Every finding on record at The Terrace at Courtenay Springs

Based on observation, interview and record review, the facility failed to establish routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks, and to maintain or improve resident health status. The facility also failed to provide accurate influenza consent forms for 5 out of 5 residents reviewed for immunizations, of a total sample of 30, (#2, #7, #44, #50, and #68).Findings:1.On 3/16/26 at 2:15 PM, an interview with the Director of Nursing (DON) and the Infection Preventionist (IP), the IP said that she had been in the position for a year. The IP explained that part of her job was to follow residents on precautions, intravenous medications, educate staff on infection control, follow residents on antibiotics, communicate to the doctors about labs and reevaluate as needed. She continued to explain that she would contact the Department of Health if she believed there was an issue with outbreaks, and that the facility used a collective approach with an Infectious Disease Doctor when it comes to treating certain infections.On 3/16/26 at 3:07 PM, the IP and the DON acknowledged that there was no evidence of infection surveillance or data collection because everything was lost when they had a power outage in January. They both acknowledged they had no data to present and therefore the facility has no infection surveillance. The IP said she did not know that she needed a binder with hard copies. The DON stated that she oversees all nurses, but failed to say if she oversees the IP. She stated for the second time, I oversee the nurses.The facility's policy on Infection Surveillance implemented and revised 1/1/26 sated A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.2. Review of the facility's Influenza Vaccine Permission Form revealed the third option provided read, I have read and understand the information provided concerning the Pneumococcal Polysaccharide Vaccine (PPSV), but I do not wish to receive the vaccine. I understand if I wish to change my decision, I will notify the nurse in changes of my care.On 3/16/26 at 2:15 PM, the IP and DON were made aware that the five influenza consents were inaccurate and that it should read the Influenza Vaccine instead of PPSV and that the typo changes should be charge. The IP stated she could not tell how long they were using the form but that's the one I've used the entire time. They both acknowledged the residents did not have accurate consent signed and the IP said that she was responsible for reviewing the consents and did not realize the form was incorrect.The facility's policy implemented and revised on 1/1/26 stated It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering residents, staff members and volunteer workers annual immunization against influenza. Within the guidelines it stated that individuals receiving the vaccine or their legal representative will be required to sign a consent form prior to the administration of the vaccine. The completed signed, and dated record will be filed in the individual's medical record or the staff medical file.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, and behavior needs for 4 of 4 residents reviewed for comprehensive care plans, of a total sample of 30 residents, (#8, #59, #44 and #95). Findings: 1. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included schizophreniform disorder, schizoaffective disorder bipolar type, unspecified dementia, and generalized anxiety disorder. Review of resident #8's electronic medical record (EMR) revealed she resided on the facility's secured memory care unit. The EMR also contained an elopement evaluation dated 12/19/25 which indicated resident #8 was at high risk for elopement. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 3/20/26 revealed resident #8 had a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated she had moderate cognitive impairment. The assessment revealed she did not use a wander/elopement alarm. Review of the comprehensive care plan for resident #8 revealed no care plan for resident's high risk for elopement status. Review of the physician orders revealed no order for a wander/elopement alarm. On 4/14/26 at 11:41 AM, resident #8 was observed as she entered through the locked doors into the secured memory care unit and entered the common area to attend activities with other residents and staff. On 4/15/26 at 8:53 AM, resident #8 was observed in the front hallway of the facility. She was unaccompanied by any staff member. Resident #8 propelled her wheelchair independently as she entered the activity room. No wander/elopement alarm was observed on the wheelchair or on the resident's wrist or ankle. On 4/15/20 at 2:03 PM, the Director of Nursing (DON) verified resident #8 was an elopement risk. She acknowledged the resident was allowed to come out of the secured memory care unit but should have a wander/elopement alarm in place. The DON confirmed the comprehensive care plan did not contain an elopement risk care plan for resident #8. 2. Resident #59 was admitted to the facility on [DATE]. His diagnoses included metabolic encephalopathy, acute kidney failure and unspecified psychosis not due to a substance or known physiological condition. Review of the MDS admission assessment with ARD of 4/03/26 revealed resident #59 had a BIMS score of 15/15 which indicated was cognitively intact. The assessment revealed he did not exhibit any behaviors during the review period and did not use a wander/elopement alarm. On 4/13/26 at 12:51 PM, resident #59 was observed in his wheelchair next to his bed. Resident's shirt was turned inside out and was on backwards. He continued to roll his wheelchair back and forth while talking and changed position in chair frequently. He was noted to have a wander/elopement alert bracelet on his right ankle. Review of resident #59's EMR revealed a physician's order dated 4/08/26 use of a wander/elopement alarm. The record also contained an elopement evaluation dated 4/10/26 which indicated resident #59 was at high risk of elopement. An accompanying nurses progress note read that due to his elopement score of 25 a wander/elopement alarm was placed to resident #59's left ankle. Review of the resident's care plan revealed no care plan indicating resident was at risk for elopement. On 4/15/26 at 2:03 PM, the DON stated resident #59 had become increasingly confused since his admission and was considered an elopement risk. She explained he should be on the secured memory care unit but a bed was not currently available. The DON stated the Social Services department was responsible for behavior care plans. The Social Services Director, who was in the room, stated that social services did not complete care plans for elopement/wandering risk. 3. Resident #44 was initially admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis of the liver, dementia with other behavioral disturbances, senile degeneration of the brain, brief psychotic disorder, blindness of left and right eye, and chronic pain syndrome. Review of resident's clinical record revealed he was admitted to hospice services on 4/17/25 with an admitting diagnosis of senile degeneration of the brain. A hospice consult dated 1/29/26 revealed the resident was a high risk for falls due to generalized weakness and declining safety awareness. The resident was noted to make attempts to get up without assistance despite multiple falls. The resident showed increased memory deficit and increased forgetfulness. A review of resident #44's progress notes revealed on 8/12/25 the resident was found sitting on the floor next to his bed. He stated that he was unsure what happened and that he was in bed and 'the next thing he knew' he was on the floor. The resident has no injuries. A progress note on 8/13/25 revealed that a fall intervention to add bolsters to the bed to define mattress perimeter was initiated. Further review of the resident's progress notes revealed on 2/15/26 the resident was found on the floor next to his bed with a skin tear to his left elbow. Resident stated he was trying to get some water. A review of resident #44's care plan revealed that the resident is a high risk for falls related to being blind, impaired mobility, fall risk score greater than 10, narcotic medications and blood pressure medications. Interventions included adding bolsters to the bed to define mattress perimeter was initiated on 8/12/25 and to ask hospice to provide a volunteer to be his companion was initiated on 2/16/26. On 4/13/26 at 1:10 PM, the resident was observed sitting on the side of his bed with his lunch tray in front of him. Resident's mattress was noted not to have bolsters and there was no a companion at bedside. On 4/13/26 at 3:05 PM, the MDS Coordinator stated that they review care plans routinely and on an as needed basis. When it comes to falls, their process is to review the care plan and interventions after each fall to see if the care plan needs to be updated and if the interventions in place are appropriate. The MDS coordinator was unsure what hospice said when the facility asked them for a companion for the resident. She agreed there was no documentation as to say whether this intervention was initiated nor the outcome. The MDS Coordinator also agreed that if the intervention for bolsters to the bed was deemed inappropriate that it should have been removed from the care plan. 4. Resident # 95 was readmitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and congestive heart failure. Review of the Minimum Data Set (MDS) admission 5-day assessment with assessment reference date (ARD) of 1/07/26 revealed that the resident had a Brief Interview for Mental Status Score of 13 out of 15 which meant she was cognitively intact, and used oxygen as a special treatment. The physician orders dated 2/27/26 read continuous oxygen at 1.5 liters per minute (LPM) via nasal cannula. On 4/13/26 at 11:30 AM, resident #95 was observed in bed, alert with her husband at the bedside. The oxygen concentrator was on, but the nasal cannula was not connected to resident. She explained that she did not use oxygen often. The tubing was observed on the floor and concentrator read 2.5 LPM. On 4/13/26 at 12:25, the Director of Nursing (DON) was asked to verify the physician order in the computer, and she stated that it was for 1.5 LPM. She was then asked to verify the flow rate on the concentrator, and she said it was at 2.5 LPM. The DON said that her expectation was that nurses should verify the orders for oxygen before assuming care during shift report. Resident #95 told the DON that she did not want oxygen and that she does not usually use it. The DON turned off the oxygen concentrator and stated that she would call the physician. On 4/13/26 at 12:37 PM, the assigned licensed practical nurse (LPN) A was made aware and said that she would follow up with doctor about the oxygen orders. LPN A said that prior to this, the resident was not refusing oxygen. LPN A said that she checked it earlier during report, but her main concern was that the oxygen was on, and the resident was wearing it. She explained she did not check the flow rate and knew she should have but did not. A review of the comprehensive care plan for resident #95 did not address oxygen or any care area with respiratory status nor refusal of therapies. On 4/15/2026 at 4:55 PM, the MDS Coordinator acknowledged that resident #95's care plan did not address any respiratory diagnoses nor oxygen administration orders. She explained that she was the one who completed the care plan and could not explain why it was not done. She explained the process was to put in a basic care plan and review the diagnoses to ensure all were on the care plan. She would then check the orders and add the interventions or other areas if needed. She acknowledged the resident did not have a respiratory care plan and it was her responsibility to add it. The facility's policy implemented 1/1/26 and revised 1/1/26 on Comprehensive Care Plans stated that It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to respond to recommendations for 1 of 1 residents reviewed for cardiac management out of 30 sampled residents, (#92). Findings:On 4/13/26 at 1:40 PM, resident #92 expressed his concerns related to blood pressure management while at the facility. The resident reported that he had cardiac surgery previously and his cardiac surgeon told him that he needed to maintain a systolic blood pressure below 130. Resident stated that, while at the facility, they would not give any antihypertensive medication unless his systolic blood pressure was above 160. Resident expressed frustration with the facility stating that his blood pressure being above 130 could be life threatening and he has relayed this information to the facility many times.Resident #92 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dissection of descending thoracic aorta, type 2 diabetes mellitus, severe morbid obesity, heart failure, chronic pain syndrome and hypertension.An aortic dissection is a tear in the inner layer of a weak area of the aorta. Blood surges through the tear, causing the inner and middle layers to separate (dissect) As diverted blood flows between the tissue layers, the normal blood flow to parts of the body may slow or stop, or the aorta may rupture completely. There are two main types of aortic dissection: Type A starts at the upper part of the aorta and typically requires open chest surgery to repair. Type B starts further down the aorta further away from the heart. (retrieved from https://my.clevelandclinic.org/health/diseases/16743-aortic-dissection on 4/29//26)Resident #92 facility progress note on 3/5/26 at 9:15 AM, revealed the resident was sent to the hospital for evaluation following an abnormal abdominal ultrasound.Review of hospital discharge paperwork on 3/13/26 revealed the resident had an abdominal aortic aneurysm (AAA) with open repair performed in 2016. He was transferred to the hospital from the facility on 3/5/26 following an abdominal ultrasound which showed a 5 centimeter (cm) abdominal aortic aneurysm. Subsequent radiology confirmed a type B aortic dissection with aneurysmal dilation up to 5.2 cm. At the hospital, vascular surgery was consulted and it was determined that dissection was likely a chronic or residual from the prior type A event and no urgent intervention was required. The plan was for systolic pressure to be kept under 130.Review of facility progress note on 3/19/26 at 12:15 AM revealed the resident called emergency services in order to be transported to the hospital related to an elevated blood pressure. Blood pressure noted to be 175/88. Further review of the progress note revealed that the on call physician services were contacted and a requested for a return call related to the resident having no as needed (PRN) orders for high blood pressure.Review of progress note on 3/19/26 at 1:30 AM revealed the physician gave a one time order of Clonidine 0.1mg and for the resident to be sent to the hospital for further evaluation.Review of hospital discharge paperwork from 3/19/26 revealed under the section titled ED course that at 6:18 AM the hospital provider was at the residents' bedside to evaluate the resident and that they would contact the facility to discuss blood pressure control with the facility physician. At 6:56 AM, hospital physician wrote that he spoke with the Nurse Practioner (NP) at the facility who stated that he was aware the resident needed close monitoring of blood pressure to maintain a systolic less than 130. Under the section titled Medical Decision Making, the hospital physician stated that prescription drug management not need at this time and the facility will review the resident's blood pressureReview of hospitals after visit summary paperwork from 3/19/26 revealed instructions for the resident to keep close monitoring of his blood pressure. The resident blood pressure per vascular surgery was to maintain systolic pressure less than 130.Facility cardiology consultation on 3/19/26 revealed the facility primary care physician referred the resident for cardiac management, The assessment and plan for managing the residents Type B [NAME] Aortic dissection was close monitoring of blood pressure and to maintain a systolic blood pressure of below 130. The resident had an order for PRN clonidine to assist with blood pressure management.Review of the resident's physician orders revealed an order for clonidine 0.1mg every 6 hours PRN for a systolic blood pressure greater than 160 with a start date of 3/19/26.Review of progress note on 3/22/26 at 7:12 PM revealed the resident raised concerns related to his elevated blood pressure and requested medication. Residents blood pressure 144/75. Writer informed the resident he had an order for clonidine as needed for a systolic blood pressure greater than 160. Writer of the note notified the physician, and no new orders were given at that time.Review of progress note on 4/14/26 at 3:08 AM revealed the resident requested his blood pressure to be taken which showed a reading of 152/84. Resident was agitated and stated he was worried about his blood pressure. The resident refused antianxiety medication and requested the physician be notified about elevated blood pressure. A subsequent noted at 4:21 AM, revealed the Nurse Practioner (NP) followed up about elevated blood pressure but gave no new orders.On 4/16/26 at 3:00 PM, the Unit Manger stated that there was no order or consultation that required the resident to maintain a systolic blood pressure below 130. She stated she was not aware before 4/13 that the resident had concerns related to his blood pressure being too high. She was not aware that hospital paperwork and facility cardiologist recommended systolic blood pressure less than 130. She acknowledged that she is responsible for reviewing consultations and hospital paperwork to ensure orders and recommendations are followed up on.Facility policy titled Consulting physician/Practioner Orders revised 1/1/2026 revealed that consulting physicians orders are those orders provided to the facility by a physician other than the resident's attending physician who is acting on the behalf of the attending physician. A consulting physician may include a surgeon or specialist such as cardiologist. For a consulting physician who gives an order in writing, the nurse will call the attending physician to verify the order and document that order.

Based on observation, interview, and record review, the facility failed to identify and provide ongoing monitoring of identified past trauma for 4 of 4 residents reviewed for Trauma Informed Care, of a total sample of 30 residents, (#40, #4, #16, #49). Findings: 1.Resident #40 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse with alcohol-induced psychotic disorder, psychoactive substance abuse with withdrawal, major depressive disorder, and anxiety. A review of the psychiatry consult on 5/23/25 revealed an excerpt from Assessment and Plan for trauma: The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology. Care Plan for PTSD diagnosis: Trauma: emotional abuse growing up with alcoholic parents. Triggers: slamming doors and yelling. Care plan: enter room calmly, introduce and self explain Further review revealed that the diagnosis of PTSD was confirmed and care plan added to the chart as the resident had active symptoms of PTSD. Review of the admission MDS assessment with assessment reference date (ARD) of 5/27/25 revealed resident #40 had Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated he had no impaired cognition. The assessment also showed that the Psychiatric /Mood disorders included depression, anxiety, psychotic disorder and PTSD. A review of resident #40's care plan revealed the resident had a risk for a mood problem related to a diagnosis of PTSD, ADHD and anxiety initiated on 5/22/25 and revised 2/18/26 with no specific interventions addressing PTSD or the triggers. On 4/15/26 at 10:01 AM, resident #40 stated that his Post Traumatic Stress Disorder (PTSD) stemmed from growing up in a military family. He stated some of his triggers included slamming door, yelling and fire drills. He also stated that he occasionally has nightmares and wakes up yelling with no memory of what had happened. Findings: 2. Resident # 4 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, major depressive disorder, other specified anxiety disorders and Post- Traumatic Stress Disorder (PTSD). Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 8/15/24 revealed active diagnoses for Psychiatric /Mood disorders included anxiety, depression and PTSD. Review of the most recent MDS quarterly assessment with ARD of 2/11/26 showed the resident had a Brief Interview for Mental Status (BIMS) Score of 9 out of 15 which indicated he had moderate impaired cognition. Active diagnoses for Psychiatric /Mood disorders included anxiety, depression and PTSD. A review of a psychiatry note dated 6/21/24 revealed an excerpt from Assessment and Plan which addressed PTSD for resident #4 as The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one months and have occurred without any substance use or organic brain pathology. On 8/23/24 a Care Plan Note (Non Face to Face) from the psychiatrist read Care Plan for PTSD diagnosis: Trauma: PTSD, Triggers: none noted and Care Plan: Refer to psychotherapy for PTSD. A review of resident #4's Care Plan revealed that he was at risk for mood distress /depression related to major depressive disorder, anxiety disorder and PTSD initiated on 11/25/25. The care plan also revealed that resident #4 required the use of psychotropic medications and antidepressants to assist with managing mood and had diagnoses of insomnia, depression, anxiety, PTSD and dementia initiated 5/23/24, however, there was no specific care plan addressing PTSD or triggers. On 4/14/26 at 4:43 PM, resident #4 was observed in his room and explained that he doesn't have any triggers or trauma and that was a long time ago. He said that doesn't bother him. On 4/15/26 at 2:34 PM, the resident stated that he recalled the psychologist had asked him about PTSD and he told her he had not served in the war he said there is a lot of things but did not think he had PTSD. 3. Resident #16 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, alcohol abuse with intoxication, persistent mood (affective) disorder and Post- Traumatic Stress Disorder (PTSD). Review of the Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 6/13/25 revealed active diagnoses for Psychiatric /Mood disorders included anxiety disorder, psychotic disorder other than schizophrenia and PTSD. Review of the most recent MDS quarterly assessment with ARD of 3/13/26 showed the resident had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated his cognition was intact. Active diagnoses for Psychiatric /Mood disorders included anxiety disorder, depression, psychotic disorder and PTSD. A review of a psychiatry subsequent note on 6/3/25 revealed an excerpt from Assessment and Plan which addressed PTSD for resident #16 as The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one months and have occurred without any substance use or organic brain pathology. Care Plan for PTSD diagnosis: Trauma: I've had a bunch of stuff. I wouldn't know where to label it as one thing. Triggers: Unable to identify any specific triggers. Care Plan: No changes. A review of resident #16's Care Plan revealed that he required the use of psychotropic medications, antidepressant medications and had diagnoses of persistent mood disorder, insomnia, anxiety, brief psychotic disorder and PTSD initiated 4/02/24, however, there was no specific care plan addressing PTSD or triggers. 4. Resident #49 was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, alcohol abuse, epilepsy, unspecified dementia, other specified anxiety disorders and adjustment disorder with depressed mood. Review of the MDS quarterly assessment with ARD of 1/20/26 revealed resident #49 had long-term and short-term memory problems with severely impaired cognitive skills for daily decision making. The document revealed resident #49 had an active diagnosis of PTSD and received anti-anxiety medications. Review of resident #49's electronic medical record (EMR) revealed a psychiatry subsequent note dated 8/15/25 which listed a new diagnosis of PTSD (Post Traumatic Stress Disorder). The documentation read, The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology. Review of resident #49's comprehensive care plan revealed a care was initiated 10/31/25 which indicated the resident demonstrated significant mood distress/depression related to her diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, anxiety disorder, post-traumatic stress disorder and adjustment disorder. The interventions were to provide counseling/intervention sessions as desired and to help the resident work on one significant problem/factor related to depression at a time. The comprehensive care plan did not contain a care plan that specifically addressed resident #49's past trauma or triggers in order to eliminate or mitigate the triggers that may cause re-traumatization of the resident. In a group meeting with the Director of Nursing (DON), MDS Coordinator, facility Administrator and Social Services Director on 4/15/2026 at 2:48 PM, the MDS Coordinator stated she reviewed the psychiatric notes and added any new diagnosis to the resident's EMR. She explained she would initiate a care plan if the resident received medications related to the diagnosis. The MDS Coordinator clarified that social services was responsible for initiating care plans that were related to a behavior. The social services director confirmed she would be responsible for initiating a PTSD care plan if she was made aware of the diagnosis. The MDS Coordinator verified that there were no trauma informed care plans initiated for the four residents identified with a diagnosis of PTSD. She acknowledged the facility staff would be unaware of the specifics of the trauma or of any triggers each resident may have in order to make attempts to avoid re-traumatization of the resident. The facility's policy and procedure for Trauma Informed Care implemented 1/01/26 read, The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. The document clarified that the facility would identify triggers which may re-traumatize residents with a history of trauma. The document indicated that trigger-specific interventions would identify ways to decrease the resident's exposure to triggers which could retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and would be added to the resident's care plan. The document included that the trauma-specific care plan interventions would recognize the interrelationship between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety.

Based on observation and interview, the facility failed to store and serve food in a manner to prevent foodborne illness in the resident population that received dietary services from the facility kitchen. Findings: During the Initial Brief Tour of the kitchen with the Food Service Director on 5/28/24 at 11:05 AM, a lunch bag was observed on one of the shelves inside the walk-in refrigerator. The Food Service Director stated the bag belonged to an employee who must have put it down by accident and forgot to take it to the employee break room. He stated he would have the employee remove it. Dietary Server C entered the walk-in refrigerator and removed her lunch bag. Food Service Director was informed the bag was on a wire shelf above two containers of raw chicken in marinade that were not fully covered with plastic wrap. On a shelf opposite the chicken was a container of cubed potatoes that were uncovered. The Food Service Director acknowledged employees should not store person items inside the walk-in refrigerator and the containers should have been covered to prevent contamination. During a follow up visit to the kitchen on 5/29/24 at 11:07 AM, Dietary Server C was observed walking toward the walk-in refrigerator carrying the lunch bag observed in the walk-in refrigerator the previous day. She reached for the door to the walk-in refrigerator and stopped when she saw the surveyor to the side. Dietary Server C then released the door handle, turned and left the kitchen. When she returned, Dietary Server C verified she had stored her lunch bag in the walk-in refrigerator the day before and was about to do it again when she saw the surveyor. She acknowledged she was not supposed to store personal items in the walk-in refrigerator. Dietary Server C was unable to explain why she had put her personal lunch inside the walk-in refrigerator previously or why she was about to do it again. During Tray Line Observation on 5/29/24 at 12:11 PM, [NAME] D was observed at a steam table as she prepared to serve lunch. She was observed with gloves on both hands. [NAME] D pulled a tray cart closer to the area and reached into the plate storage container and picked up a stack of plates with fingers on the bottom of the stack and thumbs on the top plate which touched the eating surface of the plate. She arranged the plates on the shelf to begin service when the phone rang. [NAME] D answered the phone while still wearing her gloves. She went to deliver a message and was observed as she pulled off the glove on her right hand and scratched her bare hand with her gloved left fingers. She returned to the steam table and arranged items for service when the phone rang again. [NAME] D again answered the phone and returned to the tray line. She pulled the cart closer and resumed plating food without cleaning her hands or changing gloves. [NAME] D turned and grabbed several unwrapped rolls from another table and placed them on plates, covered the plates and placed them on the tray cart for delivery. Head Chef E arrived back in the kitchen after he delivered items to the nursing units. He was informed of the observation and the surveyor asked for the staff member to change gloves due to potential for cross contamination. No supervisor was present in the kitchen to observe tray line. The facility policy and procedure, Preventing Foodborne Illness - Food Handling revised July 2014 read, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The document indicated gloves were considered single-use items and must be discarded after completing the task for which they were used.

Based on interview and record review, the facility failed to complete and submit discharge assessments timely for 6 of 6 residents reviewed for resident assessments, of a total sample of 39 residents, (#12, #40, #53, #55, #73 and #76). Findings: During a review of resident assessments, six residents were identified as having Minimum Data Set (MDS) assessments that were over 120 days past due. 1. Resident #12 was admitted to the facility on [DATE] and discharged [DATE]. Review of the medical record revealed an MDS discharge assessment was not completed or submitted following resident #12's discharge. 2. Resident #40 was admitted to the facility on [DATE] and expired [DATE]. Review of the medical record revealed an MDS death in facility tracking record was not completed or submitted following resident #40's discharge. 3. Resident #53 was admitted to the facility on [DATE] and expired [DATE]. Review of the medical record revealed an MDS death in facility tracking record was not completed or submitted following resident #53's discharge. 4. Resident #55 was admitted to the facility on [DATE] and discharged [DATE]. Review of the medical record revealed an MDS discharge assessment was not completed or submitted following resident #55's discharge. 5. Resident #73 was admitted to the facility on [DATE] and discharged [DATE]. Review of the medical record revealed an MDS discharge assessment was not completed or submitted following resident #73's discharge. 6. Resident #76 was admitted to the facility on [DATE] and discharged [DATE]. Review of the medical record revealed an MDS discharge assessment was not completed or submitted following resident #76's discharge. On [DATE] at 3:52 PM, the Director of Nursing (DON) stated she was not aware any MDS assessments had been missed. She explained the facility switched to a new electronic medical record system on [DATE]. She reviewed the submitted MDS for each identified resident and acknowledged MDS discharge assessments were not submitted for any of the 6 residents. The DON stated they must have gotten missed in the transition. On [DATE] at 1:55 PM, the MDS Coordinator reviewed the medical record for each resident. She verified MDS discharge assessments or death in facility tracking records were not submitted within the required timeframe following discharge. The facility policy and procedure MDS Completion and Submission Timeframes revised ,d+[DATE] read, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The document indicated the assessment coordinator was responsible for ensuring resident assessments were completed and submitted in accordance with current state and federal guidelines.

Based on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 43, (#50 and #54). Findings: 1. Resident #50 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, protein-calorie malnutrition, hypotension, mild cognitive impairment of unknown etiology. Review of resident #50's financial record revealed he began a Medicare Part A skilled nursing stay starting on 1/01/24, with the last day of coverage on 3/08/24. A SNF Beneficiary Protection Notification Review revealed resident #50 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #54 was admitted to the facility on [DATE], with diagnoses of traumatic ischemia of muscle, rhabdomyolysis, hypertension, cognitive communication deficit, and polyneuropathy. Review of resident #54's financial record revealed he began a Medicare Part A skilled nursing stay on March 1, 2024, with last covered day on 3/08/24. A SNF Beneficiary Protection Notification Review revealed resident #54 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). Interview with the Social Services Director on 3/08/24, at 11:23 AM, revealed Social Services did not handle the ABN and the business office was in charge of that notification. Interview with the Business Office Manager on 3/08/24, at 11:45 AM, revealed no ABNs had been issued by her while being employed at the facility. She explained she thought the Social Service department handled the ABN notifications. She also confirmed no SNF ABNs were issued for residents #50 or #54 who had remained in the facility following a Medicare Part A stay without exhausting their benefit days.

Based on observation, interview, and record review the facility failed to report an alleged violation of neglect to the State Agency (SA) as required for 1 of 2 residents reviewed for abuse/neglect, of a total sample of 39 residents, (#435). Findings: Review of the Reportable Events 2024 log revealed resident #435 self-reported neglect on 1/27/24. Review of resident #435's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and intervertebral disc degeneration. Review of resident #435's Minimum Data Set 5-day assessment with Assessment Reference Date of 1/31/24 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated she was cognitively intact. On 5/30/24 at 12:04 PM, the Director of Nursing (DON) stated resident #435 called the Department of Children and Families (DCF) and an investigator came to the facility on [DATE] to investigate her concerns. The DON explained she was only responsible for reporting adverse events to the SA, but this was not considered one. She indicated the Nursing Home Administrator (NHA) was responsible to submit the required immediate and 5-day reports for allegations of abuse and/or neglect. On 5/30/24 at 12:29 PM, the Social Services Assistant indicated she was the Abuse coordinator when resident #435 called DCF. She explained the DCF investigator came in and she was notified the same day. She stated she did not talk to resident #435 that day and might have done it the following day but could not provide evidence of her interview. She stated she did not speak to nor collect witness statements from staff assigned to resident #435 or other residents. She stated her, Superiors made the decision, to not report to the SA. She confirmed this was considered an allegation of neglect. Review of an email dated 1/28/24 at 1:04 PM, revealed the DON forwarded the message received from the DCF investigator to the NHA and Social Services. The DON added resident #435 called DCF alleging, She had to wait 30 minutes to be changed on 1/27/24. The DON indicated she met with the DCF investigator and law enforcement. The message read, We will discuss as a team how to proceed. On 5/30/24 at 1:15 PM, the NHA stated resident #435 made a self-report to DCF. He indicated the Social Services Assistant interviewed the resident, but she did not report any concerns. He stated he did not speak with the DCF investigator, and stated an allegation of neglect was not reported to him. He stated he did not believe he was called in on Sunday, 1/28/24 when the DCF investigator came to the facility. When asked about the email sent by the DON to him and social services on 1/28/24 he stated he did not remember receiving it. He indicated he could not remember when he learned about this and the DCF investigator did not disclose any information. He confirmed he had the appropriate log in to submit the federal reporting and acknowledged the facility failed to report this allegation of neglect. He stated he was waiting for the determination of the DCF report. He explained allegations of abuse or neglect were to be made within 2 hours to DCF and within 24 hours to the SA. Review of the facility's Abuse Investigation and Reporting policy and procedure revised on July 2017 read, All alleged violations involving abuse, neglect, . will be reported to the facility Administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing facility . An alleged violations involving abuse, neglect, . will be reported immediately but no later than . twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record review, the facility failed to provide written Notification of Transfer to the resident or their representative for 2 of 2 residents reviewed for hospitalization s, of a total sample of 39 residents, (#15 and #25). Findings: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis, chronic obstructive pulmonary disorder, ESBL, diabetes, and major depression. The Minimum Data Set (MDS) Annual Assessment noted that resident #25 scored 9 on the Brief Interview for Mental Status (BIMS) evaluation, which indicated the resident's cognition was moderately impaired. A Nursing Home to Hospital Transfer Form dated 5/27/24 revealed resident #25 had altered mental status. Review of the medical record revealed resident #25 was transferred to the hospital on 5/27/24. On 5/30/24 at 1:51 PM, the Admission Director confirmed resident #25 was still in the hospital but were planned to return to the facility the next day. On 5/30/24 at 2:41 PM, the Social Service Director (SSD) confirmed they could not provide documentation of written notice to the resident and/or the resident's representative. 45646 2. Resident #15 was admitted to the facility on [DATE] with diagnoses including cutaneous abscess of abdominal wall, acute respiratory failure and acute posthemorrhagic anemia. Review of the MDS admission assessment with assessment reference date of 4/09/24 revealed resident #15 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. Review of progress notes for residents #51 revealed she was transferred to the hospital on 4/23/24, 4/25/24, 5/03/24 and 5/20/24 for possible gastrointestinal bleeding. Resident #15 returned to facility after each hospitalization . Review of the Notification of Transfer or Discharge form for 4/23/24 and 4/25/24 revealed the daughter was notified of the transfer verbally; the 5/03/24 form revealed the daughter was notified of the transfer verbally and resident #15 signed the form upon her return 5/07/24; and the form dated 5/20/24 indicated the daughter was notified verbally on 5/24/24 and resident #15 signed on an unknown date. On 5/30/24 at 12:30 PM, the SSD acknowledged only two of the Notification of Transfer or Discharge forms were signed by resident #15. She stated the family was notified verbally each time. The SSD explained copies of the Notification of Transfer or Discharge forms were left in resident #15's room. On 5/30/24 at 12:33 PM, resident #15 was shown the Notification of Transfer or Discharge forms. She stated the facility had her sign some papers when she returned from the hospital. Resident #15 denied seeing those forms before and stated no one had left any copies for her previously when she had transferred to the hospital. In an interview with the Administrator and SSD on 5/30/24 at 12:45 PM, the SSD stated she had not mailed copies of the Notification of Transfer or Discharge to the resident's representative and could not provide proof she provided them to resident #15. The Administrator recalled copies had been mailed to resident representatives in the past. He explained the SSD and SSA were new, and the process just fell through the cracks. The facility's policy and procedure for Transfer or Discharge Notice revised December 2016 read, The resident and/or representative (sponsor) will be notified in writing of the following information: a. the reason for the transfer for discharge; b. the effective date of the transfer or discharge; c. the location to which the resident is being transferred or discharged .

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurately completed following a new mental health diagnosis for 1 of 1 resident reviewed for PASRR, of a total sample of 77 residents, (#80). Findings: Resident #80's medical record revealed she was admitted to the facility 5/03/24 with diagnoses of type 2 diabetes mellitus, cognitive communication deficit, unspecified dementia, anxiety and depression. The resident's PASRR forms dated 5/03/24 was completed prior to admission to the facility. The form listed anxiety disorder and depressive disorder under Section IA Mental Illness or suspected Mental Illness. Under Section II, it was noted that a secondary diagnosis of dementia was listed. A Psychiatry evaluation note dated 5/10/24 revealed a diagnosis of schizophrenia had been added to the resident's medical record. The resident was noted to have chronic and consistent psychosis. The resident also was noted to have past attempts of suicide by overdose. During the evaluation, no suicidal ideations, paranoia or hallucinations were noted. Another Psychiatry evaluation dated 5/24/24 revealed the resident was having increased paranoid and disorganized thinking. The evaluation noted the resident appeared unstable and required medication changes. Review of the resident medical record revealed no updates had been made to the PASRR form to include the new diagnosis of schizophrenia and history of suicide attempt. Interview with the Director of Nursing (DON) on March 29, 2024, at 3:31 PM, revealed the Admissions department was responsible for making sure a resident had a PASRR completed when admitted . Afterwards, the DON and unit managers performed the chart checks to ensure the information was accurate. The DON stated she handled any changes that needed to be made to the form. The DON confirmed no updates had been made to Resident #80's PASRR form to include the new schizophrenia diagnosis. Facility policy titled, Behavioral Assessment, Intervention and Monitoring revised on March 2019, indicated new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder would be referred for a PASRR Level II evaluation.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions for 1 of 3 residents reviewed for accidents, of a total sample of 39 residents, (#63). Findings: Review of the medical record revealed resident #63, an [AGE] year-old female was admitted to the facility from an acute care hospital on 3/17/23. The resident had diagnoses that included spinal stenosis (narrowing), blindness, muscle weakness, anxiety, stroke, urinary tract infection, and adult failure to thrive. The Minimum Data Set (MDS) Annual Assessment with Assessment Reference Date (ARD) 3/11/24 noted the resident's vision was severely impaired, and she scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she had moderate cognitive impairment. The assessment showed the resident had difficulty focusing attention and disorganized thinking that fluctuated and changed in severity. She was incontinent of bladder and bowel functions and received high-risk anti-depressant medications during the look back period. The MDS did not note the resident's functional abilities. The Task Description records documented the resident was dependent on staff to complete Activities of Daily Living (ADL). for mobility, and to transfer in and out of bed. The Comprehensive Care Plan included focuses for staff total assistance with daily ADL care, and high risk of falls related to debility, impaired mobility, blindness, and medication side effects with a goal that the resident would remain free of falls causing hospitalization s. An intervention was entered on 5/20/24 that read, Bolsters to mattress to define mattress perimeters. The Order Summary Report included active physician's medication orders for Escitalopram Oxalate 10 milligrams (MG) once daily for depression, and Gabapentin 300 MG three times daily for spinal stenosis. On 5/28/24 at 11:17 AM, resident #63 was observed awake, lying in bed in her room. The resident's daughter said her mother had fallen from her bed about a week prior, and she was supposed to get a new bed to keep her from falling out. She stated she was concerned because her mother sometimes forgot she was in bed, and it hadn't been changed yet. Review of the Nurses Notes on 5/17/24 indicated resident #63 was observed by a Certified Nursing Assistant (CNA) in her room lying on the floor next to her bed. It was noted that the CNA informed the nurse that the resident had likely fallen out of bed. In a joint observation with Registered Nurse (RN) A on 5/28/24 at 12:26 PM, the RN checked resident #63's bed and confirmed there was a regular mattress without bolsters. She recalled the resident was observed on the floor next to her bed about a week prior, and staff believed she fell out. On 5/28/24 at 12:32 PM, in a joint observation, the [NAME] Unit Manager checked resident #63's bed and confirmed a bolster mattress was not in place. She said all resident falls were discussed during Interdisciplinary Team (IDT) meetings every morning and afternoon. She explained, bolster mattresses were used as a fall prevention intervention because they created a perimeter around the bed and helped to prevent falling out of bed. She said the Central Supply Coordinator arranged and implemented bolster mattresses. She said she didn't know why the intervention was delayed for 8 days. On 5/29/24 at 1:35 PM, the Assistant Director of Nursing (ADON) said she also served as the facility's Risk Manager. The ADON explained that the IDT discussed all resident falls in morning meetings, and together they decided what interventions were needed. She stated, If somebody needs reminders, I communicate whatever is to be put in place; for equipment, it's central supply; in SOC (Standards of Care) we communicate whether or not the equipment came in or not. On 5/29/24 at 3:14 PM, the MDS Coordinator said she attended morning and afternoon IDT meetings where care plans were discussed. She explained she updated care plans, Per the intervention decided in meetings. In an interview with the Central Supply Coordinator on 5/30/24 at 11:18 AM, she explained Unit Managers made her aware when supplies or equipment were needed for fall interventions. She said she wasn't aware resident #63 had fallen until earlier that day when the Unit Manager told her the resident needed a bolster mattress. She stated, I do have one and when they get her up, we will get it switched out. On 5/29/24 at 1:35 PM, the Director of Nursing (DON) said the ADON was responsible for follow up to ensure fall interventions were implemented. She explained, MDS updated the care plan from what was determined in meetings. The DON checked the Electronic Health Record and said resident #63 was observed on the floor beside her bed on 5/17/24. She said the care plan was updated on 5/20/24 with an intervention for a bolster mattress. She explained ample time had passed, it was important, and the intervention should have been implemented. The DON stated, She could have a fracture if she fell out of bed. Review of the facility's standards and guidelines titled, Falls - Clinical Protocol dated March 2018 read, . Monitoring and Follow-Up . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to ensure a Midline intravenous (IV) dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for IVs, of a total sample of 39 residents, (#384). Findings: Resident #384, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included sepsis, urinary tract infection, metabolic encephalopathy, chronic obstructive heart disease, and chronic obstructive pulmonary (lung) disease. Review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (3008) dated 5/23/24 revealed the resident's primary diagnosis was acute metabolic encephalopathy with catheter-associated urinary tract infection. Documentation indicated the resident was alert, oriented, followed instructions, and had a Midline IV inserted on 5/22/24. A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm. The end of a midline, inside your body, does not go past the top of your armpit (retrieved on 6/09/24 from www.drugs.com). On 5/30/24 at 9:54 AM, resident #384 was observed in bed in her room with a right upper arm midline IV. Resident #384 stated, I get IV antibiotics for a bladder infection in the midline. The hospital put it in. The midline IV dressing was lifted up at the edges and dated 5/22/24. On 5/30/24 at 10:00 AM, Registered Nurse (RN) B, responsible for resident #384's care, was in her room and confirmed the midline IV with a transparent dressing dated 5/22/24. RN B stated the antibiotic was given at 9:00 PM so that shift would be responsible for changing the dressing every 7 days and as needed. RN B searched the electronic medical records and stated, There are no dressing change orders. A review of the physician orders revealed no orders for dressing changes for the resident's midline. On 5/30/24 at 10:36 AM, the [NAME] Wing Unit manager stated that new admissions records were reviewed by the clinical team the day after admission to ensure all orders were in place. She said the facility would change IV dressings as needed, but at least every seven days. She confirmed there were no orders in place to change the midline IV dressing, which should have been changed on 5/29/24, the previous day. On 5/30/24 at 2:43 PM, the Director of Nursing (DON) stated the resident was admitted to the facility from an acute care hospital on 5/24/24 with a midline IV inserted on 5/22/24. She stated the protocol was for the nurse to review the admitting orders with the physician, make the physician aware of the midline, and obtain an order for the midline dressing to be changed as IV antibiotics were to be administered. The facility's Central Venous Catheter Dressing Change policy, revised on 4/2016, read, Change transparent semi-permeable membrane dressings at least every 5-7 days and when wet, soiled, or not intact.

Based on observation, interview, and record review, the facility failed to ensure safe supplemental oxygen administration for 1 of 1 resident reviewed for respiratory care, of a total sample of 39 residents, (#54). Findings: Review of the medical record revealed resident #54, an [AGE] year-old female was admitted to the facility from an acute care hospital on 1/26/24. The resident had diagnoses that included traumatic muscle ischemia (lack of blood or oxygen), muscle weakness, cognitive communication deficit, thyroid disorder, neuropathy (nerve impairment), repeated falls, depression, and shortness of breath. The Minimum Data Set Quarterly Assessment with Assessment Reference Date 3/02/24 noted the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. The assessment showed the resident did not have any indicators of psychosis, behavioral symptoms, rejection of evaluation or care, and she required staff supervision or set-up assistance to complete Activities of Daily Living. Resident #54 received high-risk anti-depressant medications and did not require oxygen therapy during the look back period. On 5/28/24 at 11:26 AM and 1:56 PM, and 5/29/24 at 12:12 PM, resident #54 was observed awake in her room sitting in a wheelchair beside the bed. She was receiving supplemental oxygen via a nasal cannula at a flow rate of 3.5 liters per minute from an oxygen concentrator device. The oxygen tubing was undated. Review of the Comprehensive Care Plan included focuses for: staff assistance for daily care needs, risk for falls, and communication and cognitive deficits. The care plan did not include supplemental oxygen therapy. Review of the Order Summary Report on 5/28/24 revealed active physician's medication orders for resident #54 but contained no physician's orders for supplemental oxygen. The Weights and Vitals Summary report documented that from 1/26/24 to 4/10/24, resident #54 did not receive supplemental oxygen therapy and from 4/11/24 to 5/28/24, the resident received supplemental oxygen via a nasal cannula; the report did not note the oxygen delivery flow rates, for 48 days. The May 2024 Medication Administration Record (MAR) was reviewed. The May 2024 MAR did not have documentation entries by nurses for oxygen administration, monitoring, tubing or supply changes. In an interview on 5/29/24 at 12:17 PM, Registered Nurse (RN) A explained, nurses were responsible for entering physician's orders and monitored supplemental oxygen administration where it was recorded on the MAR. She said she was very familiar with resident #54 who she was assigned to multiple times over the past few weeks. She said the resident had been receiving oxygen therapy as needed and the RN stated, She's sick. At 12:23 PM on 5/29/24, in a joint observation with RN A, she checked resident #54's oxygen flow rate, confirmed it was set at 3.5 liters per minute, and the nasal cannula tubing was undated. The RN reset the flow rate to 2 liters per minute and said she received report from the outgoing 11:00 AM to 7:00 PM nurse. She checked the MAR and confirmed the medical record did not include physician's orders for oxygen and stated, It's supposed to be 2 liters. On 5/29/24 at 12:33 PM, in a joint observation, the [NAME] Unit Manager checked resident #54 and confirmed the resident was now receiving supplemental oxygen at a flow rate of 2 liters per minute and stated, She has been on O2 (oxygen); there should be an order. The Unit Manager checked the medical record for physician's orders and stated, You're right; it's not there and it should be, and I vaguely remember it was 2 liters. I will contact the Nurse Practitioner to clarify the orders. In an interview on 5/29/24 at 1:12 PM, with the Director of Nursing (DON), she explained that nurses entered doctor's orders into the Electronic Health Record (EHR) which included care and maintenance of oxygen, oxygen supplies, and tubing changes which showed up on the MAR. She said Unit Managers completed a check system as part of morning meetings to ensure nurses knew how to monitor oxygen administration and maintain supplies. She said it was important because tubing changes and supplies were required weekly, and if they were undated there was no way to track it, so they may not be changed out. She said too much oxygen could lead to toxicity and other complications. She checked resident #64's medical record and said nurses had entered oxygen orders the same morning. The DON conveyed that nurses must have missed the orders. Review of the facility's standards and guidelines dated October 2010 and titled Oxygen Administration read, . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing: . After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for PRN [as needed] administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure .

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented effective Performance Improvement Plans to correct and monitor previously identified deficiencies and ensure sustained improvements. Findings: The facility had deficiencies at F609 for failure to report abuse/neglect allegations, F623 for failure to provide written notice of transfer to residents who were transferred out of the facility, and at F812 for failure to ensure kitchen sanitation/cleanliness in the last recertification survey conducted on 11/09/22. Review of the Plan of Correction, which served as the facility's allegation of compliance, approved by the QAPI committee on 12/29/22 revealed the facility would monitor corrective actions to prevent re-occurrence of the concerns identified in their recertification survey. During the current survey, the following deficiencies were again identified, F609, F623, and F812 for similar concerns. As a result of these repeat citations, it was identified there was insufficient auditing and oversight of the concerns identified in the previous citations. On 5/30/24 at 2:42 PM, the Nursing Home Administrator (NHA) explained the QAPI committee worked on identified deficiencies anywhere between 90 days to 6 months. He mentioned they performed audits and discussed findings during QAPI meetings. He stated he was under the impression the repeat deficiencies were corrected. Review of the facility's QAPI Program policy revised on 10/2022 revealed the facility would develop, implement, and maintain an ongoing, facility wide QAPI program, That builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The policy contained QAPI Action Steps to follow which included, Areas that may be appropriate to monitor and evaluate include: . State Surveys and deficiencies.

Based on observation, interview, and record review, the facility's staff and interdisciplinary team (IDT) neglected to identify, communicate, and provide necessary care and services to ensure the safety of a resident who wandered; neglected to respond to a missing resident in a timely and efficient manner; and failed to recognize and address an unsecured area as an environmental hazard to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the West Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the West Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to implement policies and procedures to prevent neglect, maintain a secure environment, and respond appropriately to a report regarding a missing resident placed all residents who wandered and/or had access to the courtyard at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F641, F656, F689, and F835. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's admission Wandering/Elopement Risk assessment dated [DATE], revealed she was cognitively impaired, independently ambulatory, and verbalized her intent to leave the facility. The assessment form included a recommendation to initiate a care plan to address the identified risk factors for elopement; however, the document showed no care plan was developed at that time. Review of the facility's policy and procedure Wandering and Elopements (undated) revealed the facility would identify residents at risk for unsafe wandering. The document read, If identified to be at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of resident #25's medical record from [DATE] to [DATE] revealed nursing notes that described the resident as confused, wandering, and requiring frequent redirection. Three days after admission, a Daily Skilled Note dated [DATE] indicated nursing staff deemed it necessary to place an electronic monitoring device on the resident to address her behaviors. The medical record revealed resident #25's behaviors escalated over the next two days. A Daily Skilled Note dated [DATE] revealed the resident was anxious and confused as she wandered throughout the facility. She repeatedly verbalized her intent to leave and successfully managed to open an emergency exit door. On [DATE], resident #25's assigned nurse noted she continuously wandered around the unit and informed staff she wanted to leave the facility and go home. A Clinical Note dated [DATE], two weeks after the electronic monitoring device was placed, revealed resident #25 eloped from the facility. The Minimum Data Set (MDS) Admission assessment with assessment reference date of [DATE] revealed resident #25 was admitted to the facility from the community. Her Brief Interview for Mental Status Score was 4 out of 10 which indicated severe cognitive impairment. In conflict with nursing progress notes, the MDS assessment showed the resident had no behavioral symptoms and did not wander or use a wander alarm. The document indicated it was very important to the resident to have her family involved in discussions regarding her care. Review of the medical record revealed resident #25 had a care plan for elopement risk related to exit seeking behavior initiated on [DATE] at the time her electronic monitoring device was placed. The care plan goal was the resident would not have any successful elopement attempts. The interventions developed on [DATE] were to update elopement manuals with the resident's information, encourage activities of choice, and check the placement and function of her left ankle electronic monitoring device. The care plan did not incorporate any person-centered approaches that reflected IDT collaboration and input from the resident's family. In addition, the document did not provide instructions for direct care staff regarding effective approaches to address the resident's wandering and exit-seeking behaviors. On [DATE] at 1:21 PM, the MDS Coordinator stated she attended daily clinical meetings with other members of the IDT. She explained the team discussed new admissions, new physician orders, incidents, and any other issues that affected residents. The MDS Coordinator stated the IDT would develop appropriate care plans and interventions to meet residents' needs based on the discussions. She stated in addition to the IDT process, a care plan meeting was held with each resident and/or a representative two to three weeks after admission, to identify any additional areas of concern or necessary services. The MDS Coordinator stated resident #25's care plan meeting was not held prior to her elopement. She validated the resident's elopement care plan with basic interventions were created on [DATE], the day she had the electronic monitoring device placed. The MDS Coordinator acknowledged the care plan did not show evidence of review or revisions by the IDT prior to her elopement to ensure the resident received care and services for her escalating behaviors. In interviews on [DATE] at 1:30 PM and [DATE] at 9:49 AM, the Director of Nursing (DON) confirmed resident #25 had an electronic monitoring device applied on her fourth day in the facility as she was ambulatory and wandered. The DON confirmed the facility's IDT process included daily meetings to review residents' status, changes in condition, and care needs. She said, I was not aware of [the resident's] nighttime agitation and wandering. The DON acknowledged the IDT process therefore did not effectively identify or address the care and services required for resident #25. She confirmed resident #25 eloped from the facility on [DATE] by accessing the courtyard. She stated the resident wore an electronic monitoring device but there were no sensors at either the door to the courtyard or the gate. The DON explained the gate had a latch, but was never locked, and resident #25 quickly opened it and left the premises. The DON stated the incident investigation indicated another resident's private caregiver notified an Activity Department staff member that the resident stated she was leaving the facility. The DON explained the staff member did not inform anyone or initiate a search for the resident, but resumed her regular activities. The DON stated when the resident's assigned nurse noted she was missing at approximately 9:15 AM, all staff stopped what they were doing and searched the premises. She stated the facility followed policies and procedures by notifying the resident's family and law enforcement. The DON recalled resident #25's son and daughter arrived soon after being called, and she thought the Administrator notified law enforcement within 20 to 30 minutes after the resident was discovered to be missing. The facility was not able to show law enforcement had been notified by the Administrator. When asked what the facility's policy indicated regarding timeframe for notification of law enforcement, she explained there was no specific time period, and staff were to complete a search of the premises including the nine-story independent living facility next door first. The DON said, I believe the policy states a thorough search prior to call. She acknowledged while the cognitively impaired resident was outside the facility, she faced many potential safety hazards. The DON listed dangers that included a busy road, unleveled ground, traffic from the nearby neighborhood and schools, a construction site, woods, and a swimming pool. She stated a deputy sheriff responded to a call from dispatch regarding a wellness check request made by a concerned citizen who had picked up resident #25 at an unknown location and dropped her off at a high school. The DON stated the resident's son received a call from the deputy at approximately 10:00 AM, left to retrieve his mother, and the deputy followed them back to the facility. She recalled the deputy instructed her if the facility was ever again unable to find a resident, staff should call for assistance immediately. Review of the facility's Procedures for an Elopement/Missing Resident (undated) revealed instructions to check the sign out log for evidence of authorized leave of absence, and then make a thorough search of the building and premises. The document indicated if the resident was not located, staff would notify the Administrator, DON, Risk Manager, the resident's representative, the attending physician, and law enforcement before continuing .an extensive search of the surrounding area. The attached document, Elopement Drill Instructions (undated) revealed details regarding assigned locations to be searched by designated staff. The search included all areas of the facility, including the Assisted Living Facility. Two maintenance staff were directed to .walk the entire perimeter of the entire campus, going in opposite directions. The document did not reference the nearby eleven-story independent living facility, nor instruct staff to delay law enforcement notification until that building was searched. Review of the staff assignment sheet for Monday [DATE], noted resident #25's assigned Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM shift was CNA L. However, on [DATE] at 2:57 PM, CNA L stated she did not work on [DATE] and heard about resident #25's elopement on the following day when she returned to work. CNA L recalled someone told her CNA G was assigned to care for resident #25. On [DATE] at 3:04 PM, CNA G explained she usually worked on the 3:00 PM to 11:00 PM shift and on occasion, she would pick up a 7:00 AM to 3:00 PM shift, but usually arrived at 8:30 AM. CNA G recalled on [DATE] she was seated in the West Wing dining room assisting a resident with breakfast and saw resident #25 eating at another table. CNA G said. I am not sure I was on [resident #25's] hallway that morning. She was finishing up breakfast and next thing they said they did not see her, and we started to look for her. CNA G could not recall how many CNAs were assigned to the unit on that shift, and when asked who monitored her assigned residents from the start of the shift at 7:00 AM until 8:30 AM when she arrived, she said, Everybody gives an eye on the team until I get here. CNA G did not recall any interaction with resident #25 prior to seeing her in the dining room and could not state with certainty that she was actually assigned to the resident on the morning she eloped from the facility. On [DATE] at approximately 6:00 PM, the Staffing Coordinator provided a revised staff assignment sheet dated [DATE] which had been corrected to show CNA L did not work, and CNA G was assigned to care for resident #25. In response to multiple requests, the facility was unable to provide timeclock punch times for all CNAs who worked on the West Wing on [DATE] on the day shift. The facility provided a Payroll Punch Variance Form for CNA G. The form indicated CNA G worked from 7:00 AM to 7:15 PM, and in the comment section she wrote, No time clock. When asked to clarify the discrepancy between her earlier statement and the variance form, CNA G stated she forgot she started the day shift at 7:00 AM on [DATE]. On [DATE] at 8:47 AM, the private caregiver explained she worked in the facility six days weekly and was familiar with many of the residents, including resident #25. She stated the resident was usually confused and described her as kind of antsy on the morning she eloped. The private caregiver said, I saw her walking past the door.That day she looked like she was on a mission. She recalled resident #25 told her she had to get a ride or walk home and then headed towards the front lobby. The private caregiver stated she was worried the resident would try to go out the front door so after a while, she walked to the lobby to check on the resident's location. She stated resident #25 was not in the lobby, and the receptionist was on the telephone. She recalled Activity Aide K was working at a board in the lobby and she told her resident #25 said she was going home. The private caregiver stated Activity Aide K denied seeing the resident and continued working at the board. The private caregiver stated she then walked towards the therapy gym and on the way she asked two or three other staff members if they had seen the resident. She recalled she eventually heard an overhead page Code Purple which she was told meant there was a missing resident. On [DATE] at 2:39 PM, Activity Aide K recalled the morning resident #25 eloped. She confirmed she was in the lobby posting the activity calendar and decorating the notice board. She confirmed the private caregiver approached her and told her resident #25 was confused and said she wanted to go home. Activity Aide K said, I am doing my stuff and I did not see her. I don't know where she went through. She had confusion at times and often says she wants to home. I didn't really pay attention and I continued on doing what I was doing. Activity Aide K stated she did not report the information to the nurse as she had to finish decorating the activity board. On [DATE] at 12:40 PM, during a tour of the facility with the Maintenance Supervisor, he explained there were sensors for the electronic monitoring system at the front lobby door and the double doors in the hallway that led to the therapy gym. He explained alarms sounded when the sensors were triggered but the doors did not lock, so a resident with an electronic monitoring device could walk through the doors unimpeded. Demonstration of the electronic monitoring system revealed the alarms sounded only at the keypad at a low volume. He stated there were doors on two separate hallways that led into the courtyard, but neither had a sensor to alert staff if residents with monitoring devices exited the building. The Maintenance Supervisor explained prior to resident #25's elopement, residents, visitors, and staff had unlimited access to the courtyard. He verified the gate at the far end of the courtyard had a vertical pull latch that was never locked. On [DATE] at 2:02 PM, the Social Services Director (SSD) confirmed resident #25 was confused, alert to self only, and regularly wandered around the facility searching for her deceased mother and father. The SSD explained the resident was admitted to the facility for long-term care as she was no longer safe living in the community and required 24-hour care. The SSD verified she participated in discussions about residents during daily IDT meetings and was also responsible for completion of MDS assessment sections related to cognitive status and behavioral symptoms such as wandering. She acknowledged the MDS assessment did not accurately show resident #25's status and exit-seeking behaviors, and her elopement care plan did not reflect details of the care and services to be provided by the facility. On [DATE] at 10:41 AM, in a telephone interview with resident #25's daughter, she confirmed on the day of admission, the DON asked if her mother wandered. The daughter said, I told her she had gotten out twice when she had a urinary tract infection. She would unlock the gate by sticking her hand through it. The daughter explained her mother left her house and walked to a neighbor's house and had to be brought back home. She stated the family even had to block the front door to prevent her mother from getting out. Resident #25's daughter reiterated the facility was aware of her mother's wandering, agitation, and desire to leave. She explained during the weeks that preceded the elopement, the facility called several times to inform her that her mother was agitated and verbalized wanting to leave and go somewhere. The facility's policy and procedure Abuse Neglect Exploitation Mistreatment and Misappropriation of Property dated [DATE] revealed it was the policy of the facility to protect its residents from neglect. The document defined neglect as .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Facility Assessment Tool dated [DATE], revealed the facility was able to care for residents with impaired cognition, depression, anxiety disorder, behaviors that required interventions, Alzheimer's Disease, and dementia. The document indicated the facility would provide person-centered care by preventing abuse and neglect and identify hazards and risks for residents. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #25 eloped from the facility at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, noted to have no injuries or abnormalities, and was placed on one-to-one supervision. *On [DATE], the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for [DATE]. *On [DATE] at approximately 10:30 AM, a staff member was placed at both emergency exits without electronic monitoring system alarms for 24 hours. *As of [DATE] at approximately 6:00 PM, all the doors in the facility that did not have the electronic monitoring system alarm were armed with an emergency screamer alarm with a key override. The alarms were checked every two hours to ensure they were in place and functioned. All electronic monitoring devices are checked every shift for placement and functioning. All residents, regardless of cognitive status will have a staff member accompany them when spending time in the courtyard. Every two hours the courtyard gate is checked to ensure that it remains locked. *On [DATE], the Staff Development Coordinator initiated an in-service to cover Abuse, Neglect, and Reporting Abuse and/or Neglect; and notification to management if a resident begins to seek an exit or express a desire to leave the facility. In-services were also conducted covering the elopement policy, procedure, and prevention. A total of 97% of the staff were in-serviced by [DATE]. *On [DATE], an emergency Quality Assurance and Performance Improvement (QAPI) committee meeting was held to address the identified non-compliance. *As of [DATE], the DON sends the Corporate Nursing team the projected staffing hours every morning to ensure adequate staff was scheduled to care for the residents. *On [DATE], the Corporate Nurse Consultant assessed the knowledge of the management team regarding abuse, neglect, elopement, risk management, and reporting specific incidents to specific agencies. The Corporate Nurse Consultant educated the management team on Elopement Prevention, Risk Management, Adverse Incidents, and Reporting. *On [DATE], the Corporate Nurse Consultant gave instruction on how to conduct, and reviewed the Standards of Care Meeting with the interdisciplinary team. In this weekly meeting, run by the DON, all residents who are potentially at risk for any type of decline, have recently had a change in condition, or been involved in any type of incident are discussed to ensure their needs are anticipated and being met. *As of [DATE], the Nurse Management Team assesses the residents in the facility and completes an acuity report. This report breaks down specific needs and explains how many residents in the facility require that specific type of care. The Corporate team, and the management team utilize the weekly acuity report in conjunction with the daily staffing hours to ensure there is adequate staff in relation to the acuity of the residents. *On [DATE], the Corporate Nurse Consultant observed the care of residents provided by all direct care staff throughout the facility for all shifts. The Corporate Nurse Consultant spoke with multiple direct care staff to ensure they were able to adequately care for the current residents. *On [DATE], the Corporate Nurse Consultant visited multiple patient rooms, spoke with them about the care they received, and reviewed multiple charts to assess whether resident's needs were being met. *As of [DATE], safety checks were conducted on each resident at risk for elopement. *On [DATE], the QAPI committee held an emergency meeting on [DATE] to address the identified noncompliance with F600. *On [DATE], all cognitively intact residents were interviewed by the management team and asked the following questions: a) Have you ever been treated in a way that you feel was abusive by the staff? b) Have you felt neglected by any member of the staff? c) Has anyone spoken to you in way that was verbally abusive? d) Do you feel safe in this facility? e) Do you feel there is adequate staff here at all times to meet your needs? *On [DATE], a questionnaire was initiated for staff in the facility, asking the following: a) Have you been educated on Abuse, and Neglect? b) If you have been, approximately when was the last time? c) Do you feel that you are knowledgeable about what is expected of you here at work? d) Do you feel that you have everything you need to provide the care that is required of you? e) Do you feel that all the residents are appropriate for this environment and that their needs can be met by the staff? f) Do you feel that there is adequate staff present during all shifts to meet the resident's need? *On [DATE], responses to the above questions were reviewed with no findings of any residents who felt neglected by the staff. All staff members reported they were recently educated on neglect and abuse and could meet the needs of the residents in their care. *As of [DATE], all residents regardless of their cognitive status will have a staff member accompany them into the courtyard. Review of Courtyard Gate Lock Check forms from [DATE] to [DATE] revealed staff completed gate checks with varying frequencies, between every two hours to every six hours. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On [DATE], interviews were conducted with five Licensed Practical Nurses, three CNAs, one Personal Care Attendant, two Rehab staff, one Activities staff, one maintenance staff and one housekeeper. All verbalized understanding of the education provided. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #11, #12, and #19 related to neglect.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring of the status and activities of a vulnerable, cognitively impaired resident to prevent unsupervised exit from the facility through an unmonitored courtyard for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). This failure contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the West Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the West Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to provide the appropriate level of supervision and frequency of monitoring for a resident with known exit-seeking behavior contributed to resident #25's elopement and placed all residents who wandered at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600, F607, F641, F656, and F835. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia, [CONDITION(S)], and anxiety. Review of a Wandering/Elopement Risk assessment dated [DATE], revealed on admission, nursing staff identified resident #25 was at risk for elopement as she was cognitively impaired, independently ambulatory, and verbalized her intent to leave the facility. Although the assessment form included a recommendation to initiate an elopement care plan to address the identified risk factors for elopement, the admission nurse did not follow the instruction, and resident #25's plan of care did not include approaches to ensure her safety. Review of the facility's policy and procedure Wandering and Elopements (undated) revealed the facility would identify residents at risk for unsafe wandering. The document read, If identified to be at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of resident #25's medical record revealed a physician's order dated [DATE] that read, May go on leave with responsible party. An order dated [DATE] indicated the resident could be treated by a psychologist, and an order dated [DATE] read, Electronic monitoring device to alert staff of residents risk for exit seeking behavior, check placement on left ankle [every shift]. Resident #25 had a care plan for elopement risk related to exit seeking behavior initiated on [DATE] at the time her electronic monitoring device was placed. The care plan goal was the resident would not have any successful elopement attempts. The interventions developed on [DATE] were to update elopement manuals with the resident's information, encourage activities of choice, and check placement and function of her left ankle electronic monitoring device. The care plan did not specify the level of supervision or frequency of monitoring required, nor provide instructions on approaches to ensure the resident's safety during periods of heightened behaviors. Review of a Daily Skilled Note dated [DATE] revealed the resident was anxious and confused as she wandered throughout the facility, repeatedly verbalized her intent to leave, and successfully managed to open an emergency exit door. Review of the medical record revealed neither the progress notes nor the elopement care plan reflected additional, effective nursing interventions related to verbalization of intent to elope and the actual elopement attempt. The medical record did not show involvement of nursing management or the determination that resident #25 required increased supervision or more frequent monitoring when wandering or exit-seeking. The following day, on [DATE], resident #25's assigned nurse noted she continuously wandered around the unit and informed staff she wanted to leave the facility to go home. Review of a clinical nursing note dated [DATE] revealed resident #25's assigned nurse, Registered Nurse (RN) F, observed the resident in the West Wing dining room at approximately 8:30 AM that morning. The note indicated RN F discovered the resident was missing approximately 30 to 45 minutes later, and a search of the facility was initiated. The document revealed resident #25 was found away from the facility, and she was retrieved and returned to her room at about 10:30 AM. The elopement care plan was revised on [DATE], after the resident's elopement, to show she required one-to-one supervision. Review of resident #25's Physical Therapy Plan of Treatment for Rehabilitation dated [DATE] revealed the resident exhibited decreased safety awareness, decreased bilateral lower extremity strength, and impaired overall mobility. The evaluation indicated resident #25 was at increased risk of falls and injury due to decreased awareness of her physical limitations. A Speech Therapy Plan of Treatment for Rehabilitation dated [DATE] revealed the reason for the referral was long-term care placement .due to increasing confusion from Alzheimer's disease resulting in a functional decline in cognitive skills, safety awareness. On [DATE] at 12:13 PM, Speech Therapist O validated resident #25 did not have the reasoning ability to function in the community. She explained the resident would not be safe unsupervised, whether in the facility, at home or outside the facility. Speech Therapist O said, If she was discharged home, our recommendation would be 24-hour care. Review of a Psychiatric Evaluation Note dated [DATE] revealed facility staff informed the Psychiatric Nurse Practitioner that resident #25 was confused, wandered the hallways, and was an elopement risk. A Brief Interview for Mental Status exam resulted in a score of five, which indicated severe cognitive impairment. A Psychiatric Subsequent Note dated [DATE] revealed clinical staff reported the resident continued with confusion and anxiety and paced the halls. During the visit, the resident reported the year was 1958, and the practitioner noted the resident had disorganized thought process and loose associations. Review of a Sheriff's Office Case Report revealed a Deputy Sheriff responded to a report of a suspicious person at a local high school on [DATE] at 9:15 AM. The document indicated the involved party was resident #25 who was described as confused and disoriented. The Deputy Sheriff wrote, She advised she needed to get to school, or she would be late for class. She was convinced that she was a student in school. The report revealed resident #25 was initially seen by a citizen in the area of a nearby middle school and she solicited a ride to the high school. The report indicated the citizen was concerned and called law enforcement to report the encounter. The Deputy Sheriff noted he was able to contact resident #25's son by telephone, and the son explained his mother had severe dementia and was a resident of the facility. The document revealed the resident's son arrived on scene to transport his mother back to the facility. On [DATE] at 9:35 AM, in a telephone interview, the Deputy Sheriff confirmed he received the initial call for service on [DATE] at 9:15 AM, and responded to the local high school. He stated he learned resident #25 left the facility and walked along the main road in front of the facility and was picked up by a citizen. The Deputy Sheriff stated when he questioned resident #25, she thought she was in Ohio, but was able to provide her name and he was eventually able to find telephone contact information for her son. The deputy stated the son came to the high school to collect his mother and he followed them back to the facility. He stated facility administration informed him new owners had taken over that morning so there was a lot of activity. He said, I confirmed that the Director of Nursing (DON) was there from the previous administration. In the end, I expressed to them there was too much reliance on technology, and it cannot supersede human supervision. He explained although resident #25 wore an electronic monitoring device, it was not a foolproof intervention. The Deputy Sheriff stated there was a pool at the Independent Living facility next door which could be a danger to a confused, wandering resident. He explained he informed the DON that memory care services required a secure facility and adequate supervision. When informed resident #25 had verbalized her intent to leave the facility for weeks and even on the morning she eloped, the Deputy Sheriff said, I told them there are major issues. A predictable event is preventable. On [DATE] at 1:09 PM, in a telephone interview, resident #25's son stated he was aware his mother eloped from the facility on [DATE]. He said, All I know is she got out and wandered up the road. She got three miles away. They picked her up by the high school. He explained his mother lived in her own home prior to admission to the facility in [DATE]. The son stated the family decided to place her at the facility as there was no one at home to supervise her during the day and she also suffered extreme anxiety when left alone. The son confirmed his mother had wandered to a neighbor's home in the past. On [DATE] at 1:30 PM, the DON confirmed resident #25 eloped from the facility on [DATE] and was found by law enforcement at a local high school. The DON explained although resident #25 had an electronic monitoring device, there was no sensor with an alarm at the exit door to the courtyard and the gate was not locked. She stated the resident was last seen in the West Wing dining room by multiple Certified Nursing Assistants (CNAs) and another resident's private caregiver at about 8:30 AM. The DON stated resident #25 left the dining room, informed the private caregiver she was leaving the facility, and the private caregiver shared that information with Activity Aide K. The DON acknowledged Activity Aide K did not act on the report and returned to her duties. Review of staff statements with the DON revealed none of the CNAs on the West Wing were aware resident #25 left the unit until the assigned nurse noticed she was missing approximately 30 to 45 minutes later. The DON stated the facility notified the resident's family that their mother was missing and when the son arrived he was upset, asked how it happened, and said, This is why we brought her here. On [DATE] at 3:04 PM, CNA G stated on the day resident #25 eloped she last saw her in the West Wing dining room at approximately 8:30 AM. CNA G did not recall if she was assigned to care for the resident that day and she was not aware resident #25 was missing until an overhead page alerted all staff to search for her. CNA G recalled when resident #25 was returned to the facility, her jeans were wet, almost to her knees. She said, If she went through the ditch, that's probably why. We had rain a few days. On [DATE] at 2:02 PM and 3:30 PM, the Social Services Director (SSD) confirmed resident #25 was confused, had memory deficit, and often wandered throughout the facility searching for her deceased mother and father. The SSD explained the resident was admitted for long-term care and would not be safe in the community without 24-hour care. She said, Once we accept new residents we have to meet their needs. On [DATE] at 1:11 PM, the Maintenance Supervisor described resident #25's elopement route. He stated security camera footage showed the resident pushed on the West Wing hallway exit doors to the courtyard, followed the path to the far end of the courtyard, unlatched the gate and walked away, out of camera range. The Maintenance Supervisor demonstrated how resident #25 would have easily been able to reach through the bars on the gate and release the latch located at waist-level. He stated the elopement occurred a few days after a hurricane brought between nine and fourteen inches of rainfall to the area. The Maintenance Supervisor said, There was a lot of standing water for a while. He stated water in the [NAME] in front of the facility was above ankle-deep, and there was a deeper drainage ditch and culvert on the opposite side of the street. Review of the area map revealed resident #25 walked away from the facility towards the south, and followed the heavily trafficked, major thoroughfare for approximately 0.5 miles until she arrived at the middle school. There was no sidewalk on that side of the road, and she would have crossed a driveway, passed a heavily wooded area, and walked through standing water of unknown depths along the uneven terrain. The resident was picked up by a citizen who drove her approximately 3.5 miles to the high school which was located near a major intersection and a six-lane highway (retrieved on [DATE] from www.google.com/maps). On [DATE] at 5:20 PM, RN F stated she was resident #25's assigned nurse on the day she eloped. She recalled she saw the resident eating breakfast and approximately 30 to 45 minutes later she realized the resident was nowhere to be found. RN F stated the resident would often ask about the location of the front door or where she could get a taxi or the bus. She explained staff would try to redirect her, but that strategy was not usually very effective. RN F explained the electronic monitoring device was in place to prevent elopement and was checked by nurses every shift. She stated she had not yet checked the resident's device when she eloped. RN F said, I knew she had to be watched, absolutely. On [DATE] at 9:49 AM, the DON stated resident #25's family did not inform the facility she had exit-seeking behavior prior to admission. However, she acknowledged within four days of admission, the facility identified the resident was at risk for elopement and placed an electronic monitoring device, an intervention to promote her safety. The DON was informed the medical record included frequent nursing documentation after placement of the device related to the resident's behaviors such as wandering, exit-seeking, and verbalizing her intent to leave the facility. She stated she was not aware of the extent and impact of resident #25's behaviors, especially the nighttime agitation and wandering, and acknowledged the care plan did not show additional interventions including increased supervision were discussed by nursing management. On [DATE] at 10:41 AM, in a telephone interview, resident #25's daughter stated on the day of admission, she informed the DON her mother had wandered away from home on two occasions in the past. She stated her mother was definitely not safe during the period she was out of the facility unsupervised. She said, It was days after the hurricane and there was water ankle-deep to waist-deep outside the facility. The daughter recalled when her mother was found she wore canvas slip-on shoes with low-cut socks, and her jeans were wet to the knees. She stated she was concerned as her mother could not swim. On return to the facility, the daughter noted and informed staff that her mother had a loose ankle bracelet. The resident's daughter recalled her mother informed her she had been trying to remove the device the previous day. The Facility Assessment Tool dated [DATE] revealed the facility was able to care for residents with impaired cognition, Alzheimer's Disease, dementia, depression, anxiety, and behaviors that required interventions. The document indicated staff received mandatory dementia management training and were competent in caring for residents Alzheimer's Disease and other dementias. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #25 eloped from the facility through the courtyard gate at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, and there were no injuries or abnormalities. Resident #25 was immediately placed on one-to-one supervision. *On [DATE], the facility completed a facility-wide re-assessment of each resident's risk for elopement. All residents deemed to be at risk were provided with an electronic monitoring device to alert staff of resident's risk of exit seeking. The residents deemed to be at risk for elopement had care plans updated to reflect this assessment. No additional residents were determined to have exit seeking behaviors or made statements in reference to leaving facility. All residents deemed to be at risk for elopement, receive safety checks every 15 minutes to ensure they are safely in the facility. * As of [DATE], upon admission, all residents will be assessed to determine their elopement risk. Residents identified to be at risk for elopement will be provided with an electronic monitoring device, and an elopement risk care plan, and will receive safety checks every 15 minutes to ensure that they are still safely in the facility. *On [DATE], the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for [DATE]. *On [DATE] at approximately 10:30 AM, a staff member was placed at both emergency exits without electronic monitoring system alarms for 24 hours. *As of [DATE] at approximately 6:00 PM, all the doors in the facility that did not have the electronic monitoring system alarm were armed with an emergency screamer alarm with a key override. The alarms were checked every two hours to ensure they were in place and functioned. All electronic monitoring devices are checked every shift for placement and functioning. All residents, regardless of cognitive status will have a staff member accompany them when spending time in the courtyard. Every two hours the courtyard gate is checked to ensure that it remains locked. *On [DATE], the Staff Development Coordinator initiated an in-service to cover elopement prevention, electronic monitoring alarm system, screamer alarm system, courtyard supervision, monitoring of residents who are at risk for elopement; and notifying management of residents who are exit-seeking, and those that express a desire to leave the facility. A total of 97% of the staff were in-serviced by [DATE]. *On [DATE], an emergency Quality Assurance and Performance Improvement (QAPI) committee meeting was held to address the identified non-compliance. * As of [DATE], safety checks are conducted on each resident at risk for elopement. *On [DATE], the QAPI committee held an emergency meeting on [DATE] to address the identified noncompliance with F689. Review of Courtyard Gate Lock Check forms from [DATE] to [DATE] revealed staff completed gate checks with varying frequencies, between every two hours to six hours. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On [DATE], interviews were conducted with five LPNs, three CNAs, one Personal Care Attendant, two Rehab staff, one Activities staff, one maintenance staff and one housekeeper. All verbalized understanding of the education provided. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #11, #12, and #19 related to supervision.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to mitigate vulnerabilities in the electronic wander monitoring system; failed to maintain a secure environment to prohibit unauthorized entry and egress through the courtyard; and failed to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to ensure the safety of 5 of 5 physically and/or cognitively impaired residents identified to be at risk for elopement, of a total sample of 32 residents, (#11, #12, #14, #19 & #25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 10/03/22 at approximately 8:30 AM, resident #25 left the West Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the West Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident and instead, returned to her duties. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to maintain a safe and secure environment and implement policies and procedures to prevent neglect and elopement placed all residents who wandered and/or had access to the courtyard at risk. This failure resulted in Immediate Jeopardy starting on 10/03/22. The Immediate Jeopardy was removed on 11/09/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F641, F656, and F689. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/07/22 at 1:30 PM, the facility's Administrator and Director of Nursing (DON) confirmed resident #25 eloped from the facility on 10/03/22. The DON stated the incident investigation identified the root cause as a weak link in facility security related to the absence of electronic monitoring system sensors at the courtyard doors and an unlocked gate. The Administrator and DON could not provide documentation of an investigation with a focus on identification and prohibition of Neglect according to regulatory requirements and facility policy and procedure. The Administrator acknowledged the facility took actions to secure the courtyard after the elopement occurred. On 11/09/22 at 12:21 PM, the Administrator explained he did not have access to the reporting system required for submission of investigations related to allegations of abuse and neglect although he was the facility's designated Risk Manager. Review of the facility's policy and procedure Abuse Prevention Program revised in July 2020, indicated the facility would identify and assess all possible incidents of abuse, neglect, or mistreatment. The document revealed the Administrator was responsible for overall implementation of the policies and procedures that prohibited neglect. Review of the facility's policy and procedure for Wandering and Elopements revised in December 2020 revealed the facility would identify residents who were at risk for wandering and elopement and develop appropriate strategies and interventions to maintain safety. Review of the facility's policy and procedure Care Plans, Comprehensive Person-Centered revised in November 2020 revealed the Interdisciplinary Team (IDT) was responsible for review and revision of residents' care plans when the desired outcome is not met. On 11/09/22 at 9:49 AM, the DON stated she was not made aware of the concerns related to resident #25's continuous, escalating wandering and exit-seeking behaviors in IDT meetings. The DON confirmed the IDT conducted daily meetings and group huddle meetings prior to the resident's elopement. She validated the IDT discussion process was not as effective as it should have been. On 11/09/22 at 11:33 AM, the Medical Records staff stated she attended daily IDT meetings during which orders and incidents were reviewed. She confirmed information related to issues such as placement of resident #25's electronic monitoring device, her increased behaviors, and elopement attempts should be discussed. When asked about the effectiveness of IDT meeting discussions, the Medical Records staff said, Sometimes there are lots of side conversations. On 11/07/22 at 2:08 PM, the Administrator retraced the resident's elopement route through the courtyard. He acknowledged prior to the event; the facility's administration was aware there were no sensors for the electronic monitoring system at the courtyard doors to alert staff that residents with these devices had exited the building. Observation of the exterior exit gate revealed standing A-frame sign boards that measured approximately three feet from the ground on both sides of the gate. The signs had instructions regarding not using the gate for entry or egress. The Administrator moved the signs and unlatched the gate. He stated the gate was never locked as it was a fire exit, but the new security system would enable the gate to be locked and automatically open if the fire alarm triggered. The Administrator acknowledged the gate remained an unsecured point of entry and exit. On 11/08/22 at 12:40 PM, the Maintenance Supervisor demonstrated and acknowledged weaknesses in the facility's electronic monitoring system included protected doors did not lock to prevent exit when the alarm was triggered; alarms sounded from the keypads and were not audible in other areas of the facility such as nurses' stations; and the system was not installed at the doors that led to the courtyard. The Maintenance Supervisor explained he had been on staff for over seven years, and during that time the courtyard doors never had alarms, and the gate was always unlocked. He confirmed prior to resident #25's elopement, residents, visitors, and staff had unlimited access to the courtyard. Review of the medical records revealed concerns related to placement of electronic monitoring devices on wheelchairs rather than on the residents' extremities. Resident #11 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/08/22 at approximately 5:30 PM, the Administrator, DON, and Corporate Nurse were informed that review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They were unaware of any manufacturer's recommendations regarding placement of the monitoring devices. Review of the electronic monitoring system manufacturer's instructions revealed the device was to be worn on either the wrist or ankle. The User Guide read, The range, accuracy, function, and performance. of the device may be affected by factors including metal objects in the vicinity and placement of the device. On 11/09/22 at 4:14 PM, the Staff Development Coordinator (SDC) stated she had been on staff for almost six years and was never made aware of the manufacturer's recommendations regarding placement of electronic monitoring devices. The SDC stated after the administrative team was questioned about the different locations of residents' devices, they reviewed the manufacturer's manual and discovered the device must be placed on the resident and not on wheelchairs. On 11/09/22 at 4:23 PM, the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee met once monthly to review of quality measures, grievances and customer service issues, Resident Council meeting minutes, and other key indicators. The Administrator stated in addition to the monthly QAPI meetings, the IDT reviewed issues that impacted resident care and services including changes in resident status in daily morning meetings and huddle meetings. He explained the QAPI committee also received information from employees by way of concerns reported to a supervisor or in town hall meetings, staff meetings and departmental meetings. The Administrator stated prior to resident #25's elopement, the facility's administration was aware the courtyard gate was unlocked, and that the electronic monitoring system did not trigger doors to lock in response to wandering and elopement attempts. He explained, No [resident] had gone in and out of the back gate until that resident left. The Administrator confirmed the IDT, administrative team, and QAPI committee had not identified concerns related to person-centered care plans. The Facility Assessment Tool dated 11/19/21, revealed the facility would provide person-centered care by identifying hazards and risks for residents. The assessment listed physical environment and building needs but did not include the electronic monitoring system or the courtyard fencing and gate. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/03/22, resident #25 eloped from the facility through the courtyard gate at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, and there were no injuries or abnormalities. Resident #25 was immediately placed on one-to-one supervision. *On 10/03/22, the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for 11/10/22. *On 10/04/22, the Nurse Consultant of Education educated the management team on Elopement Prevention, Risk Management, and Adverse Incidents. *As of 10/03/22, upon admission, all residents will be assessed to determine their elopement risk. Residents identified to be at risk for elopement will be provided with an electronic monitoring device, and an elopement risk care plan. *On 10/03/22, the DON conducted an Elopement drill to obtain a baseline and assess for weakness in following the protocol. *As of 10/03/22, elopement drills will be conducted monthly on a different shift each month. Each shift will have an elopement drill at least once every quarter. * On 10/04/22, an Emergency QAPI committee meeting was held to address the identified non-compliance. *On 10/18/22, another elopement drill was conducted to assess improvement after education. *On 11/08/22, the user manual for the Wander guard system was reviewed to ensure that all components are being utilized as intended. *On 11/08/22, the QAPI committee held an emergency meeting to address the identified noncompliance with F835. Review of in-service attendance sheets revealed management staff signatures to reflect participation in education on the topics listed above, and staff signatures for participation in elopement drills. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews were conducted for residents #11, #12, and #19 revealed concerns related to placement of their electronic monitoring devices.

Based on observation, interview and record review, the facility failed to ensure kitchen staff were competent to safely and effectively perform their duties to prevent or minimize the potential for food borne illnesses. Findings: On 11/7/22 at 11:11 AM, during the initial kitchen inspection with the Kitchen Supervisor, the walk-in refrigerator was noted with soiled floors, shelves and racks. Dark black/brown mold like stains were observed on the shelves, vertical racks and the floor. The vertical pan rack had build up of white and black substance on each of the tiers. The shelf next to the exit door had a container of blueberry muffin batter mix that had spilled batter on the sides of the container. The Kitchen Supervisor stated the staff should have wiped down the batter mix tub before putting the lid back on. He indicated there was a kitchen cleaning schedule but it had not been followed due to staffing issues. The dry storage room had a large unopened bag of rice crispy cereal dated February 8, 2019. The Kitchen Supervisor stated he was going to make rice crispy treats from this bag of cereal. There was a large bag of dried cranberries that had been opened but not dated or labeled. The Kitchen Supervisor indicated the staff should have labeled the bag with the date it was opened. At the salad/sandwich preparation area, the Kitchen Supervisor picked through the lettuce with gloved hands, and removed the wilted lettuce leaves. Using the same gloves, the Kitchen Supervisor, touched the trash can and removed the lid and discarded the browned lettuce leaves. He did not sanitize his hands or change his gloves, but continued to pick through the lettuce and touched the trash can lid two more times. He then proceeded to make a sandwich without discarding the gloves or washing his hands. He placed two pieces of bread on a plate, and placed deli meat on the bread. At that point, the Kitchen Supervisor was instructed to stop, and he was informed of the potential cross contamination as he had not performed hand sanitization or changed gloves. At the dish washing area, the Dishwashing staff stated the dishwashing machine was high temperature, meaning that it used hot water to sanitize the dishes. The manufacturer's data plate that was affixed to the dishwashing machine noted a wash temperature of 160 degrees Fahrenheit and a final rinse temperature of 180 degrees Fahrenheit. The Dishwashing staff placed racks of dishes into the machine and the temperature gauge revealed the wash temperature was 120 degrees Fahrenheit and the final rinse was also 120 degrees Fahrenheit. The Dishwashing staff stated when he washed the breakfast dishes this morning he did not check either the wash nor the final rinse temperatures. When asked if there was a temperature log for the dishwashing machine, he said no. The Dishwashing staff inspected the hot water booster and said there was an error message. The Kitchen Supervisor was informed the dishwashing machine's wash and rinse temperatures were both 120 degrees Fahrenheit. He proceeded to put away the dishes that had come out of the machine. A flat top griddle was noted in the cooking area underneath the exhaust hood. A bottle of cooking oil that was three-quarters full was on the bottom shelf of the griddle. The bottom shelf was covered in oil and black debris. The Kitchen Supervisor partially pulled out the grease trap from the griddle, which was full of oil and dark clumps. When he removed the grease trap entirely, dark oily clumps fell on the bottom shelf and the floor. The Kitchen Supervisor then brought the grease trap to a trash can that had paper and other combustible materials, and emptied the used cooking oil and dark clumps into the trash can. On 11/7/22 at 11:45 AM, the Dietetic Technician Registered (DTR) was informed of the used cooking oil placed into the regular trash can. The Kitchen Supervisor at this time suggested that he could poke holes in the trash bag and let the used cooking oil drain out. A large metal receptacle, for used cooking oil, was observed outside in the dumpster area. The DTR could not explain why the kitchen supervisor did not dump the used cooking oil into this receptacle instead of a regular trash can. The DTR added she would find out about the dishwashing machine and ensure all the dishes were rewashed and rinsed at the appropriate temperatures. On 11/8/22 at 12:43 PM, the Dishwashing staff was observed washing dishes and the temperature gauge for the final rinse read, 150 degrees Fahrenheit. The DTR was present and the Dishwashing staff explained they had been using surface temperature strips to ensure the final hot water rinse temperature was at 180 degrees Fahrenheit. The Registered Dietician (RD) presented documentation from the Food and Drug Administrative Code that noted surface temperature of 160 degrees Fahrenheit reflected 180 degrees Fahrenheit at the manifold. The RD explained they were using a 165 degree Fahrenheit surface test strip. She said she was made aware of the dishwashing machine temperature concerns and instructed staff to use surface test strips. She noted this would determine if the temperature gauge needed to be replaced. The RD stated she had been at this facility for about 2 weeks, and had been focusing on clinical issues. The DTR was asked about training and education, with regards to sanitation, for the Kitchen Supervisor and the dietary staff. The DTR stated she would try to find the kitchen staff's training records but did not provide them by the end of the survey.

Based on observation, record review, and interview, the facility failed to maintain the overall cleanliness of the kitchen and ensure food was stored and distributed in a sanitary manner. Findings: On 11/7/22 at 11:11 AM, the initial kitchen inspection was conducted with the Kitchen Supervisor. He stated there was a kitchen cleaning schedule but it had not been followed due to lack of staff. The shelves in the walk-in refrigerator to the right of the entrance were noted with black substance on the sides. The shelves, vertical pan racks and flooring in the refrigerator were noted with dark black/brown mold like stains. The preparation table near the walk in refrigerator was noted with a build up of dirt/dust/food debris. The entire wall behind the the table had black/brown stains on the tile and grout. The base plate of the commercial can opener on the preparation table was covered with black and brown spots and the insert had black mold like substance on it that appeared either wet or greasy. The blade and gears of the can opener were observed with dark colored food debris and dirt. There were several 4 inch deep steam table pans stored on the bottom shelf with white and black build-up on the edges. The open can rack in the dry storage room had heavily stained black/brown mold like substance on each tier. The kitchen staff continued to put cans of food on the rack. Spilled lentils were observed on top of an open case of apple juice, and on the tile floor. There was dark debris and clumps of dust on the shelves, floors and baseboards. The bottom shelves had white strands that appeared to be cobwebs. There was a cardboard case of white taco shells that had a product code, and a date of 12/17/21 printed on the outside of the case Review of the manufacture's product information revealed the taco shells had a shelf life of 120 days (https://missionfoodscontent.imgix/nutrition/tds_sheets/ ). The dispensing nozzle on the juice dispenser was noted to have black mold like substance on the underside of the nozzle that had contact with the juice/beverage. The Kitchen Supervisor did not expand on the minimum cleaning the staff had done. On 11/7/22 at approximately 11:45 AM, the Dietetic Technician, Registered (DTR) was informed of the issues identified in the kitchen

Based on observation, and interview, the facility failed to ensure the dumpster and the immediate area was maintained in a safe, functional and sanitary manner. Findings. During the initial kitchen inspection on 11/7/22 at approximately 11:11 AM, the dumpster area was observed. There was a large dumpster that had two lids that slanted from back to front. The lids did not fit properly and there was a sizable gap between the lids that would not prevent vermin or pests from entering the dumpster. There was a round metal rod that ran through the lids that was bent and prevented the lids from closing properly. The facility's Dietetic Technician Registered (DTR) attempted to slide the lids closer together but was not successful. A large rectangular shaped used cooking oil receptacle was noted behind the dumpster. The top of this receptacle was noted with dark oily clumps of debris. The DTR stated the receptacle needed to be cleaned or replaced. A stone paneled open trash can that contained cups and other combustible material was situated near the used cooking oil receptacle. The trash can had a square, depressed top that staff had used to place cigarette butts. The DTR stated staff should not be smoking near the dumpster area especially not near the used cooking oil receptacle.

Based on interview and record review, the facility neglected to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 12 residents reviewed with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with an abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. LPN A requested assistance from Registered Nurse (RN) B since resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B assessed the resident, disregarded the Full Code order, and instructed LPN A not to perform Cardiopulmonary Resuscitation (CPR) as resident #1 was already dead. The facility's failure to ensure staff followed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . While resident #1's pulse and respirations slowed until they ceased, there was reasonable likelihood she experienced anxiety and distress. Findings: Cross Reference to F658, F726 and F678. Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] for short term rehabilitation. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with Corona Virus Disease 2019 (COVID-19) and readmitted to the facility on [DATE]. Review of resident #1's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated [DATE] indicated the physician was informed resident #1 was no longer eating or taking her medication. The note revealed the Advanced Practice Registered Nurse recommended hospice services, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's care plans revealed facilty staff did not create an Advanced Directives care plan on admission or re-admission to reflect her Full Code status. The medical record did not indicate any discussion or care planning regarding Advance Directives related to resident #1's code status after her change in condition triggered a referral to Hospice services. An Admission Minimum Data Set (MDS) assessment with assessment reference date of [DATE] documented resident #1 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. She required limited to extensive assistance with activities of daily living. On [DATE] at 1:59 PM, during a telephone interview, LPN A stated she had worked at the facility as an agency nurse for about 6 months. She said on [DATE] at 2:55 PM, Certified Nursing Assistant (CNA) C informed her that resident #1 did not look good. She said she evaluated the resident and instructed CNA C to stay at resident #1's bedside while she checked the medical record for code status. LPN A recalled RN B was seated at the nurses' station and she alerted her that she needed assistance with resident #1. LPN A said she explained to RN B that resident #1 had a full code order, but did not look good and had only a faint pulse. LPN A said she told RN B, I don't know what to do right now, but I am ready to do it. She stated RN B told her to call hospice as the resident was on hospice services. LPN A stated she called the hospice agency and was informed resident #1 had not yet been seen by a hospice representative and was scheduled to be evaluated the following day. LPN A explained she informed RN B that resident #1 was not on hospice services and then returned to the resident's room. She said she re-evaluated resident #1 who no longer had a pulse. LPN A stated RN B arrived at the bedside and confirmed resident #1's vital signs were absent. She recalled she asked RN B, Is then when we start CPR? RN B told her, No. She is already gone and I will make the phone calls. LPN A said she was under the impression CPR should be initiated if someone had no pulse, but followed the guidance of RN B instead as the resident had already died . LPN A explained she felt really bad about the incident because residents counted on nurses to take care of them. According to the American Heart Association, CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after [CONDITION(S)] (retrieved on [DATE] from www.heart.org). Review of LPN A's education record reflected no documentation of education on neglect. The facility was unable to provide documentation that LPN A participated in any training or drills on response to cardiac or respiratory arrest or Code Blue. On [DATE] at 2:35 PM, during a telephone interview, RN B stated, I already gave my statement to Human Resources and I have nothing to add. When asked what her duties were at the facility, she noted she was a staff nurse and did a little bit of everything. She explained she reviewed residents' charts for Quality Assurance accuracy and provided education to new staff and conducted in-services as needed. She recalled LPN A did not tell her that resident #1 was a full code and she did not know the resident's Advance Directives status. Although RN B acknowledged nurses should proceed according to residents' code status, she said, I can't recall if we checked the code status. She acknowledged resident #1 was not breathing when she entered the room, her vital signs were absent, and she had already expired. She said she was not aware of a written policy that required overhead paging Code Blue but she did call the sheriff's department to report the death. RN B explained she did not review the designated emergency code colors, Advanced Directives or CPR when she conducted staff education. She said, I have not received education in a very long time but identified she had access to a list of emergency code colors which was printed on the back of all staff members' name badges. A review of RN B's education record revealed she had been working at the facility since [DATE]. She had received education on abuse, neglect, and misappropriation on [DATE]. She completed a post-test dated [DATE] which read, Neglect is: a. failure to provide goods and services (care) needed to avoid physical or emotional harm or well-being. Review of RN B's personnel file revealed she held a current CPR certification which indicated she had been able to demonstrate proficiency in this lifesaving skill. The facility was unable to provide documentation that RN B participated in any training or drills related on response to cardiac or respiratory arrest. On [DATE] at 3:33 PM, the Administrator said, I do not believe this incident is neglect because I do not think it was an intentional act that the RN did not do CPR. On [DATE], in interviews at 1:40 PM and 4:30 PM, the Regional Nurse stated the Human Resources department conducted most of the orientation for newly hired staff. She said floor nurse preceptors were expected to cover emergency codes with orientees. She explained the facility did not have adequate training or an annual skills checklist that included response to Code Blue incidents. She explained the facility's root cause analysis of the incident had a preliminary conclusion of error in the nurses' judgement. The Regional Nurse stated the facility reported RN B to the State Board of Nursing for failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Nurse said, CPR is an RN's duty. It's part of the Nurse Practice Act. She acknowledged not performing CPR on a resident who desired full code status was neglect. On [DATE] at 4:28 PM, during a telephone interview, the Medical Director said he was aware RN B thought resident #1 was on hospice services and therefore decided not to start CPR. He said, It is troublesome that she had to assume. He confirmed resident #1 was a full code and CPR should have been performed. On [DATE] at 12:09 PM, the Medical Director reiterated nurses should definitely initiate CPR if a resident had a full code order. He said, It is the right thing to do. You need to follow the rules and regulations and the resident's choice. He acknowledged all nurses required re-education and stated he regretted that RN B did not do what she was supposed to do. The Medical Director said, Unfortunately bad things happen. You can't hide it. You have to report it. On [DATE] at 6:40 PM, the Director of Nursing (DON) stated her expectation was nurses would follow the American Heart Association recommendations and perform CPR for full code residents who had no pulse or no respirations. The DON said, We need to provide the services. It is a standard of practice, and in the Nurse Practice Act. It is what we have been trained for, and in-serviced on. It is the responsibility of [a nurse's] license, to maintain the well-being of our residents and honor their wishes. On [DATE] at 3:37 PM, in a telephone interview, resident #1's sister-in-law said she was informed of the resident's death on [DATE]. She explained on the previous day, [DATE] the facility called to inform her there was an investigation into her sister-in-law's death as they discovered the nurse taking care of her that day thought her code status was Do Not Resuscitate so she did not do CPR. She said she told the Administrator the resident was a full code because she was not terminally ill. She said, I was heartbroken that it happened because I was just talking to a nurse a couple of weeks earlier and had a discussion that she was a full code. I thought she was there for therapy and planned to bring her home with me when she was ready to be released. Review of the facility's Cardio-Pulmonary Resuscitation (CPR) Policy and Procedure, revised on [DATE], read, The facility's staff provide basic life support, including CPR to residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's Abuse, Neglect, and Exploitation Policy/Procedure dated [DATE], read, Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and /or supervise the delivery of patient/resident care and services to assure care is provided as required.

Based on interview and record review, the facility failed to follow accepted professional nursing standards of clinical practice for providing basic life saving measures and initiating cardiopulmonary resuscitation (CPR) for a resident requiring emergency care and failed to announce a Code Blue medical emergency for cardiopulmonary arrest for 1 of 12 residents reviewed with physician orders for Full Code of a total sample of 25 residents, (#1). On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. LPN A requested assistance from Registered Nurse (RN) B as resident #1 had a physician's order for Full Code or full resuscitation measures, and she was inexperienced with performing that procedure. RN B assessed the resident, disregarded the Full Code order, and instructed LPN A not to perform CPR as resident #1 was already dead. The facility's failure to ensure licensed nurses followed professional standards in providing basic life support and initiate CPR resulted in Immediate Jeopardy starting on [DATE]. While resident #1's pulse and respirations slowed until they ceased, there was reasonable likelihood she experienced anxiety and distress. Findings: Cross reference F600, F678 and F726 Florida Board of Nursing, Nurse Practice Act, 464.003 (19) (20) (a) (b) reads, Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician . A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] for short term rehabilitation. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with Corona Virus Disease 2019 (COVID-19) and readmitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment with assessment reference date of [DATE] documented resident #1 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. She required limited to extensive assistance with activities of daily living. Review of resident #1's medical record revealed a physician's order dated [DATE] that read, Resident is a Full Code. Review of resident #1's care plans revealed facilty staff did not create an Advanced Directives care plan on admission or re-admission to reflect her Full Code status. The medical record did not indicate any discussion or care planning regarding Advance Directives related to resident #1's code status after her change in condition triggered a referral to Hospice services. A review of the facility's timeline regarding the incident on [DATE] at 2:45 PM, included witness statements. Certified Nursing Assistant (CNA) C's statement revealed she noticed a change in resident #1's condition and she notified LPN A. LPN A's statement showed she evaluated resident #1 and noted discolored skin, lethargy, and a slow, barely noticeable pulse. LPN A requested that CNA C remain with resident #1 while she gathered equipment and notified RN B of the resident's status. LPN A's statement revealed she went to the nurse's station and noted resident #1 was a Full Code. She told RN B, This is my first full code resident in this state. Please tell me what to do, how to do it and when it needs to be done. After verification that resident was a Full Code, RN B was notified. LPN A returned to resident #1's bedside, rechecked her vital signs and found she did not have a pulse. RN B entered the room, assessed resident #1, noted no vital signs, and verified there was no pulse. RN B's witness statement revealed LPN A reported resident #1's status to her, called hospice and confirmed the resident had not been admitted to hospice services. RN B indicated upon entering resident #1's room, she assessed her and noted her blood pressure was undetectable, no pulse was present, and her oxygen level was zero percent. Neither nurse's witness statement revealed CPR was initiated as per resident wishes and physician orders or facility policy followed for calling a Code Blue for resident #1 who was Full Code with cessation of pulse and respirations. Failure to ensure nurses followed the practice of professional nursing standards to provide emergency care, basic life support and CPR resulted in resident #1's death. On [DATE] at 1:59 PM, in a telephone interview, LPN A explained she was a new nurse and had worked at the facility as an agency nurse for about 6 months. She stated her training at the facility involved being given a packet of practices and procedures and completing an orientation with another nurse. She stated she had limited experience with Full Code residents. LPN A stated she was under the impression that CPR should be initiated for Full Code residents, but the RN's instructions were not to do CPR. LPN recalled the RN said, She's gone. No need to do CPR. On [DATE] at 2:35 PM, in a telephone interview, RN B stated she conducted in-services, education, and orientation with newly hired staff. Regarding the incident with resident #1, she said she already gave a statement to the Human Resources department and had nothing to add. She confirmed she could not obtain vital signs or a pulse when she entered resident #1's room. RN B stated there was no policy that she aware of that directed how to proceed with a code. She said, Yes. I'm aware [the resident] was not breathing. Contrary to her written statement, RN B said, I can't recall if I checked code status. She stated she had not received training in a very long time regarding facility codes or Advanced Directives, and without looking at the list of emergency codes on the back of her name badge she was unsure of the codes. On [DATE], in interviews at 1:40 PM and 4:30 PM, the Regional Nurse stated the facility's Root Cause Analysis of the incident had a preliminary conclusion of error in the nurses' judgement. The Regional Nurse stated the facility reported RN B to the State Board of Nursing for failure to follow the physician's order and she expected LPN A's staffing agency to do the same. The Regional Nurse said, CPR is an RN's duty. It's part of the Nurse Practice Act. On [DATE] at 3:20 PM, the Administrator stated that during an interview with RN B, it was revealed that RN B did not go to resident #1's room right away. When she went to the resident's room, she did not detect a pulse. He stated LPN A asked RN B about starting CPR and RN B said, the resident was ashy, she's gone, I will take care of the phone calls. On [DATE] at 4:48 PM, CNA C stated she was providing her end of shift care to resident #1 and noticed the resident was not making any sounds. She said, Her color changed. It looked different, and normally she would make different sounds when I was washing her face or when I was providing care. She said she reported the changes to LPN A who came and looked at the resident and then left the room to call for help. She recalled LPN A returned and RN B arrived soon after. CNA C explained she left resident #1's room once both nurses were at the bedside, and she did not know what happened next. On [DATE] at 5:13 PM, the Medical Records/Social Services staff stated she received a call from RN B on [DATE] at 3:10 PM. She said RN B informed her that resident #1 had died . She said she asked, Was CPR done? She was full code. She stated RN B replied, Very little, she was ashy. On [DATE] at 3:51 PM, the Human Resources staff stated she did not conduct orientation for agency personnel. She explained upon hire, facility nurses were asked to provide their CPR card, it was part of the hiring process. She noted that facility nurses must maintain current CPR certification. She spoke about the facility Emergency Codes located on the back of employee name badges. She said that codes were reviewed in orientation and employees received a copy of the Emergency Codes Name on a form. Review of the facility Emergency Code Names no date, revealed Throughout the Emergency Preparedness Manual, one will see code names for different emergencies. Below is a current listing that contains the incident type and the Emergency Code Name used to alert the staff to the situation. The form showed an Incident Type for Medical Emergency with Code Name of Code Blue. On [DATE] at 6:40 PM, the Director of Nursing (DON) said her expectation was nurses would follow the American Heart Association recommendations and perform CPR for full code residents who had no pulse or no respirations. The DON said, We need to provide the services. It is a standard of practice, and in the Nurse Practice Act. It is what we have been trained for, in-serviced on. It is the responsibility of [a nurse's] license, to maintain the well-being of our residents and honor their wishes. On [DATE] at 12:09 PM, the Medical Director stated nurses should definitely initiate CPR if a resident had a full code order. He said, It is the right thing to do. You need to follow the rules and regulations and the resident's choice. He acknowledged the nurses did not initiate CPR and they should have followed professional standards for nurses. He said he regretted that RN B did not do what she was supposed to do. He added, unfortunately bad things happen. You can't hide it. You have to report it. Review of LPN A's personnel file revealed an education and training record that included a current Basic Life Support CPR card which was valid until [DATE]. Review of her Clinical Assessment with completion date of [DATE], revealed no education or competency checklist for calling a Code Blue, mock code or initiating CPR on a Full Code resident. Review of RN B's personnel file revealed she started working at the facility on [DATE]. Her education and training record included a current Basic Life Support CPR card issued on [DATE]. The record did not show any competency checklist for calling a Code Blue, initiating CPR on a Full Code resident or participation in a mock code. It was evident both LPN A and RN B were trained in Basic Life Support (BLS) CPR but neither possessed the necessary skills for life saving measures as neither initiated CPR for resident #1 when her heart stopped. According to the American Heart Association, CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest (retrieved on [DATE] from www.heart.org). Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Position Description Registered Nurse noted Understand adhere to and promote facility policies and procedures, exercising professional nursing judgement and practices. Bullet number eleven and twelve showed Coordinates care of residents. Assists nursing staff members according to needs. Review of the facility policy and procedure for Cardio-Pulmonary Resuscitation (CPR) revised on [DATE] showed, The facility's staffs provide basic life support, including CPR to residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives.

Based on interview and record review, the facility failed to follow a physician's order to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 12 residents reviewed for Full Code status, of a total sample of 25 residents, (#1). On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with an abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. LPN A requested assistance from Registered Nurse (RN) B as resident #1 had a physician's order for Full Code or full resuscitation measures, and she was inexperienced with performing that procedure. RN B assessed the resident, disregarded the Full Code order, and instructed LPN A not to perform Cardiopulmonary Resuscitation (CPR) as resident #1 was already dead. The facility's failure to ensure staff followed a physician's order to initiate CPR for resident #1 resulted in Immediate Jeopardy starting on [DATE]. While resident #1's pulse and respirations slowed until they ceased, there was reasonable likelihood she experienced anxiety and distress. Findings: Cross Reference to F600, F658 and F726. Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] for short term rehabilitation. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with Corona Virus Disease 2019 (COVID-19) and readmitted to the facility on [DATE]. Review of resident #1's medical record revealed a physician's order dated [DATE] that read, Resident is a Full Code. A nursing progress note dated [DATE] indicated the physician was informed resident #1 was no longer eating or taking her medication. The note revealed the Advanced Practice Registered Nurse recommended hospice services, and a physician's order was obtained on [DATE] for a hospice consult. Review of resident #1's care plans revealed facility staff did not create an Advanced Directive care plan on admission or re-admission to reflect her Full Code status. The medical record did not indicate any discussion or care planning regarding Advance Directives related to resident #1's code status after her change in condition triggered a referral to Hospice services. An Admission Minimum Data Set (MDS) assessment with assessment reference date of [DATE] documented resident #1 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. She required limited to extensive assistance with activities of daily living. On [DATE] at 1:59 PM, during a telephone interview, LPN A stated on [DATE] at 2:55 PM, Certified Nursing Assistant (CNA) C informed her that resident #1 did not look good. She said she evaluated the resident and instructed CNA C to stay at resident #1's bedside while checked the chart for code status. LPN A recalled RN B was seated at the nurses' station and she alerted her that she needed assistance with resident #1. LPN A noted she explained to RN B that resident #1 had a full code order, but did not look good and had only a faint pulse. LPN A said she told RN B, I don't know what to do right now, but I am ready to do it. She stated RN B told her to call hospice as the resident was on hospice services. LPN A recalled she called the hospice agency and was informed resident #1 had not yet been seen by a hospice representative and was scheduled to be evaluated the following day. LPN A said she informed RN B that resident #1 was not on hospice services and then returned to the resident's room. She noted she re-evaluated resident #1 who no longer had a pulse. She stated RN B arrived at the bedside and confirmed resident #1's vital signs were absent. She then asked RN B, Is then when we start CPR? RN B told her, No. She is already gone and I will make the phone calls. LPN A said she was under the impression CPR should be initiated if someone had no pulse, but followed the guidance of RN B instead as the resident had already died . LPN A explained she felt really bad about the incident because residents counted on nurses to take care of them. According to the American Heart Association, CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after [CONDITION(S)] (retrieved on [DATE] from www.heart.org). On [DATE] at 2:35 PM, during a telephone interview, RN B said, I already gave my statement to Human Resources and I have nothing to add. When asked what her duties were at the facility, she stated she was a staff nurse and did a little bit of everything. She explained she reviewed residents' charts for Quality Assurance accuracy and provided education to new staff and conducted in-services as needed. She stated LPN A did not tell her resident #1 was a full code and she did not know the resident's Advance Directives status. RN B acknowledged nurses should proceed according to residents' code status, but noted, I can't recall if we checked the code status. She confirmed resident #1 was not breathing when she entered the room, her vital signs were absent, and she had already expired. She identified she was not aware of a written policy that required overhead paging Code Blue to alert staff of a resident in cardiopulmonary arrest but she did call law enforcement to report the death. She said, I have not received education in a very long time but she acknowledged she had access to a list of emergency code colors which was printed on the back of all staff members' name badges. On [DATE] at 4:15 PM, RN H recalled while she was making the evening shift CNA assignments on [DATE], a CNA informed her resident #1 had expired and RN B confirmed the resident's death. RN H stated she instructed RN B to call law enforcement and RN B informed her it was already done. RN H recalled LPN A told her she asked RN B who should start CPR and RN B replied that resident #1 was gone and she would make the necessary phone calls. RN H stated LPN A informed her that CPR was never initiated. On [DATE] at 4:48 PM, CNA C stated she was provided her end of shift care to resident #1 and noticed the resident was not making any sounds. She said, Her color changed. It looked different, and normally she would make different sounds when I was washing her face or when I was providing care. She said she reported the changes to LPN A who came and looked at the resident and then left the room to call for help. She recalled LPN A returned and RN B arrived soon after. CNA C explained she left resident #1's room once both nurses were at the bedside, and she did not know what happened next. CNA C said she was certified to perform CPR and if she found a resident without a pulse, she would notify a nurse. She explained the nurse would provide further instruction on whether CPR should be started, and call a Code Blue if indicated. CNA C did not remember receiving education in the facility on CPR or code status. In interviews on [DATE] at 5:13 PM and on [DATE] at 10:45 AM, the facility's Medical Records / Social Services staff recalled on admission to the facility, she discussed Advanced Directives with resident #1 and her husband. She stated the decision was the resident would remain as Full Code status. The Medical Records / Social Services staff recalled she received a call on [DATE] at 3:10 PM from RN B who informed her resident #1 had died . She said she asked, Was CPR done? She was full code. She stated RN B replied, Very little. She was ashy. The Medical records / Social Services stated she called resident #1's sister-in-law and told her the resident had passed away and confirmed funeral arrangements. She verbalized, I did not tell her CPR was not done. A progress note dated [DATE] at 4:16 PM by the Medical Records/Social Services staff read, This writer was informed on [DATE] at 3:10 PM that resident expired at 2:55 PM. This writer then contacted proxy, where I informed her of the resident's expiration. Proxy was notably upset but accepting of passing . On [DATE], in interviews at 1:40 PM and 4:30 PM, the Regional Nurse stated the facility's Root Cause Analysis of the incident had a preliminary conclusion of error in the nurses' judgement. The Regional Nurse stated the facility reported RN B to the State Board of Nursing for failure to follow the physician's order and she expected LPN A's staffing agency to do the same. The Regional Nurse said, CPR is an RN's duty. It's part of the Nurse Practice Act. On [DATE] at 4:28 PM, during a telephone interview, the Medical Director said he was aware RN B thought resident #1 was on hospice services and therefore decided not to start CPR. He said, It is troublesome that she had to assume. He confirmed resident #1 was a full code and CPR should have been performed. On [DATE] at 6:40 PM, the Director of Nursing (DON) said her expectation was nurses would follow the American Heart Association recommendations and perform CPR for full code residents who had no pulse or no respirations. The DON said, We need to provide the services. It is a standard of practice, and in the Nurse Practice Act. It is what we have been trained for, in-serviced on. It is the responsibility of [a nurse's] license, to maintain the well-being of our residents and honor their wishes. On [DATE] at 3:37 PM, in a telephone interview, resident #1's sister-in-law stated she was informed of the resident's death on [DATE]. She explained on the previous day, [DATE] the facility called to inform her there was an investigation into her sister-in-law's death as they discovered the nurse taking care of her that day thought her code status was Do Not Resuscitate so she did not do CPR. She said she told the Administrator the resident was a full code as she was not terminally ill. She said, I was heartbroken that it happened because I was just talking to a nurse a couple of weeks earlier and had a discussion that she was a full code. I thought she was there for therapy and planned to bring her home with me when she was ready to be released. Review of the facility's Cardio-Pulmonary Resuscitation (CPR) Policy and Procedure, revised on [DATE], read, The facility's staff provide basic life support, including CPR to residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directive.

Based on interview and record review, the facility failed to ensure licensed facility and agency nurses had competencies and skill sets to appropriately provide basic life-saving skills and initiate cardiopulmonary resuscitation (CPR) for a Full Code resident requiring emergency care, and failed to orient nursing staff on facility procedures related to announcing Code Blue medical emergency for cardiopulmonary arrest for 1 of 12 residents reviewed with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. LPN A requested assistance from Registered Nurse (RN) B since resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B assessed the resident, disregarded the Full Code order, and instructed LPN A not to perform CPR as resident #1 was already dead. The facility's failure to ensure licensed nurses demonstrated competency in announcing a Code Blue medical emergency and initiating CPR for resident #1 resulted in Immediate Jeopardy starting on [DATE]. While resident #1's pulse and respirations slowed until they ceased, there was reasonable likelihood she experienced anxiety and distress. Findings: Cross reference F600, F658 and F678 Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] for short term rehabilitation. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with Corona Virus Disease 2019 (COVID-19) and readmitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment with assessment reference date of [DATE] documented resident #1 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. She required limited to extensive assistance with activities of daily living. Review of resident #1's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A social services progress note dated [DATE] at 10:30 AM described a conversation with resident #1 and her husband regarding Advanced Directives. The documentation showed resident #1 was a Full Code. A social services progress note dated [DATE] at 12:07 PM revealed no changes regarding discharge plan or Advanced Directives, and the resident remained a Full Code. Review of resident #1's medical record revealed a clinical note written by RN B, dated [DATE] at 3:10 PM. The note indicated a nurse notified RN B that resident #1 had no vital signs. In another clinical note dated [DATE] at 4:35 PM, RN B documented as a late entry that she assessed resident #1 and was unable to obtain a pulse, blood pressure, respirations, or oxygen level. A clinical note dated [DATE] at 10:34 AM, LPN A noted on [DATE] at 2:45 PM a Certified Nursing Assistant (CNA) notified her that resident #1 was discolored and lethargic. She immediately went in to check the resident's vital signs and reported her findings to the RN. The clinical note indicated the RN assessed resident #1, checked her vital signs and stated there was no pulse. There was no documentation to indicate nurses announced a Code Blue, the facility's emergency code for a medical emergency. Neither LPN A nor RN B initiated CPR for resident #1 as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's timeline regarding the incident on [DATE] at 2:45 PM, included witness statements. CNA C's statement revealed she noticed a change in resident #1's condition and she notified LPN A. LPN A's witness statement showed she evaluated resident #1 and noted discolored skin, lethargy, and a slow, barely noticeable pulse. LPN A requested that CNA C remain with resident #1 while she gathered equipment and notified RN B of the resident's status. LPN A's statement revealed she went to the nurse's station and noted resident #1 was a Full Code. She told RN B, This is my first full code resident in this state. Please tell me what to do, how to do it and when it needs to be done. After verification with Hospice to confirm resident was indeed a Full Code, RN B was notified. LPN A returned to resident #1's bedside, rechecked her vital signs and found she did not have a pulse. RN B entered the room, assessed resident #1, noted no vital signs, and verified there was no pulse. RN B's witness statement revealed LPN A reported resident #1's status to her, called hospice and confirmed the resident had not been admitted to hospice services. RN B indicated upon entering resident #1's room, she assessed her and noted her blood pressure was undetectable, no pulse was present, and her oxygen level was zero percent. Neither nurse's witness statement revealed CPR was initiated or facility policy followed for calling a Code Blue for resident #1 who was Full Code status. On [DATE] at 1:59 PM, in a telephone interview, LPN A explained she was a new nurse and had worked at the facility as agency nurse for about 6 months. She stated her training at the facility involved being given a packet of practices and procedures and completing an orientation with another nurse. She stated she had limited experience with Full Code residents. LPN A stated she was under the impression that CPR should be initiated for Full Code residents, but the RN's instructions were not to do CPR. LPN recalled the RN said, She's gone. No need to do CPR. On [DATE] at 2:35 PM, in a telephone interview, RN B stated she conducted in-services, education, and orientation with newly hired staff. Regarding the incident with resident #1, she said she already gave a statement to the Human Resources department and had nothing to add. She confirmed she could not obtain vital signs or a pulse when she entered resident #1's room. RN B stated there was no policy that she aware of that directed how to proceed with a code. She said, Yes. I'm aware [the resident] was not breathing. Contrary to her written statement, RN B said, I can't recall if I checked code status. She stated she had not received training in a very long time regarding facility codes or Advanced Directives, and without looking at the list of emergency codes on the back of her name badge she was unsure of the codes. In interviews on [DATE] at 3:30 PM and [DATE] at 1:40 PM, the Regional Nurse stated the facility did not have a formal policy or procedure for initiating CPR or calling a Code Blue. She explained the Human Resources department was responsible for most of the orientation for newly hired staff. She stated floor nurse preceptors covered facility emergency codes with new orientees. The Regional Nurse stated the preliminary conclusion from the Root Cause Analysis of the incident was an error in the nurses' judgement. She stated the facility had not provided adequate training, and she was unsure what was covered in orientation. The Regional Nurse stated the facility's annual skills competency checklist did not include the topics of calling codes, CPR skills or mock codes. On [DATE] at 4:15 PM, RN H stated on [DATE] she was informed the nurses did not start CPR for resident #1. RN H stated after the incident, she educated LPN A regarding following procedure for calling a code, initiating CPR as required on a resident with Full Code status, and getting a second opinion if she did not feel comfortable with direction given by another nurse. On [DATE] at 3:51 PM, the Human Resources staff stated she did not conduct orientation for agency personnel. On [DATE] at 12:09 PM, the Medical Director stated nurses should definitely initiate CPR for residents with Full Code orders. He explained it was the right thing to do in order to follow rules and regulation and honor residents' choices. The Medical Director stated nurses needed re-education. Review of LPN A's personnel file revealed an education and training record including current Basic Life Support CPR card which was valid until [DATE]. Review of her Clinical Assessment with completion date of [DATE], revealed no education or competency checklist for calling a Code Blue, mock code or initiating CPR on a Full Code resident. Review of RN B's personnel file revealed she was hired by the facility on [DATE]. Her education and training record included a current Basic Life Support CPR card issued on [DATE]. The record revealed documentation of in-service education and annual education on Federal and State required rules and regulations and resident rights, but no competency checklist for calling a Code Blue, initiating CPR on a Full Code resident or participation in a mock code. Both LPN A and RN B possessed the necessary skills to perform life saving measures as their Basic Life Support CPR certification tasks included performance of a pulse check on an unresponsive person, use of a bag valve mask, and rescue breathing. According to the American Heart Association, initiating basic life support improves chances of survival and recovery for victims (retrieved on [DATE] from www.heart.org). Review of the facility's policy and procedure for Resident Rights with effective date of [DATE] revealed It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. The facility will promote the exercise of rights for each resident . Review of the facility's policy and procedure for Cardio-Pulmonary Resuscitation (CPR) with effective date of [DATE] and revised on [DATE] showed The facility's staff provides basic life support, including CPR to residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . and may include recognition of sudden cardiac arrest, activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillator, if available.

Based on interview and record review, the facility failed to meet professional Standards of Quality Nursing Care as per the Nurse Practice Act by failing to follow physician orders [REDACTED].#1), and failed to follow physicians orders regarding blood pressure monitoring for 3 of 15 residents receiving anti-hypertensive and heart medications for 43 sampled residents (#6, 8 & 9). Findings: The Florida Statutes Chapter 464 The Nurse Practice Act. (SS464.001.461.027) defines the "Practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to....The administration of medications and treatments as prescribed or authorized by a dully licensed practitioner authorized by the laws of this state to prescribe such medications and treatments...." 1. Resident #1 was admitted to the facility with a history of [MEDICAL CONDITION] and hypertension. The resident's admission physician orders [REDACTED].) every 6 hours for hypertension. A review of the Medication Administration Record [REDACTED]. The resident received the first dose of [MEDICATION NAME] 60 mg. at 9 PM on 4/18/14. He received another dose on 4/19/14 at 1 AM, which was 4 hours later. A nurses's progress note dated 4/19/14 at 4 AM read that "blood pressure (BP) 98/62 and pulse (P)118." The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47". The resident was unresponsive and 911 was called. The resident was transferred to hospital and was admitted with [MEDICAL CONDITION]. An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurses involved in the medication error were given verbal warning for not transcribing and following the physician order [REDACTED]. 2. Resident #6 was admitted to the facility on [DATE] with a history of aortic valve replacement. The resident was receiving [MEDICATION NAME] 50 mg. twice daily and [MEDICATION NAME] 0.125 mg. daily. A review of the May 2014 MAR indicated [REDACTED]. This was verified with the director of nursing at 4:10 PM on 5/13/14. She stated she did not know why the nurse did not check the blood pressure or the heart rate prior to giving the medications because he was a new resident and his baseline vitals were not yet established. 3. Review of the medical record for resident #8 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the May 2014 physician order [REDACTED].), 1 tablet via gastrostomy tube (GT). Note: give [MEDICATION NAME] 2 mg. via GT daily at bedtime for hypertension. Hold for systolic blood pressure (SBP) less than 100 or heart rate less than 60. Review of the May 2014 Medication Administration Record [REDACTED]. via GT at 9 PM on 5/01/14, 5/02/14 and 5/07-11/14. Blood pressures were documented on each of these days. Review of the MAR from 5/03-06/14 revealed resident #8 did not receive [MEDICATION NAME] 2 mg. via GT because his SBP was below 100. Review of the MAR for 5/12/14 and 5/13/14 revealed resident #8 received [MEDICATION NAME] 2 mg. via GT at 9 PM. However, the nurse failed to document his blood pressure. 4. Review of the medical record for resident #9 revealed she was admitted on [DATE] for [DIAGNOSES REDACTED]. Review of the May 2014 POS revealed an order dated 7/17/12 for [MEDICATION NAME]-tts 10.1 mg./24 hour, 1 patch, [MEDICATION NAME]. Note: give [MEDICATION NAME] ([MEDICATION NAME]) patch 0.1 mg., apply 1 patch topically, 1 time weekly on Tuesday for hypertension. A second physician order, dated 4/05/13, read to monitor blood pressure (BP) weekly on Tuesday for [MEDICATION NAME] placement for hypertension. Review of the May 2014 MAR indicated [REDACTED]. Review of the April 2014 MAR indicated [REDACTED]. Review of the March 2014 MAR indicated [REDACTED]. During an interview on 5/14/14 at 4:29 PM, licensed practical nurse (LPN) #D stated "You take the resident's BP before giving any BP medications, and then you document the BP on the MAR." During an interview on 5/14/14 at 4:35 PM, LPN #E stated, "With blood pressure medications, you do a blood pressure before giving the medication. We follow the parameters on the MAR for giving BP medications."

Based on interviews and record review, the facility failed to ensure that residents were free from significant medication errors for 2 of 43 residents reviewed for medication administration (#1 & 2). Findings: 1. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. The resident's admission medication orders included [MEDICATION NAME] 60 milligrams (mg.) every 6 hours for hypertension, [MEDICATION NAME] 25 mg. twice daily for hypertension (hold if systolic <100), [MEDICATION NAME] 5 mg. daily for prevention of [MEDICAL CONDITION], and Aspirin 81 mg. daily for [MEDICAL CONDITION]. The resident was receiving all nutrition and medications via gastrostomy tube. His blood pressure at admission at 5 PM was 132/78 and pulse was 68. A review of the Medication Administration Record [REDACTED]. The resident received the first dose of [MEDICATION NAME] 60 mg at 9 PM on 4/18/14. He received another dose on 4/19/14 1 AM which was 4 hours later. Another dose was signed as given at 5 AM on 4/19/14 but a late entry documented that the nurse forgot to circle the MAR indicated [REDACTED] A nurse's progress note dated 4/19/14 at 4 AM read that blood pressure (BP) 98/62 and pulse (P)118. The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47." The resident was unresponsive and 911 was called. The resident was transferred to hospital and was admitted with [MEDICAL CONDITION], diarrhea and pneumonia. There was no documentation to reflect whether the attending physician, the emergency room physician or the family were informed that the resident received at least 2 doses of [MEDICATION NAME] within 4 hours. The resident returned to the facility 8 days later. An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurse who transcribed the wrong times and the nurse who administered the medication in error were both given verbal warnings on 4/22/14. 2. Review of the medical record for resident #2 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5/02/14 physician discharge orders and instructions from the hospital revealed an order for [REDACTED]. Review of resident #2 admission physician order [REDACTED]. po, 1 tablet BID for [MEDICAL CONDITION], which was completed by licensed practical nurse (LPN) #F. Review of resident #2 May 2014 MAR indicated [REDACTED]. po BID. The MAR indicated [REDACTED]. po, BID between 5/02-10/14. The resident was to receive one 500 mg. tablet of [MEDICATION NAME] ordered upon admission to the facility but instead received two 500 mg. tablets BID. Review of resident #2 February 2014, March 2014, and April 2014 MARs revealed she received [MEDICATION NAME] 1000 mg. po twice a day for [MEDICAL CONDITION]. Review of the nurses notes dated 5/10/14 revealed that on 5/10/14 at 6:30 PM, resident #2 complained of tingling in her left arm and discomfort in her left leg. She was extremely short of breath, her face was red, and she was extremely anxious. Her blood pressure was 187/94, heart rate 152, respiratory rate 25, and oxygen level on 3 liters of nasal oxygen was 93%. The resident experienced uncontrollable extremity movements and was frightened. The resident asked to go to the hospital. Review of the physician order [REDACTED]. The resident remained in the hospital as of 5/14/14 survey. In an interview with the administrator and director of nursing (DON), conducted on 5/13/14 at 11:20 AM, she said they were aware that resident #2 was sent to the hospital with shaking and tingling of left arm and leg. The DON revealed that she found the [MEDICATION NAME] medication error when reviewing resident #2's medical record after she was sent to the hospital. The DON also revealed that LPN #F was counseled regarding transcribing medication incorrectly.

Based on record review and interview, the facility failed to assure a system for accurately transcribing physician's MEDICATION ORDERS FOR [REDACTED]. Findings: 1. Resident #1 was admitted to the facility with a history of cerebral vascular accident and hypertension. The resident's admission medications orders included Cardizem 60 milligrams (mg.) every 6 hours for hypertension. His blood pressure at admission at 5 PM was 132/78 and pulse was 68. A review of the Medication Administration Record [REDACTED]. The resident received the first dose of Cardizem 60 mg. at 9 PM on 4/18/14. He received another dose on 4/19/14 at 1 AM, which was 4 hours later. Another dose was signed as given at 5 AM on 4/19/14 but a late entry documented that the nurse forgot to circle the MAR, indicating not given. A nursing progress note dated 4/19/14 at 4 AM read that blood pressure "(BP) 98/62 and pulse (P)118." The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47." The resident was unresponsive and 911 was called. The resident was transferred to hospital and was admitted with hypotension. There was no documentation to reflect whether the attending physician, the emergency room physician or the family were informed that the resident received at least 2 doses of Cardizem within 4 hours in error. An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurse who transcribed the medication incorrectly and the nurse who administered the medication in error were both given verbal warnings on 4/22/14. 2. Resident #3 was admitted to the facility with a history of atrial fibrillation. A review of the physician orders [REDACTED].<60. Another physician order [REDACTED]. twice daily for atrial fibrillation-hold for systolic blood pressure <100 or heart rate <60. A review of the May 2014 MAR indicated [REDACTED]. An interview was conducted with the director of nursing on 5/13/14 at 12:30 PM. She verified that the medication was not transcribed or administered accurately as per physician order. 3. Review of the medical record for resident #2 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2 admission physician order [REDACTED]. po, 1 tablet BID for seizures, completed by licensed practical nurse (LPN) #F. Review of resident #2 May 2014 Medication Administration Record [REDACTED]. 1 tablet po BID. The MAR indicated [REDACTED]. 2 tablets po BID between 5/02-10/14 instead of one tablet. Review of the nurse's notes dated 5/10/14 revealed that on 5/10/14 at 6:30 PM, resident #2 complained of tingling in her left arm and discomfort in her left leg. She was extremely short of breath, her face was red, and she was extremely anxious. Her blood pressure was 187/94, heart rate 152, respiratory rate 25, and oxygen level on 3 liters of nasal oxygen was 93%. The resident experienced uncontrollable extremity movements and was frightened. The resident asked to go to the hospital. Review of the physician order [REDACTED]. The resident remained in the hospital as of 5/14/14, the survey date. In an interview conducted on 5/13/14 at 11:20 AM, the director of nursing (DON) revealed the Keppra medication error was caused by an error related to transcription. The DON stated that LPN #F has received a counseling related to incorrectly transcribing medications.

Based on interview and record review, the facility failed to report immediately, thoroughly investigate, and prevent further potential abuse for an allegation of sexual assault for 1 of 6 sampled residents (#1) in a total census of 71 residents. Resident #1 was identified with bleeding from her vaginal area on Saturday, 3/01/14. At that time, the resident was agitated, resisting care, moaning, and crying while trying to put her hand near her vaginal area. The resident has dementia, was unable to make her needs known, and was totally dependent upon staff for all activities of daily living. The resident was sent to the hospital for evaluation and treatment for [REDACTED]. After the resident arrived in the hospital, the medical examination revealed vaginal trauma, bleeding, swelling to the vaginal area, and bruises to the inner thigh and abdomen. Sexual assault was suspected, a rape kit was performed, and the police and adult protective investigator were notified. The administrator and director of nursing indicated that they became aware of the hospital allegation of sexual assault on 3/01/14, but since they did not consider the resident's injuries to be from sexual abuse, they did not think they needed to report abuse, conduct an investigation, and protect any other residents from potential abuse. As of 5/05/14, the facility had not reported the abuse allegation to state officials to include the Agency for Healthcare Administration and the Department of Children and Families. The facility had not conducted a thorough investigation or implemented measures to prevent potential abuse to other residents. These practices resulted in Immediate Jeopardy starting on 3/01/14 and it was determined to be ongoing as of 5/12/14. Findings: Cross reference to F226. On 4/16/2014 at approximately 9:50 AM, an interview with the administrator (ADM) revealed the following: Resident #1 had blood in her brief at noon on 3/01/14 when the Occupational Therapist (OT) changed the brief. The OT notified the licensed practical nurse (LPN) #C who was caring for resident #1 that day, and LPN #C notified the registered nurse (RN) Supervisor. LPN #C notified the physician who said to send resident #1 to the local emergency room (ER) for further evaluation and treatment. The ADM said approximately 3 hours later, at 3 PM, the facility received a call from the hospital saying they would be admitting the resident and they have suspicions of sexual abuse due to her injures. The ADM said the resident did not return to the facility. On 4/16/14 at 12:15 PM, the ADM stated she was the abuse coordinator responsible for reporting and investigating all abuse allegations. She said she had no Federal immediate or 5-day abuse investigation reports for any residents. Review of the abuse log book for March and April revealed there was no documentation that an allegation of a sexual abuse occurred. The ADM said written statements were completed by the RN supervisor on 3/01/14 after the hospital called to say resident #1 had injuries that indicated sexual assault. She said the Department of Children and Families (DCF) investigator and a representative from the Brevard County Sheriff's Office (BCSO) arrived at the facility to investigate the sexual assault allegation on Monday, 3/03/14, two days after the resident's injuries were identified. In an interview with the ADM on 4/16/14 at 4:30 PM, she stated she did not think the allegation of sexual abuse from the hospital applied to the facility, therefore she did not follow the policies and procedures for abuse. She said she did not think they needed to investigate and report because "we are not the ones who suspect abuse, the hospital is." She said the resident was catheterized for a urine sample on 2/28/14 and she believed the catheter was the cause of the bleeding. She said she did not have reasonable suspicion of abuse when the resident was identified with bleeding in the vaginal area at noon on 3/01/14 while still in the facility. She said neither the OT, RN supervisor, nor LPN #C reported any suspicion of abuse to her. In an interview with the ADM on 4/30/14 at 11:57 AM, she said was notified by the director of nursing (DON) on 3/01/14 at 3 PM, 3 hours after the vaginal bleeding was identified, that resident #1 was sent to the hospital with bleeding and the DON told her the hospital suspected sexual assault due to the location and severity of the resident's injuries. She said she spoke with the DON on 3/01/14 regarding any issues with the resident's catheterization done on 2/28/14. She said the DON later spoke with the nurse who catheterized the resident and the DON reported no problems with the catheterization. The ADM said she thought the bruises on the resident's legs as noted when in the hospital were from staff holding the resident's legs to clean her on 3/01/14 before she went to the hospital. The ADM stated she did not suspect abuse when the BCSO and DCF came into the facility on Monday, 3/03/14. She said "they stated that she, resident #1, was assaulted." The ADM was asked "what is your policy and protocol?" The ADM stated, "if there is an individual suspected of abuse, we suspend them and based on this situation I would have had to suspend my entire staff and would have no one to take care of the residents. We sat down with the staff and did a time line of events." An interview with the OT on 4/30/14 at 10:48 a.m. revealed that she was aware of the abuse policies and procedures. She said her last in-service was on 12/01/13 via computer. She stated, "I evaluated resident #1 for therapy. She was confused, had poor cognition, was not participating in ADLs (activities of daily living), and did not have any behavioral issues. The resident was in the independent living apartment before her admission to the skilled nursing unit. She said she saw the resident on Saturday 3/01/14. She went into the resident's room at approximately noon. The resident was in bed. Her daughter-in-law (DIL) was in the room at that time. The resident was lying in bed with her shirt on and she was covered with a blanket. She said she spoke to the DIL, and then the DIL stepped out of the room. The OT said she checked the resident's incontinence brief to see if it was dry, which she normally did before providing therapy treatment. When she pulled the covers down and unfastened the brief, she noticed blood from the resident's vaginal area. The blood was clumpy in the front of the brief, spotty and localized on the resident's labia. The spot was about 1-2 inches and dark red. She covered the resident and immediately went to get LPN #C. She said LPN #C inspected the resident's brief. With the OT's assistance, LPN #C cleaned the resident. The OT held the resident's left leg and LPN #C held her right leg. She said the resident then became "very resistive. She did not want us to do this." The OT said she did not notice any discoloration or bruising. LPN #C wiped the vaginal area clean and then went to report the incident to the RN supervisor. LPN #C and the RN supervisor looked at the resident again. Then the RN supervisor told LPN #C to call the physician. The OT put a new brief on the resident who was very resistive when rolled onto her side. The resident held on to the bedrail and would not let go. The OT gently removed her hands from the rail. She said the resident was very rigid. She said the resident had not behaved this way prior to that day. Review of the nurses ' notes did not reveal any documentation of any examination of the resident when the bleeding was identified. When questioned regarding the resident's clothing, the OT stated that the resident was not wearing any pants or shorts when she first entered the room. When she returned to the room later, she said she noticed the resident was fidgeting and trying to put her hands down into the brief, pulling at her brief. The brief was not tight. The brief that had the blood in it was snug against the resident and not too tight. She stated that she informed LPN #C that the resident was pulling at her brief. In an interview on 4/30/14 at 11:30 AM with the hospitalist physician who cared for resident #1 after she was admitted to the hospital on [DATE], indicated the physician in the emergency room (ER) did a pelvic exam on the resident and identified bruising around the vagina and bleeding from the vagina. A rape kit was completed in the ER. The resident was admitted to the hospital. She had bleeding for the few days while she was at the hospital. The hospitalist physician said the resident had vaginal trauma and small vaginal tears. She said the family was notified that the resident was possibly assaulted. The hospitalist physician said bruising was present on the lower abdomen. She saw the resident at approximately 7-8 PM that evening. The resident had progressive [MEDICAL CONDITION] and was bed bound. There was no blood under the resident's fingernails. She said she was aware the nursing home stated they catheterized the resident on 2/28/14, but that would not explain why the resident had blood, bruising and vaginal tears. She said if there was any trauma from the catheterization, the resident might have blood in the opening that goes to the bladder, the urethra, not the vagina. Review of the ER disposition summary read, "Order for admission - medical. Preliminary [DIAGNOSES REDACTED]." An interview was conducted with the ADM/Abuse Coordinator on 5/01/14 at 11:57 a.m. She said she received a call from the Director of Nursing (DON) around 3 PM on 3/01/14 requesting release of a urinalysis for resident #1 to the hospital. She said the DON then told her about the resident "bleeding from the clitoris." When the ADM was asked if she was aware that the hospital informed the facility that resident #1 had signs and symptoms of sexual assault from her stay in the nursing home, she stated, "Yes." The ADM said that the RN supervisor told her that the resident was catheterized on 2/28/14, so "I thought the blood was related to the catheterization." The administrator said the urinalysis had identified a large amount of blood in the sample. Review of the laboratory report for the urinalysis results indicated the resident ' s urine sample was yellow and cloudy. It had characteristics indicative of a urinary tract infection, including blood and [MEDICATION NAME]. The ADM continued to say that on 3/03/14 she was informed that a law enforcement officer (LEO) was at the facility for the sexual assault investigation for resident #1. During the same time, a DCF investigator was also in the facility for resident #1. The ADM said she told the DCF investigator that resident #1 was on blood thinner and felt the bruises were from the staff holding the resident's legs to clean her. Review of the medical record revealed the resident was receiving 325 milligrams of aspirin daily. The ADM said, "once DCF and the LEO came to the facility, I didn't believe I still had to do my own investigation and file the immediate and 5-day reports." She said she still thought the bleeding was from the catheterization on 2/28/14, and not due to sexual assault in the facility. However, she provided no evidence of an investigation as to how a urinary catheterization could cause the bleeding, bruising, and tears to the vagina. On 5/01/14 at 12:41 PM a phone interview with LPN #D revealed that she catheterized resident #1 to obtain a urine sample on 2/28/14. She stated she performed the catheterization without assistance using a #16 French Foley catheter. She made one attempt and obtained dark, concentrated, yellow urine. The resident did not have any adverse reaction to the catheterization. She did not have any signs of pain, fidgeting or scratching in her groin area. Her vaginal area was normal pinkish color, clitoris was pink and normal size and there were no bruises or blood. Document 1. The ADM provided a policy on 4/16/14 titled "Courtenay Springs Village Abuse Reporting." It did not include a date of implementation or a review date. The "Policy Statement" read, "All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source. An incident or suspected incident of resident abuse must be reported either to the Abuse Hot Line Number or to the administrator or his/her designee." "Policy Interpretation and Implementation" read in part: " Any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source, . . . must be reported to either the administrator, other management staff, or the corporate office. When an alleged or suspected case of mistreatment, neglect or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of the incident: a. State Licensing and Certification Agency b. Ombudsman; if necessary c. Resident Representative d Law Enforcement officers; if needed. . . . All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected-incident-of -abuse. Such reports may be made without fear or retaliation from the facility or its staff. Reports can be made directly to the Abuse Hotline. . . . Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion or sexual assault. d. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. . . . The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to their supervisor. The following information should be reported to their supervisor: a. The name of the resident involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The names(s) of the person(s) committing the incident, if known; e. The type of abuse that was committed (i.e..: verbal, physical, sexual, etc); f. Other information that may be requested by the supervisor. . . . Upon receiving reports of physical or sexual abuse, a charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical records. . . .The charge nurse must complete a Resident Abuse Report Form and obtain a written signed and dated statement from the person reporting the incident. . . . A completed copy of the Resident Abuse Report Form and written statements from witnesses, if any, will be provided to the administrator or designee within twenty-four (24) hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within five (5) working days of the occurrence of such incidents. . . . " The Addendum to Abuse and Neglect Policy revised on 8/01/10 included, "Training"- The Director of Social Services will review the Facility Abuse and Neglect Policy with new employees during required general orientation before starting work . . . . Identification-Includes but is not limited to: Residents complaint of unusual pain or discomfort. New bruising or discoloration which is unexplained. Resident exhibiting fear, anger or crying. " The abuse definitions table included " reasonable suspicion as an objectively reasonable suspicion that a person would entertain, based upon facts that could cause a reasonable person in a like position, drawing upon his/her training and experience, to suspect abuse. " The Administrator was asked to provide any and all abuse policies and procedures on 4/30/14 at 9:30 AM. The " Abuse Reporting Policy and Procedure " was provided on 5/02/14. Document 4. Review of the Corporate-Wide "Abuse Reporting" CCP#11-03, prepared by corporate compliance & privacy officer, dated 6/11/03, approved by RHF corporate compliance committee 10/23/03, received on 5/02/14 read, "Purpose: To provide employees and facilities with the framework to fulfill their duty to report any known, suspected, or witnessed resident abuse or neglect incidents. Policy: All employees and facilities shall immediately report to the appropriate parties/entities any known, suspected, or witnessed incident(s) of resident abuse or neglect. Procedure-A. Legal Reporting Duty-All employees and those acting on the behalf of any RHF facility are under a mandatory legal duty to report any known, suspected, or witnessed incident(s) of resident abuse/neglect in any form by any person. B. Reporting by Employees-Each employee has the duty to report any resident abuse/neglect concern to both external and internal parties as described below. 1. External Reporting by Employees-Each employee is a mandatory abuse reporter under applicable federal and state law. These laws impose a duty on each employee to immediately report any known, suspected, and/or witnessed incident(s) of resident abuse/neglect in any form to the applicable government agencies . . . . Internal Reporting by Employees-a. How to Report Abuse/Neglect Any employee who knows, suspects, or witnesses resident abuse/neglect in any form shall report the incident(s) immediately to their facility s Abuse Prevention Coordinator. This report may be made prior to or after the employee reports the incident to any external parties. In addition the employee shall immediately complete a " Resident Abuse Report Form " and an Incident Report form, along with any other applicable documents as required by law. These documents shall be submitted immediately to their facility's Abuse Prevention Coordinator. b. Response to an Internal Report-Upon receipt of any report of resident abuse/neglect, the Abuse Prevention Coordinator shall promptly take the following steps: If signs and symptoms of physical or sexual abuse/neglect or other issues requiring medical attention are present, ensure that the resident ' s physician is immediately notified or emergency care is provided. If the reporter has not already done so, have the reporter complete a Resident Abuse Report Form, an Incident Report and any other requires documentation. Immediately notify the Administrator and/or Director of Nursing of the allegation so that immediate protective and other intervening actions can be identified and implemented in accordance with the General Abuse Policy. Immediately initiate the investigation process as describe in the Abuse Investigation policy. Initiate the reporting process on the behalf of the facility. E. Reporting on Behalf of the Facility 2. External Reporting Upon receipt of a report of an abuse allegation or upon suspicion of a potential abuse incident, the Abuse Prevention Coordinator, Administrator, and his/her designee shall immediately follow all applicable legal reporting obligations. In addition, all applicable documents shall be completed and submitted to the appropriate government agency(ies) within the prescribed time frames. 3. Documentation of Facility Reporting-To aid in compliance with all the facility reporting obligations and to ensure proper documentation, the Abuse Prevention Coordinator or others as assigned shall complete the state-specific RHF Facility abuse Reporting Form. The completed form shall be retained with all other abuse related documentation. The Administrator was asked to provide any and all abuse policies and procedures on 4/30/14 at 9:30 AM. Document 3. The administrator provided the "Abuse Investigation Policy and Procedure on 5/05/14. Review of the Corporate-Wide "Abuse Investigation" #CCP 11-02, prepared by the corporate compliance & privacy officer, approved by RHF corporate compliance committee dated 10/23/03 and reviewed on 11/11/05 read, " Purpose: To provide a standard framework to follow when conducting an abuse-related investigation. Policy: Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted and documented according to this policy. Procedure: A. Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted and documented by the Abuse Prevention Coordinator, Administrator, Director of Nursing or others as assigned. C. Timing and Initial Steps of Abuse-Related Investigations. Upon notification of an abuse-related report or indication of an abuse-related concern, the assigned investigator shall immediately commence the investigation process. The investigation should be completed within two (2) working days, unless extenuating circumstances. In addition to initiating the investigative process, the protective actions described in the General Abuse policy shall be immediately implemented. D. The Investigation Process-The assigned investigator shall lead and coordinate the investigation with assistance from other members of the disciplinary team. Once the need to conduct an abuse related investigation has been identified, the following steps shall be immediately completed as applicable: 1. Review any Abuse Report Forms or Incident Reports, Grievance Forms, or other completed documents specifically related to the allegation. 2. Interview all reporters. 3. Interview the resident(s) who is the subject of the abuse allegation. 4. Interview any witnesses to the alleged incident. 5. Interview the alleged abuser(s). 6. Interview staff members, agency staff, contractors, volunteers, and others from all shifts who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 7. Interview the resident ' s roommate, family members, visitors, and others who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 8. Interview any other residents who have had recent contact with the alleged abuser(s). 9. Interview the resident's physician or other health care providers who have had recent contact with the resident. 10. If applicable, review the resident's medical/health record. 11. As appropriate, have the resident ' s physician or the Medical Director physically examine the resident. 12. Conduct a social services consultation with the resident regarding the resident's feelings and reaction to the alleged incident. 13. Perform any other investigative activities as appropriate based on the allegation and other investigative findings. E. Documentation of the Investigation-1. All reporters, alleged abusers, and witness interviews shall be documented in writing and dated and signed by the interviewee. 2. Results of the physical examination and social services interview shall be documented as appropriate in the resident ' s medical/health record. 3. All follow-up and additional information required for the Incident Report shall be completed. 4. A RHF Resident Abuse Investigation Report form shall be used to formally document all investigative findings, recommended course of actions, and follow-up. F. Steps Following the Conclusion of the Investigation Following the conclusion of an abuse related investigation, the following steps shall be taken: 1. Discuss the investigative findings with the Administrator and the other members of the interdisciplinary team and Corporate Office as appropriate. 2. Complete any additional documentation and/or steps at are required to meet external reporting obligations (refer to the Abuse Reporting policy) 3. As appropriate, communicate the findings with the resident, the resident ' s family/responsible party, the reporter, and others as appropriate. 4. Identify the course of action and implement immediately. " Review of the " Retirement Housing Foundation (RHF) Resident Abuse Investigation Form " received on 5/02/14 revealed it was one page without a date and signature of the person completing the form. The form was not completed with required information. Under Alleged Abuse Incident (attach additional pages as necessary), the "report made to" was blank. The form documents type of alleged abuse - sexual. Accused Individual (attach additional pages as necessary) listed " unknown. " The ADM indicated she was the person who filled out the form However, she was not in the facility on the day the alleged abuse occurred on 3/01/14, or on 3/02/14. She said she had no other attached pages to the Resident Abuse Investigation Form. The investigation provided by the ADM and DON consisted of the " Resident Abuse Investigation Form " , statements from 4 staff members, the DON notes of whether staff "knew anything or not," and a timeframe completed by the DON. It was not thorough and did not include a summary of the findings. The "Abuse Investigation" #CCP 11-02, indicated the " Resident Abuse Investigation report Form shall be used to formally document all investigative findings, recommended course of actions, and follow up." The form does not inlcude all of the required information as listed in the policy. As of 5/05/14, the ADM had not reported the sexual assault, had not completed a thorough investigation, had not implemented measures to ensure all residents were protected from potential abuse, and had not submitted her investigative reports to state officials to include the Agency for Healthcare Administration.

Based on interview and record review, the facility failed to report immediately, thoroughly investigate, and prevent further potential abuse for an allegation of sexual assault for 1 of 6 sampled residents (#1) in a total census of 71 residents. Resident #1 was identified with bleeding from her vaginal area on Saturday, 3/01/14. At that time, the resident was agitated, resisting care, moaning, and crying while trying to put her hand near her vaginal area. The resident has dementia, was unable to make her needs known, and was totally dependent upon staff for all activities of daily living. The resident was sent to the hospital for evaluation and treatment for [REDACTED]. After the resident arrived in the hospital, the medical examination revealed vaginal trauma, bleeding, swelling to the vaginal area, and bruises to the inner thigh and abdomen. Sexual assault was suspected, a rape kit was performed, and the police and adult protective investigator were notified. The administrator and director of nursing indicated that they became aware of the hospital allegation of sexual assault on 3/01/14, but since they did not consider the resident's injuries to be from sexual abuse, they did not think they needed to report abuse, conduct an investigation, and protect any other residents from potential abuse. As of 5/05/14, the facility had not reported the abuse allegation to state officials to include the Agency for Healthcare Administration and the Department of Children and Families. The facility had not conducted a thorough investigation or implemented measures to prevent potential abuse to other residents. These practices resulted in Immediate Jeopardy starting on 3/01/14 and it was determined to be ongoing as of 5/12/14. Findings: Cross reference to F226. On 4/16/2014 at approximately 9:50 AM, an interview with the administrator (ADM) revealed the following: Resident #1 had blood in her brief at noon on 3/01/14 when the Occupational Therapist (OT) changed the brief. The OT notified the licensed practical nurse (LPN) #C who was caring for resident #1 that day, and LPN #C notified the registered nurse (RN) Supervisor. LPN #C notified the physician who said to send resident #1 to the local emergency room (ER) for further evaluation and treatment. The ADM said approximately 3 hours later, at 3 PM, the facility received a call from the hospital saying they would be admitting the resident and they have suspicions of sexual abuse due to her injures. The ADM said the resident did not return to the facility. On 4/16/14 at 12:15 PM, the ADM stated she was the abuse coordinator responsible for reporting and investigating all abuse allegations. She said she had no Federal immediate or 5-day abuse investigation reports for any residents. Review of the abuse log book for March and April revealed there was no documentation that an allegation of a sexual abuse occurred. The ADM said written statements were completed by the RN supervisor on 3/01/14 after the hospital called to say resident #1 had injuries that indicated sexual assault. She said the Department of Children and Families (DCF) investigator and a representative from the Brevard County Sheriff's Office (BCSO) arrived at the facility to investigate the sexual assault allegation on Monday, 3/03/14, two days after the resident's injuries were identified. In an interview with the ADM on 4/16/14 at 4:30 PM, she stated she did not think the allegation of sexual abuse from the hospital applied to the facility, therefore she did not follow the policies and procedures for abuse. She said she did not think they needed to investigate and report because "we are not the ones who suspect abuse, the hospital is." She said the resident was catheterized for a urine sample on 2/28/14 and she believed the catheter was the cause of the bleeding. She said she did not have reasonable suspicion of abuse when the resident was identified with bleeding in the vaginal area at noon on 3/01/14 while still in the facility. She said neither the OT, RN supervisor, nor LPN #C reported any suspicion of abuse to her. In an interview with the ADM on 4/30/14 at 11:57 AM, she said was notified by the director of nursing (DON) on 3/01/14 at 3 PM, 3 hours after the vaginal bleeding was identified, that resident #1 was sent to the hospital with bleeding and the DON told her the hospital suspected sexual assault due to the location and severity of the resident's injuries. She said she spoke with the DON on 3/01/14 regarding any issues with the resident's catheterization done on 2/28/14. She said the DON later spoke with the nurse who catheterized the resident and the DON reported no problems with the catheterization. The ADM said she thought the bruises on the resident's legs as noted when in the hospital were from staff holding the resident's legs to clean her on 3/01/14 before she went to the hospital. The ADM stated she did not suspect abuse when the BCSO and DCF came into the facility on Monday, 3/03/14. She said "they stated that she, resident #1, was assaulted." The ADM was asked "what is your policy and protocol?" The ADM stated, "if there is an individual suspected of abuse, we suspend them and based on this situation I would have had to suspend my entire staff and would have no one to take care of the residents. We sat down with the staff and did a time line of events." An interview with the OT on 4/30/14 at 10:48 a.m. revealed that she was aware of the abuse policies and procedures. She said her last in-service was on 12/01/13 via computer. She stated, "I evaluated resident #1 for therapy. She was confused, had poor cognition, was not participating in ADLs (activities of daily living), and did not have any behavioral issues. The resident was in the independent living apartment before her admission to the skilled nursing unit. She said she saw the resident on Saturday 3/01/14. She went into the resident's room at approximately noon. The resident was in bed. Her daughter-in-law (DIL) was in the room at that time. The resident was lying in bed with her shirt on and she was covered with a blanket. She said she spoke to the DIL, and then the DIL stepped out of the room. The OT said she checked the resident's incontinence brief to see if it was dry, which she normally did before providing therapy treatment. When she pulled the covers down and unfastened the brief, she noticed blood from the resident's vaginal area. The blood was clumpy in the front of the brief, spotty and localized on the resident's labia. The spot was about 1-2 inches and dark red. She covered the resident and immediately went to get LPN #C. She said LPN #C inspected the resident's brief. With the OT's assistance, LPN #C cleaned the resident. The OT held the resident's left leg and LPN #C held her right leg. She said the resident then became "very resistive. She did not want us to do this." The OT said she did not notice any discoloration or bruising. LPN #C wiped the vaginal area clean and then went to report the incident to the RN supervisor. LPN #C and the RN supervisor looked at the resident again. Then the RN supervisor told LPN #C to call the physician. The OT put a new brief on the resident who was very resistive when rolled onto her side. The resident held on to the bedrail and would not let go. The OT gently removed her hands from the rail. She said the resident was very rigid. She said the resident had not behaved this way prior to that day. Review of the nurses ' notes did not reveal any documentation of any examination of the resident when the bleeding was identified. When questioned regarding the resident's clothing, the OT stated that the resident was not wearing any pants or shorts when she first entered the room. When she returned to the room later, she said she noticed the resident was fidgeting and trying to put her hands down into the brief, pulling at her brief. The brief was not tight. The brief that had the blood in it was snug against the resident and not too tight. She stated that she informed LPN #C that the resident was pulling at her brief. In an interview on 4/30/14 at 11:30 AM with the hospitalist physician who cared for resident #1 after she was admitted to the hospital on [DATE], indicated the physician in the emergency room (ER) did a pelvic exam on the resident and identified bruising around the vagina and bleeding from the vagina. A rape kit was completed in the ER. The resident was admitted to the hospital. She had bleeding for the few days while she was at the hospital. The hospitalist physician said the resident had vaginal trauma and small vaginal tears. She said the family was notified that the resident was possibly assaulted. The hospitalist physician said bruising was present on the lower abdomen. She saw the resident at approximately 7-8 PM that evening. The resident had progressive [MEDICAL CONDITION] and was bed bound. There was no blood under the resident's fingernails. She said she was aware the nursing home stated they catheterized the resident on 2/28/14, but that would not explain why the resident had blood, bruising and vaginal tears. She said if there was any trauma from the catheterization, the resident might have blood in the opening that goes to the bladder, the urethra, not the vagina. Review of the ER disposition summary read, "Order for admission - medical. Preliminary [DIAGNOSES REDACTED]." An interview was conducted with the ADM/Abuse Coordinator on 5/01/14 at 11:57 a.m. She said she received a call from the Director of Nursing (DON) around 3 PM on 3/01/14 requesting release of a urinalysis for resident #1 to the hospital. She said the DON then told her about the resident "bleeding from the clitoris." When the ADM was asked if she was aware that the hospital informed the facility that resident #1 had signs and symptoms of sexual assault from her stay in the nursing home, she stated, "Yes." The ADM said that the RN supervisor told her that the resident was catheterized on 2/28/14, so "I thought the blood was related to the catheterization." The administrator said the urinalysis had identified a large amount of blood in the sample. Review of the laboratory report for the urinalysis results indicated the resident ' s urine sample was yellow and cloudy. It had characteristics indicative of a urinary tract infection, including blood and [MEDICATION NAME]. The ADM continued to say that on 3/03/14 she was informed that a law enforcement officer (LEO) was at the facility for the sexual assault investigation for resident #1. During the same time, a DCF investigator was also in the facility for resident #1. The ADM said she told the DCF investigator that resident #1 was on blood thinner and felt the bruises were from the staff holding the resident's legs to clean her. Review of the medical record revealed the resident was receiving 325 milligrams of aspirin daily. The ADM said, "once DCF and the LEO came to the facility, I didn't believe I still had to do my own investigation and file the immediate and 5-day reports." She said she still thought the bleeding was from the catheterization on 2/28/14, and not due to sexual assault in the facility. However, she provided no evidence of an investigation as to how a urinary catheterization could cause the bleeding, bruising, and tears to the vagina. On 5/01/14 at 12:41 PM a phone interview with LPN #D revealed that she catheterized resident #1 to obtain a urine sample on 2/28/14. She stated she performed the catheterization without assistance using a #16 French Foley catheter. She made one attempt and obtained dark, concentrated, yellow urine. The resident did not have any adverse reaction to the catheterization. She did not have any signs of pain, fidgeting or scratching in her groin area. Her vaginal area was normal pinkish color, clitoris was pink and normal size and there were no bruises or blood. Document 1. The ADM provided a policy on 4/16/14 titled "Courtenay Springs Village Abuse Reporting." It did not include a date of implementation or a review date. The "Policy Statement" read, "All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source. An incident or suspected incident of resident abuse must be reported either to the Abuse Hot Line Number or to the administrator or his/her designee." "Policy Interpretation and Implementation" read in part: " Any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source, . . . must be reported to either the administrator, other management staff, or the corporate office. When an alleged or suspected case of mistreatment, neglect or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of the incident: a. State Licensing and Certification Agency b. Ombudsman; if necessary c. Resident Representative d Law Enforcement officers; if needed. . . . All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected-incident-of -abuse. Such reports may be made without fear or retaliation from the facility or its staff. Reports can be made directly to the Abuse Hotline. . . . Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion or sexual assault. d. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. . . . The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to their supervisor. The following information should be reported to their supervisor: a. The name of the resident involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The names(s) of the person(s) committing the incident, if known; e. The type of abuse that was committed (i.e..: verbal, physical, sexual, etc); f. Other information that may be requested by the supervisor. . . . Upon receiving reports of physical or sexual abuse, a charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical records. . . .The charge nurse must complete a Resident Abuse Report Form and obtain a written signed and dated statement from the person reporting the incident. . . . A completed copy of the Resident Abuse Report Form and written statements from witnesses, if any, will be provided to the administrator or designee within twenty-four (24) hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within five (5) working days of the occurrence of such incidents. . . . " The Addendum to Abuse and Neglect Policy revised on 8/01/10 included, "Training"- The Director of Social Services will review the Facility Abuse and Neglect Policy with new employees during required general orientation before starting work . . . . Identification-Includes but is not limited to: Residents complaint of unusual pain or discomfort. New bruising or discoloration which is unexplained. Resident exhibiting fear, anger or crying. " The abuse definitions table included " reasonable suspicion as an objectively reasonable suspicion that a person would entertain, based upon facts that could cause a reasonable person in a like position, drawing upon his/her training and experience, to suspect abuse. " The Administrator was asked to provide any and all abuse policies and procedures on 4/30/14 at 9:30 AM. The " Abuse Reporting Policy and Procedure " was provided on 5/02/14. Document 4. Review of the Corporate-Wide "Abuse Reporting" CCP#11-03, prepared by corporate compliance & privacy officer, dated 6/11/03, approved by RHF corporate compliance committee 10/23/03, received on 5/02/14 read, "Purpose: To provide employees and facilities with the framework to fulfill their duty to report any known, suspected, or witnessed resident abuse or neglect incidents. Policy: All employees and facilities shall immediately report to the appropriate parties/entities any known, suspected, or witnessed incident(s) of resident abuse or neglect. Procedure-A. Legal Reporting Duty-All employees and those acting on the behalf of any RHF facility are under a mandatory legal duty to report any known, suspected, or witnessed incident(s) of resident abuse/neglect in any form by any person. B. Reporting by Employees-Each employee has the duty to report any resident abuse/neglect concern to both external and internal parties as described below. 1. External Reporting by Employees-Each employee is a mandatory abuse reporter under applicable federal and state law. These laws impose a duty on each employee to immediately report any known, suspected, and/or witnessed incident(s) of resident abuse/neglect in any form to the applicable government agencies . . . . Internal Reporting by Employees-a. How to Report Abuse/Neglect Any employee who knows, suspects, or witnesses resident abuse/neglect in any form shall report the incident(s) immediately to their facility s Abuse Prevention Coordinator. This report may be made prior to or after the employee reports the incident to any external parties. In addition the employee shall immediately complete a " Resident Abuse Report Form " and an Incident Report form, along with any other applicable documents as required by law. These documents shall be submitted immediately to their facility's Abuse Prevention Coordinator. b. Response to an Internal Report-Upon receipt of any report of resident abuse/neglect, the Abuse Prevention Coordinator shall promptly take the following steps: If signs and symptoms of physical or sexual abuse/neglect or other issues requiring medical attention are present, ensure that the resident ' s physician is immediately notified or emergency care is provided. If the reporter has not already done so, have the reporter complete a Resident Abuse Report Form, an Incident Report and any other requires documentation. Immediately notify the Administrator and/or Director of Nursing of the allegation so that immediate protective and other intervening actions can be identified and implemented in accordance with the General Abuse Policy. Immediately initiate the investigation process as describe in the Abuse Investigation policy. Initiate the reporting process on the behalf of the facility. E. Reporting on Behalf of the Facility 2. External Reporting Upon receipt of a report of an abuse allegation or upon suspicion of a potential abuse incident, the Abuse Prevention Coordinator, Administrator, and his/her designee shall immediately follow all applicable legal reporting obligations. In addition, all applicable documents shall be completed and submitted to the appropriate government agency(ies) within the prescribed time frames. 3. Documentation of Facility Reporting-To aid in compliance with all the facility reporting obligations and to ensure proper documentation, the Abuse Prevention Coordinator or others as assigned shall complete the state-specific RHF Facility abuse Reporting Form. The completed form shall be retained with all other abuse related documentation. The Administrator was asked to provide any and all abuse policies and procedures on 4/30/14 at 9:30 AM. Document 3. The administrator provided the "Abuse Investigation Policy and Procedure on 5/05/14. Review of the Corporate-Wide "Abuse Investigation" #CCP 11-02, prepared by the corporate compliance & privacy officer, approved by RHF corporate compliance committee dated 10/23/03 and reviewed on 11/11/05 read, " Purpose: To provide a standard framework to follow when conducting an abuse-related investigation. Policy: Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted and documented according to this policy. Procedure: A. Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted and documented by the Abuse Prevention Coordinator, Administrator, Director of Nursing or others as assigned. C. Timing and Initial Steps of Abuse-Related Investigations. Upon notification of an abuse-related report or indication of an abuse-related concern, the assigned investigator shall immediately commence the investigation process. The investigation should be completed within two (2) working days, unless extenuating circumstances. In addition to initiating the investigative process, the protective actions described in the General Abuse policy shall be immediately implemented. D. The Investigation Process-The assigned investigator shall lead and coordinate the investigation with assistance from other members of the disciplinary team. Once the need to conduct an abuse related investigation has been identified, the following steps shall be immediately completed as applicable: 1. Review any Abuse Report Forms or Incident Reports, Grievance Forms, or other completed documents specifically related to the allegation. 2. Interview all reporters. 3. Interview the resident(s) who is the subject of the abuse allegation. 4. Interview any witnesses to the alleged incident. 5. Interview the alleged abuser(s). 6. Interview staff members, agency staff, contractors, volunteers, and others from all shifts who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 7. Interview the resident ' s roommate, family members, visitors, and others who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 8. Interview any other residents who have had recent contact with the alleged abuser(s). 9. Interview the resident's physician or other health care providers who have had recent contact with the resident. 10. If applicable, review the resident's medical/health record. 11. As appropriate, have the resident ' s physician or the Medical Director physically examine the resident. 12. Conduct a social services consultation with the resident regarding the resident's feelings and reaction to the alleged incident. 13. Perform any other investigative activities as appropriate based on the allegation and other investigative findings. E. Documentation of the Investigation-1. All reporters, alleged abusers, and witness interviews shall be documented in writing and dated and signed by the interviewee. 2. Results of the physical examination and social services interview shall be documented as appropriate in the resident ' s medical/health record. 3. All follow-up and additional information required for the Incident Report shall be completed. 4. A RHF Resident Abuse Investigation Report form shall be used to formally document all investigative findings, recommended course of actions, and follow-up. F. Steps Following the Conclusion of the Investigation Following the conclusion of an abuse related investigation, the following steps shall be taken: 1. Discuss the investigative findings with the Administrator and the other members of the interdisciplinary team and Corporate Office as appropriate. 2. Complete any additional documentation and/or steps at are required to meet external reporting obligations (refer to the Abuse Reporting policy) 3. As appropriate, communicate the findings with the resident, the resident ' s family/responsible party, the reporter, and others as appropriate. 4. Identify the course of action and implement immediately. " Review of the " Retirement Housing Foundation (RHF) Resident Abuse Investigation Form " received on 5/02/14 revealed it was one page without a date and signature of the person completing the form. The form was not completed with required information. Under Alleged Abuse Incident (attach additional pages as necessary), the "report made to" was blank. The form documents type of alleged abuse - sexual. Accused Individual (attach additional pages as necessary) listed " unknown. " The ADM indicated she was the person who filled out the form However, she was not in the facility on the day the alleged abuse occurred on 3/01/14, or on 3/02/14. She said she had no other attached pages to the Resident Abuse Investigation Form. The investigation provided by the ADM and DON consisted of the " Resident Abuse Investigation Form " , statements from 4 staff members, the DON notes of whether staff "knew anything or not," and a timeframe completed by the DON. It was not thorough and did not include a summary of the findings. The "Abuse Investigation" #CCP 11-02, indicated the " Resident Abuse Investigation report Form shall be used to formally document all investigative findings, recommended course of actions, and follow up." The form does not inlcude all of the required information as listed in the policy. As of 5/05/14, the ADM had not reported the sexual assault, had not completed a thorough investigation, had not implemented measures to ensure all residents were protected from potential abuse, and had not submitted her investigative reports to state officials to include the Agency for Healthcare Administration. On 5/19/14, the facility implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F225. The severity and scope of the deficiencies was lowered to isolated, no actual harm with potential for no more than minimal harm to other residents who receive services from staff due to the need to implement and monitor effectiveness of their QA plan to prevent reoccurrence.

Based on interview and record review, the facility failed to implement policies and procedures to prohibit abuse for 1 of 6 sampled residents (#1) of a total facility census of 71. Resident #1 was identified with bleeding from her vaginal area on Saturday, 3/01/14. At that time, the resident was agitated, resisting care, moaning, and crying while trying to put her hand near her vaginal area. The resident has dementia, was unable to make her needs known, and was totally dependent upon staff for all activities of daily living. The resident was sent to the hospital for evaluation and treatment for [REDACTED]. Medical examination at the hospital revealed reisient #1 had vaginal trauma, bleeding, swelling to the vaginal area, and bruises to the inner thigh and abdomen. Sexual assault was suspected, a rape kit was performed, and the police and adult protective investigator from the Department of Children and Families (DCF) were notified. The administrator (ADM) and director of nursing (DON) indicated that they became aware of the hospital allegation of sexual assault on 3/01/14, but since they did not consider the resident's injuries to be from sexual abuse, they did not think they needed implement their policies and procedures for abuse in which the purpose is to "prevent, identify, investigate, and report allegations of abuse while protecting the safety of our residents and respecting our residents' rights." As of 5/05/14, the facility had not completed and operationalized 5 of the 7 components of their policy and procedure: "III. prevention, IV. identification, V. protection, IV. investigation, and VII. reporting." These practices resulted in Immediate Jeopardy starting on 3/01/14 and determined to be ongoing as of 5/12/14. Findings: Resident #1 was initially admitted to the facility on [DATE] and was readmitted to the facility after hospitalized from [DATE] to 2/23/14. Review of the medical record revealed that she had the following [DIAGNOSES REDACTED]. The nurses' notes did not document any signs of agitation, crying, or resisting care after she returned from the hospital from 2/24/14, five days prior to 3/01/14. The nurses' notes indicated the resident did not have any signs/symptoms of pain or distress. Review of the 5 day minimum data set (MDS) assessment that included the timeframe of 2/23/14 to 3/01/14, revealed that the resident was unable to complete the brief interview for mental status exam because the resident is rarely/never understood. The brief interview for mental status exam is a brief screener that aids in detecting cognitive impairment. The resident had long term and short term memory problems. She was severely impaired with decision making. She had symptoms of [MEDICAL CONDITION] including inattention, disorganized thinking, altered level of conscious (startled easily to any sound or touch, repeatedly dozing off when being asked questions, but responded to voice and touch, and was very difficult to arouse and keep aroused for the interview). The assessment indicated the resident had evidence of acute change in mental status. The resident was now frequently incontinent of bowel and bladder. She required supervision with eating and extensive assistance with locomotion using a wheelchair. The resident was totally dependent upon staff for mobility, transfers, toileting, hygiene, and eating. She was not able move from her room without assistance. She had no behaviors of resisting care or activities of daily living (ADL) assistance. The MDS indicated the resident was discharged to an acute hospital with return anticipated on 3/01/14. In an interview with the OT on 4/16/14 at 10:12 AM, she said she went to the resident's room before lunch on 3/01/14. She unfastened the incontinent brief to see if the resident needed to be changed and she saw blood in the brief. She said she then went to get LPN #C, who saw the blood and went to get the RN supervisor. The OT and the RN supervisor had to hold the resident's legs open to clean the resident. She said the resident was not communicating with them, but she was pulling at the brief with her hands. On 4/30/14 at approximately 10:45 AM, the OT added that the resident was very resistive to care on 3/01/14 when she and the RN supervisor were attempting to clean the blood. On 3/01/14, the resident was sent to the emergency room (ER) for hopsital care and treatment of [REDACTED]. Review of the hospital ER physician documentation dated 3/01/14 for resident #1, revealed the preliminary [DIAGNOSES REDACTED]. The notes documented, at 1:41 PM "patient presents with pelvic pain, vaginal bleeding. The symptoms/episode began/occurrence at unknown time....Patient brought in by emergency medical service (EMS). Upon arrival patient only speaking in French, refusing to speak in English and not fully cooperative....At 1:50 PM pelvic exam: external exam: external blood clots, moderate swelling of the labia bilateral, mild ecchymosis of the left labia. Speculum exam: scant bleeding, superficial excoriation with mild bleeding, discharge, bloody, the nurse was present for the exam....At 1:53 PM Differential Diagnosis: [REDACTED]. Physician consultation: consulted DCF for possible sexual abuse due to physical exam findings." The hospital records read: 1:56 PM - "behavior/mood is uncooperative, affect is animated, acting appropriately, but refusing to answer, patient stating 'wee' to most questions" 1:58 PM - "patient has history of dementia" 3:15 PM - "the patient's symptoms are unchanged despite medication administration. Response to treatment: the patient's symptoms have mildly improved after treatment. Physician consultation: Consulted Brevard Sheriff and Sexual Assault Victim Services (SAVS) nurse for alleged sexual assault." 7:05 PM - "rape examination performed with registered nurse and Deputy present, swabs collected and handed off to law enforcement." 7:20 PM - "mild ecchymosis to the inner right thigh, mild ecchymosis to the abdomen." Review of the hospital medical history and physical dated 3/01/14, read, "Gynecologic: she has bruising of the clitoris with blood present and coming from the vagina, some small clots, minimal blood at this time compared to the exam done in the emergency department." Review of the hospital discharge summary dated 3/05/14 revealed the following discharge Diagnoses: [REDACTED]." Upon hospital discharge, the resident was admitted to another skilled nursing facility. On 4/16/14 at 9:15 AM, in an interview with the administrator (ADM), she said a representative from DCF was in the facility the previous week on 3/03/14, to investigate alleged sexual abuse for resident #1. The ADM said she had completed her investigation prior to 4/16/14. She said she was the Abuse Coordinator for the facility. On 4/16/2014 at approximately 9:50 AM, an interview with the ADM revealed the following. Resident #1 had blood in her brief at noon on 3/01/14 when the occupational therapist (OT) started to change the brief before lunch. The OT notified the licensed practical nurse (LPN) #C who was caring for resident #1 that day, and LPN #C notified the registered nurse (RN) supervisor. LPN #C notified the physician who said to send resident #1 to the ER for further evaluation and treatment. The ADM said approximately 3 hours later, the facility received a call from the hospital saying they would be admitting the resident to the hospital and they have suspicions of sexual abuse. On 4/16/14 at 12:15 PM, the administrator stated she did not have any Federal immediate or 5-day abuse investigation reports. In an interview with the ADM on 4/16/14 at 4:30 PM, she stated she did not think the allegation of sexual abuse from the hospital applied to the facility. She said she did not think they needed to investigate and report because "we are not the ones who suspect abuse, the hospital is." She said the resident was catheterized for a urine sample on 2/28/14 and she believed the catheter was the cause of the bleeding, so she did not have reasonable suspicion of abuse when the resident was identified with bleeding in the vaginal area at noon on 3/01/14 while still in the facility and neither the OT, RN supervisor, nor LPN #C reported any suspicion of abuse to her. An interview with the OT on 4/30/14 at 10:48 a.m. revealed that she was aware of the abuse policies and procedures. She said her last in-service was on 12/01/13 via computer. She stated, "I evaluated resident #1 for therapy. She was here and then went back out to the hospital. She was confused, had poor cognition, was not participating in activities of daily living (ADLs), and did not have any behavioral issues. The resident was in the independent living apartment before her admission to the skilled nursing unit. She said she saw the resident on Saturday 3/01/14. She went into the resident's room at approximately noon. The resident was in bed. Her daughter-in-law (DIL) was in the room at that time. The resident was lying in bed with her shirt on and she was covered with a blanket. She said she spoke to the DIL, and then the DIL stepped out of the room. The OT said she checked the resident's incontinence brief to see if it was dry, which she normally did before providing therapy treatment. When she pulled the covers down and unfastened the brief, she noticed blood from the resident's vaginal area. The blood was clumpy in the front of the brief, spotty and localized on the resident's labia. The bloody spot was about 1-2 inches and was dark red. She covered the resident and immediately went to get the LPN #C. She said LPN #C inspected the resident's brief. With the OT's assistance, LPN #C cleaned the resident. The OT held the resident's left leg and LPN #C held her right leg. She said the resident then became "Very resistive. She did not want us to do this." The OT said she did not notice any discoloration or bruising. LPN #C wiped the vaginal area clean and then went to report the incident to the RN supervisor. LPN #C and the RN supervisor looked at the resident again and then the RN supervisor told LPN #C to call the physician. The OT put a new brief on the resident who was very resistive when rolled onto her side. The resident held on to the bed rail and would not let go. The OT gently removed her hands from the rail. She said the resident was very rigid. She said the resident had not behaved this way prior to that day. In an interview with the RN supervisor on 4/16/14 at 10:20 AM, she said LPN #C asked her to come to resident #1's room because the resident had blood in her incontinence brief. She said she had to help hold the resident's legs open so LPN #C could clean her. She saw a "quarter" sized blood clot just below the clitoris. She told LPN #C to call the physician. She said she should have examined the resident at that time, but she did not. In an interview with the RN supervisor on 4/30/14 at 12:55 PM, she said she was called to resident #1's room by LPN #C because the resident was identified with vaginal bleeding. She said the resident was in bed and was moaning while the OT and LPN #C were holding her legs open. She said she saw a nickel sized blood clot and her clitoris was bigger than normal. She said she informed the resident's daughter-in-law who was present at that time, that the resident had vaginal bleeding and they were going to notify the physician. In an interview with CNA #H on 4/16/14 at 10:33 AM and on 4/30/14 at 12:16 PM, who cared for resident #1 on 3/01/14 and several times since the resident was first admitted on [DATE], she stated she provided incontinence care to the resident between 9 AM and 9:30 AM on 3/01/14. She said when she wiped the resident, she did not act like she was in pain and there was no blood, bruising, or evidence of injury. She did not need any other staff to hold the resident's legs open to clean her. She said the resident was not acting differently than usual the morning of 3/01/14. She said she did not think the resident was capable of putting her hands in her brief when it was secured. She said the resident can be fidgety, but when she holds a ball, it calms her. She said she usually changes the resident's incontinence brief 3 times per shift. She said the majority of the time during the day, a family member is visiting. She said the resident was never resistant to care with her and she never pushed her hands away when doing peri care. In an interview with the ADM on 4/30/14 at 11:57 AM, she said was notified by the DON on 3/01/14 at 3 PM that resident #1 was sent to the hospital with bleeding and the DON told her the hospital suspected sexual assault due to the location and severity of the resident's injuries. She said she spoke with the DON on 3/01/14 regarding any issues with the resident's catheterization on 2/28/14. She said the DON later spoke with the nurse who catheterized the resident and the DON reported no problems with the catheterization. The ADM said she thought the bruises on the resident's legs as noted when in the hospital were from staff holding the resident's legs to clean her on 3/01/14. The ADM stated she did not suspect abuse when the Brevard County Sheriff Officer (BCSO) and a DCF investigator came into the facility on Monday, 3/03/14. She said "they stated that she was assaulted." When the ADM was asked about the facility's policy and protocol, she stated "if there is an individual suspected, we suspend them. Based on this situation I would have had to suspend my entire staff and would have no one to take care of the residents. We sat down with the staff and did a time line of events." She confirmed no staff were suspended. On 4/30/14 at 12:51 PM, an interview with the RN supervisor revealed that on 3/01/14 she called the DON to notify her that the BCSO and DCF investigator were called by the hospital in regards to resident #1's hospital admission for vaginal bleeding and bruises. She said she was instructed by the DON to go into the resident's room to see if there were any objects with blood on them. She said she decided to do a timeline, "because if anything happened and if there was an investigation I would have the information. I guess I did suspect a problem because I started a time line." She said that neither the DON, nor the Administrator came into the facility at that time, "my contact was by phone only." She said she went to talk to 4 staff members: CNA #I-fed resident #1 breakfast that day, CNA #H-direct care CNA for resident #1 that day for 7-3 shift, and LPN #C-nurse caring for resident #1 that day for 7-3 shift. The RN supervisor said she obtained written statements from CNA #H and LPN #C, but did not get a written statement from CNA #I. She did not obtain statements from any other staff members, residents, or family. Review of the timeline that was completed by the RN supervisor revealed 2 pieces of paper with typed information. The top of the page listed (resident #1's name) timeline and the following information: 2/28/14 - order was carried out by LPN #D at 5 AM for lab pick up at 6 AM (per facility policy). 3/01/14 - Approximately 8 AM CNA #I fed resident #1 breakfast. 3/01/14 - (no time) after breakfast CNA #H changed the residents brief and there was nothing unusual noted. 3/01/14 11:15 AM - Daughter-in-law came in to visit and was present when the OT was there at 12 PM. 3/01/14 12 PM - OT #A started to change resident #1 brief and noticed blood. She reported this to LPN#C, who also contacted RN supervisor. Resident #1 was assessed and the physician was notified. Orders obtained to send resident #1 to the ER for evaluation. 3/01/14 4 PM - a call was received from hospital charge nurse stating that DCF has been called because of bleeding, bruising, and abrasions to the vaginal area. ER nurse was informed about the urinalysis and she requested a copy. Lab report indicated that blood was in the specimen and that resident #1 did have a urinary tract infection. RN supervisor called and spoke with the ER nurse. She informed me that DCF has been called because of bleeding, bruising and abrasions to vaginal area. ER nurse was informed that a call was placed to the nurse (LPN #D) regarding the labs and how the urinalysis was obtained. ER nurse requested labs be faxed to them. Call placed to the DON, left message for the administrator. On 5/01/14, a review of employee written statements obtained by the RN supervisor revealed the following statements for 4 employees: RN supervisor's own statement dated 3/01/14, typed and signed by her revealed, at 12:05 PM, LPN #C called her to resident #1 room because the resident was bleeding from the urethral area. "The brief had a moderate amount of blood and urine in it and I noticed that a small blood clot below the resident's clitoris." Her statement indicated the resident was moaning, clenching her legs, and grabbing the nurse's arm as she was cleaning her peri area. It looked as if the resident was having pain. "At 3:03 PM LPN #C informed me that she received a call from the hospital nurse and they believe the bleeding is coming from the clitoris area (swollen) and some bruising on the labia." At 3:09 PM called DON with above information. LPN #C's statement, dated 3/01/14, was handwritten and signed, and revealed, at 12 noon she was called into resident #1's room by the OT because the resident was bleeding from the vaginal area. The resident was very agitated, putting her hand down towards her vaginal area. I tried pulling the resident's legs apart to see where the blood was coming from, but every time I tried to do this, the patient became very agitated with moaning and crying." Her statement indicated she informed the nursing supervisor and called the physician." The nurse's statement indicated the daughter-in-law was in the facility at that time and she informed her. OT's statement, not dated, was typed and not signed, and revealed on 3/01/14 at 11:30 AM, she went to resident #1's room for scheduled occupational treatment. Upon checking the resident's brief, she noticed blood in the brief and on her vagina. She immediately notified LPN #C. LPN #C examined the resident and noticed blood in the brief and on her vagina. She then notified the RN supervisor. LPN #C stated that she was calling the doctor. "I noticed that resident #1 continued grabbing at her brief." CNA #H's statement, not dated, was handwritten and signed, and revealed that she gave resident #1 care right after breakfast, "She was perfectly fine." Her statement indicated she changed her and there was nothing in her brief. "I got her dressed and left her in her bed with no problems." On 5/01/14 at 5:27 PM, in a phone interview with LPN #C, she explained resident #1's condition on 3/01/14. She said, "The resident was fine nothing out of the ordinary at 9 AM. The therapist came to get me and said the resident was bleeding like having a period. When we went into the room, I think it was before lunch. The therapist opened the resident's brief and there was quite a lot of blood in the brief. There was also dried blood, but not on the outside. I got some wash rags with warm water to get in there to see what was going on. We tried to pull her legs apart and the resident would just not let us open her legs. The resident was fighting. When I washed between the labia, the resident hollered. There was a significant amount of blood. I called the Supervisor and explained what was going on. I called the MD and told him that I was not sure where the blood was coming from. Every time we tried to open her legs the resident was screaming and she was trying to protect herself. When resident went to the hospital the resident was agitated. " LPN #C said that the hospital ER nurse called her on 3/01/14 at approximately 3 PM, and stated that resident #1 had bruises and tears on her vagina. She said she asked the ER nurse if the resident was raped and the ER nurse stated "yes that is what we think happened." LPN #C said she notified the RN supervisor of what the ER nurse said. She said she spoke with the police and the DCF investigator and she told her she did not think the resident was raped because everything was going ok that day. On 5/01/14 at 12:11 PM, in an interview with the DON, she stated that she had talked with the 3-11 and 11-7 shifts. Review of the documentation completed by the DON revealed a 2 page list of hand written names that was not dated or signed. The hand written list consisted of one staff member listed under 2/27/14, 11-7 shift, nine staff members listed under 2/28/14, 11-7 shift, and 14 staff members listed under 3/01/14, with no shift noted. The documentation did not include any statements from the staff members listed with the exception of CNA #H, LPN #C, and the RN supervisor. The note for those 3 staff members listed "see attached statement." However, no statements were attached. It consisted of notes such as: "nothing," "no problems," "didn't see anything." The documentation did not include interviews with any residents or family members. On 5/01/14 at 12:41 PM, a phone interview with LPN #D revealed that she catheterized resident #1 on 2/28/14. She stated she performed the catheterization by herself using a #16 French Foley catheter. She made one attempt obtaining dark, concentrated, yellow urine. The resident had no reaction to the catheterization. She did not have any signs of pain, fidgeting or scratching in her groin area. Her vaginal area was normal pinkish color, clitoris was pink and normal size and there were no bruises. Review of the training documentation for LPN #D indicated she had catheter training skills completed on 8/16/13. Record review of the 2/28/14 nurses' notes for resident #1 did not reveal any documentation of catheterization for urinalysis. Review of the laboratory results for the urinalysis collected on 2/28/14 at 5:50 AM, revealed characteristics indicative of a urinary tract infection. There were no red blood cells and a high amount of white blood cells. [MEDICATION NAME] were listed as positive and blood, urine, was listed as large. "Blood in the urine ca be eithe gross (visible) or microscopic (blood cells only visible through a microscope). Gross (visible) blood in the urine appears as light pink to deep red." (medicinenet.com). The urine color listed on the report was yellow and cloudy. It did not indicate any gross (visible) blood. The final sensitivity report revealed the resident had greater than (>)100,000 colony forming units/milliliter of pseudomonas aeruginosa, "a bacteria found widely in the environment that causes infections." (cdc.gov). On 5/01/14 at 12:11 PM, an interview with the DON revealed that she received a phone call from the RN supervisor on 3/01/14 at 12 PM that resident #1 had blood in her brief and she was sent to the hospital. She said, "The RN nursing supervisor called me again on 3/01/14 at 4 PM stating that the hospital ER nurse had called to inform the facility that the resident had bruising and swelling of the vaginal area and they thought that the resident had been sexually assaulted. The Brevard Sheriff Department and DCF were called. I instructed RN supervisor #B to do a timeline and interview staff. I spoke to other staff members, via telephone, LPN #D, LPN #C, and RN supervisor on 3/02/14. I spoke to CNA #I by phone, but I have no documentation. He stated that he was in the room and fed her breakfast. I spoke to LPN #D on 3/2/14 regarding the catheterization and she stated that the resident was not fighting when she catheterized her. The resident just laid there and I got the specimen." Review of the Retirement Housing Foundation (RHF) "Resident Abuse Investigation Form" received on 5/02/14 revealed it was one page with no date, no signature of the person completing the form, and the form was not completed with required information. Under alleged abuse incident, the "report made to" was blank. The form documents type of alleged abuse - sexual. The ADM indicated she was the person who filled out the form, however she was not in the facility on the day the alleged abuse occurred on 3/01/14 or on 3/02/14. The investigation provided by the ADM and DON consisted of the "Resident Abuse Investigation Form", statements from 4 staff members, the DON notes of whether staff "knew anything or not", and a timeframe completed by the DON. It was not thorough and did not include a summary of the findings. The ADM was asked to provide any and all abuse policies and procedures on 4/16/14 at 12:39 PM. The ADM provided 4 separate documents on 4 separate days as follows. Document 1 "Courtenay Springs Village Abuse Reporting" - The ADM provided a policy on 4/16/14 titled "Courtenay Springs Village Abuse Reporting." It did not include a date of implementation or a review date. The "Policy Statement" read, "All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source. An incident or suspected incident of resident abuse must be reported either to the Abuse Hot Line Number or to the administrator or his/her designee....Policy Interpretation and Implementation....2. Any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source.... must be reported to either the administrator, other management staff, or the corporate office. 3. When an alleged or suspected case of mistreatment, neglect or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of the incident: a. State Licensing and Certification Agency b. Ombudsman; if necessary c. Resident Representative d. Law Enforcement officers; if needed....All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected-incident-of -abuse. Such reports may be made without fear or retaliation from the facility or its staff. Reports can be made directly to the Abuse Hotline....4. "c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion or sexual assault. d. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment....5. The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to their supervisor. The following information should be reported to their supervisor: a. The name of the resident involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The names(s) of the person(s) committing the incident, if known; e. The type of abuse that was committed (i.e..: verbal, physical, sexual, etc); f. Other information that may be requested by the supervisor....6. "Upon receiving reports of physical or sexual abuse, a charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical records....7. The charge nurse must complete a Resident Abuse Report Form and obtain a written signed and dated statement from the person reporting the incident....8. A completed copy of the Resident Abuse Report Form and written statements from witnesses, if any, will be provided to the administrator or designee within twenty-four (24) hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within five (5) working days of the occurrence of such incidents...." The Addendum to "Abuse and Neglect Policy" revised on 8/01/10 included, "Training" - The Director of Social Services will review the Facility Abuse and Neglect Policy with new employees during required general orientation before starting work....Identification Includes but is not limited to: Residents complaint of unusual pain or discomfort. New bruising or discoloration which is unexplained. Resident exhibiting fear, anger or crying." The abuse definitions table included "reasonable suspicion as an objectively reasonable suspicion that a person would entertain, based upon facts that could cause a reasonable person in a like position, drawing upon his/her training and experience, to suspect abuse." Document 2 "General Abuse Policy" - The ADM was asked to provide all abuse policies and procedures on 4/30/14 at 9:30 AM. The ADM provided later that same day on 4/30/14, the Corporate-Wide "General Abuse Policy" no CCP#, prepared by the corporate compliance and privacy officer, dated 6/11/13, no approved date. It listed, "Purpose: To identify, investigate, and report allegations of abuse while protecting the safety of our residents and respecting our residents' rights. Scope: This policy applies to our communities with a healthcare component on-site, including SNF, ECC, ALF, or other licensed units. At these communities, this policy applies to the entire community. Policy: It is Retirement Housing Foundation (RHF) policy to promote residents' right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, neglect, exploitation, or any other form of abuse. Any such actions by employees and others directed towards our residents is prohibited and appropriated action shall be taken immediately....This policy includes the following elements: (I) screening, (II) training and education, (III) prevention, (IV) identification, (V) protection, (VI) investigation, and (VII) reporting. Procedure....II. Training and Education: A. Employees training and education will be conducted for all employees for the facility and shall meet all applicable and state legal requirements. Training shall at a minimum include the following items: what constitutes abuse and what types of abuse can occur, how to identify/recognize the different types of abuse, how to recognize symptoms of burnout, frustration, and stress that may lead to abuse, how to reduce stress levels to prevent abuse, when and how employees stall report their knowledge related to abuse allegations without fear of retaliation, and the abuse reporting non-retaliation policy. This training shall be held regularly, but at least during the initial orientation period of employees and annually thereafter. III. Prevention Each facility will take measures reasonably to prevent abuse-related incidents: 1. Screening 2. Training and education 3. Residents, family and legal representatives will be provided with information how and to whom they may report concerns, incidents, and grievances to without fear of retaliation 4. Posting of telephone numbers of all applicable local and state agencies 5. Grievance forms will be made readily available throughout the facility 6. Ensuring that staffs are granted appropriate breaks during work periods and adequate time off between shifts to reduce stress levels 7. For situations in which any type of abuse is more likely to occur are identified, appropriate interventions shall be implemented to minimize the risk, including, but not limited to: a. Minimizing any secluded physical environments b. Assigning knowledgeable and a sufficient number of staff to meet the needs of the residents c. Supervisory staff monitoring employee, non-employee, and the behavior of others for potential abuse concerns, such as the use of derogatory language, rough handling, ignoring resident, etc. d. Assessing, developing, implementing, and monitoring individualized care plans for the resident with needs and behaviors which may result in high risk for abuse. These residents may include those with a history of aggressive behavior, intrusive behavior, self-injurious behavior, communication disorders, high acuity, and those with total ADL dependence. IV. Identification - Assessment shall be completed for all skilled nursing facility (SNF), assisted living facility (ALF

Based on interviews and record review, the administration failed to efficiently and effectively coordinate implementation of policies and procedures regarding abuse allegations. One of 6 sampled residents (#1) in a total census of 71 sustained injuries consistent with alleged sexual assault. This failure put the other 70 residents at risk for potential abuse and serious injury. The administration failed to direct and monitor staff to ensure residents were protected from potential abuse while abuse allegations are reported and investigated. The administration failed to investigate the incident when resident #1 was identified with bleeding from her vaginal area at 12 PM on 3/01/14. The resident was agitated, moaning, and crying while trying to put her hand near her vaginal area. She was sent to the hospital for treatment at that time. The administration failed to investigate the allegation of sexual assault after they were notified by the hospital at 4 PM on 3/01/14, that the resident had injuries consistent with sexual assault. The facility failed to implement and monitor interventions post incident to prevent further potential abuse. As a result of this failure, resident #1 and the other 70 residents were at risk for serious injury from abuse. These practices resulted in Immediate Jeopardy starting 3/01/2014 and it was determined to be ongoing on 5/12/14. Findings: Cross Reference to F225 and F226. On 4/16/2014 at approximately 9:50 AM, an interview with the administrator (ADM) revealed the following. Resident #1 had blood in her brief at noon on 3/01/14 when the occupational therapist (OT) started to change the brief before lunch. The OT notified the licensed practical nurse (LPN) #C who was caring for resident #1 that day. LPN #C notified the registered nurse (RN) supervisor. LPN #C notified the physician who said to send resident #1 to the local emergency room (ER) for further evaluation and treatment. The ADM said approximately 3 hours later, the facility received a call from the hospital saying they would be admitting the resident and they have suspicions of sexual abuse. On 4/16/14 at 12:15 PM, the ADM stated she was the abuse coordinator and she is responsible conducting abuse-related investigations. The facility abuse investigation policy listed other staff who are qualified to assist in an abuse investigation to include: Administrator, director of nursing (DON), Regional Manager, Director of Quality Assurance (QA), and corporate Compliance and Privacy officer. In an interview with the ADM on 4/16/14 at 4:30 PM, she stated she did not think the allegation of sexual abuse from the hospital applied to the facility, therefore she did not follow the policies and procedures for abuse. She said she did not think they needed to investigate and report abuse because "we are not the ones who suspect abuse, the hospital is." The job descriptions for the administrator and DON were provided on 5/12/14. The job description for the Health Center Administrator (HCA) was signed by the administrator on 3/21/11. Qualifications: the HCA must be qualified by training and experience with sound management skills and the ability to make sound mature judgments. Job Summary: The HCA is responsible for planning organizing, staffing , directing, coordinating, reporting, admissions . . . Responsibilities and Duties: 2. Oversee departmental policies regarding duties and activities of the staff assigned, which assure health and safety of the resident and others and explain these policies so that the aim and purpose of the facility may be achieved by cooperative effort. 3. Supervise the recruitment, employment, and discharge of all staff . . . and assures that there are adequate numbers of staff to meet the needs of the residents on a 24 hour basis. 4. Writes Health Center policies and individual duties. . . . 6. Supervise all department heads. . . . 9. Manages and assist with all inspections performed by the state agencies when appropriate. 11. Study and keep current with the changes of all regulations. The job description for the Director of Nursing (DON) was signed by the DON on 7/02/12. Job Description: The DON has oversight of all nursing functions within the facility. She develops policies, procedures, objective and standards of practice for the entire nursing staff. Plans, coordinates, organizes, supervises, directs and evaluates nursing activities and personnel. She works to create a rehabilitative attitude among nursing members in order to contribute to the total therapeutic environment of the facility. The DON acts as the Risk Manager of the facility. Accountability: The DON reports to the Administrator. Duties and Responsibilities: 1. Defines and implements the philosophy, objectives, policies, procedures and standards of nursing practice. 2. Plans, organizes, directs, and evaluates nursing activities. 5. Maintain nursing records and reports. 7. Employs, assigns, discharges, with the Administrator's approval, schedules, guides and counsels nursing services personnel on professional matters. 10. Provides direct assistance to charge nurses. Provides direct care as necessary. 12. Evaluates quality and effectiveness of nursing care practices and activities. 18. Maintain current knowledge and practice of nursing trends. . . . 19. Ensures quality nursing care services and maintenance of continuity. 20. Advises the administrator on nursing matters and interprets and directs implementation of the Health Center's policy. 21. Responsible for compliance with Federal, State, and local standards and regulations. 22. Responsible for the execution of resident care policies. . . 24. Assumes the responsibilities of the Administrator in her absence. 28. Assures that each accident or incident involving a resident is fully documented and reported. Nurse Performance Expectations was signed by the DON on 7/02/12. Employees are required to report any signs of alleged or suspected abuse/neglect. If any suspected or alleged abuse in reported to them, they are required to report this also. An interview was conducted with the administrator on 4/30/2014 at 11:30 AM. She stated that the DON made her aware of the incident on 3/01/14 at approximately 3 PM. She stated that they did not believe that the resident had been assaulted in any way, but that the bleeding was a result of the resident having been catheterized the day before. When she was asked if there was any investigation done at the time, she said that the weekend supervisor interviewed nurse #C on the day of the incident and other staff were interviewed a few days later. She said that they did not have to suspend any of the staff as they did not believe that the resident was assaulted. She said she did not think there was a problem so she did not do anything further. She was unable to provide any investigation as to how a catheterization could cause vaginal trauma and bleeding in a manner in that would present as sexual assault. In a telephone interview conducted on 5/02/14 at 2:01 PM, the ADM was asked if the incident was discussed at their quality assessment and assurance (QAA) committee meeting. She stated that the incident was briefly discussed at the QAA meeting held on 3/18/14. She said she discussed the sexual assault allegation with the medical director on 3/03 or 3/04/14 and he did not make any recommendations. It was ADM's belief that the root cause of resident #1's vaginal bleeding was a due to the catheterization done the day before on 2/28/14. The resident had been catheterized on 2/28/14 to obtain a urine specimen. However, the ADM confirmed that there were no difficulties with the catheterization. She was unable to explain how a catheterization would cause the same level of trauma and bleeding as a sexual assault. She further added that there was no performance plan to address the sexual abuse as it was their belief that this was not the case.