Every finding on record at Surrey Place Healthcare and Rehabilitation

Based on observations, record review, and interviews, the facility failed to 1. Ensure staff who worked in the kitchen initiated proper hand hygiene in between and after touching soiled dishes and before touching clean dishes in the dish machine room, during two of four days observed (3/10/2025 and 3/12/2025), and 2. failed to follow proper food safety and storage procedures for one resident (Resident # 14) of eight residents sampled. Findings included: 1. On 3/10/2025 at 9:29 a.m., the facility's kitchen was entered and toured with Staff A, Dietary Manager. Staff A, Dietary Manager confirmed they operate a low temperature dish washing machine and pointed out the machine in the front right corner of the kitchen. The dish machine area appeared with a large mechanical dish washing machine with a metal table and table chute on the right side, which was used for soiled dishes and prerinse prior to dishes going into the dish washing machine. The left side of the machine was observed with a metal table and metal chute where clean crates of dishes went after coming out of the dish washing machine. Staff B, Dietary Aide (DA) and Staff C, DA were operating the dish washing machine. Staff B, DA and Staff C, DA were both on the right side/soiled side of the machine and were placing soiled breakfast trays, dishes, cups, bowls, or eating/dining ware that came from tray carts onto the metal table chute to be pushed over to the prerinse area. Staff B, DA was observed at the prerinse station area wearing blue plastic gloves. She was observed handling soiled eating/dining ware with her hands and was using a rinse hose to rinse off large debris from the various eating/dining ware. Staff C, DA continued to take soiled eating/dining ware from tray carts and pushed them down the metal chute towards Staff B, DA for prerinsing. At 9:31 a.m. Staff B, DA, after prerinsing soiled eating and dining ware, immediately placed the eating/dining ware into plastic crates and pushed the crate of soiled eating/dining ware into the soiled side of the machine and closed the door with her gloved hands. Staff B, DA continued to receive soiled eating/dining ware from the metal table chute and prerinsed with the hose. After the dish washing machine ran its wash and rinse cycle, Staff B, DA walked over to the left side/clean side of the machine, opened the door, and pulled out the crate full of clean and sanitized eating/dining ware with her gloved hands. Staff B, DA did not remove her gloves or wash/sanitize her hands after handling soiled eating/dining ware and before handling clean and sanitized eating/dining ware. At 9:33 a.m. Staff B, DA stated the type of dish washing machine the facility used was a high temperature dish washing machine, but she was not able to state what temperatures the wash and rinse cycles get to. She then stated, I think the wash needs to get to 150 degrees [Fahrenheit] She was unsure what the rinse cycle temperature should reach. Staff B, DA confirmed there was a chemical sanitizer and they test the clean dishes with a test strip to see if there is enough sanitizer getting through the machine and onto the eating/dining ware. She was asked if she was sure the machine was a high temperature dish washing machine. Staff B, DA could not answer and then got a verbal cue from the Staff A, Dietary Manager that the machine was a low temperature, chemical sanitizing dish washing machine. Staff B, DA demonstrated the use and operation of the low temperature dish washing machine at 9:35 a.m. Staff C, DA stood back in the right side/soiled side of the machine and continued to place soiled eating/dining ware from the tray carts and on to the metal table chute. Staff B, DA immediately put on blue plastic gloves, was not observed to wash her hands prior to, and started to prerinse soiled plastic trays with the hose. She placed prerinsed trays into a plastic crate and ran the crate of soiled eating/dining ware into the soiled side of the dish washing machine. After the machine ran its wash and rinse cycle, Staff B, DA opened the door to the dish washing machine and pushed the crate of cleaned and sanitized dishes through to the left side/clean side of the machine with her gloved hands. She walked over to the left side/clean side of the machine and retrieved the crate of cleaned and sanitized eating/dining ware with her gloved hands and began to take a new chemical sanitizer test strip and placed it on one of the trays in the crate. Staff B, DA never removed her gloves or washed her hands after handling the soiled eating/dining ware and prior to handling the clean and sanitized eating/dining ware. Staff B, DA could not get a reading from the test strip, so she walked over to the right side/soiled side of the dish washing machine area and pushed through another crate of soiled eating/dining ware into the machine. While the dish washing machine was running its cycle, Staff B, DA stood near the machine to wait for the cycle to be finished. Once the wash and sanitize cycle was completed, Staff B, DA was observed walking over to the left side/clean side of the machine and retrieved the clean crate of eating/dining ware with her gloved hands and began to conduct another chemical sanitizer test with a new test strip. Staff B, DA did not remove her soiled gloves or wash her hands after handling soiled eating/dining ware. Staff B, DA was observed retrieving soiled eating/dining ware from the soiled side of the dish machine, prerinsed the eating/dining ware, placed the soiled eating/dining ware in empty crates, sent the soiled eating/dining ware through the machine to be clean and sanitized, received the clean eating/dining ware from the clean side of the machine, and handled the clean and sanitized eating/dining ware with her unchanged and unwashed hands four more times before the surveyor left the area. During most of the observation from 9:31 a.m. through to approximately 9:42 a.m., the Staff A, Dietary Manager was in the kitchen's dish washing machine room observing the operation from both Staff B, DA and Staff C, DA. Staff A, Dietary Manager did not intervene to ensure Staff B, DA washed her hands after handling soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. On 3/12/2025 at 1:43 p.m. an observation was conducted in the facility kitchen with Staff D, DA and Staff B, DA, who were observed in the dish washing machine area and were both on the right side/soiled side of the dish machine. Staff B, DA was observed taking soiled dishes, trays, cups, bowls, or eating/dining ware from received tray carts and placed the eating/dining ware on the metal table chute. She was observed pushing the eating/dining ware down the metal chute to the prerinse station where Staff D, DA was. Staff D, DA was observed with her bare hands taking a rinsing hose and was prerinsing the soiled eating/dining ware and placed the eating/dining ware in empty plastic crates to be ran through the dish washing machine. At 1:45 p.m., Staff D, DA was observed pushing a full plastic crate of eating/dining ware into the soiled side of the dish machine with her bare hands and closed the dish washing machine door for it to run its clean and sanitizer cycle. Once the machine finished its cycle, Staff D, DA walked over to the left side of the dish washing machine, opened the door, and pulled the clean and sanitized crate of eating/dining ware out and to the clean table area. Staff D, DA did not wash her hands or don gloves after handing soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. At 1:47 p.m., Staff B, DA continued to place soiled eating/dining ware on the soiled side of the dish machine table chute and Staff D, DA continued to retrieve the soiled eating ware, prerinse them, and set them in a plastic crate to be ran through the dish washing machine. Staff D, DA walked over to the left side/clean side of the dish washing machine and retrieved clean and sanitized crates of eating/dining ware with her bare hands. She was not observed to donning gloves or washing her hands after handling soiled eating/dining ware or prior to receiving and handling clean and sanitized crates of eating/dining ware. Staff D, DA continued to handle and feed crates of soiled eating/dining ware through the soiled side of the machine and received and handled crates of clean and sanitized eating/dining ware with her bare unwashed hands for four more dishwashing cycles. In between and while the dish washing machine was in cycle, Staff D, DA took plates from an already clean and sanitized crate and stacked them in her hands and arms and brought them to a metal plate holder. She did this process three times and without washing her hands after touching and handling soiled eating/dining ware and prior to touching the clean and sanitized plates. The plates were stored in a manner as if ready to use for residents at the next meal/dining service. On 3/13/2025 at 10:45 a.m., and while in the facility's kitchen, the Staff A, Dietary Manager was interviewed with relation to the dish washing process. Staff A, Dietary Manager revealed the dish machine area is composed of two sides, one soiled side on the right and one clean side on the left. Staff A, Dietary Manager revealed typically there are two staff members in the dish washing machine area. One staff member handles the soiled dishes and runs the eating/dining ware through the soiled side of the machine while another staff member works on the clean side of the machine and receives/handles only clean and sanitized eating/dining ware that came through the machine. Staff A, Dietary Manager explained there are times when she is in the dish washing machine area assisting with cleaning dishes and she will usually be on the clean side, not the soiled side. She revealed she would only be handling clean and sanitized eating/dining ware. She also confirmed if she touches or handles soiled eating/dining ware with her bare hands or gloved hands, she would remove her gloves and wash her hands, or wash her hands if she is not gloved, prior to handling clean and sanitized eating/dining ware after they come out from the dish washing machine. Staff A revealed that she saw a lack of handwashing when handling soiled eating/dining ware and during the handling of clean and sanitized eating/dining ware during the observation of Staff B, DA and Staff C, DA on 3/10/2025. On 3/13/2025 the Dietary Manager provided an undated policy titled Dishwashing Machine, which revealed: Policy: The facility will maintain dishwashing machine in a clean condition to minimize the risk of food hazards. Dish washing machines will be cleaned three times a day after each meal. Procedure: 1. Turn the dishwashing machine on. 2. Open drain valves. 3. Remove scrap trays. 4. Spray scrap trays over garbage. 5. Spray down the inside of the dishwashing machine. 6. Scrub stains inside dishwashing machine and on outside drains using an abrasive pad soaked in warm water and detergent and de-staining solution. 7. Wash the outside of the dishwashing machine and hood with a clean cloth soaked in detergent solution. 8. Wipe down with an approved sanitizing solution. 9. Wipe with clean dampened cloth. The Dietary Manager also provided an undated policy titled Hand Washing, which revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Dietary employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing Stations a. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently. c. Make sure all hand-washing stations are equipped with the following: i. Hot and cold running water. ii. Hand cleaning liquid, powder or bar soap. iii. Individual, disposable towels, a continuous towel system that supplies the use with a clean towel or a heated - air hand-drying device. iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. 2. Hands should be washed after the following occurrences: a. Using the Restroom. b. Handling raw food (before and after). c. Touching the hair, face, or body. d. Sneezing or coughing. e. Smoking. f. Eating or drinking. g. Handling chemicals. h. Taking out garbage. i. Clearing tables. j. Touching clothing or aprons. k. Touching un-sanitized equipment, work surfaces, or wash cloths. 46498 2. On 3/10/2025 at 9:24 AM and on 3/11/2025 at 3:00 PM, Resident # 14 was observed lying down on her bed dressed in her night gown. She was observed with rotten fruit left on her bedside table for two days. An interview was conducted following the observation with Resident # 14, who stated she was going to eat the fruit later. Review of an Admission Record showed Resident # 14 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia in other diseases classified elsewhere, mild, with other behavioral disturbance and anxiety disorder, unspecified Review of a Quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. During an interview on 3/13/2025 at 10:00 AM with the Director of Nursing (DON), the DON stated Resident #14 is difficult and she doesn't let the staff take away her food. The DON also stated the resident's husband brings her food from time to time. The DON stated Resident # 14 has had a recent decline and she's assuming the resident did not want the staff to remove the fruit from her room. The DON stated if the resident refused to discard the rotten fruit, they should have reported the behaviors to the nurse or to her. The DON stated her expectations are residents' bedside tables should be cleaned off and old food should be discarded. Review of the facility policy titled Storage of Foods Brought to Residents by Family/Visitors showed: Policy Statement: Staff must be aware of and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Interpretation and Implementation 7. The Nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first. 8. The nursing and/or food service staff must discard any food prepared for the residents that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates) Photographic Evidence Obtained

Based on record reviews and interviews, the facility failed to provide a bed-hold notice at the time of transfer to three (#55, #60, and #11) of three residents sampled for hospitalizations. Findings included: 1. Review of Resident #55's admission Record revealed the resident was originally admitted on [DATE]. Review of Resident #55's Nursing Notes showed on 2/2/2025 at 11:28 a.m., Resident #55 was sent to the emergency room (ER) for evaluation following an incident. Review of Resident #55's uploaded clinical documents did not include a bed-hold notice for the resident's transfer to a higher level of care on 2/2/2025. The progress notes on 2/2/2025 did not show the resident or representative was notified of the facility bed-hold notice. Review of the facility provided admission and Financial Agreement signed by Resident #55's family member and the facility's representative on 12/10/2024 described the facility's bed-hold policy. 2. Review of Resident #60's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #60's Transfer Form showed on 2/21/2025 the resident was transferred to an acute care facility due to placement of a midline. Review of Resident #60's physician order, dated 2/21/25 at 2:43 p.m. showed the facility was to send the resident to ER for re-insertion of a midline by the vascular team. Review of Resident #60's uploaded documents did not reveal a copy of a bed-hold notice given to the resident's representative on 2/21/2025 and the resident's progress notes on 2/21/2025 did not reveal documentation showing the resident or representative had been notified or had received a bed-hold notice at the time of the transfer on 2/21/2025. Review of the facility provided Bed Hold Policy revealed it was part of the admission and Financial Agreement signed by Resident #60's legal representative on 2/4/2025. During an interview on 3/12/2025 at 2:27 p.m., the Social Services Director (SSD) reported making phone calls to the families and asking if they wanted a bed-hold. The SSD reported not really documenting family notifications of bed-hold notifications. 3. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation also revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's medical record did not reveal notice of a bed-hold related to the hospital transfer on 3/4/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated residents get the bed-hold policy when they admit and they would call the residents and go over the policy if a transfer occurred. She stated she would have to talk to the Social Services Director to confirm what process she is following to document how the residents are being notified of the bed-hold process during a transfer. Review of the facility's undated policy titled Bed Hold Policy, found in the admission packet, revealed a summary of explanation will be given to the resident, legal representative, or responsible party on admission in a copy of the bed-hold policy each time the resident is transferred for hospitalization or leaves the facility on a therapeutic leave.

Based on record review and staff interviews, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASRR) screenings were accurate prior to a admission to the facility and did not follow up with a Level II PASRR screen for two residents (Resident #41 and #16) of forty-one sampled residents. Findings included: 1. On 3/10/2025 at 1:45 p.m. Resident #41 was observed in her wheelchair while therapy staff were assisting down the hallway and to the therapy gym. At 1:49 p.m. while in the gym, Resident #41 appeared anxious, but was participating in all the exercises that were presented to her. Resident #41 kept saying I just want to go home and just need to go home. On 3/12/2025 at 8:00 a.m., Resident #41 was assisted to the 300 unit nurses desk and lobby area. She was seated in her wheelchair and was awaiting a transport ride to an appointment. Resident #41 was given information that the transport van would be thirty minutes late. She then started to cry and was very anxious to get out to her doctor's appointment and then planned to return home with home health services the following day. Review of Resident #41's medical record revealed she was admitted to the facility on [DATE] for short term therapy. Review of the diagnosis sheet revealed diagnoses to include adjustment disorder with mixed anxiety and depressed mood, anxiety (added 2/12/2025), and major depression (added 2/12/2025). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns a Brief Interview Mental Status (BIMS) score 15 out of 15, which indicated Resident #41 was cognitively intact. Review of Resident #41's electronic medical record revealed a Level I PASRR screen dated 2/10/2025, completed prior to the resident's admission to the facility, and was signed by a Licensed Clinical Social Worker (LCSW) at a hospital. The screen did not identify Mental Illness/Suspected Mental Illness (MI/SMI) diagnoses to include major depression and anxiety. Further review of the electronic medical record revealed a second Level I PASRR screen dated 2/14/2025 for Resident #41. Review of the screen revealed it was completed by a Registered Nurse at the admitted facility. Review of Section I of the PASRR screen under MI/SMI diagnoses indicated diagnosis of major depression. The screen did not identify anxiety, per Resident #41's admission diagnosis. On 3/12/2025 at 1:50 p.m., an interview with the Minimum Data Set (MDS) Coordinator, who confirmed she, along with several other staff, are responsible for the assurance of Level I PASRR completion in a timely and accurate manner. The MDS Coordinator confirmed Resident #41 was admitted to the facility on [DATE] and there were two Level I PASRR screens that were scanned into the electronic record to include one on 2/10/2025, which was incorrect, and one on 2/14/2025, which was a corrected version. The MDS Coordinator confirmed Resident #41 had diagnoses of major depression and anxiety upon her admission, and the Level I PASRR screen that came from the hospital did not reflect MI/SMI diagnoses of either major depression or anxiety. She revealed this Level I PASRR was incorrect and the facility had to complete a new one. She verified the new and revised Level I PASRR screen now only reflected major depression as an MI/SMI diagnosis, but they failed to include anxiety. She revealed the corrected Level I was not correct to reflect all appropriate MI/SMI diagnoses. The Director of Nursing (DON), who was present for this interview, also confirmed the current corrected Level I PASRR screen for Resident #41 was not correct. 46498 2. Review of an Admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, severe with psychotic symptoms, and anxiety disorder, unspecified Review of the State of Resident #16's Level I PASRR screen dated 1/9/2023 showed Mental Illness diagnoses listed as anxiety disorder and depressive disorder. Review of Section IV: PASRR Screen Completion revealed: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. On 3/12/2025 at 10:00 am, an interview was conducted with the facility's MDS Coordinator, who stated the PASRRs are reviewed on admission and at the Quality-of-Care meetings to see if there was a change with a resident diagnosis. The MDS Coordinator also stated she received training on how to complete the Level II PASRR last Monday and during the training she learned a PASRR Level II is required if a resident has a serious mental illness with dementia or if the resident has an intellectual disability, or depression with behaviors that are interfering with the resident daily life. The MDS Coordinator stated she has a list of residents who's PASRR has to be redone and submitted for a Level II review and Resident # 16 is one of the residents who is on her list that require a Level II PASRR review. The MDS Coordinator stated the facility does not have a PASRR policy. On 3/12/2025 at 10:30 am, an interview was conducted with the DON. The DON stated her expectations are for the PASRR to be accurate and most of the time the PASRR is inaccurate coming in from the hospital. If the PASRR's are inaccurate, her expectations are that they correct them so the PASRR's reflect the resident accurately. The DON stated she depends on her MDS Coordinator to accurately complete the PASRR's.

2. Review of Resident #60's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #60's Transfer Form showed on 2/21/2025 the resident was transferred to an acute care facility due to placement of a midline. Review of Resident #60's physician order, dated 2/21/2025 at 2:43 p.m. showed the facility was to send the resident to ER for re-insertion of a midline by the vascular team. Review of Resident #60's Nursing Home Transfer and Discharge Notice showed the notice was given on 2/21/2025 and effective on 3/21/2025. The form showed the resident was transferred or discharged to an acute care facility due to Your needs cannot be met in this facility, and did not include a Brief explanation to support this action. The form did not include resident representative information and was signed by the resident on 2/28/2025 and showed the resident, legal guardian, or representative received the notice on 2/28/2025. Review of Resident #60's Minimum Data Set, dated [DATE] revealed the resident's Brief Interview of Mental Status score was 10, indicating moderate cognitive impairment. An interview was conducted on 3/12/2025 at 2:12 p.m. with Staff H, Licensed Practical Nurse (LPN). The staff member reported knowing what the Nursing Home Transfer and Discharge Notice was and thought Social Services completed it. An interview was conducted on 3/12/2025 at 2:27 p.m. with the Social Services Director (SSD). The SSD confirmed doing the Nursing Home Transfer and Discharge Notice, which were typically uploaded into the resident records but may still have them in the office. The SSD stated the facility attempted to complete the Nursing Home Transfer and Discharge Notice, but 9 out of 10 times the transfer/discharge was an emergency, resident was unable to sign, and family was not in the facility so we have them sign it when they come from the hospital. The SSD was able to locate both Resident #55 and Resident #60's Nursing Home Transfer and Discharge Notices on top of her desk. The SSD stated the forms are completed then when the resident comes back we get them signed. The SSD reported being aware of the allowed time frame and stated it's an emergency and mostly wait till they come back. Review of the policy titled Social Services, Notice of Transfer and/or Discharge, undated, revealed the following: Policy Statement: The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: A. The transfer just charges necessary for the residents welfare and the residence needs cannot be met in the facility; B. The transfer discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; C. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; D. The health of the individuals in the facility would otherwise be endangered; E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) and stay at the facility; or F. The first hostility ceases to operate. Policy Interpretation and Implementation: 1. Before the facility transfers or discharges a resident, the facility will notify the resident and the representative of the transfer or discharge and the reasons for the move in writing in any language and manner they understand. 5. Should the health or safety of the individuals in the facility be endangered or the health of the resident's has improved sufficiently to allow a more immediate transfer or discharge or an immediate transfer or discharge is required by the resident's urgent medical needs or the resident has not resided in the facility for 30 days, notice would be given as soon as practicable. 7. The resident, and/ or representative will be provided with the following discharge notice requirements: a. The reason for the transfer discharge; b. The effective date of the transfer discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long term care ombudsman; e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); and f. Any statement that the resident has the right to appeal to the action to the state which includes the name, address, and telephone number of the state health department agency that has designated to handle appeals and transfers and discharge notices. 8. The social service director will be responsible for preparing the form(s) and for ensuring the resident/ representative receives the forms. If it is necessary to mail the form to the representative, a self-addressed stamped envelope will be included to facilitate the return of the signed form(s). The completed forms will be filed in the residence medical record under the Social Services tab. Based on record review and interviews, the facility failed to provide notice of transfer before a facility initiated transfer to two residents (Resident #11 and #60) out of three residents sampled for hospitalization. Findings Included: 1. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's Nursing Home Transfer and Discharge Notice revealed notice was given on 3/7/2025 with an effective date of 3/4/2025. The notice showed Resident #11 was transferred to an acute care facility, with a documented reason, Your needs cannot be met in this facility. The notice revealed the Social Service Director (SSD) signed the notice on 3/7/2025 and Resident #11 signed the form on 3/7/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated if a resident leaves the facility to go to a hospital it is typically an emergency, so she's not sure how the resident would sign the Nursing Home Transfer and Discharge Notice, which is why they would wait for the resident to return or would mail the form to the resident for their signature.

Based on observations, interviews, and record review, the facility failed to provide catheter care and services to prevent injuries and infections for two residents (#123 and #124) of nine sampled residents who utilized indwelling catheters, during two of four days observed (3/10/2025 and 3/12/2025). Findings included: 1. On 3/10/2025 at 10:25 a.m., Resident #123's room door was observed open from the main hallway. She was observed in her room seated in her wheelchair and being visited by a family member. Resident #123 was utilizing an indwelling catheter. From the hallway, the resident was observed with the catheter bag and tubing hanging directly below the seat of the wheelchair and with the bag and approximately two inches of catheter tubing on the floor. Resident #123 was observed scooting back and forth slowly while seated in her wheelchair with the catheter tubing and bag dragging on the floor. Review of Resident #123's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 2/27/2025. Review of the diagnosis sheet revealed diagnoses to include but not limited to retention of urine and neuromuscular dysfunction of bladder. Review of the current Order Summary Report for the month 3/2025, revealed the following orders for Resident #123: - Urinary Catheter Indwelling catheter size 14FR (French) with balloon size 30cc (cubic centimeters) to beside drainage bag for dx. (diagnosis) Urinary Retention - every shift related to Retention of the urine, order date 3/3/2025. A review of the current care plans with a next review date of 6/9/2025, revealed the following areas: 1. Impaired cognitive function/dementia or impaired thought process r/t (related to) BIMS (Brief Interview for Mental Status) score of 11, periods of confusion, with interventions in place as reviewed. 2. Incontinent of Urine. She has a catheter due to urinary retention and is at risk for UTI (urinary tract infection), 3/11/2025 bladder toning as ordered, with interventions to include: Observe for signs and symptoms of discomfort on urination and frequency, Catheter care as ordered, Cover drainage bag for privacy. On 3/13/2025 at 8:05 a.m., an interview was conducted with Resident #123's nurse, Staff E, Registered Nurse (RN). Staff E, RN confirmed she knew of Resident #123 and had her on her assignment since her admission. Staff E, RN also confirmed Resident #123 utilized an indwelling catheter and Resident #123 was discontinued with it yesterday on 3/12/2025. Staff E, RN said prior to the catheter being discontinued, Resident #123 utilized it at all times to include when in bed and when she is seated in her wheelchair. Staff E, RN stated when Resident #123, or any resident who utilizes an indwelling catheter, the catheter bag should be placed in a position that is off the floor and the tubing leading from the bag to the resident should be off the floor. Staff E, RN further revealed nursing staff who observe catheter bags positioned on the floor are to reposition the bag. Therapy staff can also reposition the bag and any other non-nursing staff can report the observation to nursing staff immediately. Staff E, RN confirmed catheter bag and tubing lying on the floor can present with an accident/tripping hazard, can present a risk for pulling out the tubing, and can present as an infection risk. Staff E, RN also confirmed Resident #123 does at times slowly self-propel by herself while seated in her wheelchair and she was unaware Resident #123 had her catheter bag on the floor and had tubing on the floor from excessive tension. 2. On 3/10/2025 at 12:01 p.m., Resident #124's room was approached and the door was open. From the hallway, Resident #124 was seen in her room while seated next to her bed and in a wheelchair. Resident #124 was utilizing a an indwelling catheter. The bag for the catheter was observed hanging below the seat of the wheelchair with a portion of the bag touching the floor. There were liquid contents in the bag during this observed time. The tubing to the catheter, leading from the bag to the resident, was also observed touching the floor with approximately three inches on the floor. The tubing on the floor in excess tension was observed touching the front right wheel of the wheelchair. Resident #124 was observed moving back and forth slowly with either her foot or the front wheelchair tire touching the tubing. The resident was observed with two visitors and one of the visitors repositioned the wheelchair so the resident could be facing towards them. When the visitor was repositioning the resident in the wheelchair, the tires were observed to touch and partially ran over the catheter tubing. The resident's visitor was not aware of the catheter bag and tubing on the floor when repositioning Resident #124. On 3/12/2025 at 7:20 a.m. Resident #124's room was approached and she was noted in her room, dressed for the day, and seated in her wheelchair. The residents catheter bag was touching the floor and about three inches of the catheter tubing was positioned on the floor. On 3/12/2025 at 12:00 p.m. Resident #124 was observed seated in her wheelchair next to her bed, resting with her eyes closed. The resident's catheter tubing was in excess tension with approximately two inches of the tubing on the floor. The tubing had yellow liquid contents. Review of Resident #124's medical record revealed she was admitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include chronic kidney disease, history of urinary tract infection, and obstructive and reflux uropathy. Review of Resident #124's current Order Summary Report for the month 3/2025 revealed the following orders: - Urinary Catheter Indwelling catheter size 14 fr. with balloon size 30cc for dx. urinary retention, x (every) shift related to Chronic kidney disease, order date 2/15/2025). - Check placement of catheter leg strap every shift for anchoring of catheter and tubing. Review of Resident #124's current care plans with a next review date of 5/26/2025 revealed the following areas: 1. Has history of urinary retention. Was being straight catheter intermittently and upon readmission now has an indwellling catheter. She is at risk for UTI, with interventions in place to include: Check placement of catheter leg strap every shift for anchoring of catheter and tubing, Cover drainage bag for privacy. On 3/13/2025 at 8:05 a.m., an interview was conducted with Resident #124's nurse, Staff E, RN. Staff E, RN confirmed she knew of Resident #124 and had her on her assignment since her admission. Staff E, RN also confirmed Resident #124 utilized an indwelling catheter, and that Resident #124 utilizes it at all times to include when in bed and when she is seated in her wheelchair, which is most of the day. Staff E, RN confirmed Resident #124 does at times slowly self-propel by herself while seated in her wheelchair and she was unaware there were times Resident #124 had her catheter bag on the floor with the tubing on the floor from in excess tension. On 3/13/2025 at 8:35 a.m., an interview with Staff F, Certified Nursing Assistants (CNA) and Staff G, CNA. Both confirmed they had Residents #123 and #124 on their routine work assignments. Both confirmed Resident #124 currently utilized an indwelling catheter and Resident #123 was utilizing an indwelling catheter until 3/12/2024, where it was discontinued. Staff F, CNA and Staff G, CNA both confirmed they observed both residents with portions of the catheter bag and tubing on the floor, especially when seated in a wheelchair. Staff F, CNA and Staff G, CNA also both confirmed if they see the tubing or bag on the floor, they can either reposition the bag and tubing up off the floor or they can get a nurse to reposition it, depending on the situation and how far the tubing was out and in excess tension. Staff F, CNA and Staff G, CNA revealed they find at times when either of the residents return from therapy, they find portions of the tubing on the floor and sometimes a portion of the bag on the floor. Staff F, CNA and Staff G, CNA also revealed Therapy staff are able to reposition the tubing and bag up off the floor, but sometimes they don't. Staff F, CNA sated she has reported to her nurse of instances where she found residents returned from therapy and with portions of the tubing and bag on the bare floor. Staff F, CNA and Staff G, CNA revealed Resident #124 has confusion and will sometimes try to stand up when she is seated in her wheelchair, and the tubing will become in excess tension. On 3/13/2025 at 1:20 p.m., an interview with the Physical Therapy Director revealed she and her staff, when assisting with residents and who utilize indwelling catheters, will first ensure the catheter bag and tubing are properly positioned up off the floor and with tubing free from excessive tension. She revealed they monitor the placement of the tubing and catheter bag when conducting a therapy session and if the catheter and tubing need to be repositioned, she and her staff will reposition immediately. The Physical Therapy Director also revealed she and her therapy staff will ensure the catheter and tubing are positioned appropriately and safety upon assisting the resident back to their room. She was not aware Resident #123 and #124 had catheter bags and tubing that were touching and laying on the floor. On 3/13/2025 at 10:30 a.m., the Director of Nursing (DON) provided the Catheters, Suprapubic-care of policy and procedure for review. The policy did not have a review date and revealed the following: Purpose; To provide safe and proper care of the resident with an indwelling urinary catheter, and to minimize the risk of bladder infection. Procedure: 1. Verify physician's order for catheter care. 2. Identify resident, explain procedure, and provide privacy. 7. Secure catheter tubing with a catheter strap to the inner aspect of the female thigh. 8. Position the drainage bag below the level of the resident's bladder. Secure to the bed or wheelchair in such a manner that neither the bag nor the spigot touches the floor. Coil excess tubing on bed verifying that there are no obstructions or kinks in tubing.

Based on observations, record review, and interviews, the facility failed to accurately document in the clinical record for one resident (Resident #60) of forty-one sampled residents related to a physical assessment completed during a time the resident was not in the facility. Findings included: An observation on 3/11/25 at 8:31 a.m. revealed Resident #60 was sitting up in bed with a meal in front of her. The resident did not appear to be in visible distress. Review of a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer form showed the resident was transferred to an acute care facility on 2/21/25 for a midline placement by the vascular team. Review of a physician order written on 2/21/25 at 2:43 p.m. instructed staff to send Resident #60 to the emergency room (ER) for re-insertion of midline by vascular team. Review of Resident #60's payor source information showed the facility stop billing on 2/21/25 and the resident became active on 2/27/25. Review of Resident #60's Daily Medicare A/Managed Care Nursing Note dated 2/22/25 at 7:07 p.m. revealed a temperature reading from 2/19/25, a pulse from 2/2/25, and blood pressure and respiration readings from 2/20/25. The note showed the resident was alert & oriented to person, there were no changes in the resident's mood and behavior patterns, the resident was incontinent of bladder, and the urine was clear with a normal odor. The resident was incontinent of bowel with an ileostomy. The resident's lung sounds were Within Normal Limits (WNL) and respiratory effort was normal. The resident had a regular heart rate and peripheral pulses were palpable. The residents' pupils were equal, round and reactive to light and accommodation (PERRLA), the hearing was adequate, and speech was clear and appropriate. The resident's pain measurement was shown as a smiling face revealing the scale of No Hurt. The resident was noted to have no new changes to skin integrity and no wound infection. The note did not reveal if the resident was on any isolation/precautions. The note showed the resident was receiving physical and occupational therapy. An interview was conducted on 3/13/25 at 9:38 a.m. with Staff H, Licensed Practical Nurse (LPN). The staff member reported if a resident was discharged , the facility discharged them from the electronic system. Staff H, LPN reviewed the assessment completed on Resident #60 on 2/22/25 and stated the nurse may have made a mistake and did not think any nurse would document on a discharged resident. The staff member stated at times and if needed they may go in and make a late entry on the resident but would not document an assessment on them. An interview was conducted on 3/13/25 at 9:47 a.m. with Staff I, LPN/Assistant Director of Nursing (ADON). Staff I, LPN ADON reported staff document on Daily Medicare with daily notes, for 3 days. She would expect a narrative note for new admissions and any long-term care residents on antibiotics should be documented on every shift. She reported a resident who had been discharged would not typically be documented on, except for a hospital follow up note, but would not document an assessment or a daily Medicare note on a discharged resident. The ADON reviewed Resident #60's chart and confirmed the resident left the faciity on [DATE] and thought the resident had been gone 5-6 days, thinking the resident came back on the 2/27/25. Staff I, LPN ADON stated the expectation was to assess and lay eyes on a resident when documenting and the note on 2/22/25 was not correct documentation. Review of the undated policy titled Documentation, Clinical, revealed: Policy: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all industry interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the residents care treatment and response to the care. 2. Information for the physician when prescribing medications and managing care and treatments. 3. A description of care and services that can be used for measuring the quality of care provided to a resident. 4. An ongoing record of the physical and mental status of the resident. 5. Information for the development of a plan of care for each resident. 6. Elements to support quality medical care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. Documentation as recorded to support reimbursement. Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated, and timed.

Based on observations, interviews, and record review, the facility failed to update and revise a care plan to reflect a significant weight loss for one (Resident #38) of twenty-one sampled residents. Findings Included: On 5/30/2023 at 10:00 a.m., and 1: 20 p.m., 5/31/2023 at 1:00 p.m., and 6/1/2023 at 12:00 p.m., Resident # 38, was observed lying down in her bed with her head elevated and her call light within her reach. She presented without behaviors, pain, or discomfort. The room appeared clean and well lit. A review of Resident #38's admission record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease, Unspecified, Gastro-Esophageal, Ileus Unspecified, and Reflux Disease Without Esophagitis. A review of the most current Minimum Data Set (MDS), dated [DATE], show in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the electronic health record weights and vital record showed, on 4/3/2023 Resident #38 weighed 129.6 Lbs., on 4/18/2023 111.8 Lbs., and on 5/3/2023 110.0 Lbs. A review of the Registered Dietitian (RD) weight loss follow-up note, dated 4/19/2023, showed, Current Body Weight, CBW 111.8 lbs. (4/18/23), ht 60, Body Mass Index, BMI 21.8. Reweigh for verification, CBW represents a 13.7 % loss x 30d (4/3/23 129.6 lbs). Current diet order is clear liquid due to constipation/ KUB. Resident # 38 was previously on a regular diet, regular texture thin liquid, magic cups every day, QD, mighty shakes every day and Medpass 2.0 every day. A recommendation was made to allow nutrition supplements on Clear Liquid Diet (CLD). A review of the physician order summary sheet dated 6/1/2023, showed a diet order for thin consistency, clear liquid diet, that started on 4/17/2023 to 5/5/2023. Further review showed clear liquid diet order currently discontinued. A review of the current care plan with an initial date of 9/25/2020 and a revision date of 5/8/2023, indicated the following areas: Resident is at risk for altered nutritional status related to (r/t) Parkinson's, convulsions, HTN (hypertension), hypothyroidism, occlusion/stenosis of carotid arteries, pacemaker presence, MDD (major depressive disorder), anxiety, insomnia, GERD (Gastroesophageal reflux disease), constipation, ileus, dysphagia, recent hx clear liquid diet. A review of the care plan interventions with an initial date of 9/25/2020 and a revision date of 11/24/2020, showed to honor food preference as able, monitor s/s (signs and symptoms) of dehydration and/ or fluid overload, monitor skin integrity, monitor wt per protocol, offer supplement as ordered. Further review showed the nutritional care plan was not revised after 4/18/2023 to reflect Resident #38's weight loss. On 5/30/2023 at 1: 20 p.m., an interview was conducted with Resident #38, in her room. She said she could not recall if she had lost any weight in the previous few months because no one had ever mentioned it to her. She said she was on a clear liquid diet a month ago since she was experiencing stomach issues; therefore, if she had lost any weight, it might have been because of the clear liquid diet. She said she has a healthy appetite and consumed most of her meals. On 5/31/2023 at 5:04 p.m., an interview was conducted with the Director of Nursing (DON). The DON said she thought, [Resident #38's] weight loss was a result of the several health issues she was dealing with. [Resident #38] was on an IV (intravenous) antibiotic from April 5 through April 16 for a UTI (urinary tract infection) and suffered a seizure on April 11. We wanted to send her out to the hospital since she was experiencing gastrointestinal issues that were making her constipated, but she refused to go to the hospital at that time. After we attempted to use fleet enemas to help the resident move her bowels, her doctor was informed regarding how she was still having constipation, so he gave the go-ahead to begin her on a clear liquid diet to help soften up her bowels. On April 3, [2023], a monthly weight for [Resident #38] showed she weighed 129.6 pounds. However, because the resident began a clear liquid diet on April 17, [2023], we chose to reweigh her again on April 18, [2023], and at that time, she weighed 111.8 pounds. We reweighed her on May 3rd, [2023], and her weight was 110.0 pounds. In order to help her regain weight, the Registered Dietitian intervened at that point and placed an order to restart the resident back on her nutritional supplements. The care plan was not revised to reflect Resident #38's weight loss because truthfully everything was happening so fast during that time and she was sent out to the hospital shortly after. On 6/1/2023 at 9:36 a.m., an interview was conducted with Staff A, Registered Nurse (RN), MDS coordinator. Staff A said it was not the MDS coordinator's responsibility to update or make revisions in the nutritional care plan section. However, she did reach out to the Registered Dietitian to let her know when the care plan needed to be updated or a revision needed to be made. Staff A said the only update she made on Resident #38's care plan was when she came back from the hospital. Staff A said she did not add a revision to show the resident's weight loss on the care plan. Review of the facility policy and procedures, titled, Person Centered Care Planning, revision dated 12/2016. Showed care plans were to be revised as changes in the resident's condition warrant or when there was a change in resident's preference or choice of treatment.

Based on observations, interviews, and record reviews the facility failed to ensure recliners furnished in resident rooms were maintained in ten of thirty rooms sampled with recliners. Findings included: On 7/20/21 at 3:30 p.m. a tour of the facility revealed recliners, located in resident rooms 318, 315, 316, 313, 311, 329, 113, and 159 with peeling upholstery on the backrest and arms of the chairs. Photographic evidence was obtained. On 7/21/21 at 10:00 a.m. room 320 and 322 were observed to have a recliner with peeling upholstery on the backrest. Photographic evidence was obtained. On 7/21/21 at 10:07 a.m. an interview was conducted with Staff C, housekeeper. Staff C stated she had been employed by the facility for six years, and she is responsible for cleaning all the resident rooms daily. Staff C stated she noticed the peeling on the recliners in the resident rooms, and some are worse than others. Staff C stated the recliners would peel 'fairly soon' after they were replaced. She stated the chairs are only replaced when they are broken and cannot be used by the resident. On 7/21/21 at 10:17 a.m. an interview was conducted with the Staff D, Registered Nurse (RN) Risk Manager. Staff D stated the recliners in the rooms had never been replaced to her knowledge. Staff D stated she had not noticed the peeling condition of the recliners, and no one had reported the condition of the recliners to her. On 7/21/21 at 10:23 a.m. an interview was conducted with Staff E, Certified Nurse Aide (CNA). Staff E stated she had been working at the facility for [AGE] years and she had no recollection of the recliners being replaced. Staff E stated a sheet or blanket is placed over the recliner chairs, so the peeling upholstery does not get on the resident when they sit in the recliner. On 7/21/21 at 10:37 a.m. an interview was conducted with the Maintenance Director. The Director stated if there are any problems with furniture the staff are to write it into the maintenance book so it can be addressed. He stated the staff had not informed him about any peeling upholstery on the recliner chairs. He stated if a recliner is broken and not working, they remove it from the room, and he gets the Administrator to approve getting a new one. On 7/21/21 at 10:42 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the staff put any maintenance concerns in the maintenance book to be addressed. She stated the staff are aware they are supposed to follow the process. The DON stated the staff should also let her know and if they cannot reach her, she has shift supervisors on every shift. The DON stated she was not aware of the condition of the recliners. The DON further stated the solution being used to clean the recliners may be breaking down the upholstery. On 7/21/21 at 11:18 a.m. an interview was conducted with the Maintenance Director. He stated he had spoken with the Administrator, and they purchased 25 recliners in 2017. He provided a map with a red dot in each room that currently has a recliner. The map indicated there are currently 30 recliners in the private rooms of the building. A review of the facility policy entitled 'Cleaning Carpeting and Cloth Furnishings' effective February 2006 and revised April 2015 indicated the following: Policy: Furnishings shall be maintained and cleaned regularly Procedure: 5. Stained or soiled upholstered furniture shall be cleaned in a manner consistent with the type of fabric and stain.

Based on observations, staff interview, medical record review, the facility failed to ensure one of thirty-six sampled resident's (#44) care plans related to Urinary Tract Infection (UTI) was updated to reflect the resident had a current UTI and was receiving Antibiotics. Findings included: On 7/19/2021 at 9:40 a.m. Resident #44's room was approached, and the door was open. The resident was seated in her wheelchair by the foot of the bed and was conversing with a family/visitor. At 9:55 a.m. the visitor had left the room and Resident #44 allowed this surveyor to come in the room for an interview. During interview, Resident #44 revealed that she is currently being treated and takes medications for a Urinary Tract Infection (UTI). She revealed that this was not the first time she has had a UTI. On 7/20/2021 at 8:00 a.m. an interview with a Licensed Practical Nurse, Employee A, who had Resident #44 on his assignment, confirmed Resident #44 is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review on 7/20/2021, the electronic medical record revealed Resident #44 was admitted to the facility on [DATE] for short term rehabilitation. A review of the advance directives revealed Resident #44 was her own responsible party. A review of the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services.; Bowel and Bladder - Dx [diagnosis]. UTI - checked Yes. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - UA C&S labs on time 7/23/2021 - [MEDICATION(S)] 500 mg 1 PO QID for UTI for 10 days. Order date: 7/12/2021 During further review of the record for Resident #44, the nurse progress notes revealed: 1. 7/11/2021 16:30 - Notified MD of positive urine cx for UTI. New order received for [MEDICATION(S)] 500 mg QID PO for 10 days and [MEDICATION(S)] 500 mg PO QD. Orders transcribe and faxed to pharmacy. 2. 7/13/2021 - Continues ABT for UTI no adverse reactions. 3. 7/14/2021 - Continues ABT for UTI with no adverse reactions. 4. 7/15/2021 - Continues ABT for UTI with no adverse reactions. 5. 7/15/2021 - Resident seen by MD and request referral to see GYN for frequent UTI. Schedule appt. Orders to D/C [MEDICATION(S)] 5 mg PRN. 6. 7/16/2021 - Continues ABT for UTI with no adverse reactions. 5. 7/17/2021 - Continues ABT for UTI with no adverse reactions. 6. 7/18/2021 - Continues ABT for UTI with no adverse reactions. 7. 7/19/2021 - Continues ABT for UTI with no adverse reactions. 8. 7/20/2021 01:52 - Resident continues ABT for UTI, no adverse reactions, but c/o pain after urinating. MD is aware and appt sched with gyn, resident is aware. 9. 7/20/2021 10:33 - Resident has complaint of discomfort when urinating. MD notified of resident's discomfort, new order received and [MEDICATION(S)] 100 mg BID. Repeat CS UA when ABT is completed. 10. 7/20/2021 13:59 - Continues ABT for UTI. 11. 7/21/2021 01:29 - Resident continues with ABT for UTI without adverse reactions. A review of the current Care Plans with next review date 10/3/2021 revealed the following areas: - Occasionally incontinent of bowel and bladder and requires extensive assist with toileting r/t deconditioning r/t recent hospitalization , pain to LLE d/t recent left foot surgical repair, NWB to LLE, diuretic use. admitted with UTI (resolved) 7/5/2021 with interventions to include to include: Administer medications per order, Monitor/document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, AMS, change in bx, eating patterns - initiated 7/5/2021. Further review of the care plan indicated the UTI had resolved on 7/5/2021 and did not capture Resident #44's current UTI and with current use of Antibiotics., and without interventions and approaches related to the current UTI as of 7/11/2021. On 7/21/2021 at 1:00 p.m. an interview was held with the Care Plan Coordinator related to Resident #44. She reviewed the medical record and confirmed the resident had a resolved from a UTI on 7/5/2021 but was unaware she had another UTI as of 7/11/2021. She confirmed the care plan should be reflective and revised with the current UTI and new approaches, and interventions. She also confirmed the care plan should be reflective of the medical record and updated within three to five days. A review of the Person Centered Care Plan Policy and Procedure, with a last revision date 12/2016 revealed: The Care Plans are to be revised as changes in the resident's condition warrant or when there is a change in resident preference or choice of treatment.

Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to storage of oxygen, nebulizer, and continuous positive airway pressure ([CONDITION(S)]) tubing's and supplies, consistent with professional standards of practice for three (Resident #159, Resident #158, and Resident #41) of ten residents receiving respiratory treatments. Findings included: A record review revealed Resident #159 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the orders for Resident #159 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed and nebulizer treatments with [MEDICATION(S)]-[MEDICATION(S)] solution 0.5-2.5 milligrams (mg) in 3 milliliters (ml) to inhale orally every six hours for shortness of breath. On 7/19/21 at 10:21 a.m. an observation of Resident #159's room revealed the oxygen tubing draped across the bed and the nebulizer tubing and mask was observed to be placed in the top drawer of the nightstand next to the resident's bed. Photographic evidence was obtained. A record review revealed Resident #158 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the orders for Resident #158 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed. On 7/19/21 at 10:26 a.m. an observation of Resident #158's room revealed the oxygen tubing was observed hanging freely from the concentrator. On 7/19/21 at 11:19 a.m. an observation of Resident #158's room revealed the oxygen tubing connected to a tank on the resident wheelchair was observed hanging from the tank and touching the floor. Photographic evidence was obtained. On 7/22/21 at 10:47 a.m. an observation of Resident #158's room revealed the oxygen tubing was rolled up and stuck into the handle of the oxygen concentrator. An empty plastic bag was hooked to the concentrator. Photographic evidence was obtained. A record review revealed Resident #41 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the orders for Resident #41 indicated respiratory treatments with oxygen 1-3 liters per minute via nasal cannula, and [CONDITION(S)] at home settings with humidification. On 7/20/21 at 4:16 p.m. an observation of Resident #41's room revealed the [CONDITION(S)] tubing and mask sitting on the bedside table open to air. Photographic evidence was obtained. On 7/19/21 at 11:30 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated all respiratory care supplies should be stored in a clean plastic bag with a date on the bag. She stated the respiratory supplies are to be cleaned and changed every week. She indicated oxygen tubing, nebulizer tubing and masks, and [CONDITION(S)] machines and supplies are to be cleaned for each resident use and then stored back into the plastic bags. A review of the facility policy entitled Policy and procedure for storage of Respiratory Equipment-Departmental Respiratory Therapy Prevention of Infection revised November 2011 indicated the following: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure: Infection control considerations related to oxygen administration 7. Change the oxygen cannula and tubing every seven days, or as needed 8. Keep the oxygen cannula and tubing used prn in a plastic bag when not in use Infection control considerations related to Medication Nebulizer's/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name between uses 9. Discard the administration set up every seven days

Based on observations, staff and resident interviews and medical record review, the facility failed to ensure resident food/drink preferences were honored during two meal services, and during one of four days observed (7/20/2021), for one of thirty-six sampled residents (#44). Findings included: On 7/20/2021 at 8:40 a.m. during an interview Resident #44 was served her breakfast meal tray. The Resident indicated it was OK to stay as she was going to therapy after breakfast and wanted to complete the interview while she was eating. When the tray was placed on the over-the-bed table, the resident stated, Oh good, OK, let me see what's under the lid. The resident then said, OK this is good. The resident looked at the rest of the tray and then told Employee B, Certified Nursing Assistant (CNA), Oh we have orange juice again on my tray, and I can't have orange juice, please take it away. Employee B took the juice and left the room. The Resident interview continued related to related to choices and likes/dislikes when it came to food items on her tray. She said, I can't have orange juice as I am diabetic. She pointed to her meal ticket and stated, Even my meal ticket says no juices. A review of the resident's meal ticket for the breakfast meal indicated the following: Diet - Regular, No Added Salt, Low Concentrated Sweets; Beverages - Coffee, Water. The meal ticket further revealed: Food Dislikes - Juices. Resident #44 revealed that this happens often and confirmed she would not like to have the juice brought to her and knows better not to drink it but would rather staff follow her meal choices. On 7/20/2021 at 12:20 p.m. during lunch observation, Resident #44 was served her meal. A review of the meal ticket revealed - Food Dislikes - Juices. The resident received one plastic cup of what appeared to be red juice. An interview was conducted with Resident #44 at this time, and she revealed she does not like to receive juice and has been receiving it on and off. A review of Resident #44's electronic medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. A review of the advance directives revealed the resident was her own responsible party. The Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services. The Physician's Order Sheet (POS), dated for the month 7/2021 revealed Resident #44 had a diet order to include: No Added Salt, Low Concentrated Sweets diet, with regular texture and thin consistency liquids. A review of the Care Plans with next review date 10/3/2021 revealed the following areas: - Resident at risk for altered nutrition status per MNA with interventions to include but not limited to: Diet as ordered, honor food preferences as able, offer alternative entrees as needed On 7/21/2021 at 1:45 p.m. an interview with the Kitchen Dietary Manager revealed staff plate food on the tray line in the kitchen, and the meal tickets have the diet order, and likes and dislikes. She revealed staff are to read each ticket and comply with the diet order and resident choices. She further revealed it is her responsibility to audit tickets and trays to ensure accuracy. She stated she was unaware residents were receiving food items of dislikes. On 7/22/2021 at 11:08 a.m. the Director of Nursing and the Dietary Manager confirmed the facility did not have a specific policy related to food preferences.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and four (4) errors were identified for four (#43, #35, #42, and #50) of eleven residents observed. These errors constituted a 13.33% medication error rate. Findings included: 1. On 11/6/19 at 3:44 p.m., an observation of medication administration with Staff Member C, Licensed Practical Nurse (LPN), was conducted with Resident #43. Staff Member C was observed administering the following medication: - [MEDICATION NAME]10 units (u) subcutaneously via Flex Pen. After obtaining a blood glucose (BG) level of 316 from Resident #43, the staff member retrieved the [MEDICATION NAME] Flex pen from the medication cart and returned to the resident's room. After dialing the Flex pen to 10 u and pushing the resident's sleeves up on both sides of shirt, Staff Member C removed gloves, and returned to the medication cart to obtain an alcohol pad. Staff Member C cleaned the back of Resident #43's right upper arm and administered the 10 u of [MEDICATION NAME] insulin. Staff Member C had not primed the Flex Pen prior to dialing the pen to 10 units. During an interview, on 11/6/19 at 4:19 p.m., Staff Member C stated she does not prime the Flex pens prior to administering insulin. The staff member stated Flex pens were supposed to be for self-administration. On 11/6/19 at 5:34 p.m., the Director of Nursing (DON) informed writer that Staff Member C, had told on herself. The DON stated the nurse had informed her that she had not primed the Flex pen prior to administration. The DON confirmed a Flex pen should be primed prior to administering the correct amount of insulin. During an interview, on 11/8/19 at 8:46 a.m., the Consulting Pharmacist stated part of the instructions for the Flex pen was to prime, usually with 2 units. 2. On 11/6/19 at 5:19 p.m., an observation of medication administration with Staff Member D, Licensed Practical Nurse (LPN), was conducted with Resident #35. Staff Member D was observed administering the following medications: [REDACTED] - [MEDICATION NAME] 0.4 milligram (mg) - [MEDICATION NAME] 25 mg - Polyethylene [MEDICATION NAME] 3350 17 grams (gm) - [MEDICATION NAME] 5 mg - [MEDICATION NAME] [DATE] mg Resident #35 was sitting in a reclining chair talking with a visitor. The Staff Member administered the tablets and left the Polyethylene [MEDICATION NAME] with the resident and left the room. Staff Member D stated Resident #35 had an order to drink the [MEDICATION NAME] (Polyethylene [MEDICATION NAME]) at leisure. A review of Resident #35's active physician orders did not include an order indicating the [MEDICATION NAME] could be left at the bedside so the resident could drink it at the resident's leisure, nor did the Resident have an order allowing for the self-administration of medications. 3. On 11/6/19 at 5:28 p.m., an observation of medication administration with Staff Member D, Licensed Practical Nurse (LPN), was conducted with Resident #42. Staff Member D was observed administering the following medications: [REDACTED] -20. [MEDICATION NAME] Sol 0.2-0.5% ([MEDICATION NAME]-[MEDICATION NAME]) After sanitizing hands and donning gloves, Staff Member D pulled down the skin of resident's cheekbone and dropped one drop of [MEDICATION NAME] into the right eye of the resident. Immediately following dropping the medication, liquid was observed moving down the right cheek of the resident. The staff member pulled down the cheekbone of Resident #42 and administered a drop into the left eye. No liquid was observed on the left cheekbone of the resident after the administration. Resident #42 denied the staff member's offer to wipe the tear from the right cheekbone. During an interview, on 11/8/19 at 9:16 a.m., the Director of Nursing confirmed the resident did not receive the correct dosage of eye drops if it was rolling down the cheek of the resident after administration. The nurses notes on 11/8/19 for Resident #42 did not indicate the physician was notified of the partial dosage of [MEDICATION NAME]. 4. On 11/7/19 at 7:43 a.m., an observation of medication administration with Staff Member A, Licensed Practical Nurse (LPN), was conducted with Resident #50. Staff Member A was observed administering the following medications: [REDACTED] -21. Aspirin EC ([MEDICATION NAME] coated) 81 mg -22. Carvedilol 6.25 mg -23. [MEDICATION NAME] Hcl 10 mg -24. Co [MEDICATION NAME] 100 mg - 3tabs -25. Vit B12 1000 mcg (microgram) -26. [MEDICATION NAME] 40 mg -27. [MEDICATION NAME] ([MEDICATION NAME]) 160 mg -28. [MEDICATION NAME] Oxalate 10 mg -29. [MEDICATION NAME] ([MEDICATION NAME]) 2mg tab A review of the scheduled physician orders on the (MONTH) 2019 Medication Administration Record [REDACTED]. The recorded observed medications did not find that Resident #50 received Fish Oil, along with the other medications scheduled and administered. The review of the (MONTH) MAR indicated [REDACTED]. The policy titled, Insulin Injectable Administration, dated (MONTH) 2014, indicated all medications are used in accordance with the manufacturer's recommendations or the pharmacy's directions for storage, use, and disposal. The policy did not include a procedure for the use of insulin pens. According to manufacturer's instructions, located at https://www.novo-pi.com/[MEDICATION NAME].pdf, before each injections small amounts of air may collect in the cartridge during normal use and to avoid injecting air and to ensure correct dosing, users should dial to 2 units, tap the cartridge, and press the push button all the way, a drop of insulin should appear at the tip. The policy titled, Specific Procedures for all Medications, dated (MONTH) 2011, indicated that during medication administration staff should stay with the resident until all medications are consumed and to observe the resident's consumption of medications. The policy titled, Eye Drop Administration, dated (MONTH) 2014, described the procedure for the administration of eye drops as: 9. Pull the lower eyelid down and away from the eyeball to form a pocket. 10. Hold the dropper tip directly over the eye, taking care to avoid touching the eye, or eyelid. Do not instill medications directly on the cornea. 11. Instruct resident to look upward, and place one drop into the pocket, continuing to hold the eyelid for a moment to allow the medication to distribute. 12. Release the eyelid and instruct the resident to close the eye slowly and keep it closed for one to two minutes.

Based on observations, record reviews, and interviews, the facility failed to ensure boxes containing controlled substances were permanently affixed to the refrigerator in two of two medication preparation rooms, and failed to ensure one of one insulin pens and one of one insulin vials was inaccessible to unauthorized persons, and to ensure one of five medication carts were locked when unattended. Findings included: 1. An observation, at 9:12 a.m. on 11/6/19, of the West medication room, with Staff Member A, Licensed Practical Nurse (LPN), revealed a small locked refrigerator. Inside the refrigerator was a box which contained individual vials of [MEDICATION NAME]. The box was easily removable from the refrigerator and not permanently affixed to the refrigerator. 2. An observation at 9:33 a.m., on 11/6/19, with Staff Member B, Licensed Practical Nurse (LPN), of the East medication room revealed a small locked refrigerator, which contained two plastic boxes, one of the boxes, which contained multiple vials of [MEDICATION NAME], was easily removed from the refrigerator. Staff Member B confirmed the box containing [MEDICATION NAME] was not permanently affixed to the refrigerator. 3. During the mandatory task of Medication Administration, on 11/6/19 at 3:44 p.m., Staff Member C, Licensed Practical Nurse (LPN) placed a [MEDICATION NAME], prepared to 10 units, on a resident's bedside dresser, left the room and obtained an alcohol pad from the medication cart parked beside the room's door, then returned to the room. While the [MEDICATION NAME] was unattended when Staff Member C left the room, the resident and a private-duty aide were in the resident room. 4. On 11/6/19 at 4:03 p.m., during the task of Medication Administration, Staff Member C removed a vial of insulin from a medication cart, leaving the medication cart unlocked, returned to the resident room, and placed the vial in the resident's room on an over-the-bed table. Staff Member C returned to the medication cart, removed an insulin syringe from the top drawer, locked the cart and returned to the resident room. After administering insulin to the resident, Staff Member C disposed of syringe and trash, laid insulin vial (which was in the labeled box) on the medication cart and returned to the resident's room to wash hands. On 11/6/19 at 1:30 p.m., the Director of Nursing (DON) asked to review the East medication preparation room. She opened the refrigerator and showed that a padlocked plastic box had been permanently affixed by a steel cable to the molded door shelf. The box of [MEDICATION NAME] was no longer observed in the refrigerator and the DON indicated the box was in the padlocked box. The DON stated the refrigerated controlled substance box in the West-hall medication room was also locked in a plastic box and permanently affixed. She stated I know it doesn't change anything. During an interview, on 11/8/19 at 1:30 p.m., the Consulting Pharmacist stated even though the refrigerated controlled substance boxes was behind a locked door and in a locked refrigerator, it had been recommended that the [MEDICATION NAME] ([MEDICATION NAME]) boxes be permanently affixed to the refrigerator. The DON stated, on 11/8/19 at 9:00 a.m., if medications were left at bedside, there would be an order for [REDACTED]. The policy titled, Storage of Drugs, Biologicals, Syringes, and Needles, dated (MONTH) 2011, indicated drugs, biologicals, syringes, and needles are stored under proper conditions with regard to sanitation temperature, light, moisture, ventilation, segregation, safety, security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. The procedure of the policy described that all drugs and biologicals, including treatment items are stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors. The subsection of the policy, Controlled Substances Storage, indicated Schedule II controlled substances are not accessible to anyone other than licensed nursing, pharmacy, and medical personnel designated by the facility and are stored using a double locked compartment system.

Based on observations, interviews, and record review, the facility failed to provide wound care in accordance with professional standards of practice for one Resident (Resident #10) of two residents sampled for wound care. Findings included: During an observation of Resident #10 on 8/2/18 at 9:30 a.m., Resident #10 was laying on her back in her bed. She had foot covers on both legs. She had 2 dressings on her left medial calf, and 1 dressing on her right medial calf. During an observation of Resident #10's wound care on 8/2/18 at 9:35, with two surveyors in observation. The Wound Care nurse (Staff B) performed the dressing changes with the assistance of (Staff A). Dressings and supplies (except for scissors) were prepared outside the resident's room. The drain sponges were sprayed with Safe-Clenz solution, a multi-use spray which was not taken into the room. Staff A prepared the resident for the procedure, prepared a clean field for supplies, and removed the leg protectors. At 9:35 a.m., Staff B placed her supplies on her clean field. Scissors were taken out of her pocket and put on the tray without cleaning prior to use. She washed her hands, donned gloves, and removed the old dressing on the right medial calf. She removed her gloves and washed her hands in the bathroom. Staff B donned gloves, then cleansed the wound with gauze soaked with Safe Clenz. She removed her gloves, without hand hygiene, she put on a new pair of gloves, and applied Santyl, cut the Calcium Alginate and applied it, and then applied the Allevyn dressing. She removed her gloves, took her marker out of her pocket and labeled the dressing. She then washed her hands in the bathroom. At 9:40 a.m., Staff B donned gloves, and removed the old dressing from the resident's anterior left lower leg, medial aspect. She removed her gloves and washed her hands in the bathroom. She donned new gloves and cleansed the wound. She removed her gloves and used the hand sanitizer provided by staff A before applying gloves. She donned gloves, cut the Calcium Alginate dressing to size, with the scissors and applied it. She then applied the Allevyn dressing. She removed her gloves and took her marker out of her pocket and labeled the dressing. Then she washed her hands in the bathroom. At 9:46 a.m., Staff B donned gloves, and removed the old dressing from the resident's left lower leg, medial aspect. She removed her gloves and used hand gel before applying new gloves. She cleansed the wound with Saf Clenz, and then removed her gloves. She used hand gel, and then applied new gloves. With the same scissors used to cut the calcium alginate, she cut the Xeroform, placed it on the Allevyn dressing, and then applied the dressing. She removed her gloves and labeled the dressing with her marker. She put on new gloves, and cleaned the supplies off the table. Then she removed her gloves and washed her hands in the bathroom. Staff A sanitized the tray and the scissors. During an interview on 8/2/18 at 3:20 p.m., with the Infection Control Nurse/Risk Manager (Staff C), and the Administrator and two surveyors during QA. She stated, My expectation for sanitizing equipment prior to use would be that all items, including the scissors, would be cleaned prior to use and each time the gloves are removed, hand hygiene should be performed. As long as the resident is not put at risk, staff can wash their hands in the bathroom, but otherwise we expect hand gel to be used. A review of the facility's policy titled Handwashing/Hand Hygiene, revised in (MONTH) (YEAR)), it revealed Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 7) Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: G) before handling clean or soiled dressings, gauze pads, etc.; K) after handling used dressings, contaminated equipment, etc., M) after removing gloves. The Director of Nursing was asked for a facility policy on Wound Care protocol; however she stated that the facility only had a Dressing Change-non Sterile Skill Check list available which revealed: to wash hand prior to and after glove removal.

Based on observation, interview and record review, the facility failed to obtain a timely urine specimen for one (Resident #16) of 34 sampled residents by not obtaining the specimen for 5 days after the order was written. Findings Included: An interview with Resident #16 on 8/02/18 at 11:21 a.m. was conducted while she sat in her room playing a game on her tablet. The resident stated, I still having burning on urination and just started an antibiotic and know it will take time but [MEDICAL CONDITION] urinating. Review of the nurses' notes dated 7/26/18 revealed: resident complaining of burning when urinating. Doctor contacted with a new order received. Review of the physician order [REDACTED]. Review of the nurses notes, dated 7/27/18, revealed the resident complained of burning during voiding. Pending collection of urine specimen via straight catheter sterile technique. Tolerated well. Review of the nurses' note dated 7/31/18 revealed the urinalysis obtained via clean catch, peri area cleanse before collecting sample. Review of the lab report, dated 7/30/18, with a collection time of 4:00 p.m., with results reported 8/1/18, revealed the resident with [DIAGNOSES REDACTED] Pneumoniae and [MEDICATION NAME] Aerogenes. Review of the Treatment Administration Record (TAR) with hand written note stating sample in fridge on 7/27/18 then A documented on 7/30/18. The word Rewritten with an arrow pointing down to the next line revealed UA C&S may straight cath with 7/31/18 documented as done. Review of the physician order [REDACTED].>During an interview with staff nurse A, on 8/1/18 at 2:30 p.m., she stated that she was unsure why the UA C&S took five days to collect. She stated the UA C&S is usually collected on the 3- 11 shift and passed off on each nurse until collected, depending on when the order was written. Review of the MDS revealed the resident with a Brief Interview for Mental Status (BIMS) of 14 out of 15. During an interview with the Director of Nursing (DON) on 08/02/18 at 1:58 p.m., she stated that she would expect the lab to be completed within a day and she confirmed that the lab was delayed and stated it was not acceptable. Review of the Summit Care Nursing Policies- Laboratory Test/Diagnostic Procedures: Communicating the Results effective (YEAR) page 1 of 1 revealed: the facility will track ordered labs and diagnostic procedures and promptly notify the resident's physician or nurse practitioner or physician's assistant of results of resident labs and results.

Based on observation and interviews the facility failed to maintain a safe and sanitary environment in resident bathroom and bedroom areas for 20 out of 29 rooms (101, 102, 103, 105, 107, 120, 127, 130, 132, 133, 134, 153, 154, 155, 156, 157, 158, 160, 161, 164) observed. Findings included: On 6/13/17 at 3:30 p.m. during a tour of the facility with Environmental tour with the Maintenance Director, he acknowledged the issues in following resident areas identified: 1. In Room 101, the ceiling tiles in bathroom are raised, in disrepair and stained. 2. In Room 103, has an uncovered rusted bolt on base of toilet and rusted cover on wall behind toilet. 3. In Room 107, has chipped paint on the metal frame going into bathroom, the wall behind the toilet has a hole it and is slightly soaked from water damage. There was a corroded rusted pipe cover and nozzle for water shut off in bathroom. 4. Room 157, had a hole in the bathroom wall behind toilet, the wall is in disrepair to right of sink; and there are stained and gouged door and frames into bathroom. 5. In Room 130, the walls in the room and bathroom are in disrepair. The bathroom tile at the base of the wall is pulling away from wall. There are no bolt covers over the toilet fasteners, and sharp edges are exposed. 6. In Room 132, the toilet bowl base is not straight on the tile floor exposing a hole in the floor. 7. In Room 134, has bathroom tile loose at the bottom of the wall, and there are no bolt covers over the toilet fasteners leaving sharp edges exposed. 8. In Room 153, the wall on both sides of the bathroom door is damaged and needs repair and paint. The bathroom door is damage and need repair. 9. In Room 155, the wall behind the bed is damage and needs to be repainted. There are no bolt covers over the toilet fasteners, leaving sharp edges exposed. 10. In Room 156, the wall outlet by the window is pulled out and needs repair and the wall behind the chair across from Bed A needs to be painted. There was a missing toilet fastener on right side toilet, no bolt cover over the toilet fastener on the left, leaving sharp edges exposed, and dark brown stain from sink pipe. 11. Room 157, has a hole in the bathroom wall under the sink. 12. In Room 158, the bathroom and bedroom doors are damaged. There are no bolt covers over the toilet fasteners, leaving sharp edges are exposed. 13. In Room 160, the bathroom fixture behind toilet was corroded and rusted, the doors and frames are marred leading into the bathroom. The sink was pulling away from the wall. 14. In Room 161, there were no bolt covers over the toilet fasteners, leaving sharp edges exposed. There is rusted pipe coming out of the bathroom wall. 15. In Room 164, the wall behind the bed, both doors and the wall next to the bathroom door are damaged and needs repair. There are no bolt covers over the toilet fasteners, leaving sharp edges are exposed. 16. Rooms 102, 105, 120, 127, 133 and 154 had no bolt covers over the toilet fasteners, leaving sharp edges exposed.

Based on resident and family interview, staff interview and resident record review the facility failed to ensure 1 (Resident #108) of 4 residents primary care physician and the health care surrogate were notified of a significant weight loss. Findings include: On 6/13/17 review of Resident #108's medical records revealed she was readmitted from the hospital on [DATE] with an admission weight of 227.2 pounds. On 5/5/17 Resident #108's weight was 228.0 pounds. The next weight on 5/8/17 was 203.6 pound noting as 24.4 pound weight loss since 5/5/17 a 10.7% weight loss. On 5/11/17, the weight was 183.0, a 45.0 pound weight loss since 5/5/17 a 19.7% weight loss in 6 days. Review of dietary progress note, dated 5/2/17, found the Registered Dietitian (RD) notes reflected Resident #108's readmission weight as 228.0 pounds. On 5/10/17 the RD wrote weight loss expected, Resident #108 is on a mechanical soft diet due to lost dentures. On 5/17/17 the RD wrote Resident #108's weight is 188.2 pounds a 7.6% weight loss in 1 week and will do daily weights for 1 week. There is no documentation in the medical record that Resident #108's health care surrogate and the primary care physician were notified of the 45 pound weight loss documented on 5/11/17 a 19.7% weight loss in 6 days. In an interview on 6/13/17 at 2:00 p.m., Resident #108 said when she returned from the hospital on [DATE] the facility had lost her upper and lower dentures. Because they had lost her dentures they had to change her diet from a regular diet to puree diet and now she was on a mechanical soft diet until her new dentures are made. She further said she has lost weight since the diet changes but did not know how much weight she had lost since her readmission on 5/2/17. In an interview on 6/13/17 at 3:20 p.m. Resident #108's daughter said she was Resident #108's health care surrogate. She said she visits her mother routinely at the facility and no one from the facility had updated her about the 45 pound weight loss documented on 5/11/17. In an interview on 6/14/17 at 10:10 a.m. with the Director of Nursing (DON), she confirmed Resident #108's daughter was the health care surrogate. She reviewed Resident #108's medical records and confirmed Resident #108 had lost 45 pounds from 5/5/17 to 5/11/17 a 19.7% weight loss in 6 days. The DON said there is no documentation the daughter and the primary care physician were notified on 5/11/17 of 45 pound weight loss in 6 days. She said as per their policy and procedure the primary care physician should have been notified of any significant weight loss. In an interview on 6/14/17 at 10:25 a.m. with the Dietary Manager (DM) and the RD, both confirmed Resident #108 had lost 45 pounds from 5/5/17 to 5/11/17 a 19.7% weight loss in 6 days. They said there was no documentation in the medical records they had notified the health care surrogate and/or the primary care physician of the significant weight loss identified on 5/8/17, a 10.7% and on 5/11/17 a total of 19.7%. In an interview on 6/15/17 at 10:25 a.m. with Resident #108's primary physician after review of Resident #108's medical records, the physician confirmed a 45 pound weight loss from 5/5/17 to 5/11/17. He said he was not notified of the significant weight loss when it was identified on 5/8/17 and 5/11/17. He further said while Resident #108's weight has stabilized a significant weight loss over a short period of time is not desired and could be detrimental to the resident. As per the facility's policy and procedure the facility staff should have notified him on 5/8/17 and on 5/11/17 when the significant weight loss was identified by the facility.

Based on record review, staff and resident interviews, the facility failed to reassess the effectiveness of interventions to address care and treatment related to dental / oral care for 1 (Resident #134) out of 15 care plans reviewed. The failure to follow the intervention(s) included in the care plan led to the continuing and potentially worsening of Resident #134's medical condition. Findings included: On 6/12/17 at 12:14 p.m., Resident #134 said the roof of her mouth was sore. The resident stated she had told the nurse about it. She said they have not done anything about it. On 6/13/17 a review of Resident #134's care plan, dated 5/31/17 documented a need for care related to oral discomfort as evidenced by verbal complaint of mouth feeling sore and red swollen lips. treated for [REDACTED]. The goal was for the thrush to resolve without complications or reoccurrence. The interventions included: (1) monitor for signs and symptoms of oral pain, discomfort, redness, inflamed or bleeding gums and to report abnormal findings to nurse and / or medical doctor, (2) arrange for dental consult (including transportation) as indicated or ordered. On 6/13/17 at 4:00 p.m., during an interview with Resident #134, she said her gums and the roof of her mouth hurts really bad. She said she had gotten a mouth rinse. She said she asked for the rinse one night and was told she did not have it anymore. She said they never came and asked to see her mouth or if it felt better after the rinse treatment. She said right after the rinse treatment was done, she told the nurse her gums are swollen and mouth hurts. She said the nurse did not look at her mouth or gums. She said nothing more was done. She said she would tell the nurse, again, tonight (6/13/17) when the nurse brings her medications. On 6/14/17 at 10:00 a.m., during an interview with Resident #134, said she last night she told Licensed Practical Nurse Staff A when she got her medication, that her gums and roof of her mouth hurts and her gums are swollen. She said Staff A told her she did not know anything about it and left the room. She said Staff A did not look in her mouth or at her gums. She said Staff A did not offer her anything for it, or come back and talk to her about it. She said Staff A did not tell her she would look into it to see if there was something, she could do to help her. Review on 6/14/17 a nursing 24 hour report revealed on 5/31/17 swish swallow. No other documentation regarding [MEDICATION NAME] since then. On 6/13/17 at 11:28 a.m., during an interview with Licensed Practical Nurse Staff B, she said Resident #134 had complained of mouth pain. She said the doctor first ordered throat [MEDICATION NAME], which Resident #134 did not take. Then he ordered [MEDICATION NAME] swish and swallow. She said since then, she has not complained of pain. She said she saw Resident #134's mouth when the doctor ordered the [MEDICATION NAME], and did not look like there was anything wrong with it. She said she had not looked at it since then. She said she was not told anything in report today about Resident #134's complaint of mouth pain last night. On 6/14/17 at 11:08 a.m., during an interview with the Assistant Director of Nursing, he said the 24-hour report is for the nurses to see that the orders were transcribed correctly. He said the report was so the next nurse would know about the medications. At 3:25 p.m., he said no one had said anything to him about an issue with Resident #134's gums or mouth. He said he spoke with LPN Staff B about this morning. He said he or LPN Staff B should have checked her mouth and did not. He acknowledged the care plan addressing oral issue identified the intervention for nursing to monitor it and report abnormal findings to the Medical Doctor. He said this was not done. He acknowledged there was no nursing progress note addressing oral pain, or swelling dated 6/13/17. When he observed Resident #134's mouth, he said her gums were swollen and he did see some white patches on the roof of her mouth. The resident told him it hurts my gums and roof of my mouth. On 6/14/17 at 3:10 p.m., during an interview with LPN Staff A, she said she spoke with Resident #134 last night about her [MEDICATION NAME] and showed her she received all her doses. She said Resident #134 did not complain of pain to her. She said she did not check her mouth. On 6/14/17 a review of Resident #134's Minimum Data Set documented her Brief Interview for Mental Status (BIMS), dated 5/29/17, score was 14. BIMS is a cognitive test used to determine impairment. The score is from 1-15. The higher the score, the more cognitively alert the resident is. On 6/15/17 at 10:15 a.m., Resident #134 said she was upset that she told the nurses she was in pain, her gums and mouth hurt and they did not look at it and did nothing about it.

Based on record review, staff and resident interviews the facility failed to provide services for 1 (Resident #134) out of 15 care plans reviewed. The failure to follow the intervention(s) included in the care plan led to the continuing and potentially worsening of Resident #134's medical condition. Findings included: On 6/13/17 a review of Resident #134's care plan, dated 5/31/17, documented a need for care related to oral discomfort as evidenced by verbal complaint of mouth feeling sore and red swollen lips. treated for [REDACTED]. The goal was for the thrush to resolve without complications or reoccurrence. The interventions included: (1) monitor for signs and symptoms of oral pain, discomfort, redness, inflamed or bleeding gums and to report abnormal findings to nurse and / or medical doctor, (2) arrange for dental consult (including transportation) as indicated or ordered. On 6/12/17 at 12:14 p.m., Resident #134 said the roof of her mouth was sore. She had told the nurse about it. She said they have not done anything about it. On 6/13/17 at 4:00 p.m., during an interview with Resident #134, she said her gums and the roof of her mouth hurts really bad. She said after the mouth treatment ending on 6/4/17, they never came and asked to see her mouth or if it felt better. She said she continued to tell the nurse her gums are swollen and mouth hurts. She said the nurse did not look at her mouth or gums. She said nothing more was done. She said she would tell the nurse again tonight (6/13/17) when the nurse brings her medications. On 6/14/17 at 10:00 a.m., during an interview with Resident #134, said she last night she told Licensed Practical Nurse Staff A when she got her medication, that her gums and roof of her mouth hurts and her gums are swollen. She said Staff A told her she did not know anything about it and left the room. She said Staff A did not look in her mouth or at her gums. She said Staff A did not offer her anything for it, or come back and talk to her about it. She said Staff A did not tell her she would look into it to see if there was something, she could do to help her. On 6/14/2017, a review of Resident #134's Minimum Data Set documented her Brief Interview for Mental Status (BIMS), dated 5/29/2017, score was 14, reflecting the resident was cognitively alert. On 6/13/17 at 11:28 a.m., during an interview with Licensed Practical Nurse Staff B, she said Resident #134 had complained of mouth pain. She said the doctor first ordered throat [MEDICATION NAME], which Resident #134 did not take. Then he ordered [MEDICATION NAME] swish and swallow. She said since then, she has not complained of pain. She said she saw Resident #134's mouth when the doctor ordered the [MEDICATION NAME], and did not look like there was anything wrong with it. She said she has not looked at it since then. She said she was not told anything in report today about Resident #134's complaint of mouth pain last night. On 6/14/17 at 3:25 p.m., during an interview with the Assistant Director of Nursing, he said no one had said anything to him about an issue with Resident #134's gums or mouth. He said he or LPN Staff B should have checked her mouth and did not. He acknowledged the care plan addressing oral issue identified the intervention for nursing to monitor it and report abnormal findings to the Medical Doctor. He said this was not done. He acknowledged there is no nursing progress note addressing oral pain, or swelling dated 6/13/17. When he observed Resident #134's mouth, he said her gums are swollen and he does see some white patches on the roof of her mouth. The resident told him it hurts, my gums and roof of my mouth. On 6/14/17 at 3:10 p.m., during an interview with LPN Staff A, she said she did not check Resident #134's mouth last night.

Based on observation, record review, resident, physician, and staff interview, the facility failed to provide care and services to maintain the highest practicable physical and mental well-being in the areas of medication administration; pain management; and coordination of services with other providers to meet the needs of 3 (#134, #154, #90) of 27 sampled residents. Findings included: 1. On 6/12/17 at 12:14 p.m., Resident #134 said the roof of her mouth was sore. She told the nurse about it. She said they have not done anything about it. On 6/13/17 a review of Resident #134's care plan, dated 5/31/17, documented a need for care related to oral discomfort as evidenced by verbal complaint of mouth feeling sore and red swollen lips. treated for [REDACTED]. The goal was for the thrush to resolve without complications or reoccurrence. The interventions included: (1) monitor for signs and symptoms of oral pain, discomfort, redness, inflamed or bleeding gums and to report abnormal findings to nurse and / or medical doctor, (2) arrange for dental consult (including transportation) as indicated or ordered. On 6/13/17 at 4:00 p.m., during an interview with Resident #134, she said her gums and the roof of her mouth hurts really bad. She said she had gotten a mouth rinse. She said she asked for the rinse one night and was told she did not have it anymore. She said they never came and asked to see her mouth or if it felt better after the rinse treatment. She said right after the rinse treatment was done, she told the nurse her gums are swollen and mouth hurts. She said the nurse did not look at her mouth or gums. She said nothing more was done. She said she would tell the nurse, again, tonight (6/13/17) when the nurse brings her medications. On 6/14/17 at 10:00 a.m., during an interview with Resident #134, said she last night she told Licensed Practical Nurse Staff A when she got her medication, that her gums and roof of her mouth hurts and her gums are swollen. She said Staff A told her she did not know anything about it and left the room. She said Staff A did not look in her mouth or at her gums. She said Staff A did not offer her anything for it, or come back and talk to her about it. She said Staff A did not tell her she would look into it to see if there was something she could do to help her. On 6/13/17 at 11:28 a.m., during an interview with Licensed Practical Nurse Staff B, she said Resident #134 had complained of mouth pain. She said the doctor first ordered throat [MEDICATION NAME], which Resident #134 did not take. Then he ordered [MEDICATION NAME] swish and swallow. She said since then, she has not complained of pain. She said she saw Resident #134's mouth when the doctor ordered the [MEDICATION NAME], and did not look like there was anything wrong with it. She said she had not looked at it since then. She said she was not told anything in report today about Resident #134's complaint of mouth pain last night. On 6/14/17 at 11:08 a.m., during an interview with the Assistant Director of Nursing, he said the 24 hour report was for the nurses to see that the orders were transcribed correctly. He said the report was so the next nurse would know about the medications. At 3:25 p.m., he said no one has said anything to him about an issue with Resident #134's gums or mouth. He said he spoke with LPN Staff B about this morning. He said he or LPN Staff B should have checked her mouth and did not. He acknowledged the care plan addressing oral issue identified the intervention for nursing to monitor it and report abnormal findings to the Medical Doctor. He said this was not done. He acknowledged there was no nursing progress note addressing oral pain, or swelling dated 6/13/17. When he observed Resident #134's mouth, he said her gums were swollen and he did see some white patches on the roof of her mouth. The resident told him, it hurts, my gums and roof of my mouth. On 6/14/17 at 3:10 p.m., during an interview with LPN Staff A, she said she spoke with Resident #134 last night about her [MEDICATION NAME] and showed her she received all her doses. She said Resident #134 did not complain of pain to her. She said she did not check her mouth. On 6/14/17, a review of Resident #134 Minimum Data Set documented her Brief Interview for Mental Status (BIMS) dated 5/2917 score was 14. BIMS is a cognitive test used to determine impairment. The score is from 1-15. The higher the score, the more cognitively alert the resident is. On 6/15/17 at 10:15 a.m., Resident #134 said she was upset that she told the nurses she was in pain, her gums and mouth hurt and they did not look at it and did nothing about it. 2. On 6/12/17 from 9:30 a.m. through 11:30 a.m. and 1:00 p.m. through 3:30 p.m. Resident #154 was observed in his room in bed with no activity program in progress. On 6/13/17 from 12:00 p.m. to 3:30 p.m. Resident #154 was observed in his room in his bed with no activity program in progress. Review of Resident #154's medical records revealed he was admitted to the facility 1/27/17. A hospice care plan dated 4/4/17 state Resident #54 was admitted to hospice 1/31/17. On page 36 the hospice care plan state Resident #154 would receive pet therapy. The care plan meeting sign-in sheet noted care plans dates of 2/9/17, 2/15/17 and 4/27/17. Hospice only attended the 2/15/17 facility care plan meeting. The activity care plan dated 2/8/17 noted on 2/16/17 hospice would be doing pet therapy visits. The care plan also stated the niece, the Power of Attorney (POA) refused services at this time. Review of the activity tracking sheet revealed Resident #154 had attended 4 out of 30 possible days of activities in April 2017. Resident #154 had attended 14 out of 31 days of activities in May 2017. Resident #154 attended 7 out of 14 days an activity in June 2017. No hospice activities were listed on the activity tracking sheet. The only activity progress note in Resident #154's medical record was dated 1/30/17. On 6/14/17 at 3:15 p.m., interview with the Activity Director (AD) reported she keeps track of all the activity programs each resident attends. She confirmed Resident #154 had attended 25 days of activity out of 75 days. She said hospice has not communicated with her what activities they are conducting with Resident #154. She further said she doesn't know why the hospice care plan was not updated to reflect the POA did not want pet therapy for Resident #154. She confirmed she had not updated Resident #154's activity progress note from 1/30/17 and hospice had not coordinated their activity program with the facility. On 6/14/17 at 4:30 p.m. in an interview with the Minimum Data Sheet (MDS) Coordinator, she said she was in charge of the care plan meetings and confirmed hospice did not attend the 4/27/17 care plan meeting for Resident #154. On 6/14/17 at 4:45 p.m. in an interview with the Director of Nursing (DON), she said she tries to meet with hospice on a weekly basis. She confirmed hospice did not attend Resident #154's care plan meeting on 4/27/17 and the weekly meetings with hospice did not include coordination of care with hospice related to the activity program for Resident #154. 3. Resident #90 was admitted to the facility on [DATE] with a history of Dementia. Review of the Minimum Data Set, dated dated [DATE], reflected Resident #90 has a Brief Interview Mental Status (BIMS) of 4. This score would show the resident to be severely impaired cognitively. Review of the May Medication Administration Record [REDACTED]. Review of the Pain Management Flow Sheet for Cognitively Impaired reflected on 5/21/17 N5 is documented under scale used. On 6/15/17 at 10:50 a.m. The Director of Nursing (DON) verified Resident #90 was cognitively impaired and not able to give numbers for her pain scale because of her dementia. The DON said Staff D should have documented pain observations for Resident #90 on 5/21/17. On 6/15/17 at 11:44 a.m. Staff D, Licensed Practical Nurse, verified the resident was not able to tell her the number scale. Staff D verified she had inaccurately assessed Resident #90 for her pain on 5/21/17. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was ordered to be given to the resident as needed for pain. There is no documentation in the resident's medical record of a pain assessment being completed on 6/4/17 before or after the administration of the medication. There was no documentation as to why the medication was administered to the resident. There was no documentation of the effectiveness of the medication once it was administered. On 6/15/17 11:11 a.m. The DON verified there was no pain assessment completed prior to the administration of [MEDICATION NAME] on 6/14/17 and there was no documenting of the effectiveness of the medication on that date.

Based on interview with the facility ' s nursing staff, a family member, and physicians, and review of the resident ' s medical record, facility policy, and disciplinary action reports, it was determined that the facility failed to protect the rights for one (#2) of 33 residents with a Full Code status, according to the resident census and resident code status audit tool of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation when the resident was found unresponsive, with no pulse or respirations. The facility staff did not begin the administration of CPR and did not call 911 for medical aide in accordance with their policy and procedure " Change in a Residents Condition or Status, " effective [DATE] and Revised [DATE], Advance Directives effective Feb. 2006 and revised in Nov. 2006, and the Licensed Practical Nurse position description revised ,[DATE]. The facility did not honor the advanced directives expressed by the resident. Failure of the facility staff to correctly implement advance directives resulted in findings of immediate jeopardy which was removed on [DATE] at 7:00 a.m. and the severity and scope were reduced to a D. Findings include: 1. Review of resident #2 ' s clinical record revealed a face sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. The resident signed an acknowledgement of advance directives on [DATE] indicating she fully understood that she was not required to have an Advance Directive in order to receive medical treatment at this facility and the terms of the Advance Directive document(s) that she had executed would be followed by the Facility and her care givers to the extent permitted by law. The resident checked that she had a living will, a durable power of attorney for financial authority, and a health care surrogate. All of these documents were located in the clinical record. No orders or yellow form for Do Not Resuscitate (DNR) were present in the record. Review of the resident ' s care plan, dated [DATE], revealed this resident required short term rehabilitation and desired to return home. The resident had a goal to transition to her prior living arrangements per progression of therapy, with a goal and target date of [DATE]. Review of the Discharge Goal/Plan documented by the social service representative on [DATE] revealed the discharge goal was to return home with family assistance. The physician ' s rehabilitation potential was checked as " good, " and the resident and her family were understanding and supportive of short term placement at the facility. Continued review of the clinical record revealed the resident signed an authorization for treatment form on [DATE] and [DATE] which granted " the professional staff of the nursing center to administer nursing and medical procedures as ordered by the resident ' s physician during the resident ' s stay in this center. " Review of the [DATE] physician order [REDACTED]. " Review of the vital sign record for [DATE] revealed the resident had a temperature of 96.9, a pulse of 56, respirations of 16, and a blood pressure of ,[DATE]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurses ' notes for [DATE] revealed the following entries: [DATE] 6:00 a.m. continues on antibiotics (ABT) for left lower lobe (LLL) infiltrate, no adverse reaction. Rested quietly this shift with no shortness of breath (SOB)/dyspnea. Oxygen at 2 liters as needed (PRN). Head of bed (HOB) elevated. Nebulizer treatments continue. Bed/chair alarms in place. [DATE] 11:00 a.m. Resident alert with periods of confusion. Continues on ABT for infiltrate. No signs or symptoms of adverse reactions. Remains afebrile. Oxygen saturation 96% on room air. Respirations even and unlabored. HOB up. No signs of respiratory distress noted. Will continue to monitor. [DATE] 2:00 p.m. Received PT/INR results. Call to attending physician. On call doctor gave new orders to hold [MEDICATION NAME] Monday [DATE] and recheck INR on [DATE]. [DATE] 3:00 p.m. Resident family had been in to visit earlier today. [DATE] 3:45 p.m. Oxygen saturation level at 94% on oxygen at 2 liters via nasal cannula, pulse 60. [DATE] 4:00 p.m. Resident taken to shower by C.N.A. Resident cheerful, laughing and making jokes. Resident drank [MEDICATION NAME]. Stated she wasn ' t feeling the greatest, but was feeling better then yesterday. [DATE] 4:15 p.m. Administered nebulizer treatment- resident tolerated well. [DATE] 11:00 p.m. At 5:15 p.m., C.N.A. took dinner tray into resident ' s room and found her non-responsive. Nurse responded and found resident without vital signs and nonresponsive to stimuli, body was noted to be cool to touch with ashen color. Second nurse checked resident and concurred with findings. On call doctor notified and gave order to release body to funeral home. (The DON was noted to concur with these findings and co-signed this note along with the resident ' s assigned nurse/LPN #3). [DATE] 11:15 p.m. Body picked up by funeral home at 10:40 p.m. [DATE] Late entry for [DATE] - responsible party notified of resident ' s expiration ... Review of the telephone orders revealed an order was noted by the LPN supervisor on [DATE] at 5:40 p.m. stating " May release remains to funeral home of choice ... " Review of the physician progress notes [REDACTED]. This note documented " Yesterday at 5:15 p.m. patient found ashen, cool without vital signs. No reason for CPR. Patient pronounced - family notified. " 2. A telephone interview with the resident ' s son on [DATE] at 1:25 p.m. revealed his mother had been admitted to the facility for therapy to treat a [MEDICAL CONDITION]. The resident ' s son felt his mother had been getting better, but she had contracted pneumonia during her stay at the facility and did not look well. The resident ' s son stated he was called on [DATE] at an unknown time to inform him of his mother ' s passing. He was told that about 40 minutes prior to being found unresponsive, his mother had received a shower and was in good spirits. He knew his mother had a living will stating that " if she was gone she did not want to be brought back to life. " He stated that in the past couple of days leading up to her death, she wasn ' t feeling well, but facility staff said she looked better every day. He stated there were days that she did look good, but not overall. The resident ' s son stated he thought the resident would have been better off if she had stayed in the hospital. 3. An interview with the nursing home administrator (NHA) on [DATE] at 1:52 p.m. revealed she left the facility around 3:30 p.m. to 4 00 p.m. on [DATE]. At approximately 5:40 p.m. on [DATE], she received a phone call from the Director of Nursing (DON) informing her that resident #2 had passed away. The NHA asked the DON if the resident had a DNR order. The DON initially responded " yes, " and then she said, " I don ' t know. " The administrator stated she immediately hung up with the DON and called the facility. The administrator spoke to the 3:00 p.m. to 11:00 p.m. LPN supervisor and was informed that resident #2 did not have a DNR order. The administrator informed the LPN supervisor she was coming into the facility. On the way to the facility, the NHA called the risk manager and corporate nurse to inform them of the incident and asked them to come to the facility to start an investigation. The NHA arrived at the facility around 6:20 p.m. on [DATE]. The risk manager was already present and interviewing the staff involved. The NHA and risk manager called the local police department because the resident was not on hospice, did not have a DNR order, and although she had multiple medical problems, her death was not anticipated. The police called Emergency Medical Services (EMS) who responded but did not administer any care or services. The police observed the resident ' s body for any signs of suspicious injuries, with none found. The police did not take the body and allowed the body to be released to the funeral home of the family ' s choice. All of the 3:00 p.m. to 11:00 p.m. nurses involved, who were assigned to work with residents on [DATE], were pulled from the schedule for the remainder of their shift and other nurses were brought into cover their assignments. The nurses involved in the incident remained off the schedule pending further investigation, disciplinary action, and in-service education on [DATE]. The attending physician was called on the night of [DATE] and a message was left informing him of the incident. The family was present in the facility on the night of [DATE] and they were informed of the facility ' s failure to administer CPR in the absence of a DNR order. The medical director was also contacted the following morning, [DATE], and informed of the incident. 4. Review of the Social Services - Advance Directives Policy and Procedure with an effective date of [DATE] and a Revision date of [DATE] revealed the facility failed to carry out the following items as documented in the Policy and Procedure. Policy: " Our Facility will identify a resident ' s choice for treatment and care, help the individual develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with our facility ' s ethics decision making policies and procedures, and Florida State law. " Purpose: " Our facility respects the resident ' s/legal representative ' s right to make the resident ' s own medical treatment decisions ... " Key Points: " 1. Resident Choice: Medical treatment decisions are a matter of personal choice ...the decision whether or not to act is always to the resident and/or legal representative. 2. Compliance with Florida Law: This facility will ensure that it is in compliance with the requirements of Florida law, whether statutory or as set forth in applicable court cases, on the subject of informed consent to medical treatment and the formulation of Advance Directives by residents. " 5. Review of the facility ' s Policy and Procedure for Nursing- Change in a Resident ' s Condition or Status with an effective date of [DATE] and a revision date of [DATE] revealed the facility failed to follow the following: Policy: " In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident ' s advance directives. " 6. Review of the facility ' s Licensed Practical Nurse position description revised ,[DATE] revealed the facility failed to implement the following: " Essential Functions: 2. Delivers nursing care to patients/resident. 3. Makes observations and reports pertinent information related to the care of the resident. 4. Implements the resident plan of care and evaluates the resident response. 12. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury). General Patient/Resident Care: 2. Interventions are performed in a timely manner ... 4. Treatments are completed as indicated. 8. Emergency situations are recognized and appropriate action is instituted. " 7. An interview with certified nurse ' s assistant (C.N.A.) #4 on [DATE] at approximately 3:15 p.m. revealed she has a full time assignment on the 3:00 p.m. to 11:00 p.m. shift on the front hall/rehab hall. The C.N.A. stated she was familiar with resident #2 as she was on the aide ' s regular assignment. The C.N.A. described resident #2 as being a nice lady who complained of having a head cold on [DATE]. At about 3:15 p.m. on [DATE], the C.N.A. recalled taking resident #2 ' s vital signs, which were normal, and then the C.N.A. laid her down in bed to rest. The C.N.A. remembered checking on the resident at about 4:00 p.m. and saw her working with the physical therapist in her room at that time. After this, the C.N.A. recalled another C.N.A. (#5) taking the resident for a shower. The C.N.A. saw resident #2 again at approximately 5:00 p.m. and did not notice anything unusual, " she seemed fine. " At approximately 5:20 p.m. the C.N.A. entered resident #2 ' s room with her dinner tray and placed it on her overbed table. Resident #2 ' s eyes were closed. The C.N.A. shook the resident ' s arm to wake her up, but she did not respond. The C.N.A. looked at the resident ' s chest and it was not moving. The C.N.A. stated, " I thought she had passed on but then she expelled some breath. " The C.N.A. shook the resident, again, but there was no response. The C.N.A. then began crying and looked out of the resident ' s room to get the attention of a nurse. She saw C.N.A. #5 standing in front of the nurse ' s station and LPN #2 was seated at the nurse ' s station. She called out to C.N.A. #5 to get LPN #2 to come to the room. C.N.A. #4 then noticed another nurse, LPN #1, in the room next door. C.N.A. #4 told LPN #1, " Come quick, I need you. " LPN #1 immediately responded and was informed by C.N.A. #4 that she thought resident #2 " was gone, she ' s not breathing. " C.N.A. #4 could not recall what LPN #1 did because she was so upset. The C.N.A. did remember LPN #1 left the room to go get resident #2 ' s assigned nurse, LPN #3. LPN #1 then returned to the room with LPN #3. Just as these nurses returned to the room, the 3:00 p.m. to 11:00 p.m. LPN supervisor also entered the room. The LPN supervisor felt for resident #2 ' s pulse and then stated, " We need to do CPR. " C.N.A. #4 then recalled the Director of Nursing (DON) entered the room. At this time, C.N.A. #4 asked the LPN supervisor if she could leave the room and was told yes. C.N.A. #4 then left the room and did not have any additional information to report on resident #2. 8. Interview with LPN #1 on [DATE] at 2:23 p.m. revealed she has worked at the facility for about [AGE] years on the 3:00 p.m. to 11:00 p.m. shift four days a week. LPN #1 was not familiar with resident #2, as she had a regular assignment on a different hallway. LPN #1 recalled bringing a resident a drink at about 5:15 p.m. on [DATE] when C.N.A. #4 gestured to her that she needed her in the room next door. The C.N.A. informed LPN #1 that resident #2 was not breathing right. LPN #1 looked at the resident and described her as pale, with a closed mouth. LPN #1 stated she may have been expelling some breath. The LPN tried to get an idea from the C.N.A. if resident #2 was on hospice and how long she had been in this condition. C.N.A. #4 was not able to give LPN #1 any information. LPN #1 then went to call for help and just as she did, LPN #2 was coming into the resident ' s room. LPN #1 told LPN #2, " She doesn ' t look good, the C.N.A. can ' t give me any information on this woman, and her assigned nurse is in the dining room. " LPN #2 then said, " We need the chart; I am going to get her nurse. " LPN #1 proceeded to get LPN #3 from the dining room. LPN #1 and LPN #3 immediately went to resident #2 ' s room and as they arrived there, the LPN supervisor was entering the room. The resident ' s curtain was pulled and as LPN #1 began to enter, the LPN supervisor requested a stethoscope. LPN #1 ran to get one from the medication cart. At that time, LPN #1 saw LPN #2 at the nurse ' s station. She told LPN #2, " We need the chart, " and then ran back to the resident ' s room to deliver the stethoscope. The LPN supervisor told LPN #1, " We need the DON. " LPN #1 left the room again to get the DON but saw the DON heading up the hallway with C.N.A. #5. LPN #1 told the DON she was needed in the resident ' s room and then LPN #1 went to the nurse ' s station. At this time, LPN #2 told LPN #1, " Here ' s the chart, " but when LPN #1 looked at the exterior of the chart, she noticed LPN #2 had the wrong chart. LPN #1 told LPN #2 this was the wrong chart and they then retrieved the correct chart. The two nurses went through the chart and did not see any do not resuscitate (DNR) orders. Suddenly, another C.N.A. came out of the dining room into the hallway and gestured with her hands up that she needed a nurse in the dining room. LPN #1 asked LPN #2 if he wanted to go to the dining room or should she go to the dining room. LPN #2 told LPN #1 to go to the dining room and LPN #2 stated he would take care of the chart. LPN #1 then proceeded to the dining room and did not have any additional information to report on resident #2. However, LPN #1 stated that usually when a resident is found unresponsive, an aide or a nurse stays in the room while the other person checks the resident ' s chart for code status. If indicated, they would then start CPR with one person calling the doctor, one person getting the crash cart, and then proceeding from there. In this instance, resident #2 was pale but her lips were closed and she was pushing some air out, " very faint. " Because C.N.A. #4 could not give LPN #1 any information, they needed her chart and her nurse to get more information. LPN #1 stated, " We handle a lot of hospice patients at the facility and some have DNR orders and others do not. " 9. Interview with LPN #2 on [DATE] at approximately 4:00 p.m. revealed he has worked at the facility for 2 years and has a regular part time assignment 3 days a week on the 3:00 p.m. to 11:00 p.m. shift. LPN #2 recalled he was working on new admission paperwork at the nurse ' s station on [DATE] at about 5:15 p.m. when he was informed by C.N.A. #5 that C.N.A. #4 wanted him. When LPN #2 looked up from the nurse ' s station, he saw C.N.A. #4 waving for him to come to resident #2 ' s room. LPN #2 was not familiar with resident #2, as he had never been assigned to her care, but he proceeded to the resident ' s room. As LPN #2 was walking down the hallway, he saw LPN #1 enter the room. As LPN #2 arrived at the room, LPN #1 was walking out of the room. LPN #1 stated to LPN #2, " I don ' t think this woman is breathing; I think she is dead, take a look. " LPN #2 looked at resident #2 and she appeared pale and motionless. LPN #2 took the resident ' s left arm by the wrist and shook her arm to stimulate her. He did not know the resident ' s name and was just calling out " ma ' am. " He described the resident as " just lifeless. " He checked resident #2 ' s radial pulse and carotid pulse but did not feel anything. LPN #2 recalled LPN #1 stated she didn ' t know the woman and she was going to get her nurse, LPN #3. LPN #2 stated he also was unfamiliar with the resident and he proceeded to the nurse ' s station to check the chart. As LPN #2 arrived back at the nurse ' s station, he accidentally pulled the wrong chart, but within seconds, he recalled LPN #1 arrived and told him he had the wrong chart. LPN #1 then pulled the correct chart and both LPN #1 and LPN #2 looked at the chart together. Because LPN #2 was unfamiliar with the resident, he brought the entire chart to the resident ' s room. The LPN supervisor and the DON were in the room when he arrived. LPN #2 gave the LPN supervisor the chart and did not take any further action. LPN #2 stated he did not find a DNR order when he reviewed the resident ' s record. He stated the front of resident #2 ' s chart was white and if they are a DNR, the outside of the chart is yellow. However, they still have to look for the DNR paperwork. LPN #2 stated again that he was not familiar with the resident. He felt he needed to take the chart to the room to let somebody else check it out. He recalled standing in resident #2 ' s room as the LPN supervisor and the DON situated the resident properly in the bed. He was in the room for one to two minutes at the most. He did not say anything, he just handed the LPN supervisor the chart, and the LPN supervisor stated, " I ' m going to go call the doctor. " 10. Interview with LPN #3 on [DATE] at 11:49 a.m. revealed she is a newly licensed LPN and has been working at the facility for approximately 8 months. LPN #3 works full time on the 3:00 p.m. to 11:00 p.m. shift with a regular assignment on the front hall/rehab hall. LPN #3 was familiar with resident #2 as she was her assigned nurse since she was admitted to the facility in December of 2011. The LPN described resident #2 as being " laid back, " pleasant, able to make her needs knows and attended physical and occupational therapy regularly. Her family was involved in her care and she was coming off treatment for [REDACTED]. Resident #2 was progressing well but still did not have her strength up. She was at the facility to re-gain her strength. LPN #3 recalled giving resident #2 her medications around 4:00 p.m. on [DATE]. At that time, she was getting ready to go for her shower. When the resident returned from her shower at approximately 4:15 p.m., the nurse administered her routine nebulizer treatment. The resident was talking, joking, and laughing with LPN #3. She left the resident sitting straight up in her bed after providing her the breathing treatment. At approximately 5:15 p.m. LPN #1 came to the dining room and told LPN #3 she needed to come and check her patient. LPN #1 informed her the resident didn ' t look good and there ' s something going on. LPN #3 hesitated at the door of the dining room for about a minute because she was the only nurse there but she did eventually proceed to the resident ' s room. LPN #3 arrived at the room and the LPN supervisor entered right behind her. LPN #3 walked to one side of the bed and the LPN supervisor went on the other side. The LPN supervisor checked the resident for a pulse but there was no pulse and no respirations. The LPN supervisor asked for a stethoscope. LPN #3 was not sure who left to get the stethoscope but recalled LPN #1 returning with one. The LPN supervisor could not hear a heartbeat and could not find an apical pulse. The LPN supervisor asked for someone to get the DON. The DON came in the room and also checked for vitals. The DON concurred the resident was absent of pulse and respirations. LPN #3 recalled that just as the DON was entering the room, the LPN supervisor said we should start CPR. LPN #3 was not sure if the DON heard the LPN supervisor ' s statement regarding CPR. LPN #3 stated neither one of us (meaning herself and the LPN supervisor) jumped in and started CPR. LPN #3 did not know if anyone was checking to see the resident ' s code status and she did not know the resident ' s code status off- hand. LPN #3 stated resident #2 was ashen, her mouth was open and would not close, and she was limp and cool to the touch. The LPN stated " she was lifeless. " At the end of this interview, LPN #3 began to cry. When asked why she was crying she stated, " Being a new nurse I should have known better. I guess what upsets me the most, is she should have gotten CPR. That was her wish. " LPN #3 stated she did not call the doctor, speak to the family, or have any other involvement with this incident. 11. Interview on [DATE] at 12:55 p.m. with the 3:00 p.m. to 11:00 p.m. LPN supervisor revealed she has worked at the facility for almost 6 years and has been the supervisor for the evening shift for about 3 and a half years. The LPN supervisor was somewhat familiar with resident #2. She recalled the resident had some cold symptoms about a week earlier than [DATE] and a chest x-ray was done. The resident had been on antibiotics and had stated she was not feeling good and was hoping she could shake whatever she had. On [DATE] the LPN supervisor recalled coming out of the nourishment room when she was approached by C.N.A. #5 who told her she was needed in the resident ' s room. The LPN supervisor walked to the room and over to the resident ' s side of the room. The resident was ashen in color and looked like she had expired. The LPN supervisor recalled both C.N.A. #4 and #5 were in the room as well as LPN #3. The LPN supervisor checked the resident ' s radial pulse but there was no pulse. She asked for someone to get her a stethoscope. She remembered LPN #1 bringing the stethoscope. The LPN supervisor used the stethoscope to check for an apical pulse but there was none. She raised the bed up to try to get the resident in a better position but still could not get an apical pulse. The LPN supervisor also tried to get a carotid pulse but she could not get the resident in a good position because her mouth was open and her jaw was locked. The resident was not responding to anything. The LPN supervisor asked for somebody to call for the DON so she could check also. The DON arrived within a minute to a minute and half, maybe sooner. The DON " pretty much did the same thing, and she couldn ' t get anything. " The LPN supervisor could not recall if someone went to get the resident ' s chart. She just remembered the DON saying there were no vitals, she ' s not responding, and she was cool to the touch. After talking to the DON, the LPN supervisor said she would call the doctor. The LPN supervisor received the attending physician ' s answering service and was told a different physician was on-call. The answering service placed the LPN supervisor on hold for approximately 3 to 5 minutes until the on call physician came on the line. She informed the on call physician that resident #2 had no vital signs, and was unresponsive. She also described the resident ' s ashen skin color and stiff mouth position to the doctor. The physician gave the order to release the body to the funeral home of the family ' s choice. After that, the LPN supervisor called the resident ' s family and informed them the resident had expired and they could come in to see the resident if they wished. The resident ' s family did arrive that evening, exact time unknown and informed them of the funeral home they wanted. Continued interview with the LPN supervisor revealed she did not realize the resident was a full code until about a half an hour after the resident had expired. She stated the family did not say anything to her and the doctor did not ask. She stated she did not check that part of the resident ' s chart. 12. Interview with the DON on [DATE] at 4:30 p.m. revealed she was familiar with resident #2. She had many interactions with resident #2 ' s son as he was very concerned for his mother and wanted everything just right for her. The DON recalled resident #2 had a great day on [DATE]. She was joking with the C.N.A., had received a shower, and had received her medications. At approximately 5:10 p.m. or 5:15 p.m. C.N.A. #5 came to the nurse ' s office and told the DON, " I think the LPN supervisor needs you in resident #2 ' s room. " C.N.A. #5 and the DON then proceeded to the resident ' s room. When the DON arrived, she recalled the privacy curtain was half closed. The resident was lying there, unresponsive and ashen in color. LPN #3 was on one side of the bed, C.N.A. #4 was at the bottom of the bed crying, and the LPN supervisor was standing there holding a stethoscope. The LPN supervisor asked the DON, " Can you check behind me because I can ' t hear anything. " The DON then checked for a pulse in the resident ' s wrist, heart sounds, carotid pulse, and breath sounds. The DON recalled trying to move the resident ' s jaw which wasn ' t rigid but was very difficult to move up. The resident was cool to the touch but not frigid. The DON told the LPN supervisor, " I don ' t hear anything either. " The resident ' s head of the bed was up. The LPN supervisor then looked at the clock and said, " It ' s 5:20 p.m.; I ' m going to go call the doctor. " The DON said she would stay with the resident and the DON and LPN #3 were talking and straightening up the resident ' s covers. It was at that time the DON recalled LPN #2 coming into to room behind her but not saying anything. The DON remembered the LPN supervisor walking out of the room and LPN #2 then followed the LPN supervisor. A little while later, the DON spoke to the LPN supervisor who informed her she had reached the on-call doctor for the resident ' s attending physician. The on-call doctor gave orders to release the body. About 20 minutes later, the DON called the nursing home administrator (NHA) on her drive home to inform her resident #2 had passed. The NHA asked the DON if the resident had a DNR order. The DON ' s first response was " of course " but then she said, " You know what, I never saw the chart. " The DON stated she had assumed that the reason she was called to the room was to confirm there were no vital signs as this is their typical procedure for a DNR if the DON is present in the facility. After hanging up the phone with the NHA, the DON called the facility and spoke to LPN #3. The DON asked LPN #3 if resident #2 had a DNR order. LPN #3 told the DON no; she was a full code. The DON stated that when she walked into the resident ' s room, and two nurses and a C.N.A. were just standing there, she assumed the resident was a DNR. The DON then stated " stupid, I guess we miscommunicated. " The DON said this was also when she found out LPN #2 had the resident ' s chart in his hands when he had come into the room but didn ' t say anything. Immediately after the DON discovered resident #2 did not have a DNR order, she, the corporate nurse, the administrator, and the risk manager returned to the facility to begin an investigation and start education with the staff involved. 13. Interview on [DATE] at 2:59 p.m. with C.N.A. #5 revealed she has worked at the facility for 5 years and has a regular assignment on the north hall/front hall on the 3:00 p.m. to 11:00 p.m. shift. Prior to [DATE], C.N.A. #5 had worked with resident #2 in passing. She was not assigned to care for resident #2, but she had answered her call light in the past. On [DATE] C.N.A. #5 was assigned to shower resident #2. Resident #2 was showered around 4:00 p.m. on [DATE] and appeared fine. The resident was coughing and told the C.N.A. she had a cold. The resident was moving around and was able to transfer without difficulty. The resident was pleasant and the C.N.A. did not notice anything unusual. At around 5:15 p.m. to 5:30 p.m. C.N.A. #4 stepped out of the resident ' s room and asked her to get LPN #2. C.N.A. #5 got LPN #2 and she and the LPN walked to the room to see if any assistance was needed. It was at that time C.N.A. #5 saw that resident #2 was not alive. The resident looked very pale, wasn ' t moving, and was lying back on the bed. C.N.A. #5 then left the room to find the LPN supervisor. She found the LPN supervisor and told her she needed to go to resident #2 ' s room as she looked like she was no longer alive. The C.N.A. then went to get the DON. She told the DON that she was probably going to be needed in resident #2 ' s room because she didn ' t look like she was alive. The DON and C.N.A. #5 then went to the resident ' s room. The C.N.A. asked all the staff in the room if they needed her to get anything and was told they didn ' t need her anymore. C.N.A. #5 did not have any further information to provide about resident #2. 14. Telephone interview with resident #2 ' s attending physician on [DATE] at 12:45 p.m. revealed he was not working on the night resident #2 was found unresponsive. However, he was contacted by facility staff after the incident to inform him of what had occurred. The physician was told the resident was found unresponsive, without pulse/respirations, ashen in color, and cool to the touch. He was also told that her jaw was in the open position and could not be closed. This made the phy

Based on interview with facility staff, physicians, and a family member, and review of the resident ' s medical record, facility policy, and employee disciplinary action reports, it was determined that the facility failed to ensure that needed services for resuscitation were initiated for one (#2) of 33 residents identified as full code, according to the resident code status audit tool and resident census of [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation (CPR) when the resident was found with no pulse or respirations. The facility did not implement their policy and procedure, " Change in a Residents Condition or Status, " effective [DATE] and Revised [DATE] and Advance Directives effective February 2006 and revised [DATE], as staff did not begin the administration of CPR and did not call 911 for medical aide. The facility did not honor the expressed wishes of the resident. Failure of the facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy which was removed on [DATE] at 7:00 a.m. and the severity and scope was reduced to a D. Findings include: 1. Review of resident #2 ' s clinical record was conducted. Per the facility face sheet, her birthdate was [DATE] and she was admitted to the facility on [DATE]. The resident signed an acknowledgement of advance directives on [DATE] indicating she fully understood that she was not required to have an Advance Directive in order to receive medical treatment at this facility and the terms of the Advance Directive document(s) that she had executed would be followed by the Facility and her care givers to the extent permitted by law. The resident indicated that she had a living will, a health care surrogate and a durable power of attorney for financial authority. The resident did not indicate that she had a Florida Do Not Resuscitate Order. Continued review of the clinical record revealed the resident signed an authorization for treatment form on [DATE] and [DATE] which granted " the professional staff of the nursing center to administer nursing and medical procedures as ordered by the resident ' s physician during the resident ' s stay in this center. " Review of the [DATE] physician order [REDACTED]. " The resident ' s care plan, dated [DATE], was reviewed. The resident required short term rehabilitation and desired to return home. The resident had a goal to transition to her prior living arrangements per progression of therapy, with a goal and target date of [DATE]. Review of the progress note by the advanced registered nurse practitioner (ARNP) for the attending physician on [DATE] revealed the reason for the resident ' s admission was a non-syncopal fall resulting in right [MEDICAL CONDITION] and she was status [REDACTED]. The resident also had a past medical history of [REDACTED]. The resident was oriented and alert. The impression was listed as: right [MEDICAL CONDITION], history of [MEDICAL CONDITIONS], non-syncopal fall resulting in [MEDICAL CONDITION], and dementia. The plan was to continue physical and occupational therapy. The resident was seen by the attending physician on [DATE] and [DATE] and noted to have chest x-rays which indicated a left lower lobe infiltrate. The resident was placed on two separate courses of antibiotics and her [MEDICATION NAME] breathing treatments were changed from as needed (PRN) to three times a day. In addition, an order was written on [DATE] to record oxygen saturations each shift and to maintain oxygen saturation greater than 92%. The physician also ordered 2 liters of oxygen as needed on [DATE]. The resident ' s vital signs were recorded on each shift with the most recent vital sign record completed on [DATE]. The [DATE] vital signs noted a temperature of 96.9, a pulse rate of 56, respirations of 16, and a blood pressure of ,[DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]% on the 7:00 a.m. to 3:00 p.m. shift, and 94% on the 3:00 p.m. to 11:00 p.m. shift. A review of the nurses ' notes for [DATE] revealed the following entries: [DATE] 6:00 a.m. continues on antibiotics (ABT) for left lower lobe (LLL) infiltrate, no adverse reaction. Rested quietly this shift with no shortness of breath (SOB)/dyspnea. Oxygen at 2 liters as needed (PRN). Head of bed (HOB) elevated. Nebulizer treatments continue. Bed/chair alarms in place. [DATE] 11:00 a.m. Resident alert with periods of confusion. Continues on ABT for infiltrate. No signs or symptoms of adverse reactions. Remains afebrile. Oxygen saturation 96% on room air. Respirations even and unlabored. HOB up. No signs of respiratory distress noted. Will continue to monitor. [DATE] 2:00 p.m. Received PT/INR results. Call to attending physician. On call doctor gave new orders to hold [MEDICATION NAME] Monday [DATE] and recheck INR on [DATE]. [DATE] 3:00 p.m. Resident family had been in to visit earlier today. [DATE] 3:45 p.m. Oxygen saturation level at 94% on oxygen at 2 liters via nasal cannula, pulse 60. [DATE] 4:00 p.m. Resident taken to shower by C.N.A. Resident cheerful, laughing and making jokes. Resident drank [MEDICATION NAME]. Stated she wasn ' t feeling the greatest, but was feeling better then yesterday. [DATE] 4:15 p.m. Administered nebulizer treatment- resident tolerated well. [DATE] 11:00 p.m. At 5:15 p.m. C.N.A. took dinner tray into resident ' s room and found her non-responsive. Nurse responded and found resident without vital signs and nonresponsive to stimuli, body was noted to be cool to touch with ashen color. Second nurse checked resident and concurred with findings. On call doctor notified and gave order to release body to funeral home. (The DON was noted to concur with these findings and co-signed this note along with the resident ' s assigned nurse/LPN #3). [DATE] 11:15 p.m. Body picked up by funeral home at 10:40 p.m. [DATE] Late entry for [DATE] - responsible party notified of resident ' s expiration. On [DATE] a note by the attending physician noted that yesterday at 5:15 p.m. patient found ashen, cool without vital signs. No reason for CPR. Patient pronounced - family notified. 2. An interview was conducted with certified nurse ' s assistant (C.N.A.) #4 on [DATE] at approximately 3:15 p.m. She stated she had a full time assignment on the 3:00 p.m. to 11:00 p.m. shift on the front hall/rehab hall. The C.N.A. stated she was familiar with resident #2, as she was on the aide ' s regular assignment. The C.N.A. described resident #2 as being a nice lady who complained of having a head cold on [DATE]. At about 3:15 p.m. on [DATE], the C.N.A. recalled taking resident #2 ' s vital signs, which were normal, and then the C.N.A. laid her down in bed to rest. The C.N.A. remembered checking on the resident at about 4:00 p.m. and saw her working with the physical therapist in her room at that time. Afterwards, the C.N.A. recalled another C.N.A. (#5) taking the resident for a shower. The C.N.A. saw resident #2, again, at approximately 5:00 p.m. and did not notice anything unusual, " she seemed fine. " At approximately 5:20 p.m., the C.N.A. entered resident #2 ' s room with her dinner tray and placed it on her overbed table. Resident #2 ' s eyes were closed. The C.N.A. shook the resident ' s arm to wake her up, but she did not respond. The C.N.A. looked at the resident ' s chest and saw no movement. The C.N.A. stated, " I thought she had passed on, but then she expelled some breath. " The C.N.A. shook the resident again but there was no response. The C.N.A. began crying and looked out of the resident ' s room to get the attention of a nurse. She saw C.N.A. #5 standing in front of the nurse ' s station and LPN #2 seated at the nurse ' s station. She called out to C.N.A. #5 to get LPN #2 to come to the room. C.N.A. #4 then noticed another nurse, LPN #1, in the room next door. C.N.A. #4 told LPN #1 " Come quick, I need you. " LPN #1 immediately responded and was informed by C.N.A. #4 that she thought resident #2 was gone, that she ' s not breathing. C.N.A. #4 could not recall what LPN #1 did because she was so upset. The C.N.A. did remember LPN #1 left the room to go get resident #2 ' s assigned nurse, LPN #3. LPN #1 then returned to the room with LPN #3. Just as these nurses returned to the room, the 3:00 p.m. to 11:00 p.m. LPN supervisor also entered the room. The LPN supervisor felt for resident #2 ' s pulse and then stated, " We need to do CPR. " C.N.A. #4 then recalled the Director of Nursing (DON) entered the room. At this time, C.N.A. #4 asked the LPN supervisor if she could leave the room and was told yes. C.N.A. #4 then left the room and did not have any additional information to report on resident #2. 3. During an interview with LPN #1 on [DATE] at 2:23 p.m. she stated she has worked at the facility for about [AGE] years, on the 3:00 p.m. to 11:00 p.m. shift, four days a week. LPN #1 was not familiar with resident #2, as she had a regular assignment on a different hallway. LPN #1 recalled bringing a resident a drink at about 5:15 p.m. on [DATE] when C.N.A. #4 gestured to her that she needed her in the room next door. The C.N.A. informed LPN #1 that resident #2 was " not breathing right. " LPN #1 looked at the resident and described her as pale, with a closed mouth. LPN #1 stated the resident may have been expelling some breath. The LPN tried to get an idea from the C.N.A. if resident #2 was on hospice and how long she had been in this condition. C.N.A. #4 was not able to give LPN #1 any information. LPN #1 then went to call for help, and just as she did, LPN #2 entered the resident ' s room. LPN #1 told LPN #2, " She doesn ' t look good, the C.N.A. can ' t give me any information on this woman, and her assigned nurse is in the dining room. " LPN #2 then said, " We need the chart; I am going to get her nurse. " LPN #1 proceeded to get LPN #3 from the dining room. LPN #1 and LPN #3 immediately went to resident #2 ' s room, and as they arrived there, the LPN supervisor was entering the room. The resident ' s curtain was pulled, and as LPN #1 began to enter, the LPN supervisor requested a stethoscope. LPN #1 ran to get one from the medication cart. At that time, LPN #1 saw LPN #2 at the nurse ' s station. She told LPN #2, " We need the chart " and then ran back to the resident ' s room to deliver the stethoscope. The LPN supervisor told LPN #1, " We need the DON. " LPN #1 left the room again to get the DON but saw the DON heading up the hallway with C.N.A. #5. LPN #1 told the DON she was needed in the resident ' s room and then LPN #1 went to the nurse ' s station. At this time, LPN #2 told LPN #1, " Here ' s the chart " , but when LPN #1 looked at the exterior of the chart, she noticed LPN #2 had the wrong chart. LPN #1 told LPN #2 that this was the wrong chart and they then retrieved the correct chart. The two nurses went through the chart and did not see any Do Not Resuscitate orders. Suddenly, another C.N.A. came out of the dining room into the hallway and gestured with her hands up that she needed a nurse in the dining room. LPN #1 asked LPN #2 if he wanted to go to the dining room or should she go to the dining room. LPN #2 told LPN #1 to go to the dining room and LPN #2 stated he would take care of the chart. LPN #1 then proceeded to the dining room and did not have any additional information to report on resident #2. However, LPN #1 stated that usually when a resident is found unresponsive, an aide or a nurse stays in the room while the other person checks the resident ' s chart for code status. If indicated, they would then start CPR with one person calling the doctor, one person getting the crash cart, and then proceeding from there. In this instance, resident #2 was pale but her lips were closed and she was pushing some air out, " very faint. " Because C.N.A. #4 could not give LPN #1 any information, they needed her chart and her nurse to get more information. LPN #1 stated, " We handle a lot of hospice patients at the facility and some have Do Not Resuscitate (DNR) orders and others do not. " 4. An interview with LPN #2 on [DATE] at approximately 4:00 p.m. revealed he has worked at the facility for 2 years and has a regular part time assignment 3 days a week on the 3:00 p.m. to 11:00 p.m. shift. LPN #2 recalled he was working on new admission paperwork at the nurse ' s station on [DATE] at about 5:15 p.m. when he was informed by C.N.A. #5 that C.N.A. #4 wanted him. When LPN #2 looked up from the nurse ' s station, he saw C.N.A. #4 waving for him to come to resident #2 ' s room. LPN #2 was not familiar with resident #2 as he had never been assigned to her care, but he proceeded to the resident ' s room. As LPN #2 was walking down the hallway, he saw LPN #1 enter the room. As LPN #2 arrived at the room, LPN #1 was leaving the room. LPN #1 stated to LPN #2, " I don ' t think this woman is breathing; I think she is dead. Take a look. " LPN #2 looked at resident #2 and she was pale and motionless. LPN #2 grabbed the resident ' s left arm by the wrist and shook her arm to stimulate her. He did not know the resident ' s name and was just calling out " ma ' am. " He described the resident as " just lifeless. " He checked resident #2 ' s radial pulse and carotid pulse but did not feel anything. LPN #2 recalled LPN #1 stated she didn ' t know the woman and she was going to get her nurse, LPN #3. LPN #2 stated he also was unfamiliar with the resident and he proceeded to the nurse ' s station to check the resident ' s chart. As LPN #2 arrived back at the nurse ' s station, he accidentally pulled the wrong chart but within seconds he recalled LPN #1 arriving and telling him he had the wrong chart. LPN #1 then pulled the correct chart and both LPN #1 and LPN #2 looked at the chart together. Because LPN #2 was unfamiliar with the resident he brought the entire chart to the resident ' s room. The LPN supervisor and the DON were in the room when he arrived. LPN #2 gave the LPN supervisor the chart. LPN #2 stated he did not find a DNR order when he reviewed the resident ' s record. He stated, " The front of her chart was white and we have yellow on the outside of the chart if the resident is a DNR, " but he still looked for the DNR paperwork. LPN #2 stated again that he was not familiar with the resident. He felt he needed to take the chart to the room to let somebody else check it. He recalled standing in resident #2 ' s room as the LPN supervisor and the DON situated the resident properly in the bed. He was in the room for one to two minutes at the most. He did not say anything, he just handed the LPN supervisor the chart, and the LPN supervisor stated, " I ' m going to go call the doctor. " 5. An interview with LPN #3 on [DATE] at 11:49 a.m. revealed she is a newly licensed LPN and has been working at the facility for approximately 8 months. LPN #3 works full time on the 3:00 p.m. to 11:00 p.m. shift with a regular assignment of the front hall/rehab hall. LPN #3 was familiar with resident #2 as she was on her assigned hall since admission to the facility. The LPN described resident #2 as being " laid back, " pleasant, able to make her needs known and attended physical and occupational therapy regularly. Her family was involved in her care and she was finishing treatment for [REDACTED]. The LPN stated resident #2 had been on antibiotics and breathing treatments related to the infiltrate but had also had breathing treatments at home prior to admission to the facility. Resident #2 was progressing well but still did not have her strength up, but that ' s why she was at the facility. LPN #3 recalled giving resident #2 her medications around 4:00 p.m. on [DATE]. At that time, the resident was getting ready to go for her shower. When the resident returned from her shower at approximately 4:15 p.m., the nurse administered her routine nebulizer treatment. The resident was talking, joking, and laughing with LPN #3. She left the resident sitting straight up in her bed after providing her the breathing treatment. At approximately 5:15 p.m. LPN #1 came to the dining room and told her she needed to come and check her patient. LPN #1 informed her the resident didn ' t look good and there ' s something going on. LPN #3 hesitated at the door of the dining room for about a minute because she was the only nurse there, but then she proceeded to go to the room. LPN #3 arrived at the room and the LPN supervisor entered right behind her. LPN #3 walked to one side of the bed and the LPN supervisor went to the other side. The LPN supervisor checked the resident for a pulse but there was no pulse and no respirations. The LPN supervisor asked for a stethoscope. LPN #3 was not sure who left to get the stethoscope but recalled LPN #1 returning with one. The LPN supervisor could not hear a heartbeat and could not find an apical pulse. The LPN supervisor asked for someone to get the DON. The DON came in the room and also checked for vitals. The DON concurred that pulse and respirations were absent. LPN #3 recalled that just as the DON was entering the room, the LPN supervisor said, " We should start CPR. " LPN #3 was not sure if the DON heard the LPN ' s statement regarding CPR. LPN #3 stated, " Neither one of us (meaning herself and the LPN supervisor) jumped in and started CPR. " LPN #3 did not know if anyone was checking to see the resident ' s code status. LPN #3 stated resident #2 was ashen, her mouth was open and would not close, and she was limp and cool to the touch when she arrived in the room. The LPN stated " she was lifeless. " LPN #3 stated she did not know resident #2 ' s code status at the time of the incident. At the end of this interview, LPN #3 began to cry. When asked why she was crying she stated, " Being a new nurse I should have known better. I guess what upsets me the most, is she should have gotten CPR. That was her wish. " LPN #3 stated she did not call the doctor, speak to the family, or have any other involvement with this incident. 6. During an interview on [DATE] at 2:59 p.m. with C.N.A. #5, she stated she has worked at the facility for 5 years and has a regular assignment on the north hall/front hall on the 3:00 p.m. to 11:00 p.m. shift. Prior to [DATE], C.N.A. #5 had worked with resident #2 in passing. She was not assigned to care for resident #2, but she had answered her call light in the past. On [DATE], C.N.A. #5 was assigned to shower resident #2. Resident #2 was showered around 4:00 p.m. on [DATE] and appeared fine. The resident was coughing and told the C.N.A. she had a cold. The resident was moving around okay and was able to transfer without difficulty. The resident was pleasant and the C.N.A. did not notice anything unusual. At around 5:15 p.m. to 5:30 p.m. C.N.A. #4 stepped out of the resident ' s room and asked her to get LPN #2. C.N.A. #5 found LPN #2 and she and the LPN walked to the room to see if any assistance was needed. It was at that time C.N.A. #5 saw that resident #2 was not alive. The resident looked very pale, was not moving, and was lying back on the bed. C.N.A. #5 then left the room to find the LPN supervisor. She found the LPN supervisor and told her she needed to go to resident #2 ' s room as she looked like she was no longer alive. The C.N.A. then went to get the DON. She told the DON that she was probably going to be needed in resident #2 ' s room because resident #2 didn ' t look like she was alive. The DON and C.N.A. #5 then went to the resident ' s room. The C.N.A. asked all the staff in the room if they needed her to get anything and was told they didn ' t need her anymore. C.N.A. #5 did not have any further information to provide on resident #2. 7. An interview on [DATE] at 12:55 p.m. with the 3:00 p.m. to 11:00 p.m. LPN supervisor revealed she has worked at the facility for almost 6 years and had been the supervisor for the evening shift for about 3 and a half years. The LPN supervisor was somewhat familiar with resident #2. She recalled the resident had some cold symptoms about a week earlier than [DATE] and a chest x-ray was done. The resident had been on antibiotics and had stated she was not feeling good and was hoping she could shake whatever she had. On [DATE] the LPN supervisor recalled coming out of the nourishment room when she was approached by C.N.A. #5 who told her she was needed in the resident ' s room. The LPN supervisor walked to the room and over to the resident ' s side of the room. The resident was ashen in color and looked like she had expired. The LPN supervisor recalled both C.N.A. #4 and #5 were in the room as well as LPN #3. The LPN supervisor checked the resident ' s radial pulse but there was no pulse. She asked for someone to get her a stethoscope. She was unsure who brought her the stethoscope but remembered LPN #1 bringing it in. The LPN supervisor used the stethoscope to check for an apical pulse, but there was none. She raised the bed up to try to get the resident in a better position, but still could not find an apical pulse. The LPN supervisor also tried to find a carotid pulse but she could not get the resident in a good position because her mouth was open and her jaw was locked. The resident was not responding to anything. The LPN supervisor asked for somebody to call for the DON so she could check also. The DON arrived within a minute to a minute and half, maybe sooner. The DON " pretty much did the same thing, and she couldn ' t get anything. " The LPN supervisor could not recall if someone went to get the resident ' s chart. She just remembered the DON saying there were no vitals, she ' s not responding, and she was cool to the touch. After talking to the DON, the LPN supervisor said she would call the doctor. The LPN supervisor received the attending physician ' s answering service and was told a different physician was on-call. The answering service placed the LPN supervisor on hold for approximately 3 to 5 minutes until the on call physician came on the line. She informed the on call physician that resident #2 had no vital signs and was unresponsive. She also described the resident ' s ashen skin color and stiff mouth position to the doctor. The physician gave the order to release the body to the funeral home of the family ' s choice. After that, the LPN supervisor called the resident ' s family and informed them the resident had expired and they could come in to see the resident if they wished to. The resident ' s family did arrive that evening, exact time unknown and informed them of the funeral home they wanted. Continued interview with the LPN supervisor revealed she did not realize the resident was a full code until about a half an hour after the resident had expired. She stated the family did not say anything to her and the doctor did not ask. She stated she did not check that part of the resident ' s chart. 8. An interview was conducted with the DON on [DATE] at 4:30 p.m. She stated she was familiar with resident #2. She had many interactions with resident #2 ' s son as he was very concerned for his mother and wanted everything just right for her. The DON recalled resident #2 had a great day on [DATE]. She was joking with the C.N.A., had received a shower, and had been given her medications. At approximately 5:10 p.m. or 5:15 p.m. C.N.A. #5 came to the nurse ' s office and told the DON, " I think the LPN supervisor needs you in resident #2 ' s room. " C.N.A. #5 and the DON then proceeded to the resident ' s room. When the DON arrived, she recalled the privacy curtain was half closed. The resident was lying there unresponsive, ashen in color. LPN #3 was on one side of the bed, C.N.A. #4 was at the foot of the bed crying, and the LPN supervisor was standing there holding a stethoscope. The LPN supervisor asked the DON, " Can you check behind me because I can ' t hear anything. " The DON then checked for a pulse in the resident ' s wrist, heart sounds, carotid pulse, and breath sounds. The DON recalled trying to move the resident ' s jaw, which wasn ' t rigid, but was very difficult to move. The resident was cool to the touch, but not frigid. The DON told the LPN supervisor, " I don ' t hear anything either. " The resident ' s head of the bed was up. The LPN supervisor then looked at the clock and said, " It ' s 5:20 p.m.; I ' m going to go call the doctor. " The DON said she would stay with the resident and the DON and LPN #3 were talking and straightening up the resident ' s covers. It was at that time the DON recalled that LPN #2 came in behind her but did not say anything. The DON remembered the LPN supervisor walking out and LPN #2 following the LPN supervisor. A short time later, the DON spoke to the LPN supervisor who informed her she had reached the on-call doctor for the resident ' s attending physician. The on-call doctor gave orders to release the body. Approximately 20 minutes later, the DON called the nursing home administrator (NHA) on her drive home to inform her resident #2 had passed. The NHA asked the DON if the resident had a DNR order. The DON ' s first response was " of course " but then she said, " You know what, I never saw the chart. " The DON stated she had assumed that the reason she was called to the room was to confirm there were no vital signs, as this is their typical procedure for a DNR if the DON is present in the facility. After hanging up the phone with the NHA, the DON called the facility and spoke to LPN #3. The DON asked LPN #3 if resident #2 had a DNR order. LPN #3 told the DON, " No; she was a full code. " The DON stated that when she walked into the resident ' s room, and two nurses and a C.N.A. were just standing there, she assumed the resident was a DNR. The DON then stated " stupid, I guess we miscommunicated. " The DON said this was also when she found out LPN #2 had the resident ' s chart in his hands when he had come into the room but did not say anything. Immediately after the DON discovered resident #2 did not have a DNR order, she, the corporate nurse, the administrator, and the risk manager returned to the facility. They immediately started education with the staff involved and initiated an investigation. The DON said someone called the police but she was not sure who. 9. The attending physician for resident #2 was interviewed by telephone on [DATE] at 12:45 p.m. He stated he was not working on the night resident #2 was found unresponsive. However, he was contacted by facility staff after the incident to inform him of what had occurred. The physician was told the resident was found unresponsive, without pulse/respirations, ashen in color, and cool to the touch. He was also told that her jaw was in the open position and could not be closed. This information made the physician think rigor mortis had set in, and the resident had been deceased for a while. The attending physician said the chance of reviving the resident in this state would be zero. It was his understanding that they did not call a code due to the state in which they found the resident. He had been the resident ' s treating physician during her stay in the facility, but not prior to this. He was familiar with the resident and did visit her while she was in the facility. The attending physician had completed the resident ' s death certificate and thought he had documented the cause of death as natural causes related to [DIAGNOSES REDACTED]. He did not have his medical records with him during this interview and could not be certain of the information provided. He stated the resident had severe [DIAGNOSES REDACTED] and could have expired at any time due to this condition. 10. A telephone interview on [DATE] at 3:43 p.m. with the on-call physician for resident #2 ' s attending physician revealed he had been contacted by a nurse on [DATE] and informed that resident #2 had expired. The nurse asked for permission to release the resident ' s body, and he provided the order. The nurse did not inform him of the resident ' s code status during the call. The on-call physician refused to provide any additional information. 11. Resident #2 ' s son was interviewed by telephone on [DATE] at 1:25 p.m. His mother had been admitted to the facility for therapy to treat a [MEDICAL CONDITION]. The resident ' s son felt his mother had been getting better, but she had contracted pneumonia during her stay at the facility and hadn ' t been looking very good. He stated she looked better when they gave her oxygen but she did not have oxygen on at all times. The resident ' s son stated he was called on [DATE] at an unknown time to inform him of his mother ' s passing. He was told that about 40 minutes prior to being found unresponsive, his mom had received a shower and was in good spirits. He knew his mother had a living will stating that if she was gone she did not want to be brought back to life. He stated that in the past couple of days leading up to her death she wasn ' t feeling well, but facility staff said she looked better every day. He stated there were days that she did look good but not overall. 12. A review of the Social Services - Advance Directives Policy and Procedure with an effective date of [DATE] and a Revision date of [DATE] revealed the facility failed to carry out the following items as documented in the Policy and Procedure: Policy: " Our Facility will identify a resident ' s choice for treatment and care, help the individual develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with our facility ' s ethics decision making policies and procedures, and Florida State law. Purpose: " Our facility respects the resident ' s/legal representative ' s right to make the resident ' s own medical treatment decisions ... " Key Points: " 1. Resident Choice: Medical treatment decisions are a matter of personal choice ...the decision whether or not to act is always to the resident and/or legal representative. " " 2. Compliance with Florida Law: This facility will ensure that it is in compliance with the requirements of Florida law, whether statutory or as set forth in applicable court cases, on the subject of informed consent to medical treatment and the formulation of Advance Directives by residents. " 13. Review of the facility ' s Policy and Procedure for Nursing- Change in a Residents Condition or Status with an effective date of [DATE] and a revision date of [DATE] revealed the facility failed to follow the following: Policy: " In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident ' s advance directives. " 14. Review of the facility ' s Licensed Practical Nurse position description revised ,[DATE] revealed the facility failed to implement the following: Essential Functions: " 2. Delivers nursing care to patients/resident. " " 3. Makes observations and reports pertinent information related to the care of the resident. " " 4. Implements the resident plan of care and evaluates the resident response. " " 12. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury). " General Patient/Resident Care: " 2. Interventions are performed in a timely manner ... " " 4. Treatments are completed as indicated. " " 8. Emergency situations are recognized and appropriate action is instituted. " 15. During an interview with the NHA on [DATE] at 1:52 p.m. she stated she had left the facility around 3:30p.m. to 4 00 p.m. on [DATE]. At approximately 5:40 p.m. on [DATE] she received a phone call from the DON to inform her that resident #2 had passed away. The Administrator asked the DON if the resident had a DNR order. " She said yes, and

Based on clinical record review, policy and procedure review for Advance Directives and Change in a Resident ' s Condition or Status, employee job description reviews, and interviews with facility staff, it was determined that administration failed to provide resource management to meet the needs for one (#2) of 33 residents identified as full code, according to the resident code status audit tool and resident census of [DATE]. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. This related to not implementing policies and procedures for advanced directives and a failure to administer CPR to ensure that the highest degree of attention and care was provided to residents. Failure to ensure that staff would properly implement training on emergency policies and procedures led to neglect of one resident when staff did not perform CPR and call for Emergency Medical Services (EMS/911). These actions resulted in findings of immediate jeopardy, which were removed on [DATE] at 7:00 a.m. and the severity and scope was reduced to a D. Findings included: 1. Review of the POS [REDACTED] Basic Function: 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. 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 departmental policies and procedures ... 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 6. Ensure that patient ' s/residents rights to fair and equitable treatment, self determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. 7. Recruit, select and train competent department supervisors and other auxiliary personnel. Specific Requirements: 8. Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality patient/resident care and maintaining a sound operation. 2. Review of resident #2 ' s clinical record revealed a face sheet with a date of birth of [DATE] and a date of admission to the facility of [DATE]. The resident signed an acknowledgement of advance directives on [DATE] indicating she fully understood that she was not required to have an Advance Directive in order to receive medical treatment at this facility and the terms of the Advance Directive document(s) that she had executed would be followed by the Facility and her care givers to the extent permitted by law. The resident checked that she had a living will, a durable power of attorney for financial authority, and a health care surrogate. The resident did not check the box to indicate that she had a Florida Do Not Resuscitate (DNR) order nor were any DNR orders located in her clinical record. Continued review of the clinical record revealed the resident signed an authorization for treatment form on [DATE] and [DATE] which granted " the professional staff of the nursing center to administer nursing and medical procedures as ordered by the resident ' s physician during the resident ' s stay in this center. " A review of the [DATE] physician order [REDACTED]. " Review of the " Resident Care Card " revealed the resident did not have any orders for DNR. The resident ' s care plan, dated [DATE], was reviewed. The resident required short term rehabilitation and desired " to return home. " The resident had a goal to transition to her prior living arrangements per progression of therapy with a goal and target date of [DATE]. Review of the Discharge Goal/Plan documented by the social service representative on [DATE] revealed the discharge goal was to return home with family assistance. The physician ' s rehabilitation potential was checked as " good, " and the resident and her family were understanding and supportive of short term placement at the facility. 3. A telephone interview was conducted with the resident ' s son on [DATE] at 1:25 p.m. His mother had been admitted to the facility for therapy to treat a [MEDICAL CONDITION]. The resident ' s son felt his mother had been getting better, but she had contracted pneumonia during her stay at the facility and did not look well. The resident ' s son stated he was called on [DATE] at an unknown time to inform him of his mother ' s passing. He was told that about 40 minutes prior to being found unresponsive, his mother had received a shower and was in good spirits. He knew his mother had a living will stating that " if she was gone she did not want to be brought back to life. " He stated that in the past couple of days leading up to her death, she wasn ' t feeling well, but facility staff said she looked better every day. He stated there were days that she did look good, but not overall. The resident ' s son stated he thought the resident would have been better off if she had stayed in the hospital. 4. Continued review of resident #2 ' s clinical record revealed the following nurses ' note entries for [DATE]: [DATE] 6:00 a.m. continues on antibiotics (ABT) for left lower lobe (LLL) infiltrate, no adverse reaction. Rested quietly this shift with no shortness of breath (SOB)/dyspnea. Oxygen at 2 liters as needed (PRN). Head of bed (HOB) elevated. Nebulizer treatments continue. Bed/chair alarms in place. [DATE] 11:00 a.m. Resident alert with periods of confusion. Continues on ABT for infiltrate. No signs or symptoms of adverse reactions. Remains afebrile. Oxygen saturation 96% on room air. Respirations even and unlabored. HOB up. No signs of respiratory distress noted. Will continue to monitor. [DATE] 2:00 p.m. Received PT/INR results. Call to attending physician. On call doctor gave new orders to hold [MEDICATION NAME] Monday [DATE] and recheck INR on [DATE]. [DATE] 3:00 p.m. Resident family had been in to visit earlier today. [DATE] 3:45 p.m. Oxygen saturation level at 94% on oxygen at 2 liters via nasal cannula, pulse 60. [DATE] 4:00 p.m. Resident taken to shower by C.N.A. Resident cheerful, laughing and making jokes. Resident drank [MEDICATION NAME]. Stated she wasn ' t feeling the greatest, but was feeling better then yesterday. [DATE] 4:15 p.m. Administered nebulizer treatment- resident tolerated well. [DATE] 11:00 p.m. At 5:15 p.m. C.N.A. took dinner tray into resident ' s room and found her non-responsive. Nurse responded and found resident without vital signs and nonresponsive to stimuli, body was noted to be cool to touch with ashen color. Second nurse checked resident and concurred with findings. On call doctor notified and gave order to release body to funeral home. (The DON was noted to concur with these findings and co-signed this note along with the resident ' s assigned nurse/LPN #3). [DATE] 11:15 p.m. Body picked up by funeral home at 10:40 p.m. [DATE] Late entry for [DATE] - responsible party notified of resident ' s expiration ... Review of the vital sign record for [DATE] revealed the resident had a temperature of 96.9, a pulse of 56, respirations of 16, and a blood pressure of ,[DATE]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]% on the 3:00 p.m. to 11:00 p.m. shift. Review of the telephone orders revealed an order was noted by the LPN supervisor on [DATE] at 5:40 p.m. stating " May release remains to funeral home of choice ... " Review of the physician progress notes [REDACTED]. This note documented " Yesterday at 5:15 p.m. patient found ashen, cool without vital signs. No reason for CPR. Patient pronounced - family notified. " 5. During an interview with the nursing home administrator (NHA) on [DATE] at 1:52 p.m. she stated she had left the facility early on [DATE], around 3:30 p.m. to 4 00 p.m. At approximately 5:40 p.m. on [DATE] she received a phone call from the director of nursing (DON) informing her that resident #2 had passed away. The NHA asked the DON if the resident had a DNR order. The DON " said yes at first and then she said I don ' t know. " The administrator stated she immediately hung up with the DON and called the facility. The administrator spoke to the 3:00 p.m. to 11:00 p.m. LPN supervisor and was informed resident #2 did not have a DNR order. The administrator informed the LPN supervisor she was coming into the facility. On the way to the facility, the NHA called the risk manager and corporate nurse to inform them of the incident and asked them to come to the facility to start an investigation. The NHA arrived at the facility around 6:20 p.m. on [DATE]. The risk manager was already present and was interviewing the staff involved. The NHA and risk manager called the local police department because the resident was not on hospice, did not have a DNR order, and although she had multiple medical problems, her death was not anticipated. The police called Emergency Medical Services (EMS) who responded but did not administer any care or services. The police observed the resident ' s body for any signs of suspicious injuries with none found. The police did not take possession of the body and allowed the body to be released to the funeral home of the family ' s choice. All of the 3:00 p.m. to 11:00 p.m. nurses involved, who were assigned to work with residents on [DATE], were removed from the schedule and their duties for the remainder of their shift and other nurses were brought into cover their assignments. The nurses involved in the incident remained off the schedule pending further investigation, disciplinary action, and in-service education on [DATE]. The attending physician was called on the night of [DATE] and a message was left informing him of the incident. The family was present in the facility on the night of [DATE] and they were informed of the facility ' s failure to administer CPR in the absence of a DNR order. The medical director was also contacted the following morning, [DATE], and informed of the incident. 6. The administrator and DON were interviewed on [DATE] at 9:48 a.m. Upon analyzing the investigation of the incident, they determined a system failure occurred when a resident, who was designated as a full code, did not receive CPR. Everything happened so quickly. LPN #1 and LPN #2 were getting the chart that identified resident #2 as a full code. LPN #2 returned to the room to tell the other nurses the resident ' s code status, but when he walked in, he heard the LPN supervisor say she was going to call the doctor. LPN #2 did not say anything as he thought the LPN supervisor and DON had decided " it was over. " 7. Review of the Social Services - Advance Directives Policy and Procedure with an effective date of [DATE] and a Revision date of [DATE] revealed the facility failed to carry out the following items as documented in the Policy and Procedure. Policy: " Our Facility will identify a resident ' s choice for treatment and care, help the individual develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with our facility ' s ethics decision making policies and procedures, and Florida State law. " Purpose: " Our facility respects the resident ' s/legal representative ' s right to make the resident ' s own medical treatment decisions ... " Key Points: " 1. Resident Choice: Medical treatment decisions are a matter of personal choice ...the decision whether or not to act is always to the resident and/or legal representative. 2. Compliance with Florida Law: This facility will ensure that it is in compliance with the requirements of Florida law, whether statutory or as set forth in applicable court cases, on the subject of informed consent to medical treatment and the formulation of Advance Directives by residents. " 8. Review of the facility ' s Policy and Procedure for Nursing- Change in a Resident ' s Condition or Status with an effective date of [DATE] and a revision date of [DATE] revealed the facility failed to follow the following: Policy: " In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident ' s advance directives. " 9. Review of the facility ' s Licensed Practical Nurse position description revised ,[DATE] revealed the facility failed to implement the following: " Essential Functions: 2. Delivers nursing care to patients/resident. 3. Makes observations and reports pertinent information related to the care of the resident. 4. Implements the resident plan of care and evaluates the resident response. 12. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury). General Patient/Resident Care: 2. Interventions are performed in a timely manner ... 4. Treatments are completed as indicated. 8. Emergency situations are recognized and appropriate action is instituted. " 10. An interview with certified nurse ' s assistant (C.N.A.) #4 on [DATE] at approximately 3:15 p.m. revealed she has a full time assignment on the 3:00 p.m. to 11:00 p.m. shift on the front hall/rehab hall. The C.N.A. stated she was familiar with resident #2 as she was on the aide ' s regular assignment. The C.N.A. described resident #2 as being a nice lady who complained of having a head cold on [DATE]. At about 3:15 p.m. on [DATE], the C.N.A. recalled taking resident #2 ' s vital signs, which were normal, and then the C.N.A. laid her down in bed to rest. The C.N.A. remembered checking on the resident at about 4:00 p.m. and saw her working with the physical therapist in her room at that time. After this, the C.N.A. recalled another C.N.A. (#5) taking the resident for a shower. The C.N.A. saw resident #2 again at approximately 5:00 p.m. and did not notice anything unusual, " she seemed fine. " At approximately 5:20 p.m. the C.N.A. entered resident #2 ' s room with her dinner tray and placed it on her overbed table. Resident #2 ' s eyes were closed. The C.N.A. shook the resident ' s arm to wake her up, but she did not respond. The C.N.A. looked at the resident ' s chest and it was not moving. The C.N.A. stated, " I thought she had passed on but then she expelled some breath. " The C.N.A. shook the resident again but there was no response. The C.N.A. then began crying and looked out of the resident ' s room to get the attention of a nurse. She saw C.N.A. #5 standing in front of the nurse ' s station and LPN #2 was seated at the nurse ' s station. She called out to C.N.A. #5 to get LPN #2 to come to the room. C.N.A. #4 then noticed another nurse, LPN #1, in the room next door. C.N.A. #4 told LPN #1, " Come quick, I need you. " LPN #1 immediately responded and was informed by C.N.A. #4 that she thought resident #2 " was gone, she ' s not breathing. " C.N.A. #4 could not recall what LPN #1 did because she was so upset. The C.N.A. did remember LPN #1 left the room to go get resident #2 ' s assigned nurse, LPN #3. LPN #1 then returned to the room with LPN #3. Just as these nurses returned to the room, the 3:00 p.m. to 11:00 p.m. LPN supervisor also entered the room. The LPN supervisor felt for resident #2 ' s pulse and then stated, " We need to do CPR. " C.N.A. #4 then recalled the Director of Nursing (DON) entered the room. At this time, C.N.A. #4 asked the LPN supervisor if she could leave the room and was told yes. C.N.A. #4 then left the room and did not have any additional information to report on resident #2. 11. Interview with LPN #1 on [DATE] at 2:23 p.m. revealed she has worked at the facility for about [AGE] years on the 3:00 p.m. to 11:00 p.m. shift four days a week. LPN #1 was not familiar with resident #2, as she had a regular assignment on a different hallway. LPN #1 recalled bringing a resident a drink at about 5:15 p.m. on [DATE] when C.N.A. #4 gestured to her that she needed her in the room next door. The C.N.A. informed LPN #1 that resident #2 was not " breathing right. " LPN #1 looked at the resident and described her as pale, with a closed mouth. LPN #1 stated she may have been expelling some breath. The LPN tried to get an idea from the C.N.A. if resident #2 was on hospice and how long she had been in this condition. C.N.A. #4 was not able to give LPN #1 any information. LPN #1 then went to call for help and just as she did, LPN #2 entered the resident ' s room. LPN #1 told LPN #2, " She doesn ' t look good, the C.N.A. can ' t give me any information on this woman, and her assigned nurse is in the dining room. " LPN #2 then said, " We need the chart; I am going to get her nurse. " LPN #1 proceeded to get LPN #3 from the dining room. LPN #1 and LPN #3 immediately went to resident #2 ' s room and as they arrived there, the LPN supervisor was entering the room. The resident ' s curtain was pulled, and as LPN #1 began to enter, the LPN supervisor requested a stethoscope. LPN #1 ran to get one from the medication cart. At that time, LPN #1 saw LPN #2 at the nurse ' s station. She told LPN #2, " We need the chart, " and then ran back to the resident ' s room to deliver the stethoscope. The LPN supervisor told LPN #1, " We need the DON. " LPN #1 left the room again to get the DON but saw the DON heading up the hallway with C.N.A. #5. LPN #1 told the DON she was needed in the resident ' s room and then LPN #1 went to the nurse ' s station. At this time, LPN #2 told LPN #1, " Here ' s the chart, " but when LPN #1 looked at the exterior of the chart, she noticed LPN #2 had the wrong chart. LPN #1 told LPN #2 this was the wrong chart and they then retrieved the correct chart. The two nurses went through the chart and did not find a do not resuscitate (DNR) order. Suddenly, another C.N.A. came out of the dining room into the hallway and gestured with her hands up that she needed a nurse in the dining room. LPN #1 asked LPN #2 if he wanted to go to the dining room or should she go to the dining room. LPN #2 told LPN #1 to go to the dining room and LPN #2 stated he would take care of the chart. LPN #1 then proceeded to the dining room and did not have any additional information to report on resident #2. However, LPN #1 stated that usually when a resident is found unresponsive, an aide or a nurse stays in the room while the other person checks the resident ' s chart for code status. If indicated, they would then start CPR with one person calling the doctor, one person getting the crash cart, and then proceeding from there. In this instance, resident #2 was pale but her lips were closed and she was " pushing some air out, very faint. " Because C.N.A. #4 could not give LPN #1 any information, they needed her chart and her nurse to get more information. LPN #1 stated, " We handle a lot of hospice patients at the facility and some have DNR orders and others do not. " 12. In an interview with LPN #2 on [DATE] at approximately 4:00 p.m. he revealed he has worked at the facility for 2 years and has a regular part time assignment 3 days a week on the 3:00 p.m. to 11:00 p.m. shift. LPN #2 recalled he was working on new admission paperwork at the nurse ' s station on [DATE] at about 5:15 p.m. when he was informed by C.N.A. #5 that C.N.A. #4 wanted him. When LPN #2 looked up, he saw C.N.A. #4 waving for him to come to resident #2 ' s room. LPN #2 was not familiar with resident #2, as he had never been assigned to her care, but he proceeded to the resident ' s room. As LPN #2 was walking down the hallway, he saw LPN #1 enter the room. As LPN #2 arrived at the room, LPN #1 was walking out of the room. LPN #1 stated to LPN #2, " I don ' t think this woman is breathing; I think she is dead, take a look. " LPN #2 looked at resident #2 and she appeared pale and motionless. LPN #2 took the resident ' s left arm by the wrist and shook her arm to stimulate her. He did not know the resident ' s name and was calling out " ma ' am. " He described the resident as " just lifeless. " He checked resident #2 ' s radial pulse and carotid pulse but did not feel anything. LPN #2 recalled LPN #1 stated she didn ' t know the woman and she was going to get her nurse, LPN #3. LPN #2 stated he also was unfamiliar with the resident and he proceeded to the nurse ' s station to check the chart. As LPN #2 arrived back at the nurse ' s station, he accidentally pulled the wrong chart, but within seconds, he recalled LPN #1 arrived and told him he had the wrong chart. LPN #1 then pulled the correct chart and both LPN #1 and LPN #2 looked at the chart together. Because LPN #2 was unfamiliar with the resident, he brought the entire chart to the resident ' s room. The LPN supervisor and the DON were in the room when he arrived. LPN #2 gave the LPN supervisor the chart and did not take any further action. LPN #2 stated he did not find a DNR order when he reviewed the resident ' s record. He stated the front of resident #2 ' s chart was white and if they are a DNR, the outside of the chart is yellow. However, they still have to look for the DNR paperwork. LPN #2 stated again that he was not familiar with the resident. He felt he needed to take the chart to the room to let somebody else check it out. He recalled standing in resident #2 ' s room as the LPN supervisor and the DON situated the resident properly in the bed. He was in the room for one to two minutes at the most. He did not say anything, he just handed the LPN supervisor the chart, and the LPN supervisor stated, " I ' m going to go call the doctor. " 13. Interview with LPN #3 on [DATE] at 11:49 a.m. revealed she is a newly licensed LPN and has been working at the facility for approximately 8 months. LPN #3 works full time on the 3:00 p.m. to 11:00 p.m. shift with a regular assignment on the front hall/rehab hall. LPN #3 was familiar with resident #2 as she had been her assigned nurse since the resident was admitted to the facility in December of 2011. The LPN described resident #2 as being " laid back, " pleasant, able to make her needs known and attended physical and occupational therapy regularly. Her family was involved in her care and she was completing treatment for [REDACTED]. Resident #2 was progressing well but still did not have her strength up. She was at the facility to re-gain her strength. LPN #3 recalled giving resident #2 her medications around 4:00 p.m. on [DATE]. At that time, she was getting ready to go for her shower. When the resident returned from her shower at approximately 4:15 p.m., the nurse administered her routine nebulizer treatment. The resident was talking, joking, and laughing with LPN #3. She left the resident sitting straight up in her bed after providing her the breathing treatment. At approximately 5:15 p.m. LPN #1 came to the dining room and told LPN #3 she needed to come and check her patient. LPN #1 informed her that the resident " didn ' t look good and there ' s something going on. " LPN #3 hesitated at the door of the dining room for about a minute because she was the only nurse there but she did eventually proceed to the resident ' s room. LPN #3 arrived at the room and the LPN supervisor entered right behind her. LPN #3 walked to one side of the bed and the LPN supervisor went to the other side. The LPN supervisor checked the resident for a pulse but there was no pulse and no respirations. The LPN supervisor asked for a stethoscope. LPN #3 was not sure who left to get the stethoscope but recalled LPN #1 returning with one. The LPN supervisor could not hear a heartbeat and could not find an apical pulse. The LPN supervisor asked for someone to get the DON. The DON came in the room and also checked for vital signs. The DON concurred the resident had no pulse or respirations. LPN #3 recalled that just as the DON entered the room, the LPN supervisor said, " We should start CPR. " LPN #3 was not sure if the DON heard the LPN supervisor ' s statement regarding CPR. LPN #3 stated, " Neither one of us (meaning herself and the LPN supervisor) jumped in and started CPR. " LPN #3 did not know if anyone was checking to see the resident ' s code status and she did not know the resident ' s code status off- hand. LPN #3 stated resident #2 was ashen, her mouth was open and would not close, and she was limp and cool to the touch. The LPN stated " she was lifeless. " At the end of this interview, LPN #3 began to cry. When asked why she was crying she stated, " Being a new nurse I should have known better. I guess what upsets me the most, she should have gotten CPR. That was her wish. " LPN #3 stated she did not call the doctor, speak to the family, or have any other involvement with this incident. 14. Interview on [DATE] at 12:55 p.m. with the 3:00 p.m. to 11:00 p.m. LPN supervisor revealed she has worked at the facility for almost 6 years and has been the supervisor for the evening shift for about 3 and a half years. The LPN supervisor was somewhat familiar with resident #2. She recalled the resident had some cold symptoms about a week earlier than [DATE] and a chest x-ray was done. The resident had been on antibiotics and had stated she was not feeling good and was hoping she could shake whatever she had. On [DATE] the LPN supervisor recalled coming out of the nourishment room when she was approached by C.N.A. #5 who told her she was needed in the resident ' s room. The LPN supervisor walked to the room and over to the resident ' s side of the room. The resident was ashen in color and looked like she had expired. The LPN supervisor recalled both C.N.A. #4 and #5 were in the room as well as LPN #3. The LPN supervisor checked the resident ' s radial pulse, but there was no pulse. She asked for someone to get her a stethoscope. She remembered LPN #1 bringing the stethoscope. The LPN supervisor used the stethoscope to check for an apical pulse but there was none. She raised the bed up to try to get the resident in a better position but still could not get an apical pulse. The LPN supervisor also tried to get a carotid pulse but she could not get the resident in a good position because her mouth was open and her jaw was locked. The resident was not responding to anything. The LPN supervisor asked for somebody to call for the DON so she could check also. The DON arrived within a minute to a minute and half, maybe sooner. The DON " pretty much did the same thing, and she couldn ' t get anything. " The LPN supervisor could not recall if someone went to get the resident ' s chart. She just remembered the DON saying there were no vitals, she ' s not responding, and she was cool to the touch. After talking to the DON, the LPN supervisor said she would call the doctor. The LPN supervisor received the attending physician ' s answering service and was told a different physician was on-call. The answering service placed the LPN supervisor on hold for approximately 3 to 5 minutes until the on call physician came on the line. She informed the on-call physician that resident #2 had no vital signs and was unresponsive. She also described the resident ' s ashen skin color and stiff mouth position to the doctor. The physician gave the order to release the body to the funeral home of the family ' s choice. After that, the LPN supervisor called the resident ' s family and informed them the resident had expired and they could come in to see the resident if they wished. The resident ' s family did arrive that evening, exact time unknown, and informed them of the funeral home they wanted. A continued interview with the LPN supervisor revealed she did not realize the resident was a full code until about a half an hour after the resident had expired. She stated the family did not say anything to her and the doctor did not ask. She stated she did not check that part of the resident ' s chart. 15. During an interview on [DATE] at 2:59 p.m., C.N.A. #5 revealed she had worked at the facility for 5 years and had a regular assignment on the north hall/front hall on the 3:00 p.m. to 11:00 p.m. shift. Prior to [DATE], C.N.A. #5 had worked with resident #2 in passing. She was not assigned to care for resident #2, but she had answered her call light in the past. On [DATE] C.N.A. #5 was assigned to shower resident #2. Resident #2 was showered around 4:00 p.m. on [DATE] and appeared fine. The resident was coughing and told the C.N.A. she had a cold. The resident was moving around and was able to transfer without difficulty. The resident was pleasant and the C.N.A. did not notice anything unusual. At around 5:15 p.m. to 5:30 p.m. C.N.A. #4 stepped out of the resident ' s room and asked her to get LPN #2. C.N.A. #5 got LPN #2 and she and the LPN walked to the room to see if any assistance was needed. It was at that time C.N.A. #5 saw that resident #2 was not alive. The resident looked very pale, wasn ' t moving, and was lying back on the bed. C.N.A. #5 then left the room to find the LPN supervisor. She found the LPN supervisor and told her she needed to go to resident #2 ' s room as she looked like she was no longer alive. The C.N.A. then went to get the DON. She told the DON that she was probably going to be needed in resident #2 ' s room because she didn ' t look like she was alive. The DON and C.N.A. #5 then went to the resident ' s room. The C.N.A. asked all the staff in the room if they needed her to get anything and was told they didn ' t need her anymore. C.N.A. #5 did not have any further information to provide about resident #2. 16. Interview with the DON on [DATE] at 4:30 p.m. revealed she was familiar with resident #2. She had many interactions with resident #2 ' s son as he was very concerned for his mother and wanted everything just right for her. The DON recalled resident #2 had a great day on [DATE]. She was joking with the C.N.A., had received a shower, and had received her medications. At approximately 5:10 p.m. or 5:15 p.m. C.N.A. #5 came to the nurse ' s office and told the DON, " I think the LPN supervisor needs you in resident #2 ' s room. " C.N.A. #5 and the DON then proceeded to the resident ' s room. When the DON arrived, she recalled the privacy curtain was half closed. The resident was lying there, unresponsive and ashen in color. LPN #3 was on one side of the bed, C.N.A. #4 was at the foot of the bed crying, and the LPN supervisor was standing there holding a stethoscope. The LPN supervisor asked the DON, " Can you check behind me because I can ' t hear anything. " The DON then checked for a pulse in the resident ' s wrist, heart sounds, carotid pulse, and breath sounds. The DON recalled trying to move the resident ' s jaw which wasn ' t rigid but was very difficult to move up. The resident was cool to the touch but not frigid. The DON told the LPN supervisor, " I don ' t hear anything either. " The resident ' s head of the bed was up. The LPN supervisor then looked at the clock and said, " It ' s 5:20 p.m.; I ' m going to go call the doctor. " The DON said she would stay with the resident and the DON and LPN #3 were talking and straightening up the resident ' s covers. It was at that time the DON recalled LPN #2 coming into to room behind he

Based on resident record review, facility record review and policy review and staff interview, it was determined that the facility failed to notify the physician of a change in condition for a fragile eighty five year old resident with a recent history of fall with Bilateral Subdural Hematomas and Subarachnoid bleed who sustained a second fall, following admission, with resultant serious physical harm for one of five resident ' s reviewed (#1). The resident died ten days after the fall. The facility failed to notify the physician when the resident was exhibiting signs of confusion, exhibiting more frequent complaints of a headache, and exhibiting agitation which increased to " striking out " behavior. This facility practice resulted in the determination of Immediate Jeopardy which was relieved on [DATE]. Findings include: Review of a summary, prepared by the facility on [DATE], revealed: " [AGE] year old male admitted to SNF [DATE]. admitting [DIAGNOSES REDACTED]. On [DATE] at 2: 10 a.m. resident fell out of wheelchair, hitting his head. Resident was up in wheelchair due to restlessness and confusion. Staff witnessed fall. Transferred to (hospital). admitted with Diagnosis: [REDACTED]. Review of the record for resident #1 revealed that the resident was admitted to the facility from the hospital on [DATE] at 1: 30 p.m. Review of the resident ' s hospital record, found in the resident ' s facility record, revealed a history and physical, dated [DATE], that the resident had been diagnosed with [REDACTED]. " A hospital discharge summary was also found in the resident ' s record, dated [DATE]. Review of this summary revealed [DIAGNOSES REDACTED]. Non Syncopal fall secondary to Orthostatic [MEDICAL CONDITION], Gait Ataxia secondary to Peripheral [MEDICAL CONDITIONS] with Overactive bladder, History of prior [MEDICAL CONDITION], and Memory loss secondary to multi infarct dementia. " The resident ' s prognosis was listed as " good. " Review of the resident ' s record revealed an admission nursing evaluation was completed by an LPN on [DATE]. The resident ' s diagnosis was listed as " fall with headache " and the resident was assessed as alert and oriented times three, adequate hearing, able to feed self with set up ,continent, able to make needs known, full weight bearing status and able to propel self with a wheelchair. A pain assessment also completed on admission revealed that the resident was assessed as having no pain at the time of admission. An Admission Assessment for risk of falls was also completed by a Licensed Practical Nurse (LPN) at admission on [DATE]. The resident was assessed as high risk for falls related to mental status, sensory deficits, use of assistive devices - wheelchair, transfer difficulties, unsteady gait and medications - cardiac and hypnotic. Review of nursing notes for resident # 1 revealed that the resident was noted to be " alert and oriented with no complaints of pain or discomfort at 4: 05 p.m. and, at 10: 30 p.m. on [DATE], was reported to be alert and oriented and able to make wants and needs known. Nursing notes indicate that the resident was medicated for pain one time on [DATE], at 5: 00 p.m. with Tylenol 650 mg. for a headache. Review of nurse ' s notes in the resident ' s record revealed that, beginning on [DATE], the resident was noted to have a change in his previous condition related to documentation of periods of confusion, medicated for complaints of a headache and increased agitation. Review of nursing notes for [DATE] revealed that the resident was medicated for a headache at 4: 00 a.m. with [MEDICATION NAME] 50 mg. Review of nursing notes and a pain management flow sheet revealed that at 10: 00 a.m. on [DATE], the resident was reported as " alert and oriented with periods of confusion " and at 9: 00 p.m., the resident was noted as alert and oriented with periods of confusion. The resident was medicated for complaints of a headache on [DATE] at 12: 15 p.m. 4: 15 p.m., 9 p.m. and an illegible time on [DATE] in the a.m. There was no documentation found in the resident ' s record that the physician was notified that a resident, previously assessed as alert and oriented and experiencing no pain, was having periods of confusion and being medicated for a headache approximately every four to five hours. Review of nursing notes, beginning at 9: p.m. on [DATE] and ending at 7: 30 a.m. on [DATE] revealed: [DATE] 9: 00 p.m. " Resident settled in bed, Occasional periods of confusion. Medicated for headache and C/O of [MEDICAL CONDITION]. " [DATE] 10:00 p.m. " Positive effect, denies pain and discomfort at this time. " [DATE] 10: 30 p.m. " Sleeping quietly. Respirations even and regular. Bed alarm in place and functioning. " [DATE] 12 a.m. " Up in w/c (wheelchair) with one on one care with CNA due to confusion, insistence in standing by self " . [DATE] 2 a.m. " Slept for short intervals. Bed alarm on and functioning. Resident confused, striking out at times. " [DATE] 2: 10 a.m. " Resident fell out of wheelchair, hit head, not able to tell nurse his name or birthday. Cut to left temple. BP ,[DATE], Pulse 88, Respirations 22. EMS called. [DATE] 2: 12 a.m. " Transported to (hospital). Daughter notified of transfer to hospital. [DATE] 7: 30 a.m. " Physician notified. " There was no documentation, of physician notification of changes in the resident ' s condition, prior to this time. On [DATE] at 3: 41 p.m., an interview was conducted with Nurse # 1, the Registered Nurse (RN) who provided care for resident # 1 from 7: 00 p.m. to the time of the resident ' s fall on [DATE]. Nurse # 1 was asked if she recalled the events surrounding the fall for resident # 1. She stated that she did recall. She stated that she took care of the resident on his first night in the facility (,[DATE]-[DATE]. And he was " pretty quiet but somewhat restless. She stated that on [DATE], she came on shift at 7: 00 p.m. She stated that he had been medicated for a headache before she came on duty. She stated it was very hard to get through to him that he needed to stay in bed. She stated he was crawling up out of bed, calling for his wife and was very anxious. She stated that she and CNA # 1 decided that " we would do one on one care with the CNA due to the confusion and wanting to get up and leave. " She stated " we do that a lot, we one to one the people, one to one personal interaction to calm them " She stated that she medicated the resident [MEDICATION NAME] " probably because I wanted to quiet him down and see if he would sleep " and gave him Tylenol for a headache She stated that she assessed the resident ' s vital signs at midnight ( documentation of a vital sign record in the resident ' s record revealed " ,[DATE] ,[DATE] Temperature 98.7, Pulse 90, Respirations 20 and Blood Pressure ,[DATE]. " ) She stated that the resident was placed in the hallway of the facility in his wheelchair and CNA # 1 was seated next to the resident. She stated that the resident was continuing to try and get up out of the wheelchair while seated in the hallway and CNA # 1 was attempting to calm him. An interview was conducted with CNA # 1 who was assigned to care for resident # 1 on the 11p.m. to 7 a.m. shift on ,[DATE]- [DATE]. The interview was conducted on [DATE] at 4: 35 p.m. CNA # 1 stated that she came on duty at 11: 00 p.m. on [DATE] and received report from the outgoing CNA and nurse that resident # 1 was constantly wanting to get up and calling for his wife. She stated she was told it had been going on for a while but was unable to recall if the other CNA told her how long. She stated he seemed to be agitated and constantly wanting to get up from the bed and go home. She stated that she tried to comfort him and calm him. She stated he would calm down and she would leave the resident in his room and the bed alarm would go off again and that this kept occurring. She stated she got him up in his wheelchair and took him to the bathroom and gave him something to drink. She stated he was still agitated so, for his safety, she took him down the hall. She stated she placed him in the hallway between rooms [ROOM NUMBERS] and provided " one to one " stating, and demonstrating, that she was approximately arm ' s length from him. There was no documentation found in resident # 1 ' s record that the nurse notified the physician of the resident ' s confusion and agitation. Nurse # 1 revealed, during the interview on [DATE] at 3: 41 p.m., that she did not notify the physician of the resident ' s behavior and condition. She stated that if he had continued to be agitated she would have called the physician, but, the staff member did not provide a timeframe by which notification would have been made. She stated that she felt the resident was safer in a wheelchair instead of a Geri Chair because she was afraid he would " flip out of the chair. " She stated that she did not place a chair alarm on the resident because she felt it would agitate him more if he tried to stand and the alarm would go off. She stated she made the decision to leave him up in his wheelchair as he was already in it. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have expected to be called regarding the resident ' s behavior and condition. He also stated he would have liked to have seen the resident placed in a Geri chair with a lap buddy and chair alarm for safety. During the interview with nurse # 1, on [DATE] at 3: 41 p.m., the nurse described the events surrounding the fall. She stated that she returned from lunch at 2: 00 a.m. and walked by the resident and noted he was sitting up in his wheelchair and had his eyes close and his head down nodding a little bit and he looked comfortable and quiet. She stated she thought, " Oh good he is going to sleep. We ' ll get him back into bed around 5: 00 a.m. " She stated she had just walked back to the nurse ' s station and put her book and her drink down and turned around to look down the hallway and " he just fell forward out of the wheelchair, hit his head, he didn ' t try to break his fall, he just went straight down like he had died . " She stated that this happened approximately ten minutes after she walked past him. " During the interview with CNA # 1, on [DATE] at 4: 35 p.m., the CNA described the events surrounding the resident ' s fall. She stated she placed him in the hallway between rooms [ROOM NUMBERS] ( resident ' s room was 101) and provided " one to one " stating, and demonstrating, that she was approximately arm ' s length from him. CNA # 1 was asked to describe what " one to one " was. She stated " I have the patient with me; I am constantly watching them for safety until I think they are ready to go back to bed. " She stated he continued to want to get up and that she " kept him sitting close to me " . She stated that the call light went off in another room (room [ROOM NUMBER]) and she stood up to answer it while calling down the hall or CNA # 2. She stated she said to CNA # 2 " Would you mind sitting with him while I answer the light. " She stated that at this time, the resident was seated in his wheelchair with his eyes closed and head down and " seemed to be resting. " She stated she saw CNA # 2 coming down the hall, heard the other nurse call out to her and saw CNA # 2 stop and turn to talk to the nurse and CNA # 2 did not reach the resident before she ( CNA #1) walked away. She stated she was entering the room where the call light was ringing when she heard a thump. She stated that she heard the resident fall but did not see the resident fall. Interview with Nurse 2, on [DATE] at 3: 29 p.m., revealed that after resident # 1 fell , he was " not even coherent to answer us. " Review of nursing notes, written by nurse # 1 at 2: 10 a.m., revealed that resident # 1 was " not able to tell nurse his name or birthday. " Documentation in resident # 1 ' s record revealed that the resident was transported by EMS to a local hospital. Review of the resident ' s record, obtained from the hospital revealed that the chief complaint on the EMS report was " fall with [MEDICAL CONDITION]. The resident ' s vital signs, noted by EMS at 1: 52 a.m. were blood pressure ,[DATE], pulse 78, respirations 16 and oxygen saturations 100%. The resident ' s vital signs, noted by EMS at 2: 12 a., were blood pressure ,[DATE]. Pulse 85, respirations 16, and oxygen saturations of 100 %. Review of the emergency room report revealed that the resident was triaged at the emergency room at 2: 28 a.m. with chief complaint of head pain/injury. The report from EMS to the hospital stated " patient crankier that usual, fell from wheelchair on head. " The resident ' s triage vital signs were blood pressure ,[DATE], pulse 84, respirations 22 and Glasgow coma scale of 14 (minor [MEDICAL CONDITION]). emergency room notes indicate the resident was sent for a CT scan of the head at 2: 55 a.m. The CT scan results were reported as " Acute left sided subdural hematoma with maximum thickness of 8 mm. Only minimal regional mass effect and ,[DATE] mm midline shift. A tiny right posterior paramediam subarachnoid hemorrhage and minima hematoma. There was a small amount of blood within the occipital horns. " A review of the history and physical, dictated on [DATE] at 11: 05 a.m., revealed the physician ' s assessment to be " non Syncopal fall at nursing home with resultant altered mental status changes, increased left subdural hematoma with slight midline shift and residual right sided hematoma and right sided subarachnoid hemorrhage. " Review of the hospital record for resident # 1 revealed that the resident was transferred to a Hospice on [DATE] and prognosis was noted to be poor. Review of the resident ' s record from the Hospice revealed that the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. Review of the " Florida Certificate of Death " issued by the Florida Department of Health, for resident # 1 revealed cause of death on [DATE] to be " Complications of Multiple [MEDICATION NAME] Impact Injuries of Head. " On ,[DATE]-[DATE], a review was conducted of four additional resident records: Two of these records had changes in the residents ' condition. Review of the record for resident # 2 revealed that the resident had a change of condition related to a fall with injury on [DATE]. Documentation in the resident ' s record revealed that the physician was notified of the change of condition on [DATE]. Review of the record for resident # 3 revealed that the resident had a change of condition related to a fall on [DATE] and a change of condition related to change in mental status on [DATE].The physician was notified of the change of condition on [DATE] and [DATE]. The Immediate Jeopardy was determined removed on [DATE] and the scope and severity was reduced to a D. .

Based on resident record review, facility record review and policy review, observation, and staff interview, it was determined that the facility failed to provide services necessary to avoid physical harm and failed to provide supervision which resulted in neglect of a fragile eighty five year old resident with a recent history of fall with Bilateral Subdural Hematomas and Subarachnoid bleed with resultant serious physical harm for one of five resident ' s reviewed (#1). The resident died ten days after the fall. The investigation revealed the facility neglected the resident by failing to notify the physician of a change in condition, failing to maintain the resident in a safe manner and failing to supervise the resident assessed as a high fall risk. These facility practices resulted in the determination of Immediate Jeopardy which was relieved on [DATE]. Findings include: Review of a summary ,prepared by the facility on [DATE], revealed: " [AGE] year old male admitted to SNF [DATE]. admitting [DIAGNOSES REDACTED]. On [DATE] at 2: 10 a.m. resident fell out of wheelchair, hitting his head. Resident was up in wheelchair due to restlessness and confusion. Staff witnessed fall. Transferred to (hospital). admitted with Diagnosis: [REDACTED]. Review of the record for resident #1 revealed that the resident was admitted to the facility from the hospital on [DATE] at 1: 30 p.m. Review of the resident ' s hospital record, found in the resident ' s facility record, revealed a history and physical, dated [DATE], that the resident had been diagnosed with [REDACTED]. " A hospital discharge summary was also found in the resident ' s record, dated [DATE]. Review of this summary revealed [DIAGNOSES REDACTED]. Non Syncopal fall secondary to Orthostatic [MEDICAL CONDITION], Gait Ataxia secondary to Peripheral [MEDICAL CONDITIONS] with Overactive bladder, History of prior [MEDICAL CONDITION], and Memory loss secondary to multi infarct dementia. " The resident ' s prognosis was listed as " good. " Review of nursing notes for [DATE] and the Medication Administration Record, [REDACTED]. by mouth at 9: 00 p.m. on [DATE], which was prescribed by the physician on [DATE] for [MEDICAL CONDITION]. Review of nursing notes for [DATE] and [DATE], in the resident ' s record, and interviews with staff revealed that Resident #1 was removed from his bed and his room and placed sitting upright in a wheelchair in the hallway, noted by the nurse and CNA to be seated with his eyes closed, head down and nodding, and was left unsupervised at the time of the fall which occurred in the early morning hours of [DATE]. An Admission Assessment for risk of falls was completed by a Licensed Practical Nurse (LPN) at admission on [DATE]. The resident was assessed as high risk for falls related to mental status, sensory deficits, use of assistive devices - wheelchair, transfer difficulties, unsteady gait and medications - cardiac and hypnotic. An interim care plan was completed for fall risk which listed approaches of: Assist of one for transfers Assist of one for ambulation Keep the following assistive devices within reach: wheelchair Anticipate and check for needs (include toileting) regularly and frequently Keep room free of clutter Provide adequate lighting, especially at night Orient to surroundings Refer to PT An admission nursing evaluation was also completed by the LPN on [DATE]. The resident ' s diagnosis was listed as " fall with headache " and the resident was assessed as alert and oriented times three, adequate hearing, able to feed self with set up ,continent, able to make needs known, full weight bearing status and able to propel self with a wheelchair. A pain assessment also completed on admission revealed that the resident was assessed as having no pain at the time of admission. Review of nursing notes for resident # 1 revealed that the resident was noted to be " alert and oriented with no complaints of pain or discomfort at 4: 05 p.m. and, at 10: 30 p.m. on [DATE], was reported to be alert and oriented and able to make wants and needs known. Nursing notes indicate that the resident was medicated for pain one time on [DATE], at 5: 00 p.m. with Tylenol 650 mg. for a headache. Review of nurse ' s notes in the resident ' s record revealed that on [DATE], the resident was noted to have a change in his previous condition related to documentation of periods of confusion, medicated for complaints of a headache and increased agitation. Review of nursing notes for [DATE] revealed that the resident was medicated for a headache at 4: 00 a.m. with [MEDICATION NAME] 50 mg. Review of nursing notes and a pain management flow sheet revealed that at 10: 00 a.m. on [DATE], the resident was reported as " alert and oriented with periods of confusion and at 9: 00 p.m., the resident was noted as alert and oriented with periods of confusion. The resident was medicated for complaints of a headache on [DATE] at 12: 15 p.m. 4: 15 p.m., 9 p.m. and an illegible time on [DATE] in the a.m. Review of nursing notes, beginning at 9: p.m. on [DATE] and ending at 7: 30 a.m. on [DATE] revealed: [DATE] 9: 00 p.m. " Resident settled in bed, Occasional periods of confusion. Medicated for headache and C/O of [MEDICAL CONDITION]. " [DATE] 10:00 p.m. " Positive effect, denies pain and discomfort at this time. " [DATE] 10: 30 p.m. " Sleeping quietly. Respirations even and regular. Bed alarm in place and functioning. " [DATE] 12 a.m. " Up in w/c (wheelchair) with one on one care with CNA due to confusion, insistence in standing by self " . [DATE] 2 a.m. " Slept for short intervals. Bed alarm on and functioning. Resident confused, striking out at times. " [DATE] 2: 10 a.m. " Resident fell out of wheelchair, hit head, not able to tell nurse his name or birthday. Cut to left temple. BP ,[DATE], Pulse 88, Respirations 22. EMS called. [DATE] 2: 12 a.m. " Transported to (hospital). Daughter notified of transfer to hospital. [DATE] 7: 30 a.m. " Physician notified. " Review of the nursing notes for [DATE] and [DATE] revealed no documentation that the physician was notified of any change in the resident ' s condition. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have expected to be called regarding the resident ' s behavior and condition. On [DATE] at 3: 41 p.m., an interview was conducted with Nurse # 1, the Registered Nurse (RN) who provided care for resident # 1 from 7: 00 p.m. to the time of the resident ' s fall on [DATE]. Nurse # 1 was asked if she recalled the events surrounding the fall for resident # 1. She stated that she did recall. She stated that she took care of the resident on his first night in the facility (,[DATE]-[DATE]. And he was " pretty quiet but somewhat restless. She stated that on [DATE], she came on shift at 7: 00 p.m. She stated that he had been medicated for a headache before she came on duty. She stated it was very hard to get through to him that he needed to stay in bed. She stated he was crawling up out of bed, calling for his wife and was very anxious. She stated that she and CNA # 1 decided that " we would do one on one care with the CNA due to the confusion and wanting to get up and leave. " She stated " we do that a lot, we one to one the people, one to one personal interaction to calm them " She stated that she medicated the resident [MEDICATION NAME] " probably because I wanted to quiet him down and see if he would sleep " and gave him Tylenol for a headache She stated that she assessed the resident ' s vital signs at midnight ( documentation of a vital sign record in the resident ' s record revealed " ,[DATE] ,[DATE] Temperature 98.7, Pulse 90, Respirations 20 and Blood Pressure ,[DATE]. " ) She stated that the resident was place in the hallway of the facility in his wheelchair and CNA # 1 was seated next to the resident. She stated that the resident was continuing to try and get up out of the wheelchair while seated in the hallway and CNA # 1 was attempting to calm him. She stated that she returned from lunch at 2: 00 a.m. and walked by the resident and noted he was sitting up in his wheelchair and had his eyes close and his head down nodding a little bit and he looked comfortable and quiet. She stated she thought, " Oh good he is going to sleep. We ' ll get him back into bed around 5: 00 a.m. She stated she had just walked back to the nurse ' s station and put her book and her drink down and turned around to look down the hallway and " he just fell forward out of the wheelchair, hit his head, he didn ' t try to break his fall, he just went straight down like he had died . " She stated that this happened approximately ten minutes after she walked past him. " Observation, on [DATE] at 1: 00 pm., revealed that the nursing station where Nurse # 1 stated she was when the resident fell was approximately 55 feet from the resident ' s location in the hallway.. Further interview with Nurse # 1 revealed that she did not notify the physician of the resident ' s behavior and condition. She stated that if he had continued to be agitated she would have called the physician. She stated that she felt the resident was safer in a wheelchair instead of a Geri Chair because she was afraid he would " flip out of the chair " She stated that she did not place a chair alarm on the resident because she felt it would agitate him more if he tried to stand and the alarm would go off. She stated she made the decision to leave him up in his wheelchair as he was already in it. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have liked to have seen the resident placed in a Geri chair with a lap buddy and chair alarm for safety. An interview was conducted with CNA # 1 who was assigned to care for resident # 1 on the 11 P.m. to 7 am shift on ,[DATE]- [DATE]. The interview was conducted on [DATE] at 4: 35 p.m. CNA # 1 stated that she came on duty at 11: 00 p.m. on [DATE] and received report from the outgoing CNA and nurse that resident # 1 was constantly wanting to get up and calling for his wife. She stated she was told it had been going on for a while but was unable to recall if the other CNA told her how long. She stated he seemed to be agitated and constantly wanting to get up from the bed and go home. She stated that she tried to comfort him and calm him. She stated he would calm down and she would leave the resident in his room and the bed alarm would go off again and that this kept occurring. She stated she got him up in his wheelchair and took him to the bathroom and gave him something to drink. She stated he was still agitated so for his safety she took him down the hall. She stated she placed him in the hallway between rooms [ROOM NUMBERS] ( resident ' s room was 101) and provided " one to one " stating, and demonstrating, that she was approximately arm ' s length from him. CNA # 1 was asked to describe what " one to one " was. She stated " I have the patient with me; I am constantly watching them for safety until I think they are ready to go back to bed. " She stated he continued to want to get up and that she " kept him sitting close to me " . She stated that the call light went off in another room (room [ROOM NUMBER]) and she stood up to answer it while calling down the hall or CNA # 2. She stated she said to CNA # 2 " Would you mind sitting with him while I answer the light. " She stated that at this time, the resident was seated in his wheelchair with his eyes closed and head down and " seemed to be resting " . She stated she saw CNA # 2 coming down the hall, heard the other nurse call out to her and saw CNA # 2 stop and turn to talk to the nurse and CNA # 2 did not reach the resident before she ( CNA #1) walked away. She stated she was entering the room where the call light was ringing when she heard a thump. She stated that she heard the resident fall but did not see the resident fall. Based on CNA # 1 ' s description of where resident #1 was located in the hallway and the location of the room where the call light went off (room [ROOM NUMBER]) and observation of the hallway, on [DATE] at 1: 00 p.m., CNA # 1 was approximately 10 feet away from resident # 1 when he fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 5: 10 p.m., an interview was conducted with CNA # 2. She was asked if she recalled the incident with resident # 1 and she stated that she did. She stated that she was working on the same hallway as CNA # 1 and that CNA # 1 had the resident in the hallway. She stated that CNA # 1 asked her to watch resident # 1 while she answered a call light. She stated she was by room [ROOM NUMBER] and was walking toward the patient who was between rooms [ROOM NUMBERS] in the hall. She stated she turned around to tell the nurse something and was facing away from the resident when she heard the resident fall. She stated that CNA # 1 was already in the room where the call light was ringing. She stated that neither she nor CNA # 1 was with the resident or facing the resident when he fell . She stated she did not see the resident fall. Based on the description of the location of resident # 1, provided by CNA # 1, CNA # 2's self-reported location ,and observation of the hallway , on [DATE] at 1: 00 p.m., , CNA # 2 was approximately ,[DATE] feet away from resident # 1 when the resident fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 3: 29 p.m., a phone interview was conducted with Nurse # 2 who stated that she was on duty during the incident on [DATE]. She stated that she recalled the incident. She stated that she was at the nursing station facing the hall the resident was on. She stated that he was sitting in the hallway in a wheelchair. She stated that CNA # 2 was talking to her at the nurse ' s station when CNA # 1 called out for CNA # 2 to watch the resident while she answered a call light. She stated that CNA # 1 was not with resident # 1, that she was walking down the hall, and CNA # 2 was walking down the hall toward resident #1 when he fell . She confirmed that neither CNA was with the resident at the time of the fall. She stated she was at the nursing station and she saw the resident " literally fall forward face first. " Observation, on [DATE] at 1: 00 p.m., revealed that the nursing station was located approximately 55 feet from the reported location of resident # 1 when he fell and hit his head sustaining a head injury. Interview with Nurse 2, on [DATE] at 3: 29 p.m., revealed that after resident # 1 fell , he was " not even coherent to answer us. " Review of nursing notes, written by nurse # 1 at 2: 10 a.m., revealed that resident # 1 was " not able to tell nurse his name or birthday. " Review of the Emergency Medical Services ( EMS) electronic report for [DATE] for resident # 1, hospital triage records for [DATE] for resident # 1, and facility staff interviews and documentation, revealed that there was a significant discrepancy between the time the facility stated the resident fell and EMS and hospital records. Interview with nurse # 1 revealed that she observed the resident at 2: 00 a.m. as she was returning from lunch and he fell at approximately 2: 10 a.m. Review of nursing documentation in the resident's record, written by nurse # 1, confirmed this time frame. Review of a mandatory state report, submitted by the facility on [DATE], revealed time of fall listed as 2: 10 a.m. Review of the electronic EMS report revealed that EMS was dispatched to the facility for a ground level fall for resident # 1 at 1: 43 a.m. and arrived at the hospital at 2: 25 a.m. Review of emergency room records from the hospital revealed that the resident was in triage at 2: 28 a.m. Review of the time record for nurse # 1, provided by the facility on [DATE], and revealed that Nurse # 1 was clocked out from 1: 03 a.m. until 1: 29 a.m. on [DATE]. Documentation in resident # 1 ' s record revealed that the resident was transported by EMS to a local hospital. Review of the resident ' s record, obtained from the hospital revealed that the chief complaint on the EMS report was " fall with [MEDICAL CONDITION]. The resident ' s vital signs, noted by EMS at 1: 52 a.m. were blood pressure ,[DATE], pulse 78, respirations 16 and oxygen saturations 100%. The resident ' s vital signs, noted by EMS at 2: 12 a., were blood pressure ,[DATE]. Pulse 85, respirations 16, and oxygen saturations of 100 %. Review of the emergency room report revealed that the resident was triaged at the emergency room at 2: 28 a.m. with chief complaint of head pain/injury. The report from EMS to the hospital stated " patient crankier that usual, fell from wheelchair on head. " The resident ' s triage vital signs were blood pressure ,[DATE], pulse 84, respirations 22 and Glasgow coma scale of 14 (minor [MEDICAL CONDITION]). emergency room notes indicate the resident was sent for a CT scan of the head at 2: 55 a.m. The CT scan results were reported as " Acute left sided subdural hematoma with maximum thickness of 8 mm. Only minimal regional mass effect and ,[DATE] mm midline shift. A tiny right posterior paramediam subarachnoid hemorrhage and minima hematoma. There was a small amount of blood within the occipital horns. " A review of the history and physical, dictated on [DATE] at 11: 05 a.m., revealed the physician ' s assessment to be " non Syncopal fall at nursing home with resultant altered mental status changes, increased left subdural hematoma with slight midline shift and residual right sided hematoma and right sided subarachnoid hemorrhage. " Review of the hospital record for resident # 1 revealed that the resident was transferred to a Hospice on [DATE] and prognosis was noted to be poor. Review of the resident ' s record from the Hospice revealed that the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. The fall with serious head injury resulting in death of resident # 1 occurred on [DATE]. The facility risk manager provided documentation of in servicing and staff education conducted with nurses and CNA ' s which occurred during the week of [DATE] through [DATE]. Documentation revealed an in service conducted on [DATE] by the facility risk manager for licensed nurses and signatures of completion by the facility nursing staff. Topics were listed as: 1. If a resident has a fall and strikes his/her head, initiate neuro checks. 2. If you have any doubts or there is a change in their status, initiate neuro checks. 3. If a resident is admitted with a [DIAGNOSES REDACTED]. 4. If a resident is a high risk for falls ESP at night: Have resident at the desk so as to observe at all times. 5. If resident falling asleep sitting up, try a Geri/Broda chair. Documentation revealed an in service , entitled " Safety Interventions, conducted the week of [DATE] through [DATE] for CNA ' s and signed as competed by the facility CNA ' s. Topics covered were listed as " Please check all alarms and safety interventions: 1 . That they are in place 2. That they are functioning properly 3. Check your checklist on the CNA clipboard 4. If not functioning properly - replace 5 If you need alarms/pads let (staff) know. 6. Resident at high risk for falls. Place in common areas to increase visualization. ? Remember RSP ( Rising Star Program) ? Alert nurses of changes/ condition promptly ? Anticipate needs, food, fluids , toileting " Interviews were conducted on [DATE] between 1: 25 p.m. and 1: 40 p.m., with facility CNAs. The CNAs were able to describe the steps and interventions they were to take to determine who was at risk for a fall, what safety interventions were in place, placing a high risk resident at the nursing station for closer observation, alerting other staff of the need to monitor the resident, taking the resident to activities for supervision and diversion and placing a resident in bed who was observed to be falling asleep while in a wheelchair. The Immediate Jeopardy was determined removed on [DATE] and the scope and severity was reduced to a D. . ,

Based on resident record review and staff interview, it was determined that the facility failed to provide services necessary to avoid physical harm and failed to provide supervision to prevent serious physical harm to a fragile [AGE] year old resident for one of five residents reviewed ( # 1). The investigation revealed the facility failed to accurately assess the resident, failed to notify the physician of a change in condition, failed to maintain the resident in a safe manner and failed to supervise the resident assessed as a high fall risk. The resident sustained [REDACTED]. These facility practices resulted in the determination of Immediate Jeopardy which was removed [DATE]. Findings include: 1. Review of a summary, prepared by the facility on [DATE], revealed: " [AGE] year old male admitted to SNF [DATE]. admitting [DIAGNOSES REDACTED]. On [DATE] at 2: 10 a.m. resident fell out of wheelchair, hitting his head. Resident was up in wheelchair due to restlessness and confusion. Staff witnessed fall. Transferred to (hospital). admitted with Diagnosis: [REDACTED]. Review of the record for resident #1 revealed that the resident was admitted to the facility from the hospital on [DATE] at 1: 30 p.m. Review of the resident ' s hospital record, found in the resident ' s facility record, revealed a history and physical, dated [DATE], that the resident had been diagnosed with [REDACTED]. " A hospital discharge summary was also found in the resident ' s record, dated [DATE]. Review of this summary revealed [DIAGNOSES REDACTED]. " Non Syncopal Falls resulting in bilateral Subdural Hematoma and right Subarachnoid Hemorrhage. Non Syncopal fall secondary to Orthostatic Hypotension Gait Ataxia secondary to Peripheral Neuropathy Benign Prostatic Hypertrophy with Overactive bladder History of prior Cerebrovascular Accident Memory loss secondary to Multi infarct dementia. " The resident ' s prognosis was listed as " good. " Interview with the facility Risk Manager, on [DATE] at 9: 40 a.m., revealed that a registered nurse liaison ( Nurse # 3) from the facility goes to the hospital and reviews the patient ' s medical record and meets with the patient. The registered nurse then completes a pre admission assessment which also includes a pre admission fall assessment. She stated that this pre admission assessment is part of the paperwork used by the admitting nurse when a resident is admitted to the facility. An interview was conducted , on [DATE] at 2: 30 p.m., with the Licensed Practical Nurse (LPN) ( Nurse # 4) who completed the admission evaluation of resident # 1 on [DATE], She stated that prior to completing the admission evaluation, she reviews the paperwork from the hospital, including the history and physical, and reviews the preadmission assessment. She stated she obtains the [DIAGNOSES REDACTED]. Review of the preadmission assessment and fall risk assessment completed prior to admission, dated [DATE] , the Nursing Admission Evaluation completed at Admission, dated [DATE], and a Fall Risk assessment completed at admission , dated [DATE], revealed conflicting information regarding the resident's condition related to diagnoses, sensory deficits, ADL abilities, fall risk and cognition . Review of a pre admission assessment, completed on [DATE]and signed by Nurse # 3, a registered nurse, revealed that the resident was assessed as having a [DIAGNOSES REDACTED]. The resident was assessed for ADL skills as needing " limited or extensive assist. " Ambulatory status was assessed as - " Assist with ambulation, history of falls, and assistive devices - walker." Mental Status was assessed as - " Alert /Oriented, Forgetful. " Nutritional Status was assessed as - " Assist with meals. " A " Pre Admission Fall Risk Assessment " was also completed on [DATE] by Nurse # 3. Review of this document revealed that the resident was assessed as at risk due to: Recent of previous falls Age 65 or above Loss of hearing Physical disabilities affecting mobility History of Hypertension. Review of the Nursing Admission Evaluation, which was completed by a Licensed Practical Nurse ( Nurse # 4), on [DATE] at the facility at 1: 30 p.m. revealed:. Diagnosis- " fall with headache." The resident was assessed as alert and oriented times three , adequate hearing, able to feed self with set up, full weight bearing status, wheelchair - propels self. " Review of the Assessment for Risk for fall, also completed by Nurse # 4, admission, revealed the following items were checked: Fall history Mental status - Confusion/Dementia Sensory Deficits - decreased hearing Use of Assistive Device - wheelchair Transfer difficulties Unsteady gait Medications- Cardiac and Hypnotics. Although the resident had a history of [REDACTED]. An interview was conducted, on [DATE] at 2: 30 p.m., with the Nurse # 4 who completed the nursing admission evaluation and Assessment for fall risk at the facility on [DATE] at 1: 30 p.m. She stated that the [DIAGNOSES REDACTED]. She stated when she assessed the resident he was alert and oriented , not experiencing any pain, cooperative, able to make his needs known, able to stand but not ambulate, and was not exhibiting anything that would have indicated the need for additional fall risk safety precautions such as a bed or chair alarm. The resident scored a 10 on the fall risk assessment, dated [DATE], which indicated 9 pts. and up was high risk. An interim care plan was completed for fall risk The Interim plan of care stated: "Assist of 1 for transfers" Assist of 1 for ambulation Keep the following assistive devices within reach: wheelchair Anticipate and check for needs) include toileting) regularly and frequently Keep room free of clutter Provide adequate lighting, especially at night Orient to surroundings Refer to PT. Review of the Resident Care card, used by the CNA"s to provide care to the resident, revealed that fall Precautions were not checked and cognition was listed as Alert and Oriented, neither confused nor forgetful was checked although the resident had been assessed as a high fall risk and confused and forgetful, both on the pre admission assessment and the admission evaluation. Interview with the Risk Manager, on [DATE] at 9: 40 a.m., at revealed that the facility has a process in place to ensure the accuracy of the medical record after admission but since the resident came in on a Friday afternoon, the record would not have been reviewed until Monday and the resident was already gone by then. She provided the policy, " New Admission Checklist, " dated with an effective date of February 2006, which stated: " Policy Statement: The facility will complete a new admission checklist after each admission to ensure the accuracy of the medical record, including but not limited to: physician orders [REDACTED]." Procedure; Admission nurse completed the form after admission Supervisor/designee reviews the form, as soon as possible after admission, with the Interdisciplinary Team (usually the following morning, or on Monday for weekend admissions If corrections are needed, form goes to the RN Supervisor for correction and final check. Finally, a copy of the form goes back to the Risk Manager and the original goes to the DON." Review of nursing notes for resident # 1 revealed that the resident was noted as: " Alert and oriented with no complaints of pain or discomfort at 4: 05 p.m. on [DATE]. " " Alert and oriented and able to make wants and needs known. Denies pain at this time, " at 10: 30 p.m. on [DATE]. Nursing notes indicated that the resident was medicated for pain one time on [DATE], at 5: 00 p.m. with Tylenol 650 mg. for a headache. Review of nurse ' s notes in the resident ' s record revealed that, on [DATE], the resident was noted to have a change in his previous condition related to documentation of periods of confusion, medicated for complaints of a headache and increased agitation. Review of nursing notes for [DATE] revealed that the resident was medicated for a headache at 4: 00 a.m. with Tramadol 50 mg. Review of nursing notes and a pain management flow sheet revealed that at 10: 00 a.m. on [DATE], the resident was reported as " alert and oriented with periods of confusion " and at 9: 00 p.m., the resident was noted as " alert and oriented with periods of confusion. " The resident was medicated for complaints of a headache on [DATE] at 12: 15 p.m. 4: 15 p.m., 9 p.m. and an illegible time on [DATE] in the a.m. The resident was also given Ambien 5 mg, at 9: 00 p.m. on [DATE], prescribed by the physician on [DATE] as an as needed medication for Insomnia. Review of the Drug Information Handbook for Nursing, 8th edition for Ambien, revealed: Use: Short term treatment of [REDACTED]. Warnings /Precautions: " Closely monitor elderly or debilitated patients for impaired cognitive or motor performance. Pharmacodynamics/Kinetics: Onset of action: 30 minutes Duration of action: ,[DATE] hours Time to peak: 2 hours, 4 hours with food. Half Life Elimination: [DATE].8 hours (range 1XXX,[DATE].5 hours). Review of nursing notes, beginning at 9: p.m. on [DATE] and ending at 7: 30 a.m. on [DATE] revealed: [DATE] 9: 00 p.m. " Resident settled in bed, Occasional periods of confusion. Medicated for headache and C/O of Insomnia. " [DATE] 10:00 p.m. " Positive effect, denies pain and discomfort at this time. " [DATE] 10: 30 p.m. " Sleeping quietly. Respirations even and regular. Bed alarm in place and functioning. " [DATE] 12 a.m. " Up in w/c (wheelchair) with one on one care with CNA due to confusion, insistence in standing by self " . [DATE] 2 a.m. " Slept for short intervals. Bed alarm on and functioning. Resident confused, striking out at times. " [DATE] 2: 10 a.m. " Resident fell out of wheelchair, hit head, not able to tell nurse his name or birthday. Cut to left temple. BP ,[DATE], Pulse 88, Respirations 22. EMS called. [DATE] 2: 12 a.m. " Transported to (hospital). Daughter notified of transfer to hospital. " [DATE] 7: 30 a.m. " Physician notified. " There was no documentation in the resident ' s record (including nursing notes for [DATE] and [DATE]) that the physician was notified of any change in the resident ' s condition. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have expected to be called regarding the resident ' s behavior and condition. On [DATE] at 3: 41 p.m., an interview was conducted with Nurse # 1, the Registered Nurse (RN) who provided care for resident # 1 from 7: 00 p.m. to the time of the resident ' s fall on [DATE]. Nurse # 1 was asked if she recalled the events surrounding the fall for resident # 1. She stated that she did recall. She stated that she took care of the resident on his first night in the facility (,[DATE]-[DATE]) and he was " pretty quiet but somewhat restless. She stated that on [DATE], she came on shift at 7: 00 p.m. She stated that he had been medicated for a headache before she came on duty. She stated it was very hard to get through to him that he needed to stay in bed. She stated he was crawling up out of bed, calling for his wife and was very anxious. She stated that she and CNA # 1 decided that " we would do one on one care with the CNA due to the confusion and wanting to get up and leave. " She stated " we do that a lot, we one to one the people, one to one personal interaction to calm them. " She stated that she medicated the resident with Ambien " probably because I wanted to quiet him down and see if he would sleep " and gave him Tylenol for a headache She stated that she assessed the resident ' s vital signs at midnight ( documentation of a vital sign record in the resident ' s record revealed " ,[DATE] ,[DATE] Temperature 98.7, Pulse 90, Respirations 20 and Blood Pressure ,[DATE]. " ) She stated that the resident was placed in the hallway of the facility in his wheelchair and CNA # 1 was seated next to the resident. She stated that the resident was continuing to try and get up out of the wheelchair while seated in the hallway and CNA # 1 was attempting to calm him. She stated that she returned from lunch at 2: 00 a.m. and walked by the resident and noted he was sitting up in his wheelchair and had his eyes close and his head down nodding a little bit and he looked comfortable and quiet. She stated she thought, " Oh good he is going to sleep. We ' ll get him back into bed around 5: 00 a.m. " She stated she had just walked back to the nurse ' s station and put her book and her drink down and turned around to look down the hallway and " he just fell forward out of the wheelchair, hit his head, he didn ' t try to break his fall, he just went straight down like he had died . " She stated that this happened approximately ten minutes after she walked past him. " Observation, on [DATE] at 1: 00 pm., revealed that the nursing station where Nurse # 1 stated she was when the resident fell was approximately 55 feet from the resident ' s location in the hallway.. Further interview with Nurse # 1 revealed that she did not notify the physician of the resident ' s behavior and condition. She stated that if he had continued to be agitated she would have called the physician. She stated that she felt the resident was safer in a wheelchair instead of a Geri Chair because she was afraid he would " flip out of the chair. " She stated that she did not place a chair alarm on the resident because she felt it would agitate him more if he tried to stand and the alarm would go off. She stated she made the decision to leave him up in his wheelchair as he was already in it. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have liked to have seen the resident placed in a Geri chair with a lap buddy and chair alarm for safety. An interview was conducted with CNA # 1 who was assigned to care for resident # 1 on the 11 p.m. to 7 am shift on ,[DATE]- [DATE]. The interview was conducted on [DATE] at 4: 35 p.m. CNA # 1 stated that she came on duty at 11: 00 p.m. on [DATE] and received report from the outgoing CNA and nurse that resident # 1 was constantly wanting to get up and calling for his wife. She stated she was told it had been going on for a while but was unable to recall if the other CNA told her how long. She stated he seemed to be agitated and constantly wanting to get up from the bed and go home. She stated that she tried to comfort him and calm him. She stated he would calm down and she would leave the resident in his room and the bed alarm would go off again and that this kept occurring. She stated she got him up in his wheelchair and took him to the bathroom and gave him something to drink. She stated he was still agitated so for his safety she took him down the hall. She stated she placed him in the hallway between rooms 107 and 109 ( resident ' s room was 101) and provided " one to one " stating, and demonstrating, that she was approximately arm ' s length from him. CNA # 1 was asked to describe what " one to one " was. She stated, " I have the patient with me; I am constantly watching them for safety until I think they are ready to go back to bed. " She stated he continued to want to get up and that she " kept him sitting close to me. " She stated that the call light went off in another room (room 105) and she stood up to answer it while calling down the hall or CNA # 2. She stated she said to CNA # 2 " Would you mind sitting with him while I answer the light. " She stated that at this time, the resident was seated in his wheelchair with his eyes closed and head down and " seemed to be resting. " She stated she saw CNA # 2 coming down the hall, heard the other nurse call out to her and saw CNA # 2 stop and turn to talk to the nurse and CNA # 2 did not reach the resident before she ( CNA #1) walked away. She stated she was entering the room where the call light was ringing when she heard a thump. She stated that she heard the resident fall but did not see the resident fall. Based on CNA # 1 ' s description of where resident #1 was located in the hallway and the location of the room where the call light went off (room 105) and observation of the hallway, on [DATE] at 1: 00 p.m., CNA # 1 was approximately 10 feet away from resident # 1 when he fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 5: 10 p.m., an interview was conducted with CNA # 2. She was asked if she recalled the incident with resident # 1 and she stated that she did. She stated that she was working on the same hallway as CNA # 1 and that CNA # 1 had the resident in the hallway. She stated that CNA # 1 asked her to watch resident # 1 while she answered a call light. She stated she was by room 122 and was walking toward the patient who was between rooms 107 and 109 in the hall. She stated she turned around to tell the nurse something and was facing away from the resident when she heard the resident fall. She stated that CNA # 1 was already in the room where the call light was ringing. She stated that neither she nor CNA # 1 was with the resident or facing the resident when he fell . She stated she did not see the resident fall. Based on the description of the location of resident # 1, provided by CNA # 1, CNA # 2's self-reported location ,and observation of the hallway , on [DATE] at 1: 00 p.m., , CNA # 2 was approximately ,[DATE] feet away from resident # 1 when the resident fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 3: 29 p.m., a phone interview was conducted with Nurse # 2 who stated that she was on duty during the incident on [DATE]. She stated that she recalled the incident. She stated that she was at the nursing station facing the hall the resident was on. She stated that he was sitting in the hallway in a wheelchair. She stated that CNA # 2 was talking to her at the nurse ' s station when CNA # 1 called out for CNA # 2 to watch the resident while she answered a call light. She stated that CNA # 1 was not with resident # 1, that she was walking down the hall and CNA # 2 was walking down the hall toward resident #1 when he fell . She confirmed that neither CNA was with the resident at the time of the fall. She stated she was at the nursing station and she saw the resident " literally fall forward face first. " Observation, on [DATE] at 1: 00 p.m., revealed that the nursing station where Nurse # 2 was located was approximately 55 feet from the reported location of resident # 1 when he fell and hit his head sustaining a head injury. Interview with Nurse 2, on [DATE] at 3: 29 p.m., revealed that after resident # 1 fell , he was " not even coherent to answer us. " Review of nursing notes, written by nurse # 1 at 2: 10 a.m., revealed that resident # 1 was " not able to tell nurse his name or birthday. " Review of the Emergency Medical Services ( EMS) electronic report for [DATE] for resident # 1, hospital triage records for [DATE] for resident # 1, and facility staff interviews and documentation, revealed that there was a significant discrepancy between the time the facility stated the resident fell and EMS and hospital records. Interview with nurse # 1 revealed that she observed the resident at 2: 00 a.m. as she was returning from lunch and he fell at approximately 2: 10 a.m. Review of nursing documentation in the resident's record, written by nurse # 1, confirmed this time frame. Review of a mandatory state report, submitted by the facility on [DATE], revealed time of fall listed as 2: 10 a.m. A confidential interview was conducted with a family member of resident # 1, on [DATE] at 4: 35 p.m., the family member stated that a message from Nurse # 1, informing her of the fall, was recorded on their answering machine at 2: 15 a.m. on [DATE] and the message stated that the resident had fallen at 2: 00 a.m. Review of the electronic EMS report revealed that EMS was dispatched to the facility for a ground level fall for resident # 1 at 1: 43 a.m. and arrived at the hospital at 2: 25 a.m. Review of emergency room records from the hospital revealed that the resident was in triage at 2: 28 a.m. Review of the time record for nurse # 1, provided by the facility on [DATE], and revealed that Nurse # 1 was clocked out from 1: 03 a.m. until 1: 29 a.m. on [DATE]. Documentation in resident # 1s record revealed that the resident was transported by EMS to a local hospital. Review of the resident ' s record, obtained from the hospital, revealed that the chief complaint on the EMS report was " fall with head laceration. The resident ' s vital signs, noted by EMS at 1: 52 a.m. were blood pressure ,[DATE], pulse 78, respirations 16 and oxygen saturations 100%. The resident ' s vital signs, noted by EMS at 2: 12 a., were blood pressure ,[DATE]. Pulse 85, respirations 16, and oxygen saturations of 100 %. " Review of the emergency room report revealed that the resident was triaged at the emergency room at 2: 28 a.m. with chief complaint of head pain/injury. The report from EMS to the hospital stated " patient crankier that usual, fell from wheelchair on head. " The resident ' s triage vital signs were blood pressure ,[DATE], pulse 84, respirations 22 and Glasgow coma scale of 14 (minor brain injury). emergency room notes indicate the resident was sent for a CT scan of the head at 2: 55 a.m. The CT scan results were reported as " Acute left sided subdural hematoma with maximum thickness of 8 mm. Only minimal regional mass effect and ,[DATE] mm midline shift. A tiny right posterior paramediam subarachnoid hemorrhage and minima hematoma. There was a small amount of blood within the occipital horns. " A review of the history and physical, dictated on [DATE] at 11: 05 a.m., revealed the physician ' s assessment to be " non Syncopal fall at nursing home with resultant altered mental status changes, increased left subdural hematoma with slight midline shift and residual right sided hematoma and right sided subarachnoid hemorrhage. " Review of the hospital record for resident # 1 revealed that the resident was transferred to an inpatient Hospice on [DATE] and prognosis was noted to be poor. Review of the resident ' s record from the Hospice revealed that the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. Review of the initial assessment from the Hospice, dated [DATE], revealed: " Patient fell early this month, suffered bilateral subdural hematoma (6mm on right and 5 mm on left). Patient sent to skilled facility for skilling ... became agitated, fell again out of chair, suffering acute left sided subdural hematoma with ,[DATE] mm midline shift ..... Patient confused, unable to verbalize, lethargic, emaciated, no PO for several days, laceration middle of upper forehead, tea colored urine, diminished bilateral lung fields, bruising bilateral lower extremities. " " Findings supporting prognosis: Life limiting condition. Palliative care " Review of the record form the other health care facility indicated the resident died on [DATE].on [DATE]. A confidential interview was conducted with a family member of resident # 1, on [DATE] at 4: 35 p.m. The family member stated that the Medical Examiner reported the cause of death on the death certificate as " Complications resulting from multiple blunt head trauma. " The fall with serious head injury resulting in death of resident # 1 occurred on [DATE]. The facility risk manager provided documentation of in servicing and staff education conducted with nurses and CNA ' s which occurred during the week of [DATE] through [DATE]. Documentation revealed an in service conducted on [DATE] by the facility risk manager for licensed nurses and signatures of completion by the facility nursing staff. Topics were listed as: 1. If a resident has a fall and strikes his/her head, initiate neuro checks. 2. If you have any doubts or there is a change in their status, initiate neuro checks. 3. If a resident is admitted with a [DIAGNOSES REDACTED]. 4. If a resident is a high risk for falls ESP at night: Have resident at the desk so as to observe at all times. 5. If resident falling asleep sitting up, try a Geri/Broda chair. Documentation revealed an in service , entitled " Safety Interventions, conducted the week of [DATE] through [DATE] for CNA ' s and signed as competed by the facility CNA ' s. Topics covered were listed as " Please check all alarms and safety interventions: 1 . That they are in place 2. That they are functioning properly 3. Check your checklist on the CNA clipboard 4. If not functioning properly - replace 5 If you need alarms/pads let (staff) know. 6. Resident at high risk for falls. Place in common areas to increase visualization. ? Remember RSP ( Rising Star Program) ? Alert nurses of changes/ condition promptly ? Anticipate needs, food, fluids , toileting " Interviews were conducted on [DATE] between 1: 25 p.m. and 1: 40 p.m., with facility CNAs. The CNAs were able to describe the steps and interventions they were to take to determine who was at risk for a fall, what safety interventions were in place, placing a high risk resident at the nursing station for closer observation, alerting other staff of the need to monitor the resident, taking the resident to activities for supervision and diversion and placing a resident in bed who was observed to be falling asleep while in a wheelchair. The Immediate Jeopardy was determined removed on [DATE] and the scope and severity was reduced to a D. .

Based on resident record review, facility record review and policy review, staff interviews and observations, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively to maintain the highest practicable physical , mental and psychosocial well- being for one of five residents reviewed ( # 1). Administration failed to ensure that resident # 1 was appropriately assessed, failed to ensure that the physician was notified of a change in the resident's condition, and failed to ensure that the resident who was determined to be at high risk for falls was maintained in a safe manner and adequately supervised. These practices resulted in the determination of Immediate Jeopardy which was removed [DATE]. Findings include: 1. Review of the POS [REDACTED] "Basic Function: 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. 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.) 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 6. Ensure that patient's/residents rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times." 2. An interview was conducted with the facility Risk Manager and Administrator, on [DATE] at 9: 40 a.m. The Risk Manager and Administrator both stated that they were aware of resident # 1 ' s fall on [DATE]. The Risk Manager gave a verbal report of the facility ' s investigation into the incident. The Administrator was present during this report. The Risk Manager stated that resident # 1 did go to sleep for a while on the evening of [DATE]- [DATE]. She stated that when CNA # 1 came on duty, he was getting restless and that the bed alarm was in place. CNA # 1 had to keep going back in the room, the bed was in the lowest position and the resident gave no specific reason why he wanted to get up. CNA # 1 took him to the restroom and gave him some fluids when he was trying to get out o bed. She stated CNA #1 took him out of his room to the hall; he was resting periodically then continuing to try and get up. She, CNA # 1, felt the safest intervention was to keep him in the hall where she and other staff could keep an eye on him. She stated he constantly complained of a headache and would get something for it and it would resolve. She stated he was over by room [ROOM NUMBER], sitting in a wheelchair by CNA # 1. CNA # 1 was sitting close by him but not too close because she was trying to keep him as calm as possible. The Risk Manager stated CNA # 1 put him in the hall around midnight or so and the fall happened at 2: 10 a.m. At approximately 2: 00 a.m., Nurse # 1 had walked by him and noted he was sitting calmly, resting with his eyes closed. She stated the light in room [ROOM NUMBER] went off and CNA # 1 stood up to get the light. CNA # 2 was by room [ROOM NUMBER] and was walking toward the resident and was approximately 25 feet away. Nurse # 2 was at the desk and heard a sound. Nurse # 2 said he didn ' t put his hands out, just went straight forward to floor. The Risk Manager, in the presence of the Administrator, stated that the resident was a high fall risk and had a bed alarm and a low bed. She stated that she asked, as part of her investigation, about using a Geri chair for the resident and that Nurse # 1 told her that she thought there was more change of him injuring himself in the Geri chair because he was trying to stand. She stated that she asked about using a chair alarm and that Nurse # 1 felt the use of a chair alarm would have agitated him more. She stated that the resident had " essentially one to one observation in the hall. " Interview with the Risk Manager and the Administrator, on [DATE] at 9: 40 a.m., revealed that the facility does not have a written policy for one to one supervision. The Administrator stated that " this is not a one to one facility. " The Risk Manager stated that the only time they would provide additional staff for a one to one supervision was if a resident needed one to one supervision in their room. She stated that if a resident was inappropriate to stay in their room and just needed closer supervision in the hall, they would bring them out for staff observation with no extra staff. On [DATE] at 9:45 a.m., the Administrator and the Risk Manager stated that the RN (Nurse # 1) saw the situation, made a nursing judgment not to use a Geri chair and an alarm and the resident " ended up calming down. " 3. Administration failed to ensure that resident # 1 was appropriately assessed: Review of a summary ,prepared by the facility on [DATE], revealed: " [AGE] year old male admitted to SNF [DATE]. admitting [DIAGNOSES REDACTED]. On [DATE] at 2: 10 a.m. resident fell out of wheelchair, hitting his head. Resident was up in wheelchair due to restlessness and confusion. Staff witnessed fall. Transferred to (hospital). admitted with Diagnosis: [REDACTED]. Review of the record for resident #1 revealed that the resident was admitted to the facility from the hospital on [DATE] at 1: 30 p.m. Review of the resident ' s hospital record, found in the resident ' s facility record, revealed a history and physical, dated [DATE], that the resident had been diagnosed with [REDACTED]. " A hospital discharge summary was also found in the resident ' s record, dated [DATE]. Review of this summary revealed [DIAGNOSES REDACTED]. " Non Syncopal Falls resulting in bilateral Subdural Hematoma and right Subarachnoid Hemorrhage. Non Syncopal fall secondary to Orthostatic [MEDICAL CONDITION] Gait Ataxia secondary to Peripheral [MEDICAL CONDITION] [MEDICAL CONDITION] with Overactive bladder History of prior [MEDICAL CONDITION] Memory loss secondary to Multi infarct dementia. " The resident ' s prognosis was listed as " good. " Interview with the facility Risk Manager, on [DATE] at 9: 40 a.m., revealed that a registered nurse liaison ( Nurse # 3) from the facility goes to the hospital and reviews the patient ' s medical record and meets with the patient. The registered nurse then completes a pre admission assessment which also includes a pre admission fall assessment. She stated that this pre admission assessment is part of the paperwork used by the admitting nurse when a resident is admitted to the facility. An interview was conducted , on [DATE] at 2: 30 p.m., with the Licensed Practical Nurse (LPN) ( Nurse # 4) who completed the admission evaluation of resident # 1 on [DATE], She stated that prior to completing the admission evaluation, she reviews the paperwork from the hospital, including the history and physical, and reviews the preadmission assessment. She stated she obtains the [DIAGNOSES REDACTED]. Review of the preadmission assessment and fall risk assessment completed prior to admission, dated [DATE] , the Nursing Admission Evaluation completed at Admission, dated [DATE], and a Fall Risk assessment completed at admission , dated [DATE], revealed conflicting information regarding the resident's condition related to diagnoses, sensory deficits, ADL abilities, fall risk and cognition . Review of a pre admission assessment, completed on [DATE]and signed by Nurse # 3, a registered nurse, revealed that the resident was assessed as having a [DIAGNOSES REDACTED]. The resident was assessed for ADL skills as needing " limited or extensive assist. " Ambulatory status was assessed as - " Assist with ambulation, history of falls, and assistive devices - walker." Mental Status was assessed as - " Alert /Oriented, Forgetful. " Nutritional Status was assessed as - " Assist with meals. " A " Pre Admission Fall Risk Assessment " was also completed on [DATE] by Nurse # 3. Review of this document revealed that the resident was assessed as at risk due to: Recent of previous falls Age 65 or above Loss of hearing Physical disabilities affecting mobility History of Hypertension. Review of the Nursing Admission Evaluation, which was completed by a Licensed Practical Nurse ( Nurse # 4), on [DATE] at the facility at 1: 30 p.m. revealed:. Diagnosis- " fall with headache." The resident was assessed as alert and oriented times three , adequate hearing, able to feed self with set up, full weight bearing status, wheelchair - propels self. " Review of the Assessment for Risk for fall, also completed by Nurse # 4, admission, revealed the following items were checked: Fall history Mental status - Confusion/Dementia Sensory Deficits - decreased hearing Use of Assistive Device - wheelchair Transfer difficulties Unsteady gait Medications- Cardiac and Hypnotics. Although the resident had a history of [REDACTED]. An interview was conducted, on [DATE] at 2: 30 p.m., with the Nurse # 4 who completed the nursing admission evaluation and Assessment for fall risk at the facility on [DATE] at 1: 30 p.m. She stated that the [DIAGNOSES REDACTED]. She stated when she assessed the resident he was alert and oriented , not experiencing any pain, cooperative, able to make his needs known, able to stand but not ambulate, and was not exhibiting anything that would have indicated the need for additional fall risk safety precautions such as a bed or chair alarm. The resident scored a 10 on the fall risk assessment, dated [DATE], which indicated 9 pts. and up was high risk. An interim care plan was completed for fall risk The Interim plan of care stated: "Assist of 1 for transfers" Assist of 1 for ambulation Keep the following assistive devices within reach: wheelchair Anticipate and check for needs) include toileting) regularly and frequently Keep room free of clutter Provide adequate lighting, especially at night Orient to surroundings Refer to PT. Review of the Resident Care card, used by the CNA"s to provide care to the resident, revealed that fall Precautions were not checked and cognition was listed as Alert and Oriented, neither confused nor forgetful was checked although the resident had been assessed as a high fall risk and confused and forgetful, both on the pre admission assessment and the admission evaluation. Interview with the Risk Manager, on [DATE] at 9: 40 a.m., at revealed that the facility has a process in place to ensure the accuracy of the medical record after admission but since the resident came in on a Friday afternoon, the record would not have been reviewed until Monday and the resident was already gone by then. She provided the policy, " New Admission Checklist, " dated with an effective date of February 2006, which stated: " Policy Statement: The facility will complete a new admission checklist after each admission to ensure the accuracy of the medical record, including but not limited to: physician orders [REDACTED]." Procedure; Admission nurse completed the form after admission Supervisor/designee reviews the form, as soon as possible after admission, with the Interdisciplinary Team (usually the following morning, or on Monday for weekend admissions If corrections are needed, form goes to the RN Supervisor for correction and final check. Finally, a copy of the form goes back to the Risk Manager and the original goes to the DON." 4. Administration failed to ensure that the physician was notified of a change in the resident's condition, and failed to ensure that the resident who was determined to be at high risk for falls was maintained in a safe manner and adequately supervised: Review of nursing notes for resident # 1 revealed that the resident was noted as: " Alert and oriented with no complaints of pain or discomfort at 4: 05 p.m. on [DATE]. " " Alert and oriented and able to make wants and needs known. Denies pain at this time, " at 10: 30 p.m. on [DATE]. Nursing notes indicated that the resident was medicated for pain one time on [DATE], at 5: 00 p.m. with Tylenol 650 mg. for a headache. Review of nurse ' s notes in the resident ' s record revealed that, on [DATE], the resident was noted to have a change in his previous condition related to documentation of periods of confusion, medicated for complaints of a headache and increased agitation. Review of nursing notes for [DATE] revealed that the resident was medicated for a headache at 4: 00 a.m. with [MEDICATION NAME] 50 mg. Review of nursing notes and a pain management flow sheet revealed that at 10: 00 a.m. on [DATE], the resident was reported as " alert and oriented with periods of confusion " and at 9: 00 p.m., the resident was noted as " alert and oriented with periods of confusion. " The resident was medicated for complaints of a headache on [DATE] at 12: 15 p.m. 4: 15 p.m., 9 p.m. and an illegible time on [DATE] in the a.m. The resident was also [MEDICATION NAME] mg, at 9: 00 p.m. on [DATE], prescribed by the physician on [DATE] as an as needed medication for [MEDICAL CONDITION]. Review of the Drug Information Handbook for Nursing, 8th edition for Ambien, revealed: Use: Short term treatment of [REDACTED]. Warnings /Precautions: " Closely monitor elderly or debilitated patients for impaired cognitive or motor performance. Pharmacodynamics/Kinetics: Onset of action: 30 minutes Duration of action: ,[DATE] hours Time to peak: 2 hours, 4 hours with food. Half Life Elimination: [DATE].8 hours (range 1XXX,[DATE].5 hours). Review of nursing notes, beginning at 9: p.m. on [DATE] and ending at 7: 30 a.m. on [DATE] revealed: [DATE] 9: 00 p.m. " Resident settled in bed, Occasional periods of confusion. Medicated for headache and C/O of [MEDICAL CONDITION]. " [DATE] 10:00 p.m. " Positive effect, denies pain and discomfort at this time. " [DATE] 10: 30 p.m. " Sleeping quietly. Respirations even and regular. Bed alarm in place and functioning. " [DATE] 12 a.m. " Up in w/c (wheelchair) with one on one care with CNA due to confusion, insistence in standing by self " . [DATE] 2 a.m. " Slept for short intervals. Bed alarm on and functioning. Resident confused, striking out at times. " [DATE] 2: 10 a.m. " Resident fell out of wheelchair, hit head, not able to tell nurse his name or birthday. Cut to left temple. BP ,[DATE], Pulse 88, Respirations 22. EMS called. [DATE] 2: 12 a.m. " Transported to (hospital). Daughter notified of transfer to hospital. " [DATE] 7: 30 a.m. " Physician notified. " There was no documentation in the resident ' s record (including nursing notes for [DATE] and [DATE]) that the physician was notified of any change in the resident ' s condition. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have expected to be called regarding the resident ' s behavior and condition. On [DATE] at 3: 41 p.m., an interview was conducted with Nurse # 1, the Registered Nurse (RN) who provided care for resident # 1 from 7: 00 p.m. to the time of the resident ' s fall on [DATE]. Nurse # 1 was asked if she recalled the events surrounding the fall for resident # 1. She stated that she did recall. She stated that she took care of the resident on his first night in the facility (,[DATE]-[DATE]) and he was " pretty quiet but somewhat restless. She stated that on [DATE], she came on shift at 7: 00 p.m. She stated that he had been medicated for a headache before she came on duty. She stated it was very hard to get through to him that he needed to stay in bed. She stated he was crawling up out of bed, calling for his wife and was very anxious. She stated that she and CNA # 1 decided that " we would do one on one care with the CNA due to the confusion and wanting to get up and leave. " She stated " we do that a lot, we one to one the people, one to one personal interaction to calm them. " She stated that she medicated the resident [MEDICATION NAME] " probably because I wanted to quiet him down and see if he would sleep " and gave him Tylenol for a headache She stated that she assessed the resident ' s vital signs at midnight ( documentation of a vital sign record in the resident ' s record revealed " ,[DATE] ,[DATE] Temperature 98.7, Pulse 90, Respirations 20 and Blood Pressure ,[DATE]. " ) She stated that the resident was placed in the hallway of the facility in his wheelchair and CNA # 1 was seated next to the resident. She stated that the resident was continuing to try and get up out of the wheelchair while seated in the hallway and CNA # 1 was attempting to calm him. She stated that she returned from lunch at 2: 00 a.m. and walked by the resident and noted he was sitting up in his wheelchair and had his eyes close and his head down nodding a little bit and he looked comfortable and quiet. She stated she thought, " Oh good he is going to sleep. We ' ll get him back into bed around 5: 00 a.m. " She stated she had just walked back to the nurse ' s station and put her book and her drink down and turned around to look down the hallway and " he just fell forward out of the wheelchair, hit his head, he didn ' t try to break his fall, he just went straight down like he had died . " She stated that this happened approximately ten minutes after she walked past him. " Observation, on [DATE] at 1: 00 pm., revealed that the nursing station where Nurse # 1 stated she was when the resident fell was approximately 55 feet from the resident ' s location in the hallway.. Further interview with Nurse # 1 revealed that she did not notify the physician of the resident ' s behavior and condition. She stated that if he had continued to be agitated she would have called the physician. She stated that she felt the resident was safer in a wheelchair instead of a Geri Chair because she was afraid he would " flip out of the chair. " She stated that she did not place a chair alarm on the resident because she felt it would agitate him more if he tried to stand and the alarm would go off. She stated she made the decision to leave him up in his wheelchair as he was already in it. An interview was conducted with the resident ' s physician, on [DATE] at 9: 35 a.m. The physician stated he would have liked to have seen the resident placed in a Geri chair with a lap buddy and chair alarm for safety. An interview was conducted with CNA # 1 who was assigned to care for resident # 1 on the 11 p.m. to 7 am shift on ,[DATE]- [DATE]. The interview was conducted on [DATE] at 4: 35 p.m. CNA # 1 stated that she came on duty at 11: 00 p.m. on [DATE] and received report from the outgoing CNA and nurse that resident # 1 was constantly wanting to get up and calling for his wife. She stated she was told it had been going on for a while but was unable to recall if the other CNA told her how long. She stated he seemed to be agitated and constantly wanting to get up from the bed and go home. She stated that she tried to comfort him and calm him. She stated he would calm down and she would leave the resident in his room and the bed alarm would go off again and that this kept occurring. She stated she got him up in his wheelchair and took him to the bathroom and gave him something to drink. She stated he was still agitated so for his safety she took him down the hall. She stated she placed him in the hallway between rooms [ROOM NUMBERS] ( resident ' s room was 101) and provided " one to one " stating, and demonstrating, that she was approximately arm ' s length from him. CNA # 1 was asked to describe what " one to one " was. She stated, " I have the patient with me; I am constantly watching them for safety until I think they are ready to go back to bed. " She stated he continued to want to get up and that she " kept him sitting close to me. " She stated that the call light went off in another room (room [ROOM NUMBER]) and she stood up to answer it while calling down the hall or CNA # 2. She stated she said to CNA # 2 " Would you mind sitting with him while I answer the light. " She stated that at this time, the resident was seated in his wheelchair with his eyes closed and head down and " seemed to be resting. " She stated she saw CNA # 2 coming down the hall, heard the other nurse call out to her and saw CNA # 2 stop and turn to talk to the nurse and CNA # 2 did not reach the resident before she ( CNA #1) walked away. She stated she was entering the room where the call light was ringing when she heard a thump. She stated that she heard the resident fall but did not see the resident fall. Based on CNA # 1 ' s description of where resident #1 was located in the hallway and the location of the room where the call light went off (room [ROOM NUMBER]) and observation of the hallway, on [DATE] at 1: 00 p.m., CNA # 1 was approximately 10 feet away from resident # 1 when he fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 5: 10 p.m., an interview was conducted with CNA # 2. She was asked if she recalled the incident with resident # 1 and she stated that she did. She stated that she was working on the same hallway as CNA # 1 and that CNA # 1 had the resident in the hallway. She stated that CNA # 1 asked her to watch resident # 1 while she answered a call light. She stated she was by room [ROOM NUMBER] and was walking toward the patient who was between rooms [ROOM NUMBERS] in the hall. She stated she turned around to tell the nurse something and was facing away from the resident when she heard the resident fall. She stated that CNA # 1 was already in the room where the call light was ringing. She stated that neither she nor CNA # 1 was with the resident or facing the resident when he fell . She stated she did not see the resident fall. Based on the description of the location of resident # 1, provided by CNA # 1, CNA # 2's self-reported location ,and observation of the hallway , on [DATE] at 1: 00 p.m., , CNA # 2 was approximately ,[DATE] feet away from resident # 1 when the resident fell from his wheelchair and hit his head sustaining a head injury. On [DATE] at 3: 29 p.m., a phone interview was conducted with Nurse # 2 who stated that she was on duty during the incident on [DATE]. She stated that she recalled the incident. She stated that she was at the nursing station facing the hall the resident was on. She stated that he was sitting in the hallway in a wheelchair. She stated that CNA # 2 was talking to her at the nurse ' s station when CNA # 1 called out for CNA # 2 to watch the resident while she answered a call light. She stated that CNA # 1 was not with resident # 1, that she was walking down the hall and CNA # 2 was walking down the hall toward resident #1 when he fell . She confirmed that neither CNA was with the resident at the time of the fall. She stated she was at the nursing station and she saw the resident " literally fall forward face first. " Observation, on [DATE] at 1: 00 p.m., revealed that the nursing station where Nurse # 2 was located was approximately 55 feet from the reported location of resident # 1 when he fell and hit his head sustaining a head injury. Interview with Nurse 2, on [DATE] at 3: 29 p.m., revealed that after resident # 1 fell , he was " not even coherent to answer us. " Review of nursing notes, written by nurse # 1 at 2: 10 a.m., revealed that resident # 1 was " not able to tell nurse his name or birthday. " Review of the Emergency Medical Services ( EMS) electronic report for [DATE] for resident # 1, hospital triage records for [DATE] for resident # 1, and facility staff interviews and documentation, revealed that there was a significant discrepancy between the time the facility stated the resident fell and EMS and hospital records. Interview with nurse # 1 revealed that she observed the resident at 2: 00 a.m. as she was returning from lunch and he fell at approximately 2: 10 a.m. Review of nursing documentation in the resident's record, written by nurse # 1, confirmed this time frame. Review of a mandatory state report, submitted by the facility on [DATE], revealed time of fall listed as 2: 10 a.m. A confidential interview was conducted with a family member of resident # 1, on [DATE] at 4: 35 p.m., the family member stated that a message from Nurse # 1, informing her of the fall, was recorded on their answering machine at 2: 15 a.m. on [DATE] and the message stated that the resident had fallen at 2:00 a.m. Review of the electronic EMS report revealed that EMS was dispatched to the facility for a ground level fall for resident # 1 at 1: 43 a.m. and arrived at the hospital at 2: 25 a.m. Review of emergency room records from the hospital revealed that the resident was in triage at 2: 28 a.m. Review of the time record for nurse # 1, provided by the facility on [DATE], and revealed that Nurse # 1 was clocked out from 1: 03 a.m. until 1: 29 a.m. on [DATE]. Documentation in resident # 1s record revealed that the resident was transported by EMS to a local hospital. Review of the resident ' s record, obtained from the hospital, revealed that the chief complaint on the EMS report was " fall with [MEDICAL CONDITION]. The resident ' s vital signs, noted by EMS at 1: 52 a.m. were blood pressure ,[DATE], pulse 78, respirations 16 and oxygen saturations 100%. The resident ' s vital signs, noted by EMS at 2: 12 a., were blood pressure ,[DATE]. Pulse 85, respirations 16, and oxygen saturations of 100 %. " Review of the emergency room report revealed that the resident was triaged at the emergency room at 2: 28 a.m. with chief complaint of head pain/injury. The report from EMS to the hospital stated " patient crankier that usual, fell from wheelchair on head. " The resident ' s triage vital signs were blood pressure ,[DATE], pulse 84, respirations 22 and Glasgow coma scale of 14 (minor [MEDICAL CONDITION]). emergency room notes indicate the resident was sent for a CT scan of the head at 2: 55 a.m. The CT scan results were reported as " Acute left sided subdural hematoma with maximum thickness of 8 mm. Only minimal regional mass effect and ,[DATE] mm midline shift. A tiny right posterior paramediam subarachnoid hemorrhage and minima hematoma. There was a small amount of blood within the occipital horns. " A review of the history and physical, dictated on [DATE] at 11: 05 a.m., revealed the physician ' s assessment to be " non Syncopal fall at nursing home with resultant altered mental status changes, increased left subdural hematoma with slight midline shift and residual right sided hematoma and right sided subarachnoid hemorrhage. " Review of the hospital record for resident # 1 revealed that the resident was transferred to an inpatient Hospice on [DATE] and prognosis was noted to be poor. Review of the resident ' s record from the Hospice revealed that the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. Review of the initial assessment from the Hospice, dated [DATE], revealed: " Patient fell early this month, suffered bilateral subdural hematoma (6mm on right and 5 mm on left). Patient sent to skilled facility for skilling ... became agitated, fell again out of chair, suffering acute left sided subdural hematoma with ,[DATE] mm midline shift ..... Patient confused, unable to verbalize, lethargic, emaciated, no PO for several days, laceration middle of upper forehead, tea colored urine, diminished bilateral lung fields, bruising bilateral lower extremities. " " Findings supporting prognosis: Life limiting condition. Palliative care " Review of the record form the other health care facility indicated the resident died on [DATE].on [DATE]. A confidential interview was conducted with a family member of resident # 1, on [DATE] at 4: 35 p.m. The family member stated that the Medical Examiner reported the cause of death on the death certificate as " Complications resulting from multiple [MEDICATION NAME] head trauma. " The fall with serious head injury resulting in death of resident # 1 occurred on [DATE]. The facility risk manager provided documentation of in servicing and staff education conducted with nurses and CNA ' s which occurred during the week of [DATE] through [DATE]. Documentation revealed an in service conducted on [DATE] by the facility risk manager for licensed nurses and signatures of completion by the facility nursing staff. Topics were listed as: 1. If a resident has a fall and strikes his/her head, initiate neuro checks. 2. If you have any doubts or there is a change in their status, initiate neuro checks. 3. If a resident is admitted with a [DIAGNOSES REDACTED]. 4. If a resident is a high risk for falls ESP at night: Have resident at the desk so as to observe at all times. 5. If resident falling asleep sitting up, try a Geri/Broda chair. Documentation revealed an in service , entitled " Safety Interventions, conducted the week of [DATE] through [DATE] for CNA ' s and signed as competed by the facility CNA ' s. Topics covered were listed as " Please check all alarms and safety interventions: 1 . That they are in place 2. That they are functioning properly 3. Check your checklist on the CNA clipboard 4. If not functioning properly - replace 5 If you need alarms/pads let (staff) know. 6. Resident at high risk for falls. Place in common areas to increase visualization. ? Remember RSP ( Rising Star Program) ? Alert nurses of changes/ condition promptly ? Anticipate needs, food, fluids , toileting " Interviews were conducted on [DATE] between 1: 25 p.m. and 1: 40 p.m., with facility CNAs. The CNAs were able to describe the steps and interventions they were to take to determine who was at risk for a fall, what safety interventions were in place, placing a high risk resident at the nursing station for closer observation, alerting other staff of the need to monitor the resident, taking the resident to activities for supervision and diversion and placing a resident in bed who was observed to be falling asleep while in a wheelchair. The Immediate Jeopardy was determined removed on [DATE] and the scope and severity was reduced to a D. .