included a primary diagnosis of Dementia, and Depression and Anxiety. Resident #73 was confused and unable to state her medical history. Her Brief Interview for Mental Status (BIMS) score was documented as a 3 on her Minimum Data Set (MDS). BIMS is a tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. A score of 3 out of 15 indicates severe cognitive impact. On 12/14/2023 at 12:00 p.m. in an interview with the Director of Nursing, (DON), she verified that the PASARR form dated 8/14/2022 was inaccurate and did not list the Diagnoses of Dementia, Anxiety, or Depression. There was no documentation that the facility completed an accurate Level 1 PASARR. The DON said that all new admissions are to get PASARR's reassessed for accuracy.

Based on observation, interviews, and record review, the facility failed to provide adequate supervision prevent falls for 2 residents (#9 and #18) of 3 residents reviewed for falls. The findings included: 1. Review of the Policy Fall Risk Reduction Program: Residents at risk for falls will be identified and the interdisciplinary team will work with the residents, caregivers, and family to reduce the risk of falls while maximizing dignity and independence. Components of the fall risk reduction program include but are not limited to: Addressing underlying medical issues that may contribute to fall risk and resident/responsible party/family education. Reducing the risk of falls included placing in Rising Star Program to promote communication of high risk to all staff. Providing assistance whenever the resident ambulates. Moving the resident to a room closer to a nurse's station or in a higher traffic hallway. Requesting family or friends to stay with resident at all times or use of sitters, and supervised activities when up out of bed. Review of the Rising Star Program revealed it includes assisting with ambulation as needed, anticipate needs of resident, and check on regularly/frequently. 1. Review of the hospital records dated 4/20/23, revealed Resident #9 had 2 unwitnessed falls at home, sustaining a nasal fracture. One fall was in the bathroom. The resident was noted to be alert and oriented, but not a great historian. Review of the admission record face sheet revealed Resident #9 was elderly, aged in the 9th decade, admitted to the facility on [DATE] with diagnoses of repeated falls, fracture, pacemaker, age related osteoporosis, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] section GG revealed Resident #9 required partial to moderate assistance for toileting, required supervision or touching assistance for transfers, sitting to standing, and walking 50 feet with 2 turns. Review of section I revealed diagnoses of seizure disorder and pacemaker. Review of the incident reports revealed Resident #9 had multiple falls after being admitted to the facility including falls on 5/6/23; 7/9/23; 7/10/23; 8/16/23; 9/24/23; 10/2/23; 10/26/23; and 11/13/23. Review of the Activities of Daily Living (ADLs) care plan initiated on 4/28/23 revealed the resident required touching or supervision assistance for transfers. Review of the fall care plan initiated on 4/28/23 revealed Resident #9 was at risk for further falls due to fall history, weakness, advanced age, and history of seizures. The interventions put in place on 4/28/23 included anticipate needs; be sure call light in reach and remind resident to use it; resident needs prompt response to all request for assistance; educate the resident family/care givers about safety reminders and what to do if a fall occurs; encourage activities that promote strength and improved mobility. Review of the incident report dated 5/6/23 at 2:48 a.m. revealed Resident #9 had an unwitnessed fall in the bathroom. The resident stated, I was getting into my wheelchair and didn't lock the brakes and slipped in these socks. The facility identified poor safety awareness and using wheeled walker as predisposing factors. The care plan was updated on 5/6/23 to include non-skid socks at bedtime. A Restorative Therapy care plan was initiated on 6/5/23 to maintain ambulation and mobility. Review of the incident report dated 7/9/23 at 1:45 p.m. revealed Resident #9 had a witnessed fall in the bathroom reaching for a towel and lost his balance. The facility predisposing factors were weakness/fainted, ambulating without assistance, recent c/o sore throat and general malaise. Review of the incident report dated 7/10/23 at 2:50 p.m. revealed Resident #9 had an unwitnessed fall in the bathroom. The resident took himself to the bathroom and lost balance when he stood up. The facility's immediate action was the call, don't fall sign and reeducate the resident to call for assistance. The pre-disposing factors were poor safety awareness, recent illness, weakness/fainted, confusion. The care plan was updated on 7/10/23 to increase visual checks and place a call, don't fall sign in the room. On 7/11/23 the care plan was updated with Rising Star Program. On 7/24/23 the facility updated the fall care plan to include antiseizure medications as ordered and if seizure activity noted provide safety and notify MD. Review of the incident report dated 8/16/23 at 11:16 p.m. revealed Resident #9 had an unwitnessed fall next to the bathroom door. Resident said he got up to use the bathroom. The facility instructed the resident to call for assistance before getting up. Predisposing factors identified were gait imbalance, impaired memory, weakness/fainted, improper footwear, and ambulating without assistance. Resident #9's fall care plan was updated on 8/17/23 to include prompted toileting upon rising before or after meals/activities, before bed, upon request, and as needed. Review of the incident report dated 9/24/23 at 9:45 a.m. revealed Resident #9 had an unwitnessed fall in the bathroom. He said he spit in the toilet and slipped. The predisposing factors were confused, impaired memory, poor safety awareness. The care plan was updated on 9/25/23 for medication review. Review of the incident report dated 10/2/23 at 8:10 a.m. revealed Resident #9 had an unwitnessed fall in the bathroom but was unable to give a description. The predisposing factors were confusion and poor safety awareness. The nursing to therapy communication form dated 10/5/23 by the therapist indicated Physical Therapy evaluated the resident for fall prevention. The care plan was updated on 10/5/23 to include continue current interventions. Review of the Rehabilitation and Skilled Nursing Facility Therapy to Nursing Communication form dated 10/19/23 revealed Resident #19 may ambulate in the hallways without walker. Review of the incident report dated 10/26/23 at 10:40 p.m. revealed Resident #9 had an unwitnessed fall in the doorway of his room. Predisposing factors included ambulating without assistance. The care plan was updated on 10/27/23 to re-educate Resident #9 on calling for assistance. Review of the incident report dated 11/13/23 at 8:30 p.m. revealed Resident #9 had an unwitnessed fall at the foot of the bed. Predisposing factors included impaired memory, poor safety awareness and ambulating without assistance. The root cause of the fall was resident was cleared by therapy for self-ambulation with walker. On 12/11/23 at 8:03 a.m., observed Resident #9 in his room eating breakfast. The room was located away from the nurses' station in the middle of the hallway. Resident #9 could not tell me why he had so many falls at the facility. On 12/11/23 at 12:27 p.m., Licensed Practical Nurse (LPN) Staff H said Resident #9 has fallen numerous times, has been cleared by therapy to walk without a walker, and will probably fall again. On 12/13/23 at 10:01 a.m., Physical Therapist (PT) Staff G said she discharged Resident #9 from therapy on 10/19/23. She said she completed the Therapy to Nursing Daily Communication form on 10/19/23 indicating Resident #9 may ambulate in hallways without walker. She said short-term and long-term goals were met on 10/19/23 for gait with safe ambulation on level surfaced unlimited distance using no assistive device, supervision, or touching assistance. On 12/13/23 at 3:06 p.m. LPN Staff E said Resident #9 is confused and does not think the resident would remember if told something. She said he is on the Rising Star Program because he is a fall risk. On 12/13/23 at 12:08 p.m., the Director of Nursing (DON) said we do not have enough staff to give Resident #9 one to one supervision. She said every time he falls, he is screened or evaluated by therapy. She said he is continent and not a candidate for the toileting program. She said we call the family each time he falls. On 12/13/23 at 12:21 p.m., LPN Staff D said she was unaware Resident #9 had a pacemaker and did not know who monitored the pacemaker. On 12/13/23 at 12:31 p.m. review of the medical chart revealed no interventions for monitoring the pacemaker. On 12/13/23 at 12:38 p.m., the DON verified there were no instructions in the medical record to indicate the pacemaker was being monitored. She said most residents with pacemakers have a machine in the room. On 12/13/23 at 12:53 p.m., during observation of Resident #9's room with the DON, there was no machine for monitoring the pacemaker. On 12/13/23 at 12:55 p.m., the DON said Resident #9's stepson has been monitoring the pacemaker. She said they were not aware of it until now. On 12/13/23 at 2:55 p.m., Certified Nursing Assistant (CNA) Staff F said Resident #9 is unstable on his feet, hard of hearing and confused. She said he falls, but not a lot. She said the Rising Star Program means you check on them every 30 minutes or so. On 12/14/23 at 9:16 a.m., Resident #9's son-in-law said the facility called him about the pacemaker on 12/13/23. He said they never asked about the pacemaker before then. On 12/14/23 at 10:52 a.m., during an interview with the DON and Registered Nurse (RN) Unit Manager Staff B, they acknowledged repeated falls in the bathroom for Resident #9. They said the interventions for prompted toileting and increased visual checks did not include specific times to check the resident and did not prevent Resident #9 from falling. The DON acknowledged reminding resident to call for assistance was not effective in that the resident had confusion and impaired memory. The DON said the pacemaker was an underlying medical issue that may contribute to fall risk and the facility was not monitoring it for proper functioning. The DON said Resident #9 fell two more times after therapy indicated the resident could ambulate without assistance, and there were no additional evaluations or screenings after those falls. On 12/14/23 at 11:30 a.m., Therapist Staff G confirmed Resident #9 was not re-evaluated or re-screened after the the falls on 10/26/23 and 11/13/23. 2. Review of the facility admission face sheet for Resident #18 revealed admission on 4/21/23 with diagnoses of dementia and repeated falls. Review of the admission MDS with ARD of 4/24/23 revealed the resident's BIMS was 3, meaning severe cognitive impairment. Review of Section GG revealed Resident #18 was dependent on staff for eating and toileting. Resident #18 used a wheelchair and was dependent on the helper to do all the effort. Review of the Resident 18's care plan dated 4/25/23 revealed interventions in place to prevent falls were anticipate needs, call light in reach and encourage resident to use it, resident needs prompt response to all requests for assistance, educate resident/family/caregivers about safety reminders and what to do if fall occurs, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, physical therapy evaluate and treat as ordered and as needed. Review of the incident reports revealed Resident #18 had multiple falls after admission to the facility including falls on 4/27/23, 6/9/23, 6/23/23, and 11/16/23. Review of the incident report dated 4/27/23 at 4:40 p.m., revealed Resident #18 had an unwitnessed fall in her room. Predisposing factors were listed as confusion, impaired memory, and poor safety awareness. The care plan was updated on 4/28/23 with bilateral fall mats and low bed. Review of the incident report dated 6/9/23 at 11:54 a.m., revealed Resident #18 had an unwitnessed fall in the Sunroom/Avalon Room. The predisposing factors were listed as confusion, gait imbalance, impaired memory, poor safety awareness, and ambulating without assistance. The care plan was updated on 6/9/23 with the Rising Star Program. Review of the incident report dated 6/23/23 at 6:59 a.m., revealed Resident #18 had a witnessed fall in front of the nursing station. The resident leaned forward and fell . Confusion, gait imbalance, poor safety awareness and ambulating without assistance were listed as predisposing factors. The care plan was updated on 6/23/23 to offer books, magazines, etc. to distract. Review of the incident report dated 11/16/23 at 2:10 p.m., revealed an unwitnessed fall for Resident #18. The resident fell out of bed. The care plan was updated with the call don't fall sign on 11/17/23. On 12/11/23 at 8:02 a.m., observed Resident #18 in room in bed. The bedside tray with breakfast on it was located at the end of the bed up against the wall. The resident did not respond to verbal stimulation. On 12/14/23 at 10:10 a.m., the DON acknowledged Resident #18 had severe cognitive impairment and some of the interventions to prevent falls were not appropriate. The DON said there was no evaluation to ensure Resident #18 would know what the call don't fall sign meant, so it was probably ineffective. The DON acknowledged placing the resident in the Sun/Avalon Room for supervision was ineffective because the resident had an unwitnessed fall while she was in the Sunroom/Avalon Room. The DON said the Rising Star Program was ineffective because it did not include specific time frames for checking on the resident and Resident #18 fell twice after it was added to the care plan. The DON acknowledged the resident's room was far from the nurses' station and not in a high traffic area where the resident would be seen by more staff.

Based on record review, staff interview, and observation the facility failed to maintain an indwelling catheter in a safe and sanitary manner for 1(Resident #82) of 1 resident sampled with an indwelling catheter. This has the potential to cause injury and urinary tract infection. The facility policy Catheter Care, Including Drainage Bag Care /Maintenance documented the purpose of the policy: To provide safe and proper care of the resident with an indwelling urinary catheter. To minimize the risk of bladder infection. Procedure #8 documented: Position the drainage bag below the level of the residence bladder. Secure to the bed or wheelchair in such a manner that neither the bag nor the spigot touches the floor. Review of Resident #82's clinical record revealed a physician order for an indwelling catheter (tube inserted into the bladder to drain urine) for comfort at end of life. On 12/11/23 at 9:41 a.m., during an observation, Resident #82 was in bed and not responsive. The catheter drainage bag was observed lying on the floor. Photographic evidence obtained. On 12/11/23 at 1:56 p.m., during an observation, Resident #82's catheter drainage bag was in the same position on the floor. On 12/11/23 at 2:00 p.m., during an observation and interview, Licensed Practical Nurse Staff A confirmed the catheter drainage bag should not be on the floor.

Based on observation, review of facility policy and procedures, record review, and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders, for 1 (Residents #82) of 1 resident reviewed for oxygen therapy. The facility also failed to have a system to maintain CPAP (continuous positive airway pressure therapy) and BIPAP (bi-level positive airway pressure therapy) machines in a sanitary manner for 2 (Resident #27 and #248) of 2 residents who use a CPAP/BIPAP machines (helps you breathe more easily when you sleep). This has the potential to cause respiratory infection. The findings included: The facility policy Oxygen Administration documented, The purpose of this procedure is to provide guidelines for oxygen administration. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered. Observe the resident to be sure oxygen is being tolerated. 1. Review of Resident #82's clinical record revealed an admitted [DATE] with diagnoses including dementia, protein calorie malnutrition and hypertensive heart disease. On 12/11/23 at 9:49 a.m., during an observation Resident #82 was in her bed and was not responsive to verbal stimuli. The resident had an oxygen concentrator to deliver oxygen through a nasal cannula. The oxygen concentrator was set at 0.5 L/M. Photographic evidence obtained. On 12/11/23 at 1:53 p.m., during an observation Resident #82's oxygen concentrator was turned on and set at 0.5 L/M. Review of the physician's admission orders for Resident #82 documented oxygen at 3 liters/minute (L/M) via nasal cannula continuous. On 12/11/23 at 2:15 p.m., Licensed Practical Nurse Staff A verified the oxygen concentrator was not set at 3 L/M as ordered by the physician. Staff A attempted to adjust the oxygen concentrator but was not able to increase the flow rate to 3 L/M. Staff A said the concentrator was broken. Staff A said there was no way of knowing how long Resident #82 was not receiving the physician ordered flow rate of the oxygen. The facility policy Nursing-Use of CPAP/BIPAP/APAP documented the purpose of the policy was To provide guidelines for use of CPAP (continuous positive airway pressure therapy) or BIPAP (bi-level positive airway pressure therapy) or APAP (auto adjusting positive airway pressure therapy) for the treatment of obstructive sleep apnea. Guidelines for use: Obtain MD order that includes the following: a. Specifies what type of machine is required (CPAP, BIPAP, APAP) b. Contains the specific pressure. c. Diagnosis for use (obstructive sleep apnea). d. For cleaning mask and tubing instructions. Care and maintenance specified keep the area around the machine clean and dusted to improve the air quality delivered by the machine. 2. Review of the clinical record revealed Resident #248 had an admitted [DATE] with diagnoses including morbid obesity and obstructive sleep apnea. On 12/11/23 at 11:00 a.m., during an observation Resident #248 had a CPAP machine on her bedside table. The CPAP mask was lying on top of the nightstand uncovered and in contact with other items on the nightstand, including the phone. Resident #248 said the nurse takes care of filling the water reservoir but she did not know who was responsible for the care of the mask, I suppose I am. Photographic evidence obtained. During random observation on 12/12/23 at 9:12 a.m., and 12/13/23 at 8:30 a.m., Resident #248 CPAP mask was uncovered on top of the nightstand lying on the phone and in contact with other items on the nightstand. There was debris from an artificial Christmas trees sprayed on snow next to the CPAP machine and the mask. On 12/13/23 at 10:32 a.m., Registered Nurse Unit Manager, Staff B and the Director of Nursing (DON) went to Resident #248's room and confirmed the findings with the storage of the CPAP mask. The DON confirmed the CPAP mask was not stored properly. On 12/13/23 at 10:00 a.m., in an interview Staff B said the process for the CPAP machine masks was to place the mask in a plastic bag when not in use. Staff B said we follow the physician order for the settings, and we make sure the CPAP is set to that level. Further review of Resident #248's clinical record found no documentation of a physician order for the use of the CPAP machine. 3. Medical record review for Resident #27 showed a Physician order dated 1/18/2023 to apply at pre-programmed settings with heated humidification at bedtime. Remove in the morning. On 12/11/23 at 12:15 p.m., a BIPAP oxygen mask was observed sitting on Resident #27's bedside table. Resident #27 said that staff come in every night and put the mask on him, and he takes it off and sets it on the table when he's done with it. On 12/12/23 at 12:36 p.m., observed Resident #27 sitting up in his wheelchair sleeping. His BIPAP mask was lying on the bedside table in his room uncovered. *Photographic evidence obtained. On 12/12/23 at 12:36 p.m., observed Resident #27 sitting up in his wheelchair sleeping. His BIPAP mask was lying on the bedside table in his room uncovered. Photographic evidence obtained. On 12/13/23 at 11:10 a.m. observed BIPAP mask on bedside table uncovered. On 12/14/2023 at 10:30 a.m. observed BIPAP still laying on the bedside table uncovered. On 12/14/23 at 10:40 a.m., in an interview Staff D, LPN, said the night nurse puts the BIPAP on Resident #27 when he will let them. She said the BIPAP should be stored in a plastic bag and the tubing dated and labeled. On 12/14/2023 at 10:45 a.m., in an interview Staff E, LPN said that BIPAP masks are supposed to be cleaned and covered and the tubing labeled. On 12/14/2023 at 12:00 p.m., in an interview, the DON she said CPAP BIPAP masks should be taken off in the morning by the nurse and placed in a plastic bag.

Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin was properly dated when opened and stored on one (1) of three (3) medication carts observed. Without an open date on the medications there was no way to know when it would expire. The facility also failed to ensure expired medications were removed and disposed of in one (1) of two (2) medication rooms observed. The findings included: The facility policy Medication Storage in the Facility documented when the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. The nurse shall place a date open sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless manufacturer recommends another date or regulations guidelines require different dating. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining. On 12/11/23 at 8:05 a.m., during an observation on the [NAME] Unit, medication cart 1 contained a vial of Tresiba insulin. The date opened was 9/30/23. The expiration date was 11/25/23. The findings in medication cart 1 were verified with Licensed Practical Nurse Staff C. Photographic evidence obtained. On 12/11/23 at a.m., 8:20 a.m., during an observation of the the locked medication refrigerator on the [NAME] Unit there were four (4) purified protein derivative (PPD's) single injection skin tests for tuberculosis with the expiration date 12/10/23 and 1 PPD with the expiration date 12/6/23. Registered Nurse Unit Manage Staff B confirmed the findings. Photographic evidence obtained.

Based on observation, record review and interview, the facility the facility failed to maintain an effective water management program to minimize the risk of outbreak of water borne pathogens. The findings included: The Center for Clinical Standards and Quality/Survey and Certification group (Ref S&C 17-30) revised on 6/9/17 directs facilities to, implement a water management program that considers the ASHRAE [American Society of Heating, Refrigerating, and Air Conditioning Engineers] industry standards and the CDC [Center for Disease Control] toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspection, and environmental testing for pathogens. Specify testing protocols and acceptable range for control measures and document the result of testing and corrective actions taken when control limits are not maintained . The Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/safewater/chlorine-residual-testing.html notes, The presence of free chlorine (also known as chlorine residual, free chlorine residual, residual chlorine) in drinking water indicates that: 1) a sufficient amount of chlorine was added initially to the water to inactivate the bacteria and some viruses that cause diarrhea disease; and 2) the water is protected from recontamination during storage. The presence of free chlorine in drinking water is correlated with the absence of most disease-causing organisms, and thus is a measure of the potability of water. The facility's policy titled Legionella Water Management Program, (MED-PASS, Inc. (Revised July 2017) read, Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella . The water management team will consist of at least the following personnel: The infection preventionist; the administrator; the medical director (or designee), the director of maintenance; and the director of environmental services . The water management program includes the following elements: The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices . The identification of situations that can lead to Legionella growth, such as: . construction; .water main breaks; . changes in municipal water quality; . the presence of biofilm, scale, or sediment; .water temperature fluctuations; .water pressure changes; . water stagnation; and . inadequate disinfection. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); The Control limits or parameters that are acceptable and that are monitored . A system to monitor control limits and the effectiveness of control measures . Documentation of the program . On 3/3/22 at 9:03 a.m., the administrator said he was responsible for the water management program since the previous maintenance director left. The administrator said each month the chemical services company comes to the facility and tests the water in the cooling tower. He said the cooling tower supplies the water to the heating, ventilation, and air conditioning (HVAC) system. He said the company does the testing monthly. The administrator submitted the Service Report dated 2/8/22, as an example. Review of the chemical services company service report dated 2/8/22, which included water testing for facility's HVAC system. The report did not contain testing of any other water in the facility. On 3/3/22 at 9:15 a.m., during observation of the outdoor cooling tower, the administrator said the water in the cooling tower does not supply drinking water to the facility. He said the facility's water is supplied by the county and the facility does not test the municipal water supply for chlorine or bacteria. On 3/3/22 at 9:20 a.m., during observation of the pond and fountain in the facility's courtyard, the administrator said residents and/or family members like to sit around the fountain. The administrator said chlorine tablets from the home improvement store are added to the pond (and fountain). He said here is no documentation of how much or when the chlorine tablets are added. He said the water in the pond and fountain is not tested for chlorine amount or content. The administrator said there is no routine testing for chlorine levels of water inside the facility used for such things as drinking, showering, eye wash station or ice machines. On 03/3/22 at 9:58 a.m., the Infection Preventionist said she is not involved in the Water Management Program. On 03/3/22 at 10:05 a.m., the Environmental Services Director said she does not know anything about Legionella. On 3/3/22 at 10:21 a.m., the administrator submitted the facility's Water Management Program book, which included Centers for Disease Control (CDC) guidelines, Facility Risk Assessment for Legionella, facility H2O (water) flow chart, and additional monthly Service Reports from the chemical services company for the HVAC system. He said the Maintenance Director is new and did not know he was supposed to test the water for chlorine or bacteria. On 3/3/22 at 10:48 a.m. during a telephone interview, the sales representative from the contracted chemical services company verified testing and treating of the cooling tower only. He said there was no testing of facility water supplying drinking, showering, eye wash station, ice machines, or fountains. On 3/3/22 at 11:14 a.m., the administrator again verified they were not monitoring or testing facility water for chlorine levels or Legionella.

Based on observation, record review, resident and staff interview, the facility failed to ensure they provided an ongoing program to support residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 1 (Residents #38) of 2 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. The findings included: On 2/28/22 at 10:28 a.m. Resident #38 was observed in her room lying in bed wearing a hospital gown. Via observation noted the television or the radio were not on, and Resident #38 was not participating in a facility activity. On 3/1/22 at 11:22 a.m., Resident #38 was observed in her wheelchair in the day room next to the nursing station. Via observation noted the television or the radio were not on, and Resident #38 was not participating in a facility activity. On 3/3/22 review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) assessment dated [DATE], a tool used for clinical assessment of a resident assessed Resident #38 a cognitive BIMS (Brief Interview for Mental Status) of 3 out of 15. A BIMS score between 0 to 7 means severe cognitive impairment. The Activity Quarterly Participation Review dated 1/12/22 stated Resident #38 was alert and able to make her own decisions pertaining to her leisure activities. Resident #38 enjoyed watching television, card games, going outside, keeping up with the news, and reading the newspaper daily. Resident #38's activity plan of care dated 7/22/20 and revised 7/4/21 listed a goal for Resident #38 to attend at least three weekly activity programs. On 3/3/22 at 9:08 a.m., in an interview the Activity Director said she was the only person in the activity department until early this year. She said when a resident attends a facility activity, she would put their name on the attendance sheet for that activity, and that is how she keeps track of what activities the residents' attend. The Activity Director reviewed Resident #38's medical record and confirmed Resident #38 enjoys watching television, card games, going outside, keeping up with the news, and reading the newspaper daily as noted in the Activity Quarterly Participation Review dated 1/12/22. She also said Resident #38 has dementia but enjoys going to bingo activity which are held 3 times a week. The Activity Director reviewed the activity sign-in sheets for January 2022 and February 2022 and was only able to find documentation Resident #38 attended morning resident social on 1/23/22 and did an outside activity for fresh air on 2/20/22. She said over the past two months from 1/1/22 to 3/3/22 she was only able to find documentation of Resident #38 attended two facility activities. The Activity Director said she was unable to find documentation the facility had provided an ongoing activity program for January and February 2022 which supported Resident #38's activity choices, as documented in the activity quarterly assessment dated [DATE] which are designed to meet the resident's interests and maintain Resident #38's physical, mental, and psychosocial well-being.

Based on observation, record review, interviews and review of facility policies and procedures for advance directives, the facility failed to ensure advanced care planning was in place for 3 (Resident #11, #55, and #148) of 7 sampled residents whose records were reviewed for advanced directives. The facility failed to evaluate the residents' capacity for decision making; failed to ensure information was afforded in a language and terminology that the resident and/or his/her legal representative understands regarding the residents' health status, treatment options, and expected outcomes; failed to comprehensively discuss and document the residents' choices regarding future health care that should take place during the development of the initial comprehensive assessment and care plan and periodically thereafter; failed to determine and document what treatments the residents are/were refusing; failed to assess the reasons for the residents' refusal; failed to advise the residents about the consequences of refusal; failed to offer pertinent alternative treatments; and failed to continue to provide all other appropriate services as indicated. The facility failed to ensure Resident #11, who was being treated for [REDACTED]. The facility failed to advance care plan his wishes for future health care; failed to determine, comprehensively discuss and periodically review his reasons for refusals for healthcare planning, failed to advise him, his wife and his son about the consequences of Resident #11's refusals; failed to offer alternative treatments and re-evaluate Resident #11's decision for hospitalization when he changed his mind about aggressive treatments. Resident #11 subsequently died as a result of these failures while at the facility. This failure places Resident #55 and Resident #148 who are both impaired in decision making and without advanced directives, as well as all other residents in the facility, at risk for an immediate jeopardy situation. The findings include: 1. Closed record review on [DATE] for Resident #11 showed the resident was admitted to the facility on [DATE]. The record included a Do Not Resuscitate (DNR) order signed by Resident #11 and dated [DATE]. Resident #11 signed all of his admission paperwork during the previous admission of [DATE]. An "Acknowledgement of Advance Directives" form noted Resident #11 had a DNR and no other advanced directives. This form was dated [DATE]. In an interview on [DATE] at 3:30 p.m., the Administrator (ADM) acknowledged Resident #11 signed his admission paperwork on [DATE] and the "Acknowledgement of Advanced Directives" on [DATE]. She said Resident #11 was at the facility before and it is the policy of the facility to carry admission paperwork forward in the event a resident returns to the facility within 30 days. She confirmed Resident #11's return was not anticipated. The ADM said the Social Worker (SW) was supposed to re-review the Advanced Directives with Resident #11 and document whether there were any changes in the advanced directives. Review of the history and physical dated [DATE] noted Resident #11 "...fell in front of a restaurant backwards and sustained a compression [MEDICAL CONDITION] had a squamous cell [MEDICAL CONDITION] on his lip which had been followed by MD. Progressed and it was diagnosed as a squamous cell [MEDICAL CONDITION] a past history of non-small cell lung [MEDICAL CONDITION] of squamous origin and was treated with [MEDICAL CONDITION] with great response. Relapse of a small lesion in the upper lobe squamous cell treated with Carboplatin and [MEDICAL CONDITION] therapy. Patient is not a very good historian and the review of systems was really unreliable. Only thing he complained about was weakness and pain in the back...Impression: L ,[DATE] lumbar compression fracture, squamous cell scar of the lip and under the tongue, status [REDACTED].#11 was for physical therapy as tolerated, assessments by the oncologist and radiologist, obtaining lab work, [MEDICATION NAME] (an antianxiety medication) for agitation and anxiety, continuing pain medication and he documented, the "patient may need surgery." Review of the SW/Psychosocial Data Collection and Evaluation tool dated [DATE] noted Resident #11 with an eighth grade education and support network includes a wife and 2 sons. No family issues were identified. The SW documented Resident #11 with intact short and long term memory. (This conflicts with the attending physician's assessment of the resident "not being a very good historian and the review of systems was really unreliable" on the same date.) The SW documented Resident #11 was admitted for short-term rehabilitation to achieve his goal of returning home with his wife and resident rights and advance directives were reviewed. The SW did not clarify or document what advanced directives were reviewed during the [DATE] admission or whether there were any changes to his advanced directives between the [DATE] admission and re-admission to the facility on [DATE]. In an interview on [DATE] at 3:30 p.m., the SW said her "review" meant asking what advanced directives the resident had, documenting what he had, and if he wanted any others such as a health care surrogate (HCS) or living will. She said Resident #11 told her he had a living will but didn't bring it with him. The SW did not ask about the content of the living will. She did not ask Resident #11 if he wanted to complete a new living will on this recent admission. The SW said she asked Resident #11's wife to bring the living will in to the facility and the wife said she would. The SW said at the time of the [DATE] admission, Resident #11 did not want to designate a HCS. The SW admitted she did not explain the risks associated with failing to designate a HCS in the event he could not speak for himself to the resident, his wife, or his son(s). Speech therapy was ordered and the plan of care dated [DATE] showed Resident #11's treatment [DIAGNOSES REDACTED]." The Speech Language Pathologist (SLP) documented the following reason for the referral: "This [AGE] year old male presents to speech therapy with impairments in memory, problem solving. He states that he is not remembering things/thinking as well as he used to." The SLP's assessment noted Resident #11 needs more time and requires compensatory strategies for following 2-step commands; requires more time with complex problems for following 3-step commands; is distractible; requires frequent direction in occasional situations; is moderately impaired during complex sequencing and problem solving, requiring frequent direction in occasional situations and requires occasional direction related to safety-judgment, difficulty with memory. Review of the comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of "10" (the BIMS is a screening assessment for cognitive ability; the score ranges between ,[DATE]). Resident #11 was documented to have an "acute onset mental status change" and feeling depressed. Resident #11 requires extensive assistance with activities of daily living. Active [DIAGNOSES REDACTED]. Review of the cognitive loss/dementia worksheet associated with this MDS noted Resident #11 with a moderate impairment in cognition. The SW documented the resident had short-term memory losses with forgetfulness and confusion and elected to proceed to care plan Resident #11's cognition. Review of the comprehensive care plans developed [DATE] included a plan of care for Resident #11 identifying short-term memory deficits with forgetfulness and confusion. The SW listed the following approaches: Redirect as needed; observe for changes in mental, cognitive status; offer simple choices; ask simple yes/no type questions; repeat instructions prn (as needed) to assist with comprehension; orient to location of room, dining room; remind as indicated; psych consult/eval/tx per order. Review of the SLP plan of care documented Resident #11 with moderate impairment in multi-step daily living sequencing and in functional complex problem solving and safety awareness. In an interview on [DATE] at 6:07 p.m., the SLP Rehabilitation Director said the treating SLP was trying to improve Resident #11's overall skills. She said Resident #11 might have remembered what a doctor said about his care and may need reminders later on. She said Resident #11 knew things like remembering what time to go to dinner. She didn't think he needed help with those types of decisions. She said he wanted his family involved with decision making. She knew of a stepson and a wife to be involved. She was trying to get him to need fewer cues. She said when he first started; he may need 50% help for filling out forms, completing information. They were hoping to get him to a level where he needed less cueing, minimal cueing for reasoning, word finding, and recall of new information. She said Resident #11 hadn't lost all of his memory, that it was new information, particularly lengthy, that Resident #11 needed help with complex reasoning. A care plan meeting was held with Resident #11 and his wife on [DATE]. The SW documented she reviewed resident rights and advanced directives. She did not document any detail of what she reviewed. In an interview on [DATE] at 4:30 p.m., the SW said during care plan meetings, there is a form that is completed when advanced directives are reviewed. She showed a form which includes "checkboxes" for advance directive preferences. The form showed a check mark in the boxes showing Resident #11 with a living will and also checked he did not want a living will. This documentation is in conflict. The form also shows check marks in the boxes indicating Resident #11 did not want a Durable Power of Attorney (DPOA) for Health care and Financial Authority or HCS. The record failed to show whether or not the resident chose to execute an advance directive, discussion and documentation of the resident's choices regarding future health care during the development of the initial comprehensive assessment and care plan. During the same interview, the SW said the wife never brought in Resident #11's living will. She acknowledged the review of Resident #11's care plan related to short-term memory deficits, forgetfulness and confusion. She acknowledged the SLP's plan of care related to moderate impairment in cognition related to multi-step daily living sequencing and problem solving and safety awareness. In spite of these identified deficits in cognition, the SW admitted she nor the care plan team explained the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. She admitted she did not explain the risks of the resident failing to designate a HCS to Resident #11's wife or son(s). Review of the psychiatric consult dated [DATE] indicated Resident #11 is alert with a dysphoric mood. Resident #11's orientation was not assessed. The psychiatrist ordered [MEDICATION NAME] 10 mg. for depression. Review of the 14-day MDS dated [DATE] showed Resident #11's cognition declined to a BIMS score of 9. There was no assessment of the resident's capacity for giving informed consent for healthcare decisions by the attending physician after this noted decline in cognition. The 30-day, 60-day and 90-day MDS's noted Resident #11 with a BIMS score of 10. On [DATE], the physician ordered [MEDICAL CONDITION] treatments to continue and plan for [MEDICAL CONDITION]. The record showed Resident #11 continued [MEDICAL CONDITION] and [MEDICAL CONDITION] and on [DATE] the SLP discharged Resident #11, documenting Resident #11's goals were not met; Resident #11 demonstrated functional problem solving and safety awareness for daily living tasks. The SLP documented reason for discharge: "Patient progress plateaued due to fluctuations in patient pain and fatigue." Review of nursing notes dated [DATE] at 6:00 p.m., documented the following: "Resident and wife notified this nurse of the decision not to continue any [MEDICAL CONDITION] tx, but will continue chem (o) therapy ARNP notified. MSG (message) left for (oncology facility) at the answering service." On [DATE] at 2:30 p.m., the ARNP came to the facility to assess Resident #11. Review of her notes included the following: "(Arrow down-decreased) redness noted. Will cont. with magic mouthwash as per orders. New [MEDICATION NAME] orders received. Res.(resident) to have labs in a.m." There were no other nursing notes related to Resident #11's condition until [DATE] at 8:00 a.m. by Staff B. The nursing notes included: "(arrow up) in w/c. Transport company in. Resident having difficulty breathing. O2 SATs (oxygen saturation) 60%. Unable to swallow breakfast, unable to swallow medications... 9:15 Rcvd (received) call from (MD's) office, informed them of change in condition, they cx (canceled) all upcoming appts." Review of the telephone orders dated [DATE] at 9 a.m., documented orders by the ARNP for a Hospice consult, oxygen at 3 liters via nasal cannula as needed for an oxygen saturation less than 92% and oxygen saturation (levels checked) every shift. (Pulse oximetry is a noninvasive monitoring technique used to estimate the measurement of oxygen saturation of the blood.) Review of the hospice notes dated [DATE] at 11:50 a.m., noted the hospice nurse came to the facility based on the referral for hospice, spoke with Resident #11 about hospice services to which Resident #11 and his wife agreed. The hospice nurse documented Resident #11 in agreement with discontinuing all aggressive treatments. The hospice nurse documented, "Pt is too weak to sign consents...Spoke with MDS and spouse and will attend care plan meeting this afternoon and have spouse sign for pt as pt has directed to myself and facility nurse...requested that nursing staff watch pt closely for any uncontrolled symptoms..." Review of the record failed to reveal the ARNP or SW reassessed Resident #11's capacity to make decisions about his healthcare with an oxygen level at 60% and declining condition. At 3:25 p.m., Staff C, the second shift nurse documented, "O2 (oxygen) SATs remain at 80% via nasal cannula. Lung sounds with congestion bilaterally upon auscultation call placed to (name) ARNP. New orders received for chest x-ray." No vital signs (blood pressure, pulse or respiratory rate) were obtained by Staff C. There was no documentation to support a phone call was made to Resident #11's wife or son(s) informing them of Resident #11's condition related to congested lungs and low blood oxygenation. There was no documentation to support they were informed of the risks or benefits associated with failing to hospitalize Resident #11. The ARNP's orders dated [DATE] did not include "do not hospitalize" or "do not treat." There was no documentation she came to the facility to assess the patient who was declining. Hospice notes on [DATE] at 4:25 p.m., documented: "...Pt (patient) is requesting son to make all decisions in process, facility has not informed son as of yet. There is to be a conference call with son at facility to inform him and decide plan. (Hospice nurse) will update....when ok to admit." There is no documentation Resident #11's son was called by the facility's SW or interdisciplinary team. On [DATE] at 5:01 p.m., the hospice nurse documented, "...return visit to attend meeting with staff and pt. spouse to discuss pt status and hospice services. Spouse in agreement with hospice services but states that pt may want his son, (named), to make decisions. Spouse, our SW and myself went to pt room to discuss with pt. Pt does say he wants his son to make decisions and he will do what his son wishes. States that if his son wants him to continue aggressive treatment he will agree. No one knew until today that pt wanted his son involved in decision making...informed her not to send in admit nurse yet until we speak with pt son to be sure if son and pt. are still willing to have hospice services." Notes by the SW on [DATE] documented: Quarterly Assessment and care plan meeting. Resident is declining related to [MEDICAL CONDITION] diagnosis. He has been referred to Hospice and they are to have a meeting with Hospice today. Discharge plans changed and now long-term care. [MEDICATION NAME] for depression. "Resident rights and advanced directives reviewed." The advanced directive review form dated [DATE] was completed during the care plan meeting. Resident #11's wife indicated her husband did not want a DPOA for Health Care or Financial Authority and did not want a HCS. In an interview on [DATE] at 4:30 p.m., the SW said Resident #11's wife was not officially determined to be the decision maker for her husband, therefore, should not have signed he did not want a health care surrogate or DPOA for health care or finances. The SW said she did not go back and visit with the resident because she stayed to attend other care plan meetings. She said what she meant when she documented her "review" of advanced directives during the care plan meeting was what Resident #11 currently had in place. She acknowledged Resident #11's living will was never brought to the facility. She admitted neither she nor the interdisciplinary team went back to re-assess Resident #11's decision for hospitalization , son's involvement in decision making process, or educate Resident #11 or his wife related to the risks involving lack of directives for future healthcare. She said Resident #11's capacity to make decisions was not re-evaluated and no one called Resident #11's son. In an interview on [DATE] at 2:12 p.m., the hospice nurse she said she made late entries in her notes. She said she received a call from the facility and came to the facility approximately late morning of [DATE]. She spoke with the nursing staff to find out what was going on and was informed of Resident #11's desire to stop treatments. She had to decide was who was making decisions. At that time, Resident #11 was alert and oriented and when she saw him; he was doing quite well. He had some difficulty speaking. She wanted to make sure he was capable of making his decisions. She said the resident was tired and quite weak. She said the wife was listed as the responsible party on the face sheet and Resident #11 said he wanted his wife involved. She agreed to whatever her husband wanted. The hospice nurse said they had a care plan meeting. During the care plan meeting, the wife mentioned the resident had a son. The hospice nurse stated, "I got a funny feeling (Resident #11's wife) didn't want to be involved. That she agreed whatever the son wanted." They went back to Resident #11's room and he said he wanted his son's involvement and he would do whatever his son wanted. If his son would want aggressive treatment, he would go through with it. The hospice nurse said she went back to the care plan meeting room where the MDS Coordinator and SW were and informed them Resident #11 wanted his son contacted and his son to be involved. The clinical record failed to indicate Resident #11's son was called related to his choice to designate him as decision maker and involve the son in assisting with his consideration of treatment. There was documentation Resident #11 was asked if he wanted to go to the hospital for treatment since he was reconsidering aggressive therapy. Review of the care plans at the time of the care plan meeting on [DATE] failed to show a plan of care for Hospice, decision to withhold treatment or not to hospitalize, or end of life care. During the interview on [DATE] at 2:12 p.m., the Hospice nurse confirmed Hospice was withdrawn and never initiated because Resident #11 was reconsidering his options. In an interview on [DATE] at 5:00 p.m., Staff Q said they didn't have a care plan for end of life care because Resident #11 was never deemed terminal and wasn't on Hospice. They were having a meeting to explore his options and found out he wanted his son involved and might continue treatment. At 5:00 p.m., on [DATE], Staff C, documented she administered medication to Resident #11 and that he wanted to eat dinner, but then later refused. There was no documented reassessment of Resident #11's clinical condition and no phone call to wife or son. There was no documentation to support the ARNP was provided an update on Resident #11's condition. At 5:45 p.m., on [DATE], Staff C documented the following: "Entered resident's room. Resident noted to be unresponsive to verbal and tactile stimulation. Lung sounds continue to be congested. Respirations labored...O2 SATs noted to be 48% with 2 liters of O2 via nasal cannula. VS-98, (temperature) 101 (pulse), 22 (respirations), ,[DATE] (blood pressure). Skin noted to be gray in appearance. Noted to be gasping when breathing." Five minutes later, at 5:50 p.m. on [DATE], Staff C documented, "Call placed to (name) ARNP with condition update. Instructions given to update (wife) with update." At 5:55 p.m. on [DATE], Staff C documented she called Resident #11's wife and made her aware of the change in condition and wife stated she wants no hospitalization . At 6:00 p.m. on [DATE], the ARNP was called back by Staff C and the ARNP ordered no hospitalization . At 6:15 p.m. on [DATE], Staff C documented she entered Resident #11's room and he was unresponsive. There was no breathing noted and no pulse was noted. Staff C placed a call to the ARNP to make her aware. No vital signs were taken at that time. At 6:20 p.m. on [DATE], Staff C documented she attempted to contact Resident #11's wife and at 6:45 p.m., Resident #11's wife arrived and was made aware Resident #11 expired. In an interview on [DATE] at 9:30 a.m., Resident #11's wife said it was never fully explained to her about her husband's deteriorating condition that began at 8 a.m. on [DATE] and lasted 10 hours through 5:45 p.m. She stated, "I had no clue. Only that he was now on oxygen. Did not get phone call from ARNP or Doctor." She said she walked into her husband's room at about 1:00 p.m. on [DATE] to find him on oxygen, which was something new, and no one told her why. She said all she knew was her husband was thinking about stopping his chemo and [MEDICAL CONDITION]. Her husband didn't say anything to her about no hospitalization . He did say he wanted to see what Hospice was about, so they invited hospice to the care plan meeting. Her husband didn't want to go to the meeting because he wasn't up for it. So, they explained what Hospice was about in his room. Then at the care plan meeting at 2:10 p.m., after they explained Hospice services, she didn't feel comfortable making decisions as her husband was always in control. She told them (the care plan team) his son should be involved with decision making and she would go along with whatever her husband wanted. Since her husband wanted the son to make decisions, she went along with that. She said staff knew this at the care plan meeting. She stated, "After they found out about his son, they laughed. I didn't like that." She said her husband wanted to talk with his son as he thought if his son wanted him to go for treatments, he would go. No one ever asked her for his son's phone number. She said after the care plan meeting, she went home. The next thing she knew, 4 hours later, she was getting a call that her husband was dying and was asked if she wanted her husband to go to the hospital. She said she told the facility not to send her husband to the hospital. She stated, "What else was I supposed to do at that point?" She confirmed she spoke with Resident #11's son later who informed her he never received a call related to updating him related to his father's condition prior to or after his death. In an interview on [DATE] at 11:30 a.m., Resident #11's son said no one ever called him about his father's condition. He said it was never fully explained to his mother that his father started to deteriorate the morning of [DATE]. He said no one ever called him to tell him his father wanted him to make decisions. No one called him after his father died . He said they talked to him in the past when he converted from Medicare so he didn't know why he wasn't called about his father's condition. His stepmother did inform him that she told staff in the care plan meeting that afternoon that he should be involved in decision making." In an interview on [DATE] at 12:40 p.m., Staff B said the resident [MEDICAL CONDITION] of his lip and was going for [MEDICAL CONDITION] and chemo. On [DATE], the transport company came in and Resident #11's oxygen level was 60%. She said Resident #11 couldn't swallow breakfast and his medication. She returned him to bed. She called the ARNP, received orders for oxygen for Hospice Consult. She stated she spoke to the resident who said he didn't want to go to the emergency room but didn't document this. She asked if he wanted a Hospice Consult. He said he didn't want any more chemo, [MEDICAL CONDITION] and didn't want to go to the hospital. She called for the Hospice consult. She said he was weak; he was able to talk to her and was alert at this time. She stated, "I didn't chart about the resident's condition because his chart was in care plans." She said with the oxygen on, Resident #11 "got better though was still weak." She said, "He knew what I was saying to him and was talking back to me." Staff B confirmed there was no order for Do Not Hospitalize or Do Not Treat. She admitted she did not call the ARNP back with any other assessments of Resident #11 during her shift. Staff B was not aware whether anyone discussed the risks of refusing treatment or negative consequences of poor oxygenation to Resident #11, his wife or son. In an interview on [DATE] at 1:27 p.m., Staff C said said she recalled in report, the previous nurse said resident was declining and obtained a Hospice Consult. She said Resident #11's wife wasn't sure what to do and was going to call Resident #11's son to get an understanding of what would be good for him, that Resident #11 was rethinking about going for treatment. The son was never called. Staff C said the wife told her that her husband did not want to go to the hospital, but, the nurse herself did not ask Resident #11 his wishes. She confirmed Resident #11's wife was not the decision maker for her husband. She could not confirm whether anyone called Resident #11's wife or son to explain to them the severity of his condition, or the negative outcome poor oxygenation would have throughout the day on Resident #11's health. Staff C stated, "I heard something about him thinking about going for treatment if his son would agree." Staff C confirmed she never called the son. When she found the resident unresponsive, the ARNP told her to call the wife and ask the wife if she wanted Resident #11 sent out to the hospital. It was then that his wife told her not to have Resident #11 hospitalized . In an interview on [DATE] at 1:59 p.m., the ARNP said she vaguely remembered a call on the 6th of January. She thought a care plan meeting took place where Hospice was initiated. The ARNP said no one told her Resident #11 changed his mind about aggressive treatment and that he wanted his son to be in the decision making process. The ARNP said she did not come in to assess Resident #11, did not call the wife or speak to Resident #11 about the negative outcome it would have with failing to adequately oxygenate Resident #11 throughout the day. She confirmed she did not speak to Resident #11 about who he wanted as his HCS. The ARNP said the attending physician was out of the country. She stated, "I didn't have a chance to know what happened during the care plan meeting." In an interview on [DATE] at 2:45 p.m., the SW, Staff D (who is an RN and the MDS Coordinator) and RN Unit Manager confirmed they attended the care plan meeting where Resident #11's wife attended. The SW said Resident #11's wife told her Resident #11 had a living will on admission but it was never provided. The SW said Resident #11 was complaining the [MEDICAL CONDITION] was causing a lot of pain. Resident #11 mentioned stopping the [MEDICAL CONDITION]. The SW said at one point the nurse (Staff B) had mentioned Hospice services to him if he wanted to [MEDICAL CONDITION] treatment and Resident #11 agreed to a consult where they (Hospice) just come in and talk. They arranged to meet with Resident #11 and his wife to just do the consult. The day the consult occurred happened to be Resident #11's care plan day. The SW said they were present during the care plan. Resident #11 said he was too ill to go to care plan and didn't have the strength. They came to the care plan (wife and Hospice) with his directive. They talked about his decline, what hospice could do, what services were and at the end of the care plan his wife mentioned he had a son, her stepson, and the resident may want to involve his son with this. So the hospice nurse and wife left the meeting and they went down to Resident #11's room to talk with him. The SW said she heard later on that Resident #11 wanted the son's involvement, to make him aware. The SW stated, "We were going to gather their information and call the son to ask in a conference call so that they could discuss what was going on. They didn't have the number and that evening Resident #11 passed away." The SW, Staff D and Unit Manager said they weren't told Resident #11 was actively dying. They confirmed no one went back to determine if Resident #11 was capable of making health care decisions; whether he wanted to go to the hospital since he was reconsidering aggressive treatment if his son agreed or explained the risks associated with failure to adequately oxygenate Resident #11. Review of the facility's policies and procedures for Advanced Directives failed to include the following components: Determining if the facility periodically assesses the resident for decision-making capacity and invokes the health care agent or legal representative if the resident is determined not to have decision-making capacity. Identifying the primary decision-maker (e.g., assessing the resident's decision-making capacity and identifying or arranging for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions); Defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, as appropriate; Identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions; Identifying situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition; Establishing mechanisms for documenting and communicating the resident's choices to the interdisciplinary team. Identifying the process (as provided by State law) for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes on the basis of conscience. In an interview on [DATE] at 4:00 p.m., the Administrator acknowledged she never received the [DATE] revised edition of the State Operations Manual for advanced directives which included guidance for advanced care planning for residents who desire not to execute advanced directives. 2. During an observation and interview on [DATE] at 10:05 a.m., Resident #55 said people have been stealing things from her since she's been at the facility for the past 2 years. Resident #55 was confused and could not provide specific details related to what she felt was actually stolen or missing. She named a staff member who she reported these concerns to and said no one has done anything about it. In an interview on [DATE] at

Based on observation, record reviews, interviews, and review of facility policies and procedures for advance directives, the facility failed to ensure medically-related social services for advanced directives was in place for 3 (Residents #11, #55, and #148) of 7 sampled residents whose records were reviewed for advanced directives. The facility failed to assist the residents in maintaining contact with their family or legal representatives regarding reporting changes in the residents' health; failed to assist staff in determining whether residents' were fully capable of making healthcare decisions; failed to ensure staff were informing residents and/or their legal representatives of the ramifications of the residents' healthcare choices; and failed to assist staff in the development of comprehensive plans of care of how the residents' future healthcare planning needs would be met. The findings include: 1. Closed record review on [DATE] showed Resident #11 was admitted to the facility on [DATE]. The record included showed a Do Not Resuscitate (DNR) order signed by Resident #11 and dated [DATE]. Resident #11 signed all of his admission paperwork during a previous admission on [DATE]. An "Acknowledgement of Advance Directives" form dated [DATE] noted Resident #11 had a DNR but no other advanced directives. In an interview on [DATE] at 3:30 p.m., the Administrator (ADM) acknowledged Resident #11 signed the Acknowledgement of Advanced Directives on [DATE]. She said Resident #11 was at the facility before and it is the policy of the facility to carry admission paperwork forward in the event a resident returns to the facility within 30 days. She said Resident #11's return was not anticipated. The ADM said the Social Worker (SW) was supposed to re-review the advanced directives with Resident #11 and document whether there were any changes. Review of Resident #11's history and physical dated [DATE] included a compression fracture of the spine, a squamous cell [DIAGNOSES REDACTED] on his lip, a past history of non-small cell lung [DIAGNOSES REDACTED] of squamous origin and treated with chemotherapy with great response. Relapse of a small lesion in the upper lobe lung treated with chemotherapy and radiation therapy. "Patient is not a very good historian and the review of systems was really unreliable... Impression: L,[DATE] lumbar compression fracture, squamous cell scar of the lip and under the tongue, status [REDACTED].#11 was for physical therapy as tolerated, assessments by the oncologist and radiologist, obtaining lab work, Xanax for agitation and anxiety, continuing pain medication and he documented, "patient may need surgery." There was no statement of a terminal condition and no indication Resident #11 had 6 months or less to live based on his cancer diagnosis. Review of the SW/Psychosocial Data Collection and Evaluation tool dated [DATE] noted Resident #11 with an eighth grade education and support network includes a wife and 2 sons. No family issues were identified. The SW documents Resident #11 with intact short and long term memory (this conflicts with the attending physician's assessment). The SW documented Resident #11 was admitted for short-term rehabilitation to achieve his goal of returning home with his wife and resident rights and advance directives were reviewed. The SW did not clarify or document what advanced directives were reviewed during the [DATE] admission or whether there were any changes to his advanced directives from the [DATE] admission. In an interview on [DATE] at 3:30 p.m., the SW said her "review" meant asking what advanced directives the resident had, documenting what he had, and if he wanted any others such as a health care surrogate or living will. She said Resident #11 told her he had a living will but didn't bring it with him. The SW did not ask about the content of the living will. She did not ask Resident #11 if he wanted to complete a new living will for this ([DATE]) admission. The SW said she asked the resident's wife to bring the living will in and she said she would. The SW said at the time, Resident #11 did not want to designate a Health Care Surrogate (HCS). The SW admitted she did not explain the risks associated with failing to designate a HCS to Resident #11, his wife, or his son(s) in the event he could not speak for himself. Speech therapy was ordered and the Speech Language Pathologist (SLP) documented the reason for the referral: "This [AGE] year old male presents to speech therapy with impairments in memory, problem solving. He states that he is not remembering things/thinking as well as he used to." The SLP's assessment noted Resident #11 needs more time and requires compensatory strategies for following 2-step commands; requires more time with complex problems for following 3-step commands; is distractible; requires frequent direction in occasional situations; is moderately impaired during complex sequencing and problem solving, requiring frequent direction in occasional situations and requires occasional direction related to safety-judgement, difficulty with memory. Review of the Minimum Data Set (MDS) with a reference date of [DATE] showed Resident #11 with a BIMS score of 10 (BIMS is a screening assessment with a ,[DATE] scale for cognitive ability). Resident #11 is documented to have an "acute onset mental status change" and feeling depressed. Active [DIAGNOSES REDACTED]. Review of the cognitive loss/dementia worksheet associated with this MDS notes Resident #11 with a moderate impairment in cognition. The SW documented the resident with short-term memory losses with forgetfulness and confusion and elected to proceed to care plan Resident #11's cognition. Review of the comprehensive care plan for Resident #11 developed [DATE] included a plan identifying short-term memory deficits with forgetfulness and confusion. The SW listed the following approaches: Redirect as needed; observe for changes in mental, cognitive status; offer simple choices; ask simple yes/no type questions; repeat instructions as needed to assist with comprehension; orient to location of room, dining room; remind as indicated; psych consult/eval/tx per order. Review of the SLP plan of care documents Resident #11 with moderate impairment in multi-step daily living sequencing and in functional complex problem solving and safety awareness. In an interview on [DATE] 6:07 p.m., the SLP Rehabilitation Director said Resident #11 might have remembered what a doctor said about his care and may need reminders later on. She said Resident #11 knew things like remembering what time to go to dinner. She didn't think he needed help with those types of decisions. She said the resident wanted his family involved with decision making. She knew of a stepson and a wife. She said Resident #11 hadn't lost all of his memory, but that it was new information, particularly lengthy, and that Resident #11 needed help with complex reasoning. A care plan meeting was held with Resident #11 and his wife on [DATE]. The SW documented she reviewed resident rights and advanced directives. She did not document the nature of her review. In an interview on [DATE] at 4:30 p.m., the SW she said during care plan meetings, there is a form that is completed when advanced directives are reviewed. She showed the form used. Resident #11's form noted a check mark in the boxes showing he had a living will but it was also checked he does not want a living will. This documentation is in conflict. The SW notes and nursing notes failed to document there was discussion of the resident's choices regarding future health care during the development of the initial comprehensive assessment and care plan and whether or not he did or did not want his living will. During the same interview, the SW confirmed the wife never brought in Resident #11's living will. In spite of these deficits in cognition identified, the SW admitted neither she nor the care plan team explained the risks associated with failing to designate a HCS in the event he could not speak for himself to Resident #11, his wife, or his son(s). The SW acknowledged there was no documentation by the physician or Advanced Registered Nurse Practitioner (ARNP) of whether Resident #11 was capable of making independent healthcare decisions. Review of the 14-day MDS dated [DATE] showed Resident #11's cognition declined to a BIMS score of 9. The record failed to show whether the resident's capacity for giving informed consent and capability of making independent healthcare decisions was assessed by the attending physician after this noted decline in Resident #11's cognition. Review of the psychiatric consult dated [DATE] indicated Resident #11 is alert with a dysphoric mood. Resident #11's orientation was not assessed. The psychiatrist ordered Zoloft 10 mg. for depression. On [DATE], psychiatric notes show Resident #11's mood was worsening and increased the Zoloft to 50 mg. daily. Review of the 30-day, 60-day and 90-day MDS's noted Resident #11 with a BIMS score of 10. The record showed the interdisciplinary team failed to develop a plan of care related to the resident's depression and worsening mood. The record showed Resident #11 continued radiation and chemotherapy. On [DATE] the SLP discharged Resident #11 documenting Resident #11's goals were not met. Nursing notes dated [DATE] at 6:00 p.m. documented the following, "Resident and wife notified this nurse of the decision not to continue any radiation tx, but will continue chem(o) therapy ARNP notified. MSG (message) left for (oncology facility) at the answering service." Nursing notes by Staff B on [DATE] at 8:00 a.m. included : Transport company in. Resident having difficulty breathing. O2 sats 60%. Unable to swallow breakfast, unable to swallow medications. spoke with ARNP. spoke with wife. spoke with (oncologist) Left message for (MD) office to call back. Obtained orders for oxygen, obtained orders for Hospice consult. spoke with Hospice Nurse (name). At 9:15 Received call from (MD's) office, informed them of change in condition, they canceled all upcoming appointments. Review of the hospice notes dated [DATE] at 11:50 a.m., noted the hospice nurse came to the facility based on the referral for hospice, spoke with Resident #11 about hospice services to which Resident #11 and his wife agreed. The hospice nurse documented Resident #11 in agreement with discontinuing all aggressive treatments. The hospice nurse documented, "Pt is too weak to sign consents...Spoke with MDS (nurse) and spouse and will attend care plan meeting this afternoon and have spouse sign for pt as pt has directed to myself and facility nurse...requested that nursing staff watch pt closely for any uncontrolled symptoms..." Review of the record failed to find nursing, ARNP, or SW reassessment of Resident #11's capacity to make decisions about his healthcare with an oxygen level at 60% and declining condition. The record failed to show documentation whether Resident #11 was determined to have decision-making capacity or whether decision-making ability would be transferred to his wife. There was no documentation in the record Resident #11 designated his wife as his healthcare surrogate. There was no documentation to support nursing, the ARNP, MD, or SW helped Resident #11, his wife or son understand the risk and benefits of Resident #11 declining aggressive treatment. No "Do Not Hospitalize" or "Do Not Treat" orders were found. There was no documentation to support a phone call was made by nursing or the SW to Resident #11's wife or son(s) informing them of Resident #11's condition related to congested lungs and low blood oxygenation. There was no documentation to support Resident #11, his wife or son(s) were informed of the risks associated with failing to hospitalize Resident #11. Hospice notes on [DATE] at 4:25 p.m., documented the following: "...Pt is requesting son to make all decisions in process, facility has not informed son as of yet. There is to be a conference call with son at facility to inform him and decide plan. (Hospice nurse) will update....when ok to admit." There is no documentation by the SW or interdisciplinary team Resident #11's son was called. There is no documentation the nurses taking care of Resident #11 were informed of Resident #11's reconsideration for aggressive treatment and indecisiveness as to whether he would go on Hospice. At 5:01 p.m. on [DATE], the hospice nurse documents, "...return visit to attend meeting with staff and pt. spouse to discuss pt status and hospice services. Spouse in agreement with hospice services but states that pt may want his son, (name), to make decisions. Spouse, our SW and myself went to pt room to discuss with pt. Pt does say he wants his son to make decisions and he will do what his son wishes. States that if his son wants him to continue aggressive treatment he will agree. No one knew until today that pt wanted his son involved in decision making...informed her not to send in admit nurse yet until we speak with pt son to be sure if son and pt are still willing to have hospice services." SW noted on [DATE]: Quarterly Assessment and care plan meeting. (Resident) is declining related to his CA (cancer) dx (diagnosis). He has been referred to Hospice and they are to have a meeting with Hospice today ([DATE]). Discharge plans changed and now long term care. Zoloft for depression. Resident rights and advanced directives reviewed. Review of the advanced directive review form dated [DATE] completed during the care plan meeting showed Resident #11's wife indicated her husband did not want a Durable Power of Attorney (DPOA) for Health Care or Financial Authority and did not want a Health Care Surrogate. In an interview with the SW on [DATE] at 4:30 p.m., she said Resident #11's wife was not officially determined to be the decision maker for her husband, therefore, should not have signed that the resident did not want a health care surrogate or DPOA for health care. The SW said she did not go back and visit with Resident #11 because she stayed behind to attend other care plan meetings. She said what she meant when she wrote "review" of advanced directives during the care plan meeting was what the resident currently had in place. She acknowledged Resident #11's living will was never brought in to the facility. She admitted that neither she nor the interdisciplinary team went back to re-assess Resident #11's decision for hospitalization , son's involvement in decision making process, or educate Resident #11 or his wife related to the risks of lack of advanced directives. She confirmed Resident #11's capacity to make decisions was not re-evaluated and no one called his son. In an interview with the hospice nurse on [DATE] at 2:12 p.m., she said she made late entries in her notes (after returning from the facility). She said she received a call from the facility and came to the facility approximately late morning. She spoke with the nursing staff to find out what was going on and was informed of Resident #11's desire to stop treatments. What she had to decide was who was making decisions. At that time, Resident #11 was alert and oriented and when she saw Resident #11, he was doing quite well. He had some difficulty speaking. She wanted to make sure he was capable of making his decisions. She said Resident #11 was tired and quite weak. She said the wife was listed as the responsible party on the face sheet and Resident #11 said he wanted his wife involved. She agreed to whatever her husband wanted. The hospice nurse said they had a care plan meeting. During the care plan meeting, the wife mentioned the resident had a son. The hospice nurse stated, "I got a funny feeling (Resident #11's wife) didn't want to be involved. That she agreed whatever the son wanted." They went back to Resident #11's room and he said he wanted his son's involvement and he would do whatever his son wanted. If his son would want aggressive treatment, he would go through with it. The hospice nurse said she went back to the care plan meeting room where the MDS Coordinator and SW were and informed them Resident #11 wanted his son contacted and his son involved. Neither the MDS Coordinator (Staff D) nor the SW informed the nursing staff of Resident #11's reconsideration for aggressive treatment if his son wanted him to go along with it. There was no documentation Resident #11 was asked if he wanted to go to the hospital for treatment since he was reconsidering aggressive therapy. In spite of Resident #11's low oxygen saturation levels in conjunction with his reconsideration for his son's involvement for decision making, there was no re-assessment by facility staff of Resident #11's capacity to make healthcare decisions. Review of the care plans at the time of the care plan meeting on [DATE] failed to show a plan of care for Hospice, decision to with hold treatment or do not hospitalize, or end of life care. On [DATE] at 5:45 p.m., Staff C documented: "Entered resident's room. Resident noted to be unresponsive to verbal and tactile stimulation. Lung sounds continue to be congested. Respirations labored...O2 sats noted to be 48% ... Skin noted to be gray in appearance. Noted to be gasping when breathing." Five minutes later, at 5:50 p.m., Staff C documented, "Call placed to (name) ARNP with condition update. Instructions given to update (wife) with update." At 5:55 p.m. on [DATE], Staff C documented she called Resident #11's wife and made her aware of the change in condition and wife stated she wants no hospitalization . At 6:00 p.m., the ARNP was called back by Staff C and the ARNP ordered no hospitalization . At 6:15 p.m. on [DATE], Staff C documented she entered Resident #11's room and he was unresponsive. There was no breathing noted and no pulse was noted. Staff C placed a call to the ARNP to make her aware. At 6:20 p.m., Staff C documented she attempted to contact the resident's wife and at 6:45 p.m., Resident #11's wife arrived and was made aware Resident #11 expired. In an interview on [DATE] at 9:30 a.m., Resident #11's wife said it was never fully explained to her about her husband's deteriorating condition that began at 8 a.m. on [DATE] and lasted approximately 10 hours through 5:45 p.m. She stated, "I had no clue. Only that he was now on oxygen..." She said on [DATE] she walked into her husband's room at about 1:00 p.m. to find him on oxygen, which was something new, and no one told her why. She said all she knew was her husband was thinking about stopping his chemo and radiation. Her husband didn't say anything to her about no hospitalization . He did say he wanted to see what hospice was about so they invited hospice to the care plan meeting. Her husband didn't want to go because he wasn't up for it. So, they explained about hospice in his room. At 2:10 p.m., in the care plan meeting after they explained hospice services, she didn't feel comfortable making decisions as her husband was always in control. She told them (the care plan team) his son should be involved with decision making and she would go along with whatever her husband wanted. Since her husband wanted the son to make decisions, she went along with that. She said staff knew this at the care plan meeting. She stated, "After they found out about his son, they laughed. I didn't like that." She said her husband wanted to talk with his son as he thought if his son wanted him to go for treatments, he would go. No one ever asked her for his son's phone number. She said after the care plan meeting, she went home. The next thing she knew, 4 hours later, she was getting a call that her husband was dying and was asked if she wanted her husband to go to the hospital. She said she told the facility not to send her husband to the hospital. She stated, "What else was I supposed to do at that point?" She confirmed she spoke with Resident #11's son later who informed her he never received a call related to updating him related to his father's condition prior to or even after his death. In an interview on [DATE] at 11:30 a.m., Resident #11's son said no one ever called him about his father's condition. He said it was never fully explained to his mother that his father started to deteriorate the morning of [DATE]. He said no one ever called him to tell him his father wanted him to make decisions. He said they talked to him in the past when he converted from Medicare so he didn't know why he wasn't called about his father's condition. His stepmother did inform him that she told staff in the care plan meeting that afternoon that he should be involved in decision making. In an interview on [DATE] at 2:45 p.m., the SW, Staff D (who is an RN and MDS Coordinator) and RN Unit Manager confirmed they attended the care plan meeting where Resident #11's wife attended. The SW said Resident #11's wife told her Resident #11 had a living will on admission but it was never provided. The SW said Resident #11 was complaining the radiation was causing a lot of pain. Resident #11 mentioned stopping the radiation. The SW said at one point the nurse (Staff B) had mentioned hospice services to him if he wanted to stop cancer treatment and Resident #11 agreed to a consult where they (hospice) would just come in and talk. They arranged to meet with Resident #11 and his wife to just do the consult. The day the consult occurred happened to be Resident #11's care plan day. The SW said they were present during the care plan. Resident #11 said he was too ill to go to care plan and didn't have the strength. They (the wife and hospice) came to the care plan with his directive. They talked about his decline, what hospice could do, what services were and at the end of the care plan his wife mentioned he has a son, her stepson, and Resident may want to involve his son with this. So the hospice nurse and wife left the meeting and they went down Resident #11's room to talk with him. The SW said she heard later on that Resident #11 wanted the son's involvement, to make him aware. The SW stated, "We were going to gather their information and call the son to ask in a conference call so that they could discuss what was going on. They didn't have the number and that evening Resident #11 passed away." The SW, Staff D and Unit Manager said they weren't told Resident #11 was actively dying. They confirmed no one went back to determine if Resident #11 was capable of making health care decisions; whether he wanted to go to the hospital since he was reconsidering aggressive treatment if his son agreed. Review of the facility's policies and procedures for Advanced Directives failed to include the following components: Determining if the facility periodically assesses the resident for decision-making capacity and invokes the health care agent or legal representative if the resident is determined not to have decision-making capacity. Identifying the primary decision-maker (e.g., assessing the resident's decision-making capacity and identifying or arranging for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions); Defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, as appropriate; Identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions; Identifying situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition; Establishing mechanisms for documenting and communicating the resident's choices to the interdisciplinary team. Identifying the process (as provided by State law) for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes on the basis of conscience. 2. During an interview on [DATE] at 10:05 a.m., Resident #55 said people have been stealing things from her since she's been at the facility for the past 2 years. Resident #55 was confused and could not provide specific details related to what she felt was actually stolen or missing. She named a staff member who she reported these concerns to and said no one has done anything about it. In an interview on [DATE] at 9:39 a.m., the resident's primary nurse Staff F said Resident #55 is not totally oriented and lives in the past a lot. Staff F stated, the resident "has days where she is totally with it and days where she's not." Staff F said there is no one in the facility by the name of whom Resident #55 said she reported the missing items to. Record review on [DATE] showed Resident #55 was readmitted to facility [DATE] with [DIAGNOSES REDACTED]. The history and physical dated [DATE] includes, "...(resident) comments unreliable due to dementia, cognitive impairment or other state...History obtained by staff or family member." Review of the MDS's with reference dates of [DATE], [DATE], [DATE], [DATE] noted Resident #55 with a BIMS score of 6 of 15 and with altered level of consciousness where her behavior was continuously present and did not fluctuate. Review of the most recent MDS noted a quarterly assessment with a reference date of [DATE] noted a BIMS score of 8 and documented Resident #55 remains with an altered level of consciousness. Review of the resident record showed nurses documented Resident #55's son as the Power of Attorney (POA). The demographic sheet in the front of Resident #55's record refers to her son as the POA. Review of the record failed to find a POA in place. Review of the comprehensive care plan shows a plan was developed on [DATE] identifying Resident #55 with short-term memory deficits, a deficit in judgement, and impaired decision making abilities related to her [DIAGNOSES REDACTED]. In an interview on [DATE] at 12:00 p.m., Resident #55 was asked who helps her with decision making. Resident #55 looked up to the ceiling and said, "I think it's my brother. No, wait a minute, he's dead, I think it's his daughter." She then rubbed her head and said, "Honey, I'm not sure at this point." In an interview on [DATE] at 11:17 a.m., the SW said Resident #55 is her own healthcare decision maker. The SW said Resident #55 defers to her son "a lot," and he is not the POA nor is he listed as the health care surrogate but is the responsible party in the event something should happen to Resident #55. The SW said Resident #55 did not want any other advanced directives in place other than a DNR. The SW was asked whether the resident had the capacity to understand what advanced directives were and the SW said yes, however, this conflicts with the resident's current plan of care related to impaired decision making, memory deficits and deficit in judgement. The SW confirmed Resident #55's capacity to make appropriate health care decisions was never evaluated by the attending physician in spite of her altered level of consciousness and BIMS scores of 6 and 8. 3. A review of the medical record for Resident #148 found the resident makes his own decisions and signs his own consents. On the the monthly Physician order [REDACTED].*Directives*, Code Status states: "DNR - Comfort measures only - Do not hospitalize." The report of the quarterly care plan meeting held on [DATE] documented Resident #148 attended. The Advance Directives Review form for [DATE] showed the resident has signed a DNR Order. The sections for Living Will, Durable Power of Attorney (DPOA) for Health Care Authority, and Health Care Surrogate (HCS) with corresponding election for: Have, Requested, or Refused are not completed. The Social Services Notes regarding the care plan meeting stated: "Resident Rights and Advance Directives reviewed." The notes do not document the resident was informed of the consequences of not having advance directives. In an interview on [DATE] at 3:45 p.m., when asked if he has designated anyone to have DPOA or as a HCS, Resident #148 said: "I think either my brother or daughter; I do not know for sure. I did sign a DNRO." Asked if knows about end of life decisions and who would make decisions if he is not able, the resident expressed his faith saying he believes the right decision would be made. The resident did not recall that there was an order not to hospitalize and was not sure what that even meant. The resident says he does not recall going over advance directives at the care plan meeting on [DATE]. In an interview on [DATE] at 3:50 p.m., the SW stated a social worker attended the care plan meeting with Resident #148. She said the social worker goes over the documents the facility has in the way of advance directives and advises the resident they can assist with the other tools (such as DPOA, HCS, etc.). The SW said at each quarterly care plan meeting, a form is checked off indicating which advance directives have been completed or submitted by the resident. The social worker acknowledged there is no discussion about advance directives unless initiated by the resident. A review of Social Services Notes dated [DATE] at 10:30 a.m., found the social worker queried the resident on [DATE] about acceptance of the physician's do not hospitalize order. The note stated: "The resident was in agreement of these orders." The note does not document that the ramifications of the order were explained to the resident. There is no clarification of who would be designated to make decisions in the case of incapacity or that the subject was discussed. The Immediate Jeopardy was removed on [DATE] at 5:50 p.m., and F250 (reduced from K to E), based upon the implementation of the following corrective actions taken by the facility: Reviewed and amended policies on advance directives to meet the current regulatory requirements; reviewed all residents capacity to make decisions regarding advanced directives; reviewed residents to determine if have someone appointed as decision maker in event the resident is unable to do so and provide education to resident on the risks of having no decision maker delegated; reviewed resident records for advance care planning in regards to advance directives. The facility had not revised their Advanced Directive Policy and completed training for nurses, social services and managers. Had not completed screening for all residents including physician determination of capacity as needed. Quality Assurance monitoring had not been implemented.

Based on observation, record review, interviews and review of facility policies and procedures for advanced directives and change in condition, the facility failed to effectively develop, coordinate and implement quality care and services related to advanced directives and a significant change in condition for 1 (Resident #11) of 7 sampled residents reviewed for advanced directives and failed to coordinate care for 1 (Resident#8) of 1 sampled resident currently on hospice. Staff failed to ensure advanced care planning was reviewed with Resident #11; failed to educate, coordinate and document ramifications of failing to advance care plan Resident #11's health care wishes; failed to provide education regarding Resident #11's declining condition and risks associated with refusing aggressive treatments to Resident #11's wife and son; and failed to adequately assess, monitor and provide ordered care for Resident #11's change in condition. These failures posed an immediate jeopardy situation, placing residents without advanced directives and/or care planning and/or experiencing a significant change in status at risk for serious harm, injury and/or death. The findings include: 1. Closed record review on [DATE] for Resident #11 showed the resident was re-admitted to the facility on [DATE]. The record showed a Do Not Resuscitate (DNR) signed by Resident #11 and dated [DATE]. Resident #11 had signed all of his admission paperwork during a previous admission on [DATE]. An "Acknowledgement of Advance Directives" form noted Resident #11 has a DNR but no other advanced directives. This form was dated [DATE]. In an interview on [DATE] at 3:30 p.m., the Administrator (ADM) acknowledged Resident #11 signed his admission paperwork on [DATE] and acknowledgement of Advanced Directives on [DATE]. She said Resident #11 was at the facility before ([DATE]) and it is the policy of the facility to carry admission paperwork forward in the event a resident returns to the facility within 30 days. She confirmed Resident #11's return was not anticipated. The ADM said the Social Worker (SW) was supposed to re-review the Advanced Directives with Resident #11 and document whether there were any changes in the advanced directives. Review of the history and physical dated [DATE] noted Resident #11 "..fell in front of a restaurant backwards and sustained a compression [MEDICAL CONDITION] had a squamous cell [MEDICAL CONDITION] on his lip which had been followed by MD. Progressed and it was diagnosed as a squamous cell [MEDICAL CONDITION] a past history of non-small cell lung [MEDICAL CONDITION] of squamous origin and was treated with [MEDICAL CONDITION] with great response. Relapse of a small lesion in the upper lobe squamous cell treated with Carboplastin and [MEDICAL CONDITION] therapy. Patient is not a very good historian and the review of systems was really unreliable. Only thing he complained about was weakness and pain in the back...Impression: L,[DATE] lumbar compression fracture, squamous cell scar of the lip and under the tongue, status [REDACTED].#11 was physical therapy as tolerated, assessments by the oncologist and radiologist, obtaining lab work, [MEDICATION NAME] for agitation and anxiety, continuing pain medication and "patient may need surgery." Review of the SW/Psychosocial Data Collection and Evaluation tool dated [DATE] revealed Resident #11 had an eighth grade education and support network that included a wife and 2 sons. No family issues were identified. The SW noted Resident #11 had intact short and long-term memory. (This conflicts with the attending physician's assessment of Resident #11 "not being a very good historian and the review of systems was really unreliable.") The SW documented Resident #11 was admitted for short-term rehabilitation to achieve his goal of returning home with his wife and resident rights and advance directives were reviewed. The SW did not clarify or document what advanced directives were reviewed during the [DATE] admission or whether there were any changes to his advanced directives since the [DATE] admission. In an interview with the SW on [DATE] at 3:30 p.m., she said "review" meant asking what advanced directives the resident had, documenting what he had, and if he wanted any others such as a health care surrogate or living will. She said Resident #11 told her he had a living will but didn't bring it. The SW did not ask about the content of the living will. She did not ask Resident #11 if he wanted to complete a new living will on this admission. The SW said she asked the resident's wife to bring the living will in and she said she would. The SW said at the time of the [DATE] admission, Resident #11 did not want to designate a health care surrogate (HCS). The SW admitted she did not explain the risks associated with failing to designate a HCS in the event he could not speak for himself. She admitted she did not explain the risks of failing to designate a HCS to the wife or son(s). Speech therapy was ordered. The Speech Language Pathologist (SLP)'s assessment noted Resident #11 needed more time and required compensatory strategies for following 2-step commands; required more time with complex problems for following 3-step commands; was distractible; required frequent direction in occasional situations; was moderately impaired during complex sequencing and problem solving, requiring frequent direction in occasional situations and required occasional direction related to safety-judgement, difficulty with memory. Review of the comprehensive Minimum Data Set (MDS) with a reference date of [DATE] showed Resident #11 with a Brief Interview for Mental Status (BIMS) score of 10. (The BIMS is a screening assessment of cognitive functioning ranging from ,[DATE].) Resident #11 is documented to have an "acute onset mental status change" and feeling depressed. Resident #11 required extensive assistance with activities of daily living. Active [DIAGNOSES REDACTED]. Review of the associated cognitive loss/dementia worksheet noted the resident with a moderate impairment in cognition. The SW documented the resident with short-term memory losses with forgetfulness and confusion and elected to proceed to care plan Resident #11's cognition. Review of the comprehensive care plan developed [DATE] included a plan for identified short-term memory deficits with forgetfulness and confusion. The SW listed the following approaches: Redirect as needed; observe for changes in mental, cognitive status; offer simple choices; ask simple yes/no type questions; repeat instructions as needed to assist with comprehension; orient to location of room, dining room; remind as indicated; psych consult/evaluation/treatment per order. Review of the SLP plan of care documents Resident #11 with moderate impairment in multi-step daily living sequencing and in functional complex problem solving and safety awareness. In an interview with the SLP Rehabilitation Director on [DATE] at 6:07 p.m., she said the treating SLP was trying to improve Resident #11's overall skills. She said Resident #11 might have remembered what a doctor said about his care and may need reminders later on. She said Resident #11 knew things like remembering what time to go to dinner. She didn't think he needed help with those types of decisions. She said he wanted his family involved with decision making. She knew of a stepson and a wife to be involved. They were hoping to get him to a level where he needed less cueing, minimal cueing for reasoning, word finding, and recall of new information. She said Resident #11 hadn't lost all of his memory, that it was new information, particularly lengthy, that Resident #11 needed help with complex reasoning. A care plan meeting was held with Resident #11 and his wife on [DATE]. The SW documented she reviewed resident rights and advanced directives. She did not document or explain what she reviewed. In an interview with the SW on [DATE] at 4:30 p.m., she said during care plan meetings, there is a form that is completed when advanced directives are reviewed. She showed a form which includes "checkboxes" for advance directive preferences. The form shows a check mark in the boxes showing Resident #11 had a living will and also checked he does not want a living will. This documentation is in conflict. The form also shows check marks in the boxes indicating Resident #11 does not want a Durable Power of Attorney (DPOA) for Health care and Financial Authority or Health Care Surrogate. The record failed to show discussion and documentation of the resident's choices regarding future health care during the development of the comprehensive assessment and care plan. During the same interview on [DATE], the SW admitted the wife never brought in her husband's living will. She acknowledged Resident #11's care plan related to short-term memory deficits, forgetfulness and confusion. She acknowledged the SLP's plan of care related to moderate impairment in cognition related to multi-step daily living sequencing and problem solving and safety awareness. The SW confirmed she nor the care plan team explained the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. The SW acknowledged despite identified problems related to Resident #11's cognition, there was no documentation of whether Resident #11 was capable of making independent healthcare decisions. Review of the psychiatric consult dated [DATE] indicated Resident #11 is alert with a dysphoric mood. Resident #11's orientation was not assessed. The psychiatrist ordered [MEDICATION NAME] 10 mg. for depression. On [DATE], psychiatric notes show Resident #11's mood was worsening and increased the [MEDICATION NAME] to 50 mg daily. The record showed the interdisciplinary team failed to develop a plan of care related to the resident's depression and worsening mood. On [DATE], the physician ordered [MEDICAL CONDITION] treatments to continue and plan for [MEDICAL CONDITION]. The record showed Resident #11 continued [MEDICAL CONDITION] and [MEDICAL CONDITION] and on [DATE] the SLP discharged Resident #11 documenting the goals for Resident #11's were not met; Resident #11 demonstrated functional problem solving and safety awareness for daily living tasks. The SLP documented reason for discharge: "Patient progress plateaued due to fluctuations in patient pain and fatigue." Review of nursing notes dated [DATE] at 6:00 p.m. documented the following: Resident and wife notified this nurse of the decision not to continue any [MEDICAL CONDITION] treatment, but will continue [MEDICAL CONDITION] ARNP notified. Message left for oncology facility at the answering service. Nursing notes by Licensed Practical Nurse (LPN) Staff B on [DATE] at 8:00 a.m. included: Up in wheelchair. Transport company in. Resident having difficulty breathing. Oxygen saturation 60%. Unable to swallow breakfast, unable to swallow medications. Spoke with ARNP. Spoke with wife. Spoke with oncologist. Left message(?) for physician office to call back. Obtained orders for oxygen, obtained orders for hospice consult. Spoke with Hospice Nurse. 9:15 a.m. Received call from physician office, informed them of change in condition, they canceled all upcoming appointments. Review of the telephone orders dated [DATE] at 9 a.m. showed orders by the ARNP for a hospice consult, oxygen at 3 liters via nasal cannula as needed for an oxygen saturation less than 92%, and oxygen saturation levels checked every shift. On [DATE] at approximately 12:30 p.m., the ADM was asked for the hospice consult notes as they were not in Resident #11's record. She was unaware of the hospice consult or whether hospice notes were available and said she would call the hospice agency and request them. Review of the hospice notes dated [DATE] at 11:50 a.m. noted the hospice nurse came to the facility based on the referral for hospice, spoke with Resident #11 about hospice services to which Resident #11 and his wife agreed. The hospice nurse documented Resident #11 in agreement with discontinuing all aggressive treatments. The hospice nurse documented, "Pt (patient) is too weak to sign consents...Spoke with MDS and spouse and will attend care plan meeting this afternoon and have spouse sign for pt as pt has directed to myself and facility nurse...requested that nursing staff watch pt closely for any uncontrolled symptoms..." On [DATE] at 8:00 a.m., Staff B's nursing notes showed Resident #11's oxygen level at 60% and declining condition. There were no additional assessments of Resident #11's condition. There was no documentation of "Do Not Hospitalize" or "Do Not Treat" orders in place. There was no documentation the ARNP was provided ongoing updates related to Resident #11's change in condition. Review of the record showed the resident an oxygen level at 60% and declining condition, there was no documentation whether Resident #11 was determined to have decision-making capacity or whether decision-making ability would be transferred to his wife. There was no documentation to show nursing, the ARNP, physician, or SW helped Resident #11, his wife, or his son understood the risk and benefits of Resident #11 declining aggressive treatment. On [DATE] at 3:25 p.m., LPN Staff C was the oncoming second shift nurse and documented, "O2 sats remain at 80% via nasal cannula. Lung sounds with congestion bilaterally upon auscultation call placed to (ARNP). New orders received for chest x-ray". There were no vital signs recorded (blood pressure, pulse or respiratory rate) by the nurse. There was no documentation to support a phone call was made to Resident #11's wife or son(s) informing them of Resident #11's condition related to congested lungs and low blood oxygenation. There was no documentation to support they were informed of the risks or benefits associated with failing to hospitalize Resident #11. Orders by the ARNP dated [DATE] included chest x-ray, rule out pneumonia... The orders did not include "do not hospitalize" or "do not treat". Hospice notes on [DATE] at 4:25 p.m. documented the following: "...Pt is requesting son to make all decisions in process, facility has not informed son as of yet. There is to be a conference call with son at facility to inform him and decide plan. (Hospice nurse) will update....when ok to admit." There is no documentation by the SW or interdisciplinary team that Resident #11's son was called. At 5:01 p.m. on [DATE], the hospice nurse documents, "...return visit to attend meeting with staff and pt spouse to discuss pt status and hospice services. Spouse in agreement with hospice services but states that pt may want his son, (name), to make decisions. Spouse, our SW and myself went to pt room to discuss with pt. Pt does say he wants his son to make decisions and he will do what his son wishes. States that if his son wants him to continue aggressive treatment he will agree. No one knew until today that pt wanted his son involved in decision making...informed her not to send in admit nurse yet until we speak with pt son to be sure if son and pt are still willing to have hospice services." In an interview with the SW on [DATE] at 4:30 p.m., she said Resident #11's wife was not officially determined to be the decision maker for her husband, therefore, should not have signed that Resident #11 did not want a health care surrogate or DPOA for health care or finances. The SW said she did not go back and visit with Resident #11 because she stayed behind to attend other care plan meetings. She said what she meant when she documented her "review" of advanced directives during the care plan meeting was what Resident #11 currently had in place. She acknowledged Resident #11's living will was never brought in to the facility. She admitted neither she nor the interdisciplinary team went back to re-assess Resident #11's decision for hospitalization , son's involvement in decision making process, or educate Resident #11 or his wife related to the risks involving lack of directives for future healthcare. She said Resident #11's capacity to make decisions was not re-evaluated and no one called Resident #11's son. In an interview on [DATE] at 2:12 p.m., the hospice nurse said she made late entries in her notes. She said she received a call from the facility and came to the facility approximately late morning. She spoke with the nursing staff to find out what was going on and was informed of Resident #11's desire to stop treatments. What she had to decide was who was making decisions. At that time, Resident #11 was alert and oriented and when she saw Resident #11, he was doing quite well. He had some difficulty speaking. She wanted to make sure he was capable of making his decisions. She said Resident #11 was tired and quite weak. She said the wife was listed as the responsible party on the face sheet and Resident #11 said he wanted his wife involved. She agreed to whatever her husband wanted. The hospice nurse said they had a care plan meeting. During the care plan meeting, the wife mentioned he had a son. The hospice nurse stated, "I got a funny feeling (Resident #11's wife) didn't want to be involved. That she agreed whatever the son wanted." They went back to Resident #11's room and he said he wanted his son's involvement and he would do whatever his son wanted. If his son would want aggressive treatment, he would go through with it. The hospice nurse said she went back to the care plan meeting room where the MDS Coordinator and SW were and informed them Resident #11 wanted his son contacted and his son involved. There is no documentation the MDS Coordinator (Staff D) or SW went back and informed the nursing staff of Resident #11's desire for son to be contacted and reconsideration for aggressive treatment. The record failed to reveal Resident #11's son was called related to Resident #11's choice to designate him as decision maker and involve the son in assisting Resident #11 with his reconsideration of going forward with aggressive therapy or with holding aggressive treatment. There was no documentation that Resident #11 was asked if he wanted to go to the hospital for treatment since he was reconsidering aggressive therapy. Review of the care plans at the time of the care plan meeting on [DATE] failed to show a plan of care for hospice, the decision to withhold treatment, to not hospitalize, or provide end of life care. During the interview on [DATE] at 2:12 p.m., the Hospice Nurse confirmed hospice was withdrawn and never initiated because Resident #11 was reconsidering his options. In an interview on [DATE] at 5:00 p.m., Staff Q said they didn't have a care plan for end of life care because Resident #11 was never deemed terminal and wasn't on hospice. They were having a meeting to explore his options and found out he wanted his son involved and may to continue treatment. At 4:00 p.m. on [DATE], Staff C documented vital signs and oxygen at 2 liters via nasal cannula (order was for 3 liters). Lung sounds continued to be congested bilaterally upon auscultation. Oxygen saturation was at 80%. There was no call to the ARNP updating her of Resident #11's condition. There was no order for do not hospitalize or do not treat. There was no documentation Resident #11's wife or son was called and provided education related to Resident #11's condition. There was no indication Resident #11, his wife, or son were informed of the risks of poor oxygenation would have on Resident #11. The facility failed to re-assess whether Resident #11 wanted to go to the hospital. There was no documentation to support Resident #11's wife or son(s) were called and provided an update. At 5:00 p.m., on [DATE], Staff C, documented she administered medication. There was no documented reassessment of Resident #11's clinical condition and no phone call to wife or son. There was no documentation that the ARNP was provided an update on Resident #11's condition. At 5:45 p.m., on [DATE], Staff C documented the following: "Entered resident's room. Resident noted to be unresponsive to verbal and tactile stimulation. Lung sounds continue to be congested. Respirations labored...O2 sats noted to be 48% with 2 liters of O2 via nasal cannula. (vital signs)... Skin noted to be gray in appearance. Noted to be gasping when breathing." Five minutes later, at 5:50 p.m. on [DATE], Staff C documented, "Call placed to (ARNP) with condition update. Instructions given to update (wife) with update." At 5:55 p.m. on [DATE], Staff C documented she called Resident #11's wife and made her aware of the change in condition and wife stated she wants no hospitalization . At 6:00 p.m. on [DATE], the ARNP was called back by Staff C and the ARNP ordered no hospitalization . At 6:15 p.m. on [DATE], Staff C documented she entered Resident #11's room and he was unresponsive. There was no breathing noted and no pulse was noted. Staff C called the ARNP to make her aware. No vital signs were taken at that time. At 6:20 p.m. on [DATE], Staff C documented she attempted to contact Resident #11's wife and at 6:45 p.m., Resident #11's wife arrived and was made aware Resident #11 expired. In an interview on [DATE] at 9:30 a.m., Resident #11's wife said it was never fully explained to her about her husband's deteriorating condition that began at 8 a.m. on [DATE] and lasted 10 hours through 5:45 p.m. She stated, "I had no clue. Only that he was now on oxygen. Did not get phone call from ARNP or Doctor." She said she walked into her husband's room at about 1:00 p.m. on [DATE] to find him on oxygen, which was something new, and no one told her why. She said all she knew was her husband was thinking about stopping his chemo and [MEDICAL CONDITION]. Her husband didn't say anything to her about no hospitalization . He did say he wanted to see what hospice was about so they invited hospice to the care plan meeting. Her husband didn't want to go because he wasn't up for it. So, they explained what hospice was about in his room. Then at the care plan meeting at 2:10 p.m., after they explained hospice services, she didn't feel comfortable making decisions as her husband was always in control. She told them (care plan team) his son should be involved with decision making and she would go along with whatever her husband wanted. Since her husband wanted the son to make decisions, she went along with that. She said staff knew this at the care plan meeting. She stated, "After they found out about his son, they laughed. I didn't like that." She said her husband wanted to talk with his son as he thought if his son wanted him to go for treatments, he would go. No one ever asked her for his son's phone number. She said after the care plan meeting, she went home. The next thing she knew, 4 hours later, she was getting a call that (Resident #11) was dying and was asked if she wanted her husband to go to the hospital. She said she told the facility not to send her husband to the hospital. She stated, "What else was I supposed to do at that point?" She confirmed she spoke with her husband's son later who informed her he never received a call related to updating him related to his father's condition prior to or after his death. In an interview on [DATE] at 11:30 a.m., Resident #11's son said no one ever called him about his father's condition. He said it was never fully explained to his mother that his father started to deteriorate the morning of [DATE]. He said no one ever called him to tell him his father wanted him to make decisions. No one called him after his father died . He said they talked to him in the past when he converted from Medicare so he didn't know why he wasn't called about his father's condition. His stepmother did inform him that she told staff in the care plan meeting that afternoon that he should be involved in decision making. He said, "The whole thing was handled poorly. In an interview on [DATE] at 12:40 p.m., Staff B said the resident [MEDICAL CONDITION] of his lip and was going for [MEDICAL CONDITION] and chemo. On [DATE], the transport company came in and Resident #11's oxygen level was 60%. She said Resident #11 couldn't swallow breakfast and his medication. She returned him to bed. She called the ARNP, received orders for oxygen at 3 liters via nasal cannula as needed for oxygen for sats less than 92%. Also orders were received for O2 sats every shift and orders for hospice consult. She said she spoke to the resident who said he didn't want to go to the ER (emergency room ) and didn't document this. She asked if he wanted a hospice consult. He said he didn't want any more chemo, [MEDICAL CONDITION] and didn't want to go to the hospital. She called for the hospice consult as well. She didn't do any other documentation about Resident #11's condition. He was weak; he was able to talk to her and was alert at this time. She stated, "I didn't chart about the resident's condition because his chart was in care plans." She said with the oxygen on, Resident #11 "got better" though was still weak." She said, "He knew what I was saying to him and was talking back to me." Staff B confirmed there was no order for Do Not Hospitalize or Do Not Treat. She admitted she did not call the ARNP back with any other assessments of Resident #11 during her shift. Staff B was not aware whether anyone discussed the risks of refusing treatment or negative consequences of poor oxygenation to Resident #11, his wife or son. She confirmed there was no documentation to support Resident #11 was re-assessed after 8:00 a.m. on [DATE]. In an interview on [DATE] at 1:27 p.m., Staff C said she checked Resident #11 when she came onto her shift at 3:25 p.m. She said Resident #11's oxygenation saturation levels were 80% via nasal cannula. She received orders for a chest x-ray to rule out pneumonia, and recheck PT/INR on Thursday. She did not have a Do Not Hospitalize or Do Not Treat order by the ARNP. She said she recalled in report that the nurse previous said resident was declining and obtained a hospice consult. She said Resident #11's wife wasn't sure what to do and she was going to call Resident #11's son to get an understanding of what would be good for him; that Resident #11 was rethinking about going for treatment. The son was never called. Staff C said the wife told her that her husband did not want to go to the hospital, but, Staff C did not go and ask Resident #11 his wishes. She confirmed Resident #11's wife was not the decision maker for her husband. She could not confirm whether anyone called Resident #11's wife or son to explain to them the severity of his condition, or the negative outcome poor oxygenation would have throughout the day on Resident #11's health. Staff C stated, "I heard something about him thinking about going for treatment if his son would agree." Staff C confirmed she never called the son. Staff C said she spoke with Resident #11's wife who wanted to speak with the son on the day Resident #11 was "going bad". When she found the resident unresponsive, the ARNP told Staff C to call the wife and ask the wife if she wanted Resident #11 sent out to the hospital. It was then that his wife told her not to have Resident #11 hospitalized . Staff C confirmed she did not ask any RN to comprehensively assess Resident #11's condition. She said she grabbed another LPN who was on the floor with her to validate what she was seeing. She said when she found the resident unresponsive and without a pulse, she did not take vital signs. She confirmed she documented administering oxygen at 2 liters instead of 3 liters as ordered by the ARNP. She said she did not call the RN that was on duty. She called the same LPN back into the room to validate her findings the resident expired. Staff C said the facility protocol if a resident has a change in condition is she would generally listen to lung sounds, check the apical pulse, check for responsiveness, do a chest rub, and call out the resident's name calling out their name. She would then report her findings immediately to the ARNP or MD. In an interview on [DATE] at 1:59 p.m., the ARNP said she vaguely remembered a call on the 6th (of January). She thought a care plan meeting took place where hospice was initiated. Her impression was Resident #11 seemed to have a little dementia and thought when Resident #11 wasn't speaking, the next person was his wife. The ARNP stated, "I don't know why he wasn't palliative sooner". The ARNP confirmed she was not given updates by nursing staff throughout the day regarding Resident #11's condition. The ARNP said no one told her Resident #11 changed his mind about aggressive treatment and that he wanted his son to be in the decision making process. The ARNP said she did not come in to assess Resident #11, did not call the wife or speak to Resident #11 about the negative outcome it would have with failing to adequately oxygenate Resident #11 throughout the day. She confirmed she did not speak to Resident #11 about who he wanted as his health care surrogate. The ARNP said the attending physician was out of the country. She stated, "I didn't have a chance to know what happened during the care plan meeting." She said she wasn't told Resident #11 had a son and wasn't aware Resident #11 wanted him consulted. The ARNP said the next time she was in the building, they were reviewing what happened. She didn't call Resident #11's son prior to or after Resident #11 expired. In an interview on [DATE] at 2:45 p.m., the SW, RN Staff D (who also the MDS Coordinator) and RN Unit Manager confirmed they attended the care plan meeting where Resident #11's wife attended. The SW said Resident #11's wife told her Resident #11 had a living will on admission, but it was never provided. The SW said Resident #11 was complaining the [MEDICAL CONDITION] was causing a lot of pain. Resident #11 mentioned stopping the [MEDICAL CONDITION]. The SW said at one point the nurse (Staff B) had mentioned hospice services to him if he wanted to [MEDICAL CONDITION] treatment. Resident #11 agreed to a consult where they (hospice) just come in and talk. They arranged to meet with Resident #11 and his wife to just do the consult. The day the consult occurred happened to be Resident #11's care plan meeting day. The SW said they were present during the care plan meeting. Resident #11 said he was too ill to go to care plan and didn't have the strength. They (wife and hospice nurse) came to the care plan with his directive. They talked about his decline, what hospice could do, what services were and at the end of the care plan his wife mentioned he has a son, her stepson, and resident may want to involve his son with this. So the hospice nurse and wife left the meeting and they went down Resident #11's room to talk with him. The SW said she heard later on that Resident #11 wanted the son's involvement, to make him aware. The SW stated, "We were going to gather their information and call the son to ask in a conference call so that they could discuss what was going on. They didn't have the number and that evening Resident #11 passed away." The SW, Staff D and Unit Manager said they weren't told Resident #11 was actively dying. They confirmed no one went back to determine if Resident #11 was capable of making health care decisions; whether he wanted to go to the hospital since he was reconsidering aggressive treatment if his son agreed or explained the risks associated with failure to adequately oxygenate Resident #11. In an interview on [DATE] at 12:54 p.m., the RN Unit Manager said she did not document anything at all about Resident #11's condition. She said she went in early that morning ([DATE] at 8:45 a.m.) and Resident #11 was alert, not complaining of any pain. Resident #11 could answer questions appropriately. She stated, "He was a man of very few words" She did not go in to visit Resident #11 until 5:15 p.m. She went into his room, his bed was sitting up and he was awake and alert. He said he was doing ok. She didn't know if he had any oxygen saturations obtained that day. He had a very deep smoker's voice, but that was all the time. She said a

Based on interviews, record review and review of facility policies and procedures for advance directives, the Administrator failed to ensure established policies and procedures were implemented to ensure advanced care planning was in place for 3 (Residents #11, #55, and #148) of 7 sampled residents whose records were reviewed for advanced directives. The Administrator failed to ensure advanced care planning was reviewed with Resident #11; failed to educate, coordinate and document ramifications of failing to advance care plan Resident #11's health care wishes; failed to provide education regarding Resident #11's declining condition and risks associated with refusing aggressive treatments to Resident #11's wife and son; and failed to adequately assess, monitor and provide ordered care for Resident #11's change in condition. These failures posed an immediate jeopardy situation, placing residents without advanced directives and/or care planning and/or experiencing a significant change in status at risk for serious harm, injury and/or death. The findings include: 1) Review of the "Position Description" of the Administrator reads, "Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristics duties and responsibilities Essential Functions: 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions etc.) 2. Assist in the development and implementation of the departmental policies and procedures, and establish a rapport in and between departments so that each can see the importance of team work. 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 4. Interpret the facility's policies and procedures to personnel, patients/residents, family members, visitors, etc. as may be necessary. 5. Review policies and procedures periodically, at least annually, and make changes as necessary to ensure compliance with current regulations are being continually maintained. 6. Ensure that patients/residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are established and maintained at all times...." 2) Review of the facility's policies and procedures for Advanced Directives failed to include the following components: ? Determining if the facility periodically assesses the resident for decision-making capacity and invokes the health care agent or legal representative if the resident is determined not to have decision-making capacity. ? Identifying the primary decision-maker (e.g., assessing the resident's decision-making capacity and identifying or arranging for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions); ? Defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, as appropriate; ? Identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions; ? Identifying situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition; ? Establishing mechanisms for documenting and communicating the resident's choices to the interdisciplinary team. ? Identifying the process (as provided by State law) for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes on the basis of conscience. 3) In an interview with the Administrator on [DATE] at 4:00 p.m., she acknowledged she was not aware of the [DATE] revised edition of the State Operations Manual for advanced directives which included guidance for advanced care planning for residents who desire not to execute advanced directives. 4) Closed record review on [DATE] for Resident #11 shows the resident was admitted to the facility on [DATE]. The record showed a Do Not Resuscitate (DNR) signed by Resident #11 dated [DATE]. Resident #11 signed all of his admission paperwork during a previous admission of [DATE]. An "Acknowledgement of Advance Directives" form noted Resident #11 has a DNR and no advanced directives. This form is dated [DATE]. Active [DIAGNOSES REDACTED]. The resident remained in the facility receiving therapy with the intent to return to his home. He was also receiving [MEDICAL CONDITION] treatments for [MEDICAL CONDITION]. Review of the comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] shows Resident #11 with a Brief Interview for Mental Status(BIMS) of "10." (The BIMS is a screening assessment of the resident's cognitive ability. The score ranges between ,[DATE]. The higher the score reflects a higher level of cognitive functioning of the resident.) Resident #11 is documented to have an "acute onset mental status change" and feeling depressed. Resident #11 requires extensive assistance with activities of daily living. Review of the cognitive loss/dementia worksheet associated with this MDS notes Resident #11 with a moderate impairment in cognition. The SW documented the resident with short term memory losses with forgetfulness and confusion and elected to proceed to care plan Resident #11's cognition. Review of nursing notes dated [DATE] at 6:00 p.m., documented the following: "Resident and wife notified this nurse of the decision not to continue any [MEDICAL CONDITION] tx, but will continue chem(o) therapy ARNP notified. MSG (message) left for (oncology facility) at the answering service." In an interview with the Administrator on [DATE] at 3:30 p.m., she acknowledged Resident #11 signed his admission paperwork on [DATE] and the acknowledgement of Advanced Directives on [DATE]. She said Resident #11 was at the facility before and it is the policy of the facility to carry admission paperwork forward in the event a resident returns to the facility within 30 days. She confirmed Resident #11's return was not anticipated. The Administrator said the Social Worker (SW) was supposed to re-review the Advanced Directives with Resident #11 and document whether there were any changes in the advanced directives. Review of the SW/Psychosocial Data Collection and Evaluation tool dated [DATE] notes Resident #11 with an eighth grade education and support network includes a wife and 2 sons. No family issues were identified. The SW documents Resident #11 with intact short and long term memory. (This conflicts with the attending physician's assessment of Resident #11 "not being a very good historian and the review of systems was really unreliable" on the same date.) The SW documented Resident #11 was admitted for short term rehabilitation to achieve his goal of returning home with his wife and resident rights and advance directives were reviewed. The SW did not clarify or document what advanced directives were reviewed during the [DATE] admission or whether there were any changes to his advanced directives in-between the [DATE] admission and recent admission to the facility on [DATE]. In an interview with the SW on [DATE] at 3:30 p.m., she said her "review" meant asking what advanced directives the resident had, documenting what he had, and if he wanted any others such as a health care surrogate or living will. She said Resident #11 told her he had a living will but didn't bring it with him. The SW did not ask about the content of the living will. She did not ask Resident #11 if he wanted to complete a new living will on this recent admission. The SW said she asked Resident #11's wife to bring the living will in to the facility and she said she would. The SW said at the time of the [DATE] admission, Resident #11 did not want to designate a Health Care Surrogate (HCS). The SW admitted she did not explain the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. She admitted she did not explain the risks of failing to designate a HCS to Resident #11's wife or son(s). In an interview with the SW on [DATE] at 4:30 p.m., she said during care plan meetings, there is a form that is completed when advanced directives are reviewed. She showed a form which includes "checkboxes" for advance directive preferences. The form shows a conflicting check marks in the boxes showing Resident #11 with a living will and also checked he does not want a living will. The form also shows check marks in the boxes indicating Resident #11 does not want a Durable Power of Attorney (DPOA) for Health care and Financial Authority or Health Care Surrogate. During the same interview, the SW said the wife never brought in Resident #11's living will. She acknowledged the review of Resident #11's care plan related to short term memory deficits, forgetfulness and confusion. She acknowledged the Speech Language Pathologist's plan of care relate moderate impairment in cognition related to multi-step daily living sequencing and problem solving and safety awareness. In spite of these identified deficits in cognition, the SW admitted neither she nor the care plan team explained the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. She admitted she did not explain or provide education related to the risks of Resident #11 failing to designate a HCS to Resident #11's wife or son(s). The SW acknowledged, despite identified problems related to Resident #11's cognition, there was no documentation by the physician or Advanced Registered Nurse Practitioner (ARNP) of whether Resident #11 was capable of making independent healthcare decisions. At 5:01 p.m. on [DATE], the hospice nurse documents, "...return visit to attend meeting with staff and pt (patient) spouse to discuss pt status and hospice services. Spouse in agreement with hospice services but states that pt may want his son, (named), to make decisions. Spouse, our SW and myself went to pt room to discuss with pt. Pt does say he wants his son to make decisions and he will do what his son wishes. States that if his son wants him to continue aggressive treatment he will agree. No one knew until today that pt wanted his son involved in decision making...informed her not to send in admit nurse yet until we speak with pt son to be sure if son and pt. are still willing to have hospice services." No other notes by SW until [DATE] which documents: "Quarterly Assessment and care plan meeting. (Resident #11) is declining related to his CA (cancer) dx (diagnosis). He has been referred to Hospice and they are to have a meeting with Hospice today ([DATE]). Discharge plans changed and now long term care. [MEDICATION NAME] for depression. Resident rights and advanced directives reviewed." Review of the advanced directive review form dated [DATE] completed during the care plan meeting showed Resident #11's wife indicated her husband did not want a Durable Power of Attorney (DPOA) for Health Care or Financial Authority and did not want a Health Care Surrogate. In an interview with the SW on [DATE] at 4:30 p.m., she said Resident #11's wife was not officially determined to be the decision maker for her husband, therefore, should not have signed; Resident #11 did not want a health care surrogate or DPOA for health care or finances. She said she did not go back and visit with Resident #11 because she stayed behind to attend other care plan meetings. She said what she meant when she documented her "review" of advanced directives during the care plan meeting was what Resident #11 currently had in place. She acknowledged Resident #11's living will was never brought in to the facility. She admitted neither she nor the interdisciplinary team went back to re-assess Resident #11's decision for hospitalization , son's involvement in decision making process, or educate Resident #11 or his wife related to the risks involving lack of directives for future healthcare. She said Resident #11's capacity to make decisions was not re-evaluated and no one called Resident #11's son. In an interview with the hospice nurse on [DATE] at 2:12 p.m., she said she made late entries in her notes. She said she received a call from the facility and came to the facility approximately late morning. She spoke with the nursing staff to find out what was going on and was informed of Resident #11's desire to stop tx's. What she had to decide was who was making decisions. At that time, Resident #11 was alert and oriented and when she saw Resident #11, he was doing quite well. He had some difficulty speaking. She wanted to make sure he was capable of making his decisions. She said Resident #11 was tired and quite weak. She said the wife was listed as the responsible party on the face sheet and Resident #11 said he wanted his wife involved. She agreed to whatever her husband wanted. The hospice nurse said they had a care plan meeting. During the care plan meeting, the wife mentioned he had a son. The hospice nurse stated, "I got a funny feeling (Resident #11's wife) didn't want to be involved. That she agreed to whatever the son wanted." They went back to Resident #11's room and he said he wanted his son's involvement and he would do whatever his son wanted. If his son would want aggressive treatment, he would go through with it. The hospice nurse said she went back to the care plan meeting room where the MDS Coordinator and SW were and informed them Resident #11 wanted his son contacted and his son involved. The record failed to show Resident #11's capacity to make healthcare decisions was re-evaluated. The record failed to show Resident #11, his wife or son(s) were asked where Resident #11's living will was located or whether they were re-educated about the risks associated with Resident #11's lack of planning for future healthcare in the event he could not speak for himself. The record failed to reveal Resident #11's son was called related to Resident #11's choice to designate him as decision maker and involve the son in assisting Resident #11 with his reconsideration of going forward with aggressive therapy or with holding aggressive treatment. There was no documented evidence Resident #11 was asked if he wanted to go to the hospital for treatment since he was reconsidering aggressive therapy. In spite of Resident #11's low oxygen saturation levels in conjunction with his reconsideration for his son's involvement for decision making, there was no re-assessment by facility staff or by the MD of Resident #11's capacity to make healthcare decisions. In an interview on [DATE] at 9:30 a.m., Resident #11's wife said it was never fully explained to her about her husband's deteriorating condition that began at 8 a.m. on [DATE] and lasted 10 hours through 5:45 p.m. She stated, "I had no clue. Only that he was now on oxygen. Did not get phone call from ARNP or Doctor." She said she walked into her husband's room at about 1:00 p.m. on [DATE] to find him on oxygen, which was something new, and no one told her why. She said all she knew was her husband was thinking about stopping his chemo and [MEDICAL CONDITION]. Her husband didn't say anything to her about no hospitalization . He did say he wanted to see what Hospice was about so they invited hospice to the careplan meeting. Her husband didn't want to go because he wasn't up for it. So, they explained what Hospice was about in his room. Then at the careplan meeting at 2:10 p.m., after they explained Hospice services, she didn't feel comfortable making decisions as her husband was always in control. She told them (care plan team) his son should be involved with decision making and she would go along with whatever her husband wanted. Since her husband wanted the son to make decisions, she went along with that. She said staff knew this at the careplan meeting. She stated, "After they found out about his son, they laughed. I didn't like that." She said her husband wanted to talk with his son as he thought if his son wanted him to go for treatments, he would go. No one ever asked her for his son's phone number. She said after the careplan meeting, she went home. The next thing she knew, 4 hours later, she was getting a call that (Resident #11) was dying and was asked if she wanted her husband to go to the hospital. She said she told the facility not to send her husband to the hospital. She stated, "What else was I supposed to do at that point?" She confirmed she spoke with Resident #11's son later who informed her, he never received a call to update him to his father's condition prior to or after his death. In an interview on [DATE] at 11:30 a.m., Resident #11's son said no one ever called him about his father's condition. He said it was never fully explained to his mother that his father started to deteriorate the morning of [DATE]. He said no one ever called him to tell him his father wanted him to make decisions. No one called him after his father died . He said they talked to him in the past when he converted from Medicare so he didn't know why he wasn't called about his father's condition. His stepmother did inform him that she told staff in the care plan meeting that afternoon that he should be involved in decision making. No one called him after his father died . He said he never heard anything from the MD or ARNP. He said, "The whole thing was handled poorly." In an interview with the Administrator on [DATE] at 1:55 p.m., she said she was unaware there was an issue with Resident #11's advanced directives. She said the facility does not review unexpected deaths that occur in the facility. She verified she had not known Resident #11 wanted his son to make health care decisions for him, and that the resident's son was not notified of the resident's wishes. She said she only became aware of this when it was brought to her attention during the survey. She verified the current policy in place did not include guidance to ensure advanced care planning for residents who desire not to execute advanced directives. On [DATE] at 10:30 a.m., the Administrator provided revised polices regarding advanced directives and change in resident condition. 2. During an observation and interview on [DATE] at 10:05 a.m., Resident #55 said people have been stealing things from her since she's been at the facility for the past 2 years. Resident #55 was confused and could not provide specific details related to what she felt was actually stolen or missing. She named a staff member who she reported these concerns to and said no one has done anything about it. In an interview on [DATE] at 9:39 a.m., Staff F, who is the primary nurse, said Resident #55 is not totally oriented and lives in the past a lot. Staff F stated, "(Resident #55) has days where she is totally with it and days where she's not." Staff F said there is no one in the facility by the name of whom Resident #55 said she reported the missing items to. Record review on [DATE] showed Resident #55 was readmitted to facility [DATE] with [DIAGNOSES REDACTED]. Review of the history and physical dated [DATE] includes, "...(resident) comments unreliable due to dementia, cognitive impairment or other state...History obtained by staff or family member." Review of the Minimum Data Sets (MDS) with Assessment Reference Dates (ARD) of [DATE], [DATE], [DATE], [DATE] noted Resident #55 with a BIMS (Brief Interview for Mental Status) of "6" and with altered level of consciousness where her behavior was continuously present and did not fluctuate. The BIMS is a screening tool that evaluates a resident's cognitive functioning. The score ranges between "00" (not able to participate) to "15" (high level of functioning). Review of the most recent MDS noted a quarterly assessment with an ARD of [DATE]. A BIMS of "8" is documented and Resident #55 remains with an altered level of consciousness. Review of the resident record showed nurses documented Resident #55's son as the Power of Attorney (POA). Review of the demographic sheet in the front of Resident #55's record refers to her son as the POA. In an interview on [DATE] at 12:00 p.m., Resident #55 was asked who helps her with decision making. Resident #55 looked up to the ceiling and said, "I think it's my brother. No, wait a minute, he's dead, I think it's his daughter." She then rubbed her head and said, "Honey, I'm not sure at this point." In an interview on [DATE] at 11:17 a.m., the Social Worker (SW) said Resident #55 is her own health care decision maker. The SW said Resident #55 defers to her son "a lot", and he is not the POA nor is he listed as the health care surrogate but is the responsible party in the event something should happen to Resident #55. The SW said Resident #55 did not want any other advanced directives in place other than a do not resuscitate. The SW was asked whether the resident had the capacity to understand what advanced directives were and the SW said yes. The SW confirmed Resident #55's capacity to make appropriate health care decisions was never evaluated by the attending physician in spite of her altered level of consciousness and BIMS of "6" and "8" on the MDS. In an interview on [DATE] at 11:45 a.m., the assistant director of nurses stated, "How would she (Resident #55) even have the capacity to know what an Advanced Directive is?" During an interview with the Administrator on [DATE] at 1:55 p.m., she verified she was not aware there was an issue regarding advanced directives in the facility. She said she only became aware of this when it was brought to her attention during the survey. 3. A review of the medical record for Resident #148 found that on the annual MDS dated [DATE] and on the most recent MDS the resident scored 14 on the BIMS. The score of 14 indicates the resident has a high level of understanding and decision making ability. The resident makes his own decisions and signs his own consents. The resident signed the admission agreement and the form stating he was informed of and given written information about "Advance Directives." The medical record contains a Do Not Resuscitate Order (DNRO) signed by the resident upon admission to the facility on [DATE] but no other advance directive documents. The monthly Physician order [REDACTED].*Directives*, Code Status states: "DNR - Comfort measures only - Do not hospitalize." The report of the quarterly care plan meeting held on [DATE] documents Resident #148 was in attendance. The Advance Directives review form for [DATE] shows the resident has signed a DNRO. The sections for Living Will, Durable Power of Attorney for Health Care Authority, and Health Care Surrogate are not filled in. The Social Services Notes regarding the care plan meeting states: Resident Rights and Advance Directives reviewed." The notes do not document the resident was informed of the consequences of not having advance directives. In an interview on [DATE] at 3:45 p.m., when asked if he has designated anyone to have power of attorney (POA) or as a health care surrogate, Resident #148 said: "I think either my brother or daughter I do not know for sure." "I did sign a DNRO." Asked if he knows about end of life decisions and who would make decisions if he is not able, the resident expressed his faith saying he believes the right decision would be made. The resident did not recall that there is an order not to hospitalize and was not sure what that meant. The resident says he does not recall going over advance directives at the care plan meeting on [DATE]. In an interview on [DATE] at 3:50 p.m., the SW, stated another social worker attended the care plan meeting with Resident #148. She said the social worker goes over the documents the facility has in the way of advance directives and advises the residents they can assist with the other tools (POA, Health Care Surrogate, and etc.). The SW said at each quarterly care plan meeting a form is checked off indicating which advance directives have been completed or submitted by the resident. The SW acknowledged there is no discussion about advance directives unless initiated by the resident. A review of social services notes dated [DATE] at 10:30 a.m., finds the SW queried Resident #148 on [DATE] about acceptance of the physician's do not hospitalize order. The social services note states: "The resident was in agreement of these orders." The note does not document that the ramification of the order was explained to the resident. There is no clarification of who is designated to make decisions in the case of incapacity or that the subject was discussed. During an interview with the Administrator on [DATE] at 1:55 p.m., she verified she was not aware there was an issue regarding advanced directives in the facility. She said she only became aware of this when it was brought to her attention during the survey. The Immediate Jeopardy was removed on [DATE] at 5:50 p.m., and citation F490 (reduced from K to E), based upon the implementation of the following corrective actions taken by the facility: Reviewed and amended policies on advance directives to meet the current regulatory requirements; reviewed all residents capacity to make decisions regarding advanced directives; reviewed residents to determine if have someone appointed as decision maker in event the resident is unable to do so and provide education to resident on the risks of having no decision maker delegated; reviewed resident records for advance care planning in regards to advance directives; teach and implement new change in condition form and documentation standards; educate nurses on policy and need to involve RN and/or charge nurse on any resident change in condition. The facility had not revised their Advanced Directive Policy and completed training for nurses, social services and managers. Had not completed screening for all residents including physician determination of capacity as needed. Quality Assurance monitoring had not been implemented.

Based on interviews, record reviews and review of facility policies and procedures for advance directives, the Quality Assurance Committee failed to establish and implement policies and procedures and ensure advanced care planning was in place for 3 (Resident #11, #55, and #148) of 7 sampled residents whose records were reviewed for advanced directives. The Quality Assurance Committee failed to ensure advanced care planning was reviewed with Resident #11; failed to educate, coordinate and document ramifications of failing to advance care plan Resident #11's health care wishes; failed to provide education regarding Resident #11's declining condition and risks associated with refusing aggressive treatments to Resident #11's wife and son; and failed to adequately assess, monitor and provide ordered care for Resident #11's change in condition. These failures posed an immediate jeopardy situation, placing residents without advanced directives and/or care planning and/or experiencing a significant change in status at risk for serious harm, injury and/or death. The Quality Assurance Committee failed to review the unexpected death of Resident #11 to ensure policies were in place to protect residents rights in the facility for advanced directives and significant change in condition. The findings include: Review of the facility's policies and procedures for Advanced Directives failed to include the following components: ? Determining if the facility periodically assesses the resident for decision-making capacity and invokes the health care agent or legal representative if the resident is determined not to have decision-making capacity. ? Identifying the primary decision-maker (e.g., assessing the resident's decision-making capacity and identifying or arranging for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions); ? Defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, as appropriate; ? Identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions; ? Identifying situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition; ? Establishing mechanisms for documenting and communicating the resident's choices to the interdisciplinary team. ? Identifying the process (as provided by State law) for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes on the basis of conscience. In an interview with the Administrator on [DATE] at 4:00 p.m., she acknowledged she was not aware of the [DATE] revised edition of the State Operations Manual for advanced directives which included guidance for advanced care planning for residents who desire not to execute advanced directives. 1. Closed record review on [DATE] for Resident #11 shows the resident was admitted to the facility on [DATE]. The record showed a Do Not Resuscitate (DNR) signed by Resident #11 dated [DATE]. Resident #11 signed all of his admission paperwork during a previous admission of [DATE]. An "Acknowledgement of Advance Directives" form noted Resident #11 has a DNR and no advanced directives. This form is dated [DATE]. Active [DIAGNOSES REDACTED]. The resident remained in the facility receiving therapy with the intent to return to his home. He was also receiving [MEDICAL CONDITION] treatments for [MEDICAL CONDITION]. Review of the comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] shows Resident #11 with a Brief Interview for Mental Status(BIMS) of "10." (The BIMS is a screening assessment of the resident's cognitive ability. The score ranges between ,[DATE]. The higher the score reflects a higher level of cognitive functioning of the resident.) Resident #11 is documented to have an "acute onset mental status change" and feeling depressed. Resident #11 requires extensive assistance with activities of daily living. Review of the cognitive loss/dementia worksheet associated with this MDS notes Resident #11 with a moderate impairment in cognition. The SW documented the resident with short term memory losses with forgetfulness and confusion and elected to proceed to care plan Resident #11's cognition. Review of nursing notes dated [DATE] at 6:00 p.m., documented the following: "Resident and wife notified this nurse of the decision not to continue any [MEDICAL CONDITION] tx, but will continue chem(o) therapy ARNP notified. MSG (message) left for (oncology facility) at the answering service." In an interview with the Administrator on [DATE] at 3:30 p.m., she acknowledged Resident #11 signed his admission paperwork on [DATE] and the acknowledgement of Advanced Directives on [DATE]. She said Resident #11 was at the facility before and it is the policy of the facility to carry admission paperwork forward in the event a resident returns to the facility within 30 days. She confirmed Resident #11's return was not anticipated. The Administrator said the Social Worker (SW) was supposed to re-review the Advanced Directives with Resident #11 and document whether there were any changes in the advanced directives. Review of the SW/Psychosocial Data Collection and Evaluation tool dated [DATE] notes Resident #11 with an eighth grade education and support network includes a wife and 2 sons. No family issues were identified. The SW documents Resident #11 with intact short and long term memory. (This conflicts with the attending physician's assessment of Resident #11 "not being a very good historian and the review of systems was really unreliable" on the same date.) The SW documented Resident #11 was admitted for short term rehabilitation to achieve his goal of returning home with his wife and resident rights and advance directives were reviewed. The SW did not clarify or document what advanced directives were reviewed during the [DATE] admission or whether there were any changes to his advanced directives in-between the [DATE] admission and recent admission to the facility on [DATE]. In an interview with the SW on [DATE] at 3:30 p.m., she said her "review" meant asking what advanced directives the resident had, documenting what he had, and if he wanted any others such as a health care surrogate or living will. She said Resident #11 told her he had a living will but didn't bring it with him. The SW did not ask about the content of the living will. She did not ask Resident #11 if he wanted to complete a new living will on this recent admission. The SW said she asked Resident #11's wife to bring the living will in to the facility and she said she would. The SW said at the time of the [DATE] admission, Resident #11 did not want to designate a Health Care Surrogate (HCS). The SW admitted she did not explain the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. She admitted she did not explain the risks of failing to designate a HCS to Resident #11's wife or son(s). In an interview with the SW on [DATE] at 4:30 p.m., she said during care plan meetings, there is a form that is completed when advanced directives are reviewed. She showed a form which includes "checkboxes" for advance directive preferences. The form shows a conflicting check marks in the boxes showing Resident #11 with a living will and also checked he does not want a living will. The form also shows check marks in the boxes indicating Resident #11 does not want a Durable Power of Attorney (DPOA) for Health care and Financial Authority or Health Care Surrogate. The record failed to show whether or not the resident chose to execute an advance directive, discussion and documentation of the resident's choices regarding future health care during the development of the initial comprehensive assessment and care plan. During the same interview, the SW said the wife never brought in Resident #11's living will. She acknowledged the review of Resident #11's care plan related to short term memory deficits, forgetfulness and confusion. She acknowledged the Speech Language Pathologist's plan of care relate moderate impairment in cognition related to multi-step daily living sequencing and problem solving and safety awareness. In spite of these identified deficits in cognition, the SW admitted neither she nor the care plan team explained the risks associated with failing to designate a HCS to Resident #11 in the event he could not speak for himself. She admitted she did not explain or provide education related to the risks of Resident #11 failing to designate a HCS to Resident #11's wife or son(s). The SW acknowledged, despite identified problems related to Resident #11's cognition, there was no documentation by the physician or Advanced Registered Nurse Practitioner (ARNP) of whether Resident #11 was capable of making independent healthcare decisions. The record failed to show Resident #11's capacity to make healthcare decisions was re-evaluated. The record failed to show Resident #11, his wife or son(s) were asked where Resident #11's living will was located or whether they were re-educated about the risks associated with Resident #11's lack of planning for future healthcare in the event he could not speak for himself. At 5:01 p.m. on [DATE], the hospice nurse documents, "...return visit to attend meeting with staff and pt (patient) spouse to discuss pt status and hospice services. Spouse in agreement with hospice services but states that pt may want his son, (named), to make decisions. Spouse, our SW and myself went to pt room to discuss with pt. Pt does say he wants his son to make decisions and he will do what his son wishes. States that if his son wants him to continue aggressive treatment he will agree. No one knew until today that pt wanted his son involved in decision making...informed her not to send in admit nurse yet until we speak with pt son to be sure if son and pt. are still willing to have hospice services." No other notes by SW until [DATE] which documents: "Quarterly Assessment and care plan meeting. (Resident #11) is declining related to his CA (cancer) dx (diagnosis). He has been referred to Hospice and they are to have a meeting with Hospice today ([DATE]). Discharge plans changed and now long term care. [MEDICATION NAME] for depression. Resident rights and advanced directives reviewed." Review of the advanced directive review form dated [DATE] completed during the care plan meeting showed Resident #11's wife indicated her husband did not want a Durable Power of Attorney (DPOA) for Health Care or Financial Authority and did not want a Health Care Surrogate. In an interview with the SW on [DATE] at 4:30 p.m., she said Resident #11's wife was not officially determined to be the decision maker for her husband, therefore, should not have signed; Resident #11 did not want a health care surrogate or DPOA for health care or finances. She said she did not go back and visit with Resident #11 because she stayed behind to attend other care plan meetings. She said what she meant when she documented her "review" of advanced directives during the care plan meeting was what Resident #11 currently had in place. She acknowledged Resident #11's living will was never brought in to the facility. She admitted neither she nor the interdisciplinary team went back to re-assess Resident #11's decision for hospitalization , son's involvement in decision making process, or educate Resident #11 or his wife related to the risks involving lack of directives for future healthcare. She said Resident #11's capacity to make decisions was not re-evaluated and no one called Resident #11's son. In an interview with the hospice nurse on [DATE] at 2:12 p.m., she said she made late entries in her notes. She said she received a call from the facility and came to the facility approximately late morning. She spoke with the nursing staff to find out what was going on and was informed of Resident #11's desire to stop tx's. What she had to decide was who was making decisions. At that time, Resident #11 was alert and oriented and when she saw Resident #11, he was doing quite well. He had some difficulty speaking. She wanted to make sure he was capable of making his decisions. She said Resident #11 was tired and quite weak. She said the wife was listed as the responsible party on the face sheet and Resident #11 said he wanted his wife involved. She agreed to whatever her husband wanted. The hospice nurse said they had a care plan meeting. During the care plan meeting, the wife mentioned he had a son. The hospice nurse stated, "I got a funny feeling (Resident #11's wife) didn't want to be involved. That she agreed to whatever the son wanted." They went back to Resident #11's room and he said he wanted his son's involvement and he would do whatever his son wanted. If his son would want aggressive treatment, he would go through with it. The hospice nurse said she went back to the care plan meeting room where the MDS Coordinator and SW were and informed them Resident #11 wanted his son contacted and his son involved. The clinical record failed to reveal Resident #11's son was called related to Resident #11's choice to designate him as decision maker and involve the son in assisting Resident #11 with his reconsideration of going forward with aggressive therapy or with holding aggressive treatment. There was no documented evidence Resident #11 was asked if he wanted to go to the hospital for treatment since he was reconsidering aggressive therapy. In spite of Resident #11's low oxygen saturation levels in conjunction with his reconsideration for his son's involvement for decision making, there was no re-assessment by facility staff or by the MD of Resident #11's capacity to make healthcare decisions. In an interview on [DATE] at 9:30 a.m., Resident #11's wife said it was never fully explained to her about her husband's deteriorating condition that began at 8 a.m. on [DATE] and lasted 10 hours through 5:45 p.m. She stated, "I had no clue. Only that he was now on oxygen. Did not get phone call from ARNP or Doctor." She said she walked into her husband's room at about 1:00 p.m. on [DATE] to find him on oxygen, which was something new, and no one told her why. She said all she knew was her husband was thinking about stopping his chemo and [MEDICAL CONDITION]. Her husband didn't say anything to her about no hospitalization . He did say he wanted to see what Hospice was about so they invited hospice to the careplan meeting. Her husband didn't want to go because he wasn't up for it. So, they explained what Hospice was about in his room. Then at the careplan meeting at 2:10 p.m., after they explained Hospice services, she didn't feel comfortable making decisions as her husband was always in control. She told them (care plan team) his son should be involved with decision making and she would go along with whatever her husband wanted. Since her husband wanted the son to make decisions, she went along with that. She said staff knew this at the careplan meeting. She stated, "After they found out about his son, they laughed. I didn't like that." She said her husband wanted to talk with his son as he thought if his son wanted him to go for treatments, he would go. No one ever asked her for his son's phone number. She said after the careplan meeting, she went home. The next thing she knew, 4 hours later, she was getting a call that (Resident #11) was dying and was asked if she wanted her husband to go to the hospital. She said she told the facility not to send her husband to the hospital. She stated, "What else was I supposed to do at that point?" She confirmed she spoke with Resident #11's son later who informed her, he never received a call to update him to his father's condition prior to or after his death. In an interview on [DATE] at 11:30 a.m., Resident #11's son said no one ever called him about his father's condition. He said it was never fully explained to his mother that his father started to deteriorate the morning of [DATE]. He said no one ever called him to tell him his father wanted him to make decisions. No one called him after his father died . He said they talked to him in the past when he converted from Medicare so he didn't know why he wasn't called about his father's condition. His stepmother did inform him that she told staff in the care plan meeting that afternoon that he should be involved in decision making. No one called him after his father died . He said he never heard anything from the MD or ARNP. He said, "The whole thing was handled poorly." In an interview with the Administrator on [DATE] at 1:55 p.m., she said she was unaware there was an issue with Resident #11's advanced directives. She said the facility does not review unexpected deaths that occur in the facility. She verified she had not known Resident #11 wanted his son to make health care decisions for him, and that the resident's son was not notified of the resident's wishes. She said she only became aware of this when it was brought to her attention during the survey. She verified the current policy in place did not include guidance to ensure advanced care planning for residents who desire not to execute advanced directives. On [DATE] at 10:30 a.m., the Administrator provided revised polices regarding advanced directives and change in resident condition. 2. During an observation and interview on [DATE] at 10:05 a.m., Resident #55 said people have been stealing things from her since she's been at the facility for the past 2 years. Resident #55 was confused and could not provide specific details related to what she felt was actually stolen or missing. She named a staff member who she reported these concerns to and said no one has done anything about it. In an interview on [DATE] at 9:39 a.m., Staff F, who is the primary nurse, said Resident #55 is not totally oriented and lives in the past a lot. Staff F stated, "(Resident #55) has days where she is totally with it and days where she's not." Staff F said there is no one in the facility by the name of whom Resident #55 said she reported the missing items to. Record review on [DATE] showed Resident #55 was readmitted to facility [DATE] with [DIAGNOSES REDACTED]. Review of the history and physical dated [DATE] includes, "...(resident) comments unreliable due to dementia, cognitive impairment or other state...History obtained by staff or family member." Review of the Minimum Data Sets (MDSs) with Assessment Reference Dates (ARDs) of [DATE], [DATE], [DATE], [DATE] noted Resident #55 with a BIMS (Brief Interview for Mental Status) of "6" and with altered level of consciousness where her behavior was continuously present and did not fluctuate. The BIMS is a screening tool that evaluates a resident's cognitive functioning. The score ranges between "00" (not able to participate) to "15" (high level of functioning). Review of the most recent MDS noted a quarterly assessment with an ARD of [DATE]. A BIMS of "8" is documented and Resident #55 remains with an altered level of consciousness. Review of the resident record showed nurses documented Resident #55's son as the Power of Attorney (POA). Review of the demographic sheet in the front of Resident #55's record refers to her son as the POA. In an interview on [DATE] at 12:00 p.m., Resident #55 was asked who helps her with decision making. Resident #55 looked up to the ceiling and said, "I think it's my brother. No, wait a minute, he's dead, I think it's his daughter." She then rubbed her head and said, "Honey, I'm not sure at this point." In an interview on [DATE] at 11:17 a.m., the Social Worker (SW) said Resident #55 is her own health care decision maker. The SW said Resident #55 defers to her son "a lot", and he is not the POA nor is he listed as the health care surrogate but is the responsible party in the event something should happen to Resident #55. The SW said Resident #55 did not want any other advanced directives in place other than a do not resuscitate. The SW was asked whether the resident had the capacity to understand what advanced directives were and the SW said yes. The SW confirmed Resident #55's capacity to make appropriate health care decisions was never evaluated by the attending physician in spite of her altered level of consciousness and BIMS of "6" and "8" on the MDS. In an interview on [DATE] at 11:45 a.m., the assistant director of nurses stated, "How would she (Resident #55) even have the capacity to know what an Advanced Directive is?" 3. A review of the medical record for Resident #148 found that on the annual MDS dated [DATE] and on the most recent MDS the resident scored 14 on the BIMS. The score of 14 indicates the resident has a high level of understanding and decision making ability. The resident makes his own decisions and signs his own consents. The resident signed the admission agreement and the form stating he was informed of and given written information about "Advance Directives." The medical record contains a Do Not Resuscitate Order (DNRO) signed by the resident upon admission to the facility on [DATE] but no other advance directive documents. The monthly Physician order [REDACTED]." The report of the quarterly care plan meeting held on [DATE] documents Resident #148 was in attendance. The Advance Directives review form for [DATE] shows the resident has signed a DNRO. The sections for Living Will, Durable Power of Attorney for Health Care Authority, and Health Care Surrogate are not filled in. The Social Services Notes regarding the care plan meeting states: Resident Rights and Advance Directives reviewed." The notes do not document the resident was informed of the consequences of not having advance directives. In an interview on [DATE] at 3:45 p.m., when asked if he has designated anyone to have power of attorney (POA) or as a health care surrogate, Resident #148 said: "I think either my brother or daughter I do not know for sure." "I did sign a DNRO." Asked if he knows about end of life decisions and who would make decisions if he is not able, the resident expressed his faith saying he believes the right decision would be made. The resident did not recall that there is an order not to hospitalize and was not sure what that meant. The resident says he does not recall going over advance directives at the care plan meeting on [DATE]. In an interview on [DATE] at 3:50 p.m., the SW, stated another social worker attended the care plan meeting with Resident #148. She said the social worker goes over the documents the facility has in the way of advance directives and advises the residents they can assist with the other tools (POA, Health Care Surrogate, and etc.). The SW said at each quarterly care plan meeting a form is checked off indicating which advance directives have been completed or submitted by the resident. The SW acknowledged there is no discussion about advance directives unless initiated by the resident. A review of social services notes dated [DATE] at 10:30 a.m., finds the SW queried Resident #148 on [DATE] about acceptance of the physician's do not hospitalize order. The social services note states: "The resident was in agreement of these orders." The note does not document that the ramification of the order was explained to the resident. There is no clarification of who is designated to make decisions in the case of incapacity or that the subject was discussed. During an interview with the administrator on [DATE] at 1:55 p.m., she verified she was not aware there was an issue regarding advanced directives in the facility. She said she only became aware of this when it was brought to her attention during the survey. On [DATE] at 9:20 a.m., an interview was conducted with the risk manager regarding QA. She verified there had previously been no Quality Assurance for advanced directives or significant changes in condition. She said in the future she would be auditing every unexpected death in the facility and reviewing the charts for Quality Assurance. On [DATE] at 10:30 a.m., the administrator provided revised polices regarding advanced directives, and significant change in resident condition. She stated an emergency quality assurance meeting was taking place at 12:00 p.m., to review the revised polices. In an interview with the social service director on [DATE] at 5:10 p.m., she said she had reviewed the advanced directives of all the residents in the facility. She said the facility had identified 4 more residents (Resident #86, #113, #114, and #154) that needed to have decisions made regarding advanced directives. The Immediate Jeopardy was removed on [DATE] at 5:50 p.m., and citation F520 (reduced from K to E) based upon the implementation of the following corrective actions taken by the facility: Reviewed and amended policies on advance directives to meet the current regulatory requirements; reviewed all residents capacity to make decisions regarding advanced directives; reviewed residents to determine if have someone appointed as decision maker in event the resident is unable to do so and provide education to resident on the risks of having no decision maker delegated; reviewed resident records for advance care planning in regards to advance directives; teach and implement new change in condition form and documentation standards; educate nurses on policy and need to involve RN and/or charge nurse on any resident change in condition. The facility had not revised their Advanced Directive Policy and completed training for nurses, social services and managers. Had not completed screening for all residents including physician determination of capacity as needed. Quality Assurance monitoring had not been implemented.