Every finding on record at The Bristol Care Center

Based on interviews and record review the facility failed to ensure complete and accurate nursing documentation in the medical record to reflect the care of one resident (#1) out of five residents sampled during the survey.Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including; fracture of lumbar vertebra, Diabetes Mellitus, right heel pressure ulcer, dementia, hypertension, Congestive Heart Failure (CHF), myocardial infarction, major depressive disorder, anxiety, and insomnia. Resident #1 had a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. A review of the medical record revealed on [DATE] Resident #1 had a change of status and expired at the facility. A review of the medical record revealed on [DATE] a Do Not Resuscitate Order was fully executed and signed by a Family Member (FM) and the attending physician responsible for Resident #1. A review of the progress notes revealed the following:-[DATE] 3:22 p.m. Narrative nurse note: family has medical concerns states that he has a lot of pain despite current dose of Oxycodone. Called {provider name} and received new orders. Resident will be a dependent diner, Is on OT {occupational therapy}. ARNP {Advanced Registered Nurse Practitioner} expected to see resident tonight and to call family.-[DATE] 5:16 p.m. Narrative nurse note: Orders received from APRN {name}, and transcribed. Family ok with orders.-[DATE] 6:45 p.m. Narrative Nurses note: Nurse call to room and resident observed with no rise and fall of chest, Both pulse sits are absent (Draft).-[DATE] 7:04 p.m. Narrative Nurses note: Change in condition noted and ARNP notified and new orders in placed. Order for one time abt {antibiotic} given at 5:45 pm. CSR {chest x-ray} done and awaiting results.[DATE] 7:25 p.m. Narrative Nurses note: Wife and daughter at bedside. A document titled Record of Death, dated [DATE], presented by the facility, revealed the following:-Resident Name was listed-Physician was listeddate of death [DATE]Time of Death 6:48 PMTime Physician notified 6:50 PMName of Responsible Party notified was listed with time of 7 PMNo signature of Nurse completing section was on the form, dated [DATE]. On [DATE] at 1:19 p.m. an Interview was conducted with Staff A, Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON). She stated she was working on [DATE] and was the supervisor in charge on the unit where Resident #1 was. She reported she spoke with the medical provider that day regarding concerns raised by the resident's family. She stated the family expressed concern that the resident needed to be sent to the hospital for additional testing. She stated the family requested the provider evaluate the resident. She stated she spoke to family to inform them the resident had already been evaluated on Wednesday and again the previous day. She stated the provider note indicated the resident became palliative care on the 4th. She stated the family had concerns related to increased pain and decreased eating. Staff A stated she contacted the provider who indicated he would come to the facility but later informed her he was unable to come. She stated she received an order to send the resident to the hospital. She stated the provider called to discuss the situation with the family, and the provider told her the diagnostic tests were to be performed in the facility after the discussion with the family. She stated orders to abdominal and chest x-rays, and laboratory work were placed. She stated STAT testing at the facility takes approximately four hours. She stated the x-rays were completed at 5:40 p.m. She stated the x-rays indicated no abnormal fluid, clear lung bases, and a nonspecific bowel gas pattern with scattered stool. She reported that the family did not leave the facility until approximately 5:30 p.m. and agreed to allow treatment to continue in the facility. Staff A reviewed the nursing notes for [DATE] and stated the nurse should have completed an assessment note for Resident #1, and the note should not still be in draft form. She stated the facility protocol when a resident is found unresponsive is to check the resident's code status, complete a full assessment, provide care as needed, and notify the Registered Nurse (RN) on duty to assist and confirm the residents assessment. She stated at the time of Resident #1's death, a nurse and a unit manager were present in the resident's room. She stayed the nurse contacted RN on duty (Staff B), to assess the resident and confirm death. She stated the protocol for a resident death includes; assessing vital signs, performing a full assessment, verifying code status, notifying the provider and family, and having an RN or two LPN's confirm death. She stated all documentation of the events should be placed into the medical record. On [DATE] at 1:50 p.m. an interview was conducted with Staff B, RN. Staff B stated the LPN contacted him, and he responded from the central nursing area to verify the resident did not have a pulse. He stated he informed the resident's family because the LPN did not speak Spanish. He stated he completed an assessment of the resident, and it was his practice as an RN to document his assessments. He stated he did not document his assessment or actions on [DATE] in Resident #1's medical record. On [DATE] at 1:59 p.m. an interview was conducted with the Director of Nursing (DON). She stated per facility protocol, if a nurse enters a resident's room and finds the resident without a pulse, the nurse should respond according to the resident's code status. She stated it would have been an expectation for the nurse to document what actions were taken. She stated a nurse can document that the RN was present, and responsibility for the documentation ultimately falls on the nurse providing care. The DON stated based on the documentation she reviewed, she did not see where the nurse documented what occurred. She stated the documentation is the only record that communicates the sequence of events, and she acknowledged the current documentation does not reflect what happened. She stated the record should have contained what was verbally reported to her and an accurate reflection of the event. She explained that when a patient codes, the facility uses a blue code sheet, and corresponding documentation is entered into the electronic record. She stated the facility uses a pink binder that instructs nurses on the steps to take during specific events. She stated the document guides the nurses step by step on what to do and what to document in the medical record. A review of a document provided by the facility titled Nurse Need to Know Quick Reference Guide, undated, revealed the following:--DeathNotify ProviderNotify the Responsible PartyComplete Record of Death FormDocument in electronic medical record A review of the facility policy titled Death of a Resident, Documenting, undated, revealed the following:Policy Statement:Appropriate documentation shall be made in the clinical record concerning the death of a resident.Policy Interpretation and Implementation:1. A resident may be declared deceased by a Licensed Physician, Registered Nurse or two Licensed Nurses who gather data that confirm ther are no signs of life with physician authorization n accordance with state law.2. All information pertaining to a resident's death (i.e., sate, time of death, the name and title of the individual pronouncing the resident dead, etc) must be recorded on the nurses' notes.9. All records must be completed and forwarded to Medical Records for disposition,

Based on record review and interviews, the facility failed to provide supervision to prevent an elopement for a resident with a known history of wandering for one resident (#1) of two residents sampled. On 4/19/26 at approximately 10:30 a.m., Resident #1 left the facility unsupervised and was missing for 10 hours.Findings included:Review of a progress note dated 4/19/26 revealed, At approximately 1 p.m., nurse entered resident's room to administer scheduled medications. Resident was not present in the room at that time. Immediate search of the unit was conducted with no success. Nurse proceeded to the front desk and spoke with the receptionist, who reported that the resident had left the facility earlier, appearing to sign out. There was no prior notification given to nursing staff regarding the resident's intent to leave the facility.Review of the admission record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including other toxic encephalopathy, cellulitis of lower limbs, generalized muscle weakness, adjustment disorder with depressed mood and age-related physical debility.Review of the minimum data set (MDS), dated [DATE], showed a brief interview for mental status (BIMS) score of 8 out of 15, indicating the resident was moderately impaired, and may forget daily tasks. Section E revealed the resident did not have wandering behaviors indicated.Review of the resident's medical record revealed the following:An admission elopement assessment dated [DATE] revealed the resident was not at risk.An elopement evaluation dated 3/31/26 revealed the resident has recent history of elopement or wanders with history of exit seeking within the last 90 days. The intervention called for placing the resident's picture in the elopement book. Apply wanderguard, if facility has system available.Review of a progress note dated 3/20/26 showed, Care Area Review: The IDT [interdisciplinary team] met to discuss the following care areas: Elopement. Emotional Well Being. Comments: on 3/13/26: resident was observed trying to leave out of back doors of the unit. Stated he was going home. Was easily redirected back to room and Wanderguard placed.Review of the current physician orders revealed: On 3/13/26: Wanderguard; every shift, Check for placement - right leg AND every day shift Check for function - right leg.Review of the care plan, initiated on 2/23/26 and discontinued on 5/2/26, revealed Resident #1 did not have a plan of care in place following the elopement assessment on 3/31/26 and did not have a wandering or elopement focus in place during the time of the elopement on 4/19/26.On 5/7/26 at 12:12 p.m. an interview was conducted with Staff A, Registered Nurse (RN)/ Supervisor. Staff A revealed having worked on the day Resident #1 left the facility. He stated around lunch time, the assigned nurse had discovered the resident was not in the room. He stated they immediately initiated the search and he called the code. Staff A stated having been informed that the receptionist had let the resident out.An interview with Staff B, Licensed Practical Nurse (LPN), on 5/7/26 at 12:35 p.m. revealed she was assigned to care for Resident #1 on the day he left the facility. She stated Resident #1 had wandering behaviors and wandered about the facility. She stated she did not know at the time the resident was at risk for elopement and could not confirm if he had a wanderguard. She stated when she realized he was missing, she went to the receptionist who said he went out the door. She stated the receptionist confused the resident for a visitor and let him out. She reported having searched the perimeters and when they could not immediately find him, they called Code Amber (an alert that generally indicates a vulnerable resident is missing). Staff B stated not knowing if Resident #1 was in their elopement book at the time. Staff B confirmed being notified by a family member that the resident was missing. She stated the resident was gone all day and had not been located at the time she left.During an interview with the Assistant Director of Maintenance (ADOM) on 5/7/26 at 12:58 p.m., he revealed he immediately reported to the facility following the elopement notification and checked all the doors. He confirmed if a resident had a wanderguard, it would activate the alarm, which would alert the staff the resident should not leave unsupervised. He stated, the way the system works, someone would have had to silence the alarm. He stated his inspection revealed all the doors were operating as expected. During this interview, the ADOM demonstrated the operation of the wanderguard device at the front door where Resident #1 left. The system was observed to work without concerns.An interview was conducted with the Lead MDS (LMDS) nurse on 5/7/26 at 2:10 p.m., revealing if a resident had a wanderguard, there would be a physician order, and a care plan would be in place. She stated nursing staff monitor the functionality and placement of the devices daily. In reviewing the care plan at the time of this interview, the LMDS confirmed Resident #1's wanderguard order was initiated on 3/13/26 and placed on him on 3/19/26, but a care plan was not implemented. The LMDS nurse said, The care plan was missed. It was oversight on my part. She confirmed if the care plan was not in place, the CNA task log would not show the interventions required related to monitoring and supervision of this resident. She stated unless they reviewed the elopement book, they would not have known Resident #1 was at risk for wandering or leaving.On 5/7/26 at 3:09 p.m., an interview was conducted with the Director of Nursing (DON), who confirmed having been notified at approximately 1 p.m. on 4/19/26 that Resident #1 had left the facility and his location was unknown. The DON stated she reported to the facility, joined the search and initiated their investigation process. She stated the police and family were immediately notified. The DON stated that she had interviewed all the staff who worked that day, including the receptionist. The DON stated the receptionist said Resident #1 had come to the front desk, carrying a back pack and ambulating with his walker. The receptionist asked the resident if he was a visitor and directed him to sign out but did not confirm the transaction. The DON stated the receptionist watched the resident proceed towards the front door, at which time the alarm went off. The DON stated the receptionist said she silenced the alarm and proceeded to let the resident out without confirming his identity. The DON said, She failed to notify anyone of the alarm going off and her silencing it. When I asked why she did that, she shrugged her shoulders. The DON stated no one else responded to the alarming door at the time. She stated the staff are expected to respond to all alarms. An interview with the Nursing Home Administrator (NHA) on 5/7/26 at 2:58 p.m. revealed Resident #1 had told another resident he was leaving. He stated the receptionist should not have let the resident leave the building when the wanderguard alarm sounded. The NHA said, It wasn't a competency issue; she was able to speak to the facility protocol. She was well trained. She just did not care. The NHA stated Resident #1 was was brought back by the police unharmed at 11:30 p.m., having been unaccounted for 10 hours. He stated the resident wanted to move closer to his people. The NHA stated they facilitated the move and educated all staff regarding their policies and procedures on elopement with on-going drills and audits.On 5/7/26 at 3:49 p.m., a telephone interview was conducted with the Physician. He stated he would have expected the staff to initiate the wanderguard orders sooner and implement the plan of care accordingly. He stated there was a complete breakdown with the receptionist not paying attention to the job. He stated the receptionist failed to follow their process and was let go. He stated they have introduced visitor's badges. The physician stated it was an isolated incident. Review of the facility policy titled Elopement, revised December 2007, revealed a policy statement: Staff shall investigate and report all cases of missing residents.Policy Interpretation and Implementation1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing.2. If an employee observes a resident leaving the premises, he/she should:a. Attempt to prevent the departure in a courteous manner;b. Get help from other staff members in the immediate vicinity, if necessary; andc. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises.3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall:a. Examine the resident for injuries;b. Notify the Attending Physician;c. Notify the resident's legal representative (sponsor) of the incident;d. Complete and file Report of Incident/Accident; ande. Document the event in the resident's medical record.4. If an employee discovers that a resident is missing from the facility, he/she shall:a. Determine if the resident is out on an authorized leave or pass;b. If the resident was not authorized to leave, initiate a search of the building(s) and premises;c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.);d. Provide search teams with resident identification information; ande. Initiate an extensive search of the surrounding area.

Based on record review and interview, the facility failed to provide evidence of a notification to the resident or responsible party of the patient trust account having reached $200 less than the SSI (Supplemental Security Income) resource limit of $2,000.00 for one (#2) of four residents reviewed for patient trust monies out of a total sample of ten residents. Findings included:A review of Resident #2's admission Record reflected an admission of 08/2022.The diagnosis information included but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side and need for assistance with personal care.A review of Resident #2's resident statement for personal trust fund monies revealed a balance on 07/01/2025 of $7,871.13.On 11/04/2025, $5,469.30On 12/04/2025, $6,264.65On 01/02/2025, $6,216.12For the months of 07/2025 through the date of survey, the personal trust fund reflected a monthly deposit of $964.00.On 01/05/2026 at 3:15 p.m., an interview with the Business Office Manager (BOM), she stated Resident #2 was receiving a Social Security payment of $964.00, the patient liability (room and board charge) was wrong.A review of a Notice of Case Action from the Department of Children and Families (DCF) for Resident #2, dated 02/11/2025, documented Resident #2's Medicaid eligibility with a patient liability for 12/2024, 01/2025, 02/2025, and 03/2025 ongoing to be 00.00.The BOM provided an e-mail, dated 01/05/2026 (the date of survey), which documented an inquiry to DCF, to ask about the $0 patient liability.On 01/05/2026, the BOM was asked to provide evidence of notification to the resident or resident representative of Resident #2 being within $200.00 of $2,000 asset limit. No document was provided on the date of survey.On 01/05/2026, the BOM was asked for a policy and procedure for notifying residents of being within $200.00 of the $2000.00 asset limit. No document was provided on the date of survey.

Based on observation, record review and interview, the facility failed to implement the grievance process for one (#8) of four residents reviewed. Resident #8 had been requesting assistance to obtain her Personal Need Allowance check of $130 from the Department of Children and Families (DCF) since 12/11/2024.Findings included:A review of Resident #8's admission Record, documented an admission of 09/24/2024 with diagnosis including but not limited to major depressive disorder and chronic pain.On 01/05/2026 at 12:21 p.m., Resident #8 agreed to be interviewed. Resident #8 was observed in bed, with a meal at the bedside, alert, and able to answer questions. Resident #8 stated receiving a $30 Social Security Income (SSI) check and expected an additional $130 state check. Resident #8 said, I have not received it and have been asking since 2024 with nothing happening.A search for Medicaid application processing was conducted on the internet. The processing time for an application was stated to be 45 days by the Department of Children and Families (DCF). In addition, A review of CALCULATION OF BENEFITS: BUDGETS AND TEST CALCULATIONS, https://ffic.myflfamilies.com/manual/2600, section 2640.0118 Personal Needs Allowance (MSSI). 1. If the individual has less than $160 total countable income, a supplemental payment must be authorized through the Supplemental Payment System (SPS). The personal needs allowance supplement (PNAS) cannot exceed $130 a month.An interview was conducted on 01/05/2025 at 2:55 p.m. with the Business Office Manager (BOM) regarding Resident #8. The BOM confirmed Resident #8 was admitted in 09/2024. The BOM stated Resident #8 started to complain about the $130 check, probably about 3 to 4 months after admission. Resident #8 was requesting information as to why she was not receiving the other check. The BOM stated I think there was a grievance, that would be social service. The BOM stated filling out forms to notify DCF about the $130 check, and provided a DCF fax cover sheet, dated 09/02/2025 with a change notice of living arrangements with a comment Patient not receiving State of Florida check for $130. Please update from time of her admission to (facility). The BOM stated turning the matter over to the facility's contracted Medicaid Specialist. The BOM provided an e-mail dated 11/24/2025, which spoke to an inquiry the contracted Medicaid Specialist had made on 09/21/2025 to DCF about the PNAS check of $130. No further information was made available by the facility to indicate an effort to follow-up and resolve the PNAS money issue with DCF prior to survey entrance. An interview was conducted on 01/05/2025 at 4:30 p.m. with the Social Service Director (SSD). When asked if Resident #8 had complained about not receiving a $130 check from the state, The SSD stated provided the grievance log for 12/2024. The log listed a grievance from Resident #8 to be about dietary, social services, and business office, dated 12/11/2024. The grievance was listed to be resolved, 12/12/2024. The SSD said the resident had requested to see the BOM during that period. The grievance document was not provided or available for review prior to survey exit.An interview was conducted on 01/05/2025 at 4:42 p.m., with the BOM. The BOM stated (Resident #8) was a resident at another facility, prior to admission here. The BOM said the resident was receiving the $130 check at the other facility. The BOM said, after the move, the previous facility would have returned the check(s) to the source (DCF).A review of the facility's policy and procedure titled: Grievances/Complaints filing, not dated, documented the policy statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.The policy interpretation and implementation included: .3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care int the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint.14. The results of all grievances files, investigated and reported, will be maintained on file for a minimum of three years from the issuance of the grievance decision.A review of the Business Officer Coordinator job description, signed by the Business Office Manager, 03/10/2025, documented duties and responsibilities to include: Administrative Functions:Follow up on any communication from Medicaid office in a timely manner.Communicate with Medicaid caseworker on a regular basis to ensure all documentation is submitted for approval.Maintain, secure, and update resident's financial files.Resident Rights:Maintain a written record of the resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint.

Based on observations, interviews and record review, the facility failed to ensure resident rooms, common areas, equipment and furnishings were maintained in a clean, safe and sanitary manner in four units (Northeast, Southwest, Southeast and Central) out of five units during four days (6/23/25, 6/24/25, 6/25/25, and 6/26/25) out of four days observed. Findings included: On 6/23/2025 at 10:20 a.m., 6/24/2025 at 7:50 a.m., 1:00 p.m., 6/25/2025 at 8:00 a.m. and 12:30 p.m., and on 6/26/2025 at 1:00 p.m. the following observations were made: 1.The following was observed in the North East Unit: Resident room [ROOM NUMBER] room air conditioner unit was observed with filters that were heavily caked with dust and debris. Resident room [ROOM NUMBER] was observed with the left air conditioning filter missing from the unit. The Community shower room was observed with insufficient lighting with one ceiling light not working. The lower left side and right-side walls of the shower stall were observed in disrepair with holes. There was black bio growth on the lower wall base tiles and grout. Resident room [ROOM NUMBER] was observed with several blind slats cut away measuring approximately four inches by four inches. Room air conditioner unit was observed with filters that were heavily caked with dust and debris. Resident room [ROOM NUMBER] room sink area was observed with the sink lip missing caulking and leaving an exposed space that was not cleanable. The room air conditioner unit was observed with filters that were heavily caked with dust and debris. The bed frame for bed was observed with heavily rusted surface leaving a non-cleanable space. Resident room [ROOM NUMBER] window was observed with blinds in disrepair Resident rooms 302, 301, 305, 306, 307, 308, 309, 315, 316, 319, 322, and 325 room air conditioner units were observed with filters that were heavily caked with dust and debris. Resident room [ROOM NUMBER] Call light system in the bathroom was observed torn off the wall with exposed wiring. The bed - A metal frame was observed with heavy rusting leaving a non-cleanable surface, a metal over-the-commode device was observed with grey paint peeled up leaving heavy rusting. This was an uncleanable surface. Resident room [ROOM NUMBER] bathroom was observed with a call light box off the wall, leaving exposed wires. Resident room [ROOM NUMBER] was observed with a wall in disrepair leaving a hole near the B-bed, a large red dresser was observed positioned in a manner to block the bathroom door and leaving it inaccessible. The over-the-commode device was observed with grey paint peeled up leaving heavy rusting and uncleanable surface. The blinds were observed soiled. Resident room [ROOM NUMBER] was missing a call light system in the private bathroom, three floor tiles under the room sink area were observed with heavy water damage and were not affixed to the floor. 2. In the South [NAME] Unit, the following was observed: Resident room [ROOM NUMBER]-bathroom metal over-the-commode device was observed with grey paint peeled and rusted, leaving a non-cleanable surface. Resident rooms 210, 214, 216, 218, and 219 air conditioner units were observed with filters that were heavily caked with dust and debris. The community shower room was observed with one of two stalls with black bio growth on floor tiles and lower will tiles and grouting. Resident room [ROOM NUMBER] shared bathroom was observed with a toilet paper holder missing the roll holder and there was no toilet paper observed in the bathroom. 3. In the South East Unit, the following was observed: In Resident room [ROOM NUMBER] the bathroom was blocked by furniture. Resident rooms 101, 102, 108, and 117 room air conditioner units were observed with filters that were heavily caked with dust and debris. Resident room [ROOM NUMBER] the room area sink was observed with missing caulking between the sink bowl and counter, leaving an exposed area that was non cleanable. Resident room [ROOM NUMBER] had three broken window blind slats and the bathroom door scrapped, making it hard to pull open. Resident room [ROOM NUMBER], room area vanity counter was observed to be in disrepair, along with the bathroom toilet paper holder. On 6/26/2025 at 2:09 p.m. an interview was conducted with the Maintenance Director who revealed there are two maintenance workers to include himself and the facility is very large in size accommodating two hundred and fifty plus beds. The Maintenance Director revealed he operates with work orders through an electronic record base system. He revealed if there are any issues with resident rooms, equipment, etc. He stated staff are to go into the electronic work order system and he will receive those orders. He revealed he does look at the orders to decide what things need to be fixed or repaired on a priority level. The Maintenance Director stated the residents' rooms have two air filters and they are to be changed approximately every month, per the facility's electronic maintenance system. He confirmed he and his staff have not been able to get to the air conditioner filters on monthly basis and confirmed the filters were caked with dust and debris. On 06/26/2025 at 02:23 p.m., an interview was conducted with the Director of Housekeeping. She stated housekeeping in rooms and spaces are performed daily. She stated showers and floors are cleaned by hand and with a machine. She stated maintenance vacuums the vents to clean them. She stated that she and her staff reports maintenance issues via the electronic maintenance system. (Photographic Evidence Obtained) 4. During a facility tour on 06/23/25 at 09:27 a.m. to 02:03 p.m., the following was observations were made in the central unit: room [ROOM NUMBER]'s bathroom toilet was dripping water from the pipe, at the back of the toilet connecting into the wall, down to the floor, a puddle was formed at the toilet base. The toilet bowl had an orange ring in the bowl. room [ROOM NUMBER]'s bathroom had two screws protruding from the tile next to the toilet, where the toilet paper holder should have been. The bathroom emergency call cord was on the floor and ran through a rusty screw. room [ROOM NUMBER]'s toilet bowl had multiple black rings inside. room [ROOM NUMBER]'s in room sink counter was cracked, resulting in an unfinished sharp edge and the sink bowl was not grouted to the counter, creating an uncleanable surface. In the southeast unit at the back hallway was an unlocked breaker box. room [ROOM NUMBER]'s toilet bowl had multiple black rings inside. The Central unit's day room Packaged Terminal Air Conditioning (PTAC) unit was separating from the wall and the section of wall between the unit and the window had black bio growth, white spots and the paint was peeling. room [ROOM NUMBER]'s blinds were bent, cracked, and pieces were missing. The wall by the toilet had a black bio growth. room [ROOM NUMBER]'s bathroom door handle was missing. During an interview on 06/24/25 at 08:15 a.m. Staff C, Certified Nursing Assistant (CNA) stated the floor was wet and the water appeared to be coming from the bathroom. Staff C confirmed water was slowly dripping from the toilet pipe. Staff C stated when an issue is noted a note would be made into the electronic maintenance system for repair. During an interview on 06/24/25 at 02:15 p.m. the Maintenance Director confirmed the electric panel should be locked at all times and the toilet would need repair. During an interview on 06/24/25 at 02:15 p.m. Staff E, Housekeeping Aide (HA) stated when cleaning in the rooms if they note an issue they should place the report in the electronic maintenance system. During an interview on 06/24/25 at 08:05 a.m. the Housekeeping Director (HD) confirmed the black rings in the toilets. The HD stated there was nothing that could be done about the rings. The HD confirmed the toilet paper holder was missing in room [ROOM NUMBER]. On 06/26/2025 at 02:00 P. M., the NHA and DON provided the Cleaning and Disinfecting Residents' Rooms policy and procedure, with a revision date of August 2013, revealing the purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. The guidelines revealed: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Steps in the procedure, resident room cleaning. 6. Clean horizontal surfaces (e.g., bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. 7. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. 11. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. On 06/26/2025 at 02:00 P. M., the NHA and DON provided the Resident Rights - Safe/Clean/Comfortable/ Homelike Environment policy and procedure, with no last review date. The intent showed it is the policy of the facility to provide a safe, clean, comfortable homelike environment such a manner to acknowledge and respect resident rights. The procedure revealed: 1. The resident has a right to a safe, clean, comfortable and home-like environment, including but not limited to receiving treatment and supports for daily living safely. 2. The facility must provide a safe, clean, comfortable, and home-like environment, allowing the resident to use his or her personal belongings to the extent possible. a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. (Photographic Evidence Obtained)

4. A review of Resident #50's admission record revealed an initial admission date of 01/29/2025with diagnoses included but not limited to fibromyalgia, muscle weakness, emphysema, acute myocardium Infarction, pulmonary hypertension, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypercapnia, asthma, chronic bronchitis, generalized anxiety disorder, opioid dependence, major depressive disorder recurrent, hypertension. Review of a progress note for Resident #50 dated 06/19/2025, showed MD (Medical Doctor) note, marked [late entry] scanned in on 06/25/25, reason for appointment . A second progress note dated 06/12/2025, MD note, marked [ate entry], scanned in on 6/25/25, showed, Reason for Appointment . During an interview on 06/26/2025 at 9:18 a.m. with Staff U, Licensed Practical Nurse (LPN), Unit Manager (UM) stated the MD usually comes in weekly and he has 2 or 3 ARNPs (Advanced Registered Nurse Practitioners) who come in frequently. The UM stated they come most days, but their notes are not in the system timely. During an interview on 06/25/2025 at 2:45 p.m. the Director of Nursing (DON) stated she would look in medical records for the MD notes. The DON was aware the MD notes were not in the chart and available for nursing. Review of the undated facility's policy titled Physician Services showed:11. The Physician will: (a.) Review the resident's total program of care, including medications and treatments, at each visit; (b.) Write, sign, and date progress notes at each visit. 2. A review of Resident #5's admission record revealed an initial admission date of 03/05/2018 and a re-admission date of 6/19/2025 with diagnoses included but not limited to pneumonitis due to inhalation of food and vomit; severe sepsis, dysphagia, muscle weakness, type 2 diabetes mellitus, chronic obstructive pulmonary disease. Review of Resident #5's medical record from 05/01/25 to 06/24/25 did not reveal any physician documentation. 3. A review of Resident #18's admission record revealed an admission date of 09/08/2021 with diagnoses included but not limited to protein-calorie malnutrition, cirrhosis of the liver, muscle weakness, Chronic Obstructive Pulmonary Disease, anxiety disorder, major depressive disorder recurrent, hypertension, type 2 diabetes mellitus, need for assistance with personal care and schizoaffective disorder. Review of Resident #18's medical record from 05/01/25 to 06/24/25 did not reveal any physician documentation. During an interview on 06/25/25 at 3:00 p.m. the Director of Nursing (DON) confirmed the physician documentation was not in the medical record for Resident #5 and #18. Based on record review and interviews, the facility did not ensure physician notes were available to the facility in a timely manner for four residents (#142, #5, #18, and #50) of thirty-six residents reviewed. Findings included: 1. A review of Resident #142's admission record revealed an initial admission date of 03/18/24 and re-admission date of 05/24/25 with diagnoses to include unspecified fracture of left patella subsequent encounter for closed fracture with routine healing, unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, pain in left hip, other specified disorders of bone density and structure, multiple sites, quadriplegia, unspecified, periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, other fracture of lower end of right femur subsequent encounter for closed fracture with routine healing, pain in unspecified knee, and chronic pain syndrome. An attempt to review Resident #142's physician notes from 04/2025 to 06/2025 was conducted on 6/23/25 and 6/24/25. There were no physician records available for record review. On 6/25/25 at 5:32 p.m., an interview was conducted with the Director of Nursing (DON). She stated Resident #142's physician's notes were uploaded to the progress notes section today, (6/25/25). The DON confirmed the physician notes were previously not in the medical record.

3. An observation on 06/23/2025 at 1:07 p.m. revealed Resident #55 was lying in his bed on the right side in his room. Both the door and the curtain were open. The sheet was not covering his backside, and his buttocks were exposed to the hallway. The APRN (Advanced Practice Registered Nurse) and Staff A, Licensed Practical Nurse (LPN) the wound care nurse were observed providing wound care to the resident. Resident #55's bottom was able to be observed from the room across the hall, as well as by anyone walking down the hallway. Review of the admission Record revealed Resident #55 was admitted on [DATE] and readmitted on [DATE] with diagnoses included but not limited to osteoarthritis of left and right knee, Chronic Obstructive Pulmonary Disease (COPD), chronic venous hypertension with ulcer of right lower extremity, non-pressure chronic ulcer of right lower leg, and chronic venous hypertension with ulcer of left lower extremity among other diagnoses. Review of the Annual Minimum Data Set (MDS) for Resident #55 dated 05/10/2025 showed a Brief Interview for Mental Status (BIMS) score of 15, meaning the resident was cognitively intact. Section GG showed the resident was dependent for showers. Review of the physician orders showed cleanse left posterior thigh with normal saline, pat dry, apply silver alginate and border gauze daily. Review of skin and wound note by Advanced Practice Registered Nurse (APRN) progress notes dated 6/23/2025 showed patient was evaluated today for evaluated of LLE (Left Lower Extremity) at request of nurses due to patient complaints of drainage. Patient remains on palliative care. Left Lower extremity rolled gauze wrap noted to be urine soaked with strong ammonia malodor to dressing. Patient has skin tear to left posterior thigh, patient endorses difficulty with bed mobility and frequently sliding to maneuver. and refuses to wear pants or clothing to protect lower limbs. No other complaints per nursing staff. During an interview on 06/25/2025 at 10:16 a.m. Resident #55 stated they [staff] normally close the door and curtain during care. Resident #55 stated the ARNP was standing in the door at the time of my care. Resident #55 stated, It is upsetting that they did not shut the door. Resident #55 stated he expected the staff to close the door and curtain. Resident stated, I don't' want to moon anybody. During an interview on 06/25/2025 at 12:46 p.m. the Director of Nursing (DON) stated she expected the staff to knock on the door, introduce themselves, inform the resident of services to be rendered. The DON stated she expected the staff to close the curtain and the door before providing care. The DON stated not closing the curtain and door was a breach in privacy and a dignity issue. Review of the facility's policy, Resident Rights, revised February 2011 showed Employees shall treat all residents with kindness, respect, and dignity. Policy and Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness and dignity. Based on observation, interview, and record review the facility failed to ensure dignity was maintained for residents requiring meal assistance for two residents (#141 and #204) out of 36 sampled residents and did not ensure dignity was maintained during care for one resident (#55) out of 36 residents sampled. Findings included: 1. An observation was conducted on 06/23/25 at 11:58 a.m. in the Central Unit dining room with a table of three residents and a table of four residents. Two Certified Nursing Assistants (CNAs) and a Speech Language Pathologist (SLP) were present. Resident #141 was observed sitting at the table with two other residents. Resident #141 was observed utilizing their fingers dipping into a bowl of pudding. Resident #141 returned fingers to their mouth, the pudding dropped from their fingers on the way to their mouth. The SLP stated to Resident #141, Eating with your fingers is ok as long as you are eating. No other staff members were observed to assist or encourage Resident #141 with their meal. Review of admission Record showed Resident #141 was admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, need for assistance with personal care, adult failure to thrive and anxiety. Review of Resident #141's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score is 99, indicating impaired cognition. Review of Resident #141's Activities of Daily Living (ADL) care plan, revised 07/11/22, showed resident exhibits behavior of eating with hands instead of using utensils and the interventions listed included: Staff to anticipate care needs and provide them before resident becomes overly stressed, approach resident in a calm manner and explain actions, and provide positive reinforcement for successful interactions/efforts. 2. An observation was conducted on 06/24/25 at 11:45 a.m. in the Central Unit dining room. Two tables of four residents each were in the dining room. Two residents (141 and 204) were observed sitting at a table with two other residents between each resident. Three staff members were present (two CNAs and one nurse). Resident #141 was observed to pick up a hot dog bun with chopped meat, the meat fell onto the resident's plate. Staff G, CNA started to assist Resident #141 with the remainder of the meal. Resident #204 was observed at the table with a plate, bowl, cup and silverware placed just to the lower right of the plate. Resident #204 was observed to pick up the bowl, brought the bowl to their mouth and started licking the contents from the bowl. The resident next to Resident #204's right side, kept telling Resident #204 to stop. The resident to Resident #204's right started to reach out and push Resident #204's forearm to the table, while saying, don't do that. The resident next to Resident #204 reached for Resident #204's pudding bowl and started to take the pudding away from Resident #204. Staff G, CNA who was assisting Resident #141 stood up and took the bowl from the resident and placed the bowl in the middle of the table, out of the reach of all the residents. Resident #204 cried out. Resident #204 then reached for the hot dog bun with chopped meat, which was on their plate. Resident #204 picked up the bun and the chopped meat fell off into their lap and plate. Resident #204 sighed heavily and put the bun back down on the plate, then proceeded to pick up the entire plate, brought the plate to their mouth and tried to eat the bun with chopped meat from the plate. Resident #204 was struggling while doing this and the resident to the right continued to discourage Resident #204. No staff member encouraged or assisted Resident #204 to try to utilize utensils or assisted the resident with the meal. Review of admission Record showed Resident #204 was admitted on [DATE] with diagnoses including dementia with agitation, adult failure to thrive, anxiety and need for assistance with personal care. Review of Resident #204's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score is 00, indicating impaired cognition. Review of Resident #204's Activities of Daily Living (ADL) care plan, revised 12/05/24, showed Resident #204 has a self-care deficit with . eating, . related to: impaired mobility, fracture of humerus, generalized weakness, has dx (diagnosis) of failure to thrive, Demetia, requires staff assistance with ADL'S. Staff interventions included: Cue/encourage resident to participate in ADL tasks, allow resident ample time to attempt/complete ADL tasks before intervening, staff to anticipate resident's needs with ADLs. During an interview on 06/24/25 at 02:25 p.m. Staff G, CNA confirmed Resident #141 and #204 were eating with their fingers during lunch. Staff G, CNA confirmed the resident next to Resident #204 took the pudding away. Staff G, CNA stated not being sure what to do with Resident #204 behavior as the nurse did not intervene and while they were assisting Resident #141. Staff G, CNA stated the staff should have encouraged Resident #204 to use the utensils or assisted Resident #204 sooner. During an interview on 06/26/25 at 09:46 a.m. the Director of Nursing (DON) stated the staff should have intervened and encouraged the residents to utilize utensils or assisted the residents if needed.

Based on observation, interviews and record review the facility failed to provide language assistance to a resident with limited English proficiency for one resident (#210) of 65 sampled residents. Findings included: An observation on 06/23/2025 at 12:40 p.m. revealed Resident #210 sitting at bedside in a wheelchair eating her lunch. The resident was only able to speak Spanish. Surveyor went to the nursing station to find a bilingual staff member to assist with the interview. The resident's aide came down and stated she was unable to speak Spanish. The aide stated she was able to understand if the resident had pain or not. The aide went to get Staff B, Registered Nurse (RN) and told her the resident was in pain. The surveyor went to the conference room to get another surveyor who speaks Spanish. The resident was saying in Spanish, Oh my God I'm in a lot of pain, help me please, they don't understand me. The resident appeared to be tearful and visibly in pain. The resident was observed speaking Spanish to her family member on the phone. The family member said in Spanish, They don't speak Spanish and they don't understand her. The nurse (Staff B) walked in shortly after observation and provided medication to the resident. The resident was telling the nurse in Spanish she is in a lot of pain. The nurse looked at surveyor and asked, what is the resident saying. The nurse went to get another staff member, a second aide, who assisted resident with getting into bed. A follow-up interview with resident once she was in bed revealed she primarily speaks Spanish and stated the staff don't understand her and she does not understand them. Review of the admission Record showed Resident #210 was admitted to the facility on [DATE]. The diagnoses included but not limited to disorder of brain, benign neoplasm of cerebra meninges, Diabetes with neuropathy, muscle spasm, polyneuropathy, major depressive recurrent, hypertension, repeated falls, generalized anxiety disorder, bipolar disorder, schizophrenia cervicalgia. Review of the progress note dated 06/13/2025 showed, Social Determinants of Health: Resident is [NAME] Rican. Language: Spanish Resident does need or want an interpreter to communicate with a doctor or health care staff. Lack of transportation has not kept Resident from medical appointments, meetings, work or from getting things needed for daily living. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy: Sometimes. How often do you feel lonely or isolated from those around you: Never. Review of the care plans showed Resident #210 has an alteration in communication ability related to language barrier. She does not speak English; primary language is Spanish. She understands some English speaking and able to voice some needs in English. Spanish speaking staff is available to assist with translation as needed as of 03/19/2025. Interventions included but not limited to repeat/rephrase messages as needed if resident misses part of intended message; speak to resident in simple, direct terms; ask resident yes/no questions; provide interpreter prn; ask family to interpret as able; keep call light within reach; respond to communicated needs prn. During an interview on 06/25/2025 at 12:46 p.m. the Director of Nursing (DON) stated depending on the language, they have someone who can interpret. The DON stated we have some Spanish speaking residents and try to place them on the station with the Spanish speaking staff. The DON stated the needs will depend on their cognition. The DON stated we can provide communication boards. The DON stated they do not have a list of staff members who are bilingual. The DON stated, We kind of know. She stated the SSD (Social Services Director) is bilingual, therapy staff is bilingual, nursing and aide staff. The DON stated she thought Resident #210 had a communication board. The DON stated we have therapy and one of our nurses' who floats over there (400 Hallway) on the 3-11 shift. The DON stated the resident calls her loved one to interpret also. Review of the facility's policy, Policy and Procedure: Right to Communication with Privacy, dated 1/2019 showed: 5. The resident has the right to have interpretive assistance for communication in another language. Facility will provide communication boards, staff interpreters or other means of communication as needed.

Based on observations, record review and interviews, the facility failed to accommodate residents needs related to 1.) Not having call light buttons placed within reach when in bed for five residents (#135, #79, #208, #15 and #25) out of sixty-five sampled residents and 2.) Not providing a wheelchair in order for resident (#135) to get up out from bed and out of her room per the resident's preference. Findings included: 1. On 6/25/2025 at 6:35 a.m., and 8:45 a.m. on Resident #208 was observed in bed lying under the covers. Further observations revealed the call light cord wrapped around the left upper bed rail, with the call button hanging down towards the floor. The cord and button were out of the resident's reach. On 6/26/2025 at 7:40 a.m. and 8:30 a.m. Resident #208 was observed in bed, her call light button was hanging below the bed mattress on the right side of the bed. The call light cord and button was in a position out from her reach. Review of Resident #208's medical record revealed she was admitted to the facility on [DATE]. 2. On 6/25/2025 at 6:45 a.m. Resident #15 was noted in bed with the call light button not placed within his reach. The call button and cord were lying on the floor back and behind the resident. On 6/25/2025 at 8:3 a.m. Resident #15's was noted in the same position in bed and the call light button was observed still on the floor, back behind his bed and out from his reach. On 6/26/2025 at 7:45 a.m. Resident #15's was observed in bed, the call light button and cord were positioned on the back of the bed and hanging down over the head of the bed, and out from his reach. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. 3.On 6/25/2025 at 6:45 a.m. Resident #25 was observed in bed with the call light button not placed within his reach. The call button and cord were lying on the floor back and behind the resident. On 6/25/2025 at 8:30 a.m. Resident #25 was observed in bed, the call light button was observed still on the floor, back behind his bed and out from his reach. On 6/26/2025 at 7:45 a.m. Resident #25 was observed in bed with the call light button and cord positioned on the back of the bed and hanging down over the head of the bed, and out from his reach. Review of Resident #25's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the current care plans with next review date 8/19/2025 revealed the following areas: Resident #25 is at risk for falls and fall related injuries with interventions to include but not limited to: Keep call light within reach. On 6/26/2025 at 10:00 a.m. an interview with Staff X Licensed Practical Nurse (LPN)/ Unit Manager (UM) revealed she was not aware the call light cords/buttons were not within the resident's reach. She stated the call light button should always be within the resident's when they are in bed and that staff are to observe for proper placement during each visit, every two hours. The Unit Manager revealed even if the resident does not routinely use the call light button, or rarely uses it, it still needs to be placed within his/her reach. 4. On 6/24/2025 at 10:00 a.m. an interview was conducted with Resident #135 which revealed she was having issues with the facility not getting her a wheelchair since her admission on [DATE]. She revealed she is at the facility for short term rehabilitation services, and she does receive therapy, and the facility has not provided her with any wheelchair in order to get out from bed and to go out from her room or to attend activities. Resident #135 revealed she had asked the facility staff about one month ago to include various nurses, the social service person and the Nursing Home Administrator (NHA). She revealed they came to her with a wheelchair during the first week or so of her admission and it did not fit her. She stated she needed a larger one to help her feel more comfortable in the seat. She revealed nobody ever responded back up until about a month ago, when she requested for a wheelchair again. She stated she has yet to receive one. Resident #135 confirmed had she had a wheelchair, she would get up out from bed. On 6/26/2025 at 9:30 a.m. an interview was conducted with Resident #135. She confirmed she had yet to get a wheelchair to be transferred into. She revealed she had not received any follow -up from the NHA and the Social Service Department (SSD). She revealed she had spoken with an unknown therapy staff member, and they too did not provide her with a wheelchair to use. Resident #135 revealed her aides tell her every day they did not have any wheelchairs that fit her, and she would just have to wait until they get one. Review of the medical record revealed Resident #135 was admitted to the facility on [DATE] with diagnoses to include Obesity, Adult failure to thrive, and Major depression, Anxiety. Review of the current Quarterly MDS assessment for Resident #135 dated 6/1/2025, revealed; Cognition/Brief Interview Mental Status score of 15 of 15, which indicated the resident was able to be interviewed related to her medical care and services. ADL - No impairment on both lower and upper extremities- toileting, requires substantial/Maximal assistance and was dependent for transfers. The assessment showed it was checked Yes for wheelchair as mobility device. Review of the current care plans for Resident #135 with a next review date 8/30/2025 revealed - Risk for falls and/or fall related injury related to generalized weakness, is non ambulatory, uses wheelchair as primary mode of locomotion, receives psych. meds, narcotics, with interventions in place to include but not limited to: Assist to wheel to destinations. On 6/26/2025 at 10:00 a.m. an interview was conducted with Staff X LPN/UM. She revealed the resident was assessed for a wheelchair during the first part of her admission and found that the resident did not want that wheelchair because she preferred a larger one. The Unit Manager revealed she believed Therapy had ordered another one but was not sure. The Unit Manager confirmed there was no documentation in the record to support the resident ever refused the wheelchair. On 6/26/2025 at 10:40 a.m. an interview with the Rehabilitation Director Staff Q revealed the resident was assessed and provided with a wheelchair when she was first admitted but she had heard the resident refused it and wanted another one. Staff Q revealed it was only brought to her attention yesterday (6/25/2025). She revealed the resident will be assessed and provided with a wheelchair that fits her. Staff Q could not provide any documentation to support a wheelchair was provided to the resident upon her admission, nor did she have any documentation to support the resident refused said wheelchair. Review of a facility policy titled, Call System, Resident revised September 2022 showed, the policy heading showed - Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The policy further revealed 1.) Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interviews and record reviews the facility failed to notify the physician and/or family of changes in condition (CIC) and treatment and care changes for three residents (#50 #18, #5) of 65 sampled residents. Findings included: 1. Resident #50 was admitted on [DATE]. Review of the admission showed diagnoses included but not limited to fibromyalgia, muscle weakness, emphysema, acute myocardium Infarction, pulmonary hypertension, Chronic Obstructive Pulmonary Disease, chronic respiratory failure with hypercapnia, asthma, chronic bronchitis, generalized anxiety disorder, opioid dependence, major depressive disorder recurrent, hypertension. Review of the quarterly, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Review of the physician orders for Resident #50 showed Triamterene-HCTZ Capsule 37.5-25 MG (milligram) give 0.5 mg daily for edema as of 06/22/2025 and discontinued on 6/25/25 and triamterene-HCTZ Capsule 37.5-25 MG give 0.5 mg daily for edema as of 06/25/2025 Review of the June 2025 Medication Administration Record (MAR) for Resident #50 showed Triamterene-HCTZ Capsule 37.5-25 MG (milligram) give 0.5 mg daily for edema had not been administered as of 06/25/2026. Review of the progress notes for Resident #50 showed the following: On 06/25/2025 at 4:05 p.m. Unit Manager (UM) placed a call to pharmacy to check status of medication. Pharmacy stated the prescription form was put in incorrectly and needed a new order. UM placed call to MD to advise medication form was incorrect and the delay of medication delivery. MD provided new order. UM called pharmacy and have order being sent stat to facility and MD okay new administration date. On 6/25/25, 1539, Change in Condition for edema (new or worsening), Recommendations: Triamterene 37.5/25 mg tab to take 0.5 daily. On 06/25/2025, Triamterene-HCTZ Capsule 37.5-25 MG, Give 0.5 tablet by mouth one time a day for edema half tab daily, on order. will call pharmacy to follow up. On 06/24/2025, Triamterene-HCTZ Capsule 37.5-25 MG, Give 0.5 tablet by mouth one time a day for edema half tab daily, on order. On 06/23/2025, Triamterene-HCTZ Capsule 37.5-25 MG, Give 0.5 tablet by mouth one time a day for edema half tab daily, Ordered. On 06/19/2025, MD note, late entry, scanned in on 6/25/25, reason for appointment edema. complains of LLE radicular pain, improved on muscle relaxants. Complains of edema. She has Coronary Artery Disease (CAD). she does not have Congestive Heart Failure (CHF). No dyspnea, orthopnea. Localized edema. Review of the care plans for Resident #50 showed - Resident #50 has potential for complications related to an alteration in cardiac function related to hypertension, and Coronary Artery Disease as of 01/29/2025. Interventions included but not limited to administer medications as ordered, observe for effectiveness and for side effects. Observe for new presences of or increase in edema; notify physician if noted. During an interview on 06/25/2025 at 2:45 p.m. the Director of Nursing (DON) stated she would look into why Triamterene-HCTZ had not been given to the resident and why the Medical Doctor (MD) was not informed. During an interview on 06/26/2025 at 9:18 a.m. Staff U, Licensed Practical Nurse (LPN)/ Unit Manager (UM) stated the physician inputted the Triamterene-HCTZ Capsule 37.5-25 mg. give 0.5 tablet by mouth. The UM stated the original order was placed on 06/23/2025 at 2:23 a.m. and the nurse confirmed it on 06/23/2025 at 3:09 p.m. The UM stated because it was written as a capsule, it could not be cut in half per the order. The UM stated she called the pharmacy on 06/25/2025 and the pharmacy informed her of above. The UM then called the MD, and he put in another order for tablets not capsules. The UM stated she put it in as a stat order. She stated the medication came in this morning for administration. The UM stated the procedure was to call the MD if a medication was not administered as per orders. The UM verified there was no documentation the nurses had informed the MD the medication had not been given for three days on 06/23/25, 06/24,25, 06/25/25. The UM stated she expected to see the MD notification. 2. During an interview on 06/23/25 at 02:45 p.m. the Responsible Party (RP) for Resident #5 stated the facility is terrible about notifying me of anything. The RP explained being contacted at 2:00 a.m. once and notified Resident #5 was back safely. The RP stated no one contacted me to let me know Resident #18 needed to go out to the hospital. The RP stated, didn't even know Resident #5 was gone. The RP stated not knowing Resident #5 had pneumonia or was being treated with antibiotics before one of the hospitalizations. The RP stated they didn't know she went to the hospital. They stated they were was aware of a hospitalization but was left to believe it was due to a feeding tube placement. Review of Resident #5's face sheet revealed the resident was admitted on [DATE] and readmitted on [DATE]. Review of the admission showed diagnoses included but not limited to pneumonitis due to inhalation of food and vomit; severe sepsis, dysphagia, muscle weakness, type 2 diabetes mellitus, chronic obstructive pulmonary disease. Review of the quarterly, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00 severe cognitive deficit. Review of Resident #5's physician orders revealed resident received Amoxicillin-Pot Clavulanate Oral Tablet 875-236 MG by G-tube two times a day for aspiration pneumonia for 7 days dated 05/06/25. Review of the progress notes for May 2025 did not reveal the RP was notified. During an interview on 06/25/25 at 11:37 a.m. Staff K, Registered Nurse (RN) stated the family, or RP should be notified when anything out of the ordinary occurs with the resident. The RP/family should definitely be contacted if a resident has an infection or has to go to the hospital. During an interview on 06/25/25 at 01:00 p.m. the Director of Nursing (DON) stated the expectation is for family/RP notifications to occur with a medication and transfer to the hospital. 3. Review of Resident #18's face sheet revealed resident admitted on [DATE] with diagnoses including but not limited to protein-calorie malnutrition, cirrhosis of the liver, muscle weakness, Chronic Obstructive Pulmonary Disease, anxiety disorder, major depressive disorder recurrent, hypertension, type 2 diabetes mellitus, need for assistance with personal care and schizoaffective disorder. Review of the quarterly, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Review of the Resident #18's weight log revealed: On 05/08/2025, the resident weighed 200 lbs. On 06/18/2025, the resident weighed 182 pounds which is a -9.00 % Loss. On 03/06/2025, the resident weighed 192 lbs. On 06/18/2025, the resident weighed 182 pounds which is a -5.21 % Loss. On 01/03/2025, the resident weighed 203 lbs. On 06/18/2025, the resident weighed 182 pounds which is a -10.34 % Loss. Review of Resident #18's Registered Dietitian (RD) Nutrition Risk Evaluation dated 6/22/25 revealed: Risk score 9, meaning at risk for malnutrition and weight warning: Value: 182.4, Vital Date: 2025-06-11 10:40:00.0 -10.5% , 21.4# [pound] x 2 days. -11% , 22.6# x 7 days. -8.8% , 17.6# x 34 days. -10.1% , 20.6# x 5 1/3 months. Erratic wt. [weight] changes, unknown etiology except different scales, no change in diuretic doses. Review of Resident #18's Registered Dietitian (RD) Nutrition Risk Evaluation dated 3/21/25 revealed: weight warning: Value: 192.6, Vital Date: 2025-03-06 09:47:00.0 -7.5% change [ 9.3% , 19.8# ] x 3 months. -10% change [ 10.4% , 22.3# ] x 6 months. Wt. stabilizing. The record did not reveal the physician had been notified of the weight loss for Resident #18. Review of the physician documentation available at the time of the survey did not reveal a documentation showing notification of Resident #18's weight loss status. During an interview on 06/25/25 at 01:33 p.m. Staff F, Licensed Practical Nurse (LPN) stated nurses don't notify the physician of weight loss. Staff F stated she thinks the dietary department does. During an interview on 06/26/25 at 09:31 a.m. the DON confirmed the physician should have been notified of the resident's weight loss and would need to investigate why there was no documentation. Review of the facility's policy and procedure titled Notification of Changes dated 10/2024 revealed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Examples for notification include: 1. Accidents. a. Resulting in injury. b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition. 4. A transfer or discharge of the resident from the facility. 5. A change of room or roommate assignment. 6. A change in resident rights. Review of an undated facility policy and procedure titled, Change of Condition Process revealed: intent: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Situations requiring notification include: 1. An accident involving the resident which: a. Resulting in injury. b. Potential to require physician intervention. 2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. This may include: a. life-threatening conditions, or b. Clinical complications. 3. A need to alter treatment significantly; that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This may include: a. A new infection or wound. b. Discontinuing a treatment or changing a medication due to: . 4. A decision to transfer or discharge the resident from the facility. 5. The facility must also promptly notify the resident and the resident representative, if any, when there is: a. A change in room or roommate assignment, or b. A change in resident rights under Federal or State law or regulations. 4. Upon the identification of a change in condition in a resident the Nurse will complete an evaluation of the resident's status, and document findings on the SBER Change in Condition in the resident's electronic medical record.

Based on observations, interviews and record review the facility failed to provide enteral nutrition according to physician orders for one resident (#79) out of fourteen residents sampled. Finding included: On 6/24/2025 at 7:09 a.m. Resident #79 was observed in her room and lying in bed with her head over bed approximately thirty-five to forty degrees. The observations revealed she was receiving nourishment via tube feeding system with the pump on and bottle hung. The label on the bottle read Jevity 1.5 hang date 6/24/2025, hang time 6:00 a.m., run time 40 ml/hr (milliliter/hour), and with the resident's name. The bottle was observed with approximately 800 ml of nourishment. On 6/24/2025 at 3:00 p.m. Resident #79 was observed in her room with the tube feeding bottle still hung but the system/pump was turned off. The tube line was hanging/draped over the bottle. The bottle was labeled/dated as earlier. During this observation, there was 500 ml of nourishment left in the bottle. On 6/25/2025 at 8:00 a.m., 2:00 p.m., and 3:00 p.m. Resident #79 was observed with the same bottle from 6/24/2025 and still with 500 ml of nourishment left. The observation revealed the resident had not received nourishment since 3:00 p.m. the previous day, on 6/24/2025. On 6/26/2025 at 7:10 a.m. and 9:00 a.m. Resident #79 was observed with the tube feeding system pole at bedside, with the same bottle of nourishment from 6/24/2025 (two days prior). The tubing/line was observed draped over the bottle and it was determined there still 500 ml of nourishment left in the bottle. The observation revealed the resident had not received nourishment for two days, since 3:00 p.m. on 6/24/2025. On 06/26/2025 at 8:16 a.m. an interview was conducted with Staff Y, Licensed Practical Nurse (LPN). Staff Y. When asked about the resident's tube nutrition bottle, Staff Y stated the date listed on the nutrition bottle was 06/25/2025. When she went into the room to check the nutrition bottle date and time, an observation was made in which the nutrition bottle had been thrown in the trash bin. Staff Y, LPN then stated she saw the bottle showed 6/24/2025, during the interview. She stated there may have been a mistake when entering the date on the nutrition bottle. She pulled the nutrition bottle out of the trash bin. She stated the tube nutrition bottle should be used within twenty-four hours of being hung and used. She stated if the twenty- four hours are exceeded, a new feed bottle must be hung. She stated that the resident was on the feed throughout the night. Review of Resident #79's medical record reveled she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Depression, Dysphagia, GERD, Cognition Communication deficit. Review of the current Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Section C- Cognition/Brief Interview Mental Status or BIMS score of 2 of 15, which indicated the resident was not interviewable related to her medical care and services. The ADL section showed the resident was dependent with most ADLs. The Nutrition was checked, Yes showing she receives tube feeding. Review of the current Physician's Order Sheet (POS) for the month of 6/2025 revealed orders: Enteral feed ever shift for enteral support; Start Jevity 1.5: To run at 40ml/hr. May hold for services and care. Flush feeding tube with 100ml of water every 4 hrs. and every shift for enteral support verify Jevity 1.5 tube feeding is running at 40ml hr. Flush feeding tube with 100 ml of water every 4 hrs. Order date: 6/11/2025. Review of the current care plan with next review date 9/9/2025 revealed Resident #79 was at risk for altered nutrition/hydration and unavoidable weight fluctuation/loss Dx/HX (diagnosis/history), CVA (cerebrovascular accident), R (right) hemiplegia/contracture, Aphasia, Dysphagia, Missing some dentition, Altered Consciousness, Cognitive Communication deficit, Depression, HTN (hypertension), Diuretic, Self feeding difficulty, History. Significant weight loss followed by gain, with interventions in place to include: Administer enteral feeding and flushes as ordered, observe for tolerance; Encourage adequate intake at meals. - Resident is at risk for complications associated with enteral feedings; also receiving po (by mouth) diet, at risk for aspiration, at risk for skin impairment to site, GI (gastrointestinal) distress related to tolerance of enteral formula, with interventions in place to include: Verify tube feeding placement as ordered, Check enteral feeding residuals as ordered, Administer enteral feeding and flushes as ordered, observe for tolerance, Keep Head Over Bed (HOB) elevated while feeding in process. On 6/26/2025 at 10:00 a.m. an interview with the Northeast Unit Manager, Staff X, LPN who confirmed Resident #79 was ordered for Tube Feed nourishment and also eats regular food by mouth. The Unit Manager revealed Resident #79's weights had fluctuated up and down and the dietician has been monitoring her weights and nourishment parameters. The Unit Manager was not aware the Jevity nourishment bottle was hanging in the room on the pole for 48 hours and had not been changed. She revealed once a bottle is hung and started, it should not be on the pole greater than 24 hours. She was not sure why the bottle was there and not being used. The Unit Manager was notified the bottle was hung and started on 6/24/2025 at 6:00 a.m. and left for forty-eight hours. The Unit Manager confirmed it should not have been opened, used and kept on the pole for more than twenty-four hours. Staff X, LPN was not sure why the MAR (Medication Administration) /TAR (Treatment Administration Record) were documented as Tube Feeding nourishment having been provided for the day of 6/26/2025. On 6/26/2025 at 1:00 p.m. the Nursing Home Administrator (NHA) and Director of Nursing provided the Enteral Nutrition policy and procedure with a revised date of 2018 for review. The Policy Statement revealed; Adequate Nutritional support through enteral nutrition is provided to residents as ordered. The Policy Interpretation and Implementation section revealed: 4 . Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary. 8 . The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 10 . Enteral feeding s are scheduled to try to optimize resident independence whenever possible (e.g., at night or during hours that do not interfere with the resident's ability to participate in facility activities). 11 . The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. The enteral nutrition product. b. Delivery sit (tip placement). c. The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc. d. Administration method (continuous, bolus, intermittent). e. Volume and rate of administration. f. The volume/rate goals and recommendations for advancement towards these; and g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume).

Based on observations, interviews and record review the facility failed to follow infection control standards related to hand sanitizing during medication administration and use of gloves when cleaning equipment for five residents (#52, #63, #58, #31, and #219) out of sixty-five residents sampled. Findings included: During an observation on 06/23/2025 at 9:05 a.m., Staff B, Registered Nurse (RN) was administering medications to Resident #52. Staff B stated she had already washed her hands. She opened her computer, then the medication drawer and removed the Dorzolamide HCL solution 2% eye drops inside a baggie. She removed the eye drop bottle from the baggie and placed it on a plate/barrier. Staff B applied gloves and entered the resident's room. She gave the resident a tissue. She placed a drop of eye medicine into each eye. She placed the eye drop medication back on a plate/barrier. She took the tissue from the resident and threw it away. Staff B, RN removed her gloves and threw them away, she did not perform hand hygiene. Staff B, RN exited the room to the medication cart. She inputted the information into the computer. Staff B removed the disinfectant wipe from the bottom drawer and wiped the eye drop bottle off (without applying gloves). She replaced the eye drop bottle into the baggie and placed in the medication drawer. She inputted into the computer. On 06/23/2025 at 9:10 a.m. Staff B, RN poured supplement for Resident #63. She entered Resident #63's room and handed the supplement to the resident. She did not hand sanitize before or after medication administration. Staff B, RN moved the medication cart to the next room. On 06/23/2025 at 9:15 a.m. Staff B stated Resident #58 had his other oral medications but needed his Nitroglycerin patch 0.1 mg/hour. Staff B applied gloves without hand sanitizing and opened the medication cart and removed the Nitro patch. Staff B entered the resident's room. She overlooked the resident's body for the old patch. She removed the Nitro patch and rolled it into one of the gloves and removed the second glove and threw them into the trash. Staff B reapplied gloves without hand sanitizing. She removed the Nitro patch from the packet and placed it on Resident #58's right chest area. Staff B removed her gloves and washed her hands. On 06/23/2025 at 9:20 a.m., a medication administration observation was conducted for Resident #31. Staff B, RN gathered all medications for administration. Staff B put the pills and nasal sprays onto a plate/barrier and set them on the overbed table. The nasal sprays were administered first. Staff B applied gloves without hand sanitizing and examined Resident #31's right knee. Staff B removed her gloves and reapplied gloves after hand sanitizing. Staff B applied the pain patch to the right knee. Staff B removed her gloves and reapplied her gloves without hand sanitizing. Staff B repositioned the resident's knee, brace and pillow. Staff B removed the privacy bag from the urinary drainage bag and observed the urine and replaced the privacy bag. Staff B removed her gloves, touched her clothes and hand sanitized. Staff B threw the resident's tissue away. Staff B removed the plate/barrier with the nasal sprays on it and exited the room. Staff B opened the medication cart, wiped the nasal sprays with disinfectant wipes with no gloves on. Staff B replaced the nasal sprays into the medication cart. Staff B placed the plate/barrier into the trash and inputted into the computer. At the beginning of medication administration it was noted the medication cart did not have Simethoane 80 mg (milligrams) which the resident was prescribed. Another staff member brought the medication to the medication cart. Without hand sanitizing, Staff B poured the medication into a medication cup and re-entered Resident #31's room to administer the medication. Staff B exited the room and without hand sanitizing started the administration process for the next resident. During an observation on 06/24/2025 at 11:07 a.m. Staff F, Licensed Practical Nurse (LPN) was administering medications to Resident #219. Staff F hand sanitized. She placed the blood glucose monitoring machine, two lancets, two alcohol wipes and a container of strips on a plate/barrier. She entered the room and placed the plate/barrier onto the overbed table. Staff F applied her gloves and wiped the left pointer finger off with alcohol. Staff F then used the lancet. She placed the blood glucose monitoring machine with the strip in place on the drop of blood. The glucose results were 134. She placed a tissue on the resident's finger. Staff F placed the blood glucose monitoring machine on the plate/barrier. Staff F removed her gloves and reapplied gloves with hand sanitizing. Staff F took the plate/barrier to the medication cart. Staff F removed disinfectant wipes from the medication cart and wiped the blood glucose monitoring machine and placed it covered with a wipe into a cup on the medication cart. Staff F removed her gloves and did not hand sanitize. She threw away the lancet. She placed the bottle of strips, which had not been cleaned back into a baggie. Staff F then hand sanitized. Staff F stated she was supposed to leave the blood glucose monitoring machine in the wipe for 30 seconds to 1 minute. Staff F applied one glove onto her left hand and wiped the blood glucose monitoring machine. She then removed the wipe and placed the blood glucose monitoring machine on a clean plate/barrier to dry. Staff F removed the left glove with no hand sanitizing and replaced the blood glucose monitoring machine into a baggie with the bottle of strips that had not been cleaned. Staff F placed the baggie into the medication cart drawer. Staff F went to the nursing station desk to see if there were paper Medication Administration Records (MARS) due to the internet being down. Staff F also checked the nursing station desk to see if that computer was working. The internet came back up and Staff F reviewed the insulin order for Resident #219. Staff F stated Resident #219 will receive Apidra 3 units as ordered before meals but none for the sliding scale. Staff F returned to the medication cart and put on gloves with no hand sanitizing. Staff F primed the Apidra insulin pen with 2 units and then loaded the 3 units. Staff F entered Resident #219's room and injected the insulin into her right upper extremity. Staff F removed her gloves and exited the room. Staff F removed the needle from the insulin pen, replaced the insulin pen into the baggie and replaced the baggie into the medication cart. Staff F then hand sanitized. During an interview on 06/25/2025 at 12:46 p.m. the Director of Nursing (DON) stated her expectation was for the staff to hand sanitize before and after care, between residents, between glove changes, when moving from one resident room to another, before and after medication administration. The DON stated the blood glucose monitoring machine was to stay wet from 1 to 3 minutes. The DON stated the nurse should have gloves on while cleaning with wipes. Review of the facility's policy, Hand Hygiene, accessed May 2025 showed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Policy and Explanation and Compliance Guidelines showed: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table showed: Between resident contacts Before performing invasive procedures Before applying and after removing personal protective equipment (PPE), including gloves Before preparing or handling medication Before performing resident care procedures After handling items potentially contaminated with blood, body fluids, secretions, or excretions 6. Additional considerations: a. the use of gloves does not replace hand hygiene if you task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's policy, Administrating Medications, reviewed March 2023 showed 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Glucometer Disinfection, April 2025 showed the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Policy Explanation and Compliance Guidelines. 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use. 2. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant. 3. Glucometers will be cleaned and disinfected after each use and according to the disinfectant manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 4. Procedure: b. wash hands. E. put on gloves. i. using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer j. after cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to dry. L. perform hand hygiene.

Based on interviews and record review, the facility failed to ensure patient care equipment to include mechanical lifts were maintained in a safe operating condition for one resident (#142) of 65 sampled.Findings included: On 6/23/25 at 3:52 p.m., an interview was conducted with Resident #142. She was observed sitting up in bed, watching television. She stated she had an incident about a month and a half ago. Resident #142 said she fell from the Hoyer lift. She stated, The Hoyer locked, and the certified nursing assistant (CNA) didn't realize it. She said she went to hospital as a result of the fall as she was in a lot of pain. Resident #142 confirmed the Director of Nursing (DON) said the Hoyer needed to be removed, but it was not. She said the same Hoyer that was used during the incident was being used currently. She said the CNAs complained to her about that Hoyer lift. Resident #142 stated, It's happened where it's locked, they have to kick the wheel to align it. It [Hoyer lift] has jerked before, but this was a hard jerk. A review of Resident #142's admission record revealed an initial admission date of 3/18/24 and re-admission date of 5/24/25. Further review of the admission record revealed diagnoses to include unspecified fracture of left patella subsequent encounter for closed fracture with routine healing (onset date of 5/4/25), unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing (onset date 3/18/24), pain in left hip, other specified disorders of bone density and structure, multiple sites, quadriplegia, unspecified, periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, other fracture of lower end of right femur subsequent encounter for closed fracture with routine healing (onset date of 3/18/24), pain in unspecified knee, and chronic pain syndrome. A review of Resident #142's quarterly Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 5/20/25, revealed a Brief Interview for Mental Status (BIMS) of 15, which means cognitively intact. On 6/23/25 at 4:33 p.m., an interview was conducted with Staff M, Risk Manager (RM)/ Assistant Director of Nursing (ADON) and the Director of Nursing (DON) regarding Resident #142's fall on 4/28/25. Staff M, RM/ADON stated Resident #142 was, Assisted to the ground, she didn't fall. Staff M, RM/ADON said two CNAs had assisted Resident #142 using a Hoyer lift. She said one CNA was in the front while the other staff member was guiding the sling and pushing the lift. Staff M, RM/ADON said the Hoyer was hard to push, the resident shifted in the sling then slid, and both CNA's grabbed the resident underneath her arms while assisting her to the floor. The DON confirmed as part of the investigation, the staff completed a return demonstration. The DON said she was told by the staff the legs of the Hoyer were initially open when the CNA went to push the lift. She stated, They were pushing with the legs straight to put her in bed. The Hoyer was stuck, jerked, and she ended up repositioning. The DON said the Hoyer and sling was removed from the unit. The DON said the maintenance staff cleaned out debris from the wheels because they thought the wheel got stuck during the transfer. On 6/24/25 at 3:33 p.m., a phone interview was conducted with Staff P, CNA regarding the fall incident that occurred on 4/28/25 involving Resident #142. Staff P, CNA said she was at the bottom steering the lift and Staff O, CNA, was at the top. She said the lift was facing the sink initially and Staff O, CNAs back was towards the A bed. She said the feet of the lift were starting to go under Resident #142's bed with the legs closed. Staff P, CNA said when turning the Hoyer to the bed, it became stiff and hard to maneuver. She stated, I can't understand what happened. She said they couldn't prevent Resident #142 from falling, therefore, they held her under her arms to make her fall, Slower. She said the nurse and Staff M, RM/ADON came shortly after the incident where they demonstrated what happened. She said the lift was removed and she's not sure if it's currently in use. She stated she thinks the lift is the issue. She said, It worked fine putting her in the shower chair. She said she always tells the nurse to put the issue with the lift in the work order system. She stated, The CNAs biggest problem is the lift. During an interview on 6/24/25 at 4:26 p.m., Staff J, CNA said the Hoyer lifts don't frequently work. She said sometimes it's a battery issue, that they aren't charged, but sometimes the lifts are hard to push. On 6/24/25 at 4:39 p.m., an interview with Staff H, CNA was conducted. She stated, The lifts make the job very difficult, we have to search sometimes when we cannot find one, then they are hard to handle.On 6/24/25 at 4:42 p.m., an interview was conducted with Staff S, CNA. She said sometimes the legs of the Hoyer lift get stiff. She said she had to use a lot of strength to turn the lift. She stated, It's not good for us and the residents. On 6/25/25 at 8:55 a.m., an interview was conducted with Staff T, Maintenance Assistant. He said he checked the Hoyer lifts monthly. He said his inspection included checking the wheels to see if they are dirty, if the remote is functioning, if the batteries held a charge, and if the lift needed to be re-serviced. Staff T, Maintenance Assistant said they are not licensed to service the lifts. He said the maintenance staff would take the lift to inspect if there was something wrong, it would stay out of commission, and the vendor takes care of repairing the issue. He confirmed the last time the vendor came to inspect the lifts was January 10, 2025. He stated the results of the inspection revealed the vendor did not find any issues with the lifts. Staff T, Maintenance Assistant confirmed he inspected the lift that was used in the fall incident involving Resident #142. He stated he cleaned the wheels, and he recalled the wheels were dirty. He stated, There was a lot of stuff in it. The facility did not provide a policy on lift maintenance.

Based on record review and interviews, the facility failed to ensure one resident (#1) out of three residents sampled were assessed immediately by a nurse after being found on the floor by facility staff. Findings included: Review of an admission Record dated 5/6/2025 showed Resident #1 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to nontraumatic intracerebral, hemorrhage in hemisphere, subcortical, and flaccid hemiplegia affecting right dominant side. Review of a Nurse Progress note dated 4/22/2025, authored by Staff A, Registered Nurse (RN), showed The [Certified Nursing Assistant,] CNA found the resident lying in the resident restroom. The CNA stated that two CNA placed the resident on the toilet as resident requested and 5 min[utes] later they found the resident on the floor in the resident restroom. It was noted when the nurse entered the resident's room, she observed the CNA lifting the resident to bed. The nurse assessed Resident #1 for pain or injuries after the resident was placed in bed. During an interview on 5/6/2025 at 12:40 p.m., with Staff A, RN, Staff A, RN stated on the day Resident #1 fell she was in another room administering medication. When she was coming out of the room, someone told her Resident #1 was on the floor. When she went to the room, two CNAs were in the bathroom picking Resident #1 up from the floor and placed him in his wheelchair. Staff A, RN stated she assessed Resident #1 after the CNAs placed him back in his chair, she did an incident report, and notified the resident's daughter. Staff A, RN stated whenever a resident has a fall, the nurse is supposed to assess the resident before a CNA can move the resident. During an interview on 5/5/2025 at 1:30 p.m., with Staff B, CNA, Staff B, CNA stated she assisted Resident #1 to the bathroom on the day of his fall. Staff B, CNA stated her and the orientee placed Resident # 1 on the toilet and left him in the bathroom because he asked for privacy. She stated she left his room because she overheard another resident screaming in another room. When she got to the other room she had to assist the other resident on the toilet. She stated when she was headed back to Resident #1's room, a housekeeper told her Resident #1 was on the floor in the bathroom. Staff B, CNA stated her and the orientee assisted Resident #1 off the floor and placed him in his wheelchair. The nurse assessed him before they assisted him back to his bed. Staff B, CNA stated the nurse was standing in the room while they were picking the resident up off the floor. During an interview on 5/5/2025 at 1:27 p.m. with Staff C, License Practical Nurse/ Unit Manager (LPN UM), Staff C, LPN UM stated on 4/22/2025, Resident #1 wanted to use the bathroom and two CNA staff placed him on the toilet and gave him his call light. She stated Resident #1 had fallen off the toilet, but she was not present on the unit when he fell. Staff C, LPN UM stated the protocol is if the nurse is not present, the CNAs are supposed to notify the nurse, the nurse does her assessment on the resident, and they notify the doctor and the family. The CNAs are not allowed to move the patient and they must wait until the nurse assesses the resident. During an interview on 5/5/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated when a resident falls, the CNAs notify the nurse, the nurse conducts an assessment and completes an incident report, they notify the primary care provider and the family, and Emergency Services if needed depending on the situation. The DON stated CNAs are not allowed to move a resident after a fall until the nurse assesses the resident. Review of the facility in-service titled Reporting Falls dated 4/21/2025 showed under Objective, anytime a resident is observed on the floor, witnessed falling to the floor, or assisted to the floor by staff, it is a facility requirement that a Fall Protocol is followed. 1. While on the ground, assess resident for injuries; Range of Motion (ROM), pain, vitals with blood sugar, and skin. 4. Notify the unit manager/supervisor, or nurse leadership present in the building at the time of the incident and the risk manager.

Based on interview and record review, the facility failed to provide physician ordered medication for one resident (#1) out of three residents reviewed. Findings included: Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and discharged on 4/23/25. His medical diagnoses included nontraumatic intracerebral hemorrhage in hemisphere, subcortical and flaccid hemiplegia affecting the right dominant side. Review of Resident #1's hospital discharge medication list revealed Pregabalin 75 mg [milligrams] oral capsule three times a day. Next dose: 4/21/25 at 8:00 PM. Review of Resident #1's April 2025 physician orders revealed an order with a start date of 4/22/25 and an end date of 4/23/25 for Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. Review of Resident #1's April Medication Administration Record revealed in five out five medication administration opportunities, Resident #1 did not receive the ordered Pregabalin 75 milligrams three times a day from 4/21/25 through his discharge on [DATE]. All five medication administration opportunities were documented as 9. Review of the chart codes revealed 9=Other/See Nurse's Notes. Review of Resident #1's electronic medication administration record (eMAR)-Administration Note dated 4/22/25 at 6:43 AM revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. New admit [admission]. Awaiting script [prescription]. MD [Medical Doctor] made aware. Review of Resident #1's eMAR-Administration Note dated 4/22/25 at 1:35 PM written by Staff A, Agency Registered Nurse (RN) revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. I called the pharmacy and the customer services stated: They don't have script for lyrica. MD should be notified. Review of Resident #1's eMAR-Administration note dated 4/22/25 at 9:00 PM. revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. on order Review of Resident #1's eMAR-Administration note dated 4/22/25 at 5:08 AM revealed Pregabalin Oral Capsule 75 MG. Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. There was no documentation for this dose. Review of Resident #1's eMAR-Administration note dated 4/23/25 at 1:40 PM revealed Pregabalin Oral Capsule 75 MG. Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. medication [sic] not on hand med [medication] not available in ekit [emergency medication kit] pharm [pharmacy] called md [sic] notified. Review of the facility's emergency medication drug list revealed pregabalin 25 mg was available in the emergency drug kit. An interview was conducted on 5/5/25 at 1:00 PM with Staff A, Agency RN. She said Resident #1 was a new admission when she was assigned to him, within his first 24 hours. She said when resident's medications are not in the medication cart, she calls the pharmacy to see where the medication is. She said she called the pharmacy about Resident #1's missing pregabalin medication and the pharmacy said they did not have the prescription, but she does not remember if she called the physician to get a prescription. An interview was conducted on 5/5/25 at 1:22 PM with Staff C, Licensed Practical Nurse (LPN), Unit Manager. She said when there is a new admission the medications are put into the electronic record and sent to the pharmacy. Paper prescriptions for controlled medications are faxed to the pharmacy and the medications should be administered according to when the hospital recommends when the next dose is supposed to be given. If the pharmacy has not delivered the medications by the time it is due the medication should be pulled from the emergency drug kit and if the medication is not in the emergency drug kit, the physician should be notified and there should be documentation the physician was notified, and the pharmacy should be contacted. She said Resident #1 did not receive his pregabalin because a prescription was not sent to the pharmacy but the physician was notified about it on 4/23/25 per the documentation. An interview was conducted on 5/5/25 at 2:18 PM with the Director of Nursing (DON). She said for new admissions the nurses get the medication list from the hospital and it is transcribed into the electronic record and sent to the pharmacy electronically. If the medication is a controlled medication and the nurse has the paper prescription the paper prescription is faxed to the pharmacy. If the nurse does not have a paper prescription for a controlled medication the physician is notified and the physician will call the pharmacy and order the medication. The nurse should document the notification to the physician that a prescription was needed for a controlled medication. The DON confirmed pregabalin is a controlled medication and required a prescription. She said if medications are not onsite the nurses will see if the emergency drug kit has the medication. Any controlled medication the nurse would have to get a code from the pharmacy to pull the medication. If the medication is not in the emergency drug kit the physician should be notified and there should be documentation the physician was notified and any orders they may give. An interview was conducted on 5/5/25 at 3:11 PM with the DON. She said she spoke with the pharmacy and during the weekdays the medication cut off time to put in physician medication order is 12:00 AM. If the medication is ordered by 12:00 AM the pharmacy will try to get the medications delivered by 4:00 PM the next day. If it is not on the 4:00 PM delivery the medication should be on the 3:00 AM delivery. The DON said she called the pharmacy and they confirmed they did not get a prescription for the pregabalin, therefore, the medication was not delivered to the facility, and the nurses could not pull it out of the emergency drug kit because there was no prescription at the pharmacy. She said Resident #1 should have received his pregabalin medication and the nurses should have kept calling the physician until the medication was delivered. Review of the facility's Administering Medications policy, reviewed March 2023, revealed: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 2. The director of nursing [sic] services supervises and directs all personnel who administer medications and/or have related functions. . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choice and preferences, consistent with his or her care plan .

Based on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for five (#228, #145, #163, #25 and #60) of eight residents reviewed for PASRRs. Findings included: 1. Review of Resident #228's admission record revealed an admitted [DATE] with the following diagnoses: Generalized anxiety disorder, upon admitted d 12/23/24 Bipolar disorder diagnosis upon admitted d 12/23/24. Depression diagnosis upon admitted d 12/23/24. New diagnosis of brief psychotic disorder was added on 01/22/25. The review showed the level I PASRR was not updated, and a level II was not submitted for consideration. On 01/28/25 at 3:38 p.m., an interview was conducted with the Social Services Director (SSD). She stated the expectation was to review PASRRs upon admission, and update when the resident has a new diagnosis. The SSD stated she sent information to psych and during the IDT (Interdisciplinary team) meeting they determine if PASRRs should be updated. She stated they had reviewed resident #228 on 1/22/25. The SSD stated there was a timing issue. She said, The PASRR should have been reviewed and updated sooner. 50732 2. Review of the Admission Record showed Resident #145 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. Review of Resident #145's Level 1 PASRR screening revealed the date of the PASRR was 03/10/2022 and was the admission PASRR from another facility. The resident was admitted to the current facility in 2024 and the PASRR was not updated for the current admission. During an interview on 01/30/2025 at 9:08 a.m., the Social Services Director said she reviewed the PASRR when the resident was admitted . She was not aware that the PASRR for Resident #145 was not updated when the resident was admitted . 3. Review of the Admission Record showed Resident #163 was originally admitted to the facility on [DATE] with a subsequent admitted [DATE]. Admitting diagnoses included dementia with other behavioral disturbance, Alzheimer's disease, anxiety disorder, major depressive disorder recurrent, encephalopathy. Review of the PASRR dated 04/03/2024 for Resident #163, Section 1: PASRR Screen Decision-Making Part A. revealed the qualifying diagnoses of anxiety disorder and major depressive disorder were not marked. 37999 4. On 1/27/25 at 10:40 a.m., Resident #25 was observed in the hallway, propelling self in wheelchair. During the survey the resident was observed on the patio with other residents and had moved to another unit. Review of Resident #25's Admission Record revealed the [AGE] year old resident was admitted to the facility on [DATE] and recently readmitted on [DATE] following a short acute care stay. The record included diagnoses not limited to brief psychotic disorder, major depressive disorder recurrent moderate (MDD), uncomplicated sedative, hypnotic or anxiolytic abuse, unspecified single episode major depressive disorder, generalized anxiety disorder, unspecified post-traumatic stress disorder (PTSD), unspecified not intractable epilepsy without status epilepticus, and cognitive communications deficit. Review of Resident #25's Pre-Admission Screening and Resident Review (PASRR) dated 12/23/24, included the resident's mental illness diagnoses of anxiety disorder, depressive disorder, psychotic disorder, substance abuse, PTSD, and the related intellectual disorder (ID) condition of epilepsy. The screening showed the functional criteria was likely to continue indefinitely and resulted in substantial functional limitations in three or more major life activities: capacity for independent living, mobility, and self-care. The review of section II of the screening's decision-making revealed there was no indication the individual had or might have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage, did not have an issue with interpersonal functioning, concentration, persistence and/or pace, or adaptation to change in a continuing or intermittent basis. The screening did not reveal the resident had a recent history of more intensive psychiatric treatment than outpatient care or had experienced an episode of significant disruption to the normal living situation. The PASRR revealed the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. Review of Resident #25's Interdisciplinary Team (IDT) Psych meeting form showed Bolded diagnoses are Serious Mental Illness requiring PASRR II while nonbolded need PASRR I. The IDT psych form for Resident #25, dated 11/6/24, included the bolded diagnosis of PTSD. The plan was to change the indication of alprazolam and hydroxyzine to generalized anxiety disorder (GAD), for gradual dose reduction (GDR) decrease quetiapine to 25 milligrams (mg) every bedtime (qhs) and to increase trazodone to 100 mg qhs. Review of Resident #25's IDT Psych meeting form, dated 12/4/24 continued to include the bolded diagnosis of PTSD. The form instructed Bolded diagnoses are Serious Mental Illness requiring PASRR II while nonbolded need PASRR I. The IDT team received instructions to discontinue hydroxyzine for a GDR and to increase trazodone to 25 mg twice daily (BID) (and) 100 mg q hs. During an interview on 1/30/25 at 9:08 a.m., the Social Service Director (SSD) reviewed Resident #25's PASRR and IDT psych notes then stated the resident would be reviewed again. 5. On 1/27/25 at 1:54 p.m., Resident #60 was observed lying in bed, yelling, restless, and pulling at his shirt. The door to the resident's room was shut. Staff L, Certified Nursing Assistant (CNA) reported this was a behavior of the resident and the aide had already dressed the resident multiple times. The staff member reported not having enough time to go to the laundry to get a mechanical lift pad to get the resident out of bed. On 1/27/25 at 4:11 p.m. the resident continued to be yelling out from his room. Review of Resident #60's Admission Minimum Data Set (MDS) revealed the resident was admitted on [DATE]. The MDS revealed the resident did not require a Level II PASRR at the time of admission. The comprehensive assessment did not include any mental illnesses or intellectual disabilities, however did include the diagnosis of non-Alzheimer's dementia. Review of Resident #60's Quarterly MDS, dated [DATE], revealed the resident continued with the diagnosis of non-Alzheimer's dementia and depression other than bipolar. The MDS revealed the resident was receiving antipsychotic and antidepressant medication(s). Review of the IDT Psych form, dated 1/22/25, showed Resident #60 had the diagnoses of major depressive disorder (MDD), unspecified severity dementia with other behavioral disturbance, and brief psychotic disorder. The note showed on 12/18/24 the resident had a gradual dose reduction (GDR) to decrease quetiapine to 50 mg qhs (every bedtime) and increase Trazodone to 25 (mg) BID and 125 mg qhs. Review of Resident #60's PASRR dated 1/8/25, revealed mental illness diagnoses of depressive disorder, psychotic disorder, and unspecified mood disorder. The screening showed the resident had a primary diagnosis of dementia with validating documentation to support the diagnosis. The decision-making box revealed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis and serious mental illness, intellectual disability, or both. A Level II PASRR may only be terminated by the level II PASRR evaluator in accordance with 42 CFR 483.128(m)(2)(i) or 42 CFR 483.128(m)(2)(ii). The PASRR completion box showed the individual did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #60's psych Nurse Practitioner (PMHNPN) note, dated 7/24/24 the resident had a chief complaint of depression and dementia. The reason for the evaluation was for the psychiatric evaluation and treatment of depressed mood and disorganized and confused thinking. Review of Resident #60's psych Nurse Practitioner note, dated 12/26/24 showed the resident had a past psychiatric history of depression, dementia, and psychosis. The note revealed during the last visit the resident was combative and uncooperative with care for staff report and the resident was started on Depakote twice daily for mood, increased Trazodone to 25 mg twice daily (BID) and 125 mg every bedtime (QHS) and decreased quetiapine to 50 mg QHS. The practitioner revealed during the visit on 12/26/24 the resident had no worsening mood with the decrease of quetiapine and was cooperative and compliant with care. An interview was conducted on 1/30/25 at 9:08 a.m. with the Social Service Director (SSD). The SSD reported reviewing PASRR's when residents were admitted and reviewed new diagnoses twice a month at the psych meeting. The SSD stated the system would notify her if a Level II PASRR was to be done and should be done anytime there was an update. She confirmed Resident #60's diagnoses of depressive disorder, psychotic disorder, unspecified mood disorder, and a primary diagnosis of dementia. The SSD stated the resident did not need a Level II because the system did not tell them the resident needed one. Review of the policy, Pre-Admission Screening and Resident Review, revised March 2019, revealed the following: 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per of the Medicaid Pre- Admission Screening and Resident Review (PASARR) process. a. The facility reviews all new admission Level I PASARR screenings with input from psych services for all potential/ new admissions, regardless of payer source, to determine with the individual meets the criteria for a MD, ID, or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASSAR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in their facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified. F

Based on observation, record review, and interview, the facility failed to provide needed care and services for one resident (#200) of three residents reviewed with an immune deficiency syndrome, one resident (#170) of two residents reviewed for therapy services, and one resident (#60) of two residents reviewed for maintaining routine lab work. Findings included: 1. During an interview on 01/27/25 at 10:37 a.m., Resident #200 stated, the last time the doctor was at the facility, I had to beg the doctor to order blood work to see if my antiretroviral therapy medication was working for my [immune deficiency syndrome]. The facility completed my blood work, but I still have not heard any results yet. Review of the Admission Record showed Resident #200 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified cirrhosis of liver, severe protein-calorie malnutrition, immune deficiency syndrome, pancytopenia, acute kidney failure and candidal stomatitis. Review of the Medication Discharge Report showed Medications to continue taking that have changed: Start Taking: bictegravir/emtricitabine/tenofovir (Biktarvy 50 mg [milligrams]-200 mg-25 mg oral tablet) 1 tablet (s) by mouth once a day. Refills 0. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form showed Section C. Decision Making Capacity marked Resident #200 was capable to make his own healthcare decisions. Review of the Care Plan showed Resident #200 was at risk for decline in mental or physical condition related to diagnosis of [immune deficiency syndrome] and the disease process. The goal included Resident will remain free of avoidable complications [related to] r/t [immune deficiency syndrome] process, Cirrhosis of the Liver. The interventions included: - Administer medications as ordered; observe for effectiveness and for SEs - Provide diet as ordered. Offer alternatives as needed. Weights as ordered - Obtain labs as ordered; report results to physician - Provide emotional support as needed - Psych consult/treatment as ordered - Observe for new onset of sx/sx [sign and symptoms] of disease progression and for complications related to disease progression; update physician if noted. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Section C-Cognitive Patterns Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Review of active physician orders showed: - A physician order dated 04/25/24 showed Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. - A physician order dated 01/16/25 showed, Infectious disease consult for [immune deficiency syndrome] follow-up. - A physician order dated 06/11/24 showed, [Appointment] Appt December 11 at 1215 pm with Dr [name] MD at [address]. - A physician order dated 06/06/24 showed, [Name, Address and phone number of Community Health] on 07/02/24 at 1:30 p.m. - A physician order dated 06/06/24 showed, FL Health Department [address and phone number] on 06/11/24 at 8:00 a.m. Review of the completed physician orders showed: - A physician order dated 05/07/24 showed, [Cluster of Differentiation 4]CD4/[Cluster of Differentiation 8]CD8 Ratio (Lymphocyte Subset Panel 4) | HIV-1 DNA, Qualitative, PCR- one time only related to [immune deficiency syndrome]. - A physician order dated 01/17/25 showed, CD4/CD8 Ratio (Lymphocyte Subset Panel 4)- one time only related to [immune deficiency syndrome]. - A physician order dated 05/08/24 showed, Infectious Disease appointment with Florida Department of Health [address and phone number] every day and night for anti-viral meds for 1 day. - A physician order dated 05/10/24 showed, Infectious Disease [name of clinic} June 10 at 1:00 p.m. [address and phone number] one time only until 06/10/24. Review of the Lab Results Reports showed the following: - A review of the Lab Results Report showed the CD4/CD8 Ratio (Lymphocyte Subset Panel 4) results were collected on 05/08/24, received on 05/10/24 and reported on 05/13/24. The CD4 showed a L (low) result score of 7 with a reference range of 30-61. The Absolute CD4+ Cells showed a L (low) result score of 65 with reference range of [PHONE NUMBER]. The CD8 showed a H (high) result score of 80 with reference range of 12-42. The Absolute CD8 + Cells showed a score of 784 with reference range of [PHONE NUMBER]. - A review of the Lab Results Report showed the CD4/CD8 Ratio (Lymphocyte Subset Panel 4) results were collected on 01/17/25, received on 01/19/25 and reported on 01/21/25. The CD4 showed a L (low) result score of 13 with a reference range of 30-61. The Absolute CD4+ Cells showed a L (low) result score of 119 with reference range of [PHONE NUMBER]. The CD8 showed a H (high) result score of 64 with reference range of 12-42. The Absolute CD8 + Cells showed a score of 595 with reference range of [PHONE NUMBER]. During an interview on 01/29/25 at 12:22 p.m., the Director of Nursing (DON) stated she was the one who was responsible for everything including immunodeficiency medications and lab work to ensure the antireoviral therapy medication (ART) being administered was effective for residents with a immune deficiency syndrome. The DON stated Resident #200 was not being treated for an immune deficiency syndrome. The State Agency (SA) surveyor reviewed Resident # 200's physician orders and lab work with the DON who then stated, Oh I guess he is. The DON stated that she did not follow up timely lab work for residents with immune deficiency syndrome as the lab work was prescribed by the physician and when lab work was due the physician would order it. The DON stated, as lab work results are received by the facility the nurse would contact the physician if any lab results were flagged or abnormal. The DON stated that the nurse who would be responsible for Resident #200 lab work results was identified as Licensed Practical Nurse (LPN) Unit Manager East (UME). During an interview on 01/29/25 at 12:30 p.m., Staff B, Licensed Practical Nurse (LPN) Unit Manager East (UME) stated any flagged or abnormal labs would be called in by the nurse on duty and then I would be the nurse's second set of eyes to ensure the lab results were called and the physician was notified. Staff B LPN, UME stated she reviewed Resident #200's lab work physically on the computer on 01/22/24 however it appeared that the nurse had already spoken with the Nurse Practitioner on 01/20/24. During an interview on 01/29/25 at 12:41 p.m. Staff C, Nurse Practitioner (NP) stated she was notified of Resident #200's abnormal lab work by the nurse and was also notified that Resident #200 tested positive for detection of an immune deficiency syndrome. Staff C stated that the physician had ordered antireoviral therapy medication (ART) however Resident #200 had refused to take the medications all the time and refused consultations set up for him for Infectious Disease (ID) Consults. Staff C stated the physician had set up Infectious Disease (ID) before in the past and he refused to go. Staff C stated as far as the required lab work testing goes the general blood work testing for residents with immune deficiency syndrome labs should be every 6 months. Staff C stated, Once the lab results are received, the facility will notify myself or the physician of any irregularity and it is the responsibility of the physician if they want to order anything new. During an interview on 01/29/25 at 12:55 p.m., the DON stated Resident #200 had a long history of refusing his medications and going to the Infectious Disease Doctor (ID) at the local health department. The DON reiterated, We set things up for him and then he refuses to go. During an additional interview on 01/29/25 at 2:18 p.m., the DON stated Resident #200 will tell you he does not like to go sit at the Health Department. The DON stated that when Resident #200 first came to the facility there was no antireoviral therapy medication being administered to Resident #200. During an interview on 01/29/25 at 2:23 p.m., Resident #200 stated that he was in the process of being transferred to an assisted living facility soon. Resident #200 stated he would not have to beg for blood work to see if the antireoviral therapy medications were working there. Resident #200 stated, I do not refuse my medications or any appointments. A review of the Medication Administration Records (MAR) showed the following: May 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. Resident #200 received this medication daily per physician orders except for the dates of 05/15/24 and 05/16/24 documented with the number 1 (Medication Refused). June 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome] . Resident #200 received this medication daily per physician orders. No refusals noted. July 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. August 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [ immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. [DATE] MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. October 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. - November 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [ immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. December 2024 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [ immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. January 2025 MAR - Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [ immune deficiency syndrome]. Resident #200 received this medication daily per physician orders. No refusals noted. A review of the Treatment Administration Record (TAR) showed the following: May 2024 TAR - Infectious Disease appointment with Florida Department of Health on 05/10/24 at 8:00 a.m. [address and phone number] every day and night for anti-viral meds for 1 day. The TAR showed a y for yes revealing Resident #200 went to the appointment on 05/09/24 Night and on 05/10/24 Day shifts. June 2024 TAR - Infectious Disease [name of clinic} June 10 at 1:00 p.m. [address and phone number] one time only until 06/10/24. The TAR had a blank spot in the space for the date of 06/10/24. - FL Health Department [address and phone number] on 06/11/24 at 8:00 a.m. The TAR showed X in the space for the date of 06/11/24. July 2024 TAR - [Name, Address and phone number of Community Health] on 07/02/24 at 1:30 p.m. The TAR showed X in the space for the date of 07/02/24. August 2024 TAR - No appointments scheduled for the month of August 2024 September 2024 TAR - No appointments scheduled for the month of September 2024 October 2024 TAR - No appointments scheduled for the month of October 2024 November 2024 TAR - No appointments scheduled for the month of December 2024 December 2024 TAR - [Appointment] Appt December 11 at 1215 pm with [name of physician] MD at Florida [address]. The TAR showed X in the space for the date of 12/11/24. January 2025 TAR - Infectious disease consults for [immune deficiency syndrome] follow-up. The TAR showed no date or time for the follow-up with X in the space for all days in the Month of January 2025. In a further interview on 01/29/25 at 3:18 p.m., Resident #200 stated that the facility provided only one appointment when he was taken to the Health Department (HD). Resident #200 stated this appointment occurred when he was first admitted to the facility. Resident #200 stated he was in a lot of pain as he waited for over an hour at the HD and told the driver he was in pain and wanted to go back to the facility. Resident #200 stated the driver refused to take him back to the facility. Resident #200 stated after two more hours of waiting he made a big scene in the lobby and the driver finally drove him back to the facility missing the HD appointment. Resident #200 stated he was never re-scheduled for another outside appointment again because no one had ever discussed any appointments with him again until today. Resident #200 stated he figured after the HD episode when he first came in, he figured it was like a one and done thing, so the facility never scheduled him for an appointment again. Resident #200 stated he was approached by the DON today and was informed of his abnormal lab work results that showed his antireoviral therapy medication (ART) was not working as he figured it was not. Resident #200 stated he was off ART for about a year until he went into the hospital back in February 2024 or March of 2024. Resident #200 stated he had such a bad experience with the HD that he did not want to go back but would like to go to a local Community Health facility. Resident #200 stated he had made a new appointment with the local Community Health facility for 02/18/25 at 1:00 p.m. for his immune deficiency syndrome needs. Resident #200 stated that he should be in the assisted living facility by then and he will be sure to go to his self-scheduled appointment. During an interview on 01/29/25 at 3:36 p.m., the DON stated that she did not discuss any lab work with Resident #200 and would never tell him his medications were not working. The DON stated, I would never discuss lab work with a resident. The DON stated she spoke with Resident #200 today and asked him if he was ready to go back to the health department again. The DON stated Resident #200 responded don't push it. During an interview on 01/30/25 at 10:00 a.m., the DON stated if the MAR had an order documented on it but there was an X in all boxes that meant the order was not active for those days. The DON stated if the MAR had an order documented on it but there were holes for those days, that meant the staff forgot to document. The DON stated if a resident refused medications or treatment that refusal would be documented on the MAR or TAR by a number usually 1 meaning medication refused or in a progress note. During an interview on 01/30/25 at 10:31 a.m., the Social Services Director (SSD) stated the social services department was responsible for scheduling transportation for residents outside appointments. The SSD stated she would look to see if Resident #200 had any scheduled outside appointments in the last six months but stated, I don't think so. During an additional interview on 01/30/25 at 11:03 a.m., the SSD stated Resident #200 had no scheduled outside appointments in the last six months, so no transportation was needed to be scheduled. Review of Progress Notes showed the following: - A Behavior Note dated 5/10/2024 showed, Pt LOA to Health Department appt. for Biktarvy drug assistance. Calls received from this facility's staff escort stating resident refused appt and requested to be returned to facility. Added that resident became loud and aggressive and threw items on the floor. Writer spoke with resident via phone reminding resident of the purpose of appointment for ADAP and the importance of medication compliance per our previous educational conversation. Resident verbalized understanding of teaching but Health Department staff called shortly after stating resident could not be be seen due to refusal of appt. Psych ARNP made aware. - A Palliative Care Note dated 07/06/24 showed, Palliative care follow up visit for comfort measures and chronic disease symptom management of [immune deficiency syndrome], liver cirrhosis, debility and chronic pain. On 06/12/24 discussion with patient due to refusing [immune deficiency syndrome] medications and infectious disease appointments. Patient reports he would like to follow up with [Name of Community Health] and ensure he had his anxiety medications prior to appointment. Patient has capacity to make his own medical decisions. - A review of all progress notes for June 2024, July 2024 and December 2024 showed with no progress notes that revealed Resident #200 refused any medications or appointments. During an interview on 01/30/25 at 8:56 a.m., Resident #200's Attending Physician (AP) stated Resident #200 was a resident who had an immune deficiency syndrome, however, as his AP he follows this resident but does not monitor Resident #200's immune deficiency syndrome progress or antireoviral therapy medications (ART). Resident #200's AP stated Resident #200 should have an Infectious Disease (ID) doctor that would monitor and order Resident #200's ART and lab work as none of that was in his scope of practice as Resident #200's AP. Resident #200's AP stated that he had never ordered Resident #200's ART. Resident #200's AP did not know who Resident's Infectious Disease doctor (ID) was. Resident #200's AP stated that the lab work results came back abnormal, it was probably because Resident #200 refused his medications. Resident #200's AP stated according to the DON and nursing staff, Resident #200 refused to take his medications and refused to go to appointments all the time. The AP stated that in general all residents who have an immune deficiency syndrome should have blood work every three to six months. The AP stated Resident #200's lab work completed 8 months apart (one collected on 05/08/24 and the second collected on 01/17/25) could be because Resident #200 refused. Resident #200 AP stated if the lab work results showed abnormal then it would be up to Resident #200's Infectious Disease Doctor to make changes in his ART. An additional review of the physician order dated 04/25/24 showed Biktarvy Oral Tablet 50-200-25 MG (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate)- Give 1 tablet by mouth one time a day for [immune deficiency syndrome]. The medication was ordered by Resident #200's Attending Physician with an end date of indefinite. Review of Resident #200's Census Page showed no Infectious Disease Doctor (ID) identified. During an interview on 01/30/25 at 9:22 a.m., Staff B LPN, UME stated she did not believe Resident # 200 had an ID at this time, as he was just followed by the Attending Physician. During an interview on 01/30/25 at 9:28 a.m., the DON stated that Resident #200 was not established with an ID because he would not go to the Health Department. The DON stated the facility did not have an ID who came to the facility. The DON stated, she did think Resident #200 was established with an ID in the community. The DON stated, I think he has an appointment with them, but he will not tell me who it is. During an interview on 01/29/25 at 1:38 p.m., the DON stated, We have no policy on immune deficiency syndrome Management. During an interview on 01/30/25 at 3:00 p.m., the DON stated We have no policy on Quality of Care. Review of the facility's policy Resident Rights revised date February 2021 showed 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: h. be supported by the facility in exercising his or her rights; i. exercise his or her rights as a resident without interference, coercion, discrimination or reprisal from the facility; o. be notified of his or her medical condition and of any changes in his or her medical condition; s. choose an attending physician and participate in decision-making regarding his or her care. Review of the facility's policy Administering Medications/Physician Orders revised date April 2019 showed, Policy and Implementation 18. If medication is withheld, refused or administered outside the scheduled time, the person giving the medication must document this in the medical record. Review of the facility's [NAME] of Rights showed, Residents of nursing homes shall not be deprived of any rights, benefits or privilege's guaranteed by law and the Florida and United States Constitutions. You, as a long-term care resident, have the right to: Receive adequate and appropriate health care; choose your own physician and pharmacy; be informed of your medical condition and treatment including the right to make an informed decision to refuse treatment. Review of the facility's Residents' Rights 101 showed: Right to Self-Determination - Choice of activities, schedules, health care and providers, including attending physician. - Request, refuse and/or discontinue treatment. Right to be fully informed of: -The type of care to be provided, and risks and benefits of proposed treatments -Changes to the plan of care, or in medical or health status -Rules and Regulations, including the long-term care ombudsman program and the state survey agency 2. On 1/27/25 at 10:40 a.m., an observation of Resident #170 revealed she was sitting up in bed, watching television, with a blanket over her legs up to her waist, and glasses on her lap. An interview with the resident revealed she had resided at the facility for approximately seven months. When asked about nutrition/dietary concerns, she stated she has restrictions related to food but did not feel she needed those restrictions anymore. She denied issues with chewing/swallowing. A plastic box with dentures was observed on the bedside table, to the left of Resident #170. She stated she had no issues with the dentures. On 1/28/25 at 12:20 p.m., an observation of Resident #170 revealed she was sitting up in bed, with the bedside table in front of her, and a meal tray on top. An observation of the plate revealed the resident consumed approximately 75% of the meal. With Resident #170's permission, a review of the lunch meal ticket revealed a mechanical soft diet. She stated she was previously working with speech therapy, and that was why she had an order for a mechanical diet. Resident #170 stated she did need a mechanical diet anymore and would like a regular diet. She stated she had discussed with staff about wanting to upgrade the diet to regular. Resident #170 stated there had been no follow-up since she mentioned it. Photographic Evidence Obtained. A review of Resident #170's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. The Admission Record revealed diagnoses to include: cerebral infarction, unspecified, mild protein-calorie malnutrition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, dysphagia, oropharyngeal phase, and cognitive communication deficit. A review of Resident #170's Quarterly Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 12/3/24, revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. A review of Resident 170's Active Orders revealed the following under Dietary, Regular diet Mechanical Soft texture, Thin consistency, Magic Cup with lunch/dinner. May substitute mighty shake PRN [as needed], with a start date 9/30/24 and revision on 1/27/25. A review of Resident #170's progress notes revealed a nutrition note, dated 12/7/24, to include the following, . Diet Orders: Regular Diet-Mech Soft-Thin Liquids, Magic Cup BID [twice a day] with lunch/dinner, Snacks as offered . Resident remains on a regular diet, appropriate r/t [related to] medical condition. Dx [diagnoses] dysphagia, edentulous, does not wear her dentures (has upper dentures), requires mech soft textures, tolerating well. Independent diner w/ [with] set up/assist prn. Resident is at risk for altered nutrition/hydration/malnutrition and unavoidable weight fluctuation/loss r/t Dx/Hx [history] of CVA [cerebrovascular accident], R [right] Hemiparesis, . Dementia, Depression, Cognitive-Communication Deficit, Aphasia, Dysphagia, Altered Consistencies, . Edentulism, Altered Consistencies, Anxiety, . Self-Feeding Difficulties at times, Decreased PO [by mouth] on occasion. Further review of Resident #170's progress notes revealed a palliative care note, dated 1/6/25, to include the following . Patient is seen in room laying in bed watching television . Alert and oriented x 4. Patient also reports loss of appetite because her diet has not advanced from mechanical soft texture. She is hoping to speak with dietary about this. Assessment and Plan: Recommend discontinuing multivitamin tablet once patient addresses diet with Dietary and appetite improves. Patient agreeable to discontinue multivitamin once oral intake improves to reduce pill burden . A review of Resident #170's evaluations revealed a note titled, LCSV [unknown abbreviation] IDT [interdisciplinary team] Referral to Therapy, dated 12/11/24, which included the following documentation, . Therapy Referral . Date of referral: 12/11/24 . IDT Evaluation: . Resident and family requesting diet upgrade . referred to therapy . Therapy response . SLP [Speech Language Pathology] Evaluation & Treatment . Response to Referral Completed by: . DOR [Director of Rehab] Date of Response: 12/11/24. A review of Resident #170's speech therapy notes revealed certification periods of 8/31/24 - 9/29/24, and 9/30/24 - 10/29/24. A review of the speech therapy discharge summary, dated 10/19/24, revealed the following documentation, Baseline (8/1/2024) mod cues to use css [communication severity scales] and aspiration precaution mech soft/nectar . Previous (10/7/2024) Mechanical soft solid, thin liquids diet-Mild . Discharge (10/16/2024) Mechanical soft solid, thin liquid diet-Mild . Further review of the speech therapy discharge summary revealed the following documentation, D/C [discharge] destination: Long term care setting, D/C reason: Exhausted benefits, patient/RSP [unknown abbreviation] declines treatment . Diet/Liquids Diet Recs - Solids = Mechanical Soft textures Diet Recs - Liquids = Thing liquids . On 1/29/25 at 11:20 a.m., an interview was conducted with Staff D, Registered Dietitian (RD) who stated Resident #170's current diet order is, Regular mechanical soft, thin liquids. She stated the original order date was on 9/30/24, with a revision on 1/27/25. Staff D, RD stated if she received a consult for diet advancement she would refer to speech therapy. On 1/29/25 at 12:15 p.m., an interview was conducted with Staff E, SLP. She stated she's been working at the facility for three months. A review of the speech therapy evaluations was conducted with Staff E, SLP. She stated Resident #170 had an evaluation, dated 8/1/2024, which revealed severely impaired swallowing, eating unsafe amounts and decreased safety awareness. As a result of the evaluation, the previous SLP recommended the following diet for Resident #170, Mechanical soft and nectar thick liquid diet, with goals to advance that diet. Staff E, SLP stated Resident #170's last speech evaluation was 8/1/24, and she was last screened on 8/14/24. She stated Resident #170, Will be coming up on her quarterly evaluation soon. Staff E, SLP stated there are no recent orders for speech therapy. She stated she could not confirm what happened with the referral on 12/11/24. Staff E, SLP stated the DOR receives the referral and puts the evaluation on their calendar. On 1/29/25 at 12:35 p.m., an interview with the DOR revealed the last time Resident #170 was on the speech therapy caseload was on 10/16/24. She stated she is not sure what happened with the therapy referral dated 12/11/24. The DOR confirmed she marked on the referral for speech therapy to evaluate Resident #170. She stated the resident will be screened today by Staff E, SLP. The facility confirmed they do not have a policy related to coordinating care with therapy, to include referrals to therapy. 3. On 1/27/25 at 1:54 p.m. Resident #60 was heard yelling out and pulling at his shirt appearing to be trying to remove it. Staff L, Certified Nursing Assistant (CNA) stated this (trying to remove clothing) was a behavior and had already dressed the resident multiple times. Review of Resident #60's Admission Minimum Data Set, dated dated dated [DATE] revealed the resident had been admitted on [DATE]. Review of Resident #60's Psychiatry note, dated 12/26/24 revealed the resident was started on Depakote 250 milligrams (mg) twice daily for mood. Review of Resident #60's Order Summary, active as of 1/30/25, included diagnoses of hypokalemia, unspecified anemia, unspecified protein-calorie malnutrition, unspecified chronic kidney disease, unspecified hypothyroidism, Type 2 Diabetes mellitus with other specified complication, dementia and other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, moderate recurrent major depressive disorder, and unspecified severity vascular dementia with agitation. The summary revealed the following orders: - Levothyroxine Sodium 50 microgram (mcg) - Give 50 mcg by mouth in the morning for thyroid. - Simvastatin 20 mg- Give 1 tablet by mouth at bedtime for hyperlipidemia. - Valproic Acid Oral Solution 250 mg/5 milliliter (mL) - Give 10 ml by mouth at bedtime for mood. - Valproic Acid Oral Solution 250 mg/5 mL - Give 5 mL by mouth one time a day for mood. - Complete Blood Count (CBC) with auto differential/Basic Metabolic Panel with estimated glomerular filtration rate (eGFR)/Lipid panel with Calculation of Low-Density Lipoprotein Cholesterol (Calc LDL)/Hemoglobin A1c/ Thyroid-Stimulating Hormone (TSH)/Valproic Acid (Depakote) **Scheduled 1/10/25; Auto-Send 1/10/25 12:00 a.m.** one time only related to hypothyroidism unspecified, chronic kidney disease unspecified, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypokalemia, anemia unspecified, type 2 diabetes mellitus with other specified complication. The order was ordered on 1/9 and started on 1/10/25. - Valproic Acid (Depakote) **Sent to lab 1/23/25 12:04 a.m. one time only related to chronic kidney disease unspecified. This order was obtained on 1/22 and was to start on 1/23/25 with no end date. Review of Resident #60's progress notes dated 1/9/25, showed routine lab orders received from the Advanced Practitioner Registered Nurse (APRN). New orders received and noted. Review of Resident #60's electronic results tab revealed no results for the testing ordered to be completed on 1/10/25. An interview was conducted on 1/30/25 at 3:42 p.m. with the Director of Nursing (DON). The DON provided the Lab log dated 1/10/25 which showed the bloodwork had been refused. The DON stated the lab

Based on observations, record reviews, and interviews, the facility failed to screen one (#123) resident for orthotic use and failed to apply orthotics for two (#14 and #31) of 23 residents. Findings included: 1. On 1/27/25 at 10:22 a.m., Resident #123 was observed lying in bed with the head of the bed raised. The observation showed a left-hand brace/splint lying on the bedside dresser out of reach of the resident. The resident reported previously wearing the orthotic device when on therapy. The resident stated nobody puts it on now, don't have anyone to put it on me, and reported his niece put it on him last Thursday. On 1/28/25 at 8:55 a.m., Resident #123 was observed lying in bed with orthotic on bedside dresser. Review of Resident #123's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, unspecified rheumatoid arthritis, and unspecified site unspecified osteoarthritis. Review of Resident #123's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. The functional ability assessment of the resident revealed a range of motion impairment of one upper extremity and bilateral lower extremities. Review of Resident #123's Certified Nursing Assistant (CNA) [Brand name for a desktop file system] did not reveal staff were to apply the observed left hand orthotic. Review of Resident #123's Physical/Occupational Therapy Screening form, effective 9/27/23 at 12:57 p.m., revealed there was no change in condition, would not benefit from skilled services at that time, and the resident was performing at prior level. Review of Resident #123's Range of Motion: Functional Limitation Screen, effective 9/27/23 at 12:51 p.m., revealed the resident had moderate limitation in range of motion (ROM) of the left shoulder and slight ROM limitation in the left wrist. The comment revealed the resident operated at prior level of function since discharge (d/c) from caseload. Review of Resident #123's care plan did not reveal the observed orthotic was to be applied to the resident left upper extremity. An interview was conducted on 1/29/25 at 11:15 a.m. with Staff F, Licensed Practical Nurse (LPN). The staff member stated therapy put Resident #123's orthotic on, don't quote me on that. Staff F stated the resident did not wear it daily but believed therapy had worked with the resident at one point of time. An interview was conducted on 1/29/25 at 1:52 p.m. with the Director of Rehabilitation (DoR). The DoR reported the resident did not have a contracture, had trialed a splint but did not require it anymore. The staff member stated therapy had received a referral today at 11:54 p.m. The DoR stated the resident felt the need for the splint. She said therapy waited for a referral or a quarterly screen, screened 9/27/23 and not sure why the resident had not had a quarterly screen since April. 2. On 1/27/25 at 2:07 p.m. Resident #14 was observed lying in bed, with bilateral hands with contractures and was not wearing orthotic devices. On 1/29/25 at 11:39 a.m. Resident #14 was observed wearing a right-hand palm protector. Staff N, Certified Nursing Assistant (CNA) observed and stated the resident had been a resident at the facility for a long time and the staff member did not normally work this hall. Staff N attempted to open the left hand that did not have a palm guard. On 1/30/25 at 7:57 a.m. Resident #14 was observed with Staff O, Registered Nurse (RN). The staff member confirmed the resident was not wearing either bilateral elbow braces or a left- hand palm guard. Review of Resident #14's Admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, functional quadriplegia, right and left foot contractures, and right ankle contracture. Review of Resident #14's Order Summary Report revealed the following orders: - Patient (Pt) to wear bilateral elbow orthotics for up to 2 hours (hrs) daily to reduce skin breakdown in between elbow crease. Order date: 4/22/2024 Review of Resident #14's care plan revealed the following focuses and interventions: - Potential for alteration in comfort-pain related to (r/t) decreased mobility and limited movement of multiple joints. The interventions included instructed nursing to use pillows to support in position of comfort for the resident. - (Resident) has a potential for complication r/t contractures of bilateral hands and bilateral elbows - bilateral palm guards and bilateral elbow splints. The interventions instructed CNAs and nursing to Apply/remove splint/brace for joint protection as ordered. - (Resident) has contractures to upper extremities and bilateral foot drop r/t an old Cerebral vascular Accident (CVA). The interventions included: (Resident) has a left elbow extension, may wear this up to 6 hours daily as tolerated. Remove for hygiene and check skin integrity. an B palm guards, B elbow splints. Patient to wear left hand roll splint and left elbow extension splint up to 6 hours daily. Review of Resident #14's CNA [Brand name for a desktop file system] revealed the resident to wear bilateral palm guards on right (R) and left (L) hand to reduce skin breakdown at all times except when bathing. Check skin integrity. Review of Resident #14's Treatment Administration Record (TAR) revealed the order to wear bilateral palm guards on R and L hands at all times was ordered 6/12/24 and discontinued 1/22/25. The administration line for this order had X's for all days of January and did not reveal if nursing staff had applied the palm guards prior to discontinuation. Review of the Splint Audit Form revealed Resident #14 was to have bilateral palm guards At all times except when bathing and bilateral elbow splints up to 2 hours. The audit forms received revealed the following: - Wednesday 1/22: did not reveal the bilateral pal guards or bilateral elbow splints had been applied. - Thursday 1/23: revealed the bilateral palm guards had been applied, and bilateral elbow splints had been applied. The form did not reveal a time the splints had been applied or when they had been removed. - Friday 1/24: revealed the bilateral palm guards had been applied, and bilateral elbow splints had been applied. The form did not reveal a time the splints had been applied or when they had been removed. - Monday 1/27: revealed bilateral palm guards had been applied. The form did not show the resident's bilateral elbow splints had been applied. - Tuesday 1/28: revealed bilateral palm guards had been applied. The form did not show the resident's bilateral elbow splints had been applied. The audit did not reveal a time the bilateral elbow splints had been applied or taken off. The request for CNA documentation for the task of bilateral palm guards was not provided. The facility provided a Task List Report which instructed nursing that Pt was to wear bilateral palm guards on R and L had to reduce skin breakdown at all times except when bathing. The task was initiated on 6/12/24 and did not show a resolved/canceled date. The task report did not reveal if nursing had applied Resident #14's bilateral elbow splints or palm guards on Saturdays or Sundays when Staff P was not working. An interview was conducted on 1/29/25 at 2:03 p.m. with the Director of Rehabilitation (DoR). The DoR stated Resident #14 wears bilateral elbow splints and bilateral palm guards which the Rehab tech put on. The DoR reported the left palm guard was missing, and the CNA yesterday had informed her of throwing it away because it was soiled. The DoR reported the palm guards are washable. An interview was conducted on 1/29/25 at 5:18 p.m. with the DoR and Staff P, Rehab Tech. The DoR stated the facility was working on the process on who applied the splints on the weekends. Staff P reported she worked Monday through Friday. The DoR stated the process was for the CNAs to apply them on the weekends and sometimes they still do. 3. On 1/27/25 at 10:15 a.m., Resident #31 was observed asleep in bed, wearing a right elbow orthotic and another brace/splint was observed lying on bedside dresser. On 1/28/25 at 8:53 a.m. Resident #31 was observed lying in bed with orthotic sitting on top of bedside dresser. On 1/29/25 at 11:10 a.m. Resident #31 was observed lying in bed with orthotic on bedside dresser. On 1/29/25 at 11:28 am. Resident #31 was observed not wearing brace/splint on right hand and orthotic (previously seen on dresser) was not observed on dresser. An observation of Resident #31 was conducted on 1/29/25 at 11:30 a.m. with Staff Q, Certified Nursing Assistant (CNA). Staff Q reported not normally working this hallway. On 1/29/25 at 11:37 a.m. Staff Q removed brace/splint from a drawer of the bedside dresser. Staff Q stated she would put the brace on the resident when she got to the resident if it [Brand name for a desktop file system] told her to. On 1/30/25 at 8:04 a.m. Resident #31 was observed lying in bed and was not wearing right-hand orthotic and the device was not observed on bedside dresser. Review of Resident #31's Admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other seizures, and type 2 diabetes mellitus with hyperglycemia. Review of Resident #31's Order Summary Report included an order active as of 7/18/24, Occupational Therapy (OT) skilled intervention: Continue with OT treatment (tx) 5 times(x)/week for 30 days for tx codes M24.541, M24.521,(and) R29.3. TX may include therapeutic exercise (there ex), there activities (act), self care, NRME, orthotic management/training (mgmt), manual there, (and) wheelchair (wc) mgmt. Review of Resident #31's CNA [Brand name for a desktop file system] instructed: - Maintenance Program - Splint/Brace program: Patient (Pt) to wear right (R) elbow orthotic for up to 4 hours daily or as tolerated. Check skin integrity. - Maintenance Program - Splint/Brace program: Pt to wear R resting skin splint for up to 4 hours daily or as tolerated. Check skin integrity. Review of the Resident #31's Splint Audit Form revealed Staff P had documented the following: - Wednesday 1/22/25 R elbow splint, scheduled for 4 hours was applied without a time on and did not reveal a time the splint was removed. - Wednesday 1/22/25 R hand splint, scheduled for 4 hours was not applied. - Thursday 1/23/25 R elbow splint and R hand splint scheduled for 4 hours had been applied however the audit did not reveal when the splints had been applied or when they were removed, did not document if resident was able to tolerate up to 4 hours. - Friday 1/24/25 R elbow splint and R hand splint scheduled for 4 hours had been applied however the audit did not reveal when the splints had been applied or when they were removed, did not document if resident was able to tolerate up to 4 hours. - No audit for Saturday 1/25 or Sunday 1/26/25 was provided. - Monday 1/27/25 R elbow splint, scheduled for 4 hours was applied without time on and did not reveal the time splint was removed. - Monday 1/27/25 R hand splint, scheduled for 4 hours was not applied. - Tuesday 1/28/25 R elbow splint, Staff P documented nurse will remove. The audit did not reveal a time the splint was applied or taken off. - Tuesday 1/28/25 R hand splint, scheduled for 4 hours was not applied. Review of Resident #31's CNA daily task revealed staff were to document q (every) shift the Maintenance Program - Splint/Brace program: Patient (Pt) to wear right (R) elbow orthotic for up to 4 hours daily or as tolerated. Check skin integrity and the Maintenance Program - Splint/Brace program: Pt to wear R resting skin splint for up to 4 hours daily or as tolerated. Check skin integrity. The documentation showed CNA's were documenting once per day, did not document the time splints/braces were applied or taken off. The CNAs documented the splint/brace program at approximately the same time documentation was completed for the resident's ability for oral hygiene, to position from lying to sitting on side of bed and of bathe/shower evening shift Tuesday and Friday, shower every Tuesday and Friday 3-11 (p.m.) shift (which CNA's were instructed to chart as completed every day every shift). The CNAs did not document the time of splint/brace application or removal and did not document the application of the right-hand splint on 1/22/25. An interview was conducted on 1/29/25 at 1:57 p.m. with the Director of Rehabilitation (DoR). The DoR stated Resident #31 did wear an elbow and hand splint, and the rehab department was working on a process, the rehab tech puts on splints daily for all residents. She stated the facility had started the process for the rehab tech a week or two ago. The DoR stated the tech took them off at 4 hours that way they are put on and off at the right times and did not have a scheduled time braces were put on, the tech documented on paper, had issue with (computer) access but was fixed yesterday. Review of the policy - Range of Motion, undated, showed The purpose of this procedure is to exercise the resident's joints and muscles. 1. Verify that there is a physician's order for this procedure. If there is no order for treatment, contact attending physician to obtain treatment orders. (Note: Document the receipt of telephone orders in the resident's medical record.) 2. Review the resident's care plan to assess for any special needs of the resident. The policy instructed staff to Report other information in accordance with facility policy and professional standards of practice. Review of the policy - Specialized Rehabilitative Services, revised December 2009, showed Our facility will provide rehabilitative services to residents as indicated by the Minimum Data Set (MDS). 1. In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel. 2. Specialized rehabilitative services include the following: a. Physical therapy; b. Speech pathology/audiology; c. Occupational/activity therapy; 3. Therapeutic services are provided only upon written order of the resident's attending physician. 4. Only licensed or certified personnel who are registered to provide specialized therapy or rehabilitative services will be permitted to perform such services. 5. Once a resident has met his/ her care goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or certified nurses' aides will implement to ensure that the resident maintains his/ her functional and physical status.

Based on observations, interviews and record review, the facility failed to ensure the medication error rate was less than five percent. Twenty-nine medication administration opportunities were observed, and four errors were identified for two residents (#135 and #220) out of five residents observed. These errors constituted a 13.79% medication error rate. Findings included: 1. On 01/29/25 at 9:15 a.m., an observation was made of Staff G, Licensed Practical Nurse, (LPN). Staff G dispensed the following medication for Resident #135: - Calcium Carbonate 750 milligram (mg) chew tablet Upon entering the resident room, Resident #135 was alert. Staff G administered the medication, performed hand hygiene, and exited the room. Review of Resident #135's Active orders revealed the following order related to the observed administration of medications: - Calcium Carbonate Oral Tablet 600 mg (Calcium Carbonate) Give 1 tablet by mouth one time a day for supplement On 01/30/25 10:50 a.m., an interview with the Director of Nursing (DON) was conducted. She stated during medication administration, nurses utilized the Medication Administration Record (MAR) to compare and made sure medications being pulled and given matched what the order was on the MAR. It would not be appropriate to sign off on medications showing that they were administered when they were not given. 2. An observation was conducted on 1/28/25 at 9:37 a.m. of medication administration with Staff F, LPN. Staff F was observed preparing the following medications for Resident #220: -Fluoxetine 60 mg x 1 tablet -Fluoxetine 10 mg x 1 tablet -Bupropion HCL SR 150 mg x 1 tablet -Amlodipine 10 mg x 1 tablet -Docusate Sodium 100 mg x 1 tablet -Loratadine 10 mg x 1 tablet -Fluticasone Propionate and Salmeterol 250 mcg/50 mcg x 1 puff. -Flonase 2 sprays each nostril Review of Resident #220's MAR showed Staff F, LPN also signed off Metoprolol 50 mg, Omeprazole 20 mg, and Metformin HCL 100 mg as given during medication administration, however, those medications were not observed. Review of Resident #220's physician orders showed Fluoxetine 60 mg x 1 tablet, Fluoxetine 10 mg x 1 tablet, Bupropion HCL SR 150 mg x 1 tablet, Amlodipine 10 mg x 1 tablet, Docusate Sodium 100 mg x 1 tablet, Loratadine 10 mg x 1 tablet, Fluticasone Propionate and Salmeterol 250 mcg/50 mcg x 1 puff, Flonase 2 sprays each nostril, Metoprolol 50 mg x 1 tablet, Omeprazole DR 20 mg x 1 tablet, and Metformin HCL 1000 mg x 1 tablet were all scheduled to be given at 9:00 a.m. An interview was conducted on 1/28/25 at 12:25 p.m. with Staff F, LPN. She reviewed Resident #220's medication orders and said the Metoprolol, Omeprazole, and Metformin were the last three medications listed, and they showed up on a different screen. Staff F said I didn't go over and click on the next screen and I didn't do that. Oh no. Staff F said she went back later and gave those three medications. When told the times would be verified on the Medication Admin Audit Report, Staff F then said oh they may show up at the same time. I clicked on them and just didn't give them. I went back and gave them. When asked to clarify what she said previously about not going to the last screen and not seeing those three medications during the medication administration that was observed, Staff F said, Oh I don't know. Review of Resident #220's Medication Admin Audit Report for 1/28/25 showed all the medications listed above, including the three that were not administered were signed off as given at 10:06 a.m. on 1/28/25 during the observed medication administration. Review of a facility policy titled Administering Medications, revised April 2019, showed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including and required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. 6. Medications can be administered within one (1) hour before or after their prescribed time, unless otherwise specified. 10. The individual administer the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 18. If a medication is withheld, refused, or administered outside the scheduled time, the person giving the medication must document this in the medical record. 51097

Based on interviews and record review, the facility failed to obtain consent prior to utilizing funds for one resident (#46) of two reviewed. Findings included: During a telephone interview on 01/27/25 at 2:05 p.m., Resident #46's Responsible Party (RP) and POA (Power of Attorney) stated he was upset. He said, The facility owed her [Resident #46] $3000. They bought her a new chair without consent. The RP stated the resident was incapacitated and she did not move, she was in bed 24 hours a day, 7 days a week and does not utilize the new chair. He stated, the facility had to spend her money, for whatever reason and thought they could decide on their own. The RP stated he was the designated RP. He stated the facility did not ask if they could purchase the chair. The RP stated he wanted the facility to reimburse the account because that was not a wise use of Resident #46's money, as she was recently enrolled in hospice. The POA said, I did not authorize the purchase. He stated he had spoken with the Business Office Manager (BOM). Review of the admission record confirmed the resident had a designated resident - representative, for medical decisions, care conference person, emergency contact #1, Health care proxy and the responsible party. Review of a notarized Florida Durable Power of Attorney form dated 8/19/24 showed Resident #46 had a designated POA. Review of the admission record revealed Resident #46 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses to include seizures, unspecified dementia, and unspecified sequelae cerebrovascular disease. Review of a quarterly Minimum Data Set (MDS) dated [DATE] showed in section C1000 the resident was severely impaired and never/rarely makes decisions. Review of a grievance filed on 01/24/25 showed- concern: Questions about RMFS -Resident Fund Management System Under Resolution the form showed Business office showed/Therapy. Action take not resolve: Therapy discussed chair usage (spend down). Review of a document titled, Withdrawal Record - Name of facility, dated 12/23/24 showed, credit petty cash account $2,924 for medical equipment. The unsigned document was created by the BOM. Review of a document titled, Quotation dated 12/12/24 showed description of item, [brand name of chair] 20'' tilt/recline with full Trendelenburg. On 01/29/25 at 1:18 p.m., an interview was conducted with the BOM and the Director of Rehabilitation (DOR). The BOM stated she had received a grievance that the POA was concerned about the purchase of a chair that was purchased on 12/24/24 because of a Medicaid spend down. She stated the chair was worth approximately $3000. The BOM stated the facility was her payee at the time. The BOM stated she had spoken to the DOR to see if there was something Resident #46 could use therapeutically that could help the resident. The DOR said they did an Occupational Therapy (OT) evaluation. She said Resident #46 was dependent and was usually in bed, all the time. The chair was purchased on 12/12/24, she was assessed for positioning. The DOR stated they had the resident on case load previously for contraction management and caregiver training. She stated resident was not trialed for the new purchase because she was bed-bound before that and had not been in a chair. The BOM said, The goal was to spend down the money. During this interview, the BOM and DOR confirmed they did not try to contact Resident #46's family or POA regarding the purchase of a $3000 chair for the resident who could not consent. On 01/29/25 at 2:35 p.m., an observation and interview was attempted with Resident #46. The resident did not speak. An immediate interview was conducted with Resident #46's roommate who was alert and oriented. She stated prior to the chair purchase, Resident #46 never got out of bed, but sometime mid-December they got her a chair. She confirmed her roommate could not speak for herself and that the staff got her out of bed every now and then. On 01/29/25 at 03:26 p.m., an interview was conducted with Resident #46's Occupational Therapist. She stated she had conducted an assessment on 12/12/24 to assess sitting position and determined the resident needed a chair. She stated they trialed it at least 3 times. She stated she did not notify the POA/family because, it was my understanding the BOM was going to do so. Resident #46's OT stated they did not notify the family of the change in care plan. The OT stated they should have consulted with the family. She said, We felt we were doing the right thing. During an interview on 01/29/25 at 4:19 p.m., the Director of Nursing (DON) stated she did not know Resident #46 was no longer on therapy case load. The DON could not confirm how often Resident #46 had been up in the chair and who was assisting her. She stated she thought caregiver training was still on-going. The DON stated she could not speak of the consent as she was not directly involved. On 01/30/25 at 3:36 p.m., the Nursing Home Administrator (NHA) stated Resident #46's POA had reached out. He was uncomfortable with how the money was spent. The NHA stated to his knowledge the resident had used the [brand name of chair], and his plan was to follow up with the POA and discuss how they were going to handle the issue going forward. Review of a facility policy titled, Management of Resident' Personal Funds, dated March 2021, showed under policy implementation - #5. The resident is informed in advance of any charges imposed to his or her personal funds.

41015 48441 39866 Based on observations, interviews, and record review, the facility failed to prevent accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of a 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. the facility's fire alarm was triggered when Resident #102, while smoking in her room unsupervised, caused her mattress, privacy curtain, and oxygen concentrator to catch on fire. Staff extinguished the fire, the fire department and emergency medical services (EMS) were called, and residents on the same hallway as Resident #102 were evacuated. Resident #102 sustained a 1st degree burn to her left forearm and shortness of breath due to smoke inhalation. On 10/21/23 Resident #102 was transferred to the hospital for evaluation and treatment. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their person, were seen lighting other residents' cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The facility had no effective process in place to ensure residents received smoking safety devices. The facility lacked a functioning process for supervised smoking times. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to ensure the safety, supervision, and prevention of accidents and hazards resulted in findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: On 11/28/23 from 8:56 a.m. to 9:47 a.m. smoking observations were conducted on the main smoking patio of the facility. Staff O, Certified Nursing Assistant (CNA), was present for the observations. A total of nine residents were observed entering and leaving the main smoking patio during the observations. Staff O, CNA, stated he was the smoking aide but he was not the usual smoking aide. The following observations were noted: At 8:56 a.m. Resident #114 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:10 a.m. he left the smoking area and did not turn in his cigarettes or lighter to the smoking aide. At 8:59 a.m. Resident #96 pulled a cigar pack and a lighter out of his shirt pocket and lit his cigar and placed the package and lighter back in his shirt pocket. At 9:00 a.m. Resident #162 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:08 a.m. he left the smoking patio and did not turn in his cigarettes and lighter. At 9:16 a.m. Resident #102 asked Resident #61 (another resident on the smoking patio) if he could light her cigarette; he said yes, self-propelled his wheelchair closer to Resident #102 and lit her cigarette. Staff O, CNA, was on the smoking patio at this time. At 9:17 a.m. Resident #61 left the main smoking patio with his lighter in his hand. At 9:07 a.m. Resident #198 pulled a pack of cigarettes and lighter out of his shirt pocket, lit his cigarette, and placed them back in his shirt pocket. At 9:14 a.m. he pulled out an electronic cigarette and held it in his hand. At 9:37 a.m. he put his electronic cigarette back in his shirt pocket and left the main smoking patio. Staff O, CNA, held the door open for the resident to exit smoking patio. Resident #198 did not return his smoking materials prior to exiting the smoking patio. At 9:03 a.m. Resident #131 pulled a pack of cigarettes and a lighter out of her pocket and lit her cigarette. At 9:11 a.m. she left the smoking patio and did not turn in her cigarettes or lighter. At 9:17 a.m. she returned to the main smoking patio and pulled out a pack of cigarettes and a lighter out of her jacket pocket and lit her cigarette. At 9:20 a.m. Resident #131 was observed to have lit Resident #188's cigarette with Staff O, CNA, present in the main smoking patio. Resident #188 returned to his chair on the smoking patio. Resident #188 was observed to have black and orange stains on his right pointer finger, right middle finger, and right thumb. Resident #188 said he had those stains from smoking: it's nicotine. The resident was observed to be smoking his cigarette without an apron on and the ash tray in his lap. At 9:30 a.m. Resident #188 left the smoking area. At 9:34 a.m. Staff O, CNA, held the smoking patio door open as Resident #131 left the main smoking patio and she did not turn in her smoking materials. At 9:18 a.m. Resident #324 pulled out a pack of cigarettes and a lighter from his pants pocket and lit his cigarette. At 9:24 a.m. he left the smoking area and did not turn in his cigarettes or lighter to Staff O, CNA. The resident was assisted out of the main smoking patio door by Staff O, CNA. At 9:23 a.m. Resident #162 returned to the main smoking patio and pulled a cigarette pack and a lighter out of his pants pocket and lit his cigarette in front of Staff O, CNA, and put his lighter and cigarettes back in his pocket. At 9:33 a.m. Resident #162 left the main smoking patio pushing Resident #102 in her wheelchair. Staff O, CNA, opened the main smoking patio door to escort them out. Resident #162 did not turn in his smoking materials. At 9:27 a.m. Resident #184 pulled a cigarette pack and a lighter out of his jacket pocket and lit his own cigarette. At 9:47 a.m. he left the smoking patio and did not turn in his smoking materials. An interview was conducted on 11/28/23 at 9:41 a.m. with Staff O, CNA. He said, this is where we store 'some' of the cigarettes, he opened the smoking cart, and there was a total of 20 boxes with names and numbers on them. (Photographic evidence obtained). Review of the facility's Resident Smokers List, undated, revealed there were 44 residents in the facility who smoke. On 11/28/23 at 9:45 a.m. an interview was conducted with Staff K, Activities Director (AD) and Staff O, CNA. Staff K, AD, came to the smoking patio and stated the process for obtaining and stocking the cigarettes in the smoking cart was activity staff's responsibility. Staff K, AD, and Staff O, CNA said residents were supposed to ask for their cigarettes, and get their cigarettes from the locked smoking cart from their personal drawer. They stated, they are supposed to light the residents' cigarettes for them. Staff K, AD said all the residents who smoke were recently educated on the smoking policy. Maybe last month. We can ask them [the residents who smoke] for their smoking materials and some of them will give them up, but most of them will not and we can't force them to give it to us. On 11/28/23 at 8:58 a.m. through 11/28/23 at 9:47 a.m. Staff O, CNA did not attempt to ask residents for their smoking materials prior to exiting the main smoking patio. Staff O, CNA did not attempt to intervene when residents were lighting other residents' cigarettes. Throughout the observation it was observed there were 2 smoking aprons hanging up in the middle of the main smoking patio not in use. The aprons were white and well kept. A resident council meeting was held on 11/28/23 at 10:00 am with eight members of the resident council including the Resident Council President. During the meeting the residents expressed the facility has not done anything about residents smoking in their rooms. The residents said at least eight to nine residents are smoking in their rooms and the facility is not doing anything about it. The residents said they can't go to the courtyard (non-smoking area) because of the residents who smoke. They stated about three weeks ago a resident caught on fire. They stated the facility does nothing about it and the Administrator is aware. The members stated the AD and staff try very hard, but the issue is the residents that go to the store on their own and hide the smoking materials. They stated the floor staff need to do a better job. They stated they would like to go to the courtyard. They said one resident smokes weed so they took his oxygen away. They stated residents smoke [NAME] in front of other residents and there is no respect for others. The residents said there was a designated area outside for the residents who smoke and a separate area outside for the residents who don't smoke, but the smoking residents take over all areas. On 11/29/23 at 9:59 a.m. an interview was conducted with Staff O, CNA. He said, We had two people who needed a smoking apron on yesterday [11/28/23], one of them you met yesterday, [Resident #188], I asked him if he can put on his apron, and he told me 'No, I don't need it' so that's why I was keeping close to him. After that, the Activities Director talked to him, and he wore his apron the rest of the day. I knew he needed an apron because the Activities Director told me. He and another guy needed them. We can go to the Activities Director if we need something or have a question, because I don't normally do the smoking. An interview was conducted on 11/29/23 at 9:14 a.m. with Staff DD, Activities Assistant. She said, normally she was the one who comes and does the smoking during the smoking times but since the state surveyors were here, the AD had her out on the smoking patio for eight hours a day and administration said she has to do this until the state surveyors leave. During the interview Resident #188 was observed to have a smoking apron on with his ash tray in his lap and ashes on his apron. Staff DD, Activities Assistant said, I know [Resident #188] needs an apron because you see his fingers are brown because he smokes his cigarettes till the end, and he shakes so he needs the apron. I just know what the residents need by looking at them and I am familiar with them because I used to be their CNA. We do not have a book or anything that says what the residents need during smoking, you can just tell. An interview was conducted on 11/29/23 at 4:55 p.m. with Staff DD, Activities Assistant. She said, I used to do just half hour increments for smoking, not all eight hours. At 4:00 p.m. today I had 35 smokers. This is the only smoke area for residents. Those who LOA [leave of absence] don't need supervision. If cigarette and lighter drawer storage is empty the resident is keeping their lighters and cigarettes. An interview was conducted on 11/29/23 at 5:29 p.m. with the Nursing Home Administrator (NHA). He said, The smoking times are posted on the door. You may have noticed that I have had someone out there all day. We have a lot of residents here that are non-compliant, and the smokers are saying that they are smoking in non-smoking areas because no one is out there for them to smoke during the smoking times, which is not true. So, I am trying something new for them, starting mid last week, a staff member stays out there instead of coming just for the smoke times. At first there was a CNA from each unit doing the smoking times but then I noticed that the CNAs will be busy during that time or the CNAs have to leave the floor to go do the smoking times so I incorporated the activities staff in it but then I noticed that the activities staff will just get done with an activity and it will take them two to three minutes to get to the smoking patio and the residents' excuse was staff weren't there on time and that is why they are going to the courtyard to smoke. So, now I have someone scheduled at the smoking patio from 9:00 a.m. to 7:00 p.m. and it should be an activities staff member on the smoking patio. The NHA provided the facility's Designated Smoke Times posted on the door of the smoking patio and said The posting is wrong. From 6:30 p.m. to 7:00 p.m. a CNA from South [NAME] unit is not scheduled to be on the smoking patio, the activities staff are still scheduled to be out on the smoking patio. Then from 9:00 p.m. to 9:30 p.m. a Northwest unit CNA is scheduled to be on the smoke patio and 11:00 p.m.-11:30 p.m. a Central unit CNA is scheduled to be on the smoke patio. The 3:00 p.m.-11:00 p.m. nurse assigns a CNA to the smoking patio, and it is put on the assignment board. Review of the Designated Smoke Times ALL UNITS posting provided by the NHA from the main smoking patio door revealed the following: 9:00AM-9:30AM (ACT) [Activities] 11:00AM-11:30AM (ACT) 1:00PM-1:30PM (ACT) 4:00PM-4:30PM (ACT) 6:30PM-7:00PM (SW) [Southwest] 9:00PM-9:30pm (NW) [Northwest] 11:00PM-11:30PM (CN) [Central] **All Resident Must Comply with Designated Smoking Times and Locations. ** All Residents Must Leave Smoking Materials in Designated Smoke Locker. *All assigned Units/Activities are responsible for taking residents to designated smoking area and monitoring during smoke times. An observation was conducted on 11/29/23 at 5:00 p.m. The AD locked the door of the smoking area and stated the smoking area will be open during the scheduled hours per the designated smoke times posting. On 11/29/23 at 5:48 p.m. the NHA contradicted his previous statement that staff were assigned to be out on the smoking porch continually from 9:00 a.m. to 7:00 p.m. by saying I just reminded everyone of their scheduled times to make sure everyone remembers. He said no one is on the smoking patio now because it's 5:48 . The NHA stopped midsentence, turned around and walked away. On 11/29/23 at 5:52 p.m. the smoking area remained locked. An interview was conducted on 11/29/23 at 5:40 p.m. with Staff FF, CNA. He stated he had done smoking before. He said he knew the residents well and had a good rapport with them. He said Some residents take their cigarettes and lighters to their rooms and others leave them in the box. An interview was conducted on 11/29/23 at 6:00 p.m. with Staff W, CNA. He stated he had done smoking breaks before. He stated I don't know about any aprons; I just go out, they smoke, and I come back in. He also said there had been a couple fires in the building; he just doesn't know which residents they were. 1. A review of the Admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the Reesident #61 was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she would expect to see oxygen saturations being monitored at least every shift. There should be ongoing monitoring because Resident #61 had an order for oxygen as needed, and he smokes. The DON stated he had an order to monitor oxygen saturations. She confirmed the last oxygen saturation was checked in September. The DON stated that was not her expectation and there could be some negative effects because he was not being monitored as he should be for oxygen saturations. On 12/01/23 at 2:08 p.m., Staff BB, Resident #61's Physician, stated the resident does not want to hear anything you have to say. She last saw him on 10/30/23 and she talked to him about smoking issues. They were concerned about the time he spent on the smoking patio wearing the oxygen with the portable oxygen tank on the wheelchair. She said she discontinued the continuous oxygen but Resident #61 would just put himself on the oxygen when he came back from smoking. 2) Review of Resident #102's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses include but are not limited to, tobacco use, acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of pulmonary embolism, emphysema, need for assistance with personal care, muscle weakness, essential tremor, metabolic encephalopathy, pleural effusion, cognitive communication deficit, dysphagia, oropharyngeal phase, other specified arthritis, unspecified abnormalities of gait and mobility, chronic pulmonary embolism, anxiety disorder, and major depressive disorder. Review of Resident #102's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #102 on 11/27/23 at 9:59 a.m. The Resident was observed to be in her room, sitting in her wheelchair on 3 liters of oxygen via nasal cannula. The resident was observed to have a small circular hole with black edges on her upper right thigh of her pants. The resident said her pants came that way. The resident said the staff keep her smoking materials and they stick to the smoking schedule. She said she takes off her oxygen when she smokes, and she does not use an apron when she smokes. Review of Resident #102's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, does not have the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is not able to light a cigarette safely with a lighter, the resident does not smoke safely (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish a cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Indicate resident need for safety smoking aides: resident must wear smoking apron at all times. Maintenance of smoking materials: Resident must request smoking materials from staff . Additional Comments: Resident refused smoking apron. Review of Resident #102's Resident/Family Tool dated 10/21/23, completed by Staff C, ADON, revealed the identified learner was the Resident. She understands basic information. Her readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters[sic] and or vape pens). Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (e.g., cigarettes, lighters). Resident cannot smoke near any combustible items such as oxygen tanks & concentrators. Informed resident that per smoking evaluation, she meets the requirements for wearing a smoking apron s/t[sic] incident resulting in a fire after she dropped a cigarette. Resident informed that if smoking policy is violated again, she will be subject to discharge. Resident verbalized understanding & agreement with everything, except smoking apron. Resident stated she will only smoke in designated area, but she doesn't want an apron. Resident verbalized understanding of personal safety risks r/t [related to] wearing apron during smoking breaks. Review of Resident #102's physician orders revealed an order with a start date of 8/13/2023 and no end date of Oxygen at 2 liters/minute via- Nasal cannula every night shift for Respiratory Distress. An order started on 11/10/23 without an end date to Cleanse BURN TO LEFT ARM with normal saline--Gently pat dry--Apply Xeroform to wound--Wrap with kerlix--Secure with tape. Change daily on 3-11 shift. Review of Resident #102's November treatment administration record (TAR) revealed the order was completed as ordered. Review of Resident #102's Narrative Nurses note dated 10/21/23 at 2:01 p.m. revealed, At around 0403 [4:03 a.m.] Smoke alarm sounded. Writer [sic] witnessed smoke and fire in resident's room. Resident was evacuated along with others while code red and 911 were called. Fire was put out with fire extinguisher. Police and fire department arrive [sic] and assisted staff member to evacuate the wing. Per nurse, Resident has burn to her left upper extremity and complaining of difficulty breathing s/p [status post] smoke inhalation. Resident left the facility with O2 [oxygen] via non-re-breather mask with 911. Resident reported to 911 that she was smoking in the room. Assigned nurse to call MD [Medical doctor] and Family member for notification. Review of Resident #102's change in condition dated 10/21/23 revealed At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 110/64, 10/21/2023 05:03 a.m. Position: Sitting l (left)/arm Pulse: P 88, 10/21/2023 4:05 p.m. Pulse Type: Irregular, chronic RR: R 32, 10/21/2023 5:06 a.m. Temp: T 97.6, 10/21/2023 5:05 a.m. Route: Forehead (non-contact) Weight: W 97.0 lb., 10/5/2023 10:27 a.m. Scale: Mechanical Lift Pulse Oximetry: O2 94 %, 10/21/2023 5:05 a.m. Method: Oxygen via Nasal Cannula .Nursing observations, evaluation, and recommendations are Resident was assess for burns due to her mattress burning . A Narrative Nursing note dated 10/21/23 at 5:54 p.m. revealed PT [patient] returned from hospital with new order for Keflex 500 mg daily. On 10/21/23 at 6:00 p.m. the Narrative Nursing note revealed Resident returned to facility from ER [emergency room ] at 1738 [5:38 p.m.]. Resident sent out for burns and dyspnea [difficulty breathing] s/p [status post] smoke inhalation from fire incident earlier today. Resident violated smoking policy by smoking in her room w/ [with] oxygen concentrator present, later resulting in a fire. Resident now returning w/ pressure dressing to left forearm and gauze dressing to right posterior forearm. New skin tear noted under the latter dressing. VSS [vital signs stable], but resident was noted to still have some respiratory discomfort. HOB [head of bed] elevated and Nasal Canula [sic] on 2 LPM [liters per minute], which helped alleviate shortness of breath. During Auscultation, breath sounds were noted to be diminished. Apical pulse normal and regular. Resident did verbalize having some pain. Pain medication given by nurse on duty after assessment to ensure safety of narcotic administration. Resident was then educated on smoking policy and the importance of adhering to it. Resident was apologetic and verbalized agreement and consent w/ complying to smoking policy going forward. Informed resident that smoking re-evaluation resulted in her qualifying for a smoking apron during smoking breaks for safety purposes. Resident stated her refusal to wear apron, as she does not agree with its necessity. Resident educated on the benefits of wearing apron while smoking. Resident verbalized understanding of personal safety risks if she does not wear apron but still stated that she will not wear it. Psychology/Psychiatry consult placed for follow up s/p [status post] incident. On call physician notified of resident's return, present status/condition, new dressing to burn, and new order for prophylactic Keflex s/t [sic] to right forearm burns. Resident comfortable and sleeping in her bed at this time. Review of Resident #102's Admission Nursing Comprehensive Eval dated 8/4/23 revealed a smoking evaluation to include, the resident uses tobacco/nicotine products, she uses cigarettes (non-electronic), the resident has the cognitive ability to smoke safely, has the visual ability to smoke safely, physical dexterity to smoke safely, and the physical ability to smoke safely. 02b. Resident Observation She is not able to light a cigarette safely with a lighter. She smokes safely, she utilizes the ash tray safely and properly. She is able to extinguish a cigarette safely and completely when finished smoking. The resident is able to communicate the reason oxygen must always be shut off prior to lighter use and the resident is able to communicate the risks associated with smoking. She has the cognitive ability revealed the resident may smoke independently or with set up. The resident was assessed not to need smoking aides such as aprons or a cigarette holder. There was no indication on the smoking evaluation if the resident may or may not maintain her own smoking materials. Review of Resident #102's care plan initiated on 8/17/23 revealed [Resident #102] desires to smoke. Resident has been assessed as able to smoke with supervision. Her goal included Resident will demonstrate safe smoking practices thru the next review date. Interventions included Maintain smoking materials in designated area. Provide assistance with lighting cigarette. Apply/remove smoking apron. Observe for decline in hand dexterity; assist to hold cigarette as needed. And Inform resident of smoking cessation options upon resident request prn [as needed]. The care plan dated 10/21/23 revealed [Resident #102] exhibits the following behaviors AEB [as evidenced by] smoking inside the facility in the room. [Resident #102] aware of the smoking policy and chose to deviated [sic] from it. The goal included, [Resident #102] will followed [sic] the facility smoking through the next review date. Interventions included Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of resident and others: remove from situation as able. Provide positive reinforcement for successful interactions/efforts. Request psychiatric consult as needed. Update physician of increase in presence or severity of behaviors as indicated. The care plan dated 10/27/23 revealed Resident Choices: Resident has made the following choice(s) regarding his/her care: She uses oxygen and still prefers to smoke, She do [sic] not follow the smoking policy and refuses to wear smoking apron, which puts her at an increased risk for self-arm [sic]. Resident refuses to keep nasal canula in designated oxygen tubing bag. The goal included, Resident will verbalize understanding of potential risks and benefits associated with his/her choices. The interventions included, Continue to encourage resident to wear smoking apron for smoking safety. Honor resident choices. Monitor resident for changes in condition related to choices. Notify physician of resident choices that are contrary to physician orders. Provide education to resident/responsible party related to choices that are not congruent with physician orders, industry standards or acceptable practices in the skilled nursing facility and the risks involved with their choices. Staff to continue to remind [Resident #102] of the facility smoking pol[TRUNCATED]

41015 48441 39866 Based on observations, interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to prevent continued accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. the facility's fire alarm was triggered when Resident #102 was able to smoke in her room, unsupervised, causing her mattress, privacy curtain, and oxygen concentrator to catch on fire. Staff extinguished the fire, the fire department, and Emergency Medical Services (EMS) were called, residents on the same hallway as Resident #102 were evacuated. Resident #102 sustained a 1st degree burn to her left forearm and shortness of breath due to smoke inhalation. On 10/21/23 Resident #102 was transferred to the hospital for evaluation and treatment. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their person, were seen lighting other resident's cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The facility had no effective process in place to ensure residents received smoking safety devices. The facility lacked a functioning process for supervised smoking times. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to ensure the improvement in safety after life threatening smoking events occurred resulted in the in findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: An interview was conducted on 12/1/23 at 3:48 p.m. with Staff R, Assistant Nursing Home Administrator/Risk Manager, and the DON (Director of Nurses). The DON stated the only Performance Improvement PLan (PIP) the facility had in place was the smoking PIP. She stated the quality indicators were education, care plans, residents with oxygen have care plans, and all smoking supplies stored appropriately. The DON stated the PIP started in October 2023. Staff R and the DON stated the PIP had not been successful in ensuring safe smoking and the monitoring of smoking. The DON said the facility was holding daily Ad Hoc meetings to review the audits, but they were unable to find the sign in sheets. The DON stated the facility had not had another QAPI meeting to review the smoking PIP and the meeting was supposed to be on Tuesday, 11/28/23. The DON confirmed the last QAPI meeting was held in October 2023. 1. A review of the Admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the resident was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she would expect to see oxygen saturations being monitored at least every shift. There should be ongoing monitoring because Resident #61 had an order for oxygen as needed, and he smokes. The DON stated he had an order to monitor oxygen saturations. She confirmed the last oxygen saturation was checked in September. The DON stated that was not her expectation and there could be some negative effects because he was not being monitored as he should be for oxygen saturations. On 12/01/23 at 2:08 p.m., Staff BB, Resident #61's Physician, stated the resident does not want to hear anything you have to say. She last saw him on 10/30/23 and she talked to him about smoking issues. They were concerned about the time he spent on the smoking patio wearing the oxygen with the portable oxygen tank on the wheelchair. She said she discontinued the continuous oxygen but Resident #61 would just put himself on the oxygen when he came back from smoking. 2) Review of Resident #102's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses include but are not limited to, tobacco use, acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of pulmonary embolism, emphysema, need for assistance with personal care, muscle weakness, essential tremor, metabolic encephalopathy, pleural effusion, cognitive communication deficit, dysphagia, oropharyngeal phase, other specified arthritis, unspecified abnormalities of gait and mobility, chronic pulmonary embolism, anxiety disorder, and major depressive disorder. Review of Resident #102's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #102 on 11/27/23 at 9:59 a.m. The Resident was observed to be in her room, sitting in her wheelchair on 3 liters of oxygen via nasal cannula. The resident was observed to have a small circular hole with black edges on her upper right thigh of her pants. The resident said her pants came that way. The resident said the staff keep her smoking materials and they stick to the smoking schedule. She said she takes off her oxygen when she smokes, and she does not use an apron when she smokes. Review of Resident #102's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, does not have the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is not able to light a cigarette safely with a lighter, the resident does not smoke safely (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish a cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Indicate resident need for safety smoking aides: resident must wear smoking apron at all times. Maintenance of smoking materials: Resident must request smoking materials from staff . Additional Comments: Resident refused smoking apron. Review of Resident #102's Resident/Family Tool dated 10/21/23, completed by Staff C, ADON, revealed the identified learner was the Resident. She understands basic information. Her readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters[sic] and or vape pens). Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (e.g., cigarettes, lighters). Resident cannot smoke near any combustible items such as oxygen tanks & concentrators. Informed resident that per smoking evaluation, she meets the requirements for wearing a smoking apron s/t[sic] incident resulting in a fire after she dropped a cigarette. Resident informed that if smoking policy is violated again, she will be subject to discharge. Resident verbalized understanding & agreement with everything, except smoking apron. Resident stated she will only smoke in designated area, but she doesn't want an apron. Resident verbalized understanding of personal safety risks r/t [related to] wearing apron during smoking breaks. Review of Resident #102's physician orders revealed an order with a start date of 8/13/2023 and no end date of Oxygen at 2 liters/minute via- Nasal cannula every night shift for Respiratory Distress. An order started on 11/10/23 without an end date to Cleanse BURN TO LEFT ARM with normal saline--Gently pat dry--Apply Xeroform to wound--Wrap with kerlix--Secure with tape. Change daily on 3-11 shift. Review of Resident #102's November treatment administration record (TAR) revealed the order was completed as ordered. Review of Resident #102's Narrative Nurses note dated 10/21/23 at 2:01 p.m. revealed, At around 0403 [4:03 a.m.] Smoke alarm sounded. Writer [sic] witnessed smoke and fire in resident's room. Resident was evacuated along with others while code red and 911 were called. Fire was put out with fire extinguisher. Police and fire department arrive [sic] and assisted staff member to evacuate the wing. Per nurse, Resident has burn to her left upper extremity and complaining of difficulty breathing s/p [status post] smoke inhalation. Resident left the facility with O2 [oxygen] via non-re-breather mask with 911. Resident reported to 911 that she was smoking in the room. Assigned nurse to call MD [Medical doctor] and Family member for notification. Review of Resident #102's change in condition dated 10/21/23 revealed At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 110/64, 10/21/2023 05:03 a.m. Position: Sitting l (left)/arm Pulse: P 88, 10/21/2023 4:05 p.m. Pulse Type: Irregular, chronic RR: R 32, 10/21/2023 5:06 a.m. Temp: T 97.6, 10/21/2023 5:05 a.m. Route: Forehead (non-contact) Weight: W 97.0 lb., 10/5/2023 10:27 a.m. Scale: Mechanical Lift Pulse Oximetry: O2 94 %, 10/21/2023 5:05 a.m. Method: Oxygen via Nasal Cannula .Nursing observations, evaluation, and recommendations are Resident was assess for burns due to her mattress burning . A Narrative Nursing note dated 10/21/23 at 5:54 p.m. revealed PT [patient] returned from hospital with new order for Keflex 500 mg daily. On 10/21/23 at 6:00 p.m. the Narrative Nursing note revealed Resident returned to facility from ER [emergency room ] at 1738 [5:38 p.m.]. Resident sent out for burns and dyspnea [difficulty breathing] s/p [status post] smoke inhalation from fire incident earlier today. Resident violated smoking policy by smoking in her room w/ [with] oxygen concentrator present, later resulting in a fire. Resident now returning w/ pressure dressing to left forearm and gauze dressing to right posterior forearm. New skin tear noted under the latter dressing. VSS [vital signs stable], but resident was noted to still have some respiratory discomfort. HOB [head of bed] elevated and Nasal Canula [sic] on 2 LPM [liters per minute], which helped alleviate shortness of breath. During Auscultation, breath sounds were noted to be diminished. Apical pulse normal and regular. Resident did verbalize having some pain. Pain medication given by nurse on duty after assessment to ensure safety of narcotic administration. Resident was then educated on smoking policy and the importance of adhering to it. Resident was apologetic and verbalized agreement and consent w/ complying to smoking policy going forward. Informed resident that smoking re-evaluation resulted in her qualifying for a smoking apron during smoking breaks for safety purposes. Resident stated her refusal to wear apron, as she does not agree with its necessity. Resident educated on the benefits of wearing apron while smoking. Resident verbalized understanding of personal safety risks if she does not wear apron but still stated that she will not wear it. Psychology/Psychiatry consult placed for follow up s/p [status post] incident. On call physician notified of resident's return, present status/condition, new dressing to burn, and new order for prophylactic Keflex s/t [sic] to right forearm burns. Resident comfortable and sleeping in her bed at this time. Review of Resident #102's Admission Nursing Comprehensive Eval dated 8/4/23 revealed a smoking evaluation to include, the resident uses tobacco/nicotine products, she uses cigarettes (non-electronic), the resident has the cognitive ability to smoke safely, has the visual ability to smoke safely, physical dexterity to smoke safely, and the physical ability to smoke safely. 02b. Resident Observation She is not able to light a cigarette safely with a lighter. She smokes safely, she utilizes the ash tray safely and properly. She is able to extinguish a cigarette safely and completely when finished smoking. The resident is able to communicate the reason oxygen must always be shut off prior to lighter use and the resident is able to communicate the risks associated with smoking. She has the cognitive ability revealed the resident may smoke independently or with set up. The resident was assessed not to need smoking aides such as aprons or a cigarette holder. There was no indication on the smoking evaluation if the resident may or may not maintain her own smoking materials. Review of Resident #102's care plan initiated on 8/17/23 revealed [Resident #102] desires to smoke. Resident has been assessed as able to smoke with supervision. Her goal included Resident will demonstrate safe smoking practices thru the next review date. Interventions included Maintain smoking materials in designated area. Provide assistance with lighting cigarette. Apply/remove smoking apron. Observe for decline in hand dexterity; assist to hold cigarette as needed. And Inform resident of smoking cessation options upon resident request prn [as needed]. The care plan dated 10/21/23 revealed [Resident #102] exhibits the following behaviors AEB [as evidenced by] smoking inside the facility in the room. [Resident #102] aware of the smoking policy and chose to deviated [sic] from it. The goal included, [Resident #102] will followed [sic] the facility smoking through the next review date. Interventions included Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of resident and others: remove from situation as able. Provide positive reinforcement for successful interactions/efforts. Request psychiatric consult as needed. Update physician of increase in presence or severity of behaviors as indicated. The care plan dated 10/27/23 revealed Resident Choices: Resident has made the following choice(s) regarding his/her care: She uses oxygen and still prefers to smoke, She do [sic] not follow the smoking policy and refuses to wear smoking apron, which puts her at an increased risk for self-arm [sic]. Resident refuses to keep nasal canula in designated oxygen tubing bag. The goal included, Resident will verbalize understanding of potential risks and benefits associated with his/her choices. The interventions included, Continue to encourage resident to wear smoking apron for smoking safety. Honor resident choices. Monitor resident for changes in condition related to choices. Notify physician of resident choices that are contrary to physician orders. Provide education to resident/responsible party related to choices that are not congruent with physician orders, industry standards or acceptable practices in the skilled nursing facility and the risks involved with their choices. Staff to continue to remind [Resident #102] of the facility smoking policy and redirect her as needed. A phone interview was conducted with Resident #102's Advanced Registered Nurse Practitioner (ARNP) on 12/1/23 at 3:05 p.m. She said she was made aware the resident smoked in her room and caused a fire in the building. She said the resident went to the hospital and returned so quickly that they sent her back to the hospital for monitoring because they were still cleaning everything up. It was a mess. The ARNP said Resident #102 had a 1st degree burn to her left arm that was getting better. She was being seen by wound care and having treatments. When she went to the hospital, they dressed her burn and gave her antibiotics which she continued when she came back to the facility. I was not aware that she needs a smoking apron and refuses it but I know she refuses everything including pharmacological treatment. The day after the fire I did offer smoking cessation options, but she declined it and I continue to offer it to her . 3) Review of Resident #131's Admission Record revealed she was admitted on [DATE]. Review of her medical diagnosis included but are not limited paraplegia, major depressive disorder, schizoaffective disorder, and muscle weakness (generalized). Review of Resident #131's Quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #131 on 11/28/23 at 7:50 a.m. The resident said she kept her cigarettes and lighter on her, but she may start turning them in at 4:00 p.m. so they know she wasn't sleeping with them. Sometimes when cigarettes are kept in the box [secured smoking cart], they get stolen but if people want some of my cigarettes that's fine, they can have them. So, I should start turning them in at night. Review of Resident #131's Smoking Evaluation dated 10/21/2023, completed by Staff C, Assistant Director of Nursing (ADON) revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, Has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Residents utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Maintence of smoking materials: Resident must request smoking materials from staff. Review of Resident #131's Resident/Family Education Tool V2 dated 10/21/23 revealed the identified learner was the Resident . Outcome of Education Session verbalizes understanding. Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters and or vape pens). Resident cannot smoke near any combustible such as oxygen tanks and concentrators. Review of Resident #131's care plan dated 8/3/23 revealed [Resident #131] desires to smoke. Resident has been assessed as able to smoke with supervision. Resident prefer [sic] not to follow the smoking policy AEB [as evidenced by]: She[sic] is smoking in non-smoking courtyard. The goals included Resident will demonstrate safe smoking practices thru the next review date and Resident will adhere to the smoking policy daily thru the next review date. Intervention included Remind and encourage resident to follow smoking policy. Maintain smoking materials in designated area. Accompany resident to designated smoking area and provide supervision. 4) Review of Resident #324's Admission Record revealed he was admitted to the facility on [DATE]. His medical diagnoses included but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, major depressive disorder, weakness, and homelessness. Review of Resident #324's Admission MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating the resident is cognitively intact. Review of Resident #324's Admission Nursing Comprehensive Eval dated 11/8/23 revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary of Review: Resident must be supervised by staff, volunteer, or family member at all times when smoking. And the resident must request smoking materials from staff. Resident/resident representative/family have been informed of smoking policies/procedures . Review of Resident #324's care plan dated 11/9/23 revealed [Resident #324] desires to smoke. Resident has been assessed as able to smoke per facility policy with supervision. The goal included Resident will adhere to the smoking policy daily thru the next review date. The interventions included Maintain smoking materials in designated area. Accompany resident to designated smoking area and provide supervision. Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed. An interview was conducted on 12/1/23 at 3:26 p.m. with the Director of Nursing (DON). She said residents sign a smoking policy upon admission because it is part of the admission packet. She confirmed Resident #324 did not have a signed smoking policy upon admission but he does now. 5) Review of Resident #184's Admission Record revealed he was admitted to the facility on [DATE]. His medical diagnoses include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, alcohol abuse, tobacco use, cellulitis, personal history of methicillin resistant staphylococcus aureus [MRSA] infection, muscle weakness (generalized), need for assistance with personal care, other dysphagia, and other speech disturbances. Review of Resident #184's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. Review of Resident #184's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary of Review A. Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. And the Resident must request smoking materials from staff. Review of Resident #184's Resident/Family Education Tool V2 dated 10/21/23 revealed the identified learner was the Resident. Understands basic information. Readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident educated to the smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters [sic] and or vape pens). Resident cannot smoke near any combustible such as oxygen tanks and concentrators. Review of Resident #184's care plan initiated on 5/2/23 revealed [Resident #184] desires to smoke. Resident has been assessed as able to smoke with supervision. His goal included Resident will demonstrate safe smoking practices thru the next review date. His interventions included Maintain smoking materials in designated area. Provide assistance with lighting cigarette. Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed. Observe for decline in hand dexterity; assist to hold cigarette as needed. Inform resident of smoking cessation options upon resident request prn [as needed]. Review of Resident #184's 3008 dated 4/12/23 revealed Primary diagnosis Burn LLE [left lower extremity] 2% TBS [total body surface] Review of Resident #184's hospital record located in his medical record, revealed a [TRUNCATED]

41015 48441 39866 Based on observations, record review, and interview, the facility failed to develop and implement an effective policy and procedure to address smoking safety and fire hazards for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. On 9/22/23 at 5:11 p.m. Resident #61 was found by the Nursing Home Administrator smoking (alleged) marijuana in an unauthorized smoking area of the facility. On 10/21/23 at 4:03 a.m. Resident #102, who was on oxygen, was permitted to keep smoking materials at the bedside and as a result Resident #102 was harmed when she smoked in bed on 10/21/23 and started a fire inside the facility. Resident #102 burned herself on her left arm and suffered shortness of breath due to smoke inhalation and was transferred to the hospital for evaluation and treatment. The event endangered all residents in the facility. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their persons, were seen lighting other resident's cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to develop, implement, and enforce a smoking safety policy resulted in the findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: On 11/28/23 from 8:56 a.m. to 9:47 a.m. smoking observations were conducted on the main smoking patio of the facility. Staff O, Certified Nursing Assistant (CNA), was present for the observations. A total of nine residents were observed entering and leaving the main smoking patio during the observations. Staff O, CNA, stated he was the smoking aide but he was not the usual smoking aide. The following observations were noted: At 8:56 a.m. Resident #114 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:10 a.m. he left the smoking area and did not turn in his cigarettes or lighter to the smoking aide. At 8:59 a.m. Resident #96 pulled a cigar pack and a lighter out of his shirt pocket and lit his cigar and placed the package and lighter back in his shirt pocket. At 9:00 a.m. Resident #162 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:08 a.m. he left the smoking patio and did not turn in his cigarettes and lighter. At 9:16 a.m. Resident #102 asked Resident #61 (another resident on the smoking patio) if he could light her cigarette; he said yes, self-propelled his wheelchair closer to Resident #102 and lit her cigarette. Staff O, CNA, was on the smoking patio at this time. At 9:17 a.m. Resident #61 left the main smoking patio with his lighter in his hand. At 9:07 a.m. Resident #198 pulled a pack of cigarettes and lighter out of his shirt pocket, lit his cigarette, and placed them back in his shirt pocket. At 9:14 a.m. he pulled out an electronic cigarette and held it in his hand. At 9:37 a.m. he put his electronic cigarette back in his shirt pocket and left the main smoking patio. Staff O, CNA, held the door open for the resident to exit smoking patio. Resident #198 did not return his smoking materials prior to exiting the smoking patio. At 9:03 a.m. Resident #131 pulled a pack of cigarettes and a lighter out of her pocket and lit her cigarette. At 9:11 a.m. she left the smoking patio and did not turn in her cigarettes or lighter. At 9:17 a.m. she returned to the main smoking patio and pulled out a pack of cigarettes and a lighter out of her jacket pocket and lit her cigarette. At 9:20 a.m. Resident #131 was observed to have lit Resident #188's cigarette with Staff O, CNA, present in the main smoking patio. Resident #188 returned to his chair on the smoking patio. Resident #188 was observed to have black and orange stains on his right pointer finger, right middle finger, and right thumb. Resident #188 said he had those stains from smoking: it's nicotine. The resident was observed to be smoking his cigarette without an apron on and the ash tray in his lap. At 9:30 a.m. Resident #188 left the smoking area. At 9:34 a.m. Staff O, CNA, held the smoking patio door open as Resident #131 left the main smoking patio and she did not turn in her smoking materials. At 9:18 a.m. Resident #324 pulled out a pack of cigarettes and a lighter from his pants pocket and lit his cigarette. At 9:24 a.m. he left the smoking area and did not turn in his cigarettes or lighter to Staff O, CNA. The resident was assisted out of the main smoking patio door by Staff O, CNA. At 9:23 a.m. Resident #162 returned to the main smoking patio and pulled a cigarette pack and a lighter out of his pants pocket and lit his cigarette in front of Staff O, CNA, and put his lighter and cigarettes back in his pocket. At 9:33 a.m. Resident #162 left the main smoking patio pushing Resident #102 in her wheelchair. Staff O, CNA, opened the main smoking patio door to escort them out. Resident #162 did not turn in his smoking materials. At 9:27 a.m. Resident #184 pulled a cigarette pack and a lighter out of his jacket pocket and lit his own cigarette. At 9:47 a.m. he left the smoking patio and did not turn in his smoking materials. An interview was conducted on 11/28/23 at 9:41 a.m. with Staff O, CNA. He said, this is where we store 'some' of the cigarettes, he opened the smoking cart, and there was a total of 20 boxes with names and numbers on them. (Photographic evidence obtained). Review of the facility's Resident Smokers List, undated, revealed there were 44 residents in the facility who smoke. On 11/28/23 at 9:45 a.m. an interview was conducted with Staff K, Activities Director (AD) and Staff O, CNA. Staff K, AD, came to the smoking patio and stated the process for obtaining and stocking the cigarettes in the smoking cart was activity staff's responsibility. Staff K, AD, and Staff O, CNA said residents were supposed to ask for their cigarettes, and get their cigarettes from the locked smoking cart from their personal drawer. They stated, they are supposed to light the residents' cigarettes for them. Staff K, AD said all the residents who smoke were recently educated on the smoking policy. Maybe last month. We can ask them [the residents who smoke] for their smoking materials and some of them will give them up, but most of them will not and we can't force them to give it to us. On 11/28/23 at 8:58 a.m. through 11/28/23 at 9:47 a.m. Staff O, CNA did not attempt to ask residents for their smoking materials prior to exiting the main smoking patio. Staff O, CNA did not attempt to intervene when residents were lighting other residents' cigarettes. Throughout the observation it was observed there were 2 smoking aprons hanging up in the middle of the main smoking patio not in use. The aprons were white and well kept. A resident council meeting was held on 11/28/23 at 10:00 am with eight members of the resident council including the Resident Council President. During the meeting the residents expressed the facility has not done anything about residents smoking in their rooms. The residents said at least eight to nine residents are smoking in their rooms and the facility is not doing anything about it. The residents said they can't go to the courtyard (non-smoking area) because of the residents who smoke. They stated about three weeks ago a resident caught on fire. They stated the facility does nothing about it and the Administrator is aware. The members stated the AD and staff try very hard, but the issue is the residents that go to the store on their own and hide the smoking materials. They stated the floor staff need to do a better job. They stated they would like to go to the courtyard. They said one resident smokes weed so they took his oxygen away. They stated residents smoke [NAME] in front of other residents and there is no respect for others. The residents said there was a designated area outside for the residents who smoke and a separate area outside for the residents who don't smoke, but the smoking residents take over all areas. On 11/29/23 at 9:59 a.m. an interview was conducted with Staff O, CNA. He said, We had two people who needed a smoking apron on yesterday [11/28/23], one of them you met yesterday, [Resident #188], I asked him if he can put on his apron, and he told me 'No, I don't need it' so that's why I was keeping close to him. After that, the Activities Director talked to him, and he wore his apron the rest of the day. I knew he needed an apron because the Activities Director told me. He and another guy needed them. We can go to the Activities Director if we need something or have a question, because I don't normally do the smoking. An interview was conducted on 11/29/23 at 9:14 a.m. with Staff DD, Activities Assistant. She said, normally she was the one who comes and does the smoking during the smoking times but since the state surveyors were here, the AD had her out on the smoking patio for eight hours a day and administration said she has to do this until the state surveyors leave. During the interview Resident #188 was observed to have a smoking apron on with his ash tray in his lap and ashes on his apron. Staff DD, Activities Assistant said, I know [Resident #188] needs an apron because you see his fingers are brown because he smokes his cigarettes till the end, and he shakes so he needs the apron. I just know what the residents need by looking at them and I am familiar with them because I used to be their CNA. We do not have a book or anything that says what the residents need during smoking, you can just tell. An interview was conducted on 11/29/23 at 4:55 p.m. with Staff DD, Activities Assistant. She said, I used to do just half hour increments for smoking, not all eight hours. At 4:00 p.m. today I had 35 smokers. This is the only smoke area for residents. Those who LOA [leave of absence] don't need supervision. If cigarette and lighter drawer storage is empty the resident is keeping their lighters and cigarettes. An interview was conducted on 11/29/23 at 5:29 p.m. with the Nursing Home Administrator (NHA). He said, The smoking times are posted on the door. You may have noticed that I have had someone out there all day. We have a lot of residents here that are non-compliant, and the smokers are saying that they are smoking in non-smoking areas because no one is out there for them to smoke during the smoking times, which is not true. So, I am trying something new for them, starting mid last week, a staff member stays out there instead of coming just for the smoke times. At first there was a CNA from each unit doing the smoking times but then I noticed that the CNAs will be busy during that time or the CNAs have to leave the floor to go do the smoking times so I incorporated the activities staff in it but then I noticed that the activities staff will just get done with an activity and it will take them two to three minutes to get to the smoking patio and the residents' excuse was staff weren't there on time and that is why they are going to the courtyard to smoke. So, now I have someone scheduled at the smoking patio from 9:00 a.m. to 7:00 p.m. and it should be an activities staff member on the smoking patio. The NHA provided the facility's Designated Smoke Times posted on the door of the smoking patio and said The posting is wrong. From 6:30 p.m. to 7:00 p.m. a CNA from South [NAME] unit is not scheduled to be on the smoking patio, the activities staff are still scheduled to be out on the smoking patio. Then from 9:00 p.m. to 9:30 p.m. a Northwest unit CNA is scheduled to be on the smoke patio and 11:00 p.m.-11:30 p.m. a Central unit CNA is scheduled to be on the smoke patio. The 3:00 p.m.-11:00 p.m. nurse assigns a CNA to the smoking patio, and it is put on the assignment board. Review of the Designated Smoke Times ALL UNITS posting provided by the NHA from the main smoking patio door revealed the following: 9:00AM-9:30AM (ACT) [Activities] 11:00AM-11:30AM (ACT) 1:00PM-1:30PM (ACT) 4:00PM-4:30PM (ACT) 6:30PM-7:00PM (SW) [Southwest] 9:00PM-9:30pm (NW) [Northwest] 11:00PM-11:30PM (CN) [Central] **All Resident Must Comply with Designated Smoking Times and Locations. ** All Residents Must Leave Smoking Materials in Designated Smoke Locker. *All assigned Units/Activities are responsible for taking residents to designated smoking area and monitoring during smoke times. An observation was conducted on 11/29/23 at 5:00 p.m. The AD locked the door of the smoking area and stated the smoking area will be open during the scheduled hours per the designated smoke times posting. On 11/29/23 at 5:48 p.m. the NHA contradicted his previous statement that staff were assigned to be out on the smoking porch continually from 9:00 a.m. to 7:00 p.m. by saying I just reminded everyone of their scheduled times to make sure everyone remembers. He said no one is on the smoking patio now because it's 5:48 . The NHA stopped midsentence, turned around and walked away. On 11/29/23 at 5:52 p.m. the smoking area remained locked. An interview was conducted on 11/29/23 at 5:40 p.m. with Staff FF, CNA. He stated he had done smoking before. He said he knew the residents well and had a good rapport with them. He said Some residents take their cigarettes and lighters to their rooms and others leave them in the box. An interview was conducted on 11/29/23 at 6:00 p.m. with Staff W, CNA. He stated he had done smoking breaks before. He stated I don't know about any aprons; I just go out, they smoke, and I come back in. He also said there had been a couple fires in the building; he just doesn't know which residents they were. An interview was conducted on 11/30/23 at 10:19 a.m. with the Nursing Home Administrator (NHA). He said, There are two resident designated smoking areas, one off the secured unit for the secured unit residents, and one right off of the central unit for all the other residents who smoke. A staff member should be on the secured unit smoking area at all times with the residents. A staff member brings them out to smoke. On the secured unit, that is a little different; the residents will ask you to smoke and that's when they will take them out. There are scheduled times but the residents don't like to follow those times so they will take them out whenever they ask. On October 21st I got a call around 4am I was told [Resident #102] was smoking in her room and the concentrator caught on fire and the fire department had to come out. But the fire was already put out by the time they [fire department] came because it was just the concentrator and the mattress that caught on fire. The resident said she smoked in her room because she felt anxious. So, she was sent out to the hospital. She has a small burn mark on her arm, and she was also on a concentrator [oxygen concentrator] so we sent her to the hospital so they can do an assessment on her to make sure she was all right. The hospital sent her back probably about 30 minutes later. I sent her back to the hospital so I can get the situation taken care of, we were still cleaning up. One of her diagnoses was acute respiratory failure so I felt she should have been there just a little bit longer. She was having difficulty breathing when she was first sent to the hospital. I did not see her when she was first sent to the hospital, I saw her when she came back, and she did not have any soot or burns on her face. We removed the resident from the room, and they removed all the residents in the immediate area, the whole strip of residents on her hallway leading to the nurses station were removed from their rooms and we put them on different units because of the smoke smell. The fire alarms did go off, but the sprinklers did not. Code red was initiated, and they called the fire department. One of the nurses came with the fire extinguisher because there was smoke coming from the oxygen concentrator at that point. The fire department came and checked out everything, EMT [emergency medical team] came to take the resident to the hospital. Then I arrived and we started to clean and open the windows. The equipment that was burned such as the mattress and the concentrator were taken out . Approximately 5 percent of the mattress was burned. The resident was lying on the mattress, and she was wearing her nasal cannula which was attached to the oxygen concentrator and the oxygen concentrator was on. The resident was smoking in her bed with her oxygen on and she dropped her cigarette. The concentrator was not in flames, but it was burning, it was starting to melt. Where the tubing was connected to the concentrator there was a fist-size melted area. The mattress was melted, everyone was saying that it was melted but no flames that I know of. The piece of the nasal cannula that was connected to the concentrator was melted and midway down the nasal cannula from her face was melted together. It was as if she was lying in bed and the piece of the nasal cannula that was by her hand melted together. After the clean-up was done, we offered psych services to all the residents in the immediate area. None of them needed it, they were more upset that I was talking to them waking them up. Later that day I asked them if they were okay, do they know what happened, is there someone they would like to speak with. Of the people I talked to only one person said she knew there was a fire, the other ones didn't know anything. After that we notified the family . of [Resident #102], the [family] lives [out of state], we asked her [the family] how she [Resident #102] got the lighter and she [the family] said she did not know but [Resident #102] has friends down there, so we figured it was one of the other residents because when we asked [Resident #102] who her friends were she was just naming other residents. At that point none of the residents had a change in condition. We started reeducation for all the residents on the smoking policy. That education was started on 10/21/23 and completed 10/21/23. All the smoking residents, we had them sign the smoking policy again because they sign it at admission. The staff were educated on the smoking policy as well as supervision, just supervision, the nurse said she was right there when everything happened but just supervision on the residents at all times as much as possible. The staff member was sitting right in the day room and [Resident #102's] door is the second door from the day room and as soon as she heard the fire alarm, she [NAME] into action . She had just finished her rounds checking all the residents, answering all the call lights and she had just sat down. We also reeducated everyone on the code red drill. Audited resident care plans related to smoking. We added to our daily room audits, which management does, to observed for smoking materials and to notify management. We had all the smoking residents sign an agreement saying they understand they will receive a 30-day discharge notice if they don't remain compliant with the policies. We updated smoking evals for all smoking residents. We have a smoking list of all residents who smoke. Upon admission we ask them if they like to smoke, and we add them to the list. And then for any residents who start to smoke after admission, they [residents] will notify us that they like to smoke, and we will add them to the smoking list. They will usually notify activities because they are the ones who purchase the cigarettes and lighters . [Resident #102] returned with a burn, so she returned with orders to care for her burn. She told me she wasn't in any pain, and she apologized about it. So now [Resident #162] takes her down to the smoking patio to make sure she goes there to smoke. Through the audits we found that residents were going to the courtyard to smoke and that is not a smoking area. We would see them and tell them you know you can't smoke out here, let's go to the smoking patio and they would flick the cigarette out and go to the smoking patio. There is no ash tray or smoking receptacles on the courtyard. Then they would tell me the door wasn't open to the smoking patio and it would be just a couple minutes that the door wasn't open during the smoking time. So as of last night [11/29/23] I have converted 2 staff to be designated smoking aides. The first staff comes in at 9:00 a.m. and leaves at 4:00p.m. and the second one comes at 4:00 p.m. and leaves at 11:30 p.m. On the weekends activity aides will be out there from 9:00a.m.-4:00p.m. then from 4:00p.m.-11:30p.m. the aide who normally does 4:00p.m.-11:30p.m. will cover that until I hire someone. She said she needs the extra hours by working 7 days a week. If she calls out, then we will staff an extra aide to cover. The staff are being educated today [11/30/23] on what each smoking resident needs and what. The smoking safety materials are documented in the care plan, on the Kardex, and I would have to look up exactly where that information is. So, I can tell you [Resident #96] and [Resident #191] and sometimes [Resident #57], I think that's his name, they go out front of the building and smoke. We tell them a million times hey you can't smoke up here, please don't smoke here and they will say oh my bad and they will throw out their butts and go off the property. We tell them every single day when you sign out LOA [leave of absence] that means you are leaving the property. Those guys are signing out LOA telling us they are leaving .I told them please feel free to use the employee smoking area . [Resident #61] is non-compliant with the smoking policy as well. He is one of the residents I caught on the courtyard. I don't think he was smoking a cigarette, by the time you get there close up to him he had something in his hand, but it wasn't lit. I assumed it wasn't a cigarette unless he rolls his own cigarettes. I suspect that has happened two separate times but by the time you get close to him he isn't smoking. The first time I saw him he was on the nonsmoking courtyard. He had the oxygen tank on the back of his wheelchair, the nasal cannula wasn't connected to it and the oxygen tank was not on. I can't recall the date, it could've been a few months ago, it's blending in with all the dates. It was noted that [Resident #61] didn't need a portable oxygen tank so his oxygen was discharged , he was educated, he was asked if we could search his room and he denied. He was issued a 30-day notice for non-compliance of the smoking policy because he was one of the smokers who signed the agreement that he would follow the smoking policy or else he would receive a 30-day notice . He said he wasn't going anywhere, and he wasn't smoking. To my knowledge he was not noncompliant since. We did close the non-smoking courtyard for a couple weeks until we figured out a plan. We opened it back up on 11/21/23 and it was closed down for 3 weeks prior to that. We have issued 30-day notices to 5 or 6 people, and they all refused to leave, and they all refused to sign it as well. We gave them a couple different SNF [Skilled Nursing Facility] options and some ALF's [Assisted Living Facility]. So now we are trying to cater to the situation to make it more welcoming to the smokers. My plan now is to alleviate all excuses they will say why they aren't going to comply to it. My next steps is to see if my regional people can take them to court. I just think the residents are just non-compliant and resistant to the rules. The only feedback I have gotten why they won't smoke on the smoking patio is that the staff are taking too long to get there. When we opened the courtyard back up the effective plan was that activities could stay out on the smoking patio all the time. I feel it is effective except for the residents who sign out and smoke out front. There have been no complaints from the resident; we actually got a thank you from the resident for having it open all the time. The NHA confirmed residents have paraphernalia on them and he confirmed it has the potential to affect all the residents in the facility including residents who do not smoke. The NHA said none of the residents who smoke have any other behaviors except maybe one but she is compliant with her behavior. An interview was conducted on 12/01/23 at 9:11 a.m. with Staff L, Social Services Assistant. She said, I am part of angel rounds. We do it [angel rounds] every day. We ask if there are any issues, check the rooms for trash bags, gloves, anything that needs to be labeled in bags, maintenance of the room check to see if anything needs to be checked up or fixed, check to make sure their call lights are in place. There is a check off sheet we fill out every day. When I do my angel round rooms, I don't think a lot of my residents smoke, but I don't recall seeing smoking materials out. I do see residents in the halls with their smoking materials going to the smoke porch. Review of Bristol Care Center ANGEL ROUNDS form, undated, revealed Daily Check List the sheet did not reveal a section related to smoking materials. An interview was conducted on 11/30/23 at 9:52 a.m. with Staff CC, Receptionist/Accounts Payable. She said, Before residents leave, they have to sign out at the nurse's station first because they have to check their charts to see if they have an LOA order and they call me from the nurses station and let me know. Then the residents have to sign out at my desk as well. [Resident #191] goes out front and smokes. They are supposed to be closer to the end of the road if they smoke. I don't know where [Resident #191] goes when he smokes. I have had education. I just know they are not supposed to be right here [pointed to the front door], they are supposed to be closer to the road .the ones I know who go out to smoke I don't look to see if they have left the property. I just know they have to smoke farther down, by the road; I don't know if that is off the property or not. I have only been here since April. An interview was conducted with the NHA on 11/30/23 at 3:53 p.m. He said he doesn't know how long the smoking issues had been going on. He excused himself from the interview. An interview was conducted with the Director of Nursing (DON) on 11/30/23 at 4:00 p.m. She said, We [facility staff] are not allowed to touch the residents' things and they tell us [facility staff] no when we ask to search their rooms . When the residents are in the hallway with their smoking materials on them, we ask can we have them and they give it up to us, but then the process happens again whether the family brings it to them, or they go on leave and they get it. This has been going on since I have been here in July [2023] that I have seen residents with their smoking materials on them. 1. A review of the Admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the resident was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she would expect to see oxygen saturations being monitored at least every shift. There should be ongoing monit[TRUNCATED]

Based on observation, record review and interview the facility failed to protect the resident's right to be free from abuse by not ensuring one resident (#30) out of two residents reviewed was free from restraints which caused physical harm (bruising and skin tear). Findings included: Review of the facility's November 2023 Reporting log showed one entry dated 11/19/23 with an allegation of abuse. The entry included Resident 30's name, the report number and the allegation of abuse was unsubstantiated. During an interview on 11/27/23 at 10:40 a.m. the Risk Manager (RM) stated she was notified by Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON) on 11/19/23 around 2:01 p.m. that a certified nursing assistant was transferring Resident #30 from bed to a wheelchair and caused Resident #30's hands to bruise and caused a skin tear. The RM stated, following the chain of command she notified the Administrator/Abuse Coordinator immediately. The RM stated Staff S, Certified Nursing Assistant (CNA) admitted to restraining Resident #30's hands down and caused the skin tear. The RM said, I immediately educated him on not restraining residents. The RM stated the incident occurred on 11/19/23 around 5:00 a.m.; however, I was not notified until 2:01 p.m. However, the staff know they are supposed to report to me immediately within 2 hours. The RM stated she spoke with Resident #30 who alleged Staff S, CNA came into his room and bruised his hands, all because he did not want to get up. The RM stated another resident called the police on behalf of Resident #30 and said she followed up with the police while they were here. The RM stated Staff S, CNA did work until the end of the shift on 11/19/23 due the incident not being reported to staff until the end of day shift around 2:45 p.m. Review of Staff S's, CNA witness statement, dated 11/20/23, showed, 530 AM second to last person I take care of. Usually I leave him until last because he don't like to be changed. Came in room with stuff to change him. He was sleeping and I turned on the lights [Resident #30] eyes open and repositioned himself he yelled at me turn lights off. I went to the sink he turned light off. I told him I need to change you. I turned the light back on I pulled the sheet off and he pulled it on, I pulled it back off again I explained his bed was wet and he need to be changed. He said [explicative] I want to sleep. I explained I can't leave you like this. I opened his brief. He was ok but when I tried to turn him like normally do, he punched me 10 times from a supine position. I grabbed right shoulder and turned him quickly while he was punching me. He tried to get up and still cussing me out after a while he gave up I changed his brief and gown I am not sure I successfully changed him and removed fitted sheet. He punched again and again I grabbed his hand and tore his skin on hand. I only grabbed the hand that tore. I do hold his hand down when your replacing he tried to wipe his blood on me. I then told the nurse his hand was torn when I grabbed his hand from his punches. He was still cursing me out and I grabbed the wheelchair to help him in the bed, but he transferred himself back to bed. He call me the N word lots of time. I am sorry about grabbing his arms I didn't mean to hurt his hand. During an interview on 11/27/23 at 10:50 a.m. the RM stated Staff S, CNA should have introduced himself and left Resident #30 alone as he asked. The RM stated Staff S, CNA did not respect or show dignity to Resident #30 by restraining him and opening his brief. The RM stated she started education on abuse with the entire building, but only educated Staff S, CNA on not restraining residents. The RM stated no respect or dignity training was provided to staff. The RM stated Staff S, CNA was terminated because of a substantiated allegation of abuse. Review of Staff T's, Registered Nurse (RN) witness statement dated 11/19/23 at 5:30 p.m. showed, Called to the room this morning 11/19/23 at 6:00 a.m. by Nursing Assistant. Reported patient with skin tear to right hand. Small amount of bleeding noted. Area cleaned bandaged applied. Nursing Assistant was changing linen. Cause unknown. Review of Resident #88's witness statement dated 11/19/23 at 2:28 p.m. showed, Resident states she call the [County] Sheriff Department to report that [Resident #30] got jumped on. Resident states [Resident #30] told her CNA rough with him. Review of Resident #30's witness statement dated 11/19/23 at 2:25 p.m. showed, Resident states around 6 am guy come in and grab his night shirt and stated he has to get you up. Grabs my hands to sit me up and I stated, look at what your doing you stupid Nurse then he left I transferred to wheelchair. My hand bleeding and bruise. Review of Staff U's, Licensed Practical Nurse (LPN) witness statement dated 11/19/23 at 3:50 p.m. showed, This nurse arrived this AM. Was given report by an off going LPN (nightshift). She stated resident received a skin tear and then she cleaned it up and applied a [adhesive bandage]. No further details were given. Review of the facility's five-day reportable showed the 11/19/23 allegation of abuse was not substantiated. Review of Staff S's, CNA employee record revealed a Notice of Disciplinary Action dated 11/20/23 and showed, 11-19-23 Alleged Abuse pending investigation. 11-20-23 12:43 p.m. Alleged abuse upon investigation was found to be substantiated. Investigation performed, Abuse found to be substantiated . CNA terminated. During an interview on 11/27/23 at 11:15 a.m. the RM stated there was a discrepancy between the five-day reportable results and Staff S's, CNA employee file. The RM stated Staff S, CNA was terminated due to the abuse of Resident #30. The RM stated the Administrator/Abuse Coordinator was responsible for making the final decision as to whether an abuse investigation was substantiated or not. During an interview on 11/29/23 at 11:30 a.m. the Administrator/Abuse Coordinator stated, I went by the definition of abuse when I answered No to the allegation being substantiated. The Administrator/ Abuse Coordinator stated abuse was defined as a willful act to cause harm. The Administrator/ Abuse Coordinator stated he believed that Staff S, CNA did not go into Resident #30's room and willfully set out to hurt Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was wrong for holding Resident #30 down, and confirmed Staff S's actions caused harm resulting in a skin tear. Continuing, he stated but Staff S, CNA did not willfully mean to harm [Resident #30]. The Administrator/Abuse Coordinator stated Staff S, CNA was terminated because he restrained Resident #30 and should not have acted this way. The Administrator/Abuse Coordinator stated that Staff S's employee record was wrong because the abuse was not substantiated. The Administrator/Abuse Coordinator was asked why was Staff S terminated if abuse was not substantiated? The Administrator/Abuse Coordinator stated Staff S was terminated because he should have left Resident #30's room when he was asked to, but he chose to stay. The Administrator/Abuse Coordinator was asked for any reasonable person who stated No to another person's actions and it is not respected wouldn't that be considered intentional actions? The Administrator/Abuse Coordinator stated, To me, he did not set out to willfully hurt the resident. I know the resident and I know the employee and I know there was no willful act to cause harm, but because he did not walk away he was termed because his actions resulted in harm. Review of the Admission Record showed Resident #30 was admitted to the facility on [DATE] with diagnoses to include to urinary tract infection, site not specified, paroxysmal atrial fibrillation, muscle weakness generalized, adult failure to thrive and schizoaffective disorder, bipolar type. Review of Resident #30's current care plan, initiated on 12/2/21, showed, Focus: [Resident #30] prefers to deviate from plan of care with refusing psych services. Interventions: Accept resident's right to refuse and show respect for resident's decisions. The goal, with a target date of 12/28/23, showed: Resident will remain free from complications related to deviation from plan of care thru next review date. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). Review of a progress noted dated 11/19/2023 at 6:27 a.m. showed, Patient noted with skin tear to right low hand. Small amount of bleeding noted. Area cleaned and dry bandage applied. An additional progress note dated 11/19/2023 at 3:27 p.m. showed, Resident called 911 they arrived. MOD [Manager on Duty] notified resident making allegations. Risk manager notified. Spoke with ARNP [Advance Registered Nurse Practitioner] for [Doctor's Name] to notify them of the incident. Residents [family member] called no message left voicemail full. Skin assessment completed. Review of Resident #30's skin assessment dated [DATE] at 3:34 p.m. showed, B. NEW skin conditions: Right hand (back) skin tear, Left hand (back) discoloration noted and other (specify) discoloration right arm above wrist. During an interview on 11/30/23 at 8:50 a.m. Resident #30 stated the morning that [Staff S, CNA] woke me up it was about 6:00 a.m. and [Staff S] told me I had to get up. I do not like to get up until about 8:30 a.m. Resident #30 stated, when I told [Staff S] No, [Staff S] proceeded to pull me up by my arms bruising me. Resident #30 stated he continued to tell Staff S he did not want to get up however Staff S CNA did not listen and pulled him by his arms to a seated position on his bed. Resident #30 stated, I feel like I was abused. An observation on 11/30/23 at 8:50 a.m. showed Resident #30 had bruising on his left arm above the wrist and a skin tear on his right hand. Photographic Evidence was obtained with the resident's permission. During an interview on 11/30/23 at 2:00 p.m. Staff U, Licensed Practical Nurse (LPN) stated when she came on shift about 6:45 a.m. the day of 11/19/23 she was given report by the morning nurse who stated Resident # 30 had a new skin tear that was cleaned up and a bandage was put on it. She said there was no mention of abuse and she did not think to ask about abuse. Staff U, LPN stated, I was the nurse who completed the skin assessment on 11/19/23. Review of the facility's policy titled, Abuse, Neglect, Exploitations and Misappropriation Prevention Program, revised date April 2021 showed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive and emotional problems.

Based on observation, record review and interview the facility failed to protect the resident's right to be free from abuse by not ensuring one resident (#30) out of two residents reviewed was free from restraints which caused physical harm (bruising and skin tear). Findings included: Review of the facility's November 2023 Reporting log showed one entry dated 11/19/23 with an allegation of abuse. The entry included Resident 30's name, the report number and the allegation of abuse was unsubstantiated. During an interview on 11/27/23 at 10:40 a.m. the Risk Manager (RM) stated she was notified by Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON) on 11/19/23 around 2:01 p.m. that a certified nursing assistant was transferring Resident #30 from bed to a wheelchair and caused Resident #30's hands to bruise and caused a skin tear. The RM stated, following the chain of command she notified the Administrator/Abuse Coordinator immediately. The RM stated Staff S, Certified Nursing Assistant (CNA) admitted to restraining Resident #30's hands down and caused the skin tear. The RM said, I immediately educated him on not restraining residents. The RM stated the incident occurred on 11/19/23 around 5:00 a.m.; however, I was not notified until 2:01 p.m. However, the staff know they are supposed to report to me immediately within 2 hours. The RM stated she spoke with Resident #30 who alleged Staff S, CNA came into his room and bruised his hands, all because he did not want to get up. The RM stated another resident called the police on behalf of Resident #30 and said she followed up with the police while they were here. The RM stated Staff S, CNA did work until the end of the shift on 11/19/23 due the incident not being reported to staff until the end of day shift around 2:45 p.m. Review of Staff S's, CNA witness statement, dated 11/20/23, showed, 530 AM second to last person I take care of. Usually I leave him until last because he don't like to be changed. Came in room with stuff to change him. He was sleeping and I turned on the lights [Resident #30] eyes open and repositioned himself he yelled at me turn lights off. I went to the sink he turned light off. I told him I need to change you. I turned the light back on I pulled the sheet off and he pulled it on, I pulled it back off again I explained his bed was wet and he need to be changed. He said [explicative] I want to sleep. I explained I can't leave you like this. I opened his brief. He was ok but when I tried to turn him like normally do, he punched me 10 times from a supine position. I grabbed right shoulder and turned him quickly while he was punching me. He tried to get up and still cussing me out after a while he gave up I changed his brief and gown I am not sure I successfully changed him and removed fitted sheet. He punched again and again I grabbed his hand and tore his skin on hand. I only grabbed the hand that tore. I do hold his hand down when your replacing he tried to wipe his blood on me. I then told the nurse his hand was torn when I grabbed his hand from his punches. He was still cursing me out and I grabbed the wheelchair to help him in the bed, but he transferred himself back to bed. He call me the N word lots of time. I am sorry about grabbing his arms I didn't mean to hurt his hand. During an interview on 11/27/23 at 10:50 a.m. the RM stated Staff S, CNA should have introduced himself and left Resident #30 alone as he asked. The RM stated Staff S, CNA did not respect or show dignity to Resident #30 by restraining him and opening his brief. The RM stated she started education on abuse with the entire building, but only educated Staff S, CNA on not restraining residents. The RM stated no respect or dignity training was provided to staff. The RM stated Staff S, CNA was terminated because of a substantiated allegation of abuse. Review of Staff T's, Registered Nurse (RN) witness statement dated 11/19/23 at 5:30 p.m. showed, Called to the room this morning 11/19/23 at 6:00 a.m. by Nursing Assistant. Reported patient with skin tear to right hand. Small amount of bleeding noted. Area cleaned bandaged applied. Nursing Assistant was changing linen. Cause unknown. Review of Resident #88's witness statement dated 11/19/23 at 2:28 p.m. showed, Resident states she call the [County] Sheriff Department to report that [Resident #30] got jumped on. Resident states [Resident #30] told her CNA rough with him. Review of Resident #30's witness statement dated 11/19/23 at 2:25 p.m. showed, Resident states around 6 am guy come in and grab his night shirt and stated he has to get you up. Grabs my hands to sit me up and I stated, look at what your doing you stupid Nurse then he left I transferred to wheelchair. My hand bleeding and bruise. Review of Staff U's, Licensed Practical Nurse (LPN) witness statement dated 11/19/23 at 3:50 p.m. showed, This nurse arrived this AM. Was given report by an off going LPN (nightshift). She stated resident received a skin tear and then she cleaned it up and applied a [adhesive bandage]. No further details were given. Review of the facility's five-day reportable showed the 11/19/23 allegation of abuse was not substantiated. Review of Staff S's, CNA employee record revealed a Notice of Disciplinary Action dated 11/20/23 and showed, 11-19-23 Alleged Abuse pending investigation. 11-20-23 12:43 p.m. Alleged abuse upon investigation was found to be substantiated. Investigation performed, Abuse found to be substantiated . CNA terminated. During an interview on 11/27/23 at 11:15 a.m. the RM stated there was a discrepancy between the five-day reportable results and Staff S's, CNA employee file. The RM stated Staff S, CNA was terminated due to the abuse of Resident #30. The RM stated the Administrator/Abuse Coordinator was responsible for making the final decision as to whether an abuse investigation was substantiated or not. During an interview on 11/29/23 at 11:30 a.m. the Administrator/Abuse Coordinator stated, I went by the definition of abuse when I answered No to the allegation being substantiated. The Administrator/ Abuse Coordinator stated abuse was defined as a willful act to cause harm. The Administrator/ Abuse Coordinator stated he believed that Staff S, CNA did not go into Resident #30's room and willfully set out to hurt Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was wrong for holding Resident #30 down, and confirmed Staff S's actions caused harm resulting in a skin tear. Continuing, he stated but Staff S, CNA did not willfully mean to harm [Resident #30]. The Administrator/Abuse Coordinator stated Staff S, CNA was terminated because he restrained Resident #30 and should not have acted this way. The Administrator/Abuse Coordinator stated that Staff S's employee record was wrong because the abuse was not substantiated. The Administrator/Abuse Coordinator was asked why was Staff S terminated if abuse was not substantiated? The Administrator/Abuse Coordinator stated Staff S was terminated because he should have left Resident #30's room when he was asked to, but he chose to stay. The Administrator/Abuse Coordinator was asked for any reasonable person who stated No to another person's actions and it is not respected wouldn't that be considered intentional actions? The Administrator/Abuse Coordinator stated, To me, he did not set out to willfully hurt the resident. I know the resident and I know the employee and I know there was no willful act to cause harm, but because he did not walk away he was termed because his actions resulted in harm. Review of the admission Record showed Resident #30 was admitted to the facility on [DATE] with diagnoses to include to urinary tract infection, site not specified, paroxysmal atrial fibrillation, muscle weakness generalized, adult failure to thrive and schizoaffective disorder, bipolar type. Review of Resident #30's current care plan, initiated on 12/2/21, showed, Focus: [Resident #30] prefers to deviate from plan of care with refusing psych services. Interventions: Accept resident's right to refuse and show respect for resident's decisions. The goal, with a target date of 12/28/23, showed: Resident will remain free from complications related to deviation from plan of care thru next review date. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). Review of a progress noted dated 11/19/2023 at 6:27 a.m. showed, Patient noted with skin tear to right low hand. Small amount of bleeding noted. Area cleaned and dry bandage applied. An additional progress note dated 11/19/2023 at 3:27 p.m. showed, Resident called 911 they arrived. MOD [Manager on Duty] notified resident making allegations. Risk manager notified. Spoke with ARNP [Advance Registered Nurse Practitioner] for [Doctor's Name] to notify them of the incident. Residents [family member] called no message left voicemail full. Skin assessment completed. Review of Resident #30's skin assessment dated [DATE] at 3:34 p.m. showed, B. NEW skin conditions: Right hand (back) skin tear, Left hand (back) discoloration noted and other (specify) discoloration right arm above wrist. During an interview on 11/30/23 at 8:50 a.m. Resident #30 stated the morning that [Staff S, CNA] woke me up it was about 6:00 a.m. and [Staff S] told me I had to get up. I do not like to get up until about 8:30 a.m. Resident #30 stated, when I told [Staff S] No, [Staff S] proceeded to pull me up by my arms bruising me. Resident #30 stated he continued to tell Staff S he did not want to get up however Staff S CNA did not listen and pulled him by his arms to a seated position on his bed. Resident #30 stated, I feel like I was abused. An observation on 11/30/23 at 8:50 a.m. showed Resident #30 had bruising on his left arm above the wrist and a skin tear on his right hand. Photographic Evidence was obtained with the resident's permission. During an interview on 11/30/23 at 2:00 p.m. Staff U, Licensed Practical Nurse (LPN) stated when she came on shift about 6:45 a.m. the day of 11/19/23 she was given report by the morning nurse who stated Resident # 30 had a new skin tear that was cleaned up and a bandage was put on it. She said there was no mention of abuse and she did not think to ask about abuse. Staff U, LPN stated, I was the nurse who completed the skin assessment on 11/19/23. Review of the facility's policy titled, Abuse, Neglect, Exploitations and Misappropriation Prevention Program, revised date April 2021 showed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive and emotional problems.

Based on observation, record review and interview the facility failed to ensure all allegations of abuse and injuries of unknown source were reported within the required two hour time frame for two residents (#30 and #137) out of two residents reviewed for reporting allegations of abuse. Findings included: 1. Review of the facility's November 2023 Reporting log showed one entry dated 11/19/23 with an allegation of abuse. The entry included Resident 30's name, report number and the allegation of abuse was unsubstantiated. During an interview on 11/27/23 at 10:40 a.m. Staff R, Risk Manager (RM) stated she was notified by Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON) on 11/19/23 around 2:01 p.m. that a certified nursing assistant was transferring Resident #30 from bed to a wheelchair and caused Resident #30's hands to bruise and caused a skin tear. The RM stated, following the chain of command she notified the Administrator/Abuse Coordinator immediately. The RM stated that Staff S, Certified Nursing Assistant (CNA) admitted to restraining Resident #30's hands down and caused the skin tear. The RM stated, I immediately educated him on not restraining Residents. The RM stated the incident occurred on 11/19/23 around 5:00 a.m. however I was not notified until 2:01 p.m. The RM stated the staff know they are supposed to report to me immediately within two hours. The RM stated the facility reported the allegation of abuse a little later than the two hours required. The RM stated when the allegation was reported to her at 2:01 p.m. on 11/19/23 she believed the allegation was not reported until around 5:00 p.m. on 11/19/23, missing the mandatory two hour reportable time. The RM was asked for a copy of the Nursing Home Reporting Federal Five Day Report Manager Status Log for the reported incident. Review of the Nursing Home Reporting Federal Five Day Report Manager Status Log showed Resident #30's immediate report [number] was initially submitted to the State Agency on 11/19/23 at 6:13 p.m. Review of Staff S's, CNA witness statement, dated 11/20/23 showed, 530 AM second to last person I take care of. Usually I leave him until last because he don't like to be changed. Came in room with stuff to change him. He was sleeping and I turned on the lights [Resident #30] eyes open and repositioned himself he yelled at me turn lights off. I went to the sink he turned light off. I told him I need to change you. I turned the light back on I pulled the sheet off and he pulled it on, I pulled it back off again I explained his bed was wet and he need to be changed. He said [explicative] I want to sleep. I explained I can't leave you like this. I opened his brief. He was ok but when I tried to turn him like normally do, he punched me 10 times from a supine position. I grabbed right shoulder and turned him quickly while he was punching me. He tried to get up and still cussing me out after a while he gave up I changed his brief and gown I am not sure I successfully changed him and removed fitted sheet. He punched again and again I grabbed his hand and tore his skin on hand. I only grabbed the hand that tore. I do hold his hand down when your replacing he tried to wipe his blood on me. I then told the nurse his hand was torn when I grabbed his hand from his punches. He was still cursing me out and I grabbed the wheelchair to help him in the bed, but he transferred himself back to bed. He call me the N word lots of time. I am sorry about grabbing his arms I didn't mean to hurt his hand. During an interview on 11/27/23 at 10:50 a.m. the RM stated Staff S should have introduced himself and left Resident #30 alone as he asked. The RM stated Staff S certainly did not respect or show dignity to Resident #30 by restraining him and opening his brief. The RM stated Staff S, CNA was terminated because of a substantiated allegation of abuse. Review of Staff T's, Registered Nurse (RN) witness statement dated 11/19/23 at 5:30 p.m. showed, Called to the room this morning 11/19/23 at 6:00 a.m. by Nursing Assistant. Reported patient with skin tear to right hand. Small amount of bleeding noted. Area cleaned bandaged applied. Nursing Assistant was changing linen. Cause unknown. Review of Resident #88's witness statement dated 11/19/23 at 2:28 p.m. showed, Resident states she call the [County] Sheriff Department to report that [Resident #30] got jumped on. Resident states [Resident #30] told her CNA rough with him. Review of Resident #30's witness statement dated 11/19/23 at 2:25 p.m. showed, Resident states around 6 am guy come in and grab his night shirt and stated he has to get you up. Grabs my hands to sit me up and I stated look at what your doing you stupid Nurse then he left I transferred to wheelchair. My hand bleeding and bruise. Review of Staff U's, Licensed Practical Nurse (LPN) witness statement dated 11/19/23 at 3:50 p.m. showed, This nurse arrived this AM. Was given report by an off going LPN (nightshift). She stated the resident received a skin tear and then she cleaned it up and applied a band-aid. No further details were given. Review of the facility's five-day reportable showed the 11/19/23 allegation of abuse was not substantiated. Review of Staff S's, CNA employee record revealed a Notice of Disciplinary Action dated 11/20/23 and showed, 11-19-23 Alleged Abuse pending investigation. 11-20-23 12:43 p.m. Alleged abuse upon investigation was found to be substantiated. Investigation performed, Abuse found to be substantiated. CNA terminated. During an interview on 11/27/23 at 11:15 a.m. the RM stated there was a discrepancy between the five-day reportable results and Staff S's, CNA employee file. The RM stated Staff S, CNA was terminated due to the abuse of Resident #30. The RM stated the Administrator/Abuse Coordinator was responsible for making the final decision as to whether an abuse investigation was substantiated or not. During an interview on 11/29/23 at 11:30 a.m. the Administrator/Abuse Coordinator stated, I went by the definition of abuse when I answered No to the allegation being substantiated. The Administrator/ Abuse Coordinator stated abuse was defined as a willful act to cause harm. The Administrator/ Abuse Coordinator stated he believed that Staff S, CNA did not go into Resident #30's room and willfully set out to hurt Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was wrong for holding Resident #30 down, and confirmed Staff S's actions caused harm resulting in a skin tear. Continuing, he stated but Staff S, CNA did not willfully mean to harm Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was terminated because he restrained Resident #30 and should not have acted this way. The Administrator/Abuse Coordinator stated that Staff S's employee record was wrong because the abuse was not substantiated. The Administrator/Abuse Coordinator was asked why was Staff S terminated if abuse was not substantiated? The Administrator/Abuse Coordinator stated Staff S was terminated because he should have left Resident #30's room when he was asked to, but he chose to stay. The Administrator/Abuse Coordinator was asked for any reasonable person who stated No to another person's actions and it is not respected wouldn't that be considered intentional actions? The Administrator/Abuse Coordinator stated, To me, he did not set out to willfully hurt the resident. I know the resident and I know the employee and I know there was no willful act to cause harm, but because he did not walk away he was termed because his actions resulted in harm. Review of the Admission Record showed Resident #30 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, site not specified, paroxysmal atrial fibrillation, muscle weakness generalized, adult failure to thrive and schizoaffective disorder, bipolar type. Review of Resident #30's current care plan, initiated on 12/2/21, showed, Focus: [Resident #30] prefers to deviate from plan of care with refusing psych services. Interventions: Accept resident's right to refuse and show respect for resident's decisions. The goal, with a target date of 12/28/23, showed: Resident will remain free from complications related to deviation from plan of care thru next review date. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). Review of a progress noted dated 11/19/2023 at 6:27 a.m. showed, Patient noted with skin tear to right low hand. Small amount of bleeding noted. Area cleaned and dry bandage applied. An additional progress note dated 11/19/2023 at 3:27 p.m. showed, Resident called 911 they arrived. MOD [Manager on Duty] notified resident making allegations. Risk manager notified. Spoke with ARNP [Advance Registered Nurse Practitioner] for [Doctor's Name] to notify them of the incident. Residents [family member] called no message left voicemail full. Skin assessment completed. Review of Resident #30's skin assessment dated [DATE] at 3:34 p.m. showed, B. NEW skin conditions: Right hand (back) skin tear, Left hand (back) discoloration noted and other (specify) discoloration right arm above wrist. During an interview on 11/30/23 at 8:50 a.m. Resident #30 stated the morning that [Staff S, CNA] woke me up it was about 6:00 a.m. and [Staff S] told me I had to get up. I do not like to get up until about 8:30 a.m. Resident #30 stated, when I told [Staff S] No, [Staff S] proceeded to pull me up by my arms bruising me. Resident #30 stated he continued to tell Staff S he did not want to get up however Staff S CNA did not listen and pulled him by his arms to a seated position on his bed. Resident #30 stated, I feel like I was abused. An observation on 11/30/23 at 8:50 a.m. showed Resident #30 had bruising on his left arm above the wrist and a skin tear on his right hand. Photographic Evidence was obtained with the resident's permission. During an interview on 11/30/23 at 2:00 p.m. Staff U, Licensed Practical Nurse (LPN) stated when she came on shift about 6:45 a.m. the day of 11/19/23 she was given report by the morning nurse who stated Resident # 30 had a new skin tear that was cleaned up and a bandage was put on it. She said there was no mention of abuse and she did not think to ask about abuse. Staff U, LPN stated, I was the nurse who completed the skin assessment on 11/19/23. 2. During an interview on 11/27/23 at 10:15 a.m. Resident #137 stated Staff V, Registered Nurse (RN) came in my room on Tuesday (11/21/23) and deliberately caused a verbal fight with her. Resident #137 stated she asked Staff V, RN to come in twice a shift but Staff V only came in once at 7:30 p.m. Resident #137 stated, all other nurses come in twice a shift except for Staff V and she had never checked my blood sugar, gave me insulin or checked my blood pressure. Resident #137 stated, when Staff V, RN was asked to come to my room twice a shift she (Staff V) said, Don't tell me how to do my job. I asked for the other nurse on shift to come give me my medications because I did not trust Staff V, RN to give them to me, but the other nurse never came. Resident #137 stated on Thursday (11/23/23) I did not get my insulin or blood pressure medication again. Resident #137 stated on Friday (11/24/23) Staff V, RN came to my room and started another fight with me and said to me, I am here today so you don't want your medication again. Resident #137 stated she told Staff V, RN no that I would like for the other nurse to give my meds to me, and that was when Staff V responded the other nurse was not going to give the meds to you. Resident #137 stated Staff V told her that she (Resident #137) had a problem with everyone. Resident #137 stated, I said no, I just don't want my meds given to me by you. Resident #137 stated she waited a while and didn't get her meds so she called the non- emergency sheriff's department line on Friday (11/23/23) when Staff V, RN would not give her medications to her again. Resident #137 stated an officer from the [County] Sheriff's department came and talked with me. I informed the officer that I don't trust Staff V, RN because she has never given me my medication or checked my blood sugar, not once. Resident #137 stated the police officer got the other nurse to give her medications but the other nurse stated Staff V, RN never told her Resident #137 requested her for medication administration. Resident #137 stated, I told staff I wanted to file a grievance about this but no one came in to have me file one yet. Review of the Facility's Grievance Log from September 2023 to November 2023 showed no grievances related to medication administration concerns. During an interview on 11/27/23 at 11:17 a.m. the Administrator/Abuse Coordinator stated police were called to the facility last week, but it was not about Resident #137. The Administrator/Abuse Coordinator stated he had not heard of any incidents related to Resident #137 last week. The Administrator/Abuse Coordinator stated if there was an incident the Unit Manager should have informed the Risk Manager who would have then informed him. The Administrator/Abuse Coordinator stated he was only present in the facility on 11/24/23 for about four hours that day. When informed Resident #137 called the police on Friday and they responded to a concern that Staff V, RN was not providing medication to Resident #137, the Administrator/Abuse Coordinator stated no reporting had been completed on this allegation from 11/24/23. He stated no one had notified him of this incident until now. The Administrator/Abuse Coordinator stated, They should report to the Risk Manager and then to me so that we can ensure timely reporting. This was not done. The Administrator/Abuse Coordinator stated anytime the police were in the facility it should be reported to him. During an interview on 11/27/23 at 12:32 p.m. Staff J, LPN/UM (Licensed Practical Nurse/Unit Manager) stated she did have a conversation with Staff V, RN about giving her medications. Staff J, LPN/UM stated Resident #137 did not want Staff V, RN to give her medications. Staff J, LPN/UM stated she called Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON), who advised if Resident #137 wanted to refuse medications have Staff V, RN with two other staff as witnesses to offer medications to Resident #137. During an interview on 11/27/23 at 3:00 p.m. Staff W, Certified Nursing Assistant (CNA) stated Resident #137 never refused care from him. Staff W, CNA stated Resident #137 asked for another nurse to give her medications on Friday and then the next thing the police came. Staff W, CNA stated he witnessed Resident #137 refusal for Staff V, RN's attempt to administer medications. Resident #137 asked for another nurse to give her medications and then Staff Y, Licensed Practical Nurse (LPN) administered Resident #137's medications after the police left. During an interview on 11/27/23 at 3:15 p.m. Staff Y, LPN stated on 11/24/23, 11/25/23 and 11/26/23 she administered medications to Resident #137. Staff Y, LPN stated Staff V, RN would come get her to administer Resident #137's medications when it was time. Staff Y, LPN stated that it does not happen very often that she would have to give medications for another nurse, but she did on 11/24/23, 11/25/23 and 11/26/23. Staff Y, LPN stated Resident #137 was alert and oriented and had the right to request she administer her medications. Review of the Admission Record showed Resident #137 was admitted to the facility on [DATE] with diagnoses to include unspecified diastolic (congestive) heart failure, type 2 diabetes without complications, major depressive disorder, single episode, moderate and chronic migraine without aura. Review of the care plan revealed it was updated on 11/24/23 with a new focus that showed, [Resident #137] exhibits the following behaviors: combative with care, refusing medications, anxiousness, etc- refusing nursing care, speaker music extremely loud. The interventions included: Anticipate care needs and provide them before resident becomes overly stressed, Approach resident in a calm manner and explain actions, reappproach resident if agitation is noted, request psychiatric consult if needed and update the physician of increased presence or severity of behaviors. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #137 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact). During an interview on 11/29/23 at 10:50 a.m. the Risk Manager (RM) stated she was first made aware of the incident involving Resident #137 on 11/24/23 by the Agency for Health Care Administration (AHCA) surveyor who reported the allegation on 11/27/23 to the Administrator. The RM stated she reviewed Resident #137's medication administration record for November 2023 and Resident #137 did miss her medications on 11/22/23 and 11/23/23. The RM stated the one date showed medication was refused. The RM stated any resident had the right to be provided medication by another nurse. The RM stated Staff V, RN had been suspended as of today pending investigation. The RM stated knowing the conflict between Staff V, RN and Resident #137, If I have anything to do with it [Staff V RN] would not be assigned to [Resident #137] again. Continuing she said, I plan to go through to see if any grievances for medication look at refusals. The RM stated law enforcement was notified of the incident on 11/24/23 by Resident #137 and Resident #137's representative and Abuse Registry were notified on 11/27/23 after the AHCA Surveyor reported the incident to the facility. During an interview on 11/29/23 at 1:20 p.m. the Administrator/Abuse Coordinator stated, We are currently investigating so, I don't feel comfortable talking about this case until we fully investigate this. During a telephone interview on 11/29/23 at 2:55 p.m. Staff V, RN stated Resident #137 never had a problem until the facility put a roommate in Resident #137's room that she did not like. Staff V, RN stated she had known Resident #137 for a long time. Staff V stated that she explained to Resident #137 she did not have a private room, so a roommate was placed in her room. Staff V stated Resident #137 started saying, I don't like you. Staff V, RN stated Resident #137 accused her of giving her the wrong pill and told me I do what I want. Staff V stated Resident #137 does not like when staff go in her room, and with a roommate staff have to go in the room. Staff V stated after that Resident #137 started saying I was not to administer her medications anymore. I did notify Staff J, LPN/UM that Resident #137 called the police and refused for me to administer her medications. I did work 11/25/23 and 11/26/23 on Resident #137's unit after the incident on 11/24/23, but I never took care of [Resident #137] again. I never went back into [Resident #137's] room again. Staff V, RN stated, Right now I am suspended pending investigation. During an interview on 11/30/23 at 2:55 p.m. Staff J, LPN/UM stated Staff V, RN did report to me and informed me the police were at the facility on 11/24/23. Staff J LPN/UM stated she was informed that Resident #137 called the police regarding medication refusal. Staff J, LPN/UM stated that she made sure that she reported the police presence in the facility to the Risk Manager on 11/24/23. During an interview on 11/30/23 at 3:00 p.m. the Risk Manager (RM) stated she did not recall getting any notice on 11/24/23 from Staff J, LPN/UM. The RM proceeded to take out two phones and showed there were no emails or texts on 11/24/23 from Staff J, LPN/UM. The RM stated the first time she heard about the police being in the facility for Resident #137 was when the State Surveyor reported it. Review of the facility's policy titled, Abuse, Neglect, Exploitations and Misappropriation - Reporting and Investigating, revised September 2022, showed: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to law. 3. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury.

Based on observation, record review and interview the facility failed to ensure all allegations of abuse and injuries of unknown source were reported within the required two hour time frame for two residents (#30 and #137) out of two residents reviewed for reporting allegations of abuse. Findings included: 1. Review of the facility's November 2023 Reporting log showed one entry dated 11/19/23 with an allegation of abuse. The entry included Resident 30's name, report number and the allegation of abuse was unsubstantiated. During an interview on 11/27/23 at 10:40 a.m. Staff R, Risk Manager (RM) stated she was notified by Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON) on 11/19/23 around 2:01 p.m. that a certified nursing assistant was transferring Resident #30 from bed to a wheelchair and caused Resident #30's hands to bruise and caused a skin tear. The RM stated, following the chain of command she notified the Administrator/Abuse Coordinator immediately. The RM stated that Staff S, Certified Nursing Assistant (CNA) admitted to restraining Resident #30's hands down and caused the skin tear. The RM stated, I immediately educated him on not restraining Residents. The RM stated the incident occurred on 11/19/23 around 5:00 a.m. however I was not notified until 2:01 p.m. The RM stated the staff know they are supposed to report to me immediately within two hours. The RM stated the facility reported the allegation of abuse a little later than the two hours required. The RM stated when the allegation was reported to her at 2:01 p.m. on 11/19/23 she believed the allegation was not reported until around 5:00 p.m. on 11/19/23, missing the mandatory two hour reportable time. The RM was asked for a copy of the Nursing Home Reporting Federal Five Day Report Manager Status Log for the reported incident. Review of the Nursing Home Reporting Federal Five Day Report Manager Status Log showed Resident #30's immediate report [number] was initially submitted to the State Agency on 11/19/23 at 6:13 p.m. Review of Staff S's, CNA witness statement, dated 11/20/23 showed, 530 AM second to last person I take care of. Usually I leave him until last because he don't like to be changed. Came in room with stuff to change him. He was sleeping and I turned on the lights [Resident #30] eyes open and repositioned himself he yelled at me turn lights off. I went to the sink he turned light off. I told him I need to change you. I turned the light back on I pulled the sheet off and he pulled it on, I pulled it back off again I explained his bed was wet and he need to be changed. He said [explicative] I want to sleep. I explained I can't leave you like this. I opened his brief. He was ok but when I tried to turn him like normally do, he punched me 10 times from a supine position. I grabbed right shoulder and turned him quickly while he was punching me. He tried to get up and still cussing me out after a while he gave up I changed his brief and gown I am not sure I successfully changed him and removed fitted sheet. He punched again and again I grabbed his hand and tore his skin on hand. I only grabbed the hand that tore. I do hold his hand down when your replacing he tried to wipe his blood on me. I then told the nurse his hand was torn when I grabbed his hand from his punches. He was still cursing me out and I grabbed the wheelchair to help him in the bed, but he transferred himself back to bed. He call me the N word lots of time. I am sorry about grabbing his arms I didn't mean to hurt his hand. During an interview on 11/27/23 at 10:50 a.m. the RM stated Staff S should have introduced himself and left Resident #30 alone as he asked. The RM stated Staff S certainly did not respect or show dignity to Resident #30 by restraining him and opening his brief. The RM stated Staff S, CNA was terminated because of a substantiated allegation of abuse. Review of Staff T's, Registered Nurse (RN) witness statement dated 11/19/23 at 5:30 p.m. showed, Called to the room this morning 11/19/23 at 6:00 a.m. by Nursing Assistant. Reported patient with skin tear to right hand. Small amount of bleeding noted. Area cleaned bandaged applied. Nursing Assistant was changing linen. Cause unknown. Review of Resident #88's witness statement dated 11/19/23 at 2:28 p.m. showed, Resident states she call the [County] Sheriff Department to report that [Resident #30] got jumped on. Resident states [Resident #30] told her CNA rough with him. Review of Resident #30's witness statement dated 11/19/23 at 2:25 p.m. showed, Resident states around 6 am guy come in and grab his night shirt and stated he has to get you up. Grabs my hands to sit me up and I stated look at what your doing you stupid Nurse then he left I transferred to wheelchair. My hand bleeding and bruise. Review of Staff U's, Licensed Practical Nurse (LPN) witness statement dated 11/19/23 at 3:50 p.m. showed, This nurse arrived this AM. Was given report by an off going LPN (nightshift). She stated the resident received a skin tear and then she cleaned it up and applied a band-aid. No further details were given. Review of the facility's five-day reportable showed the 11/19/23 allegation of abuse was not substantiated. Review of Staff S's, CNA employee record revealed a Notice of Disciplinary Action dated 11/20/23 and showed, 11-19-23 Alleged Abuse pending investigation. 11-20-23 12:43 p.m. Alleged abuse upon investigation was found to be substantiated. Investigation performed, Abuse found to be substantiated. CNA terminated. During an interview on 11/27/23 at 11:15 a.m. the RM stated there was a discrepancy between the five-day reportable results and Staff S's, CNA employee file. The RM stated Staff S, CNA was terminated due to the abuse of Resident #30. The RM stated the Administrator/Abuse Coordinator was responsible for making the final decision as to whether an abuse investigation was substantiated or not. During an interview on 11/29/23 at 11:30 a.m. the Administrator/Abuse Coordinator stated, I went by the definition of abuse when I answered No to the allegation being substantiated. The Administrator/ Abuse Coordinator stated abuse was defined as a willful act to cause harm. The Administrator/ Abuse Coordinator stated he believed that Staff S, CNA did not go into Resident #30's room and willfully set out to hurt Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was wrong for holding Resident #30 down, and confirmed Staff S's actions caused harm resulting in a skin tear. Continuing, he stated but Staff S, CNA did not willfully mean to harm Resident #30. The Administrator/Abuse Coordinator stated Staff S, CNA was terminated because he restrained Resident #30 and should not have acted this way. The Administrator/Abuse Coordinator stated that Staff S's employee record was wrong because the abuse was not substantiated. The Administrator/Abuse Coordinator was asked why was Staff S terminated if abuse was not substantiated? The Administrator/Abuse Coordinator stated Staff S was terminated because he should have left Resident #30's room when he was asked to, but he chose to stay. The Administrator/Abuse Coordinator was asked for any reasonable person who stated No to another person's actions and it is not respected wouldn't that be considered intentional actions? The Administrator/Abuse Coordinator stated, To me, he did not set out to willfully hurt the resident. I know the resident and I know the employee and I know there was no willful act to cause harm, but because he did not walk away he was termed because his actions resulted in harm. Review of the admission Record showed Resident #30 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, site not specified, paroxysmal atrial fibrillation, muscle weakness generalized, adult failure to thrive and schizoaffective disorder, bipolar type. Review of Resident #30's current care plan, initiated on 12/2/21, showed, Focus: [Resident #30] prefers to deviate from plan of care with refusing psych services. Interventions: Accept resident's right to refuse and show respect for resident's decisions. The goal, with a target date of 12/28/23, showed: Resident will remain free from complications related to deviation from plan of care thru next review date. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). Review of a progress noted dated 11/19/2023 at 6:27 a.m. showed, Patient noted with skin tear to right low hand. Small amount of bleeding noted. Area cleaned and dry bandage applied. An additional progress note dated 11/19/2023 at 3:27 p.m. showed, Resident called 911 they arrived. MOD [Manager on Duty] notified resident making allegations. Risk manager notified. Spoke with ARNP [Advance Registered Nurse Practitioner] for [Doctor's Name] to notify them of the incident. Residents [family member] called no message left voicemail full. Skin assessment completed. Review of Resident #30's skin assessment dated [DATE] at 3:34 p.m. showed, B. NEW skin conditions: Right hand (back) skin tear, Left hand (back) discoloration noted and other (specify) discoloration right arm above wrist. During an interview on 11/30/23 at 8:50 a.m. Resident #30 stated the morning that [Staff S, CNA] woke me up it was about 6:00 a.m. and [Staff S] told me I had to get up. I do not like to get up until about 8:30 a.m. Resident #30 stated, when I told [Staff S] No, [Staff S] proceeded to pull me up by my arms bruising me. Resident #30 stated he continued to tell Staff S he did not want to get up however Staff S CNA did not listen and pulled him by his arms to a seated position on his bed. Resident #30 stated, I feel like I was abused. An observation on 11/30/23 at 8:50 a.m. showed Resident #30 had bruising on his left arm above the wrist and a skin tear on his right hand. Photographic Evidence was obtained with the resident's permission. During an interview on 11/30/23 at 2:00 p.m. Staff U, Licensed Practical Nurse (LPN) stated when she came on shift about 6:45 a.m. the day of 11/19/23 she was given report by the morning nurse who stated Resident # 30 had a new skin tear that was cleaned up and a bandage was put on it. She said there was no mention of abuse and she did not think to ask about abuse. Staff U, LPN stated, I was the nurse who completed the skin assessment on 11/19/23. 2. During an interview on 11/27/23 at 10:15 a.m. Resident #137 stated Staff V, Registered Nurse (RN) came in my room on Tuesday (11/21/23) and deliberately caused a verbal fight with her. Resident #137 stated she asked Staff V, RN to come in twice a shift but Staff V only came in once at 7:30 p.m. Resident #137 stated, all other nurses come in twice a shift except for Staff V and she had never checked my blood sugar, gave me insulin or checked my blood pressure. Resident #137 stated, when Staff V, RN was asked to come to my room twice a shift she (Staff V) said, Don't tell me how to do my job. I asked for the other nurse on shift to come give me my medications because I did not trust Staff V, RN to give them to me, but the other nurse never came. Resident #137 stated on Thursday (11/23/23) I did not get my insulin or blood pressure medication again. Resident #137 stated on Friday (11/24/23) Staff V, RN came to my room and started another fight with me and said to me, I am here today so you don't want your medication again. Resident #137 stated she told Staff V, RN no that I would like for the other nurse to give my meds to me, and that was when Staff V responded the other nurse was not going to give the meds to you. Resident #137 stated Staff V told her that she (Resident #137) had a problem with everyone. Resident #137 stated, I said no, I just don't want my meds given to me by you. Resident #137 stated she waited a while and didn't get her meds so she called the non- emergency sheriff's department line on Friday (11/23/23) when Staff V, RN would not give her medications to her again. Resident #137 stated an officer from the [County] Sheriff's department came and talked with me. I informed the officer that I don't trust Staff V, RN because she has never given me my medication or checked my blood sugar, not once. Resident #137 stated the police officer got the other nurse to give her medications but the other nurse stated Staff V, RN never told her Resident #137 requested her for medication administration. Resident #137 stated, I told staff I wanted to file a grievance about this but no one came in to have me file one yet. Review of the Facility's Grievance Log from September 2023 to November 2023 showed no grievances related to medication administration concerns. During an interview on 11/27/23 at 11:17 a.m. the Administrator/Abuse Coordinator stated police were called to the facility last week, but it was not about Resident #137. The Administrator/Abuse Coordinator stated he had not heard of any incidents related to Resident #137 last week. The Administrator/Abuse Coordinator stated if there was an incident the Unit Manager should have informed the Risk Manager who would have then informed him. The Administrator/Abuse Coordinator stated he was only present in the facility on 11/24/23 for about four hours that day. When informed Resident #137 called the police on Friday and they responded to a concern that Staff V, RN was not providing medication to Resident #137, the Administrator/Abuse Coordinator stated no reporting had been completed on this allegation from 11/24/23. He stated no one had notified him of this incident until now. The Administrator/Abuse Coordinator stated, They should report to the Risk Manager and then to me so that we can ensure timely reporting. This was not done. The Administrator/Abuse Coordinator stated anytime the police were in the facility it should be reported to him. During an interview on 11/27/23 at 12:32 p.m. Staff J, LPN/UM (Licensed Practical Nurse/Unit Manager) stated she did have a conversation with Staff V, RN about giving her medications. Staff J, LPN/UM stated Resident #137 did not want Staff V, RN to give her medications. Staff J, LPN/UM stated she called Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADON), who advised if Resident #137 wanted to refuse medications have Staff V, RN with two other staff as witnesses to offer medications to Resident #137. During an interview on 11/27/23 at 3:00 p.m. Staff W, Certified Nursing Assistant (CNA) stated Resident #137 never refused care from him. Staff W, CNA stated Resident #137 asked for another nurse to give her medications on Friday and then the next thing the police came. Staff W, CNA stated he witnessed Resident #137 refusal for Staff V, RN's attempt to administer medications. Resident #137 asked for another nurse to give her medications and then Staff Y, Licensed Practical Nurse (LPN) administered Resident #137's medications after the police left. During an interview on 11/27/23 at 3:15 p.m. Staff Y, LPN stated on 11/24/23, 11/25/23 and 11/26/23 she administered medications to Resident #137. Staff Y, LPN stated Staff V, RN would come get her to administer Resident #137's medications when it was time. Staff Y, LPN stated that it does not happen very often that she would have to give medications for another nurse, but she did on 11/24/23, 11/25/23 and 11/26/23. Staff Y, LPN stated Resident #137 was alert and oriented and had the right to request she administer her medications. Review of the admission Record showed Resident #137 was admitted to the facility on [DATE] with diagnoses to include unspecified diastolic (congestive) heart failure, type 2 diabetes without complications, major depressive disorder, single episode, moderate and chronic migraine without aura. Review of the care plan revealed it was updated on 11/24/23 with a new focus that showed, [Resident #137] exhibits the following behaviors: combative with care, refusing medications, anxiousness, etc- refusing nursing care, speaker music extremely loud. The interventions included: Anticipate care needs and provide them before resident becomes overly stressed, Approach resident in a calm manner and explain actions, reappproach resident if agitation is noted, request psychiatric consult if needed and update the physician of increased presence or severity of behaviors. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #137 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact). During an interview on 11/29/23 at 10:50 a.m. the Risk Manager (RM) stated she was first made aware of the incident involving Resident #137 on 11/24/23 by the Agency for Health Care Administration (AHCA) surveyor who reported the allegation on 11/27/23 to the Administrator. The RM stated she reviewed Resident #137's medication administration record for November 2023 and Resident #137 did miss her medications on 11/22/23 and 11/23/23. The RM stated the one date showed medication was refused. The RM stated any resident had the right to be provided medication by another nurse. The RM stated Staff V, RN had been suspended as of today pending investigation. The RM stated knowing the conflict between Staff V, RN and Resident #137, If I have anything to do with it [Staff V RN] would not be assigned to [Resident #137] again. Continuing she said, I plan to go through to see if any grievances for medication look at refusals. The RM stated law enforcement was notified of the incident on 11/24/23 by Resident #137 and Resident #137's representative and Abuse Registry were notified on 11/27/23 after the AHCA Surveyor reported the incident to the facility. During an interview on 11/29/23 at 1:20 p.m. the Administrator/Abuse Coordinator stated, We are currently investigating so, I don't feel comfortable talking about this case until we fully investigate this. During a telephone interview on 11/29/23 at 2:55 p.m. Staff V, RN stated Resident #137 never had a problem until the facility put a roommate in Resident #137's room that she did not like. Staff V, RN stated she had known Resident #137 for a long time. Staff V stated that she explained to Resident #137 she did not have a private room, so a roommate was placed in her room. Staff V stated Resident #137 started saying, I don't like you. Staff V, RN stated Resident #137 accused her of giving her the wrong pill and told me I do what I want. Staff V stated Resident #137 does not like when staff go in her room, and with a roommate staff have to go in the room. Staff V stated after that Resident #137 started saying I was not to administer her medications anymore. I did notify Staff J, LPN/UM that Resident #137 called the police and refused for me to administer her medications. I did work 11/25/23 and 11/26/23 on Resident #137's unit after the incident on 11/24/23, but I never took care of [Resident #137] again. I never went back into [Resident #137's] room again. Staff V, RN stated, Right now I am suspended pending investigation. During an interview on 11/30/23 at 2:55 p.m. Staff J, LPN/UM stated Staff V, RN did report to me and informed me the police were at the facility on 11/24/23. Staff J LPN/UM stated she was informed that Resident #137 called the police regarding medication refusal. Staff J, LPN/UM stated that she made sure that she reported the police presence in the facility to the Risk Manager on 11/24/23. During an interview on 11/30/23 at 3:00 p.m. the Risk Manager (RM) stated she did not recall getting any notice on 11/24/23 from Staff J, LPN/UM. The RM proceeded to take out two phones and showed there were no emails or texts on 11/24/23 from Staff J, LPN/UM. The RM stated the first time she heard about the police being in the facility for Resident #137 was when the State Surveyor reported it. Review of the facility's policy titled, Abuse, Neglect, Exploitations and Misappropriation - Reporting and Investigating, revised September 2022, showed: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to law. 3. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury.

Based on record review, interview, facility documentation review and policy review the facility failed to accurately identify a resident, follow facility policy, and accurately identify a code status of one resident (#1) out of six residents reviewed for advance directives. Resident #1, had physician orders and care plan showing her wishes were for a Full Code (meaning all resuscitation procedures will be provided to keep her alive if found without a pulse and/or respirations). On [DATE] when Resident #1 was found to be unresponsive without pulse and respirations, resuscitation efforts were begun, and then stopped due to a mistake in identifying the correct medical record. Resuscitation efforts were started again after Resident #1's actual medical record was found and a nurse realized the error. The resident was not successfully revived and was pronounced dead by Emergency Medical Service (EMS) staff. This failure created a situation that resulted the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: A review of Resident #1's medical record showed an admitted [DATE] with admitting diagnoses of Type II Diabetes Mellitus without Complications, History of Falling, Anemia, unspecified, Vascular Dementia with behavioral disturbance, Dizziness, and giddiness, Generalized edema, Acute kidney failure unspecified and other osteoporosis with current fracture to right humorous, subsequent encounter for fracture with routine healing. A physician order dated [DATE] showed Full Code. The comprehensive care plan showed a focus of Resident has an HCP [Healthcare Proxy] and incapacity and is a full code. With initiated date of [DATE]. A goal of Resident #1's designated representative will be educated regarding Advance Directive options through the target date of [DATE]. Intervention showed Full Code. Resident #1's facesheet showed full code. Review of a progress note, written by Staff A, Registered Nurse (RN), dated [DATE] at 10:03 AM showed, At 1045 [p.m. on [DATE]] I went, and the resident refused the medication, which is crush, she did not want to open her mouth to take to take it. I continued with my rounds and at 1258 the CNA (Certified Nursing Assistant) came to tell me that the resident was not responding. I went to the room to see and confirm that she was not breathing active code [NAME] [Spanish word for blue] and I put the Cardiopulmonary Resuscitation (CPR) table[tablet] on the oxygen tank, and I started CPR when I went for the third cycle. The nurse and the supervisor tell me to stop not touching it, its Do Not Resuscitate (DNR), we stopped the CPR. I picked up the equipment when I come to the computer to make the report, I realized that was an error by the nurse and the supervisor because it is a full code, and I activated the blue code [generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest], and I ran to the room. I told the CNAs to activate the blue code by intercom and CPR continued until 911 arrived and relieved us. Review of Resident #1's medical record showed a minimum data set (MDS) dated [DATE] with Death in the Facility. Review of the facility's documentation, the listing of all discharges for [DATE], showed Resident #1 had expired on [DATE]. A review of the facility's documentation Adverse Incident Tracker for the month [DATE] showed a [DATE] incident identifying Resident #1 with a description of CPR incident and report date of [DATE]. During an interview on [DATE] at 10:38 a.m., the Director of Nursing (DON) stated that she was notified of a Code Blue on [DATE] around 5:00 a.m. The DON stated she was told that the police were notified and already in the facility. DON remembered that around 8:00 a.m. on [DATE] RN Staff B informed the DON that a code blue was called on Resident #1. DON stated that the way she understood the code blue incident the morning of [DATE] was a CNA found Resident #1 and called for the Nurse (identified as RN Staff A). The DON stated that RN Staff A called a Code Blue and started CPR. The DON stated that LPN (Licensed Practical Nurse) Staff C obtained the wrong chart to verify code status and RN Staff B then informed RN Staff A that Resident #1 was a DNR and not to touch Resident #1 as it was verified that she was a DNR. The DON stated that upon investigation once RN Staff A quit CPR and went to the computer to document it was found that Resident #1 was a full code, so a code blue was called again, and CPR was resumed until EMS arrived. The DON stated that the incident was recorded as an adverse situation with neglect and reported within 24 hours of the incident. The DON stated that the incident occurred on [DATE] and the incident was reported on [DATE]. The DON stated that as of right now RN staff A and RN staff B were suspended but LPN Staff C was back to work already. The DON stated that LPN Staff C was cleared on the CPR incident already because the only involvement LPN Staff C had was pulling a Resident hard copy chart and giving the chart to the supervisor. A review of Resident #1's medical record showed a Code Blue Form dated [DATE]. The Code Blue Form showed chain of events dates that included: Time of Respiratory/Cardiac Arrest: [DATE] at 12:58 a.m. Code Blue Called: [DATE] at 12:59 a.m. Code Status Verified: [DATE] at 1:05 a.m. 911 Called: [DATE] at 12:59 a.m. CPR Initiated: [DATE] at 12:59 a.m. EMS Arrived: [DATE] at 1:35 a.m. Physician Notification: [DATE] at 2:00 a.m. Responsible Party Notified: [DATE] at 2:10 a.m. DON Notification: [DATE] at 1:45 a.m. Additional Comments: 10:45 (p.m.) the resident refused the acetaminophen and then the CNA at 1258 reported that the patient did not respond CPR was started and then they ordered to stop and not touch the patient because it was DNR when I returned to my computer to make the report I realized that is was an error full code and activate the blue and ran code for the room and we started CPR until the paramedics arrived. During an interview on [DATE] at 2:30 p.m., LPN Staff C stated that when code blue was called, everyone went running to the code blue unit. LPN Staff C stated that she pulled a medical chart by room number and handed it to RN Staff B who verified code status in the computer. LPN Staff C stated after handing the chart over to the supervisor she then went back to the assigned unit to check on all the residents on her assigned unit. LPN Staff C stated, I verified the Resident who coded based on room number. LPN Staff C was asked if Resident #1 was in a private room? LPN staff C stated no, Resident #1 had three to four people in the room she was assigned to. LPN Staff C stated that there was training on code blue and rapid response protocol prior (on [DATE]) to the incident on [DATE] and the protocol was followed but the issue was the wrong chart was pulled. LPN Staff C verified the chart that was pulled was Resident #7's chart the roommate of Resident #1. A review of Resident #7's medical record showed an admitted [DATE] with admitting diagnoses of Multiple Sclerosis, other malignant neoplasm of skin of nose, hyperlipemia, Unspecified Dementia, Depression and Anxiety. A State of Florida Do Not Resuscitate Order was in place with a date of [DATE]. A physician order dated [DATE] showed DNR. The Comprehensive Care plan showed Resident #7 has expressed the following wishes regarding code status and has the following advance directives in place: DNR with initiated date of [DATE]. During an interview on [DATE] at 2:40 p.m., RN Staff B stated when code blue was called on [DATE] everyone responded. Staff B came from Southwest Hall to assist with the code on Northwest Hall. RN Staff B remembered going right to the computer to verify code status. RN Staff B stated the name of the Resident was given and the code status on point click care was matched with the name in the physical chart with a matching code status of do not resuscitate (DNR). RN Staff B explained that the name of the Resident that was given for code status verification was not correct, the name given for code verification was Resident #7's (Resident #1's roommate) information that stated DNR instead of Resident #1. Both nurses confirmed DNR status for Resident #7 and then we both yelled down she is DNR do not touch her. After cardiopulmonary resuscitation (CPR) was discontinued RN Staff B and LPN Staff C went to the room and called time of death. RN Staff B stated all nurses went back to their assigned units and began working again. RN Staff B stated maybe 10 to 15 minutes later a Certified Nursing Assistant (CNA) came running down the hall stating, it was the wrong the chart. RN Staff B remembered a second code blue was called and CPR was initiated again until the EMS arrived. RN Staff B stated that when looking for Resident #1's chart no one could find it at first as the medical chart was not located on the same unit where Resident #1 resided, but someone eventually found the chart on another unit. On [DATE] at 6:00 p.m., an interview was attempted with RN Staff A. The nurse's phone number was called and Staff A answered by saying what do you want? Staff A was told the call was to discuss an incident regarding a resident at the facility. Staff A RN said do you speak Spanish? and then said I only speak Spanish and call back when you can speak Spanish and the phone was disconnected. Review of the facility's documentation Risk Management Witness Statement written by RN Staff A dated [DATE] showed, At 1045 (p.m.) I went to the room and the patient refused the medicine and I continued with rounds. At 12:58 AM the CNA [CNA Staff E] tell me that the patient was not breathing. I went to the room with the crash cart and the oxygen when I get there the patient was not breathing and I started CPR and told [CNA Staff F and CNA Staff D] to activate code blue and to look the medical record but when I was in the middle of the CPR the [LPN Staff C] grab a book and says she was a DNR and the supervisor says stop CPR and when I went come back to the computer I look other record figured out that she was a full code and the nurse [LPN Staff C] did a mistake so I called [CNA Staff D] and tell her to activate the code blue for the second time so I went to the room and start CPR until the paramedics was here. Review of the facility's documentation showed an In-service was conducted on [DATE] on the topics of Code Blue, Rapid Response, documentation, signs and symptoms of hyper and hypo glycemic and fall monitoring. During an interview on [DATE] at 5:00 p.m., RN Staff B stated that she was told Resident #7's name instead of Resident #1's name to verify code status. RN Staff B stated it was a communication error. RN Staff B stated that when the code blue was called around 12:55 a.m. on [DATE] she went to assist. RN Staff B stated that RN Staff A was asked to identify the Resident who coded, and Staff A stood there looking at her like a deer in headlights frowned, and then shrugged. RN Staff B stated that RN Staff A began looking around for Certified Nursing Assistant (CNA) Staff D to translate for him because he did not understand what RN Staff B asked. RN Staff B again asked RN Staff A who coded and RN Staff A identified the Resident as Resident #7. RN Staff B stated that was when LPN Staff C pulled the medical chart and handed the medical chart to RN Staff B for verification of code status in the electronic medical record. RN Staff B stated the code status matched as a DNR so they yelled to RN Staff A to in the room performing CPR to stop CPR it had been verified she was DNR. RN Staff B stated that both she and LPN Staff C went to the room and called the time of death about 1:05 a.m. RN Staff B stated Resident #1 was clearly dead there was no pulse and no respirations. RN Staff B stated that both she and LPN Staff C went back to their assigned unit to care for their assigned residents. RN Staff B stated that lack of communication in English was the cause of the mix-up as RN Staff A could not understand the questions RN Staff B asked during the code blue. RN Staff B stated that was when she realized that RN Staff A was not bilingual in English and was solely Spanish speaking which was a barrier and safety issue during an emergency like a code blue. RN Staff B stated that it took her three times to write out her witness statement because the DON continued not to accept it and said the state would not accept the witness statements. RN Staff B stated after the third witness statement was written the DON approved it and accepted it. RN Staff B stated that once returning to the unit she was assigned to about 10 to 15 minutes later CNA Staff D came running down the hall and said, that was not the right person that Resident #1 was a full code. RN Staff B said she called the second code blue and asked for Resident #1's medical record to verify. RN Staff B stated that was when they discovered the hard copy medical record was missing. RN Staff B stated she asked everyone to go throughout the facility and look for Resident #1's hard copy medical record. RN Staff B stated it was CNA Staff D who eventually found Resident #1's hard copy chart on another unit. RN Staff B stated Resident #1's hard copy medical record and electronic medical record showed in fact that Resident #1 was a full code. RN Staff B stated that the code blue was called and so was 911 per facility protocol. RN Staff B stated that as a supervisor she felt RN Staff A's inability to understand the English language was more of a concern during the code blue as RN Staff A did not understand nor could answer questions quickly or accurately in a time of emergency. RN Staff B explained that CNA Staff D would come to her at the beginning of a shift, and request to be reassigned to work with RN Staff A. She said CNA Staff D would tell her it was because CNA Staff D needed to work on the same hallway as RN Staff A in order to translate English language to Spanish language. RN Staff B stated that as a new supervisor she wanted to make sure staff were where they needed to be, so she always honored CNA Staff D request to work on the unit with RN Staff A. RN Staff B stated that she knew CNA Staff D assisted RN Staff A with some translation but had no idea that the translation assistance was full time throughout the shift. RN Staff B stated that she reported this concern to the DON, and had a conversation with the DON about the lack of communication and miscommunication during the [DATE] code blue incident. RN Staff B stated she informed the DON that RN Staff A's English language barrier was very concerning that night when he did not understand her. RN Staff B stated she had experience and training in CPR and Advanced Cardiovascular Life Support (ACLS) and believed the communication and the lack of understanding without a translator for RN Staff A caused the mix-up during the first code blue process. During an interview on [DATE] at 9:50 a.m., the DON stated that RN Staff A could speak English and that sometimes RN Staff A would have delayed thinking about what was being discussed but then RN Staff A could answer. The DON stated that RN Staff A did know the English language and could communicate with English speaking residents and staff. The DON was asked about any accommodations RN Staff A may have needed related to a language barrier. The DON stated RN Staff A had no accommodations because he could communicate in English just as well as speaking in Spanish. During an interview on [DATE] at 11:20 a.m., CNA Staff E stated that when doing rounds the morning of [DATE] Resident #1 when you touched her she was able to verbalize. CNA Staff E stated that when she touched Resident #1 later that morning, she was ice cold and did not move and was not breathing. CNA Staff E stated that she went to the door and yelled for RN Staff A to come. CNA Staff E stated when RN Staff A got to the door, she led RN Staff A to Resident #1 where he began to assess Resident #1. CNA Staff E stated that she knew Resident #1 but did not identify Resident #1 with RN Staff A, as she just led RN Staff A to Resident #1 when RN Staff A walked in. CNA Staff E stated that she knew Resident #1 prior to the code blue incident as CNA Staff E worked with Resident #1 over on the Southeast Unit. CNA Staff E was asked if RN Staff A was able to communicate well with staff and residents. CNA Staff E responded that RN Staff A did not speak English well, but everyone who worked with him helped him when he was working. CNA Staff E stated that RN Staff A would answer questions very slowly and it took time for RN Staff A to respond as he had to have time to think about what is being asked. CNA Staff E stated that she did not speak Spanish, so she was never much help to RN Staff A. CNA Staff E stated that the morning of [DATE] there were two staff members who could speak Spanish that night, so they helped him through that ,d+[DATE] shift. CNA Staff E stated that for instance, CNA Staff E watched RN Staff A write up his witness statement all in Spanish first and then the other staff helped him translate his statement over to English. CNA Staff E stated that RN Staff A was asking about words in Spanish and the staff would tell RN Staff A what the word was in English. During an interview on [DATE] at 12:09 p.m., the DON reviewed Resident #1's medical record with the survey team. The medical record showed Resident #1's census page. Resident #1's census page showed Resident #1 was moved off Southeast Unit on [DATE] to the Northwest unit. The DON was asked if Resident #1's medical record was placed back on the Southeast unit by accident or if the chart was left on the Southeast unit when Resident #1 was transferred to Northwest unit on [DATE]. The DON said that she just didn't know, there was no way of knowing that but confirmed the medical record was not on the correct unit when Resident #1 stopped responding on [DATE]. During an interview on [DATE] at 1:15 p.m., LPN Staff G stated that when receiving report from RN Staff A, he was a little hard to understand. LPN Staff G stated that RN Staff A did speak English, but it was very thick English. LPN Staff G stated that staff would have to listen very carefully. LPN Staff G stated that he did think RN Staff A knew what was talking about but was just a little difficult to understand. During an interview on [DATE] at 1:26 p.m., RN Staff H stated that RN Staff A did have broken English. RN Staff H stated that he could understand RN Staff A but when RN Staff A spoke English it was not always spoken in the correct form. RN Staff H stated a lot of the times, staff had to listen to what RN Staff A said and then try to figure out what RN Staff A meant. RN Staff H stated that he only knew of one complaint from a Nurse (identified as LPN Staff I) who had stated that she could not understand what RN Staff A was saying. RN Staff H stated that LPN Staff I had discussed the communication barrier with him. RN Staff H stated he did feel that RN Staff A's English skills were a little bit of a communication barrier. During an interview on [DATE] at 3:09 p.m., LPN Staff I stated, RN Staff A, was a little hard to understand, especially during shift change and report. LPN Staff I stated that RN Staff A had some broken English and there was a language barrier there. During an interview on [DATE] at 6:48 p.m., CNA Staff F and CNA Staff D were interviewed. CNA Staff D stated that the morning of [DATE] she was not Resident #1's assigned CNA. CNA Staff D identified CNA Staff E as the assigned CNA for Resident #1. CNA Staff D stated that CNA Staff E yelled that Resident #1 was not responding and was cold, so RN Staff A ran into the room with the crash cart. RN Staff A assessed Resident #1 and said no pulse or respirations and said activate a code blue and go find the chart. CNA Staff D stated that I went to look for the hard copy chart and was looking for room (Resident #1's room and bed). CNA Staff D stated the chart was missing and she could only find the charts for the other 3 residents in room (Resident #1's room). At this time, CNA Staff F stated, I wasn't even looking for the name. CNA Staff D stated that LPN Staff C came to the unit and pushed us CNAs out of the way, took one of the charts and said here is the chart. CNA Staff D stated that LPN Staff C opened the (wrong) chart and said she (Resident #1) is a DNR. CNA Staff D stated that RN Staff B took the chart from LPN Staff C and then opened the electronic medical record and said yes, they match she is a DNR. CNA Staff D stated that was when both LPN Staff C and RN Staff B yelled into the room not to touch her, she was a DNR. CNA Staff D stated that when RN Staff A got back to the nurses' station RN Staff B was making a list of what RN Staff needed to do next such as call the family, doctor, and DON. CNA Staff D stated that RN Staff A did not always understand a lot of things when people spoke in English, so I was always there to translate for him. CNA Staff D explained that was why she always made sure she was scheduled on that unit with RN Staff A every time he worked. CNA Staff D stated that RN Staff B made the to do list because of the communication barrier. When RN Staff A had the hard copy medical record in his hand and sat down at the computer to document RN Staff A stated, this is not the right Resident, Resident #1 is a full code. CNA Staff D stated that she remembered that Resident #1 had been on the Southeast Unit prior to being moved to the Northwest Unit two to three weeks prior. CNA Staff D stated that was where Resident #1's chart was found, it appeared the hard copy chart was never moved with the Resident #1 when transferred to Northwest unit. CNA Staff D stated by the time Resident #1's chart was found the paramedics were there. The paramedics were concerned that there could have been a delay in treatment and called the police to the facility. CNA Staff D stated that the police then decided to question each staff member one on one. CNA Staff D stated that she offered to help translate for RN Staff A when the police asked questions, but the police ended up getting their own officer who spoke Spanish to speak with RN Staff A. CNA Staff D stated that after the Resident #1 incident on [DATE] CNA Staff D was called in to speak with the Regional Nurse who asked CNA Staff D to come in and talk and make a witness statement regarding the incident. CNA Staff D stated the Regional Nurse asked her to write that Resident #1 was dead prior to the first code blue being called. CNA Staff D stated that she could not write that on the witness statement because as a CNA she could not assess or call a death. During an interview on [DATE] at 5:00 p.m., the Administrator stated that he had spoken with RN Staff A regarding the code blue incident and RN Staff A was able to tell the Administrator that he had started CPR on Resident #1 because RN Staff A knew Resident #1 was a full code and only stopped CPR because the Nurse Supervisor advised him to stop. A review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) not dated showed, Policy: It is the policy of the center to initiate CPR if the resident is without pulse or respirations and is a full code. Procedure: 1.Resident identified with lack of breathing and pulse. 2. Responder calls for assistance (doesn't leave resident alone) 3. Team responds and brings medical record and code chart. 4. Vital signs taken. 5. Code status is verified from the medical record. 6. 911 (EMS) is called by staff members 7. Code chart is stocked with needed, easily accessible items. 8. Physician is notified. 9. Family is notified. 10. CPR is not stopped unless EMS arrives and takes over. 11. History/Paperwork is provided to EMS upon arrival. 12. Code procedure turned over to EMS as appropriate. 13. Appropriate transfer forms completed and give to EMS. Facility immediate actions to remove the Immediate Jeopardy included: On [DATE]th 2023, DON was informed that a resident had coded and CPR was ceased and restarted prior to EMS arrival. The Center has taken the following steps to ensure the safety of our residents who are at risk for Advance directive related to CPR and Code status compliance. Resident family was notified of outcome of CPR attempt at approximately 1:15 am on [DATE]th 2023 Physician notified of incident - At approximately 1:15 am on [DATE]th 2023 Administrator, DON, Nurse manager notified of incident and reported to facility on [DATE]th 2023 All residents in facility were audited for advance directives preferences to ensure accuracy, 100% on [DATE]th 2023 Facility-initiated code blue drill on [DATE]th 2023 All chart locations were audited to ensure in proper location on [DATE]th 2023 100% complete. CPR competency plus competency quiz and proper identification of code status for resident via chart, and EHR (Electronic Health Record) and resident photo in EHR for all staff initiated on [DATE]. [DATE] - 75% complete [DATE] - 90% complete [DATE] - 95% complete [DATE] -100% complete No employee will be permitted to work until they have completed in-services and competencies(nursing). Staff contacted via phone on [DATE] to contact facility for training prior to returning to work. DON or designee will be completing work on completion of training with competencies. This issue was taken to Quality Assurance Performance Improvement (QAPI) at an ad-hoc (when necessary) meeting on [DATE] to discuss the event and necessary adequate follow up. QAPI meeting discussed CPR Policy & Procedures, Education, Chart locations and disaster drills. Daily review of new admissions for code status and any code status change request will be completed by Nurse Management and Social Services for any concerns so that corrective actions can be identified/implemented as appropriate. CPR Drills completed at facility on [DATE] and will be on-going weekly for 1 month and biweekly for 1 month, then quarterly on all shifts. This Administrator is responsible for oversight of this plan. Verification of the facility's removal plan was conducted by the survey team on [DATE]. The Regional Nurse and the Administrator provided the State Survey team with documentation showing records of the facility actions to remove the immediacy: Bristol CPR Incident [DATE] Timeline included witness statements and five-day follow-up Audit conducted of all Resident code statuses, matching care plan and charts. Nurse CPR Certification Audit with all active CPR cards available CPR Policy QAPI Ad Hoc Meeting Minutes with CPR Policy In-Service Attendance Record with CPR Competency Quizzes Interviews were conducted with 47 Staff, 16 licensed nurses, 23 CNAs and 8 other staff. The staff members were able to state that they had been trained and were knowledgeable about the facility CPR policy. Based on verification of the facility's removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Maintenance Director, the facility's Medical Director, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 13 residents sampled for supervision, was provided with supervision and services related to the resident's known exit-seeking behaviors and attempts to open exit doors on the secured dementia care unit. The facility nursing staff failed to ensure the safety of Resident #1; on 01/16/2022 they were unaware the resident exited the secured dementia unit through a door equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked). Before the elopement, the resident was known by staff to have removed the power source to the exit door. The facility determined that on the day of the elopement the resident removed the wires to open the exit door and leave without an alarm sounding. The resident exited the secured unit to an outdoor courtyard surrounded by a vinyl fence. Resident #1 was then able to exit the outdoor, fenced in area by pushing open a gate equipped with an electromagnetic locking device heavily rusted from outdoor conditions to a small parking lot and onto the sidewalk outside of facility grounds and into the community. Resident #1 ambulated unassisted and unsupervised 0.8 miles down the sidewalk along a 4-lane road with heavy traffic until he was discovered by a staff member who called local police to help return him to the facility. The facility failed to [MEDICATION(S)] to prevent the elopement by not providing extra supervision for the resident and not taking actions to prevent the resident from damaging wires to the electromagnetic door. Resident #1's elopement from the facility provided for a likelihood of serious harm or death due to his cognitive impairments, visual impairments, and impairments in mobility. The facility also failed to ensure a wander monitoring bracelet was functional for one resident (#10) of six residents sampled for wander monitoring bracelets on 04/12/2022. Resident #10 had a history of exit seeking behaviors and required a functioning wander monitoring bracelet to help prevent elopement from the facility. Resident #10's non-functioning wander monitoring bracelet provided a likelihood for serious harm due to cognitive impairments. This resulted in findings of Immediate Jeopardy occurring on 01/16/2022 and removed on 04/15/2022, with the scope and severity reduced to a D. Findings include: 1) A review of Resident #1's progress notes revealed a note, dated 01/16/2022 at 5:15 PM, which documented, Writer [The facility's Director of Nursing], NHA (Nursing Home Administrator), and BOM [Business Office Manager] spoke to [Resident #1's] son regarding him leaving the facility today. BOM translated to family member in Spanish. All questions/concerns were answered. Son was pleased with the update. Will continue with plan of care. Review of a progress note dated 01/16/2022 at 5:21 PM, written by the Director of Nursing (DON), revealed, [Resident #1] returned to facility no s/s [signs or symptoms] of distress or discomfort noted. [Resident #1] denies pain at this time in Spanish. The progress note also revealed, Assigned CNA [Certified Nursing Assistant] asked [Resident #1] where he was going when he left, per resident he was going to [NAME]. Dinner and hydration provided to resident. Resident on 1:1 at this time will continue plan of care. Review of a progress note dated 01/15/2022 at 3:55 AM, written by Staff U Assistant Director of Nursing (ADON) revealed, Resident #1 showed little interest or pleasure in doing things. Physically Aggressive. Resists Cares. Wandering. Other behaviors noted .Being intrusive wandering in other resident's room. Resident wandering up and down. Review of a progress note dated 01/13/2022 at 1:26 PM, written by Staff R, Licensed Practical Nurse (LPN) revealed, [Resident #1] Restless/Fidgety. Easily agitated. Resists cares. Wandering. Exit-seeking, confused. Resident is exit-seeking, has one-on-one supervision. A review of a local police report dated 01/16/2022 at 7:22 PM revealed under the section titled Narrative Text, on 01/16/2022 at approximately 1621 (4:21 PM), (police) responded to (local business) regarding a suspicious person call. Upon arrival, (local police) were advised that Resident #1 was under the belief that the (local business) was his residence and appeared to be confused. Resident #1 was unable to provide any detailed regarding who he was, where he lived, or who his guardians were. Resident #1 was identified via a hospital band from (a local hospital) wrapped around his right wrist. Dispatch contacted the hospital in an attempt to gather further information on Resident #1, however, the hospital did not have any recent records to provide. (Local police) were able to obtain a name and phone number for Resident #1's son. Police contacted Resident #1's son who confirmed that the resident was currently residing at the facility. (Local police) transported Resident #1 to the facility where custody was transferred to the facility's Director of Nursing (DON). The DON advised the alarms to the front doors of the facility were possibly malfunctioning which could have contributed to Resident #1's escape. According to Google Maps (https://www.google.com/maps/) walking distance to the (Local business) where Resident #1 was found by police was 0.8 miles from the facility. The walking directions revealed that Resident #1 crossed four lanes of traffic to walk to the address where he was found. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, major depressive disorder, generalized anxiety disorder, history of falling, Type 2 Diabetes, ankylosing spondylitis of unspecified sites in spine, mood disorder due to known physiological condition with depressive features, generative disease of the nervous system, essential hypertension, unspecified [CONDITION(S)] and dysphagia. A review of Resident #1's Admission Nursing Comprehensive Evaluation, dated on 12/31/2021, revealed in Section 7 - Elopement Evaluation, Resident #1 was alert with continuous confusion, had behaviors of wandering but never eloped, was totally or mostly dependent in locomotion, and was actively exit seeking. Resident #1's Elopement Risk Score was determined to be 12, indicating Resident #1 was at risk for elopement. Resident #1's Elopement Evaluation also revealed a (wander monitoring bracelet) was applied and his picture was placed in the facility's elopement book. A review of Resident #1's physician order summary revealed the following: - An order, dated 01/16/2022 for a (wander monitoring bracelet), expires 02/2022, check location and check for placement every shift. The order was discontinued on 02/01/2022. - An order, dated 02/01/2022 for a (wander monitoring bracelet), expires 08/2024, check for placement every shift. - An order, dated 02/01/2022 for a (wander monitoring bracelet), expires 08/2024, check for function every night shift. Resident #1's physician orders did not reveal orders related to use of a wander monitoring bracelet or wander monitoring bracelet checks for placement and functioning prior to 01/16/2022. A review of Resident #1's care plan revealed a Focus, initiated on 01/06/2022, that (Resident #1) was at the facility for Long Term placement due to the need for 24 hour supervision/care with a goal to meet (Resident #1's) psychosocial needs daily with assistance from staff. Review of Resident #1's care plan also revealed a Focus, initiated 01/10/2022, (Resident #1) is at risk for falls and/or fall related injury related to generalized weakness, unsteady gait, and has a history of falls. Interventions included to supervise the resident during transfers and ambulation for unsteady gait and impaired balance and keep environment clean and free of clutter in the walkways. Review of Resident #1's care plan revealed a Focus, initiated 01/10/2022, (Resident #1) has an alteration in visual function as evidence by a diagnosis of dementia, making it difficult to accurately assess visual ability. Interventions included to provide adequate lighting, provide assistance with Activities of Daily Living (ADL) tasks as needed, and maintain a safe environment; notify resident of changes in environment as needed. A review of Resident #1's care plan also revealed a Focus, initiated on 01/16/2022, (Resident #1) has a potential for elopement due to cognitive impairment and is ambulatory. Interventions included to perform frequent observations of the resident's whereabouts every shift, provide redirection when observed towards exit doors, apply (wander monitoring bracelet) as ordered verify placement every shift and check for proper functioning daily, include resident in Elopement Book, and update responsible party if resident elopes. Review of Resident #1's care plan revealed a Focus, initiated 01/06/2022, (Resident #1) had impaired cognitive function as evidence by impaired decision-making skills, being oriented to person and place only, and short term and long term memory impairment related to a diagnosis of dementia. Interventions included to address (Resident #1) by preferred name and provide orientation to time of place as needed. A review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 01/08/2022, revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) interview was not conducted with Resident #1 due to being rarely or never understood. Resident #1's MDS Assessment also revealed under Section E - Behavior, that Resident #1 did not display behaviors of wandering. Section G - Functional Status of Resident #1's MDS Assessment revealed Resident #1 required limited physical assistance of one person for walking in rooms, walking in corridors, and locomotion on and off of the unit. Resident #1's MDS Assessment also revealed under Section P - Restraints and Alarms, a wander/elopement alarm was not used. An interview was conducted on 04/12/2022 at 9:50 AM with Staff B, CNA. Staff B, CNA stated she was Resident #1's assigned CNA on 01/16/2022 when Resident #1 eloped from the facility. Around 4:00 PM to 5:00 PM timeframe, Staff B, CNA assisted Resident #1 to the toilet, changed his brief, and left him in his room to pass dinner trays out to the residents on the unit. When Staff B, CNA went to deliver Resident #1's dinner tray around 5:00 PM, he was no longer in his room. Staff B, CNA stated she looked for Resident #1 in his room and was not able to find him and alerted the nurse on duty. The rest of the staff on the unit began to search for Resident #1 and were not able to locate the resident on the unit. A call was announced over the intercom system and staff began to look for Resident #1 outside and in the parking lot area. Staff B, CNA stated she exited the unit through the back door and into the fenced in courtyard area to search for Resident #1. Staff B, CNA also stated, I think the gate was open, which was how Resident #1 exited the facility grounds. Staff B, CNA stated after not being able to find the resident, she returned to the facility and began taking care of the other residents on the unit. Resident #1 was later returned to the unit and Staff B, CNA stated Resident #1 was found on the streets walking on the sidewalk. A follow up interview was conducted on 04/12/2022 at 11:18 AM with Staff B, CNA. Staff B, CNA stated Resident #1 had been on the secured dementia care unit since his admission on 12/31/2021, he wandered around the unit, and was observed to be near the facility exit doors frequently. When redirected from the exit doors of the secured dementia care unit, Resident #1 would become upset with the staff. Staff B, CNA stated Resident #1 pulled the wires off of the sensors a lot of times prior to the elopement on 01/16/2022 and maintenance staff had to fix the doors several times as a result. Staff B, CNA also stated she did not hear an alarm when Resident #1 eloped from the unit and she thinks the door going outside to the fenced in patio area was open at the time. Staff B, CNA stated she was working with all agency staff on 01/16/2022 during the 3 PM to 11 PM shift and the other staff were not familiar with Resident #1. Resident #1 was brought back to the facility around 6:00 PM, given a shower, and was placed on 1 to 1 supervision for safety. Staff B, CNA stated Resident #1 was not hurt and was not able to state what happened after he left the building. A telephone interview was conducted on 04/14/2022 at 10:19 AM with Staff B, CNA. Staff B, CNA stated the door to the patio behind the dementia care unit had been broken many times and there was a chain like wire at the top of the unit that was always falling apart. Staff B, CNA also stated she reported all maintenance issues to the nurse on duty but was unable to state who she reported the issues to or a date and time of any reported issues. Staff B, CNA stated maintenance staff had fixed the door more than five times in the past but was not able to state dates or times. Staff B, CNA also stated Resident #1 would shake the exit doors very hard at times and expressed desire to exit out of them, which required redirection and notification to the nurse on duty. An interview was conducted on 04/12/2022 at 9:45 AM with Staff A, CNA on the facility's secured dementia care unit. Staff A, CNA said to get to the outdoor patio area from the secured unit, a staff member must enter a code on the keypad to disable the magnetic lock. If a resident has a (wander monitoring bracelet) and the system is working properly, the resident should not be able to get out of the door because the code will not work if a resident with a (wander monitoring bracelet) is near the door. Staff A, CNA stated the alarm to the door would beep when activated, but the volume was low and if a staff member was around the corner on the unit the sound would barely be audible. An interview was conducted on 04/13/2022 at 8:33 AM with Staff D, LPN on the secured dementia care unit. Staff D, LPN stated Resident #1 had previously been exit seeking and would go toward the exit doors of the unit quite often but not as much recently. Staff D, LPN also stated Resident #1 would go from door to door on the unit and bang on them because he wanted to get off of the unit. Staff D, LPN was not able to state any details related to Resident #1's elopement on 01/16/2022 and was not sure how the resident managed to open the doors. An observation was made during the interview of Resident #1 resting in bed and being assisted with his breakfast meal by a staff member. Resident #1 was speaking Spanish to the staff member in between taking bites of food. A telephone interview was conducted on 04/14/2022 at 8:52 AM with Staff Q, LPN. Staff Q, LPN stated he was familiar with Resident #1 and that he displayed wandering behaviors and confusion due to having dementia. Staff Q, LPN also stated he was the nurse on duty on the secured dementia care unit on 01/16/2022 when Resident #1 eloped from the facility. A CNA on the unit, who Staff Q, LPN was not able to name, was searching for Resident #1 on the secured dementia care unit around 5:00 PM. A supervisor, who Staff Q, LPN was not able to name, called a Code Silver over the intercom system and he began to search on the back patio area of the unit. Staff Q, LPN stated he was not sure if all of the magnetically locked doors or outdoor gate were functioning properly and could not recall exactly how Resident #1 was able to open the doors. Staff Q, LPN also stated Resident #1 did have a (wander monitoring bracelet) at the time and had not witnessed the resident seeking exit before. An interview was conducted on 04/14/2022 at 10:52 AM with Staff T, LPN. Staff T, LPN stated she worked as the weekend supervisor on 01/16/2022 for the facility from 7 AM to 7 PM. Staff T, LPN stated Resident #1 eloped from the facility around dinner time and she was notified by Staff Q, LPN Resident #1 could not be found on the secured dementia unit. Staff T, LPN immediately called a Code Silver over the intercom system to indicate that Resident #1 was missing, and all facility staff began to search for the resident. Staff C, BOM at the time, found Resident #1 walking on the sidewalk and brought him back to the facility. Staff T, LPN stated the DON and NHA took over from there related to the elopement and related assessments and notifications. Staff T, LPN stated she was not very familiar with Resident #1, and she was not sure how Resident #1 was able to exit the facility. A review of the facility assignment sheets for 01/16/2022 for the dementia care unit, provided by the DON, revealed the following staff assignments for the 3 PM to 11 PM shift: - Staff Q, LPN - Staff B, CNA, Assigned to Resident #1 - Staff K, Agency CNA - Staff L, Agency CNA A telephone interview was conducted on 04/13/2022 at 11:19 AM with Staff K, Agency CNA. Staff K, Agency CNA stated she usually worked on the 11 PM to 7 AM shift and had been assigned Resident #1 several times. Resident #1 could be aggressive at times and sometimes required assistance of two staff members during care but Staff K, Agency CNA was not able to state if Resident #1 was exit seeking or was seen near exit doors on the unit. Staff K, Agency CNA stated she was not sure if she worked on the 3 PM to 11 PM shift on 01/16/2022 and did not know any details related to Resident #1's elopement from the facility on 01/16/2022. A telephone interview was conducted on 04/13/2022 at 11:28 AM with Staff L, Agency CNA. Staff L, Agency CNA stated she was not familiar with Resident #1 and could not recall working on the secured dementia care unit on 01/16/2022 for the 3 PM to 11 PM shift or the 11 PM to 7 AM shift. Staff L, Agency CNA also stated she was not aware of Resident #1's elopement from the facility on 01/16/2022 and had not heard any information related to the incident. A telephone interview was conducted on 04/13/2022 at 3:31 PM with Staff C, Business Office Manager (BOM) at the time of the elopement. Staff C was working for the facility on 01/16/2022 and was the Manager on Duty (MOD) that day. Staff C stated he conducted rounds in the morning on 01/16/2022 to make sure all facility doors were secured, including the vinyl gate behind the secured dementia care unit, and did not find any issues related to the doors or gate. Staff C also stated on 01/16/2022 around 5:00 PM, he was traveling in his car back to the facility from a break when he saw Resident #1 walking down the sidewalk along the road about 0.5 miles from the facility. Staff C was not able to get to Resident #1 because he was on the opposite side of the road and traffic was heavy on the road. Staff C stated he saw a local police officer about a half mile down the road and asked for assistance to escort Resident #1 back to the facility because he knew that Resident #1 was combative at times. Resident #1 was brought back to the facility without injuries. On 3/28/2022 at 1:01 PM, an interview was conducted with the Director of Maintenance, who said he had worked at the facility for one year. He said that they had a resident that pulled out wires on the door [the French/patio doors]; he broke it. He said they had to come and fix the door and put the wires back together. He was asked how he knew Resident #1 broke the door. He answered Because he had done it before. I fixed it myself; 2 wires that I put together. He pulled the wires out. I was here the day he left, but I was gone by the time he left. Normally, I leave at 3:30 PM. Do not recall if I saw him that day. We have cameras, but they do not work. Since the new company took over. I know that they worked in October; but, not since. On 3/28/2022 at 1:24 p.m., a review of the doors for the secure unit was conducted with the Maintenance Director. The French/patio doors were reviewed; the doors were observed to be locked. He explained that if a resident with a (wander monitoring bracelet) comes close to the door, that the code box will light up and you cannot put the code into the door. He stated that Resident #1 for the date that he left, he had pulled out the wires that were located above the door, the 2 wires, that was how he was able to leave. An interview was conducted on 04/12/2022 at 9:30 AM with the DOM who said that the dementia care unit had two main doors to get on and off the unit, which required a passcode. The DOM stated following Resident #1's elopement from the facility, he determined Resident #1 pulled out an exposed wire, which provided power to an electromagnetically locked door, which disabled the magnetic lock and allowed Resident #1 to exit to the outside fenced area without setting off the alarm. The DOM also determined the magnet holding the gate closed in the fenced in area surrounding the outdoor patio area had failed, which allowed Resident #1 to push the gate open once he was outside and exit the facility grounds. The DOM stated prior to Resident #1's elopement, the power wire to the magnetic lock for the door leading out to the patio area was exposed and they have since placed a plastic cover over the wire, so it was no longer exposed. At this time, the DOM said the issue had not been identified by maintenance staff before Resident #1's elopement occurred. The DOM stated when a resident with a (wander monitoring bracelet) was near the secured door, the keypad to the door would be disabled and a bypass code was required to open the door. If a resident with a wander monitoring bracelet were to attempt to push the door open, an alarm would sound, and the door would open in about 10 seconds. During the interview, the door alarm sound was tested with Resident #1 next to the door on the secured dementia care unit. A muted beep sound was heard during the door test and the DOM stated, It is not loud, but it is there. An observation was conducted on 04/12/2022 at 9:38 AM, with the DOM, of the outdoor gate Resident #1 opened on 01/16/2022 when he eloped from the facility. The DOM stated the gate did not hold properly and the magnetic lock failed when Resident #1 pushed it open because the magnetic lock was rusted and in bad shape. The DOM stated when Resident #1 pushed on the gate, the magnet disengaged and did not hold but had been replaced following the elopement. An interview was conducted on 04/12/2022 at 11:52 AM with the DOM. The DOM stated after Resident #1's elopement, both the interior door locks and the exterior gate locks were repaired. The DOM also stated the rust was cleaned off the magnetic lock on the outer fence gate and had since been working. The DOM stated door checks were conducted daily on the outer gate, but full force was not placed on the gate when testing its locking operation. The DOM also stated again he was not aware of Resident #1 pulling any wires off of doors prior to the elopement on 01/16/2022 and he did not have to make any repairs to the doors or outside gate prior to the incident. Review of the facility maintenance logs for December 2021 and January 2022 revealed no maintenance requests were made before 01/16/2022 related to the side door that Resident #1 exited from or the fence gate that Resident #1 pushed open. A tour was conducted on 04/13/2022 at 9:48 AM with Staff E, Maintenance Assistant, who was performing maintenance on the main entrance door to the secured dementia care unit, and the DOM. Staff E Maintenance Assistant stated he did not have maintenance work orders for repairs to the doors, but he shows up and fixes the doors if the staff call. Staff E, Maintenance Assistant was not able to state how many times the doors were repaired. During the tour, the main entrance door had a low volume beeping sound. The DOM stated the low volume sound was an issue that they identified, and they did not know how to fix the issue with the type of system that was installed. 2) An observation of wander monitoring bracelet checks was conducted on 04/12/2022 at 10:03 AM on the facility's secured dementia care unit for six residents (including Resident #1 and Resident #10) with Staff A, CNA and Staff B, CNA. A testing device was used to detect the signal of the wander monitoring bracelet and indicated if a device is working or not. A test of Resident #1's wander monitoring bracelet revealed the device was functioning correctly. A test of Resident #10's wander monitoring bracelet revealed the device was not functioning properly and a signal was not detected. Staff A, CNA stated the (wander monitoring bracelet) should have been working but was not able to state when the (wander monitoring bracelet) was last checked for functioning. Resident #10 was escorted to the exit door of the unit by Staff B, CNA. The exit door alarm system did not respond to Resident #10's wander monitoring bracelet and two more attempts were made by Staff B, CNA. Staff B, CNA stated if the resident was too close to the (wander monitoring bracelet) receiver then it wouldn't work. Staff B, CNA assisted Resident #10 back and forth to the door multiple times in an attempt to trigger Resident #10's wander monitoring bracelet with the receiver but was unsuccessful. Staff B, CNA stated Resident #10's (wander monitoring bracelet) was not functioning properly and that she would notify the nurse on duty. A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of metabolic [CONDITION(S)], mood disorder due to known physiological features with depressive episodes, unspecified dementia without behavioral disturbances, generalized anxiety disorder, and restlessness and agitation. A review of Resident #10's Elopement Risk Evaluation, dated 01/16/2022 revealed Resident #10 was alert with continuous confusion, did not wander and never eloped, ambulated independently, and was content with placement, resulting in an Elopement Risk Score of 10, indicating Resident #10 was at risk for elopement. Resident #10's Elopement Risk Evaluation also revealed a (wander monitoring bracelet) was applied and her picture was placed in the facility's elopement book. A review of Resident #10's physician orders summary revealed the following orders: - An order dated 04/12/2022 for (wander monitoring bracelet) to right ankle. Expiration March 2025. Check for functioning every day shift. - An order dated 04/12/2022 for (wander monitoring bracelet) to right ankle. Expiration March 2025. Check for placement every shift. A review of Resident #10's physician orders did not reveal any orders related to functioning and placement of a wander monitoring bracelet prior to 04/12/2022. A review of Resident #10's care plan revealed a Focus, initiated 08/20/2021, of Resident #10 having a potential for elopement due to cognitive impairment, exit seeking, wandering around unit, and wandering near exit doors. Interventions included to place Resident #10 on the secured unit, provide redirection when observed going towards exit doors, and apply (wander monitoring bracelet) to the right ankle, verify placement every shift, and check for proper functioning daily. A review of Resident #10's MDS Assessment, dated 02/15/2022, revealed under Section C - Cognitive Patterns, a BIMS score of 7, which indicated Resident #10 had severely impaired cognition. Resident #10's MDS Assessment also revealed under Section G - Functional Status Resident #10 required supervision only for walking in her room, walking in corridors, and locomotion on and off of the unit. Resident #10's MDS Assessment revealed under Section P - Restraints and Alarms, a wander/elopement alarm was not used. An interview was conducted on 04/13/2022 at 10:11 AM with Staff F, Housekeeper. Staff F, Housekeeper stated she had worked at the facility for about 3 months and had not received any in-service training related to elopement procedures in the facility. An interview was conducted on 04/13/2022 at 10:14 AM with Staff D, LPN. Staff D, LPN stated the last in-service she was provided related to elopement procedures was sometime in 2021. An interview was conducted on 04/13/2022 at 10:30 AM with Staff I, Agency LPN. Staff I, Agency LPN stated she worked at the facility three or four times a month and had not received in-service training related to elopement procedures at the facility. A telephone interview was conducted on 04/13/2022 at 11:52 AM with Staff P, Agency LPN. Staff P, Agency LPN stated she had never worked on the facility's secured dementia care unit and was not familiar with any residents on the unit. Staff P, Agency LPN also stated she had not received any in-service training related to elopement from the facility. A review of the facility's education related to Resident #1's elopement from the facility was conducted on 04/14/2022 at 10:46 AM with Staff S, Assistant Director of Nursing (ADON). Staff S, ADON confirmed the facility did not educate 100% of its staff after Resident #1's elopement on 01/16/2022 and verified the findings with the facility staff roster. A telephone interview was conducted on 04/13/2022 at 11:56 AM with the facility's Medical Director (MD). The MD stated he was familiar with Resident #1, who had a history of dementia with episodes of anxiety and depression. Resident #1 was exit seeking and continued to be exit seeking but has been on and off. The MD stated the facility notified him of Resident #1's elopement from the facility on 01/16/2022 but could not recall when he was notified. The MD was not able to recall details related to Resident #1's elopement but stated Resident #1 was found unharmed. The MD was not able to state if Resident #1 had a (wander monitoring bracelet) at the time of the elopement and stated that a (wander monitoring bracelet) would require a physician's order. An interview was conducted on 04/13/2022 at 10:35 AM with Staff J, LPN Unit Manager (UM). Staff J, LPN UM stated she was the Unit Manager for the secured dementia care unit and was a little bit familiar with Resident #1. Staff J, LPN UM was not able to state why Resident #1 was placed on 1 to 1 supervision on 01/13/2022 but stated 1 to 1 supervision would require a physician's order. Staff J, LPN UM stated she was not working the day that Resident #1 eloped, but she had heard about the incident from facility staff. A review of Resident #1's physician's orders did not reveal an order for 1 to 1 supervision on 01/13/2022. An interview was conducted on 04/13/2022 at 12:45 PM. The DON stated agency staff were educated on facility policy and procedure through use of a binder kept at the reception desk. Agency staff read through the binder and sign they have read the policies. The DON stated they do not review the policies and procedures themselves with agency staff, but supervisors were available on the units for any questions. A review of the sign in log in the agency education book revealed one date only, 10/08/2021. The DON reviewed the sign in log and stated more agency staff should be on the sign in sheet because multiple agency staff had worked in the facility since 10/08/2021. An interview was conducted on 04/12/2022 at 12:28 PM with the NHA and the Director of Nursing. The NHA stated she was notified on 01/16/2022 around 5:00 PM Resident #1 was not in his room and was not found anywhere in the facility and immediately traveled to the facility. In the 20 or 30 minutes it took for the NHA to drive to the facility, Resident #1 was already located and returned to the secured dementia care unit. The facility's investigation revealed Resident #1 damaged the wires to an electromagnetic locking device on a side door leading to the fenced courtyard outside the facility. This allowed Resident #1 to open the door without sounding an alarm. The NHA stated once Resident #1 was outside and approached a magnetically closed gate in the surrounding fenced in area, he was able to push the gate really hard and caused it to open, which allow[TRUNCATED]

Based on interview with families and facility staff, and review of residents' medical records and facility policy, the facility failed to document any reason for discharge from the facility for four of four sampled residents (#1, #2, #3, #4), of a total sample of 12 residents discharged from the Memory Unit from [DATE] through to [DATE]. Findings included: 1- Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS completed on [DATE] assessed the resident's cognitive abilities as severely impaired (Brief Interview for Mental Status = 3). Section Q included that the resident had no active discharge plan to return to the community. A care plan meeting was documented in the progress notes as having been held on [DATE]. The family was documented as not being able to participate. Notes from the care plan meeting, documented by the Social Services Director (SSD), indicated, no new referrals needed at this time. meds and care discussed. Further review of the progress notes in the resident's medical record revealed a note dated [DATE] at 16:05, writer spoke to the son concerning his mother being discharged . Son is requesting mother discharge to (local assisted living facility ALF) ) on ,[DATE]. 1823 (ALF assessment form) signed and faxed. Home Health to provide therapy services. The next note, dated [DATE] at 11:05 a.m., read, resident is alert and oriented to person with confusion. Discharge to ALF with medications, accompany son and daughter. All discharge instructions given to son, verbalized understanding. Resident ambulating with rolling walker assisted with two staff to son's car, no distress noted. Further review of the progress notes did not reveal how the decision to discharge came about. There was no care plan related to discharge planning to track the decision and approaches the facility was using to assist in the discharge. There were no notes related to ensuring the resident, and family, were prepared for the change in this resident's life. There were no additional nurses notes or notes by the social services department documenting the family's request to have their family member discharged and no notes by facility staff documenting why the resident would be discharged from a locked, secured Memory Unit to an Assisted Living Facility. There were no notes indicating which of the six required reasons for discharge or transfer supported this decision. Review of the Nursing Home Transfer and Discharge Notice (AHCA Form ,[DATE]) was reviewed and noted to not have a Resident Representative listed on page one. The Resident Representative however, signed the second page of the form. The Date Notice is given was the resident's discharge date ([DATE]) with an effective date of [DATE]. The Reason for Discharge or Transfer was not marked. Documented under Brief explanation to support this action was the documentation ALF. In an interview with the resident's son, on [DATE] beginning at 2:10 p.m., it was confirmed that the facility phoned him after the holidays in January to let him know that they needed to move the residents out of the Memory Unit as they were renovating the unit and the residents would no longer be safe. He reported that he told the facility in the call that he must have missed the mailing, the written notice, as this call was a surprise to him. He reported that the facility said he hadn't missed the mailed document, there hadn't been one, this call was the notice. He confirmed he was very surprised, and very unhappy about it. He confirmed that he and his sister assumed this would be his mother's home and she seemed very stable and happy. He agreed that the facility had made a 'consultant' available who was very helpful in finding another facility for his mother. He reported he was happy with the new facility and his mother seemed to have settled easily, but he said the facility provided no support, other than having the consultant phone him. He said he called the facility a few times for some additional information, left his name and phone number and never got a call back. He ended the call by saying he was very disappointed in how it all ended up. 2. Resident #2 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, completed on [DATE], assessed the resident as being cognitively impaired (BIMS = 3). Section Q documented the resident as not having an active discharge plan to the community. review of the resident's medical record revealed [REDACTED]. The notes about the care plan meeting content included, plan of care provided with facility discussion, meds and labs reviewed, current diet discussed, code status - daughter mentioned her mother will remain as DNR, does not wish to make any changes at this time. Further review of the progress notes, between November's care plan meeting and the end of December did not discuss the decision for the resident to discharge from the facility. A note written by the nurse dated [DATE] at 11:04 read, resident alert and responding verbally. respirations even and unlabored. head to toe assessment performed while receiving shower. no skin issues observed. oxygen saturation 97% room air. ,[DATE] 18 76 97.6. departed facility with belongings, meds, proper administration of meds per this nurse. attendants x two from (local ALF) for transport. Stable condition noted. (sic) The next noted was dated [DATE], timed at 11:15 a.m., and written by the Social services director , read, (Local ALF) rep (representative) was in facility to transfer resident to new home. Rep signed proper discharge paperwork. Resident and rep left facility with all medications. Social services will continue to assist as needed. (sic) Review of the care plans for Resident #2 did not reveal a discharge care plan with interventions to assist the resident and family in locating a new home or with ensuring the resident and family were prepared for the change. Review of the AHCA form 3120, Nursing Home Transfer and Discharge Notice , revealed the date the notice was given was the date the resident was discharged - [DATE]. The effective date of the notice was [DATE]. There was no reason given for the discharge and in the section on the form for Brief explanation to support this action was the documentation, SNF - SNF. None of the six reasons required for discharge or transfer was checked on the form. Contained in the resident's medical record was an ALF 1823 assessment form. The resident's medical record was not clear as to where the resident discharged - an ALF or another SNF (skilled nursing facility). In an interview with the resident's daughter, on [DATE] beginning at 1:00 p.m., the daughter reported that a week or so before Christmas she got a call from the social services director at the facility telling her that the Menory Unit was closing for renovations, which would begin in January. She was told, since your mother is a wanderer, she would need to find some where else to live as the renovations would mean the doors would be open and she might not be safe. The daughter reported she was very surprised, that her mother was settled in and doing well. She reported that she didn't know how long the process of finding some where else for her mother to live would take. But she received a call from a 'consultant' who had gotten her name from the facility, who said she would help her find a secured unit for her mother. In a second call to the resident's daughter, on [DATE] beginning at 10:20 a.m., the daughter confirmed that she had not felt she had any recourse in the decision that the facility had made - that she had to move her mother out of the facility. She understood the move was 'a must' and renovations would begin soon. She confirmed she had not received the document that she had signed or any documentation from the facility as to her mother's rights with contact agencies to speak with. 3. Resident # 3 was admitted to the facility initially on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS completed on [DATE] revealed the resident's cognitive status was assessed as severely impaired (BIMS = 2). Per Section Q, there was no active discharge plan to the community. Review of progress notes in the resident's medical record revealed on [DATE], a care plan meeting was held, and the resident's daughter attended. The progress note included what was discussed at the meeting: code status discussed, confirmed to remain DNR, no changes made, consents reviewed, no new referrals needed, meds and care discussed, social services to assist prn. ( A prior care plan meeting, held on [DATE], included the daughter's statement, very pleased with the care her father is receiving at this facility and doesn't want him to move). Review of the care plans for Resident #3 revealed there was no Discharge Planning care plan to assist in preparing the resident and family for the change in living environment for the resident. In an interview with the Social Services Director, on [DATE] beginning at 4:50 p.m., she reported that the resident's wife had wanted the resident to live in an ALF, and the wife had begun the discharge process. She reported that when the wife died , the daughter took over. On [DATE] at 13:11, the nurse's note read, resident's daughter in facility today to confirm her father's discharge to (ALF). daughter requesting her father discharge on [DATE], she will be in the facility after 5 p.m., to transport him to new place. 1823 (ALF assessment ) and proper discharge paperwork has been faxed to facility. On [DATE] at 1500, the nurse's note read, daughter in to transport resident to ALF. Resident alert and responding verbally with periods of confusion. Respirations even and nonlabored. head to toe assessment performed before departing. no skin issues observed per this writer. Oxygen saturation 98% on room air. Blood pressure ,[DATE], 18, 80, 98.2. departed facility with belongings. meds and proper instructions to properly given meds to nurse upon arrival at facility. stable condition noted. There were no additional notes in the resident's medical record documenting the reason for the discharge. Review of the AHCA 3120 form, Nursing Home Transfer and Discharge Notice revealed the Date the notice was given was the date the resident was discharged from the facility. The effective date of the discharge was [DATE]. There was no reason given on the form for Discharge or Transfer. Under Brief explanation to support this action, it was written, SNF - SNF. The Social Services Director was questioned about the reason for the discharge, on [DATE] beginning at 4:50 p.m., and why the form was blank. She reported that her assistant had completed the form and she didn't know the form was incomplete. The SSD signed the form on [DATE], the day the resident was discharged . In an interview with the resident's daughter, on [DATE] beginning at 10:30 a.m., she confirmed she received a call from the facility letting her know that her father would have to move out. She reported that she was told that the Memory Unit was being renovated and everyone had to move out. She said it was sort of a 'rush job' and that she had just a few days to find a place. She reported that her father was doing okay, but then said that he is living in an ALF where everyone speaks Spanish, but her father doesn't. She said that the owner speaks English but the owner isn't around all of the time. She also said that at the facility her father was independently ambulatory, not even needing to use a walker. She said that now he needs to use a wheelchair to get around. She confirmed she had signed papers for the discharge and thought she had received copies, but didn't know that they included agency contact numbers to phone to ask about her father's rights and an appeal process. She reported that she didn't think about having the ability to appeal, she just thought they were closing the unit and she had to move her father to a different facility. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment completed on [DATE] revealed the resident's cognitive abilities were assessed as severely impaired (BIMS = 3). Section Q documented no discharge plan. review of the resident's medical record revealed [REDACTED]. Respirations even and nonlabored . Head to toe assessment performed before departing. No skin issues observed. oxygen saturation 98% on room air. Blood Pressure ,[DATE] 18 76 98.2. Resident was transported to ALF per the facility transportation department. Resident departed facility with his belongings, medications and proper instructions to properly give medications to nurse upon arrival to the facility per this nurse. Stable condition noted upon departure. Further review of the resident's electronic medical record did not reveal a reason for the discharge. In an interview with the Social Services Director, on [DATE] beginning at 5:00 p.m., she reported that the resident was very aggressive and had bad behaviors, on one to one for awhile. She reported when she spoke with the resident's son, he was aware of the resident's behaviors. She reported that the resident's family had tried in the past to have the resident discharged to an ALF, but the discharge had to be placed on hold. She wasn't aware what had happened to the plan to discharge. Review of the care plans revealed there was no discharge care plan for this resident even though the plan to discharge had been discussed in the Fall of 2018, per notes in the resident's medical record. Review of a progress note dated [DATE] revealed the resident's care plan meeting had been held without the family in attendance. The note included what was discussed at the meeting, but did not discuss possible discharge as had been discussed in [DATE] progress notes or related to the resident's discharge on [DATE]. 5. In an interview with the Director of Nurses (DON) on [DATE] beginning at 1:00 p.m., it was revealed that neither she nor the Administrator had provided 30 day notices to discharge to any of the residents on the 100 unit (Memory Unit). She reported that they had not asked any residents to leave. She reported that the Social Services Director had spoken directly with residents' families explaining that there would be changes in the unit related to renovations and there was the offer of any help the family might need related to a change in the focus of the unit. The DON did not remember when these conversations with families began to occur and confirmed that the discussions were only verbal, there was no written document provided to the families or responsible parties. She provided a list of twelve residents who had discharged from the Memory Unit from [DATE] through to [DATE]. At 6:55 p.m., on [DATE], the surveyor confirmed with the Administrator, Director of Nurses (DON) and Assistant Director of Nurses that there were not care plans related to discharge, or care plans that were revised to address residents discharging due to renovations in the Memory Unit causing the unit to be less secure for residents' requiring a secured unit. The Administrator confirmed that care plans had not been developed to address discharge planning. The DON added that since the residents were considered to be long term residents, there had been no care plans developed for them. 6. Review of the facility policy, Notice of Resident's Rights Regarding Transfer or Discharge, revealed the Policy statement: The Facility will transfer and/or discharge residents if one or more of the following in accordance with state law under the following circumstances: a. It is necessary for the resident's welfare and the resident's needs cannot be met in the Facility (documentation required by resident's physician in the medical record.) b. The discharge is appropriate because the resident 's health has improved sufficiently, so that the resident no longer needs the services provided by the Facility (documentation required by resident's physician in the medical record.) c. The safety of individuals in the Facility is endangered. d. The health of individuals in the Facility is otherwise endangered (documention required by a physician in the medical record.) e. The resident has failed, after reasonable and appropriate notice , to pay for (or have paid under Medicare, Medicaid, or state supplementation) a stay in the facility. f. The Facility is ceasing to operate. Procedure: 1. If the Facility proceeds with a discharge under one or more of the above-referenced circumstances, the Facility will issue a written notice of discharge that includes an effective date and a discharge location. A copy will be provided to the resident and the legal representative. 2. The Facility will document the discharge in the medical record. Under a, b, and d above a physician will also document in the medi al record. 3. The Facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This may include coordinating appropriate services to assist in the transfer/discharge process. Such services may include contacting other facilities, home health agencies, pharmacies, durable medical equipment and/or other providers. A list of other resources to aid in a successful discharge will be provided to the resident or legal representative when appropriate. 4. This process may necessitate providing the resident's medical information to other potential facilities and providers. 5. The Nursing Department will contact the resident's physician for discharge orders if applicable. Review of four of the twelve residents discharged from the Memory Unit in [DATE], [DATE] and February 2019 were not discharged per the facility policy. No reason was given for the discharges, either on the Nursing Home Discharge and Transfer form or in the residents' medical records.

Based on interview with families and facility staff, and review of residents' medical records and facility policy, the facility failed to document any reason for discharge from the facility for four of four sampled residents (#1, #2, #3, #4), of a total sample of 12 residents discharged from the Memory Unit from (MONTH) (YEAR) through to (MONTH) 2019. Findings included: 1- Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS completed on [DATE] assessed the resident's cognitive abilities as severely impaired (Brief Interview for Mental Status = 3). Section Q included that the resident had no active discharge plan to return to the community. A care plan meeting was documented in the progress notes as having been held on [DATE]. The family was documented as not being able to participate. Notes from the care plan meeting, documented by the Social Services Director (SSD), indicated, no new referrals needed at this time. meds and care discussed. Further review of the progress notes in the resident's medical record revealed a note dated [DATE] at 16:05, writer spoke to the son concerning his mother being discharged . Son is requesting mother discharge to (local assisted living facility ALF) ) on ,[DATE]. 1823 (ALF assessment form) signed and faxed. Home Health to provide therapy services. The next note, dated [DATE] at 11:05 a.m., read, resident is alert and oriented to person with confusion. Discharge to ALF with medications, accompany son and daughter. All discharge instructions given to son, verbalized understanding. Resident ambulating with rolling walker assisted with two staff to son's car, no distress noted. Further review of the progress notes did not reveal how the decision to discharge came about. There was no care plan related to discharge planning to track the decision and approaches the facility was using to assist in the discharge. There were no notes related to ensuring the resident, and family, were prepared for the change in this resident's life. There were no additional nurses notes or notes by the social services department documenting the family's request to have their family member discharged and no notes by facility staff documenting why the resident would be discharged from a locked, secured Memory Unit to an Assisted Living Facility. There were no notes indicating which of the six required reasons for discharge or transfer supported this decision. Review of the Nursing Home Transfer and Discharge Notice (AHCA Form ,[DATE]) was reviewed and noted to not have a Resident Representative listed on page one. The Resident Representative however, signed the second page of the form. The Date Notice is given was the resident's discharge date ([DATE]) with an effective date of [DATE]. The Reason for Discharge or Transfer was not marked. Documented under Brief explanation to support this action was the documentation ALF. In an interview with the resident's son, on [DATE] beginning at 2:10 p.m., it was confirmed that the facility phoned him after the holidays in (MONTH) to let him know that they needed to move the residents out of the Memory Unit as they were renovating the unit and the residents would no longer be safe. He reported that he told the facility in the call that he must have missed the mailing, the written notice, as this call was a surprise to him. He reported that the facility said he hadn't missed the mailed document, there hadn't been one, this call was the notice. He confirmed he was very surprised, and very unhappy about it. He confirmed that he and his sister assumed this would be his mother's home and she seemed very stable and happy. He agreed that the facility had made a 'consultant' available who was very helpful in finding another facility for his mother. He reported he was happy with the new facility and his mother seemed to have settled easily, but he said the facility provided no support, other than having the consultant phone him. He said he called the facility a few times for some additional information, left his name and phone number and never got a call back. He ended the call by saying he was very disappointed in how it all ended up. 2. Resident #2 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, completed on [DATE], assessed the resident as being cognitively impaired (BIMS = 3). Section Q documented the resident as not having an active discharge plan to the community. review of the resident's medical record revealed [REDACTED]. The notes about the care plan meeting content included, plan of care provided with facility discussion, meds and labs reviewed, current diet discussed, code status - daughter mentioned her mother will remain as DNR, does not wish to make any changes at this time. Further review of the progress notes, between November's care plan meeting and the end of (MONTH) did not discuss the decision for the resident to discharge from the facility. A note written by the nurse dated [DATE] at 11:04 read, resident alert and responding verbally. respirations even and unlabored. head to toe assessment performed while receiving shower. no skin issues observed. oxygen saturation 97% room air. ,[DATE] 18 76 97.6. departed facility with belongings, meds, proper administration of meds per this nurse. attendants x two from (local ALF) for transport. Stable condition noted. (sic) The next noted was dated [DATE], timed at 11:15 a.m., and written by the Social services director , read, (Local ALF) rep (representative) was in facility to transfer resident to new home. Rep signed proper discharge paperwork. Resident and rep left facility with all medications. Social services will continue to assist as needed. (sic) Review of the care plans for Resident #2 did not reveal a discharge care plan with interventions to assist the resident and family in locating a new home or with ensuring the resident and family were prepared for the change. Review of the AHCA form 3120, Nursing Home Transfer and Discharge Notice , revealed the date the notice was given was the date the resident was discharged - [DATE]. The effective date of the notice was [DATE]. There was no reason given for the discharge and in the section on the form for Brief explanation to support this action was the documentation, SNF - SNF. None of the six reasons required for discharge or transfer was checked on the form. Contained in the resident's medical record was an ALF 1823 assessment form. The resident's medical record was not clear as to where the resident discharged - an ALF or another SNF (skilled nursing facility). In an interview with the resident's daughter, on [DATE] beginning at 1:00 p.m., the daughter reported that a week or so before Christmas she got a call from the social services director at the facility telling her that the Menory Unit was closing for renovations, which would begin in January. She was told, since your mother is a wanderer, she would need to find some where else to live as the renovations would mean the doors would be open and she might not be safe. The daughter reported she was very surprised, that her mother was settled in and doing well. She reported that she didn't know how long the process of finding some where else for her mother to live would take. But she received a call from a 'consultant' who had gotten her name from the facility, who said she would help her find a secured unit for her mother. In a second call to the resident's daughter, on [DATE] beginning at 10:20 a.m., the daughter confirmed that she had not felt she had any recourse in the decision that the facility had made - that she had to move her mother out of the facility. She understood the move was 'a must' and renovations would begin soon. She confirmed she had not received the document that she had signed or any documentation from the facility as to her mother's rights with contact agencies to speak with. 3. Resident # 3 was admitted to the facility initially on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS completed on [DATE] revealed the resident's cognitive status was assessed as severely impaired (BIMS = 2). Per Section Q, there was no active discharge plan to the community. Review of progress notes in the resident's medical record revealed on [DATE], a care plan meeting was held, and the resident's daughter attended. The progress note included what was discussed at the meeting: code status discussed, confirmed to remain DNR, no changes made, consents reviewed, no new referrals needed, meds and care discussed, social services to assist prn. ( A prior care plan meeting, held on [DATE], included the daughter's statement, very pleased with the care her father is receiving at this facility and doesn't want him to move). Review of the care plans for Resident #3 revealed there was no Discharge Planning care plan to assist in preparing the resident and family for the change in living environment for the resident. In an interview with the Social Services Director, on [DATE] beginning at 4:50 p.m., she reported that the resident's wife had wanted the resident to live in an ALF, and the wife had begun the discharge process. She reported that when the wife died , the daughter took over. On [DATE] at 13:11, the nurse's note read, resident's daughter in facility today to confirm her father's discharge to (ALF). daughter requesting her father discharge on [DATE], she will be in the facility after 5 p.m., to transport him to new place. 1823 (ALF assessment ) and proper discharge paperwork has been faxed to facility. On [DATE] at 1500, the nurse's note read, daughter in to transport resident to ALF. Resident alert and responding verbally with periods of confusion. Respirations even and nonlabored. head to toe assessment performed before departing. no skin issues observed per this writer. Oxygen saturation 98% on room air. Blood pressure ,[DATE], 18, 80, 98.2. departed facility with belongings. meds and proper instructions to properly given meds to nurse upon arrival at facility. stable condition noted. There were no additional notes in the resident's medical record documenting the reason for the discharge. Review of the AHCA 3120 form, Nursing Home Transfer and Discharge Notice revealed the Date the notice was given was the date the resident was discharged from the facility. The effective date of the discharge was [DATE]. There was no reason given on the form for Discharge or Transfer. Under Brief explanation to support this action, it was written, SNF - SNF. The Social Services Director was questioned about the reason for the discharge, on [DATE] beginning at 4:50 p.m., and why the form was blank. She reported that her assistant had completed the form and she didn't know the form was incomplete. The SSD signed the form on [DATE], the day the resident was discharged . In an interview with the resident's daughter, on [DATE] beginning at 10:30 a.m., she confirmed she received a call from the facility letting her know that her father would have to move out. She reported that she was told that the Memory Unit was being renovated and everyone had to move out. She said it was sort of a 'rush job' and that she had just a few days to find a place. She reported that her father was doing okay, but then said that he is living in an ALF where everyone speaks Spanish, but her father doesn't. She said that the owner speaks English but the owner isn't around all of the time. She also said that at the facility her father was independently ambulatory, not even needing to use a walker. She said that now he needs to use a wheelchair to get around. She confirmed she had signed papers for the discharge and thought she had received copies, but didn't know that they included agency contact numbers to phone to ask about her father's rights and an appeal process. She reported that she didn't think about having the ability to appeal, she just thought they were closing the unit and she had to move her father to a different facility. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment completed on [DATE] revealed the resident's cognitive abilities were assessed as severely impaired (BIMS = 3). Section Q documented no discharge plan. review of the resident's medical record revealed [REDACTED]. Respirations even and nonlabored . Head to toe assessment performed before departing. No skin issues observed. oxygen saturation 98% on room air. Blood Pressure ,[DATE] 18 76 98.2. Resident was transported to ALF per the facility transportation department. Resident departed facility with his belongings, medications and proper instructions to properly give medications to nurse upon arrival to the facility per this nurse. Stable condition noted upon departure. Further review of the resident's electronic medical record did not reveal a reason for the discharge. In an interview with the Social Services Director, on [DATE] beginning at 5:00 p.m., she reported that the resident was very aggressive and had bad behaviors, on one to one for awhile. She reported when she spoke with the resident's son, he was aware of the resident's behaviors. She reported that the resident's family had tried in the past to have the resident discharged to an ALF, but the discharge had to be placed on hold. She wasn't aware what had happened to the plan to discharge. Review of the care plans revealed there was no discharge care plan for this resident even though the plan to discharge had been discussed in the Fall of (YEAR), per notes in the resident's medical record. Review of a progress note dated [DATE] revealed the resident's care plan meeting had been held without the family in attendance. The note included what was discussed at the meeting, but did not discuss possible discharge as had been discussed in [DATE] progress notes or related to the resident's discharge on [DATE]. 5. In an interview with the Director of Nurses (DON) on [DATE] beginning at 1:00 p.m., it was revealed that neither she nor the Administrator had provided 30 day notices to discharge to any of the residents on the 100 unit (Memory Unit). She reported that they had not asked any residents to leave. She reported that the Social Services Director had spoken directly with residents' families explaining that there would be changes in the unit related to renovations and there was the offer of any help the family might need related to a change in the focus of the unit. The DON did not remember when these conversations with families began to occur and confirmed that the discussions were only verbal, there was no written document provided to the families or responsible parties. She provided a list of twelve residents who had discharged from the Memory Unit from (MONTH) (YEAR) through to (MONTH) 2019. At 6:55 p.m., on [DATE], the surveyor confirmed with the Administrator, Director of Nurses (DON) and Assistant Director of Nurses that there were not care plans related to discharge, or care plans that were revised to address residents discharging due to renovations in the Memory Unit causing the unit to be less secure for residents' requiring a secured unit. The Administrator confirmed that care plans had not been developed to address discharge planning. The DON added that since the residents were considered to be long term residents, there had been no care plans developed for them. 6. Review of the facility policy, Notice of Resident's Rights Regarding Transfer or Discharge, revealed the Policy statement: The Facility will transfer and/or discharge residents if one or more of the following in accordance with state law under the following circumstances: a. It is necessary for the resident's welfare and the resident's needs cannot be met in the Facility (documentation required by resident's physician in the medical record.) b. The discharge is appropriate because the resident 's health has improved sufficiently, so that the resident no longer needs the services provided by the Facility (documentation required by resident's physician in the medical record.) c. The safety of individuals in the Facility is endangered. d. The health of individuals in the Facility is otherwise endangered (documention required by a physician in the medical record.) e. The resident has failed, after reasonable and appropriate notice , to pay for (or have paid under Medicare, Medicaid, or state supplementation) a stay in the facility. f. The Facility is ceasing to operate. Procedure: 1. If the Facility proceeds with a discharge under one or more of the above-referenced circumstances, the Facility will issue a written notice of discharge that includes an effective date and a discharge location. A copy will be provided to the resident and the legal representative. 2. The Facility will document the discharge in the medical record. Under a, b, and d above a physician will also document in the medi al record. 3. The Facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This may include coordinating appropriate services to assist in the transfer/discharge process. Such services may include contacting other facilities, home health agencies, pharmacies, durable medical equipment and/or other providers. A list of other resources to aid in a successful discharge will be provided to the resident or legal representative when appropriate. 4. This process may necessitate providing the resident's medical information to other potential facilities and providers. 5. The Nursing Department will contact the resident's physician for discharge orders if applicable. Review of four of the twelve residents discharged from the Memory Unit in (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019 were not discharged per the facility policy. No reason was given for the discharges, either on the Nursing Home Discharge and Transfer form or in the residents' medical records.

Based on review of the residents' medical records and facility policy, and interview with facility staff and responsible parties, the facility failed to ensure the responsible parties were provided documented reasons for discharge and required timing of the notice, for four (#1, #2, #3, #4) of twelve residents identified by the facility who had been discharged from the Memory Unit between December 2018 March 2019. Findings included: 1. In an interview with the Director of Nurses (DON) on 3/28/2019 beginning at 1:00 p.m., it was revealed that neither she nor the Administrator had provided 30 day notices of discharge to any of the residents on the 100 unit (Memory Unit). She reported that they had not asked any residents to leave. She reported that the Social Services Director had spoken directly with residents' families explaining that there would be changes in the unit related to renovations and there was the offer of any help the family might need related to a change in the focus of the unit. The DON did not remember when these conversations with families began to occur and confirmed that the discussions were only verbal, there was no written document provided to the families or responsible parties. She provided a list of twelve residents who had discharged from the Memory Unit from December 2018 through to March 2019. 2. In a review of the medical records for four sampled residents from the twelve residents identified as having been discharged from the Memory Unit, the AHCA Nursing Home Transfer and Discharge Notice had been completed for each of the four residents. For each of the four residents, there was no reason given (checked off) for the Discharge or Transfer. The form lists the six reasons a facility may discharge or transfer a resident. For the section identified as Brief explanation to support this action , Resident #1 had the explanation ALF given; Residents #2 and #3 had SNF - SNF given, and Resident #4 had nothing in that space documented. For all four residents, the Date the Notice was given was the date the resident was discharged from the facility. The Effective Date was 30 days from the date of discharge. The intent of the 30 day notice is to give the resident or responsible party time to appeal the decision. 3. Resident #1 had been a resident of the facility since 4/9/2018. Her cognition had been assessed as severely impaired by the Minimum Data Set (MDS) Assessment completed on 1/16/2019. In an interview with the resident's son, on 3/29/2019 beginning at 2:10 p.m., he reported that he was very surprised by a phone call he received in early January from the facility. He reported that he was told that the Memory Unit was being renovated and residents needed to be moved as they might not be safe during the renovations. He was told that he had not missed a mailed notice, as he had thought the phone call was a follow up to a mailed notice. He reported that he got a call from someone else reporting they were assisting the facility in finding alternate placement for the residents. He confirmed his mother was doing ok, but he was very disappointed in how it all ended up. 4. Resident #2 had been a resident of the facility since 3/20/2017. Her cognition had been assessed as severely impaired by the MDS assessment completed on 09/27/2018. In an interview with the resident's daughter on 03/29/2019 at 1:00 p.m., and 4/1/2019 at 10:00 a.m., she reported that she received a phone call before Christmas notifying her that the Memory Unit was closing due to renovations. She was told that her mother might not be safe as the doors would be open during the renovations and her mother was a wanderer. She reported that with the Holidays coming she felt she had to move on finding a new place and appreciated the help the consultant gave her in finding a new place for her mother. She confirmed she did not receive any written documents about the reason for the transfer or the appeal process. 5. Resident #3 had been a resident of the facility since 4/1/2015. His cognition had been assessed as severely impaired by the MDS assessment dated [DATE]. In an interview with the resident's daughter, on 4/1/2019 beginning at 10:30 a.m., the daughter reported that she was told that the Memory Unit was closing and all the residents had to move out. She felt it was a 'rush job' and she had just a few days to find a place for her father. She confirmed she had received some documents that she had signed at the time of the discharge but hadn't realized they were contact agencies and phone numbers where she could appeal the decision. She reported that she didn't think there was any recourse, that the unit was closing and she had to move her father out. 6. In a review of the facility Policy entitled Notice of Resident's Rights Regarding Transfer or Discharge, the statement: The Facility will transfer and/or discharge residents if one of more of the following in accordance with state law under the following circumstances: with the six reasons a facility may discharge a resident, per Regulation. The Policy included under Procedure, that a written notice of discharge that includes an effective date and discharge location would be provided to the resident and legal representative. Also that the discharge would be documented in the resident's medical record.

Based on review of the residents' medical records and facility policy, and interview with facility staff and responsible parties, the facility failed to ensure the responsible parties were provided documented reasons for discharge and required timing of the notice, for four (#1, #2, #3, #4) of twelve residents identified by the facility who had been discharged from the Memory Unit between (MONTH) (YEAR) (MONTH) 2019. Findings included: 1. In an interview with the Director of Nurses (DON) on 3/28/2019 beginning at 1:00 p.m., it was revealed that neither she nor the Administrator had provided 30 day notices of discharge to any of the residents on the 100 unit (Memory Unit). She reported that they had not asked any residents to leave. She reported that the Social Services Director had spoken directly with residents' families explaining that there would be changes in the unit related to renovations and there was the offer of any help the family might need related to a change in the focus of the unit. The DON did not remember when these conversations with families began to occur and confirmed that the discussions were only verbal, there was no written document provided to the families or responsible parties. She provided a list of twelve residents who had discharged from the Memory Unit from (MONTH) (YEAR) through to (MONTH) 2019. 2. In a review of the medical records for four sampled residents from the twelve residents identified as having been discharged from the Memory Unit, the AHCA Nursing Home Transfer and Discharge Notice had been completed for each of the four residents. For each of the four residents, there was no reason given (checked off) for the Discharge or Transfer. The form lists the six reasons a facility may discharge or transfer a resident. For the section identified as Brief explanation to support this action , Resident #1 had the explanation ALF given; Residents #2 and #3 had SNF - SNF given, and Resident #4 had nothing in that space documented. For all four residents, the Date the Notice was given was the date the resident was discharged from the facility. The Effective Date was 30 days from the date of discharge. The intent of the 30 day notice is to give the resident or responsible party time to appeal the decision. 3. Resident #1 had been a resident of the facility since 4/9/2018. Her cognition had been assessed as severely impaired by the Minimum Data Set (MDS) Assessment completed on 1/16/2019. In an interview with the resident's son, on 3/29/2019 beginning at 2:10 p.m., he reported that he was very surprised by a phone call he received in early (MONTH) from the facility. He reported that he was told that the Memory Unit was being renovated and residents needed to be moved as they might not be safe during the renovations. He was told that he had not missed a mailed notice, as he had thought the phone call was a follow up to a mailed notice. He reported that he got a call from someone else reporting they were assisting the facility in finding alternate placement for the residents. He confirmed his mother was doing ok, but he was very disappointed in how it all ended up. 4. Resident #2 had been a resident of the facility since 3/20/2017. Her cognition had been assessed as severely impaired by the MDS assessment completed on 09/27/2018. In an interview with the resident's daughter on 03/29/2019 at 1:00 p.m., and 4/1/2019 at 10:00 a.m., she reported that she received a phone call before Christmas notifying her that the Memory Unit was closing due to renovations. She was told that her mother might not be safe as the doors would be open during the renovations and her mother was a wanderer. She reported that with the Holidays coming she felt she had to move on finding a new place and appreciated the help the consultant gave her in finding a new place for her mother. She confirmed she did not receive any written documents about the reason for the transfer or the appeal process. 5. Resident #3 had been a resident of the facility since 4/1/2015. His cognition had been assessed as severely impaired by the MDS assessment dated [DATE]. In an interview with the resident's daughter, on 4/1/2019 beginning at 10:30 a.m., the daughter reported that she was told that the Memory Unit was closing and all the residents had to move out. She felt it was a 'rush job' and she had just a few days to find a place for her father. She confirmed she had received some documents that she had signed at the time of the discharge but hadn't realized they were contact agencies and phone numbers where she could appeal the decision. She reported that she didn't think there was any recourse, that the unit was closing and she had to move her father out. 6. In a review of the facility Policy entitled Notice of Resident's Rights Regarding Transfer or Discharge, the statement: The Facility will transfer and/or discharge residents if one of more of the following in accordance with state law under the following circumstances: with the six reasons a facility may discharge a resident, per Regulation. The Policy included under Procedure, that a written notice of discharge that includes an effective date and discharge location would be provided to the resident and legal representative. Also that the discharge would be documented in the resident's medical record.

Based on review of care plans, the resident's medical record and facility policy, and interview with facility staff and residents' responsible parties, the facility failed to develop discharge care plans for four (#1, #2, #3, #4) of twelve residents identified as having been discharged from the Memory Unit between [DATE] and [DATE]. Findings included: 1. In an interview with the Administrator, Director of Nurses, (DON) and Assistant Director of Nurses, on [DATE] beginning at 6:55 p.m., it was reported that the four sampled residents did not have care plans related to discharge planning. The DON reported that there had been no care plans developed for the residents as all of them were identified as long term care residents. The Director of Nurses had explained earlier in the day ([DATE] at 1:00 p.m.,) that none of the residents in the Memory Unit had been provided with a 30 day notice of discharge and no residents had been asked to leave. The DON reported that Social Services staff had phoned all of the residents' responsible parties to explain that the Memory Unit was to be renovated and residents may not remain secure in the unit as the doors would be open. She reported that the facility's assistance was offered in any way that was needed. 2. Resident #3 was admitted to the facility on [DATE]. His cognitive status was determined to be severely impaired per the Minimum Data Set (MDS) conducted on [DATE]. The Social Services Director (SSD) explained on [DATE] beginning at 4:50 p.m., that the resident's wife had wanted him to live in an Assisted Living Facility but she died before she could transfer him to an ALF. The SSD reported that the daughter took over that task. Review of the progress notes located in the resident's medical record revealed on [DATE] the resident was discharged to an ALF. There was no prior note indicating this process in finding an ALF for the resident was taking place. There was a note documenting a care plan had taken place on [DATE] with no reference to a possible discharge with referrals made to ALF's for the resident. There was no care plan to refer to, developed when the resident's wife was attempting to get her husband discharged to an ALF. In an interview with the resident's daughter on [DATE] beginning at 10:30 a.m., the daughter reported that she was told, in a phone conversation, that the Memory Unit was closing and all the residents had to move out. She felt it was a rush job and she had just a few days to find a place for her father. She felt her father was doing ok, but then commented that most of the residents at the ALF spoke Spanish and her father did not. She also said that since the discharge, her father was not walking, but using a wheelchair to get around. She reported that he had been walking around, with a walker, at the other facility, but now could not walk. 3. Resident #4 was admitted to the facility on [DATE]. Per the MDS assessment completed on [DATE] the resident's cognition was identified as severely impaired. Review of progress notes revealed on [DATE] the social services and administrator contacted the resident's family /son to verify possible placement with a secured ALF. The resident's son advised that family are open to placement as long as placement is secured and in the same area. The next note referring to a discharge to an ALF was dated [DATE] which read, discharge on hold until further notice . son aware. A care plan meeting was held on [DATE] with no reference to possible discharge to an ALF or that the discharge plan had changed. Resident #4 had no care plan developed in the Fall to address the 'possible placement in a secured ALF or to address the verbal notice of discharge provided to the resident's family resulting in the resident's discharge on [DATE]. 4. Residents #1 and #2 had no care plans related to discharge from the facility, even after their families received calls from the facility indicating the Memory Unit was going to be renovated and the new unit might not be secure. In interviews with family members of both Residents #1 and #2, it was reported as a big surprise that their family member would need to be moved. Both responsible parties reported that they assumed this was their family member's home. There were no care plans developed to address the concerns that might arise from the change in the focus of the Memory Unit and needing to find a new facility. Resident #1 had been a resident of the facility since [DATE]. Her cognition had been assessed as severely impaired by the Minimum Data Set (MDS) Assessment completed on [DATE]. Further review of the progress notes in the resident's medical record revealed a note dated [DATE] at 16:05, writer spoke to the son concerning his mother being discharged . Son is requesting mother discharge to (local assisted living facility ALF) ) on ,[DATE]. 1823 (ALF assessment form) signed and faxed. Home Health to provide therapy services. The next note, dated [DATE] at 11:05 a.m., read, resident is alert and oriented to person with confusion. Discharge to ALF with medications, accompany son and daughter. All discharge instructions given to son, verbalized understanding. Resident #2 had been a resident of the facility since [DATE]. Her cognition had been assessed as severely impaired by the MDS assessment completed on [DATE]. Review of the quarterly MDS assessment, completed on [DATE], assessed the resident as being cognitively impaired (BIMS = 3). Section Q documented the resident as not having an active discharge plan to the community. Review of the AHCA form 3120, Nursing Home Transfer and Discharge Notice, revealed the date the notice was given was the date the resident was discharged - [DATE]. 5. Review of the Facility policy entitled Notice of Resident's Rights Regarding Transfer of Discharge revealed under point #3,the facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.

Based on review of care plans, the resident's medical record and facility policy, and interview with facility staff and residents' responsible parties, the facility failed to develop discharge care plans for four (#1, #2, #3, #4) of twelve residents identified as having been discharged from the Memory Unit between (MONTH) (YEAR) and (MONTH) 2019. Findings included: 1. In an interview with the Administrator, Director of Nurses, (DON) and Assistant Director of Nurses, on [DATE] beginning at 6:55 p.m., it was reported that the four sampled residents did not have care plans related to discharge planning. The DON reported that there had been no care plans developed for the residents as all of them were identified as long term care residents. The Director of Nurses had explained earlier in the day ([DATE] at 1:00 p.m.,) that none of the residents in the Memory Unit had been provided with a 30 day notice of discharge and no residents had been asked to leave. The DON reported that Social Services staff had phoned all of the residents' responsible parties to explain that the Memory Unit was to be renovated and residents may not remain secure in the unit as the doors would be open. She reported that the facility's assistance was offered in any way that was needed. 2. Resident #3 was admitted to the facility on [DATE]. His cognitive status was determined to be severely impaired per the Minimum Data Set (MDS) conducted on [DATE]. The Social Services Director (SSD) explained on [DATE] beginning at 4:50 p.m., that the resident's wife had wanted him to live in an Assisted Living Facility but she died before she could transfer him to an ALF. The SSD reported that the daughter took over that task. Review of the progress notes located in the resident's medical record revealed on [DATE] the resident was discharged to an ALF. There was no prior note indicating this process in finding an ALF for the resident was taking place. There was a note documenting a care plan had taken place on [DATE] with no reference to a possible discharge with referrals made to ALF's for the resident. There was no care plan to refer to, developed when the resident's wife was attempting to get her husband discharged to an ALF. In an interview with the resident's daughter on [DATE] beginning at 10:30 a.m., the daughter reported that she was told, in a phone conversation, that the Memory Unit was closing and all the residents had to move out. She felt it was a rush job and she had just a few days to find a place for her father. She felt her father was doing ok, but then commented that most of the residents at the ALF spoke Spanish and her father did not. She also said that since the discharge, her father was not walking, but using a wheelchair to get around. She reported that he had been walking around, with a walker, at the other facility, but now could not walk. 3. Resident #4 was admitted to the facility on [DATE]. Per the MDS assessment completed on [DATE] the resident's cognition was identified as severely impaired. Review of progress notes revealed on [DATE] the social services and administrator contacted the resident's family /son to verify possible placement with a secured ALF. The resident's son advised that family are open to placement as long as placement is secured and in the same area. The next note referring to a discharge to an ALF was dated [DATE] which read, discharge on hold until further notice . son aware. A care plan meeting was held on [DATE] with no reference to possible discharge to an ALF or that the discharge plan had changed. Resident #4 had no care plan developed in the Fall to address the 'possible placement in a secured ALF or to address the verbal notice of discharge provided to the resident's family resulting in the resident's discharge on [DATE]. 4. Residents #1 and #2 had no care plans related to discharge from the facility, even after their families received calls from the facility indicating the Memory Unit was going to be renovated and the new unit might not be secure. In interviews with family members of both Residents #1 and #2, it was reported as a big surprise that their family member would need to be moved. Both responsible parties reported that they assumed this was their family member's home. There were no care plans developed to address the concerns that might arise from the change in the focus of the Memory Unit and needing to find a new facility. Resident #1 had been a resident of the facility since [DATE]. Her cognition had been assessed as severely impaired by the Minimum Data Set (MDS) Assessment completed on [DATE]. Further review of the progress notes in the resident's medical record revealed a note dated [DATE] at 16:05, writer spoke to the son concerning his mother being discharged . Son is requesting mother discharge to (local assisted living facility ALF) ) on ,[DATE]. 1823 (ALF assessment form) signed and faxed. Home Health to provide therapy services. The next note, dated [DATE] at 11:05 a.m., read, resident is alert and oriented to person with confusion. Discharge to ALF with medications, accompany son and daughter. All discharge instructions given to son, verbalized understanding. Resident #2 had been a resident of the facility since [DATE]. Her cognition had been assessed as severely impaired by the MDS assessment completed on [DATE]. Review of the quarterly MDS assessment, completed on [DATE], assessed the resident as being cognitively impaired (BIMS = 3). Section Q documented the resident as not having an active discharge plan to the community. Review of the AHCA form 3120, Nursing Home Transfer and Discharge Notice, revealed the date the notice was given was the date the resident was discharged - [DATE]. 5. Review of the Facility policy entitled Notice of Resident's Rights Regarding Transfer of Discharge revealed under point #3,the facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.

Based on review of clinical and hospital records and facility policies and procedures, interviews with the Social Worker, nursing and administrative staff, a family member, and the resident's physician, it was determined that the facility failed to protect the rights of 1 (#2) of 6 sampled residents related to the implementation of Advanced Directives. The facility failed to honor Resident #2's expressed wishes related to Advanced Directives and end of life decisions. The facility failed to ensure the Social Worker contacted the resident's physician in a timely manner, upon receipt of a signed Do Not Resuscitate (D.N.R.) form from Resident #2's Attorney In Fact & Health Care Surrogate, and obtained a physician's orders [REDACTED].#2's death. The facility failed to follow its own policies and procedures for Advance Directives and Do Not Resuscitate (DNR), and ensure the Advanced Directive for Do Not Resuscitate was entered in the clinical record, and nursing staff had correct Advanced Directive information available for review in an emergency. The facility initiated CPR (Cardiopulmonary Resuscitation) on Resident #2 who had a [DIAGNOSES REDACTED]. She had a Living will that expressed her wishes not to have life prolonging procedures in the event of a terminal condition, and a State of Florida DNR order form signed by her Attorney in Fact and Health Care Surrogate. The facility violated Resident #2's right to refuse treatment. The facility failed to protect Resident #2 from unwanted, potentially violent interventions in her last moments of life. Failure of facility staff to implement Advance Directives correctly resulted in findings of Immediate Jeopardy on [DATE], which was removed on [DATE] and reduced to the scope and severity of D. Findings included: Review of the General Durable Power of Attorney of (resident's name), dated (MONTH) 19, (YEAR) found that Resident #2's Primary Contact and sibling was appointed to serve as Durable Power of Attorney. The Primary Contact and sibling was appointed as the Health Care Surrogate, according to the Living Will Declaration and Designation of Health Care Surrogate . on (MONTH) 13, (YEAR). This document reflected that Resident #2 did not want any artificial life prolonging procedures in the event she had a terminal condition. During review of facility documents provided by the facility, a Florida Department of Health, State of Florida Do Not Resuscitate (DNR) form was found. It was dated [DATE] and signed by Resident #2's POA/HCS (Power of Attorney/Health Care Surrogate), the resident's sister. The physician, however, had not signed the document. Resident #2 was admitted to the facility in (MONTH) (YEAR) with a pertinent [DIAGNOSES REDACTED]. In an interview with the social worker on [DATE] at 2:06 p.m., she said she went in to the resident's room that day, with a shirt she had found that belonged to the resident's roommate. Resident #2 was making gurgling noises. She called the nurses right away. The suction machine was used on the resident, and she went in to try to calm her down. The nurse said she just stopped breathing. They did CPR. They called EMS. The family was not present. Her nurses called to let her family know. She said she spoke briefly to the family. The sister asked her what was going on, and the nurse explained what was going on medically with the resident. EMS were in there. The resident's sister asked why they were doing CPR. We told her the physician did not sign the DNR order form, so we had to follow physician orders. When the Social Worker was asked about the State of Florida DNR order form, she said she did not recall when she had spoken to the resident's sister about it. She said they did talk about it. The resident's sister said she would come in to sign the form, but she did not come in. She asked that we mail the DNR form to her. The social worker said she did not recall when the facility mailed the form. The resident's sister signed it and mailed it back. She confirmed that she let the physician know that she had paperwork that needed to be signed, but she did not let him know what it was. He said he would get to it on his next visit. The physician was leaving the facility and she caught him at the door. Since the doctor had not signed it, it had not been placed in the chart. A telephone interview was conducted with the resident's physician on [DATE] at 8:55 a.m. He said the social worker did not tell him the resident had a DNR form that needed to be signed. She told him something needed to be signed, but she did not tell him what it was, or what resident it was for. If the facility had a DNR form for him to sign it takes 2 seconds. He would have signed it immediately. They could have faxed the form to him as well and he would have signed it. If a family member has already signed the document, it should have been given to him to sign immediately. The facility has to get the document to him right away. They did not tell him the resident's family member did not want CPR. He was not aware the family member objected to the code. An interview was conducted with the resident's nurse, Staff A, RN (Registered Nurse) at 1:15 p.m. on [DATE]. She said she was passing medications when the social worker approached her with the news the resident's breathing was sounding funny. She went in the resident's room and checked her oxygen saturation and lung sounds. She went to get suction and notify the supervisor. When she returned to the room, the resident was not breathing and did not have a pulse. She called code blue and got the crash cart. She said she looked in the electronic clinical record and retrieved the paper chart. She did not see a DNR order. The resident was a full code. CPR was initiated. Other nurses came to help. Some were calling the doctor and 911. The family was notified. The resident's sister came to the facility sometime after the chest compressions started. EMS (Emergency Medical Services) arrived and took over CPR. Then they transported the resident to the hospital. In an interview with Staff B, RN Supervisor at 1:35 p.m. on [DATE], she said she was called to the unit from the central supply closet. It was about 10:00 a.m. She went to the resident's room. When she entered the room, the nurse and the social worker were in there. The social worker started calling the resident's name because she was not responding. The nurse did too. The resident just kind of slumped over. Then she instructed the nurse to check the computer and her chart to see what the resident's code status was. When the nurse realized the resident was a full code, she called the code. They got the crash cart. Another nurse called 911 while they were performing CPR. Then EMS arrived and they took over CPR. The resident's family arrived when EMS were in the room. EMS had been there maybe 10 or 15 minutes or so. Then EMS transferred the resident to the hospital. In an additional interview with the social worker on [DATE] at 3:01 p.m., she said the resident's sister dated the DNR form. The resident had a decline, so her sister mentioned that she probably wanted to make her a DNR. She asked the resident's sister if she wanted to come in to sign the paperwork. She did not come in. She followed up with a phone call. The resident's sister was busy with her life and so the social worker asked if she wanted it mailed it to her. She agreed to have it mailed to her. She confirmed she had not documented the conversation in the medical record, and had no recollection when the conversation with the resident's sister took place. An interview was conducted with the Social Services Director (SSD) on [DATE] at 10:24 a.m. She said that she and the Social Worker typically do check each other's mailbox if someone is sick or on vacation. Of course, they cover each other as needed. She said she believed the DNR order form was on the Social Worker's desk and not in her mailbox. She was not aware there was a signed DNR order form for the resident. She said Social Services frequently talks with family members regarding advance directives including code status. At the time that a resident or representative signified they would like to sign a DNR form, Social Services explains the form to them, and has the family print and sign the form. Also, we would explain that the form is not valid until the physician signs the form. Until that DNR is signed by both the family and the physician, it is not in effect. The physician order [REDACTED]. She said her understanding was that the family and physician had to sign the form in order for the facility to get an order. The DNR order was not obtained to her knowledge. It was the social worker's responsibility to ensure the resident's wishes were followed through. It was a group effort with the physician, social services, and nursing. She said she thinks it starts with social services. At 11:04 a.m. on [DATE] in an interview with the ADON (Assistant Director of Nursing), she said she was not aware there was a conversation going on between the social worker and the resident's sister. The SSD was also present during the interview, and she added that, typically, upon admission and during care plan meetings there was discussion regarding code status and it was documented in the record. Social Services documents the code status on the social service initial assessment and social service evaluations. Ideally yes, there should have been documentation of a conversation about advance directives. On [DATE] at 3:18 p.m., another interview was conducted with the social worker. She said she really did not recall where she kept the DNR form. She said usually she would put them in a folder on a clipboard of documents that needed to be signed. The following information was found in Resident #2's electronic medical record: The physician's orders [REDACTED].#2 was a FULL CODE. The last note entered in the record regarding a discussion of Advance Directives was on [DATE]. The social worker indicated that a care plan meeting was held with the resident's sister and Resident #2 continued to be a full code. The Resident #2's admission MDS assessment, dated [DATE] Section C, Cognitive Patterns, C0500, showed a BIMS (brief interview for mental status) summary score was three, indicating the resident had severe cognitive impairment. Section B of the MDS assessment, Hearing, Speech, and Vision, Section B0700, showed the resident could be understood, as indicated by the code '0'. Understood. Section B0800 Ability to understand others, showed she could understand others as indicated by the code '0' Understands-clear comprehension. At that time, she was frequently incontinent of bladder and bowel as indicated by Section H, Bowel and Bladder, H0300. Urinary continence, 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding), and H0400. Bowel Incontinence, 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least 1 episode of continent bowel movement). Section G of the MDS, Functional Status, section G0600. Mobility Devices, showed the resident was using a walker and wheel chair for mobility, with limited assistance of staff for locomotion. According to Section G0110. Activities of Daily Living (ADL) Assistance was, C. walk in room, ADL self-performance, code '2' Limited Assistance. ADL support provided, was coded '2' One person physical assist. D. Walk in corridor, ADL self-performance coded '2' Limited assistance, and ADL support provided, coded '2' One person physical assist. E. Locomotion on unit, ADL self-performance, coded '2' limited assistance, and ADL support provided, coded '2' One person physical assist. A Recreation Evaluation dated [DATE] showed the resident was using a walker for mobility, as shown under IV. Physical Status, E. Assistive Devices. She was moderately dependent for ability to participate in activities, as indicated by VII. Level of Participation in Activities. She had been a photographer, and she enjoyed singing, dancing, religious services, and conversation with her peers. The Resident's most recent quarterly MDS assessment, dated [DATE], showed her BIMS score had worsened, from section C-Cognitive Patterns, C0500, '99', indicating severe cognitive impairment (rarely ever understood). Section B, Hearing, Speech, and Vision, indicated the resident was able to be understood, B0700. Makes self understood, coded '0' Understood, and B0800. Ability to understand others, coded '0' Understands. Section H, Bowel and Bladder, showed she became totally incontinent, as indicated by H0300. Urinary Continence, coded 3. Always incontinent, and H0400 Bowel Continence coded 3. Always incontinent. According to Section G, Functional Status, the resident no longer was using a walker, as indicated by G0600. Mobility Devices, B. Walker, 'no'. She was using a wheel chair only for mobility as indicated by G0600. Mobility Devices C. Wheelchair, 'yes'. The resident's self-performance ability and staff support had declined as well, as indicated by Section G0110. Activities of Daily Living (ADL) Assistance, E. Locomotion on unit, coded '4' Total dependence, and ADL support provided, coded '2' One person physical assist. A nurse's note entered by the resident's nurse, Staff A, RN on [DATE] reflected that, at 9:40 a.m., the Social Worker informed the nurse the resident was not looking well. The nurse entered the resident's room, observed the resident, and then exited the room and obtained a suction machine. The nurse then suctioned the resident two times, at which time the resident leaned forward and turned blue. The nurse then checked the resident's pulse and lung sounds, which were absent. The social worker paged the supervisor. Code blue was activated. 911 was called. Resident #2 was sent to the hospital by stretcher by EMS at 10:35a.m. Another nurse's note, entered by Staff B, RN Supervisor on [DATE] stated that at 10:00 a.m. she was called to the resident's room and found the resident having shallow respirations and difficulty breathing. Bilateral upper lung sounds were abnormal and there was phlegm in her mouth. The nurse suctioned the resident twice and the resident became unresponsive. Staff called her name three times and touched her shoulder, but she did not respond. Staff checked her pulse and heart sounds and found no regular rate/rhythm. At 10:03 a.m. staff checked the paper and electronic chart for code status, confirming the resident was a full code. Code blue was then initiated. At 10:04 a.m. staff initiated CPR (cardiopulmonary resuscitation), oxygen, and called 911. At 10:10 a.m., EMS relieved staff from CPR. At 10:35 a.m., they transported the resident to the hospital. The resident's sister was present and accompanied the resident to the hospital. A note entered by the social worker, also dated [DATE], indicated she went to the resident's room at approximately 9:55 a.m. and noted the resident was gurgling. She proceeded to call the nurse to the room and raised the head of the bed. The nurse began suctioning the resident. She called the supervisor to the room, and then called 911. Staff called Code blue. Review of the Ambulance Run Sheet, reflected an incident date of [DATE] at 09:57:24. The Narrative report for the 911 ambulance call of that date reflected, Responded w/ES for [MEDICAL CONDITION]. Arrived on scene to find staff performing CPR. Initial assessment revealed pt had no pulse and was not breathing. Manual chest compressions were continued by HCFR. Staff states they were with the pt when she stopped breathing. Family was on scene and states pt was complaining yesterday that she had DIB. ACLS was started as noted in report. Pt was placed on the auto pulse at a pulse check. Pt was administered medications as noted in report. Approximately 20 minutes on scene ROSC was obtained. Pt had a weak cartid pulse. Pt was moved to the rescue at that time without incident. Pt was reassessed in rescue with no change. ROSC was maintained throughout transport. Pt was monitored as noted in report. Pt care was transferred to ER RN with ROSC. Resident #2 was described in the [DATE] Hospital Emergency records as a 72 y/o female with Primary medical history of [REDACTED].SNF to be in cardio [MEDICAL CONDITION] arrest. EMS reports that they performed CPR for 20 minutes total PTA, administering 3 epi and 4 mg total of [MEDICATION NAME]. They also administered 500 ccIVF. They report that patient has faint pulse upon arrival with blood pressure ,[DATE]. EMS reports that accucheck was 110. Upon arrival at the ED, patient went into asystole and CPR was initiated by ED staff. History is otherwise limited due to patient's clinical condition. Review of the Hospital Emergency Department (ED) record, dated [DATE] at 10:45:00, found that Resident # 2 presents in cardio-respiratory arrest. The onset was 09:58 this morning. Witnessed arrest yes, by family by bystander(s). Initial cardiac rhythm Asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation, automated external defibrillator, oxygen, intravenous fluids, [MEDICATION NAME]. Preceding symptoms unknown. Risk factors consist of hypertension. Continued review of the emergency room Record Procedure documentation included treatment notes completed by the Physician: CPR Time: [DATE] 10:48:00 CPR was performed: In addition to other critical care activities, Per American Heart Association (AHA) guidelines. Performed by: Self. Supervision: I directly supervised the performance of CPR on this patient. Total time: 7 minutes. Endotracheal Intubation. Time: [DATE] 10:52:00. Confirmed: Patient, procedure, and site correct. Consent: Emergent. Indication: [MEDICAL CONDITION] . Critical Care note. Total time: 35 minutes spent engaged in work directly related to patient care and/or available for direct patient care Critical condition(s) addressed for impending deterioration include: respiratory, cardiovascular, central nervous system. Associated risk factors: cardio-pulmonary arrest . Impression and Plan. [DIAGNOSES REDACTED]. Plan. Condition: Expired . Counseled: Family, Regarding diagnosis, Family understood. The Emergency Department record Physician Notes reflected: Had a long conversation with Patient's POA and patient's sister who states that she signed DNR paperwork, however, physician did not sign off on it in the nursing facility. She wants patient to be DNR, wants to withdraw care, does not want patient to be given pressors or further resuscitation, wants patient extubated. Time: [DATE] 11:14:00 Notes: Patient is asystolic. Time of death called. During a telephone interview with the resident's sister on [DATE] at 4:54 p.m., she said the resident's niece was her caregiver for about three months, and then the resident went to an ALF (Assisted Living Facility), where she fell . After that, the resident was admitted to the facility. The facility notified her by telephone they found the resident unresponsive that day ([DATE], (YEAR)). She told them she was on her way to the facility. When she arrived at the facility, the paramedics were doing CPR. She was very upset. She said she had signed a Florida DNR form and the facility found it that Sunday morning ([DATE]). She asked the social worker why they were doing the CPR. The Social Worker told her it was because the doctor had not signed the DNR yet, and the Social Worker did not know why. She asked the social worker if they had reached out to him. The Social Worker told her they were trying to reach out to him now. The social worker said they had to follow the procedure because the doctor never signed the DNR form. A nurse told her she could sign the DNR form at the hospital. Then the paramedics took her sister to the hospital. When she arrived at the hospital, she spoke to the receptionist and told her that she was instructed by the facility she could sign the DNR form right away. The receptionist told her the nursing home did not send any papers over. The receptionist took her back where they were doing CPR on her sister. She became upset and asked them to stop. She knew her sister had been deteriorating. I told them she did not want it, I did not want it. I didn't want any of that stuff done to her. The resident would not have wanted it. She said it hurt me terribly when I got there and they were doing that. I couldn't even watch the CPR. They were pounding on her. It was awful. They did stop the CPR. On [DATE] at 10:35 a.m., an interview was conducted with the Director of Nursing (DON). She said her expectation was that, upon a family member signing a DNR, their wishes be carried out effectively. She expected that the physician would be contacted immediately and they get that done as soon as possible. Policy, Do Not Resuscitate Order, [DATE] I. General Statement of Policy The facility will recognize the resident/resident representative's right to exercise their wishes and make choices concerning receipt of emergency measures to maintain life functions. The facility will not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Residents with Do Not Resuscitate (DNR) orders will be clearly identified. Staff will be trained on how to identify residents with a DNR order and related advance directives. II. Definitions Advance Directives are legal documents that allow the resident/resident representative to clearly define and clarify their decisions about end of life care ahead of time. Advance Directives are a means of notifying resident wishes to the resident's family, representative, friends, and healthcare professionals and to avoid confusion at a future date. Examples of Advanced directives include but are not limited to: DNR, Health Care Proxy (HCP). Durable Power of Attorney (DPOA), Living Will. III. Procedure A. Upon admission, significant change of condition, and quarterly thereafter, the social worker/nurse/designee will discuss the resident/resident representative's wishes for advance directives. These wishes are clearly documented in the resident's medical record. B. If the resident/resident representative chooses a DNR as part of the advance directives, this wish is identified on the resident's medical record. C. All staff is trained on the meaning of advance directives and DNR, how to identify residents who have a DNR in effect. The staff will honor the DNR and other advance directives. D. DNR 1. DNR orders (on state approved form) are signed by the resident's attending physician and the resident/resident's representative as permitted by state law. an order for [REDACTED]. Policy, Advanced Directives, [DATE] I. General Statement of Policy The facility will honor the wishes of the resident/ representative regarding medical concerns by honoring the existing advance directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advance directives. For those residents who do not have advanced directives, the facility will honor the opportunity to formulate advance directives. The facility will provide assistance, education, medical, social work and spiritual support to both resident and representative in order to help the resident decide on/formulate advance directives if he/ she so wish. Advance directives may be changed at any time. If a resident has not chosen any advanced directives and becomes unable to make medical decisions for himself/herself then the facility will provide full medical interventions up to and including cardiopulmonary resuscitation. II. Definition An advance directive is a written document or witnessed verbal instruction by which a person makes provision for healthcare decisions in the event that in the future, he/she becomes unable to make those decisions. Advanced directives such as a living will or durable Power of attorney for healthcare for health care proxy relate instruction for the provision of healthcare when the individual is incapacitated. Other advance directives may include but are not limited to DNR, (Do not resuscitate) DNI (Do not intubate) DNH (Do not hospitalize) Full code (all medically viable means to save life) III. Procedure A. Admission: Upon admission, the admitting nurse will inquire about the presence of advanced directives. If the resident has advanced directives, they are noted in the medical record and this information will be communicated following the process as outlined in this policy. i. Medical orders are required for all advance directives including full code, DNR, DNI, etc. ii. If a newly admitted resident becomes incapacitated prior to a written medical order in the advanced directives are known, the advanced directives will be honored. iii. If a newly admitted resident becomes incapacitated prior to a written medical order and the advanced directives are not known then the facility will provide full medical life-sustaining treatment (Full Code) B. Social services: The social worker will meet with the resident/representative after admission and will review and confirm any existing advance directive. The social worker will offer education and assistance concerning advance directives at this time and at any future moment if the resident/representative requires further help or wishes to change his/her advanced directives. C. Communication of Advance Directives: 2. If the resident has a DNR, electronic identifiers will be placed in the EMR (electronic medical record): i. MD order for all Advance Directives including Full Code. ii. Advanced directives will be placed in the EMR for code status on the banner at the top of the medical record. iii. Social Services Evaluation iv. Baseline Care plan Facility actions to remove the Immediate Jeopardy: 1. An interview was conducted with the DON, NHA (Nursing Home Administrator), SSD, and ADON on [DATE] at 4:06 p.m. The Nursing Home Administrator said social services will be monitoring advance directives more closely. The SSD said that upon admission they will review advance directives and ensure it is entered into the medical record accurately, and that a care plan is in place. If a resident or family member signs an advance directive, the physician will be notified immediately. If the physician is not available then the facility will fax the form to him. Additionally, once the form has been signed by the resident or representative, if we still are unable to contact the physician, then 2 RNs can obtain a telephone order for the DNR to be valid for 24 hours, and if it is a weekend, they will call and renew it every 24 hours. 2. An investigation of the event was completed. The AHCA immediate report was completed on [DATE]. The state Abuse Agency and Law Enforcement were called on [DATE]. 3. On [DATE], the social worker was suspended pending investigation. She returned to work on [DATE] and received disciplinary action in her personnel file and education on the proper procedure for processing advanced directives. 4. A full audit of every resident in the building was completed on [DATE] to include code status, care plan, physician's orders [REDACTED].#1, #3, #4, #5, and #23 reflected no other concerns with honoring advance directives. 5. Staff education was completed; Social Services at 100% on [DATE] and Nursing staff at 100% on [DATE]. The facility had 69 licensed nurses, one social worker, and one Director of Social Services. 6. A performance improvement plan was created using root cause analysis; lack of staff knowledge of procedure for code status. The first QAPI meeting related to this was held on [DATE] and the Administrator indicated this was ongoing. The nursing management team and social services would continue to review new admissions and new orders, code status orders/changes Monday through Friday and weekends as indicated. The on-call Nurse Manager would review orders and new admissions on the weekend to ensure code status was properly entered on the electronic record. 7. A second audit was completed on [DATE] of every resident in the building. Family members were called to confirm the code status was accurate. 8. Audits are on-going and will continue weekly for 1 month, then monthly in addition to new admissions and care plan meetings. 9. At 3:42 PM on [DATE], interviews with twelve random nursing staff & social service interviews were completed and confirmed nursing & Social Service staff were knowledgeable of the policy and procedure for ensuring the resident/representative's code status was upheld. Three nurses from ,[DATE] shift were interviewed. Six nurses from ,[DATE] were interviewed. Three nurses from ,[DATE] shift were interviewed. In addition, the social worker was interviewed to ensure she was properly educated. Immediate Jeopardy was determined to be removed on [DATE] at 5:00 p.m. and the severity was reduced to a D.

Based on interviews with the facility's social worker, nursing and administrative staff, a family member, and the resident's physician, review of clinical and hospital records and facility policies and procedures, it was determined that the facility neglected a resident by failing to provide the structures and processes to honor the Advance Directives to have CPR (cardiopulmonary resuscitation) withheld in the event of her death, for one (#2) of 6 sampled residents. The social worker failed to obtain a physician's signature on a State of Florida Do Not Resuscitate (DNR) Order form, and the facility failed to obtain a physician's orders [REDACTED].#2, contrary to the stated and written communication of the resident's Attorney in Fact/ Health Care Surrogate, who was acting upon the known preference of the resident. The facility initiated CPR (Cardiopulmonary Resuscitation) on Resident #2, who was [AGE] years old, was diagnosed with [REDACTED]. The facility failed to protect Resident #2 from unwanted, potentially violent interventions in her last moments of life. Failure of facility staff to implement Advance Directives correctly resulted in findings of Immediate Jeopardy on [DATE], which were removed on [DATE] and reduced to the scope and severity of D. Findings included: Resident #2 was admitted to the facility on (MONTH) 29, (YEAR) with a pertinent [DIAGNOSES REDACTED]. In a telephone interview with the resident's sister on [DATE] at 4:54 p.m., she said the resident's niece was her caregiver for about three months, and then the resident went to an ALF (Assisted Living Facility), where she fell . After that, the resident was admitted to the facility. The facility notified her by telephone they found the resident unresponsive that day ([DATE], (YEAR)). She told them she was on her way to the facility. When she arrived at the facility, the paramedics were doing CPR. She was very upset. She said she had signed a Florida DNR form and the facility found it that Sunday morning ([DATE]). She asked the social worker why they were doing the CPR. The Social Worker told her it was because the doctor had not signed the DNR yet, and the Social Worker did not know why. She asked the social worker if they had reached out to him. The Social Worker told her they were trying to reach out to him now. The social worker said they had to follow the procedure because the doctor never signed the DNR form. A nurse told her she could sign the DNR form at the hospital. Then the paramedics took her sister to the hospital. When she arrived at the hospital, she spoke to the receptionist and told her that she was instructed by the facility she could sign the DNR form right away. The receptionist told her the nursing home did not send any papers over. The receptionist took her back where they were doing CPR on her sister. She became upset and asked them to stop. She knew her sister had been deteriorating. I told them she did not want it, I did not want it. I didn't want any of that stuff done to her. The resident would not have wanted it. She said it hurt me terribly when I got there and they were doing that. I couldn't even watch the CPR. They were pounding on her. It was awful. They did stop the CPR. According to the American College of Chest Physicians (US) study at https://journal.chestnet.org/article/S,[DATE](15),[DATE]/fulltext: In a prospective study of the complications of cardiac resuscitation, 705 cases were autopsied to identify the cause of death and the pathologic findings attributable to cardiac resuscitation. [MEDICATION NAME] complications were observed in 42.7% of the cases. A total of 31.6% had rib fractures, 21.1% had sternal fractures, and 18.3% were reported as having anterior mediastinal hemorrhage; 20.4% of the cases had an upper airway complication. Abdominal visceral complications were noted in 30.8% of the cases, and [MEDICAL CONDITION] complications occurred in 13% of the resuscitation population. Life-threatening complications, such as heart and great vessel injuries, occurred in 5% of the cases. Review of the General Durable Power of Attorney of (resident's name), Dated (MONTH) 19, (YEAR) found that the resident's Primary Contact and sibling was appointed to serve as Durable Power of Attorney. The Primary Contact and sibling was appointed as the Health Care Surrogate, according to the Living Will Declaration and Designation of Health Care Surrogate . on (MONTH) 13, (YEAR). This document reflected that Resident #2 did not want any artificial life prolonging procedures in the event she had a terminal condition. Review of the Hospital Emergency Department (ED) record, dated [DATE] at 10:45:00, found that Resident # 2 presents in cardio-respiratory arrest. The onset was 09:58 this morning. Witnessed arrest yes, by family by bystander(s). Initial cardiac rhythm Asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation, automated external defibrillator, oxygen, intravenous fluids, [MEDICATION NAME]. Preceding symptoms unknown. Risk factors consist of hypertension. Resident #2 was described in the Emergency records as a 72 y/o female with Primary medical history of [REDACTED].SNF to be in cardio [MEDICAL CONDITION] arrest. EMS reports that they performed CPR for 20 minutes total PTA, administering 3 epi and 4 mg total of [MEDICATION NAME]. They also administered 500 ccIVF. They report that patient has faint pulse upon arrival with blood pressure ,[DATE]. EMS reports that accucheck was 110. Upon arrival at the ED, patient went into asystole and CPR was initiated by ED staff. History is otherwise limited due to patient's clinical condition. Continued review of the emergency room Record Procedure documentation included treatment notes completed by the Physician: CPR Time: [DATE] 10:48:00 CPR was performed: In addition to other critical care activities, Per American Heart Association (AHA) guidelines. Performed by: Self. Supervision: I directly supervised the performance of CPR on this patient. Total time: 7 minutes. Endotracheal Intubation. Time: [DATE] 10:52:00. Confirmed: Patient, procedure, and site correct. Consent: Emergent. Indication: [MEDICAL CONDITION] . Critical Care note. Total time: 35 minutes spent engaged in work directly related to patient care and/or available for direct patient care Critical condition(s) addressed for impending deterioration include: respiratory, cardiovascular, central nervous system. Associated risk factors: cardio-pulmonary arrest . Impression and Plan. [DIAGNOSES REDACTED]. Plan. Condition: Expired . Counseled: Family, Regarding diagnosis, Family understood. The Emergency Department record Physician Notes reflected: Had a long conversation with Patient's POA and patient's sister who states that she signed DNR paperwork, however, physician did not sign off on it in the nursing facility. She wants patient to be DNR, wants to withdraw care, does not want patient to be given pressors or further resuscitation, wants patient extubated. Time: [DATE] 11:14:00 Notes: Patient is asystolic. Time of death called. The following information was found in Resident #2's electronic medical record: The physician's orders [REDACTED].#2 was a FULL CODE. The last note entered in the record regarding a discussion of Advance Directives was on [DATE]. The social worker indicated that a care plan meeting was held with the resident's sister and Resident #2 continued to be a full code. Resident #2's admission MDS assessment, dated [DATE] Section C, Cognitive Patterns, C0500, showed a BIMS (brief interview for mental status) summary score was three, indicating the resident had severe cognitive impairment. Section B of the MDS assessment, Hearing, Speech, and Vision, Section B0700, showed the resident could be understood, as indicated by the code '0'. Understood. Section B0800 Ability to understand others, showed she could understand others as indicated by the code '0' Understands-clear comprehension. At that time, she was frequently incontinent of bladder and bowel as indicated by Section H, Bowel and Bladder, H0300. Urinary continence, 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding), and H0400. Bowel Incontinence, 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least 1 episode of continent bowel movement). Section G of the MDS, Functional Status, section G0600. Mobility Devices, reflected that Resident #2 was using a walker and wheel chair for mobility, with limited assistance of staff for locomotion. According to Section G0110. Activities of Daily Living (ADL) Assistance was, C. walk in room, ADL self-performance, code '2' Limited Assistance. ADL support provided, was coded '2' One person physical assist. D. Walk in corridor, ADL self-performance coded '2' Limited assistance, and ADL support provided, coded '2' One person physical assist. E. Locomotion on unit, ADL self-performance, coded '2' limited assistance, and ADL support provided, coded '2' One person physical assist. A Recreation Evaluation, dated [DATE], showed the resident was using a walker for mobility, as shown under IV. Physical Status, E. Assistive Devices. She was moderately dependent for ability to participate in activities, as indicated by VII. Level of Participation in Activities. She had been a photographer, and she enjoyed singing, dancing, religious services, and conversation with her peers. Resident #2's most recent quarterly MDS assessment, dated [DATE], found that her BIMS score had worsened, from section C-Cognitive Patterns, C0500, '99', indicating severe cognitive impairment (rarely ever understood). Section B, Hearing, Speech, and Vision, indicated the resident was able to be understood, B0700. Makes self-understood, coded '0' Understood, and B0800. Ability to understand others, coded '0' Understands. Section H, Bowel and Bladder, showed she became totally incontinent, as indicated by H0300. Urinary Continence, coded 3. Always incontinent, and H0400 Bowel Continence coded 3. Always incontinent. According to Section G, Functional Status, the resident no longer was using a walker, as indicated by G0600. Mobility Devices, B. Walker, 'no'. She was using a wheel chair only for mobility as indicated by G0600. Mobility Devices C. Wheelchair, 'yes'. The resident's self-performance ability and staff support had declined as well, as indicated by Section G0110. Activities of Daily Living (ADL) Assistance, E. Locomotion on unit, coded '4' Total dependence, and ADL support provided, coded '2' One person physical assist. An interview was conducted with the resident's nurse, Staff A, RN (Registered Nurse) at 1:15 p.m. on [DATE]. She said she was passing medications when the social worker approached her with the news the resident's breathing was sounding funny. She went in the resident's room and checked her oxygen saturation and lung sounds. She went to get suction and notify the supervisor. When she returned to the room, the resident was not breathing and did not have a pulse. She called code blue and got the crash cart. She said she looked in the electronic clinical record and retrieved the paper chart. She did not see a DNR order. The resident was a full code. CPR was initiated. Other nurses came to help. Some were calling the doctor and 911. The family was notified. The resident's sister came to the facility sometime after the chest compressions started. EMS (Emergency Medical Services) arrived and took over CPR. Then they transported the resident to the hospital. In an interview with Staff B, RN Supervisor at 1:35 p.m. on [DATE], she said she was called to the unit from the central supply closet. It was about 10:00 a.m. She went to the resident's room. When she entered the room, the nurse and the social worker were in there. The social worker started calling the resident's name because she was not responding. The nurse did too. The resident just kind of slumped over. Then she instructed the nurse to check the computer and her chart to see what the resident's code status was. When the nurse realized the resident was a full code, she called the code. They got the crash cart. Another nurse called 911 while they were performing CPR. Then EMS arrived and they took over CPR. The resident's family arrived when EMS were in the room. EMS had been there maybe 10 or 15 minutes or so. Then EMS transferred the resident to the hospital. In an interview with the social worker on [DATE] at 2:06 p.m., she said she went in to the resident's room that day, with a shirt she had found that belonged to the resident's roommate. Resident #2 was making gurgling noises. She called the nurses right away. The suction machine was used on the resident, and she went in to try to calm her down. The nurse said she just stopped breathing. They did CPR. They called EMS. The family was not present. Her nurses called to let her family know. She said she spoke briefly to the family. The sister asked her what was going on, and the nurse explained what was going on medically with the resident. EMS were in there. The resident's sister asked why they were doing CPR. We told her the physician did not sign the DNR order form, so we had to follow physician orders. When she was asked about the State of Florida DNR order form, she said she did not recall when she had spoken to the resident's sister about it. She said they did talk about it. The resident's sister said she would come in to sign the form, but she did not come in. She asked that we mail the DNR form to her. The social worker said she did not recall when the facility mailed the form. The resident's sister signed it and mailed it back. She confirmed that she let the physician know that she had paperwork that needed to be signed, but she did not let him know what it was. He said he would get to it on his next visit. The physician was leaving the facility and she caught him at the door. Since the doctor had not signed it, it had not been placed in the chart. In an additional interview with the Social Worker on [DATE] at 3:01 p.m., she said the resident's sister dated the DNR form. The resident had a decline, so her sister mentioned that she probably wanted to make her a DNR. She asked the resident's sister if she wanted to come in to sign the paperwork. She did not come in. She followed up with a phone call. The resident's sister was busy with her life and so the social worker asked if she wanted it mailed it to her. She agreed to have it mailed to her. She confirmed she had not documented the conversation in the medical record, and had no recollection when the conversation with the resident's sister took place. A telephone interview was conducted with the resident's physician on [DATE] at 8:55 a.m. He said the social worker did not tell him the resident had a DNR form that needed to be signed. She told him something needed to be signed, but she did not tell him what it was, or what resident it was for. If the facility had a DNR form for him to sign it takes 2 seconds. He would have signed it immediately. They could have faxed the form to him as well and he would have signed it. If a family member has already signed the document, it should have been given to him to sign immediately. The facility has to get the document to him right away. They did not tell him the resident's family member did not want CPR. He was not aware the family member objected to the code. An interview was conducted with the Social Services Director (SSD) on [DATE] at 10:24 a.m. She said that she and the Social Worker typically do check each other's mailbox if someone is sick or on vacation. Of course, they cover each other as needed. She said she believed the DNR order form was on the Social Worker's desk and not in her mailbox. She was not aware there was a signed DNR order form for the resident. She said Social Services frequently talks with family members regarding advance directives including code status. At the time that a resident or representative signified they would like to sign a DNR form, Social Services explains the form to them, and has the family print and sign the form. Also, we would explain that the form is not valid until the physician signs the form. Until that DNR is signed by both the family and the physician, it is not in effect. The physician order [REDACTED]. She said her understanding was that the family and physician had to sign the form in order for the facility to get an order. The DNR order was not obtained to her knowledge. It was the social worker's responsibility to ensure the resident's wishes were followed through. It was a group effort with the physician, social services, and nursing. She said she thinks it starts with social services. At 11:04 a.m. on [DATE] in an interview with the ADON (Assistant Director of Nursing), she said she was not aware there was a conversation going on between the social worker and the resident's sister. The SSD was also present during the interview, and she added that, typically, upon admission and during care plan meetings there was discussion regarding code status and it was documented in the record. Social Services documents the code status on the social service initial assessment and social service evaluations. Ideally yes, there should have been documentation of a conversation about advance directives. On [DATE] at 3:18 p.m., another interview was conducted with the social worker. She said she really did not recall where she kept the DNR form. She said usually she would put them in a folder on a clipboard of documents that needed to be signed. During review of facility documents provided by the facility, a Florida Department of Health, State of Florida Do Not Resuscitate (DNR) form was found. It was dated [DATE] and signed by Resident #2's POA/HCS (Power of Attorney/Health Care Surrogate), the resident's sister. The physician, however, had not signed it. Upon review of the paper medical record, a Determination of Incapacity to make medical decisions, dated [DATE], was found. A physician had signed it. The document stated that the resident did not have reasonable medical probability of recovering medical and physical capacity to directly exercise rights to give informed consent for medical decisions. A nurse's note entered by the resident's nurse, Staff A, RN on [DATE] reflected that, at 9:40 a.m., the Social Worker informed the nurse the resident was not looking well. The nurse entered the resident's room, observed the resident, and then exited the room and obtained a suction machine. The nurse then suctioned the resident two times, at which time the resident leaned forward and turned blue. The nurse then checked the resident's pulse and lung sounds, which were absent. The social worker paged the supervisor. Code blue was activated. 911 was called. Resident #2 was sent to the hospital by stretcher by EMS at 10:35a.m. Review of the Ambulance Run Sheet, found an incident date of [DATE] at 09:57:24. The Narrative report for the 911 ambulance call of that date reflected, Responded w/ES for [MEDICAL CONDITION]. Arrived on scene to find staff performing CPR. Initial assessment revealed pt had no pulse and was not breathing. Manual chest compressions were continued by HCFR. Staff states they were with the pt when she stopped breathing. Family was on scene and states pt was complaining yesterday that she had DIB. ACLS was started as noted in report. Pt was placed on the auto pulse at a pulse check. Pt was administered medications as noted in report. Approximately 20 minutes on scene ROSC was obtained. Pt had a weak carotid pulse. Pt was moved to the rescue at that time without incident. Pt was reassessed in rescue with no change. ROSC was maintained throughout transport. Pt was monitored as noted in report. Pt care was transferred to ER RN with ROSC. Another nurse's note, entered by Staff B, RN Supervisor on [DATE] stated that at 10:00 a.m. she was called to the resident's room and found the resident having shallow respirations and difficulty breathing. Bilateral upper lung sounds were abnormal and there was phlegm in her mouth. The nurse suctioned the resident twice and the resident became unresponsive. Staff called her name three times and touched her shoulder, but she did not respond. Staff checked her pulse and heart sounds and found no regular rate/rhythm. At 10:03 a.m. staff checked the paper and electronic chart for code status, confirming the resident was a full code. Code blue was then initiated. At 10:04 a.m. staff initiated CPR (cardiopulmonary resuscitation), oxygen, and called 911. At 10:10 a.m., EMS relieved staff from CPR. At 10:35 a.m., they transported the resident to the hospital. The resident's sister was present and accompanied the resident to the hospital. A note entered by the social worker, also dated [DATE], indicated she went to the resident's room at approximately 9:55 a.m. and noted the resident was gurgling. She proceeded to call the nurse to the room and raised the head of the bed. The nurse began suctioning the resident. She called the supervisor to the room, and then called 911. Staff called Code blue. On [DATE] at 10:35 a.m., an interview was conducted with the Director of Nursing (DON). She said her expectation was that, upon a family member signing a DNR, their wishes be carried out effectively. She expected that the physician would be contacted immediately and they get that done as soon as possible. Review of the Policy, Abuse, Neglect and Exploitation of Residents, dated [DATE]: I. Policy Statement It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mist treatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to, staff, other residents, consultants, volunteers, contractors and staff from other agencies, family members, legal guardians, resident representatives, friends or other individuals. Such acts when proven to have been committed by an employee, are cause for dismissal and possible criminal prosecution. Comprehensive policies and procedures have been developed to aid the facility and the prevention of abuse, neglect, exploitation, mistreatment or misappropriation of property of the residents. II. Responsibilities: All personnel (including volunteers) in all departments will be required to alert indicators of suspected or actual abuse, neglect and exploitation. The resident has assisted to safety and is protected against further harm, and if abuse is suspected, personnel report their observations to their supervisor immediately and without delay. All individuals will be encouraged to report any signs of suspected abuse, neglect, and exploitation. Any employee witnessing or having knowledge of an act of abuse/neglect/exploitation, who does not report it to the supervisory person in charge may be subject to disciplinary action. Administrator/designee is responsible for operating all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility. The abuse prohibition coordinator will coordinate all investigations while ensuring the resident safety and will report findings to the regulatory agencies as required. Refer to policy on abuse reporting. The facility will provide abuse prohibition training to all new employees, affiliates and volunteers. All staff will receive this training on an annual basis. Refer to policy Facility Training on Abuse Prevention. It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to: use of derogatory language, rough handling of residents, ignoring residents while giving care; directing residents who need toileting assistance to urinate/defecate in their clothing, etc. The facility Interdisciplinary Care Plan Team will develop a plan of care of residents with needs and behavioral issues that may lead to conflict or neglect as applicable. The facility will provide necessary behavioral health care and services in accordance with their comprehensive assessment and plan of care. III. Definitions: Neglect is the failure to provide goods or services which are necessary to maintain physical or mental health, and necessary to avoid physical harm, mental anguish or mental illness. Neglect may be a repeated course of conduct or single incident. Neglect is also the repeated failure to follow the plan of care, and a failure to follow the plan of care that results in injury of the resident. IV. Procedure: A. Seven Components of Prevention and Detection 2. Training: Staff receives training via orientation, annually and on an ongoing basis as needed regarding related policies and procedures related to abuse, neglect, exploitation, and misappropriation of resident property, involuntary seclusion and abandonment: 3. Prevention: Specific incidents a review to identify areas for improvement and needed policy changes or interventions to be implemented this includes, but is not limited to, specific environmental, operational, staffing issues, Educational and supervisory issues. All interactions between staff members and other individuals at the facility must have as their legitimate goal, the healthful, proper, humane care and treatment of [REDACTED]. (Conscious of willful non-action which results in emotional/physical injury is viewed in the same manner as that caused by improper or excessive action). The resident's assessment and care plan, as well as staff supervision and ongoing monitoring are used to identify residents and staff with at risk behavior(s). 4. Identification: Staff receives education about behavioral and situational signals that may indicate risk for or the presence of abuse, neglect, or misappropriation of property. A person shall not knowingly: Fail to report an incident of mistreatment or other offense; Attempt, with or without threats or promise of benefit, to induce another to fail to report an incident of mistreatment or other offense; Alter, change without authorization, destroy or render unavailable a report made by another; and/or screen reports or withhold information to reporting agencies. It is the moral and legal responsibility of our staff members to identify, prevent and report suspected or witnessed abuse, exploitation and neglect to their immediate supervisor on site, or social worker immediately. This will subsequently be reported to the Administrator/DON/designee. An incident/accident report will be completed. 6. Investigation and Reporting (refer to policy, Abuse Reporting and policy Abuse Investigations). The nurse will immediately notify the physician, and the resident/resident's Responsible party and/or designated family member of a report of suspected abuse or neglect involving the resident. The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly and objectively. The Administrator/DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate. 7. Responding. Occurrences will be analyzed to determine if any changes in policy and procedures should be implemented to prevent future occurrences. Policy, Do Not Resuscitate Order, [DATE] I. General Statement of Policy The facility will recognize the resident/resident representative's right to exercise their wishes and make choices concerning receipt of emergency measures to maintain life functions. The facility will not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Residents with Do Not Resuscitate (DNR) orders will be clearly identified. Staff will be trained on how to identify residents with a DNR order and related advance directives. II. Definitions Advance Directives are legal documents that allow the resident/resident representative to clearly define and clarify their decisions about end of life care ahead of time. Advance Directives are a means of notifying resident wishes to the resident's family, representative, friends, and healthcare professionals and to avoid confusion at a future date. Examples of Advanced directives include but are not limited to: DNR, Health Care Proxy (HCP). Durable Power of Attorney (DPOA), Living Will. III. Procedure A. Upon admission, significant change of condition, and quarterly thereafter, the social worker/nurse/designee will discuss the resident/resident representative's wishes for advance directives. These wishes are clearly documented in the resident's medical record. B. If the resident/resident representative chooses a DNR as part of the advance directives, this wish is identified on the resident's medical record. C. All staff is trained on the meaning of advance directives and DNR, how to identify residents who have a DNR in effect. The staff will honor the DNR and other advance directives. D. DNR 1. DNR orders (on state approved form) are signed by the resident's attending physician and the resident/resident's representative as permitted by state law. an order for [REDACTED]. Policy, Advanced Directives, [DATE] I. General Statement of Policy The facility will honor the wishes of the resident/ representative regarding medical concerns by honoring the existing advance directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advance directives. For those residents who do not have advanced directives, the facility will honor the opportunity to formulate advance directives. The facility will provide assistance, education, medical, social work and spiritual support to both resident and representative in order to help the resident decide on/formulate advance directives if he/ she so wish. Advance directives may be changed at any time. If a resident has not chosen any advanced directives and becomes unable to make medical decisions for himself/herself then the facility will provide full medical interventions up to and including cardiopulmonary resuscitation. II. Definition An advance directive is a written document or witnessed verbal instruction by which a person makes provision for healthcare decisions in the event that in the future, he/she becomes unable to make those decisions. Advanced directives such as a living will or durable Power of attorney for healthcare for health care proxy relate instruction for the provision of healthcare when the individual is incapacitated. Other advance directives may include but are not limited to DNR, (Do not resuscitate) DNI (Do not intubate) DNH (Do not hospitalize) Full code (all medically viable means to save life) III. Procedure A. Admission: Upon admission

Based on interviews with the facility's social worker, nursing and administrative staff, a family member, and the resident's physician, review of clinical and hospital records and facility policies and procedures, it was determined that the facility's administration failed to utilize resources effectively and efficiently to protect the rights of 1 (#2) of 6 sampled residents to have end of life wishes honored. Facility administration failed to ensure that Resident #2's wishes, communicated by her Attorney In Fact & Health Care Surrogate, were followed for implementation of a Do Not Resuscitate form. Facility administration failed to ensure the policies and procedures put in place for Advance Directives and DNR (Do Not Resuscitate) were followed, and failed to ensure nursing staff had accurate Advance Directive information available for review in case of emergency. The facility initiated CPR (Cardiopulmonary Resuscitation) on Resident #2, a [AGE] year old, who had [MEDICAL CONDITION], and was declining, even though the resident did not want artificial life prolonging measures in the event of a terminal condition. This resulted in findings of Immediate Jeopardy on [DATE], which were removed and reduced to a D on [DATE]. Findings included: The undated job description for the facility Administrator included a hire date of [DATE] and included the following language: Position description Administrator Basic Function Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristic Duties and Responsibilities Essential Functions 2. Assist in the development and implementation of departmental policies and procedures, and establish a rapport in and between departments so that each can see the importance of teamwork. 3. Ensure that all personnel, patients/residents, visitors, and the general public follow established policies and procedures. 6. Ensure that the patient's/ resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right wage complaints are well established and maintained at all times. 7. Recruit, select and train competent department supervisors and other auxiliary personnel. 15. Delegate authority, responsibility, and accountability to other responsible persons. Marginal Functions 9. Review and check competence of the work force and make necessary adjustments/corrections as required or that may become necessary. Supervision Exercised The administrator exercises administrative and functional supervision over the entire facility. The undated job description for the Director of Nursing (DON) included a signature date of [DATE]. (The ADON -Assistant Director of Nursing, was the acting/interim DON at the time of the incident.) The job description reflected the following: Basic Function Responsible for effective overall management of the Nursing Department and coordination with other disciplines to provided quality care to all patients/residents. Characteristics and Responsibilities Essential functions 1. Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 2. Coordinates interdisciplinary patient/resident care management efforts. 3. Ensures effective and efficient organization and staffing of the nursing department. 4. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self-care capacities, identity, independence, choice and opportunity for social interaction. 5. Monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitoring the effective and efficient use of budgeted resources (personnel, supplies, equipment). 8. Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator. Supervision Exercised Exercises administrative and functional supervision over nursing personnel. Minimum Performance Standards Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 3. Incorporates nursing philosophy, standards and objectives into the evaluation process for staff and nursing services. Coordinates interdisciplinary patient/resident care management efforts. 1. Provides direction as to format and approach to patient/resident care management. 2. Ensures implementation of resident care planning format to comply with patients/residents needs and various regulatory agency requirements. The undated job description for the Assistant Director of Nursing was signed on [DATE]. Department: Nursing Reports to: Director of Nursing Job Summary: Responsible for assisting the Director of Nursing in planning, organizing, staffing, directing, coordinating, reporting, budgeting, inventory, control, and management of facility, people, supplies, and equipment in such a way that meaningful nursing service is established to render the optimum level of resident care. The ADON reports directly to the DON. Main Duties: A. Support the facility's philosophy of care and strive to achieve its goals and objectives. B. Assist the DON in planning, organizing, and directing the Nursing Department. C. Identify the needs, problems, and progress of nursing services and make recommendations for improvement. D. Assist in developing and administering nursing service policies. E. Assist in establishing standards of nursing practices. F. Assist in defining or revising job requirements, qualifications, and functions of nursing personnel. I. Enforce policies which are established by the Administrator, DON, and other departments which affect nursing. M. Ensure that nursing personnel provide treatments, medication, diets, rehabilitative nursing care, activities of daily living, protective services, and training in self-care as stated in the care plan to ascertain that optimum comfort and care is provided. N. Make rounds and observe individual residents who are experiencing episodes of acute illness, deterioration in health status, recent injury, recovering from surgery, etc., so as to be acquainted with the resident's status, both physically and emotionally and to ascertain that staff is rendering proper care. The undated job description for the Director of Social Services was signed on [DATE] and included duties consisting of the following: Basic Function Responsible for planning, developing, organizing, implementing, evaluating. And directing the Social Services Department in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to ensure that the medically related emotional and social needs of the patients/residents are met/maintained on an individual basis. Characteristic Duties and Responsibilities Essential Functions 1. Plan, develop, organize, implement, evaluate, and direct the social service programs of this facility. 2. Meet with administration, medical and nursing staff, and other related departments in planning social services. 4. Assist in the developing, administering, and coordinating of department policies and procedures. 5. Keep abreast of current federal and state regulations, as well as professional standards, and make recommendations on changes in policies and procedures to the Administrator. 8. Develop and implement policies and procedures for the identification of medically related social and emotional needs of the patient/resident. 19. Assume the authority, responsibility, and accountability of directing the social service department. Review of the facility policy on Advance Directives, including changes to the document, provided the following: Policy, Advanced Directives, [DATE] I. General Statement of Policy The facility will honor the wishes of the resident/ representative regarding medical concerns by honoring the existing advance directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advance directives. For those residents who do not have advanced directives, the facility will honor the opportunity to formulate advance directives. The facility will provide assistance, education, medical, social work and spiritual support to both resident and representative in order to help the resident decide on/formulate advance directives if he/ she so wish. Advance directives may be changed at any time. If a resident has not chosen any advanced directives and becomes unable to make medical decisions for himself/herself then the facility will provide full medical interventions up to and including cardiopulmonary resuscitation. II. Definition An advance directive is a written document or witnessed verbal instruction by which a person makes provision for healthcare decisions in the event that in the future, he/she becomes unable to make those decisions. Advanced directives such as a living will or durable Power of attorney for healthcare for health care proxy relate instruction for the provision of healthcare when the individual is incapacitated. Other advance directives may include but are not limited to DNR, (Do not resuscitate) DNI (Do not intubate) DNH (Do not hospitalize) Full code (all medically viable means to save life) III. Procedure A. Admission: Upon admission, the admitting nurse will inquire about the presence of advanced directives. If the resident has advanced directives, they are noted in the medical record and this information will be communicated following the process as outlined in this policy. i. Medical orders are required for all advance directives including full code, DNR, DNI, etc. ii. If a newly admitted resident becomes incapacitated prior to a written medical order in the advanced directives are known, the advanced directives will be honored. iii. If a newly admitted resident becomes incapacitated prior to a written medical order and the advanced directives are not known then the facility will provide full medical life-sustaining treatment (Full Code) B. Social services: The social worker will meet with the resident/representative after admission and will review and confirm any existing advance directive. The social worker will offer education and assistance concerning advance directives at this time and at any future moment if the resident/representative requires further help or wishes to change his/her advanced directives. C. Communication of Advance Directives: 2. If the resident has a DNR, electronic identifiers will be placed in the EMR (electronic medical record): i. MD order for all Advance Directives including Full Code. ii. Advanced directives will be placed in the EMR for code status on the banner at the top of the medical record. iii. Social Services Evaluation iv. Baseline Care plan. Review of the facility's current policy on Do Not Resuscitate Orders included the following language: Policy, Do Not Resuscitate Order, [DATE] I. General Statement of Policy The facility will recognize the resident/resident representative's right to exercise their wishes and make choices concerning receipt of emergency measures to maintain life functions. The facility will not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Residents with Do Not Resuscitate (DNR) orders will be clearly identified. Staff will be trained on how to identify residents with a DNR order and related advance directives. II. Definitions Advance Directives are legal documents that allow the resident/resident representative to clearly define and clarify their decisions about end of life care ahead of time. Advance Directives are a means of notifying resident wishes to the resident's family, representative, friends, and healthcare professionals and to avoid confusion at a future date. Examples of Advanced directives include but are not limited to: DNR, Health Care Proxy (HCP). Durable Power of Attorney (DPOA), Living Will. III. Procedure A. Upon admission, significant change of condition, and quarterly thereafter, the social worker/nurse/designee will discuss the resident/resident representative's wishes for advance directives. These wishes are clearly documented in the resident's medical record. B. If the resident/resident representative chooses a DNR as part of the advance directives, this wish is identified on the resident's medical record. C. All staff is trained on the meaning of advance directives and DNR, how to identify residents who have a DNR in effect. The staff will honor the DNR and other advance directives. D. DNR 1. DNR orders (on state approved form) are signed by the resident's attending physician and the resident/resident's representative as permitted by state law. an order for [REDACTED]. Resident #2 was admitted to the facility in (MONTH) (YEAR) with a pertinent [DIAGNOSES REDACTED]. Resident #2's admission MDS assessment, dated [DATE] Section C, Cognitive Patterns, C0500, showed a BIMS (brief interview for mental status) summary score was three, indicating the resident had severe cognitive impairment. Section B of the MDS assessment, Hearing, Speech, and Vision, Section B0700, showed the resident could be understood, as indicated by the code '0'. Understood. Section B0800 Ability to understand others, showed she could understand others as indicated by the code '0' Understands-clear comprehension. At that time, she was frequently incontinent of bladder and bowel as indicated by Section H, Bowel and Bladder, H0300. Urinary continence, 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding), and H0400. Bowel Incontinence, 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least 1 episode of continent bowel movement). Section G of the MDS, Functional Status, section G0600. Mobility Devices, showed the resident was using a walker and wheel chair for mobility, with limited assistance of staff for locomotion. According to Section G0110. Activities of Daily Living (ADL) Assistance was, C. walk in room, ADL self-performance, code '2' Limited Assistance. ADL support provided, was coded '2' One person physical assist. D. Walk in corridor, ADL self-performance coded '2' Limited assistance, and ADL support provided, coded '2' One person physical assist. E. Locomotion on unit, ADL self-performance, coded '2' limited assistance, and ADL support provided, coded '2' One person physical assist. A Recreation Evaluation, dated [DATE], reflected the resident was using a walker for mobility, as shown under IV. Physical Status, E. Assistive Devices. She was moderately dependent for ability to participate in activities, as indicated by VII. Level of Participation in Activities. She had been a photographer, and she enjoyed singing, dancing, religious services, and conversation with her peers. The Resident's most recent quarterly MDS assessment, dated [DATE], reflected her BIMS score had worsened, from section C-Cognitive Patterns, C0500, '99', indicating severe cognitive impairment (rarely ever understood). Section B, Hearing, Speech, and Vision, indicated the resident was able to be understood, B0700. Makes self understood, coded '0' Understood, and B0800. Ability to understand others, coded '0' Understands. Section H, Bowel and Bladder, showed she became totally incontinent, as indicated by H0300. Urinary Continence, coded 3. Always incontinent, and H0400 Bowel Continence coded 3. Always incontinent. According to Section G, Functional Status, the resident was no longer using a walker, as indicated by G0600. Mobility Devices, B. Walker, 'no'. She was using a wheel chair only for mobility as indicated by G0600. Mobility Devices C. Wheelchair, 'yes'. The resident's self-performance ability and staff support had declined as well, as indicated by Section G0110. Activities of Daily Living (ADL) Assistance, E. Locomotion on unit, coded '4' Total dependence, and ADL support provided, coded '2' One person physical assist. An interview was conducted with the resident's nurse, Staff A, RN (Registered Nurse) at 1:15 p.m. on [DATE]. She said she was passing medications when the social worker approached her with the news the resident's breathing was sounding funny. She went in the resident's room and checked her oxygen saturation and lung sounds. She went to get suction and notify the supervisor. When she returned to the room, the resident was not breathing and did not have a pulse. She called code blue and got the crash cart. She said she looked in the electronic clinical record and retrieved the paper chart. She did not see a DNR order. The resident was a full code. CPR was initiated. Other nurses came to help. Some were calling the doctor and 911. The family was notified. The resident's sister came to the facility sometime after the chest compressions started. EMS (Emergency Medical Services) arrived and took over CPR. Then they transported the resident to the hospital. In an interview with Staff B, RN Supervisor at 1:35 p.m. on [DATE], she said she was called to the unit from the central supply closet. It was about 10:00 a.m. She went to the resident's room. When she entered the room, the nurse and the social worker were in there. The social worker started calling the resident's name because she was not responding. The nurse did too. The resident just kind of slumped over. Then she instructed the nurse to check the computer and her chart to see what the resident's code status was. When the nurse realized the resident was a full code, she called the code. They got the crash cart. Another nurse called 911 while they were performing CPR. Then EMS arrived and they took over CPR. The resident's family arrived when EMS were in the room. EMS had been there maybe 10 or 15 minutes or so. Then EMS transferred the resident to the hospital. In an interview with the Social Worker on [DATE] at 2:06 p.m., she said she went in to the resident's room that day, with a shirt she had found that belonged to the resident's roommate. Resident #2 was making gurgling noises. She called the nurses right away. The suction machine was used on the resident, and she went in to try to calm her down. The nurse said she just stopped breathing. They did CPR. They called EMS. The family was not present. Her nurses called to let her family know. She said she spoke briefly to the family. The sister asked her what was going on, and the nurse explained what was going on medically with the resident. EMS were in there. The resident's sister asked why they were doing CPR. We told her the physician did not sign the DNR order form, so we had to follow physician orders. When she was asked about the State of Florida DNR order form, she said she did not recall when she had spoken to the resident's sister about it. She said they did talk about it. The resident's sister said she would come in to sign the form, but she did not come in. She asked that we mail the DNR form to her. The Social Worker said she did not recall when the facility mailed the form. The resident's sister signed it and mailed it back. She confirmed that she let the physician know that she had paperwork that needed to be signed, but she did not let him know what it was. He said he would get to it on his next visit. The physician was leaving the facility and she caught him at the door. Since the doctor had not signed it, it had not been placed in the chart. In an additional interview with the social worker on [DATE] at 3:01 p.m., she said the resident's sister dated the DNR form. The resident had a decline, so her sister mentioned that she probably wanted to make her a DNR. She asked the resident's sister if she wanted to come in to sign the paperwork. She did not come in. She followed up with a phone call. The resident's sister was busy with her life and so the social worker asked if she wanted it mailed it to her. She agreed to have it mailed to her. She confirmed she did not document the conversation in the medical record, and had no recollection when the conversation with the resident's sister took place. A telephone interview was conducted with the resident's physician on [DATE] at 8:55 a.m. He said the social worker did not tell him the resident had a DNR form that needed to be signed. She told him something needed to be signed, but she did not tell him what it was, or what resident it was for. If the facility had a DNR form for him to sign it takes 2 seconds. He would have signed it immediately. They could have faxed the form to him as well and he would have signed it. If a family member has already signed the document, it should have been given to him to sign immediately. The facility has to get the document to him right away. They did not tell him the resident's family member did not want CPR. He was not aware the family member objected to the code. An interview was conducted with the Social Services Director (SSD) on [DATE] at 10:24 a.m. She said that she and the Social Worker typically do check each other's mailbox if someone is sick or on vacation. Of course, they cover each other as needed. She said she believed the DNR order form was on the Social Worker's desk and not in her mailbox. She was not aware there was a signed DNR order form for the resident. She said Social Services frequently talks with family members regarding advance directives including code status. At the time that a resident or representative signified they would like to sign a DNR form, Social Services explains the form to them, and has the family print and sign the form. Also, we would explain that the form is not valid until the physician signs the form. Until that DNR is signed by both the family and the physician, it was not in effect. The physician order is taken when that form is signed. She said her understanding was that the family and physician had to sign the form in order for the facility to get an order. The DNR order was not obtained to her knowledge. It was the social worker's responsibility to ensure the resident's wishes were followed through. It was a group effort with the physician, social services, and nursing. She said she thinks it starts with social services. At 11:04 a.m. on [DATE] in an interview with the ADON (Assistant Director of Nursing), she said she was not aware there was a conversation going on between the social worker and the resident's sister. The SSD was also present during the interview, and she added that, typically, upon admission and during care plan meetings there was discussion regarding code status and it was documented in the record. Social Services documents the code status on the social service initial assessment and social service evaluations. Ideally yes, there should have been documentation of a conversation about advance directives. On [DATE] at 3:18 p.m., another interview was conducted with the Social Worker. She said she really did not recall where she kept the DNR form. She said usually she would put them in a folder on a clipboard of documents that needed to be signed. During review of facility documents provided by the facility, a Florida Department of Health, State of Florida DNR form was found. It was dated [DATE] and signed by Resident #2's POA/HCS (Power of Attorney/Health Care Surrogate), the resident's sister. The physician had not signed it. Upon review of the paper medical record, a Determination of Incapacity to make medical decisions, dated [DATE], was found. A physician had signed it. The document stated that the resident did not have reasonable medical probability of recovering medical and physical capacity to directly exercise rights to give informed consent for medical decisions. Further review of the paper record showed a Living Will Declaration and Designation of Health Care Surrogate (HCS), dated [DATE], which stated that Resident #2 did not want any artificial life prolonging procedures in the event she had a terminal condition. She designated her sister as her Health Care Surrogate, and gave her Power of Attorney (POA) for all her affairs, as a guardian in the event she should become incapacitated. The document was notarized on [DATE]. The following information was found in Resident #2's electronic medical record: The physician's orders in the electronic medical record at the facility dated [DATE] indicated Resident #2 was a FULL CODE. The last note entered in the record regarding a discussion of Advance Directives was on [DATE]. The social worker indicated that a care plan meeting was held with the resident's sister and Resident #2 continued to be a full code. A nurse's note entered by the resident's nurse, Staff A, RN on [DATE] reflected that, at 9:40 a.m., the Social Worker informed the nurse the resident was not looking well. The nurse entered the resident's room, observed the resident, and then exited the room and obtained a suction machine. The nurse then suctioned the resident two times, at which time the resident leaned forward and turned blue. The nurse then checked the resident's pulse and lung sounds, which were absent. The social worker paged the supervisor. Code blue was activated. 911 was called. Resident #2 was sent to the hospital by stretcher by EMS at 10:35 a.m. Another nurse's note, entered by Staff B, RN Supervisor on [DATE] stated that at 10:00 a.m. she was called to the resident's room and found the resident having shallow respirations and difficulty breathing. Bilateral upper lung sounds were abnormal and there was phlegm in her mouth. The nurse suctioned the resident twice and the resident became unresponsive. Staff called her name three times and touched her shoulder, but she did not respond. Staff checked her pulse and heart sounds and found no regular rate/rhythm. At 10:03 a.m. staff checked the paper and electronic chart for code status, confirming the resident was a full code. Code blue was then initiated. At 10:04 a.m. staff initiated CPR (cardiopulmonary resuscitation), oxygen, and called 911. At 10:10 a.m., EMS relieved staff from CPR. At 10:35 a.m., they transported the resident to the hospital. The resident's sister was present and accompanied the resident to the hospital. A note entered by the Social Worker, also dated [DATE], indicated she went to the resident's room at approximately 9:55 a.m. and noted the resident was gurgling. She proceeded to call the nurse to the room and raised the head of the bed. The nurse began suctioning the resident. She called the supervisor to the room, and then called 911. Staff called Code blue. On [DATE] at 10:35 a.m., an interview was conducted with the Director of Nursing (DON). She said her expectation was that, upon a family member signing a DNR, their wishes be carried out effectively. She expected that the physician would be contacted immediately and they get that done as soon as possible. The Ambulance Run Report and the hospital Emergency Department documentation reflected the following life saving efforts upon transport from the facility: Review of the Ambulance Run Sheet, found an incident date of [DATE] at 09:57:24. The Narrative report for the 911 ambulance call of that date reflected, Responded w/ES for [MEDICAL CONDITION]. Arrived on scene to find staff performing CPR. Initial assessment revealed pt had no pulse and was not breathing. Manual chest compressions were continued by HCFR. Staff states they were with the pt when she stopped breathing. Family was on scene and states pt was complaining yesterday that she had DIB. ACLS was started as noted in report. Pt was placed on the auto pulse at a pulse check. Pt was administered medications as noted in report. Approximately 20 minutes on scene ROSC was obtained. Pt had a weak carotid pulse. Pt was moved to the rescue at that time without incident. Pt was reassessed in rescue with no change. ROSC was maintained throughout transport. Pt was monitored as noted in report. Pt care was transferred to ER RN with ROSC. Review of the Hospital Emergency Department (ED) record, dated [DATE] at 10:45:00, found that Resident # 2 presents in cardio-respiratory arrest. The onset was 09:58 this morning. Witnessed arrest yes, by family by bystander(s). Initial cardiac rhythm Asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation, automated external defibrillator, oxygen, intravenous fluids, [MEDICATION NAME]. Preceding symptoms unknown. Risk factors consist of hypertension. Resident #2 was described in the Emergency records as a 72 y/o female with Primary medical history of [REDACTED].SNF to be in cardio [MEDICAL CONDITION] arrest. EMS reports that they performed CPR for 20 minutes total PTA, administering 3 epi and 4 mg total of [MEDICATION NAME]. They also administered 500 ccIVF. They report that patient has faint pulse upon arrival with blood pressure ,[DATE]. EMS reports that accucheck was 110. Upon arrival at the ED, patient went into asystole and CPR was initiated by ED staff. History is otherwise limited due to patient's clinical condition. Continued review of the emergency room Record Procedure documentation included treatment notes completed by the Physician: CPR Time: [DATE] 10:48:00 CPR was performed: In addition to other critical care activities, Per American Heart Association (AHA) guidelines. Performed by: Self. Supervision: I directly supervised the performance of CPR on this patient. Total time: 7 minutes. Endotracheal Intubation. Time: [DATE] 10:52:00. Confirmed: Patient, procedure, and site correct. Consent: Emergent. Indication: [MEDICAL CONDITION] . Critical Care note. Total time: 35 minutes spent engaged in work directly related to patient care and/or available for direct patient care Critical condition(s) addressed for impending deterioration include: respiratory, cardiovascular, central nervous system. Associated risk factors: cardio-pulmonary arrest . Impression and Plan. [DIAGNOSES REDACTED]. Plan. Condition: Expired . Counseled: Family, Regarding diagnosis, Family understood. The Emergency Department record Physician Notes reflected: Had a long conversation with Patient's POA and patient's sister who states that she signed DNR paperwork, however, physician did not sign off on it in the nursing facility. She wants patient to be DNR, wants to withdraw care, does not want patient to be given pressors or further resuscitation, wants patient extubated. Time: [DATE] 11:14:00 Notes: Patient is asystolic. Time of death called. In a telephone interview with the resident's sister on [DATE] at 4:54 p.m., she said the resident's niece was her caregiver for about three months, and then the resident went to an ALF (Assisted Living Facility), where she fell . After that, the resident was admitted to the facility. The facility notified her by telephone they found the resident unresponsive that day ([DATE], (YEAR)). She told them she was on her way to the facility. When she arrived