Every finding on record at Tallahassee Memorial Hospital Extended Care

Based on observation, interviews and policy review, the facility failed to properly store medications for 1 of 6 patients sampled for medication storage (Resident 195). The findings include: On 08/16/22 at approximately 10:32 AM, an observation was made of a hard plastic bin attached to the wall in Resident 195's room. Inside the bin was noted 4 insulin pens. The bin did not lock and was held closed by a magnetic latch. (Photographic evidence obtained). On 08/16/22 at approximately 10:38 AM, an interview was conducted with Staff A, a Registered Nurse (RN). Staff A, RN, stated she left the insulin pens inside Resident 195's room because Resident 195 was on isolation. On 08/16/22 at approximately 11:09 AM, an interview was conducted with Staff B, RN, who stated she did not leave insulins inside patient's rooms. She further stated facility nursing staff stored the insulins inside bins assigned to each specific patient inside the medication room while not in use. On 08/16/22 at approximately 12:42 PM, an interview was conducted with the Director of Nursing (DON) who stated that after the observation of the insulin pens the facility had conducted an in-service, with staff in the building, educating everyone on proper medication storage and that this education. The DON further stated there was not a facility procedure or policy to store insulin pens inside isolation rooms. Facility Policy and Procedure Drug Storage Security dated 06/02/2008, revised 09/09/2021, was reviewed. Procedure stated if not administered or used, the drug should be returned to the return bin for non-controls and waste for controls within 30 minutes.

Based on observations, staff interviews, record review, and facility's policy review, the facility failed to ensure a resident (Resident # 35) receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding on 1 of 1 resident sampled. The findings are: On 6/7/2021 at approximately 11:21 AM, resident # 35's enteral feeding tubing and bag were dated 6/6/21 at 6:57 AM, while feeding pump was in use at 40 mililiters per hour (ml/hr). On 6/8/2021, at approximately 11:23 AM, resident # 35's enteral feeding tubing and bag were dated 6/6/2021 at 6:57 AM, while feeding pump was in use at 40 ml/hr. On 6/8/2021 at approximately 4:40 PM, an interviewed was conducted with Staff A, a Licensed Practical Nurse (LPN), who stated that the enteral feeding tube and bags were changed every 24 hours and that resident # 35's feeding tubing and bag should have been changed on 6/7/2021. On 6/9/2021 at approximately 9:41 AM, an interview was conducted with the Director of Nursing (DON), who revealed that facility's enteral feeding tubing and bags were changed every 24-48 hours depending the system and resident #35's enteral feeding tubing and bag were supposed to be changed every 24 hours. A review of resident # 35's medical record revealed that the resident had a gastrostomy tube (a surgically inserted tube through the wall of the abdomen directly into the stomach to allow medications and liquids including liquid foods) placed on 5/28/2021 and feedings via gastrostomy tube were initiated on 6/4/2021. A review of the clinical progress notes dated 6/5/2021 at 6:45 AM, revealed that feeding tube was not flushing and needed to be de-clogged. A review was conducted of Facility's policy on Enteral Nutrition dated 8/2004 and revised on 1/15/2021 read: enteral nutrition bags, bottles, tubing, irrigation set or syringes will be changed every 24 hours. On 6/10/2021 at approximately 10:04 AM, an interview was conducted with Staff B, LPN, who revealed that feeding tubes could clog if they were not changed every 24 hours.

Based on observations, interviews, resident and facility record review, the facility failed to ensure that proper personal protective equipment was worn for a resident on contact isolations precautions for 1 of 10 residents on isolation precautions. The findings include: On 10/29/2019 at approximately 11:20 AM, observed on the door for Resident #24, was a hanging bin with Personal Protective Equipment (PPE) and signage to indicate STOP - CONTACT ISOLATION. Inside the room, was an unknown male who was not wearing PPE, leaning onto the resident's overbed table reviewing paperwork. On 10/29/2019 at approximately 11:25 AM, an interview was conducted with the male, who was a family member of resident #24. The family member knew the resident was on contact isolation, because of the bin on the door and stated he had observed staff members entering the room wearing gown and gloves. He stated no one had informed him that he needed to wear PPE. On 10/30/2019 at 11:36 AM, an interview with Staff Nurse C, regarding residents on Contact Isolation. He stated he would expect anyone entering the room would wear the appropriate PPE which is noted on the door. He stated he would expect family to wear PPE as well - unless they refused, any refusals or education would be documented in the medical record. He stated, when the family member comes in next time I will inform him. On 10/31/2019 at approximately 10:30 AM, an interview was conducted with the Director of Infection Control and Prevention (DICP), and the Infection Control Manager (ICM) for the Rehabilitation facility. Both had just been down to review signage for resident's along the first floor hall on contact isolation. The signage, the DICP explained, was for staff to follow and not required for visitors or family. The DICP was informed that staff interviewed were not aware of that understanding, as staff expected visitors and family to don PPE unless they refuse. He confirmed there was nothing on the facility's signage that distinguished between staff and visitors. The DICP did state that family and visitors are informed to wash their hands before leaving the room; when the DICP was asked how they are informed - he said by the 'signage. At this time the DICP was asked If you are expecting the visitor/family to wash hands, but not don on PPE - where is this distinguished in your signage? Both the ICP and ICM agreed that the staff need better education and that the signage needs to clarify the precautions that are needed for visitors/family. A review was conducted of the facility's Policy and Procedure related to [MEDICAL CONDITION] (MDROS) which indicated under Section II. ISOLATION PRECAUTIONS . D. Contact Precautions shall be considered for patients infected or colonized with an MDRO. A case by case decision will be made. See the policy on Contact Precautions in this manual. The facility's policy and procedure related to Contact Precautions, was also reviewed. Both policies and procedures failed to address contact precautions for family and visitors.

Based on observation of oxygen concentrators, staff interview, and policy and procedure review the facility failed to maintain oxygen concentrators in a sanitary manner and failed to have a policy in place for the checking and cleaning of oxygen concentrator filters for 1 of 3 residents (#77) reviewed for respiratory care. The findings include: An observation was made on 10/29/19 at 12:59 PM, of the oxygen concentrator for Resident #77. At the time of the observation there was no filter in the machine and the external vent was noted to be dirty and dusty. On 10/30/19 at 11:46 AM, Employee B, a Respiratory Therapist, was interviewed regarding oxygen equipment. She was shown the back of the concentrator in resident #77's room. She was asked if the concentrator should be cleaned. She said, In this case I would dispose of the filter and put in a new one. Photographic evidence obtained An interview was conducted with the Director of Nursing (DON) on 10/30/19 at 4:31 PM, during which the oxygen concentrator in Resident #77's room was checked. At this time the DON observed with the surveyor that the outside vent was dusty and the filter was not present. The DON opened the vent and observed dust inside where the permanent filter was located. He stated that an outside company comes in and checks all equipment annually. He then said they were supposed to have come in today (10/29/19) and checked all of the concentrators. He was asked for a policy and procedure regarding oxygen equipment for maintaining cleanliness of the filters and tubing. On 10/31/19 at 8:20 AM, a follow-up interview was conducted with the DON who said there is currently no specific policy for the care of concentrators. He did produce a policy for Respiratory Services which states E. All facility provided equipment will be assessed and maintained by Clinical Engineering. On 10/31/19 10:00 AM, the DON stated he has reached out to respiratory services for a policy to be developed for the specific care and maintenance of oxygen concentrators.

Based on observation, record review, and interview the facility failed to include, to the extent practicable, the participation of the resident and resident's representative in the development of the comprehensive care plan for 1 of 1 sampled residents for care planning (resident #2). The findings include: A review of resident # 2's medical record showed that the resident's most recent admission was on 10/08/2018 with the pertinent [DIAGNOSES REDACTED]. On 10/29/19 at approximately 12:02 PM, in interview with resident #2's health care proxy, she expressed that the facility did not communicate well with her or include her in healthcare decisions. She expressed that she had not been invited to participate in the resident's care plan meetings since he had been admitted . On 10/30/19 at approximately 1:15 PM, during interview with staff F and G, both social workers, it was expressed that neither one had invited the resident's representative to attend care plan meetings or to be included in the development of the resident's care plan. On 10/30/19 at approximately 1:28 PM, during interview with staff A, a Registered Nurse who acts as the resident's care plan coordinator, the staff member was unaware that the resident had a healthcare proxy and confirmed that there had not been an invitation for participation in the resident's care plan meeting.

Based on observation, record review, and interview the facility failed to include, to the extent practicable, the participation of the resident and resident's representative in the development of the comprehensive care plan for 1 of 1 sampled residents for care planning (resident #2) and failed to revise the care plan for 1 of 1 residents sampled for limited range of motion (resident #2). The findings include: Record review of resident # 2's medical record showed that the resident had a most recent admission of 10/08/2018 with the pertinent [DIAGNOSES REDACTED]. On 10/29/19 at approximately 12:02 PM, in interview with resident #2's health care proxy, she expressed that the facility did not communicate well with her or include her in healthcare decisions. She expressed that she had not been invited to participate in the resident's care plan meetings since he had been admitted . On 10/30/19 at approximately 1:15 PM, during interview with staff F and G, both social workers, it was expressed that neither one had invited the resident's representative to attend care plan meetings or to be included in the development of the resident's care plan. On 10/30/19 at approximately 1:28 PM, during interview with staff A, Registered Nurse and the resident's care plan coordinator, the staff member was unaware that the resident had a healthcare proxy and confirmed that there had not been an invitation for participation in the resident's care plan meeting. On 10/29/19 at approximately 11:33 AM, observation of resident #2 in bed in his room showed notable contracture to his right hand. The resident was unable to be interviewed. Record review of the resident's care plan with the most recent date of 4/5/2019 with updates through 10/3/2019 showed that the resident had multiple contractures and listed Passive Range of Motion with activities of daily living as an intervention. There was no evaluation of the contractures or current orders for therapy pertaining to the contractures. Upon request, Occupational Therapist H performed an evaluation of the resident's upper extremity contractures on 10/31/19 at approximately 11:05 AM. Review of the completed assessment of the contractures showed that nursing staff had reported that the resident refused treatment with devices and splinting and there was additional instruction for nursing staff to use a rolled cloth placed in the palms of the hands with the left hands thumb placed on the outside of the rest of the fingers for 15 minutes or more a day. On 10/31/2019 at approximately 1:35 PM, in interview with facility Director of Nursing, he stated that he believes at some point during a prior admission the resident received splinting but refused. He also expressed that he would expect a refusal of care to be noted in the resident's care plan. On 10/31/19 at approximately 1:43 PM, during interview with staff J, Certified Nursing Assistant (CNA) it was expressed that the CNA had been using a rolled washcloth in the palms of the resident's hand. She stated that there was no restorative nursing order to do this, but that other CNA's had instructed her to do this. On 10/31/19 at approximately 2:31 PM, during interview with staff K, L, and M, CNAs, they expressed that they had used a rolled cloth in the hands of the resident because in the past the resident had received splinting devices but was resistant to those devices and frequently refused. They expressed that it was not a restorative order to do so but they had done so on their own accord. On 10/31/19 at approximately 2:02 PM, during interview with the facility Directory of Therapy expressed that there was a break in communication and that refusal of care and implementation of interventions such as using a rolled wash cloth to aide in contracture prevention would be something that would be expected in a care plan and would contribute to the resident's continuity of care. On 10/31/19 at approximately 2:28 PM, during interview with staff A, the residents care plan coordinator, she expressed that a resident's refusal of any type of care is something that should be included in the resident's care plan.

Based on observation and interviews, the facility failed to ensure that Nurse Staffing information was posted on a daily basis that included the facility name, current date, the total number and the actual hours worked by licenses and unlicensed nursing staff, Registered nurses, Licensed Practical Nurses and Certified Nursing Assistants and the daily census. The findings include. On 10/30/19 a tour of the facility failed to locate the required posting for nursing. Each floor had a white board that had the staff on duty for each shift however no other information was noted. On 10/30/19 at approximately 11:34 AM, an interview was conducted with the Director of Nursing (DON) during which he stated we post the names of people on the shift per day. We have a staffing sheet that is kept at the nursing station. At this time he was asked if the posting included the total number and actual hours worked for licensed and unlicensed staff and if the information was posted in a readable form in an area that is prominent for residents and visitors, the DON stated he could not demonstrate that nurse staffing is posted containing the required components. The Administrator and the DON came to discuss the requirements on 10/30/19 at 12:24 PM. They were both read the regulation. The Administrator stated, We will make a sheet and get that posted.

Based on closed record review and staff interviews, the facility failed to develop and implement an appropriate plan of action to identify and correct process failures following the death of a resident with a [MEDICAL CONDITION] (surgical opening in the windpipe) for 1 of 1 residents sampled (#31). This situation resulted in immediate jeopardy. Resident #31 was the only resident with a [MEDICAL CONDITION] (trach) at the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F678. F695 and F684 for additional information. Findings include: Closed record review was conducted for resident #31 and revealed the resident had passed away at the facility on [DATE]. Review of documentation in the medical record of resident #31 showed that on [DATE] resident #31 initiated his call light for assistance. Registered nursing staff members D, J, & L attended to the resident and found his [MEDICAL CONDITION] (artificial airway) had become dislodged and the resident was in acute respiratory distress and turning blue per the documentation of events. The nurses did place a call to summon the respiratory therapist (RT) on duty at the hospital across the street and made several unsuccessful attempts to reinsert [MEDICAL CONDITION] provide rescue breathing; however, the nurses never attempted to seek the services of emergency medical personnel because they stated the resident was a Do Not Resuscitate (DNR). Documentation showed the resident expired approximately 20 minutes after being found in respiratory distress and prior to the arrival of the RT from the main hospital. See F678, F684 and/or F695 for additional information. On [DATE] at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON) during which he described the incident as unfortunate and stated the resident was a DNR so the nurses had not called for emergency assistance when the resident was in respiratory distress. He stated that emergency assistance would be to call 911; however, the resident had been a DNR so this was not done. When he was asked if this had been reported as an incident, he stated, again, the resident was a DNR. He also stated he had conducted a review of the incident and determined the staff had acted appropriately; however, the facility had discussed the need for Respiratory Therapy (RT) to be onsite 24 hours a day, 7 days a week. On [DATE] at approximately 9:30 AM, an interview was conducted with the Administrator in which he stated the resident was a DNR and this was the reason a morbidity review had not been conducted. He further stated that the DON had determined the staff acted appropriately. On [DATE] at approximately 11:40 AM, a follow-up interview with the administrator was conducted. He stated that the facility was still open to admitting patients with tracheostomies on a case by case basis, and felt the case of resident #31 was unique because the resident [MEDICAL CONDITION] of his larynx, which created more complex breathing issues. He stated this resident was not on palliative care or hospice at the time of his death and confirmed that while staff had attempted to reestablish the resident's airway and had called for the respiratory therapist, they had not attempted to contact emergency medical services because the resident had been a Do Not Resuscitate (DNR). He also stated that there had been an investigation by the DON and that the Risk Manager at the hospital had referred to the DON's investigation and since the resident was a DNR, they decided it did not need to be reported nor would it need to be included in the facility's Quality Assurance Performance Improvement program. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on closed record review, policy review and staff interviews, the facility failed to ensure 1 of 1 resident (#31) with a [MEDICAL CONDITION] (trach) was free from neglect by failing to acquire emergency medical treatment for [REDACTED]. during night shift hours. This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F678 and F684 for additional information. Findings Include: On [DATE] a closed record review was conducted for resident #31, who was reported to have expired at the facility on [DATE]. The review revealed that the resident had been admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] (surgical opening in the windpipe) that would require respiratory services around the clock as evidenced by the discharge planning documentation from Tallahassee Memorial Hospital, in which on [DATE] the Case Manager stated that traditional Skilled Nursing Facilities (SNF) do not have respiratory therapists ,[DATE] thus TMRC (Tallahassee Memorial Rehab Center) is likely his only option, as well as during the physician interview on [DATE] at 1:00pm in which the physician stated he would not have admitted the resident to the facility if he had known a respiratory therapist was not available around the clock. Review of physician orders [REDACTED]. A review of the Minimum Data Set Assessment (MDS) revealed that the Admission Assessment had been completed on [DATE]. Section O0100 indicated resident #31 required oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of the plan of care dated [DATE] for resident #31 showed no plan of care related to the resident's [MEDICAL CONDITION]. Review of respiratory therapy documentation showed resident #31 was being assessed every 4 hours during the hours of 7AM to 11 PM; however, after the therapist left for the night, [MEDICAL CONDITION] not assessed by a respiratory therapist for up to 12 hours. On [DATE] respiratory documentation showed resident #31 was assessed at 8:33 PM and was not assessed again until 5:20 AM on [DATE]. Likewise, on [DATE], respiratory documentation showed the resident had been assessed at 9:30 PM, and was not assessed again until 5:59 AM on [DATE]. This same pattern occurred on subsequent night shifts on [DATE] when the resident went 9 hours without assessment by respiratory on the night shift and on [DATE] when the resident went 12 hours without respiratory assessment. Further review of the nursing documentation found that on [DATE] at 12:10 AM the resident summoned the nurse by pressing his call light. When the registered nurse, staff member L, entered the resident's room, he found the resident'[MEDICAL CONDITION] half-way out and the patient was in respiratory distress. The nurse attempted to reinsert [MEDICAL CONDITION] when attempts were not successful, the charge nurse was notified and the respiratory therapist (RT) was summoned from across the street at the main hospital. Documentation showed the charge nurse also made unsuccessful attempts to reinsert the resident's trach, and that nursing staff had attempted to use an Ambu bag, but could not pump air in and could not see the resident's chest rise. (Ambu bags are used to deliver air through a person's nose and mouth to their lungs when in severe respiratory distress or arrest). Documentation also revealed resident #31 went into respiratory arrest and passed away immediately prior to the arrival of the respiratory therapist from the main hospital across the street from the facility. None of the documentation revealed that staff had attempted to contact emergency medical services when resident #31 was found in respiratory distress. On [DATE] at approximately 1:00 PM, an interview was conducted with the resident's physician, who had also signed the resident's death certificate. During the interview, the physician stated the resident had passed away after [MEDICAL CONDITION] become dislodged and nursing staff had been unsuccessful in their attempts to reinsert the trach. He went on to reveal that he had not been aware that respiratory therapy was not available onsite at the facility at night and that if he had been aware of this, he would not have admitted the resident, as it was vital that the resident's airway be maintained. He stated he would no longer be admitting residents with trachs to the facility until RT could be available around the clock. He further stated that if the resident had been transferred to the emergency room (ER) when [MEDICAL CONDITION] become dislodged, he could have been back in his room in 30 minutes with [MEDICAL CONDITION] place. On [DATE] at approximately 1:56 PM, an interview was conducted with staff member E, a registered respiratory therapist (RRT), during which he stated that respiratory therapy was not available onsite at the facility after 11 PM and that he worked the 3PM-11PM shift. He stated that respiratory therapy could be called from the hospital if they were needed, but it could take a while for them to get to the facility. He also stated the respiratory therapists made rounds every 4 hours during the night to check on tracheostomies and provide services and that trachs can become dislodged, which is why emergency equipment was kept at the bedside of residents with trachs. On [DATE] at approximately 9:19 AM, an interview was conducted with staff member F, an RRT, who stated he worked the 7AM-3PM shift. He explained that respiratory therapists were employed by the main hospital, but were housed at the facility from 7AM to 11PM. He stated that the respiratory therapist housed at the facility could also be pulled at any time to assist at the main hospital. He confirmed that residents with trachs were assessed by respiratory therapy every four hours around the clock, but stated that the respiratory therapists did not create or follow any plans of care for the residents, just provided care per the physician orders. On [DATE] at approximately 9:10 AM, an interview was conducted with staff member J, a registered nurse (RN), who was present at the time resident #31 passed away. She stated that the resident called the nursing station and that registered nurse L (RN L) went to the room and shortly thereafter called down the hall reporting, he's blue. After telling registered nurse D (RN D), to get the crash cart she was informed the resident was a Do Not Resuscitate (DNR). She stated that when she arrived to the resident's room, she found that the resident'[MEDICAL CONDITION] half way out. She reported she and RN L attempted to use the Ambu bag but the air was coming out the side of the trach. She revealed the resident was moving, his eyes were open and he had a pulse when they arrived in the room; however, after several unsuccessful attempts to reinsert [MEDICAL CONDITION] resident just stopped. When asked if anyone called 911 for emergency medical services (EMS), she stated no, because after all attempts to open his airway, he did not have a pulse and was a DNR. She stated normally staff would call 911 when a patient was declining because they did not have the stuff they needed for advanced life support, stating the crash carts at the facility had suction and an automated external defibrillator (AED). When asked about emergency treatment for [REDACTED]. On [DATE] at approximately 2:25 PM, an interview was conducted with registered nurse A, [MEDICAL CONDITION] and procedure for obtaining emergency medical services for a resident with a DNR. She stated she had [MEDICAL CONDITION] about 2 years ago that included how to care for a trach, but not how to re-insert one if it should become dislodged. She stated that if a resident'[MEDICAL CONDITION] dislodged, respiratory therapy would be notified and would address the issue. When asked what she would do if respiratory therapy was not available, she reported she would then call 911 from the resident's room. She stated that a DNR did not limit the nurses' ability to call for emergency care if the resident was in respiratory distress. On [DATE] at approximately 3:25 PM, an interview was conducted with registered nurse B, during which she stated that respiratory therapy took care of the facility tracheostomies and that there was suction at the bedside [MEDICAL CONDITION]. She stated she had received training in school and in orientation regarding how to care for a trach; however, this did not include re-inserting one if it became dislodged. She also stated she would call 911 if the resident was having respiratory distress and respiratory therapy was not available. On [DATE] at approximately 9:00 PM, a telephone interview was conducted with registered nurse D. She reported that she had worked the night of the incident with resident #31 and was the one who called respiratory therapy when they first discovered [MEDICAL CONDITION] dislodged. She reported that she had to call twice for respiratory therapy to come and during the second call was told he is on his way. She reported they should have called 911 but they were trying to maintain his airway and he was a DNR so they did not. She also reported that she had received training on how to care for [MEDICAL CONDITION] not what to do when [MEDICAL CONDITION] dislodged. A review was conducted of facility policy #,[DATE], Identification and Reporting of Alleged Abuse, Neglect and Exploitation of a Vulnerable Adult, revised [DATE]. The policy defined neglect as the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including but not limited to, food, clothing, medicine, shelter, supervision, and medical services that a prudent person would consider essential for the well-being of a vulnerable adult. The policy further identified neglect as repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. The policy provided indicators for identification of abuse, neglect or exploitation of vulnerable adults which included untreated medical conditions and further stated that any hospital personnel and/or medical staff member who knew or has reasonable cause to suspect that an aged person or disabled adult had been subjected to abuse or neglect would immediately report the case to the central abuse hotline so that an investigation can be conducted. Review of facility policy #120.210.020, Healthcare Emergencies, revised [DATE], stated Tallahassee Memorial Rehabilitation Center will initiate basic life support and call 911 to summon Emergency Medical Services in the event of a medical emergency. The State of Florida Department of Health defines a Do Not Resuscitate Order (DNRO) as a form used to identify people who do not wish to be resuscitated in the event of respiratory or [MEDICAL CONDITION]. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on closed record review and staff interviews, the facility failed to identify and report a case of resident neglect to the appropriate state agencies for 1 of 1 residents (#31). This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F600 and F684 for additional information. Findings Include: Closed record review was conducted for resident #31 and revealed the resident had passed away at the facility on [DATE]. Review of documentation in the medical record of resident #31 showed that on [DATE] resident #31 initiated his call light for assistance. Registered Nursing staff members D, J, & L attended to the resident and found his [MEDICAL CONDITION] (artificial airway created by a surgical opening in the windpipe) had become dislodged and the resident was in acute respiratory distress and turning blue per the documentation of events. The nurses placed a call to summon the respiratory therapist (RT) on duty at the hospital across the street and made several unsuccessful attempts to reinsert [MEDICAL CONDITION] provide rescue breathing; however, the nurses never attempted to seek the services of emergency medical personnel because they stated the resident had a Do Not Resuscitate (DNR) order. Documentation showed the resident expired approximately 20 minutes after being found in respiratory distress and prior to the arrival of the RT from the main hospital. See F600 for additional information. On [DATE] at approximately 11:40 AM, an interview was conducted with the administrator in which he stated the facility did [MEDICAL CONDITION] on a case by case basis and stated that the case of resident #31 had been unique because the resident [MEDICAL CONDITION] in his larynx which made more complex breathing issues. He confirmed resident #31 had not been on palliative care or hospice during admission. Nursing staff had attempted to reestablish the resident's airway and had called respiratory services, but had not provided emergency care beyond attempting to insert [MEDICAL CONDITION] the resident was a DNR. He stated that there was an investigation of the incident done by the Director of Nursing (DON) and the hospital's Risk Manager had referred to the DON's investigation. Since the resident was a DNR, it was determined that the incident did not need to be reported, have a mortality review conducted, or be included in the facility's Quality Assurance Performance Improvement (QAPI) program as the staff had acted appropriately. A review was conducted of facility policy #,[DATE], Identification and Reporting of Alleged Abuse, Neglect and Exploitation of a Vulnerable Adult, revised [DATE]. The policy defined neglect as the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including but not limited to, food, clothing, medicine, shelter, supervision, and medical services that a prudent person would consider essential for the well-being of a vulnerable adult. The policy further identified neglect as repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. The policy provided indicators for identification of abuse, neglect or exploitation of vulnerable adults which included untreated medical conditions and further stated that any hospital personnel and/or medical staff member who knew or has reasonable cause to suspect that an aged person or disabled adult had been subjected to abuse or neglect would immediately report the case to the central abuse hotline so that an investigation can be conducted. On [DATE] at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON) during which he described the incident as unfortunate and stated the resident was a DNR so the nurses had not called for emergency assistance when the resident was in respiratory distress. He stated that emergency assistance would be to call 911; however, the resident had been a DNR so this was not done. When he was asked if this had been reported as an incident, he stated, again, the resident was a DNR. He also stated he had conducted a review of the incident and determined the staff had acted appropriately; however, the facility had discussed the need for Respiratory Therapy (RT) to be onsite 24 hours a day, 7 days a week. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency. The facility initiated the neglect report and provided the first draft to the state agency.

Based on closed record review and staff interviews, the facility failed to establish and implement a patient centered plan of care for 1 of 1 resident (#31) receiving respiratory services for [MEDICAL CONDITION] (trach) care, which resulted in harm to the resident when [MEDICAL CONDITION] dislodged and staff were not aware of appropriate treatment measures. This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F678 and F684 for additional information. Findings include: On [DATE] a closed record review was conducted for resident #31 who was reported to have expired at the facility on [DATE]. The review revealed that the resident had been admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] (surgical opening in the windpipe) that would require around the clock respiratory care. The record for resident #31 revealed that on the night of [DATE], the resident had used his call light to seek assistance. Staff who responded found the resident'[MEDICAL CONDITION] become dislodged and the resident was in acute respiratory distress. The staff called for a respiratory therapist (RT) from the main hospital across the street and made several unsuccessful attempts to reinsert the resident'[MEDICAL CONDITION] well as perform rescue breathing prior to the resident expiring some 20 minutes after initiating his call light and prior to the arrival of the respiratory therapist. See F684 for additional information. Review of respiratory therapy documentation showed resident #31 was being assessed every 4 hours during the hours of 7AM to 11 PM; however, after the therapist left for the night, [MEDICAL CONDITION] not assessed by a respiratory therapist for up to 12 hours. On [DATE] respiratory documentation showed resident #31 was assessed at 8:33 PM and was not assessed again until 5:20 AM on [DATE]. Likewise, on [DATE], respiratory documentation showed the resident had been assessed at 9:30 PM, and was not assessed again until 5:59 AM on [DATE]. This same pattern occurred on subsequent night shifts on [DATE] when the resident went 9 hours without assessment by respiratory on the night shift and on [DATE] when the resident went 12 hours without respiratory assessment. Resident #31 was admitted to the facility on [DATE]. A review of physician orders [REDACTED]. A review of the Minimum Data Set Assessment (MDS) revealed that the Admission Assessment had been completed on [DATE]. Section O0100 indicated resident #31 required oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of the plan of care dated [DATE] for resident #31 showed no plan of care related to the resident's [MEDICAL CONDITION]. On [DATE] at approximately 1:56 PM, an interview was conducted with staff member E, a registered respiratory therapist (RRT), during which he stated that respiratory therapy was not available onsite at the facility after 11 PM and that he worked the 3PM-11PM shift. He stated that respiratory therapy could be called from the hospital if they were needed, but it could take a while for them to get to the facility. He also stated the respiratory therapists made rounds every 4 hours during the night to check on tracheostomies and provide services and that trachs can become dislodged, which is why emergency equipment was kept at the bedside of residents with trachs. On [DATE] at approximately 9:19 AM, an interview was conducted with staff member F, a registered respiratory therapist (RRT), who stated he worked the 7AM-3PM shift. He explained that respiratory therapists were employed by the main hospital, but were housed at the facility from 7AM to 11PM. He stated that the respiratory therapist housed at the facility could also be pulled at any time to assist at the main hospital. He confirmed that residents with trachs were assessed by respiratory therapy every four hours around the clock, but stated that respiratory therapists did not create or follow any plans of care for the residents, just provided care per the physician orders. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on closed record review and staff interviews, the facility failed to provide basic life support for 1 of 2 residents (#31) by failing to obtain emergency medical treatment for [REDACTED]. This situation resulted in immediate jeopardy. Resident #31 was the only resident with a [MEDICAL CONDITION] (surgical opening in the windpipe) at the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F600 and F684 for additional information. Findings Include: On [DATE] a closed record review was conducted for resident #31, who was reported to have expired at the facility on [DATE]. The review revealed that the resident had been admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] that would require respiratory services around the clock as evidenced by the discharge planning documentation from Tallahassee Memorial Hospital, in which on [DATE] the Case Manager stated that traditional Skilled Nursing Facilities (SNF) do not have respiratory therapists ,[DATE] thus TMRC (Tallahassee Memorial Rehab Center) is likely his only option, as well as during the physician interview on [DATE] at 1:00pm in which the physician stated he would not have admitted the resident to the facility if he had known a respiratory therapist was not available around the clock. Review of respiratory therapy documentation showed resident #31 was being assessed every 4 hours during the hours of 7AM to 11 PM; however, after the therapist left for the night, [MEDICAL CONDITION] not assessed by a respiratory therapist for up to 12 hours. On [DATE] respiratory documentation showed resident #31 was assessed at 8:33 PM and was not assessed again until 5:20 AM on [DATE]. Likewise, on [DATE], respiratory documentation showed the resident had been assessed at 9:30 PM, and was not assessed again until 5:59 AM on [DATE]. This same pattern occurred on subsequent night shifts on [DATE] when the resident went 9 hours without assessment by respiratory on the night shift and on [DATE] when the resident went 12 hours without respiratory assessment. Further review of the nursing documentation found that on [DATE] at 12:10 AM the resident summoned the nurse by pressing his call light. When the registered nurse, staff member L, entered the resident's room, he found the resident'[MEDICAL CONDITION] half-way out and the patient was in respiratory distress. The nurse attempted to reinsert [MEDICAL CONDITION] when attempts were not successful, the charge nurse was notified and the respiratory therapist (RT) was summoned from across the street at the main hospital. Documentation showed the charge nurse also made unsuccessful attempts to reinsert the resident's trach, and that nursing staff had attempted to use an Ambu bag, but could not pump air in and could not see the resident's chest rise. (Ambu bags are used to deliver air through a person's nose and mouth to their lungs when in severe respiratory distress or arrest). Documentation also revealed resident #31 went into respiratory arrest and passed away immediately prior to the arrival of the respiratory therapist from the main hospital across the street from the facility. None of the documentation revealed that staff had attempted to contact emergency medical services when resident #31 was found in respiratory distress. On [DATE] at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON), during which he described the incident as unfortunate. He stated the resident was a DNR so the nurses had not called for emergency assistance when the resident was in respiratory distress. He stated that emergency assistance would be summoned by calling 911; however, the resident had been a DNR so this was not done. On [DATE] at approximately 9:30 AM an interview was conducted with the Administrator in which he stated the resident was a DNR and this was the reason a morbidity review had not been conducted. He further stated that the DON had determined the staff acted appropriately. On [DATE] at approximately 1:00 PM, an interview was conducted with the resident's physician, who had also signed the resident's death certificate. During the interview, the physician stated the resident had passed away after [MEDICAL CONDITION] become dislodged and nursing staff had been unsuccessful in their attempts to reinsert the trach. He went on to reveal that he had not been aware that respiratory therapy was not available onsite at the facility at night and that if he had been aware of this, he would not have admitted the resident, as it was vital that the resident's airway be maintained. He stated he would no longer be accepting residents with trachs to the facility until RT could be available around the clock. He further stated that if the resident had been transferred to the emergency room (ER) when [MEDICAL CONDITION] become dislodged, he could have been back in his room in 30 minutes with [MEDICAL CONDITION] place. On [DATE] at approximately 9:10 AM, an interview was conducted with staff member J, a registered nurse (RN), who was present at the time resident #31 passed away. She stated that the resident called the nursing station and that registered nurse L (RN L) went to the room and shortly thereafter called down the hall reporting, he's blue. After telling registered nurse D (RN D), to get the crash cart she was informed the resident was a Do Not Resuscitate (DNR). She stated that when she arrived to the resident's room, she found that the resident'[MEDICAL CONDITION] half way out. She reported she and RN L attempted to use the Ambu bag but the air was coming out the side of the trach. She revealed the resident was moving, his eyes were open and he had a pulse when they arrived in the room; however, after several unsuccessful attempts to reinsert [MEDICAL CONDITION] resident just stopped. When asked if anyone called 911 for emergency medical services (EMS), she stated no, because after all attempts to open his airway, he did not have a pulse and was a DNR. She stated normally staff would call 911 when a patient was declining because they did not have the stuff they needed for advanced life support, stating the crash carts at the facility had suction and an automated external defibrillator (AED). When asked about emergency treatment for [REDACTED]. On [DATE] at approximately 12:42 PM a follow-up interview was conducted with the administrator. He stated the facility did not have a specific policy for DNR, stating they referred to the hospital's policy#120.210.020 for Healthcare Emergencies. On [DATE] at approximately 2:25 PM, an interview was conducted with registered nurse A, [MEDICAL CONDITION] and procedure for obtaining emergency medical services for a resident with a DNR. She stated she had [MEDICAL CONDITION] about 2 years ago that included how to care for a trach, but not how to re-insert one if it should become dislodged. She stated that if a resident'[MEDICAL CONDITION] dislodged, respiratory therapy would be notified and would address the issue. When asked what she would do if respiratory therapy was not available, she reported she would then call 911 from the resident's room. She stated that a DNR did not limit the nurses' ability to call for emergency care if the resident was in respiratory distress. On [DATE] at approximately 3:25 PM, an interview was conducted with registered nurse B, during which she stated that respiratory therapy took care of the facility tracheotomies and that there was suction at the bedside [MEDICAL CONDITION]. She stated she had received training in school and in orientation regarding how to care for a trach; however, this did not include re-inserting one if it became dislodged. She also stated she would call 911 if the resident was having respiratory distress and respiratory therapy was not available. On [DATE] at approximately 9:00 PM, a telephone interview was conducted with registered nurse D. She reported that she had worked the night of the incident with resident #31 and was the one who called respiratory therapy when they first discovered [MEDICAL CONDITION] dislodged. She reported that she had to call twice for respiratory therapy to come and during the second call was told he is on his way. She reported they should have called 911 but they were trying to maintain his airway and he was a DNR so they did not. She also reported that she had received training on how to care for [MEDICAL CONDITION] not what to do when [MEDICAL CONDITION] dislodged. Review of facility policy #120.210.020, Healthcare Emergencies, revised [DATE], stated Tallahassee Memorial Rehabilitation Center will initiate basic life support and call 911 to summon Emergency Medical Services in the event of a medical emergency. The State of Florida Department of Health defines a Do Not Resuscitate Order (DNRO) as a form used to identify people who do not wish to be resuscitated in the event of respiratory or [MEDICAL CONDITION]. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on closed record review, policy review and staff interviews, the facility failed to ensure 1 of 1 resident (#31) with a [MEDICAL CONDITION] (surgical opening in the windpipe) received quality care by failing to acquire emergency medical treatment for [REDACTED]. (trach) during night shift hours. This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Findings include: On [DATE] a closed record review was conducted for resident #31, who was reported to have expired at the facility on [DATE]. The review revealed that the resident had been admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] (surgical opening in the windpipe) that would require respiratory services around the clock as evidenced by the discharge planning documentation from Tallahassee Memorial Hospital, in which on [DATE] the Case Manager stated that traditional Skilled Nursing Facilities (SNF) do not have respiratory therapists ,[DATE] thus TMRC (Tallahassee Memorial Rehab Center) is likely his only option, as well as during the physician interview on [DATE] at 1:00pm in which the physician stated he would not have admitted the resident to the facility if he had known a respiratory therapist was not available around the clock. Review of physician orders [REDACTED]. A review of the Minimum Data Set Assessment (MDS) revealed that the Admission Assessment had been completed on [DATE]. Section O0100 indicated resident #31 required oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of the plan of care dated [DATE] for resident #31 showed no plan of care related to the resident's [MEDICAL CONDITION]. Review of respiratory therapy documentation showed resident #31 was being assessed every 4 hours during the hours of 7AM to 11 PM; however, after the therapist left for the night, [MEDICAL CONDITION] not assessed by a respiratory therapist for up to 12 hours. On [DATE] respiratory documentation showed resident #31 was assessed at 8:33 PM and was not assessed again until 5:20 AM on [DATE]. Likewise, on [DATE], respiratory documentation showed the resident had been assessed at 9:30 PM, and was not assessed again until 5:59 AM on [DATE]. This same pattern occurred on subsequent night shifts on [DATE] when the resident went 9 hours without assessment by respiratory on the night shift and on [DATE] when the resident went 12 hours without respiratory assessment. Further review of the nursing documentation found that on [DATE] at 12:10 AM the resident summoned the nurse by pressing his call light. When the registered nurse, staff member L, entered the resident's room, he found the resident'[MEDICAL CONDITION] half-way out and the patient was in respiratory distress. The nurse attempted to reinsert [MEDICAL CONDITION] when attempts were not successful, the charge nurse was notified and the respiratory therapist (RT) was summoned from across the street at the main hospital. Documentation showed the charge nurse also made unsuccessful attempts to reinsert the resident's trach, and that nursing staff had attempted to use an Ambu bag, but could not pump air in and could not see the resident's chest rise. (Ambu bags are used to deliver air through a person's nose and mouth to their lungs when in severe respiratory distress or arrest). Documentation also revealed resident #31 went into respiratory arrest and passed away immediately prior to the arrival of the respiratory therapist from the main hospital across the street from the facility. None of the documentation revealed that staff had attempted to contact emergency medical services when resident #31 was found in respiratory distress. On [DATE] at approximately 1:00 PM, an interview was conducted with the resident's physician, who had also signed the resident's death certificate. During the interview, the physician stated the resident had passed away after [MEDICAL CONDITION] become dislodged and nursing staff had been unsuccessful in their attempts to reinsert the trach. He went on to reveal that he had not been aware that respiratory therapy was not available onsite at the facility at night and that if he had been aware of this, he would not have admitted the resident, as it was vital that the resident's airway be maintained. He stated he would no longer be admitting residents with trachs to the facility until RT could be available around the clock. He further stated that if the resident had been transferred to the emergency room (ER) when [MEDICAL CONDITION] become dislodged, he could have been back in his room in 30 minutes with [MEDICAL CONDITION] place. On [DATE] at approximately 1:56 PM, an interview was conducted with staff member E, a registered respiratory therapist (RRT), during which he stated that respiratory therapy was not available onsite at the facility after 11 PM and that he worked the 3PM-11PM shift. He stated that respiratory therapy could be called from the hospital if they were needed, but it could take a while for them to get to the facility. He also stated the respiratory therapists made rounds every 4 hours during the night to check on tracheotomies and provide services and that trachs can become dislodged, which is why emergency equipment was kept at the bedside of residents with trachs. On [DATE] at approximately 9:19 AM, an interview was conducted with staff member F, an RRT, who stated he worked the 7AM-3PM shift. He explained that respiratory therapists were employed by the main hospital, but were housed at the facility from 7AM to 11PM. He stated that the respiratory therapist housed at the facility could also be pulled at any time to assist at the main hospital. He confirmed that residents with trachs were assessed by respiratory therapy every four hours around the clock, but stated that the respiratory therapists did not create or follow any plans of care for the residents, just provided care per the physician orders. On [DATE] at approximately 9:10 AM, an interview was conducted with staff member J, a registered nurse (RN), who was present at the time resident #31 passed away. She stated that the resident called the nursing station and that registered nurse L (RN L) went to the room and shortly thereafter called down the hall reporting, he's blue. After telling registered nurse D (RN D), to get the crash cart she was informed the resident was a Do Not Resuscitate (DNR). She stated that when she arrived to the resident's room, she found that the resident'[MEDICAL CONDITION] half way out. She reported she and RN L attempted to use the Ambu bag but the air was coming out the side of the trach. She revealed the resident was moving, his eyes were open and he had a pulse when they arrived in the room; however, after several unsuccessful attempts to reinsert [MEDICAL CONDITION] resident just stopped. When asked if anyone called 911 for emergency medical services (EMS), she stated no, because after all attempts to open his airway, he did not have a pulse and was a DNR. She stated normally staff would call 911 when a patient was declining because they did not have the stuff they needed for advanced life support, stating the crash carts at the facility had suction and an automated external defibrillator (AED). When asked about emergency treatment for [REDACTED]. On [DATE] at approximately 2:25 PM, an interview was conducted with registered nurse A, [MEDICAL CONDITION] and procedure for obtaining emergency medical services for a resident with a DNR. She stated she had [MEDICAL CONDITION] about 2 years ago that included how to care for a trach, but not how to re-insert one if it should become dislodged. She stated that if a resident'[MEDICAL CONDITION] dislodged, respiratory therapy would be notified and would address the issue. When asked what she would do if respiratory therapy was not available, she reported she would then call 911 from the resident's room. She stated that a DNR did not limit the nurses' ability to call for emergency care if the resident was in respiratory distress. On [DATE] at approximately 3:25 PM, an interview was conducted with registered nurse B, during which she stated that respiratory therapy took care of the facility tracheotomies and that there was suction at the bedside [MEDICAL CONDITION]. She stated she had received training in school and in orientation regarding how to care for a trach; however, this did not include re-inserting one if it became dislodged. She also stated she would call 911 if the resident was having respiratory distress and respiratory therapy was not available. On [DATE] at approximately 9:00 PM, a telephone interview was conducted with registered nurse D. She reported that she had worked the night of the incident with resident #31 and was the one who called respiratory therapy when they first discovered [MEDICAL CONDITION] dislodged. She reported that she had to call twice for respiratory therapy to come and during the second call was told he is on his way. She reported they should have called 911 but they were trying to maintain his airway and he was a DNR so they did not. She also reported that she had received training on how to care for [MEDICAL CONDITION] not what to do when [MEDICAL CONDITION] dislodged. Review of facility policy #120.210.020, Healthcare Emergencies, revised [DATE], stated Tallahassee Memorial Rehabilitation Center will initiate basic life support and call 911 to summon Emergency Medical Services in the event of a medical emergency. The State of Florida Department of Health defines a Do Not Resuscitate Order (DNRO) as a form used to identify people who do not wish to be resuscitated in the event of respiratory or [MEDICAL CONDITION]. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on closed record review and staff interviews, the facility failed to ensure 1 of 1 resident (#31) received appropriate [MEDICAL CONDITION] (surgical opening in the windpipe) care, including life-saving emergency medical treatment for [REDACTED]. This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate (DNR) order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F600 and F678 for additional information. Findings included: On [DATE] a closed record review was conducted for resident #31, who was reported to have expired at the facility on [DATE]. The review revealed that the resident had been admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] (surgical opening in the windpipe) that would require respiratory services around the clock as evidenced by the discharge planning documentation from Tallahassee Memorial Hospital, in which on [DATE] the Case Manager stated that traditional Skilled Nursing Facilities (SNF) do not have respiratory therapists ,[DATE] thus TMRC (Tallahassee Memorial Rehab Center) is likely his only option, as well as during the physician interview on [DATE] at 1:00pm in which the physician stated he would not have admitted the resident to the facility if he had known a respiratory therapist was not available around the clock. Review of physician orders [REDACTED]. A review of the Minimum Data Set Assessment (MDS) revealed that the Admission Assessment had been completed on [DATE]. Section O0100 indicated resident #31 required oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of the plan of care dated [DATE] for resident #31 showed no plan of care related to the resident's [MEDICAL CONDITION]. Review of respiratory therapy documentation showed resident #31 was being assessed every 4 hours during the hours of 7AM to 11 PM; however, after the therapist left for the night, [MEDICAL CONDITION] not assessed by a respiratory therapist for up to 12 hours. On [DATE] respiratory documentation showed resident #31 was assessed at 8:33 PM and was not assessed again until 5:20 AM on [DATE]. Likewise, on [DATE], respiratory documentation showed the resident had been assessed at 9:30 PM, and was not assessed again until 5:59 AM on [DATE]. This same pattern occurred on subsequent night shifts on [DATE] when the resident went 9 hours without assessment by respiratory on the night shift and on [DATE] when the resident went 12 hours without respiratory assessment. Further review of the nursing documentation found that on [DATE] at 12:10 AM the resident summoned the nurse by pressing his call light. When the registered nurse, staff member L, entered the resident's room, he found the resident'[MEDICAL CONDITION] half-way out and the patient was in respiratory distress. The nurse attempted to reinsert [MEDICAL CONDITION] when attempts were not successful, the charge nurse was notified and the respiratory therapist (RT) was summoned from across the street at the main hospital. Documentation showed the charge nurse also made unsuccessful attempts to reinsert the resident's trach, and that nursing staff had attempted to use an Ambu bag, but could not pump air in and could not see the resident's chest rise. (Ambu bags are used to deliver air through a person's nose and mouth to their lungs when in severe respiratory distress or arrest). Documentation also revealed resident #31 went into respiratory arrest and passed away immediately prior to the arrival of the respiratory therapist from the main hospital across the street from the facility. None of the documentation revealed that staff had attempted to contact emergency medical services when resident #31 was found in respiratory distress. On [DATE] at approximately 1:00 PM, an interview was conducted with the resident's physician, who had also signed the resident's death certificate. During the interview, the physician stated the resident had passed away after [MEDICAL CONDITION] become dislodged and nursing staff had been unsuccessful in their attempts to reinsert the trach. He went on to reveal that he had not been aware that respiratory therapy was not available onsite at the facility at night and that if he had been aware of this, he would not have admitted the resident, as it was vital that the resident's airway be maintained. He stated he would no longer be admitting residents with trachs to the facility until RT could be available around the clock. He further stated that if the resident had been transferred to the emergency room (ER) when [MEDICAL CONDITION] become dislodged, he could have been back in his room in 30 minutes with [MEDICAL CONDITION] place. On [DATE] at approximately 1:56 PM, an interview was conducted with staff member E, a registered respiratory therapist (RRT), during which he stated that respiratory therapy was not available onsite at the facility after 11 PM and that he worked the 3PM-11PM shift. He stated that respiratory therapy could be called from the hospital if they were needed, but it could take a while for them to get to the facility. He also stated the respiratory therapists made rounds every 4 hours during the night to check on tracheotomies and provide services and that trachs can become dislodged, which is why emergency equipment was kept at the bedside of residents with trachs. On [DATE] at approximately 9:19 AM, an interview was conducted with staff member F, an RRT, who stated he worked the 7AM-3PM shift. He explained that respiratory therapists were employed by the main hospital, but were housed at the facility from 7AM to 11PM. He stated that the respiratory therapist housed at the facility could also be pulled at any time to assist at the main hospital. He confirmed that residents with trachs were assessed by respiratory therapy every four hours around the clock, but stated that the respiratory therapists did not create or follow any plans of care for the residents, just provided care per the physician orders. On [DATE] at approximately 9:10 AM, an interview was conducted with staff member J, a registered nurse (RN), who was present at the time resident #31 passed away. She stated that the resident called the nursing station and that registered nurse L (RN L) went to the room and shortly thereafter called down the hall reporting, he's blue. After telling registered nurse D (RN D), to get the crash cart she was informed the resident was a Do Not Resuscitate (DNR). She stated that when she arrived to the resident's room, she found that the resident'[MEDICAL CONDITION] half way out. She reported she and RN L attempted to use the Ambu bag but the air was coming out the side of the trach. She revealed the resident was moving, his eyes were open and he had a pulse when they arrived in the room; however, after several unsuccessful attempts to reinsert [MEDICAL CONDITION] resident just stopped. When asked if anyone called 911 for emergency medical services (EMS), she stated no, because after all attempts to open his airway, he did not have a pulse and was a DNR. She stated normally staff would call 911 when a patient was declining because they did not have the stuff they needed for advanced life support, stating the crash carts at the facility had suction and an automated external defibrillator (AED). When asked about emergency treatment for [REDACTED]. On [DATE] at approximately 9:00 PM, a telephone interview was conducted with registered nurse D. She reported that she had worked the night of the incident with resident #31 and was the one who called respiratory therapy when they first discovered [MEDICAL CONDITION] dislodged. She reported that she had to call twice for respiratory therapy to come and during the second call was told he is on his way. She reported they should have called 911 but they were trying to maintain his airway and he was a DNR so they did not. She also reported that she had received training on how to care for [MEDICAL CONDITION] not what to do when [MEDICAL CONDITION] dislodged. An interview was conducted with the facility's Director of Nursing (DON) on [DATE] at 10:00 AM. The DON stated the facility historically had [MEDICAL CONDITION] patients with no troubles in the past and that nurses were trained with competencies being performed for the management of tracheostomies. On [DATE] at approximately 10:45 AM , upon request, the facility's designated Clinical Education Coordinator provided the content of training provided to nursing staff for [MEDICAL CONDITION] care and suctioning. Review of the materials failed to include emergency procedures related to [MEDICAL CONDITION] or procedures for tubes that become dislodged. The materials included a sign-in sheet, dated [DATE], that included 7 Registered Nurses and 4 Licensed Practical Nurses. Review of the [MEDICAL CONDITION] care and suctioning in-service failed to include RNs L and J, who responded the [MEDICAL CONDITION] emergency for resident #31 on the night of [DATE]. The State of Florida Department of Health defines a Do Not Resuscitate Order (DNRO) as a form used to identify people who do not wish to be resuscitated in the event of respiratory or [MEDICAL CONDITION]. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. At the time of the survey, the facility had no residents with a [MEDICAL CONDITION]. The facility placed an immediate ban on the admission of any residents with tracheostomies. All nurses and certified nursing assistants working onsite at the time of the survey were re-educated that in the event of a medical emergency they will initiate basic life support and call 911 to summon Emergency Medical Services. This education was immediately initiated by staff on duty at 3:15pm, and the training was witnessed by the survey team. Sixty two team-members were re-educated prior to survey team exit. All nurses not immediately available were to be educated prior to starting their next shift. The facility policy #120.210.020, Healthcare Emergencies was re-written during the survey to incorporate the new training. A copy was provided to the state agency.

Based on interviews and record reviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets necessary to provide care for residents with tracheostomies. The training for nurses failed to include training on the emergency treatment regarding tracheal tube dislodgement and response to respiratory distress for residents with a Do Not Resuscitate Order (DNRO). This resulted in the death of 1 of 1 resident (#31) with a tracheal tube dislodgement. The facility's clinical staff list documented 11 Licensed Practical Nurses and 34 Registered Nurses providing clinical care within the facility, including sampled nurses A, B, D, J and L. This situation resulted in immediate jeopardy. Resident #31 was the only resident with [MEDICAL CONDITION] the time, but there were 2 residents who had a Do Not Resuscitate order. The Administrator and Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 13, (YEAR) at approximately 11:30 AM. Immediate Jeopardy was removed the same day at 6:15 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. See F684 for additional information. Findings: A closed record review was conducted for resident #31, who have expired at the facility on [DATE]. The review revealed that resident #31 was admitted to the facility on [DATE] for short term rehabilitation for laryngeal [MEDICAL CONDITION] (cancer of the voice box) and a [MEDICAL CONDITION] (surgical opening in the windpipe). Documentation revealed that on the night of [DATE], the resident summoned for help using his call light and nursing staff responded, finding the resident in respiratory distress after [MEDICAL CONDITION] become dislodged. The nurses tried to reinsert the trach, provide rescue breathing, and summoned a respiratory therapist from across the street at the main hospital, but did not attempt to contact 911 for emergency medical treatment because they stated the resident had a Do Not Resuscitate Order (DNRO) and the resident subsequently expired. See F684 for additional information. On [DATE] at approximately 2:25 PM, an interview was conducted with registered nurse A, [MEDICAL CONDITION] and procedure for obtaining emergency medical services for a resident with a DNR. She stated she had [MEDICAL CONDITION] about 2 years ago that included how to care for a trach, but not how to re-insert one if it should become dislodged. She stated that if a resident'[MEDICAL CONDITION] dislodged, respiratory therapy would be notified and would address the issue. When asked what she would do if respiratory therapy was not available, she reported she would then call 911 from the resident's room. She stated that a DNR did not limit the nurses' ability to call for emergency care if the resident was in respiratory distress. On [DATE] at approximately 3:25 PM, an interview was conducted with registered nurse B, during which she stated that respiratory therapy took care of the facility tracheotomies and that there was suction at the bedside [MEDICAL CONDITION]. She stated she had received training in school and in orientation regarding how to care for a trach; however, this did not include re-inserting one if it became dislodged. She also stated she would call 911 if the resident was having respiratory distress and respiratory therapy was not available. On [DATE] at approximately 9:00 PM, a telephone interview was conducted with registered nurse D. She reported that she had worked the night of the incident with resident #31 and was the one who called respiratory therapy when they first discovered [MEDICAL CONDITION] dislodged. She reported that she had to call twice for respiratory therapy to come and during the second call was told he is on his way. She reported they should have called 911 but they were trying to maintain his airway and he was a DNR so they did not. She also reported that she had received training on how to care for [MEDICAL CONDITION] not what to do when [MEDICAL CONDITION] dislodged. On [DATE] at approximately 9:30 AM, a review of the provider's facility's assessment, dated [DATE], was conducted. The assessment included a list of nursing department education for (YEAR)-2018. The education documented Licensed Practical Nurse and Registered Nurse In-Services to include [MEDICAL CONDITION] care. An interview was conducted with the facility's Director of Nursing (DON) on [DATE] at 10:00 AM. The DON stated the facility historically had [MEDICAL CONDITION] patients with no troubles in the past and that nurses were trained with competencies being performed for the management of tracheostomies. On [DATE] at approximately 10:45 AM , upon request, the facility's designated Clinical Education Coordinator provided the content of training provided to nursing staff for [MEDICAL CONDITION] care and suctioning. Review of the materials failed to include emergency procedures related to [MEDICAL CONDITION] or procedures for tubes that become dislodged. The materials included a sign-in sheet, dated [DATE], that included 7 Registered Nurses and 4 Licensed Practical Nurses. Review of the [MEDICAL CONDITION] care and suctioning in-service failed to include Registered Nurses L and J, who responded the [MEDICAL CONDITION] emergency for resident #31 on the night of [DATE]. Review of the facility's clinical staff list, provided by the administrator, documented 11 Licensed Practical Nurses and 34 Registered Nurses providing clinical care within the facility. On [DATE] at approximately 12:45pm, an interview was conducted with the facility administrator, who stated, this case was an isolated event related to the patient's diagnosis. He further stated that resident #31 had a Do Not Resuscitate Order (DNRO), which is why chest compressions were not initiated. When asked his expectations for nursing staff related to dislodged trachs, he stated the expectation was for nursing and respiratory to reinsert the [MEDICAL CONDITION] and not necessarily call EMS (Emergency Medical Services). On [DATE] at approximately 5:30 PM, an interview with the facility's Director of Nursing revealed the nursing staff had not received education related to reinsertion of [MEDICAL CONDITION] and revealed the facility did not have a policy and procedure for management of dislodged [MEDICAL CONDITION]. The DON stated they would begin the education process and provided a document titled Education Plan for Nursing Staff. The document stated the Registered Nurses and Licensed Practical Nurses would be provided a hands-on mandatory training that included (1) [MEDICAL CONDITION] Care (2) [MEDICAL CONDITION] emergencies (accidental removal of trach) (3) Always call [DATE]- for patients in distress (4) Policy regarding healthcare emergencies in the ambulatory setting and (5) Respiratory role. The document further stated Certified Nursing Assistants would be provided training for (1) Patients in distress and (2) Policy regarding healthcare emergencies in the ambulatory setting. The proposed education plan documented respiratory staff would assist with education and [MEDICAL CONDITION] set-up for insertion in an emergency situation.

Based on observation and facility policy and procedure review, the facility failed to ensure staff performed hand hygiene prior to and during medication administration for 2 of 6 staff members observed ( Staff A and Staff S) Findings include: On (MONTH) 12, (YEAR) beginning at approximately 8:45am, medication administration was observed performed by 6 different staff members. At approximately 9:15am, Staff A was observed to enter resident #14's room. Staff A, wheeling a computer, stopped to perform hand hygiene and then donned on a pair of gloves. Staff A proceeded to administer the medications by scanning the patient's armband, and popping each pill into a medication cup after scanning the medication. She then reached into her pocket to retrieve scissors to cut open a [MEDICATION NAME] and applied it to the resident's lower back and to cut open a pack of Florinex granules. The scissors were not sanitized prior to use. She retrieved a pen from her pocket, in which to date the patch, and obtained water for the resident. She then proceeded to mix the bottle of antibiotic powder by inserting the small bag of normal saline to assist in diluting the powdered medication. The medication was then set up for administration utilizing a medication pump. The patient had a PICC (peripherally inserted central catheter) line. The line was flushed with a syringe of normal saline and then the medication tubing was attached to the PICC line to begin infusion. The nurse failed to change her gloves, sanitize her hands and equipment between oral, topical and IV medication administration, and after reaching into her pocket with gloves. At approximately 09:55am, Staff S was observed to enter resident #30's room for medication administration. Staff S failed to perform hand hygiene before administering medications. A review of the facility's presented policy on Hand Hygiene indicated that staff were to wear gloves when contact with blood or other potentially infectious materials, such as mucous membranes and non intact skin could occur. It also stated that gloves should be removed after caring for a patient and not worn for more than one patient and that gloves should also be changed during patient care if moving from a contaminated body site to a clean body site.

Based on observation and staff interview the facility failed to maintain equipment in a clean and sanitary manner for 1 of 3 freezers observed. Findings include: An initial tour of the kitchen was conducted on 9/5/17, at approximately 10:00 AM. During the tour, a small freezer next to cold storage used to house ice creams served to residents was observed to have a black substance on the handles and along the rims of the sliding door that covers the top of the freezer. A large buildup of ice was noted on the sides and along the top of the freezer. Staff was asked when the freezer was last cleaned and defrosted and they stated it was done monthly but could not provide a date and failed to produce a log of the monthly cleanings by the survey exit on 9/7/2017.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for [MEDICAL CONDITION] medications for 2 of 5 residents sampled for unnecessary medications (#122 and #384). Findings: Resident #122 A review of resident #122's medications included [MEDICATION NAME] 75 milligrams daily for depression [MEDICATION NAME] milligrams nightly for [MEDICAL CONDITION]. A review of the resident's care plans conducted on 9/6/17 at approximately 1:00pm failed to include a comprehensive plan of care for the use of the [MEDICAL CONDITION] medications. On 9/6/17 at approximately 1:15pm, an interview conducted with the facility's Minimum Data Set(MDS) Coordinator, employee A, confirmed the above findings. She stated the medications are addressed in the resident's plan of care for falls. A review of resident #122's plan of care for potential for falls listed the use of [MEDICATION NAME] a contributing factor for falls, but failed to include a goal or interventions for the use of the medications. A review of the resident's annual MDS assessment with a reference date of 9/1/2016 was conducted on 9/7/17 at approximately 10:00am, in the presence of the MDS Coordinator. The Care Area Assessment (CAA) Summary triggered psychosocial well-being and [MEDICAL CONDITION] drug use with documented indication for care planning decision. A review of the care planning decision indicated to proceed with care planning. The MDS Coordinator, employee A, again confirmed there was not to a plan of care in place for the medications; and stated we include the medications as a contributing factor for potential falls, but have never developed a separate plan of care for [MEDICAL CONDITION] medications. Resident #384 A record review of resident #384's care plan dated 8/2/2017 was conducted on 9/6/17. The care plan did not address [MEDICAL CONDITION] medication use. A review of Resident #384's Minimum Data Set (MDS) was conducted on September 6, 2017. The Care Area Assessment Summary of the MDS, completed on August 6, 2017, triggered a [MEDICAL CONDITION] drug use care area and was marked for a care plan to be completed for this care area. An interview was conducted with employee A, MDS Staff, on 9/7/17 at approximately 9:40 am. When asked what happen when a care area triggers, employee A stated, We make a decision whether or not to complete a care plan for the triggered care area. When asked specifically about Resident #384's triggered care area [MEDICAL CONDITION] drug use, she stated, When it triggered, we mentioned the fact that she was on [MEDICAL CONDITION] meds on her 'fall care plan' and we thought mentioning it there was enough so we did not address it specifically.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the prescribed physician orders [REDACTED]. A total of 30 administration observations were conducted with 3 medication administration errors observed resulting in a medication administration error rate of 10%. The findings were: On 9/7/17 at approximately 9:45am, a medication administration observation for the scheduled 9:00am medication administration was initiated. The registered Nurse(RN), employee B, stated she had 3 residents scheduled for 9:00am medications, but they were in therapy and not available for administration. When asked when the residents would get their medications, she replied whenever they return. The nurse further stated, residents are frequently not available for medication administration if they have gone to therapy. On 9/7/17 at approximately 10:02am, this surveyor observed the therapy department staff members proceeding to room [ROOM NUMBER] with a walker in hand. Employee B was asked if the resident (#122) in room [ROOM NUMBER] had medications to be administered, she replied yes. The nurse obtained the medications and prepared to administer the medications which included, but not limited to, [MEDICATION NAME] (blood pressure medication) 5 milligrams scheduled to administered before meals with dose due at 8:00am; [MEDICATION NAME] (blood sugar medication) 5 milligrams daily scheduled to administered with with breakfast; and [MEDICATION NAME] Insulin Pen (blood sugar medication) scheduled to be administered before meals with a 7:30am time indicated on the Medication Administration Record. When employee B was asked why the medications scheduled for 7:30am and 8:00am had not been given, she replied he was not in his room. Employee B stated the resident #122's blood sugar was obtained by a nursing student at 7:30am and reported to her to be 209 for which the resident should have received 2 Units of insulin. When the nurse was questioned about the insulin being administered late, she stated maybe I should not give the insulin now since it is getting close to lunch time. She proceeded to administer the [MEDICATION NAME] that was ordered to be administered before meals; and the resident stated I am supposed to take the [MEDICATION NAME] before I eat. The nurse also proceeded to administer the [MEDICATION NAME] that was ordered to be administered with breakfast. A review of the resident #122's physician orders [REDACTED]. The orders included to administer [MEDICATION NAME] 5 milligrams three times daily before meals; and to administer [MEDICATION NAME] 5 milligrams daily with breakfast with a note to give 30 minutes before a meal. An interview with the facility's Director of Nursing (DON) on 9/7/17 at approximately 10:20am was conducted and at that time he was informed of the above observations and employee B's comment regarding residents not being available for medication administration. The DON confirmed the medications were not administered in accordance with the physician orders. The DON further stated, the nurses are provided a therapy schedule for each patient so they are aware of when patients are going to therapy; and stated, the nurses can go to the therapy department to administer the medications if the patients are not in their room. A review of the resident#122's Medication Administration Record [REDACTED]. An interview was conducted with the resident, in the presence of the DON, on 9/7/17 at approximately 10:30am. The resident was informed his medical record documented he had refused his 7:30am insulin. Resident stated I did not refuse it. I did not know I was supposed to get insulin this morning. An interview was conducted with Employee B, in the presence of the DON, on 9/7/17 at approximately 10:45am. Employee B was asked why she documented resident refused his 7:30am insulin when she had told the surveyor during the medication administration observation that she had not given it because he was not in his room. She initially replied he refused his blood sugar checks last night and then stated because he refused it at 10am. This refusal was not observed by this surveyor as documented by Employee B. This surveyor observed employee B, RN, decide not to administer the insulin at 10:05am since she failed to administer at 7:30am as prescribed.

Based on observation, interview and review of facility policy, the facility failed to ensure that stored foods were labeled with the appropriate date for 1 of 2 refrigerators observed and failed to ensure that expired food was disposed for 1 of 3 storage areas. Findings include: An initial tour of the kitchen was conducted on 9/5/17 at approximately 10:00 am. During the tour, two pans of jello, both of which were 1/2 full, were found in the large refrigerator. Both pans were without dates noting when they had been placed into the refrigerator. At this time the Dietary manager stated those items should have been dated and she was unable to determine when they had been placed in the refrigerator. During inspection of the upright cooler used to store beverages and the alternative meal choices, 9 individual cup size servings of thickened orange juice were found to be expired in July of 2017. The Dietary manager verified that the juice was expired and proceeded to remove it from the cooler. During a follow up inspection on 9/6/17, at approximately 2:00 pm of the dry storage area, three containers of Ensure Compact were noted to have expired in March of 2017. Those items were found on the bottom shelf in the second of three dry storage cabinets, dietary manager verified that the Ensure had expired and she stated, we thought all these items had been thrown away. On 9/7/17 at approximately 9:30am, an interview was conducted with the Director of Food Services General Manager of Kitchen Operations. During the interview, he stated that all items placed in the cooler or freezer to include jello were to be dated, so staff can dispose of items within 24 hours. A review of the facility's policy 603-Operational Standard: Food Labeling and Storage Guide Lines with an effective date of June 2017 stated that All items prepared on site and packed for consumption are to be dated for usage within one day.