Every finding on record at Timberlane Health & Rehabilitation

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure two front locking mechanisms were locked during a wheelchair transport of one (Resident #1) of five residents reviewed for van transportation safety. This failed practice resulted in an injury associated with the death of Resident #1. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to CFR 483.25(d) (Accidents) at a scope and severity of J. The Administrator was informed of the IJ on [DATE] at 2:25 PM, and notified it was considered to be Past Non-Compliance (PNC). The findings include: A review of an admission Record for Resident #1 indicated the facility admitted Resident #1 with diagnoses that included dependence on renal dialysis, muscle weakness, and cerebrovascular disease (stroke). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #1 was a maximum assist or dependent on staff with all activities of daily living and used a manual wheelchair for mobility. A review of Resident #1's Care plan, revised on [DATE], revealed the resident was at risk for bleeding due to being on antiplatelet medications. Interventions included monitoring for any adverse reactions including black tarry stools, sudden and severe headaches, and blood tinged or red blood in the urine. Dependence on dialysis was noted on the Care Plan with three appointments a week, Monday, Wednesday, and Friday. Interventions to assist with dialysis involved monitoring the resident's left upper arm for any bleeding or infection. A review of the Medication Administration Record, (MAR) for July of 2026 revealed Resident #1 had received an antiplatelet medication on [DATE]. A review of the facility's Motor Vehicles policy with a revision date of [DATE] revealed if driving the facility van, the employee must be trained on proper procedure and van usage During an interview on [DATE] at 3:59 PM, Driver #1 described the process to load residents into the facility van. They first load in one resident, applying the wheelchair brake and two wheelchair securement system (WSS) straps to the front of the resident's wheelchair before tightening the locking mechanism until a click was heard. Then a second resident was loaded, and the process was repeated. Driver #1 stated they would then move back to the first resident; staff would secure the back of the wheelchair with two more WSS straps and tighten the locking mechanism until a click was heard. A WSS strap was placed around the resident's waist, and the wheelchair was then shaken to see if it moved. This process was repeated for the second resident. -Driver #1 stated they (Driver #1) interrupted the normal process on [DATE] as they were in a hurry to start up the van to get the air conditioner running to cool off the residents. Driver #1 loaded in both Resident #1 and Resident #5, then applied the wheelchair brakes and WSS straps to the front of their wheelchairs and tightened the locking mechanisms. Then Driver #1 went to the front of the van and started it before returning to finish securing the residents. Driver #1 stated normally they fully strap down the residents in the van before starting it. I thought I had it tight enough, but I obviously didn't because it came loose. Driver #1 stated when returning from the dialysis center, during an uphill portion of the road, Resident #1's wheelchair fell backwards. Driver #1 immediately stopped the van and called the Director of Nursing (DON), who arrived onsite within 10 minutes. Upon the DON's arrival, Resident #1 became unresponsive. The DON did not find a pulse and immediately started Cardiopulmonary Resuscitation (CPR). Emergency Medical Technicians (EMT) arrived at the scene approximately two minutes later and Resident #1 was transported to the Emergency Department (ED). A review of the Transporter wheelchair safety check offs provided by the Administrator on [DATE] revealed that Driver #1 completed several training in-services prior to the incident, with the last one completed on [DATE]. A review of Driver #1's employee file revealed their background check and license were verified in July of 2024. A review of the medical files from the ED included a computed tomography (CT) scan that showed a fracture of the thoracic 1 (T1) vertebra of the spine along with a 3-millimeter subdural hematoma (brain bleed). Resident #1 was later transported to a tertiary care center on [DATE]. A review of the medical files from the tertiary care center revealed that Resident #1 passed away on [DATE] secondary to an anoxic brain injury resulting from cardiac arrest. A review of the Transport Van weekly Inspection done by the Maintenance Director showed it had last been inspected on [DATE] with a Monthly Transport Van Inspection by the Maintenance Director completed on [DATE]. The Maintenance Director inspected the facility van again on [DATE] after the incident with no negative findings of the wheelchair securement system A review of the third-party wheelchair securement service provider on the facility van, last dated [DATE], did not reveal an issue with the systems transport straps. During an interview on [DATE] at 2:14 PM, Resident #5 confirmed that Driver #1 loaded Resident #1 into the van first and subsequently loaded Resident #5. They stated both of their wheelchairs had their wheelchair brakes applied and that Driver #1 had applied the front two wheelchair securement system straps and locked the straps before starting the van to run the air conditioner. Driver #1 returned and applied the back two WSS straps to both resident's wheelchairs and locked them before starting to drive. When going uphill the front two straps came flying off of Resident #1's wheelchair and the resident fell backwards. Resident #5 confirmed that the van immediately stopped, the DON arrived and started CPR with EMTs arriving shortly after. During an interview on [DATE] at 9:04 AM, Driver #2 was asked to describe the process of securing residents in the transport and revealed residents were placed into a transport-only wheelchair with nonskid pads underneath them. From there, staff load the residents into the facility van and apply the wheelchair brakes. Driver #2 stated they apply the front WSS straps to the front of the wheelchair and tighten the locking mechanism until it clicks. They then load in the second resident, apply the WSS to the front of the second resident's wheelchair, and turn the locking mechanism until it clicks. They return back to the first resident and apply two WSS straps to the back of their wheelchair, tightening the locking mechanism until it clicks and applying a WSS strap around the resident's waist before shaking the wheelchair to check for movement. They then move to the second resident and repeat the process. During an interview on [DATE] at 2:00 PM, the Maintenance Director revealed he inspects the transport straps weekly. He stated that he places red tape on the transport wheelchairs to mark where the straps go on the axial bolts for each of the structural parts, because it will hold up that way. The Maintenance Director reported attending the service provider's in-service training on the transport system including straps every six months and providing the facility's own in-service training upon return. During an interview on [DATE] at 10:13 AM, the General Manager from the service provider stated, There is no way, if the wheelchair is properly hooked up, that it could fall backwards. They stated if the front wheelchair securement system straps were properly applied and tightened with the locking mechanism there was no way for it to come loose without equipment failure. The General Manager stated that he had just serviced the facility van on [DATE] and found no mechanical failure with the installed transport straps. The General Manager also reported inspecting the van on [DATE] after the incident involving Resident #1 with no negative findings. The General Manager also confirmed that the facility employees attended an in-service training held by the service provider on the wheelchair securement system every six months with a service inspection of the facility vans. During a subsequent interview on [DATE] at 10:55 AM, Driver #1 stated she thought she had locked both locks on the front wheelchair wheels but must not have tightened them since both wheels came up off the ground. During an interview on [DATE] at 11:42 AM, the Director of Nursing (DON) stated that they called 911 and rushed over to the scene as soon as they received the phone call from Driver #1. Upon arrival, Driver #1 and Resident #5 were prompting Resident #1 to respond with no response. The DON reported immediately starting CPR after checking for a pulse and continued until the EMTs arrived. Driver #1 had already moved the wheelchair out from underneath Resident #1 and folded it in the corner of the van. The DON stated that they implemented transport specific wheelchairs after the accident to ensure there would be no issues with the wheelchair for future incidents. Driver #1 was suspended pending investigation. They confirmed that the facility van was immediately sent to the service provider for inspection and retraining was performed for all transport drivers. During an interview on [DATE] at 12:16 AM the Administrator confirmed that after the incident the van was sent to be evaluated and Driver #1 was suspended. They implemented retraining of all transport drivers and included the riders in the wheelchair securement system training, just as a second trained pair of eyes. The Administrator also made a Transporter List of all trained and approved drivers and riders on [DATE] and gave the list of approved drivers and riders to the DON and Social Services Director. They also confirmed that Maintenance inspected a group of wheelchairs and marked them as transport wheelchairs to be specifically used for that purpose after the incident. The Administrator stated the Social Services Director and DON were in-serviced on the use of the Transporter List. A laminated picture guide of where to place the locking transport straps was also implemented and attached to the driver seat in the facility vans. The Administrator also implemented a daily check-off sheet stating what drivers, riders, and residents were traveling and required the Administrator's signature prior to departure. They stated on [DATE] all transports to and from the facility were monitored by a second trained staff member for accuracy for two weeks and after that period once a week for four weeks. The Administrator stated that Resident #1 had been seated in a facility-owned wheelchair at the time, and the Maintenance Director had inspected it after the incident with no deficits. The Administrator elected to decommission the wheelchair regardless. A review of the in-service training notes and the Transporter list was conducted with no issues found. The laminated picture guide for locking transport straps was observed in the vans. The daily check-off sheet and transport specific wheelchairs were also reviewed and verified. A review of the in-services, daily check-off sheet, transport specific wheelchairs and laminated picture guide was determined to return the facility to compliance on [DATE].

Based on observation, interviews, record review and facility policy review , it was determined the facility failed to ensure multi-dosed insulin vials were labeled in accordance with currently accepted professional standards specifically insulin was not labeled with the date the vial was first accessed for five (Residents #1, #6, #7, #8, and #9) of seven residents reviewed. The findings include: During an observation of insulins and concurrent interview on 06/30/2026 at 11:05 AM, Licensed Practical Nurse (LPN)#1 indicated Resident #9's multi-dose [fast-acting insulin] vial was not labeled with the opened date. She stated with the vial not being properly labeled, she could not access it. LPN #1 stopped with the administration process and took the unlabeled insulin bottle to the Director of Nursing (DON) to report it. LPN #1 and the DON went to dispose of the insulin vial and obtained a new vial of insulin. LPN #1 labeled the new vial and withdrew four units to administer to Resident #9. During a concurrent observation and interview on 06/30/2026 at 11:42 AM, LPN #1 indicated Resident #7's [rapid-acting] multi-dose insulin vial was not properly labeled with the opened date. She stated with the vial not being properly labeled, she could not access it. LPN #1 stopped with the administration process and took the unlabeled insulin bottle to the Director of Nursing (DON) to report it. LPN #1 and DON went to dispose of the insulin vial and obtained a new vial of insulin. During an observation on 06/30/2026 at 11:58 AM, this surveyor with the Assistant Director of Nursing (ADON) present, observed LPN #1 check all remaining insulin in the medication cart. Five (Residents #1, #6, #7, #8, and #9) of seven resident's multi-dose insulin vials were not labeled with an opened date. Review of a facility provided Medication Administration Record (MAR) printout of Resident #1's Insulin Administration dated June 2026 highlighted by facility staff to indicate that the [second rapid acting insulin] multi-dosed vial was opened, and unlabeled with pharmacy date of delivery as 06/02/2026 and was administered to Resident #1 31 times after the printed date of delivery from the facility pharmacy. Review of a facility provided MAR print out of Resident #6's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [fast acting insulin] multi-dosed vial was opened, and unlabeled with pharmacy date of delivery as 06/26/2026 and was administered to Resident #6 six times after the printed date of delivery from the facility pharmacy. Review of a facility provided MAR print out of Resident #7's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [long-acting insulin] multi-dosed vial was opened, and unlabeled with a pharmacy date of delivery as 06/15/2026 and was administered to Resident #7 31 times after the printed date of delivery from the facility pharmacy. Review of a facility provided MAR print out of Resident #7's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [rapid-acting insulin] multi-dosed vial was opened, and unlabeled with pharmacy date of delivery as 06/19/2026 and was administered to Resident #7 25 times after the printed date of delivery from the facility pharmacy. Review of a facility provided MAR print out of Resident #8's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [second rapid-acting insulin] multi-dosed vial was opened, and unlabeled with a pharmacy date of delivery as 06/22/2026 and was administered to Resident #8 11 times after the printed date of delivery from the facility pharmacy. Review of a facility provided MAR print out of Resident #8's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [long-acting insulin] multi-dosed vial was opened, and unlabeled with a pharmacy date of delivery as 06/26/2026 and was administered to Resident #8 four times after the printed date of delivery from the facility pharmacy Review of a facility provided MAR print out of Resident #9's Insulin Administration dated June 2026, highlighted by facility staff to indicate the [long-acting insulin] multi-dosed vial was opened, and unlabeled with a pharmacy date of delivery as 06/17/2026 and was administered to Resident #9 13 times after the printed date of delivery from the facility pharmacy. Review of a [rapid-acting insulin] Package Insert revised 01/2026, revealed the subcutaneous insulin may be stored for 28 days when refrigerated at 41 degrees (*) Fahrenheit (F) and for 14 days at room temperature up to 86*F. Review of a [long-acting insulin] Package Insert revised 05/2025, revealed the multi-dose vial opened should be used within 28 days refrigerated or room temperature. Review of a[a second rapid-acting insulin] Package Insert revised 06/2025, revealed the subcutaneous insulin may be stored for 28 days when refrigerated at 41* F and for 14 days at room temperature up to 86*F. Review of a [fast-acting insulin] Package Insert revised 02/2023, revealed the multi-dose vial opened should be used within 28 days refrigerated or room temperature. During an interview on 06/30/2026 at 12:42 PM, the Pharmacist revealed the printed date on the bottom of the multi-dose vial is the date the order was completed and delivered to the facility. The Pharmacist stated, I am unsure when the vials were opened, that it was the facility's responsibility to write the opened date on the vial for staff's awareness. The pharmacist also stated, The four insulins that the manufacturer package inserts were requested for were insulins that could only be opened and used up to 28 days, then must be discarded. The Pharmacist further stated, There are some insulins that can be used to the expiration date but not these four [referring to the insulins found unlabeled in the cart]. During an interview on 06/30/2026 at 2:14 PM, LPN #2 verbalized, Multi-dose insulin vials must have the opened date on the vial and not just on the outside of the bag. She stated, if not, nurses would not know when the 28 days ended. Insulin does not work as it should past the 28 days. During an interview on 06/30/2026 at 2:47 PM, the ADON stated, The expectation of a nurse when opening an insulin vial was to write the opened date on the vial, check the expiration and make sure the insulin was in the vial. The ADON stated once the insulin goes past 28 days, the insulin would be ineffective. The open date should be written on the vial, and not the bag the insulin is kept in. The ADON further stated, In-services had been completed but with her being so new, she could not give dates. During an interview on 06/30/2026 at 3:24 PM, the DON stated, The expectation of nurses were to date the bag and vial when opened and new bottles of insulin were to be stored in the refrigerator until used. The DON also stated, If staff found a vial that did not have the date, they were to notify the DON. The DON stated, The pharmacy gets the medications in the facility quickly when they run out. If insulin is not disposed of after 28 days; the insulin potency is affected. During an interview on 07/01/2026 at 9:00 AM, LPN #4 stated, When administering insulin to a resident, LPN #4 looked for the opened date, expiration date, name of resident, resident date of birth and how much was being administered. LPN #4 stated, If the insulin vial did not have an open date, LPN #4 would not administer insulin from the vial due to not knowing when it was opened. During an interview on 07/01/2026 at 12:15 PM, the Medical Director (MD) stated, If insulin was used past the 28 days, the insulin may lose effectiveness and that is why it is restricted past that time. Nurses have to follow policies and procedures 100%, that is not an option. During an interview on 07/01/2026 at 12:51 PM, the Administrator stated, It is very important for insulin to be labeled with the open date. The dates are there for a reason and I'm sure it has some interference with the insulin. Review of facility policy titled Medication Labeling and Storage revised February 2023 indicated multi-dose vials that have been opened or accessed are discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on interviews, record review, and facility document review, it was determined the facility failed to ensure staff administered medication according to accepted professional standards and failed to follow physician orders for one (Resident #4) of one resident reviewed The findings include: Review of Resident #4's admission Record, revealed Resident #4was admitted on [DATE] with medical diagnoses that included: disorder of circulatory system, type-2 diabetes mellitus, morbid obesity, essential hypertension, peripheral vascular disease, chronic kidney disease, dependence on renal dialysis, and depression. Review of Resident #4's Care Plan initiated on 04/17/2026, revealed Resident #4 had hypertension, depression, used an antidepressant, and was dependent for hemodialysis for End Stage Renal Disease (ESRD). Review of [the local hospital] After Visit Summary, dated 06/05/2026, revealed Resident #4 was discharged from the hospital and back to the facility with a prescription for an antihypotensive medication to be given three times (TID) a day. The local hospital's After Visit Summary gave instructions to HOLD the antihypotensive medication if the systolic blood pressure (SBP) was greater than 120. Review of the Medication Order Summary dated 06/05/2026 showed the antihypotensive medication was given TID with a note: added greater than to the order. This order was discontinued on 06/11/2026. A new order dated 06/11/2026 revealed the antihypotensive medication was to be given TID and HELD IF SBP was greater than120. Review of the [name brand antihypotensive medication] Package Insert, with a revision date of 01/2017 indicated, it was used for the treatment of symptomatic orthostatic hypotension and could cause marked elevation of supine blood pressure. Review of Resident #4's Medication Administration Record (MAR) dated June 2026, indicated the following date, times, administration or held medication, and blood pressure readings at the time of the administration of medication. 06/06/2026 at 8:00 AM- blood pressure (BP) 157/77- medication was administered by LPN #2. 06/06/2026 at 1:00 PM- BP was 157/77- medication was administered by LPN #2. 06/06/2026 at 8:00 PM- BP was 136/79- medication was administered by LPN #5. 06/07/2026 at 800 AM- BP 127/69- medication was administered by LPN #2. 06/07/2026 at 1:00 PM- BP 127/69- medication was administered by LPN #2. 06/07/2026 at 8:00 PM- BP 136/91- medication was administered by LPN #5. 06/08/2026 at 8:00 AM- BP 142/86 - medication was administered by LPN #5. 06/08/2026 at 1:00 PM- BP not taken due to resident not in facility 06/08/2026 at 8:00 PM- BP 110/68 medication held due to vitals outside of parameters for administration by LPN #5. 06/09/2026 at 8:00 AM- BP 109/67- medication was administered by LPN #2. 06/09/2026 at 1:00 PM- BP 113/69- medication was administered by LPN #2. 06/09/2026 at 8:00 PM-BP 91/90- medication held due to vitals outside of parameters for administration by LPN #6. 06/10/2026 at 8:00 AM- BP 137/75- medication held due to vitals outside of parameters for administration. 06/10/2026 at 1:00 PM- BP not taken due to resident not in facility 06/10/2026 at 8:00 PM- BP 166/88, medication was administered by LPN #6. 06/13/2026 at 8:00 AM-BP 136/72, medication was administered by LPN #2. The medication was administered by staff nine times when Resident #4's BP was greater than 120 and failed to administer the medication two times when Resident #4's systolic blood pressure BP was less than120, totaling eleven medication errors for the antihypotensive medication. During an interview on 06/29/2026 at 12:15 PM a family member of Resident #4 stated during a care plan meeting, the family asked what medications Resident #4 was currently taking. The family members questioned the facility staff and why the antihypotensivie was being administered when the order was to hold if SBP was greater than120. The family member stated, The Director of Nursing (DON) informed them it was a medication error, and it would be addressed. The DON further stated, Disciplinary action would be taken on the staff who administered the medication. The family member stated, There is no telling how long the medication error would have occurred if I wouldn't have questioned them in that care plan meeting. During an interview on 06/30/2026 at 1:30 PM the Advanced Practice Registered Nurse (APRN), explained when a resident was readmitted to the facility from the hospital, the resident's orders were reviewed either the next day or on Monday if it occurred on a weekend. The APRN stated, The discharge orders from the hospital are reviewed and are entered by either the Unit manager or the Admitting Nurse. The APRN also stated, The [antihypotensive medication] is used for hypotensive episodes and is prescribed to a lot of the dialysis residents and the nurse should always get a BP reading before administering the medication. The APRN indicated if the medication was not administered for a BP reading of less than 120, the BP would continue to drop. The APRN explained he did do not participate in the care plan meetings but the [resident's] family is more concerned with medications. During an interview on 06/30/2026 at 3:24 PM, the Director of Nursing (DON) indicated [NAME] a resident was readmitted from the hospital, the unit manager or nurse entered the hospital discharge orders. The following weekday, the clinical team reviewed orders that were entered. The clinical team consisted of the Minimum Data Set (MDS) Coordinator, the unit manager, the DON, and the Assistant Director of Nursing (ADON). The DON stated, When a medication error happened in the facility, medication error incident and accident (I&A) was completed, an in-service was conducted with the staff, disciplinary action occurred if needed, and the family and provider were notified. During a follow up interview on 07/01/2026 at 8:27 AM, the DON stated the medication error was identified on 06/10/2026 at 9:15 PM by the nurse and addressed on 06/11/2026. The on-call physician was notified, and the staff was instructed to monitor the BP every two hours for eight hours. LPN #2, LPN #5, and LPN #6 were disciplined, and an in-service was immediately done. The DON provided the [name brand antihypotensive medication] internal investigation documents for review. Review of [the antihypotensive medication] Internal Investigation document revealed a medication error form was completed for Resident #4, and LPN #2, LPN #5, and LPN #6 disciplinary action forms were completed and signed by the staff and DON. The investigation documents also included an in-service that had been completed on 06/11/2026 over the topics of Medication administration, Six Rights of Medication Administration and Medications with Parameters. During an interview on 07/01/2026 at 12:15 PM, the Medical Director (MD) stated, The antihypotensive medication was used to increase BP and the expectation of staff at the facility was to follow orders. If the order was to hold the medication for SBPg120, the staff should have held it. The MD stated, With renal residents, medication works differently, and the nephrologist was the one to make changes. The MD also stated, We follow the guidance of the nephrologist. The MD stated he participated in the Quality Assessment & Assurance (QAA) meetings monthly and this had been discussed at length at the meetings. Review of a [antihypotensive medication] Package Insert from the Food and Drug Administration (FDA) reference identification (ID) indicated [antihypotensive medication] was indicated for the treatment of symptomatic orthostatic hypotension. It could cause marked elevation of supine blood pressure. [antihypotensive medication] should not be used in patients with persistent and excessive supine hypertension.

Through observation, interview, and policy reviews, the facility failed to ensure hand hygiene was conducted, that equipment, utensils, plates, cups, and food dome covers were clean and/or properly stored, and that food items had open and expiration dates. These failed practices has the potential to effect 33 sampled residents. The findings: On [DATE] at 9:37 AM, Dietary Aide #1 confirmed an orange whip dessert, uncovered on counter, should had been covered prior to walking away because flies or anything could have gotten in it. On [DATE] at 7:06 AM, the surveyor observed three coffee carafes were neither inverted nor had a cover. On [DATE] at 7:07 AM, the following was observed: 43 plates stacked upon each other leaned left without a cover; a pitcher of water for thinning cooked cereals was on the bottom shelf uncovered; a double basket deep fryer had unknown particles atop the grease, adhered to the baskets and ledge, with a built up brown sticky unknown substance in the outside top crease of the grease. On [DATE] at 7:22 AM, aluminum foil used as a cover for dessert bowls failed to cover the left side and front of the storage container. A trash can was touching the shelving unit where clean oven-mitts, vinyl gloves and aluminum foil were stored. On [DATE] at 7:28 AM, the dishwasher had chunks of unknown substance laying on top and smeared to the front and sides of the dishwasher. On [DATE] at 7:28 AM, in the dishwasher clean area seven bowls were not inverted on a tray, one cup and two scoops were not covered on the second shelf. The third shelf held two storage containers with various equipment and utensils not covered nor stored inverted. On [DATE] at 7:33 AM, 7:38 AM, 7:44 AM, and 7:49 AM Dietary Aide 1's fingers touched the insides of food dome covers. On [DATE] at 7:34 AM, 7:38 AM, 7:52 AM and 7:55 AM, the Cook's fingers touched the plate's surface where food is placed. On [DATE] at 7:45 AM, 68 food dome lids were open side up on the prep table without a cover. On [DATE] at 7:36 AM, 7:43 AM, 7:44 AM, 7:45 AM and 7:53 AM, Dietary Aide #1 used their left hand pushed the milk cart away from the serving line to take a meal tray to serving window, then returned to the serving line with the left hand pulled the milk cart to the serving area. Without washing hands, Dietary Aide #1 used the left hand to get a food dome cover with the finger touching the inside. On [DATE] at 7:47 AM, Dietary Aide #1 touched the inside surface of a cereal bowl lid. On [DATE] at 7:50 AM, Dietary Aide #1 left the serving line, opened room tray cart, with both hands pushed the cart towards the kitchen door. Dietary Aide #1 returned to the serving line, picked up a food dome lid with the left hand. Right hand held a pair of tongs. Dietary Aide #1 left serving line, with both items, opened the warming oven, removed a biscuit and returned to the serving line. Placed biscuit on plate then covered with food dome lid, without washing hands. On [DATE] at 8:01 AM, in the kitchen refrigerator the following failed to have an expired date: one bowl of tuna, two bowls of orange whip, one container of chicken and dumplings, one container of chicken salad, and one container of chicken noodle soup. On [DATE] at 8:05 AM, 14 eggs had been left over the stove for 60 minutes. The Dietary Manager confirmed eggs need to be put in the refrigerator immediately after use. There is concern of cross-contamination. On [DATE] at 8:12 AM, in the walk-in refrigerator a box of 40 four-ounce yogurts did not have an open date. On [DATE] at 8:14 AM, in the Walk-in freezer one 4.4 fluid ounce frozen kiwi-strawberry flavored smoothie was not sealed. On [DATE] at 8:20 AM, a pan with dried rice was uncovered in the dry goods storage room. On [DATE] at 8:21 AM, the following food items in bulk bins failed to have an open and expired date: rice, flour, cornbread mix, powdered milk, picante sauce, graham crackers and saltine crackers. On [DATE] at 8:30 AM. an open package of tortilla shells did not have a received or expiration date. On [DATE] at 8:34 AM, one 46 fluid ounce tomato juice had a dent next to the top seal. On [DATE] at 8:39 AM, a container of 10 tea bags had not been fully closed. On [DATE] at 8:41 AM, the Dietary Manager confirmed food items should have expiration date, as we don't want to give residents expired food for safety reasons. On [DATE] at 9:03 AM, the Dietary Manager confirmed food domes need to be on the rack, so they don't get dirty or knocked on the floor. The utensils, bowls, cups, and plates need to be covered to keep insects or something from dropping on them. This is a sanitary concern for residents. On [DATE] at 9:05 AM, the Dietary Manager confirmed the trashcan should not be touching clean shelving unit with items used for food. On [DATE] at 9:08 AM, the Dietary Manager confirmed the dishwasher should have been cleaned the night before, due to cross contamination. The deep fryer should have been cleaned with the cover over the grease bin. The deep fryer is used to cook for the residents. There is a concern of sanitation and cross contamination from old food on the grates. On [DATE] at 9:10 AM, the Dietary Manager confirmed the orange whip dessert and water pitcher for hot cereal needed to be covered, anything could have gotten into them. On [DATE] at 9:13 AM, the Dietary Manager confirmed whenever staff leave the serving line or touch an item not used for serving hands must be washed before food is served. Staff should not touch the food surface area of plate; food dome lid or bowl covers with fingers or thumb. These are cross-contamination and sanitation concerns. An In-service Education Report for cleaning with signatures dated [DATE] was provided. Page two showed deep fryer weekend cleaning schedule task not signed as completed. Page four showed drain and clean fryer Thursdays. An In-service Training Module for Food Safety (,d+[DATE], Ben e. [NAME] Foods), signatures and date not provided. Page 6 showed always follow good receiving procedures. Hands should be cleaned after handling soiled equipment or utensils and after engaging in any other activities that contaminate the hands. An Employee Food Safety In-service: Maintaining and Cleaning Equipment (DMA Education Course, Second Edition by [NAME] [NAME], MS, RD, Updated 2012, www.ANFPonline.org), without signatures and date, showed page four Rule #2 clean equipment at the end of each use/day Essential for sanitation.

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure hydrocortisone 1/2% was stored in a locked compartment and not left at the bedside for 1 (Resident #8) to prevent the risk for accidental overdose, or injury. This failed practice had the potential to affect 1 (Resident #8) sampled resident reviewed for storing medication at the bedside without self-administration rights. Findings include: a. A review of a policy titled Self-Administration of Medications, (Revised, December 2016) revealed the IDT team must assess a resident to see if they are safe for self-administration rights. Resident rooms are not considered a safe place for medication storage, and medications must be stored in a safe and secure area. Medications can be stored in the med carts, or in the medication room, but not in a residents room. b. 08/27/2024 08:50 AM, Resident #8 was observed eating from the resident ' s over the bed table with hydrocortisone cream 1/2% resting on the right side of the over the bed table. c. Licensed Practical Nurse (LPN) #7 checked the medication administration record (MAR) on 08/27/2024 at 08:56 AM, and LPN #7 confirmed there was not an order for steroid cream 1/2 % for Resident #8. LPN #7 accompanied the Surveyor to Resident 8's room and removed a tube of steroid cream from the over the bed table. LPN was asked if there are any residents with self-administration rights. LPN #7 said there were no residents with self-administration rights, because it is not safe and another resident could find the medication and put it in their eyes or mouth. d. On 08/29/2024 at 09:27 AM, the Director of Nursing (DON) was asked if they have any residents with self-administration rights, and the DON said no residents have self-administration rights. When asked for the process for self-administration rights, the DON said the process is to complete an assessment, notify the doctor and get an order, then it would need to be care planned, and it is important for residents to not have medication at the bedside so nursing can oversee what the residents are taking. 2.a. On 08/27/2024 at 02:30 PM, Licensed Practical Nurse (LPN) #9 was asked to identify 4 loose narcotic bottles from a double locked drawer of the 400/500/600/700 Hall refrigerator located in the medication room. LPN #9 was observed holding 1 of 4 bottles up to the light and studying the bottle before confirming it was an antianxiety medication belonging to Resident #63. b. On 08/27/2024 at 02:36 PM, LPN #10 verified a very faded bottle with a 95 on the cap was 7.75 ml (milliliter) of an opioid pain medication after placing it on the light of a cell phone. ADON #6 and the Nurse Consultant approached and were told LPN #10 was trying to identify 1 of 4 narcotics found locked in the medication room refrigerator. The Nurse Consultant looked at the bottle and confirmed that it should have already been sent back to the pharmacy. c. On 08/27/2024 at 01:04:05 PM, the Nurse Consultant provided a policy titled Storage of Medications, (Revised, April 2007) revealing nursing staff are responsible for maintaining medication storage in a clean, safe, and sanitary manner. Drug containers with improper labels should be returned to the pharmacy for proper labeling, and discontinued, outdated, or deteriorated drugs will be returned to the pharmacy or destroyed.

Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to properly lift a resident with the legs open on a mechanical lift for 1 (Resident #79) resident to ensure the mechanical lift was balanced to prevent accidents or injuries based on 1 of 1 observation. The findings are: 1. A review of an in-service topic Skills Fair: Mechanical Lift Use, (Dated, 06/27/2024) revealed that Certified Nursing Assistant (CNA) #8 had been in-serviced on how to use a mechanical lift. 2. A review of resident 79's Care Plan, (Revised, 08/19/2024) revealed that Resident #79 requires a mechanical lift with 2-person assistance due to impaired mobility. 3. On 08/26/2024 at 10:05 AM, CNA #8 and CNA #3 entered Resident #79's room with a mechanical lift. CNA #8 rolled the mechanical lift under the bed with the legs in a closed position. The Surveyor observed CNA #8 raise Resident #79 from the bed and rolled the resident to the center of the room with the legs in the closed position. 4. On 08/26/2024 at 10:12 AM, CNA #8 was asked what process was used for raising and lowering residents from the bed with a mechanical lift. CNA #8 confirmed that the legs of the mechanical lift are supposed to be in the open position but confirmed that she does not know why. During the interview CNA #8 was asked if she has been in-serviced on the mechanical lift, and CNA #8 confirmed that she was in-serviced. 5. During an interview with the Director of Nursing (DON) on 08/29/2024 at 09:35 AM, the DON confirmed staff are in-serviced on transferring residents by mechanical lifts. The DON was asked what the process was for raising and lowering a resident with a mechanical lift. The DON stated 2 staff members should be present, and the legs should be in the open position to keep the mechanical lift balanced, because the lift could tip over if the legs are in the closed position. 6. On 08/29/2024 at 11:20 PM, the DON provided a policy titled Safe lifting and Movement of Residents, (Revised, 12/2007) revealed staff are observed for competency, and skills technique in lifting and moving residents in order to protect residents and staff, and to prevent accidents or injuries. A user manual for the [named] mechanical lift was not received. 49413

Based on interview, record review, and policy review, the facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within 30 days for 1 (Resident #235) of 1 sampled resident for whom the facility-maintained trust accounts per a list provided by the Administrator on 08/2/2024 at 3:33 PM. The findings are: l. Resident #235 was documented as having transferred to a different facility according to resident's Discharge Summary on 05/01/2024. 2. A document titled Timberlane Health and Rehabilitation Trust-Current Account Balance As of 08/27/2027 documented that a trust account for Resident #235 contained a closing balance of $120.00. 3. On 08/29/24 at 10:29 AM, the Surveyor asked the Business Office Manager (BOM) to identify the date Resident #235 had discharged . The BOM verified that Resident #235 was discharged on [DATE]. The Surveyor asked the BOM how long the facility was permitted to convey residual funds in trust accounts. The BOM indicated 30 days. 4. On 08/29/2024 at 11:01 AM, the Surveyor asked the Administrator how long the facility was permitted to convey funds after a resident discharge. The AD indicated 30 days. 5. A policy titled Policy & Procedure Patient Trust was provided by the Administrator on 08/29/2024 at 3:42 PM. The policy did not address the return of resident funds upon resident discharge or death.

Based on observation, interviews, record review, and facility document review, the facility failed to have a process in place to identify refrigerated narcotic expiration or use by dates to ensure refrigerated narcotics were returned to the pharmacy in a timely manner affecting 3 (Resident #63, #64, #185) sampled residents, and the facility failed to ensure periodical accounting for all controlled narcotics, antianxiety medication, affecting 1 deceased (Resident #185) sampled resident discharged from the facility on [DATE] to prevent possible loss or misappropriation of resident medications. Findings include: 1.a. On [DATE] at 02:36 PM, Licensed Practical Nurse (LPN) #9 was observed removing 3 bottles of antianxiety medication belonging to Resident #63, #64, and #185 and 1 bottle of opioid pain medication belonging to Resident #63 from the refrigerated, permanently affixed medication drawer located in the [DATE]/700 Hall medication room. LPN #9 confirmed the 4 opened bottles of medication were undated. LPN #9 and LPN #10 confirmed they could not tell when the medication bottles were opened but the fill dates on the bottles are from [DATE]-[DATE]. During an interview, LPN#9 and LPN #10 were asked for the expiration date of the opened medications and both LPNs confirmed they did not know. LPN #9 stated if a medication is expired it might not be effective. b. On [DATE] at 03:00 PM, the Assistant Director of Nursing (ADON) #6 and Nurse Consultant were asked how to tell if an open bottle of antianxiety medication or opioid pain medication was expired. ADON #6 was observed looking at an antianxiety medication, and the Nurse Consultant stated the label is covering that information, and confirmed if narcotics are expired, they would want to send them back to the pharmacy right away to prevent diversion. c. On [DATE] at 12:00 PM, the Nurse Consultant told the Surveyor an antianxiety medication would expire 90 days after being opened, and depending on how it is stored opioid pain medication could expire in as little as 7 days after it is opened. 2.a. On [DATE] at 02:40 PM, Licensed Practical Nurse (LPN) #9 confirmed Resident #185 had 1 bottle of antianxiety medication. LPN #9 stated she will need help finding narcotic page 116 because Resident #185 was deceased . LPN #9 and LPN #10 stated they were counting narcotic pages 87 (Resident #64), 95 (Resident #63) and 96 (Resident #63), but they were not counting Resident #185's medication, found on narcotic page 116 because Resident #185 was deceased . b. During an interview with the Assistant Director of Nursing (ADON) #6 On [DATE] at 03:12 PM, the Surveyor asked what process staff were expected to follow when a resident died or was discharged . ADON #6 confirmed that staff are to turn the medications in to the Director of Nursing (DON) as soon as possible so they can be returned to the pharmacy. When asked why the facility would expect narcotics to be returned as soon as possible, ADON #6 said the medication could be stolen. The Nursing Consultant stated that when a person dies their medication page is not brought forward to a new narcotic page anymore, and the medication should be given to the DON to return to the pharmacy to prevent diversion. c. On [DATE] at 03:13 PM, ADON #6 provided narcotic book page 116 showing a balance of 29.5 ml of antianxiety medication. The Nurse Consultant stated Resident #185 only had 1 dose on [DATE]. LPN #9 confirmed that during the narcotic count she assumed the other nurse had narcotic page 116, and confirmed it was not being counted. ADON #6 and Nurse Consultant were asked if they had any concerns with a narcotic not being accounted for since [DATE], and the Nurse Consultant stated that if they had a dishonest nurse the narcotic could have been stolen and they would not have known. d. A review of a policy titled Storage of Medications, (Revised, [DATE]) revealed that nursing is responsible for the storage of medications being stored properly. Drugs that are out of date or have deteriorated should be sent back to the pharmacy or destroyed.

Based on record review and interview, the facility failed to ensure written notification of transfer/discharge to another facility was provided to the resident and/or resident's representative, and the state Ombudsman, to protect the rights of 1 (Resident #83) of 1 sampled resident who transferred to a different facility in the last 90 days. 1. Review of a NSG/MD Discharge Summary for Resident #83 revealed the resident was discharged from the facility on 06/07/2024. a. On 08/29/2024 at 10:50 AM, the Administrator (AD) was asked who keeps up with the discharges and sends them to the state Ombudsman. The AD indicated that she did. The AD was then asked if a resident is transferred to another facility, is a notification sent to the Ombudsman. The AD indicated that she keeps a list for the month and at the end of the month it is sent to the Ombudsman. The AD was asked if Resident #83 should be on the transfer log for June? The AD indicated that Resident #83 should be but was left off. b. A Policy titled Transfer or Discharge Documentation provided by the Administrator on 08/29/2024, did not address notifications to the Ombudsman.

Based on record review and interview, the facility failed to ensure a comprehensive care plan addressed a high-risk medication, insulin, to ensure planning was completed for individualized and appropriate care and services for 1 (Resident #43) of 18 (Residents #7, #8, #10, #12, #16, #40, #43, #47, #49, #54, #57, #58, #59, #64, #77, #79, #135 and #286) sampled residents whose care plans were reviewed. The findings are: Resident #43's Medical Diagnosis section of the electronic health record, not dated, was reviewed and indicated a diagnosis of inadequate controls of levels of sugar in the blood (diabetes). The Order Summary dated 08/29/2024 was reviewed and indicated an order for Glargine insulin (a long acting, synthetic form of insulin) 100 units/milliliter (Unit/ML) and was dated 01/14/2024. The instructions were to inject 64 units subcutaneously (under the skin=SQ) one time a day for diabetes. A Care Plan dated 08/22/2024 was reviewed and indicated Resident #43 could have skin integrity issues and had issues with vision, both related to diabetes. The care plan did not indicate any care measures for diabetes, address Glargine insulin usage, or include any adverse reactions or signs and/or symptoms to monitor the resident for. The annual Minimum Data Set (MDS) with an assessment reference date of 06/29/2024 was reviewed and indicated Resident #43 had a Brief Interview for Mental Status score of 15, which indicated cognitively intact. This MDS indicated the resident received insulin injections, a high-risk drug class, during the last seven days or since admission or entry. On 08/28/2024 at 3:58 PM, the Director of Nursing (DON) was interviewed and asked to review Resident #43's annual MDS medication section for June of 2024. She confirmed the annual MDS for June 2024 indicated the resident had received insulin injections and there was a number 7 in the box. She was asked to review the resident's care plan and she confirmed there was no indication for insulin usage or signs and/or symptoms to monitor the resident for. She was asked who was responsible for completing the care plans and she stated the MDS Coordinator. She was asked what drives the care plan and she stated the MDS assessment. She confirmed insulin, a high-risk medication, should be care planned. She was asked to review Resident #43's order summary and asked if there was an order to monitor the resident for signs and or symptoms of insulin use and she confirmed there was no order. A Care Plans, Comprehensive Person-Centered policy, with a revision date of December 2016, provided by the Nurse Consultant was reviewed and indicated this type of care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and was developed for each resident. This policy indicated the comprehensive person-centered care plan would incorporate identified problem areas and risk factors associated with identified problems and would be developed within seven days of the completion of the required comprehensive assessment (MDS).

Based on observations, interviews, record review, review of resident meal slips, and facility policy review, the facility failed to honor meal preferences for 1 (Resident #52) sampled resident with a standing order for 2 glasses of tea to ensure good hydration. This failed practice had the potential to affect 4 (Resident #7, #43, #47, #58) sampled residents that were observed for dining to ensure proper hydration and nutrition. Findings include: A review of the Medical Diagnosis portion of Resident #52's health record revealed diagnoses of type II diabetes, stroke, and dysphagia. 1. On 08/26/24 at 12:25 PM, Resident #52 was observed coughing very strongly in the dining room and stated they (Resident #52) needed more tea. There was about 1/2 inch of tea colored fluid and ice observed in a cup. The meal slip showed Resident #52 had standing orders for two 8-ounce cups of tea. 2. On 08/26/24 at 12:39 PM, Assistant Director of Nursing (ADON) #5 came to the table and was asked to look at Resident #52's meal slip. ADON #5 confirmed Resident #52 did not get two cups of tea, and confirmed the meal slip showed a standing order for two 8-ounce cups of tea. When asked for the reason Resident #52 gets two 8-ounce cups of tea, ADON #5 said, It is [Resident #52's] preference. 3. On 08/29/24 at 09:20 AM, the Director of Nursing (DON) was asked who is responsible for making sure residents received their meal preferences. The DON stated dietary staff discuss preferences with residents, and the Certified Nursing Assistants (CNAs) or staff should check the tray and go back to the kitchen if something is wrong. When asked why it is important for residents to receive their standing orders or preferences, the DON stated that they wanted to honor the resident's wishes. 4. On 08/29/24 at 11:20 AM, the DON provided a policy titled Food and Nutrition Services Staff which did not address food preferences of the residents.

Based on observation, record review, and interview, the facility failed to ensure residents were free from accidents with the use of a stand-up lift; staff were supervised in the use of the stand-up lift and the resident's care plan was followed for 1 (Resident #1) of 3 sampled residents (Residents #1, #2 and #4) per a list of residents who require the use of a stand-up lift provided by Administrator 11-13-23 at 12:24 pm. The findings are: 1. On 11-13-23 at 11:50 am, review of Resident #1's file revealed the resident's last re-admitted was 3-31-23 for CVA (cerebral vascular accident) effects, Chronic Kidney Disease, Hypertension, Schizophrenia, and Rheumatoid Arthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9-23-2023 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), and documented the resident required extensive assistance of 2 persons with transfers. a. On 11-13-23 at 11:50 am, review of Resident #1's Progress Notes revealed. Note dated 10-15-23 documented Resident #1 requested that Certified Nursing Assistant (CNA) #1 not assist or provide care anymore. CNA #1 was pulled from residents' care. Progress Note dated 10-18-23 documented Resident #1 reports pain in left side rib area. Progress Note dated 10-19-23 documented Resident #1 with increased pain and crying. Per Progress Note dated 10-20-23 at 3:00 am, Resident #1 returned to facility, and diagnosed with Rib Contusion. b. On 11-13-23 at 12:00 pm, review of Resident #1's Care Plan documented, .TRANSFER: The resident requires stand up Lift with (2) staff assistance for transfers . Date Initiated: 03/29/2021 and Revision on: 12/30/2022. c. On 11-13-2023 at 12:35 pm, during an interview with Resident #1, the resident recalled CNA #1 using the standing lift during her incontinent brief change on her about a month ago. Reported CNA #1 hooked up left side of lift strap to machine and then started raising the lift part up and stretched me on the left side. Only the aide had failed to hook up the right side of strap to lift machine. When asked how many aides were in the room and assisting with the incontinent care and the standing lift the day of this incident, Resident #1 stated, One, only CNA #1 and you can ask my roommate, she is my witness. There should have been two but that time there was only one. d. On 11-13-2023 at 1:00 pm, the Surveyor observed Standing Lift use on Resident #1. Two CNAs came into Resident #1's room to perform incontinent care. Observed CNA #2 place lift harness under residents' arms and secure it around chest area with self-adhesive fastener. Then CNA #3 placed the standing lift machine close in front of Resident #1 and CNA #2 hooked the lift harness straps to both sides of the lift machine hook areas. e. On 11-13-2023 at 1:10 pm, the Surveyor asked CNA #2 (Restorative Aide), Can one person use the standing lift? She replied, It is always a two-person lift, never a one person. We do in-services and training on this with all the new staff, and they are told it is always a two person staff lift. CNA #3 stated, It is kind of a new lift for the facility, maybe had the stand lift a year or so, and we were told it is always a two-person lift. f. On 11-13-2023 at 3:00 pm, review of the Incident and Accident report dated 10-19-2023 documented, .[Resident #1] stated about 3 weeks ago, C.N.A. [CNA #1] was lifting her in the stand-up lift and only hooked one side of the sling to the lift and began to lift resident and immediately stopped and hooked the other side and then lifted resident with the lift . g. On 11-14-2023 at 9:10 am, during an interview with the Assistant Director of Nursing (ADON) regarding standing lift use by staff. The ADON stated, It is to be used by two staff members, for standing transfers, anytime it is used. The Surveyor asked if the lift was used by 2 staff members on the day of the incident on Resident #1, by CNA #1. The ADON stated, I am not sure, but I believe it was just the one CNA from what I have read in the notes and reports. h. On 11-14-2023 at 11:25 am, review of Resident #1's Closet Care Plan documented, .TRANSFER SKILLS .With 2 Assist Mechanical Lift with Stand-up ., dated 2/11/23. i. On 11-14-2023 at 12:45 pm, during an interview with Licensed Practical Nurse (LPN) #1, when asked who is responsible for updating the closet care plans for each resident. LPN#1 stated, We all are, if we see a needed change, we (the nurses) update them. When asked who is responsible for supervising and making sure care plans are followed, LPN #1 stated, Well, we all are. j. On 11-14-2023 at 1:20 pm, during an interview with CNA #4, when asked to tell the Surveyor the steps for using the standing lift on a resident, she stated, Always hook up both sides of the harness. It is secured around the resident then the two straps hook on the lift machine and it is based on the size of the resident, and it is always to be used by two staff members when performing a lift. When asked where the CNA's get the information regarding a resident's transfer ability and if a resident requires the use of a lift and how many staff members are to perform the task, she replied, It is on the residents care plan that is kept in the residents closet for the aides to use. k. On 11-14-2023 at 2:00 pm, during an interview with the Director of Nursing (DON), the DON said the CNAs get the transfer information from the closet care plans of the residents, and they can ask the nurses of course but the main place is the closet care plan on each of the residents. When asked when were you aware of the incident on Resident #1 regarding the standing lift with the CNA #1? She replied, On 10-19-23, when the resident told us. The Surveyor asked did CNA #1 have anyone in the room to assist with the standing lift of Resident #1? The DON replied, No, [CNA #1] told us she was alone in doing it and said she knew she was supposed to have someone to help her, but she just did not that day. And CNA stated that she had been trained and the policy was on the use of the standing lift with two staff but just did not do it that day. The Surveyor asked what did the Resident #1's care plan document regarding transfers. She replied, Standing lift two person transfer, and the aide admitted to knowing that she just did not follow it. l. On 11/14/23 at 11:14 am, review of Sit-to-Stand Patient Lift Owner's Manual stated, .4. Attach the sling straps to the hooks .

Based on observation, interview, and record review, the facility failed to ensure dented cans were removed from stock; foods were dated when received to assure first in first out usage; scoops used in dry storage bins were stored in a plastic bag, and items stored in the refrigerator were dated and labeled to prevent potential for food bone illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 87 residents residing in the facility. The findings are: 1. On [DATE] at 10:46 AM, observed a 1 can of Cream of Chicken soup with a dented rim. The Surveyor asked the Dietary Manager what was done with dented cans. The Dietary Manager stated, If the can is not dented too bad, they use it, if it is too bad, they put it in the bottom shelf and try and return it. 2. On [DATE] at 10:48 AM, observed 11 bags of mini marshmallows not dated on a shelf in the pantry. The Surveyor asked the Dietary Manager if food items should be dated when they are received in the kitchen. The Dietary Manager stated, Yes. 3. On [DATE] at 10:49 AM, observed two scoops on top of the dry storage bins of powdered milk and flour covered in a white substance and not in a bag. The Dietary Manager indicated that the dietary staff must have used the scoops and not put them back up properly. The Surveyor asked how the scoops should be stored. The Dietary Manager indicated that they were to be stored in a dated, sealed plastic bag. 4. On [DATE] at 10:56 AM, on a shelf in the walk-in refrigerator was a transparent container of a brown substance. The container was covered with plastic wrap but was not dated. The Dietary Supervisor stated the substance was gravy and should have been labeled and dated to avoid serving the residents expired food. 5. A facility policy titled, Food Receiving and Storage, with a revised date of [DATE], provided by the Administrator on [DATE] at 4:08 PM documented, Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated .

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored on the medication cart; beverages were not stored in the medication refrigerator, and narcotics were surrendered in a timely manner. The findings are: 1. On 09/26/23 at 10:20 AM, observed on the 300 Hall an unsupervised medication cart pushed against the wall with medications cards containing medications on top. The Surveyor asked Licensed Practical Nurse (LPN) #1 to identify the medications and count the pills. LPN #1 identified the following medications: i) Pantoprazole (stomach acid reducer) DR (delayed release) 40 milligrams - 1 tablet. ii) Potassium Cl (Chloride) (a potassium supplement) ER (extended release) 10 milliequivalent - 6 tablets. iii) Myrbetriq (overactive bladder treatment) ER 25 milligram - 5 tablets. a. On 09/26/23 at 10:23 AM, LPN #1 said, I did not realize there were still some pills in those. The Pantoprazole DR and Potassium CL ED was out for reorder, and I think the Myrbetriq is discontinued. LPN #2 said she was responsible for the cart, and someone could have taken the pills. LPN #2 said, Medications are not stored on top of the cart. 2. On 09/27/23 at 11:05 AM, in the residents' medication refrigerator was a can of orange soda, a small can of lemon soda, and an opened bottle of dark green soda. The Surveyor asked LPN #2 to describe the bottle of opened soda. LPN #2 said, I do not know what is mixed in that bottle of soda. It is very dark green, and not just [Name] soda. LPN #2 said it is not appropriate to leave drinks in the residents' medication refrigerator. 3. On 09/27/23 at 11:14 AM, observed two plastic bags of medications resting behind the locked narcotic box in the 500/600 Hall medication room refrigerator. LPN #2 identified Bag #1 contents as a full 30 milliliter multi-dose bottle of Lorazepam. LPN #2 said, This resident passed away about three months ago. a. On 09/27/23 at 11:36 AM, the Surveyor asked LPN #2 to identify the medications dated 09/27/2022 and the volume of contents in Bag #2. LPN #2 said, This resident passed in 2022. LPN #2 and Assistant Director of Nursing (ADON) #1 identified the following medications in Bag #2: i) 30 milliliter multi-dose bottle of Morphine Sulfate, containing 26.5 milliliters. ii) 30 milliliter multi-dose bottle of Lorazepam, containing 24.75 milliliters. iii) 30 milliliter Hyosyne Dro (anticholinergic/antispasmodic), containing 12 milliliters. b. On 09/27/23 at 11:42 AM, the Surveyor asked LPN #2 how medications are handled when a resident discharges or expires. LPN #2 said, The charge nurse notifies the Director of Nursing (DON) or the ADON and they surrender the medication. c. On 09/27/23 at 1:30 PM, LPN #2 and ADON #1 provided documentation of the controlled substance book showing the above Morphine and Lorazepam had not been surrendered at this time. 4. On 09/27/23 at 2:42 PM, the Surveyor asked the DON what is the process of surrendering narcotics. The DON said they fill out a medication destruction form and two nurses sign them out of the controlled substance book when it is time to send them in. Medications are double locked and stored in the DON office. The Surveyor asked if a resident was discharged last year should the medications be surrendered. The DON said, Yes, absolutely. The DON said, leaving medication on top of the medication cart is not appropriate. The DON said it is never okay to put food or drinks into the medication refrigerator, because it is meant for resident medication use. 5. A facility policy titled, Storage of Medications, provided by the DON on 09/27/23 at 3:19 PM documented, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location. Medications must be stored separately from food and must be labeled accordingly .

Based on observation, interview and record review, the facility failed to ensure bilevel positive airway pressure/continuous positive airway pressure (BiPAP/CPAP) masks and/or oxygen tubing were stored in a bag or container when not in use 2 (Residents #26, and #322) of 5 (Residents #1, 26, 36, 48 and 322) sampled residents who received oxygen therapy, updrafts, and/or BiPAP/CPAP therapy. The findings are: 1. On 09/25/23 at 12:00 PM, observed a CPAP mask resting on Resident #26's bedside dresser. The mask was not in a closed bag or container. a. On 09/25/23 at 2:27 PM, Resident #26 said, Nobody has given me a bag to store my mask in. I put it on and off myself, but no . I do not have a bag to put it in. I did not know. c. On 09/26/23 at 1:56 PM, observed Resident #26's CPAP mask resting on top of the CPAP machine. The mask was not in a closed bag or container. d. On 09/26/23 at 2:22 PM LPN #1 said mask are supposed to be stored in a bag. e. A Physicians Order dated 09/20/23 noted Resident #26 was to use an overnight pulse ox with Bi-Pap for 7 days. 48630 2. On 09/25/23 at 10:59 AM, observed Resident #322's CPAP mask, nebulizer mouthpiece, and nasal cannula not stored in a bag. a. On 09/25/23 at 2:23 PM, observed Resident #322's CPAP mask, nebulizer mouthpiece, and nasal cannula not stored in a bag. b. On 09/26/23 at 9:36 AM, observed Resident #322's nasal cannula hanging on the oxygen concentrator and not stored in a bag. c. On 09/26/2023 at 2:17 PM, the Surveyor asked the Director of Nursing (DON), How should oxygen tubing and CPAP/BiPAP headgear, and nebulizer mouthpieces be stored when not in use? The DON responded, In a ziplock or plastic personal belongings bag when not in use.

Based on observation and interview, the facility failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control. This failed practice had the potential to affect all 87 residents. The findings are: 1. On 09/28/23 at 9:10 AM, the Administrator confirmed she was aware the Infection Preventionist requires a certification and confirmed two people are in training for the Infection Preventionist certification but are not currently certified.

Based on record review and interview the facility failed to ensure personal funds were not misappropriated, for 3 (Resident #1, #2, #3) of 3 (resident#1, #2, #3) sampled residents who had money held in a trust fund by the facility. This failed practice resulted in past noncompliance. The findings are: 1. Review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities, (DMS-762) form revealed on May 9, 2023, a routine business office audit was conducted., During the audit a check in the amount of $3,629.61, payable to the facility was discovered. The check had been cashed without an endorsement on the back. The check stub noted the amount of $100.00, with an individual's name, and the $100.00 was deducted from Resident #1 trust account. a. A check for $1475.00 had been written out of Resident #1's trust account on 1/3/23 the memo documented for roof repairs. The check was deposited by the Business Office Manager (BOM's) landlord. b. A check on 4/28/23 was written to Resident #1 daughter, who did not have authorization to receive funds. A deduction of $574.00 on 3/17/23 was found on Resident #1 account, there was no check or withdrawal documentation to support the deduction. A total of $2,104.00 was deducted from Resident #1 account. The Facility has refunded the money to the account. c. A deduction in the amount of $285.22 was made to the trust account of Resident #2. A notation to close the account was noted although the account had a balance of $1,000. Resident #2 family received $285.22 from the account. A check for $1000.00 was made out to another individual with a notation to close the account. On 1/12/23 another check for $894.40 from the account which was made out to another individual and endorsed by the individual and the BOM. The total amount deducted from Resident #2 account was $1,894.40. The facility has refunded the money to the account. Review of Resident #3 trust transaction history revealed on 5/1/23 a withdrawal correction of $1823.59. The facility action plan provided by the facility indicates that reimbursement with interest was completed to each resident that had been affected within 5 days of discovering the theft. Further corrective action steps have been put in place. On 6/29/23 at 3:30 PM an interview with the Administrator; she stated The misappropriation did happen but that it was not a facility failure but the BOM's failure, the facility had made every resident affected whole with reimbursement of funds with interest. The BOM had been suspended immediately then terminated. Reportable to OLTC on all incidents on misappropriation had been made. Checkpoints were put in place to prevent this from occurring in the future.

Based on observation, record review and interview, the facility failed to ensure food items stored in the freezer were covered or sealed and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen according to the list provided by the Dietary Supervisor dated 6/16/2022 The findings are: 1. On 6/15/2022 at 1:27 PM, the following observations were made in the walk-in freezer: a. An opened zip lock bag that contained slices of cheese was stored on a shelf in the refrigerator. The bag was not sealed. b. A box of diced potatoes was on a shelf in the refrigerator with an expiration date of 6/13/2022. c. Two opened boxes of biscuits were stored on a shelf in the walk-in freezer. The boxes were not covered or sealed. d. An opened box of dinner rolls was stored on a shelf in the freezer. The box was not covered or sealed. e. An opened box of hot dogs was on a shelf in the walk-in freezer. The box was not covered or sealed. 2. On 6/15/2022 at 1:28 PM., the cabinet below the deep fryer had one quarter of an inch-thick accumulation of grease. The 3 pallets to the shelf of the deep fryer were covered in grease. Dietary Employee #1 was asked how often the shelf was cleaned and Dietary Employee stated, I have not been able to clean it. 3. On 6/15/2022 at 4:02 PM., Dietary Employee #1 took out a can of cheese sauce from the storage room and placed it on the counter. He opened the can with a can opener and without washing his hands, he grabbed the fried okra with his bare hands and poured them in a pan to be served to the residents for supper. 4. On 6/15/2022 at 4:05 PM., Dietary Employee #2 pushed a cart that contained trays of dessert into the walk-in refrigerator. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then used her gloved hands to pick up cookies and placed them in individual bags to serve to the residents for supper. 5. On 6/15/2022 at 4:15 PM., Dietary Employee #1 washed his hands in the hand washing sink. After washing his hands, he used his bare hands to turn off the faucet. He pressed down on the lever activating the paper towel dispenser, contaminating his hands. He pulled tissue paper out and dried his hands. He pulled gloves from the glove box and placed them on his hands, which contaminated the gloves. He picked up a pot of macaroni from the stove and poured it into a colander. He picked up a spoon from the tip that goes into the food and used it to scrape macaroni from the pot into a pan. He then used his gloved hand to push the macaroni into a spoon and poured it into a pan. He added cheese sauce and mixed, covered it with a lid, and placed it on the steam table to be served to the residents for supper. Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have changed gloves and washed my hands. 6. On 6/15/2022 at 4:29 PM., Dietary Employee #2 washed her hands, after washing her hands, she turned off the faucet with her hands and dried off her hands with tissue papers. She removed gloves from the box and placed them on her hands. She opened a can of Mexican Chili Beans, picked up a bag of bread from the bread rack, untied it, and placed it on the counter. She opened the refrigerator and took out a zip lock bag that contained slices of turkey and a zip lock bag that contained slices of cheese and placed them on the counter. Without changing gloves and washing her hands, she removed slices of bread from the bread bag and placed them on the tray and removed slices of turkey and slices of cheese and placed them on top of the bread. She wrapped them individually with saran wrap to be served to the residents who requested turkey and cheese sandwich for supper. 7. On 6/15/2022 at 4:43 PM., Dietary Employee #2 picked up the water hose with her bare hands, used it to spray off leftover food items from the dishes, contaminating her hands. She placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, Dietary Employee #2 moved to the clean side in the dishwasher area and picked up clean glasses by the rims and placed them on the clean cart. Dietary Employee #2 did not wash her hands before picking up clean glasses for the residents to use in drinking their beverages for supper meal. At 5:29 PM, Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 8. On 6/16/2022 at 7:22 AM., Dietary Employee #3 was wearing gloves while assisting on the breakfast tray line. She picked up cartons of milk, cartons of ensure, cartons of ice cream and a banana, contaminating her hands. Without changing gloves and washing her hands, she picked up glasses by the rims and placed them on the trays to be served to the residents with their breakfast meal. At 8:08 AM, Dietary Employee #3 was asked, what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 9. The facility policy provided by the Administrator on 6/16/2022 at 9:26 AM documented, on the dietary department employees are required to wash their hands on the occasions listed below: . I. After picking up anything from the floor . J. Any other time deemed necessary .

Based on record review and interview, the facility failed to ensure physicians orders accurately documented the residents' code status to enable staff to quickly determine the correct response, per the residents' and / or families' wishes for any life-sustaining treatments in the event of a resident's incapacitation or cardiopulmonary arrest for 2 (Residents #9 and #58) of 2 sampled residents whose clinical records were reviewed for Advanced Directive information. This failed practice had the potential to affect 83 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated [DATE]. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (,[DATE] indicates moderate impairment) on a Brief Interview for Mental Status (BIMS). a. A facility form titled Original Physician order [REDACTED]. I have conferred with the resident and / or his / her legal Guardian, Primary Family Member, Health Care Proxy and agree with the residents wishes Not to Accept Cardiopulmonary Resuscitation (CPR). This decision is justified by sound medical judgement consistent with the standards of reasonable medical practice . b. A physician's orders [REDACTED]. CPR Full Code . Please see misc. (miscellaneous) documentation . c. On [DATE] at 1:10 p.m., the Director of Nursing (DON) was asked, What is (Resident #9's) order for code status? The DON looked in the Electronic Medical Record and stated, The physician's orders [REDACTED]. The DON was asked, What does (Resident #9's) Advanced Directive say her Code Status should be? She stated, Her last Advanced Directive says she is a DNR (Do Not Resuscitate). I will have to look into that. We will get the order corrected if it is not right. 2. Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 10 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. A Physicians Order dated [DATE] documented, .CPR Full Code . Please see misc. documentation . b. A facility form titled Code Status signed and dated February 26, 2021 by the Patient Representative documented, .Do Not Resuscitate . instruction means when a person's heart beat and breathing stop because of cardiac or respiratory arrest, the person does not want to be revived by cardiopulmonary resuscitation (CPR) and death is probable . I want a DNR Code Status (Do Not Resuscitate) . c. A Care Plan dated [DATE] documented, .Code Status is Full Code . If (Resident #58's) heart stops beating or the resident stops breathing, CPR will be initiated per the resident's / responsible party's wishes . d. On [DATE] at 1:15 p.m., the Director of Nursing (DON) was asked, What are (Resident #58's) current orders for Code Status? The DON reviewed the resident's orders in the Electronic Medical Record and stated, The Doctor's Order states that he is a Full Code. The DON was asked, What does (Resident #58's) Advanced Directive say about his Code Status? The DON reviewed the Electronic Record and stated, His Code Status form documents he wants to be a DNR (Do Not Resuscitate). He does not have a signed Doctor's Order on the chart saying he is a DNR. We should have gotten that to the doctor for signature when he admitted in February. The DON was asked, Who is responsible for getting Advanced Directives completed and entered into the resident's medical record? The DON stated, That is usually the Admissions person or the Social Director. It appears we may have the incorrect status on these two residents. We will verify their Code Status and correct the orders if needed. We will also audit the Code Status for the whole building. 3. A facility policy titled Advanced Directive provided by the Administrator on [DATE] at 1:45 p.m. documented, .Advanced Directives will be respected in accordance with state law and facility policy . 1. Upon admission, the resident will be provided with written information concerning the right . to formulate an Advanced Directive if he or she chooses to do so . 10. The Plan of Care for each resident will be consistent with his or her documented treatment preferences and / or Advanced Directive . 21. The Director of Nursing or designee will notify the Attending Physician of Advanced Directives so that the appropriate order can be documented in the residents medical record and Care Plan.

Based on observation of the 8:00 p.m. / 9:00 p.m. medication pass on 3/31/2021, record review, and interview, the facility failed to ensure Physician's Orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 1 (Resident #175) of 1 sampled resident observed during the medication pass resulting in medication errors. Medication errors were made by 1 Medication Nurse (Registered Nurse) #1 observed administering medications in the facility. This failed practice had the potential to affect 21 residents who received medications from Medication Nurse (RN) #1 on the 100 Hall / 200 Hall according to the list provided by the Director of Nursing on 4/2/2021. The medication error rate was 8.11% based on observations of 37 medications administered and a total of 3 medication errors detected. The findings are: 1. Resident #175 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/18/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS). a. The Physician's Order Listing dated March 2021 documented, .[MEDICATION NAME] Allergy 24 HR (Hours) Tablet . 5 mg (milligrams) Give 1 tablet by mouth one time a day for seasonal allergies [REDACTED].>b. The Physician's Order Listing dated March 2021 documented, .MVI (Multivitamin) with Minerals 1 tablet QD (every day) . c. The Physician's Order Listings dated March 2021 and April 2021 documented, .Multiple Vitamins (with) Minerals Tablet . Give 1 tablet by mouth one time a day for Supplement . d. The Physician's Order Listing dated April 2021 documented, .[MEDICATION NAME] Allergy Tablet 10 mg (milligrams) Give 1 tablet by mouth one time a day for seasonal allergies [REDACTED]. e. On 3/31/2021 at 8:47 p.m., Medication Nurse #1 administered Wal-Zyr which was [MEDICATION NAME] and gave another [MEDICATION NAME] 10 milligrams (mg) from a stock bottle. There was no [MEDICATION NAME] administered, and there was no [MEDICATION NAME] medication located in the Medication Cart for this resident. Prior to the administration of the medication, Medication Nurse #1 was asked if the resident was supposed to receive 2 [MEDICATION NAME] ([MEDICATION NAME]) 10 mg tablets. Medication Nurse #1 stated, Yes, she has been getting 2. The Physician's Order documented the resident was to receive [MEDICATION NAME] 5 mg 1 tablet. f. Medication Nurse #1 also administered a Multivitamin to the resident. The Physician's Order documented the resident was to receive Multivitamin with Mineral.

Complaint # (AR 909) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure licensed nurses demonstrated competency with management of a [MEDICAL CONDITION], as evidenced by failure of licensed nursing staff to routinely assess, monitor and document bowel output for a resident with a [MEDICAL CONDITION], which resulted in a delay in identifying and addressing a serious complication when bowel elimination to the [MEDICAL CONDITION] was interrupted, and failure to ensure a bowel assessment was conducted and the physician was immediately consulted when the resident's emesis developed characteristics that were indicative of possible bowel obstruction for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION]. This failed practice resulted in immediate jeopardy (removed), which caused or could have caused serious harm, injury, or death to Resident #1, who developed a partial bowel obstruction secondary to a prostomial hernia with resulting bowel perforation. There were no other residents in the facility with colostomies, according to a list provided by the Director of Nursing on 1/31/18. The Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the removed immediate jeopardy condition on 1/31/18. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of one person for activities of daily living, and had an ostomy. a. The Plan of Care initiated 4/11/16 and dated as revised on 1/22/18 documented, Resident has the potential risk for complications related to altered elimination device for bowel elimination as evidenced by [MEDICAL CONDITION]. Goal: Resident will not develop complications related to [MEDICAL CONDITION] . Approaches: Check [MEDICAL CONDITION] each shift and PRN (as needed) for appropriate fit, leakage, and need for emptying. Provide ostomy care per standards . b. Nursing Progress Notes dated 12/23/17 through 12/29/17 contained no documentation of nausea, vomiting or other gastrointestinal (GI) issues. c. An Orders Administration Note dated 12/30/17 at 8:00 a.m. documented, [MEDICATION NAME] Solution 25 mg/ml (milligrams per milliliter) Inject 1 ml intramuscularly every 4 hours as needed for nausea and vomiting per standing orders. Vomited x (times) 1. d. The SBAR (Situation Background Assessment Recommendation) Communication Form dated 12/30/17 at 8:15 a.m. documented, Abdominal / GI Evaluation: .Nausea and / or vomiting . Primary Care Clinician Notified . 12/30/17 (at) 8:15 a.m . Recommendations of Primary Clinicians . SO (standing order) [MEDICATION NAME] 25 mg IM (intramuscularly) every six hours PRN for nausea and vomiting . e. An Orders Administration Note dated 12/30/17 at 3:11 p.m. documented, Elder c/o (complains of) pain all over, PRN Tylenol given, notified (physician), NO (new order) to get flu swab . f. Nursing Hot Rack Charting dated 12/30/17 at 10:08 p.m. documented the following: 1.) 16:15 (4:15 p.m.) Noted to have mod (moderate) amt (amount) of undigested food in emesis . 2.) 17:00 (5:00 p.m.) consumed few sips of tea. Refused soup and crackers . 3.) 19:45 (7:45 p.m.) Noted to have mod amt emesis of undigested food. [MEDICATION NAME] 25 mg IM given at this time. 4.) 20:30 Awake. No further emesis noted . Results of flu swab rec. (received) with results neg (negative) . g. Orders Administration Notes dated 12/31/17 at 5:52 a.m. documented, [MEDICATION NAME] . 25 mg . elder has nausea and vomiting brown emesis . The follow-up note timed at 7:24 a.m. documented, .PRN administration was effective . There was no documentation regarding the odor of the emesis or of a bowel assessment that included bowel sounds, presence or absence of abdominal distention or pain, nor of any notification to the physician regarding any changes at this time or at any time on the 11:00 p.m. to 7:00 a.m. shift; however, the next Nursing Note was dated 12/31/17 at 12:41 p.m. and documented, 11/7 (11:00 p.m. to 7:00 a.m. shift) nurse reported to this nurse that Elder was noted to have emesis with bowel like odor this a.m. (morning). Abdomen noted to be distended and tender to touch. Bowel sounds active in right upper and lower quadrant but noted to be hypoactive in left upper and lower quadrants. (Advanced Practice Nurse (APN)) made aware with new orders to send to ER (emergency room ) with evaluation . 0915 (9:15 a.m.) ambulance here to transport to ER . The resident's transfer to the hospital emergency room occurred approximately 3 hours and 23 minutes after the 11:00 p.m. to 7:00 a.m. shift nurse noted the change in the resident's emesis. There had been no documentation regarding whether [MEDICAL CONDITION] output was present, absent, normal or abnormal at any time since the nausea and vomiting was initially noted on 12/30/17 at 8:00 a.m. h. Hospital #1's Emergency Department Notes dated 12/31/17 documented the following: 1.) 9:31 a.m. - Triage Assessment: Pain: Complains of abdomen pain, currently is 8 out of 10 on a pain scale. At worst was 10 out of 10 on a pain scale. Quality of pain is described as being aching and crampy. Pain began 1 day ago. Abdomen is distended, obese, hard around [MEDICAL CONDITION] left side of abdomen. Bowel sounds present in right upper quadrant, left upper quadrant and right lower quadrant. Abdomen is tender to palpation in left lower quadrant. Reports cramping . 2). 10:30 a.m. - Acute Abdominal Series documented, H/O (history of) abdominal pain. Impression: Marked [MEDICATION NAME] distention of the stomach. Dilated loops of small bowel within the left abdomen with air-filled levels consistent with small obstruction. Fecal residue within the right colon is noted. 3). 2:57 p.m. - NG (nasogastric) tube was inserted, removed 400 ml (approximately 13.5 ounces) of brown liquid. CT (computerized tomography) abdomen and pelvis . Impression: Left lower quadrant [MEDICAL CONDITION] with prostomial hernia containing loop of small bowel which is causing obstructive point with high grade small bowel obstruction. There is some mild thickening of the herniated loop of bowel with stranding and fluid . Report called to doctor in emergency at 17:05 hours (5:05 p.m.). 4). 5:54 p.m. - Disposition: Transfer ordered to (Hospital #2). [DIAGNOSES REDACTED]. Reason for transfer: Surgery - Higher Level of Care . i. Hospital #2's medical records dated 12/31/17 for the resident documented, Emergency Department . 12/31/17 . arrival at 20:42 (8:42 p.m.). Resident was placed on the urology unit . Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. j. On 1/30/18 at 11:40 a.m., the Director of Nursing (DON) was asked for documentation of monitoring of the resident's [MEDICAL CONDITION] output. The DON and Nurse Consultant provided a copy of the resident's [MEDICAL CONDITION] documentation, which consisted of records of changing the [MEDICAL CONDITION] bag and an elimination sheet. There was no documentation of bowel output for the entire month of December 2017. The DON stated, This is all of the documentation that we have for the [MEDICAL CONDITION]. She was asked why no bowel movements were documented for this resident and stated, There were none being documented. The December 2017 Medication Administration Record (MAR), provided by the DON on 1/30/18 documented, [MEDICAL CONDITION] bag to be changed every shift and PRN. There were nurses' signatures documented on the MAR of daily [MEDICAL CONDITION] bag changes, but no documentation of the presence or absence of [MEDICAL CONDITION] output and whether the output was normal or abnormal for the resident. k. On 1/30/18, the following staff members were interviewed regarding the resident's [MEDICAL CONDITION] output: 1.) At 2:30 p.m., Certified Nursing Assistant (CNA) #1 stated, .I worked on that Friday (12/29/17); I don't think she did have a BM (bowel movement). The bag was just flat. I came to work at 6:45 a.m., and it looked like a new bag from night shift changing it. She normally had BMs daily, but she did not have one on that Friday. I checked her about 11:00 a.m., and it ([MEDICAL CONDITION] bag) was flat. I left at 1:00 p.m. 2.) At 2:40 p.m., Licensed Practical Nurse (LPN) #1 stated, Yes. I know she had a big one that Thursday (12/28/17). That Friday (12/29/17), I don't remember changing the [MEDICAL CONDITION] bag. There was not enough in there to change it. When asked if the resident normally had bowel movements via the [MEDICAL CONDITION] daily, the LPN stated, Every day, sometimes several times a day. One day I had to change it ([MEDICAL CONDITION] bag) two times. When asked if the resident was having pain on 12/29/17, the LPN stated, No, she was not having any pain that Friday. 3.) At 2:50 p.m., LPN #1 stated, .I don't believe she did (have a bowel movement on Friday 12/29/17). Her abdomen did not look distended, but I do recall her complaining of general stuff, pain around her side area that she always complained of. She took her ([MEDICAL CONDITION]) bag off that night and I had to put it back on. I gave her some Milk of Magnesia (MOM), but there were no results before I left. I gave it just before 9:00 p.m. The LPN was asked if the resident normally had bowel movements via the [MEDICAL CONDITION] daily and stated, Yes, she normally had BMs. When asked if there was any stool visible in the resident's [MEDICAL CONDITION] bag on Friday, 12/29/17, the LPN stated, No. 4.) At 3:15 p.m., CNA #3 stated, .I don't recall a BM on that day (12/29/17); she could have. l. The facility removed the immediate jeopardy on 12/31/17, and reduced the scope / severity to G, as evidenced by the following: 1.) On 1/31/18 at 12:40 p.m., the DON was asked if the facility had identified the problem with lack of documentation of the resident's [MEDICAL CONDITION] output after the resident was hospitalized . She stated, Yes, we determined there was a problem with the [MEDICAL CONDITION] outputs; there were none documented. She was asked, What did you put in place as a plan of correction for this? She stated, We have put in place for the CNAs to continue forward when they are documenting in the kiosk and go to the output section so that a [MEDICAL CONDITION] output will be documented. This will also alert us to know who hasn't had a BM in 3 days. A clinical alert will show up on the computers. She was asked, How are you monitoring this? She stated, The nursing managers are now monitoring the clinical alerts 5 days a week. 2.) On 1/31/18 at 2:55 p.m., the Medical Director was contacted via phone call and was asked if aware the facility was not monitoring bowel output for a resident with a [MEDICAL CONDITION]. He stated, Yes, I am now. I spoke with the DON, and they are going to start doing them. 3.) On 1/31/18 at 4:00 p.m., the DON provided the facility's written corrective action plan dated 12/31/17, which documented the following: a. On 12/31/17, the facility identified opportunities for improvement specific to the documentation of bowel movements as it relates to [MEDICAL CONDITION] patients. Specifically, omissions in the documentation of bowel movements physical appearance/characteristics were noted from resident's record. b. The facility nursing management team implemented staff documentation specific to the size and form of all bowel movements observed as care is provided by staff. c. An added precaution was implemented linking the facility clinical alert system to any resident lacking a documented bowel movement over a 3 day / 9 shift time span. d. Staff in services were implemented regarding additional follow up by licensed charge nurses and department managers in order to ensure compliance with the above plan. e. Additional assessment requirements implemented at time to ensure all residents with a [MEDICAL CONDITION] receive documented bowel sounds auscultated along with follow up as appropriate findings.

Complaint # (AR 909) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to provide necessary care and services to identify and manage bowel complications, as evidenced by failure to routinely assess, monitor and document bowel output for a resident with a [MEDICAL CONDITION], which resulted in a delay in identifying and addressing a serious complication when bowel elimination to the [MEDICAL CONDITION] was interrupted, and failure to ensure a bowel assessment was conducted and the physician was immediately consulted when the resident's emesis developed characteristics that were indicative of possible bowel obstruction for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION]. This failed practice resulted in immediate jeopardy (removed), which caused or could have caused serious harm, injury, or death to Resident #1, who developed a partial bowel obstruction secondary to a prostomial hernia with resulting bowel perforation. There were no other residents in the facility with colostomies, according to a list provided by the Director of Nursing on 1/31/18. The Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the removed immediate jeopardy condition on 1/31/18. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of one person for activities of daily living, and had an ostomy. a. The Plan of Care initiated 4/11/16 and dated as revised on 1/22/18 documented, Resident has the potential risk for complications related to altered elimination device for bowel elimination as evidenced by [MEDICAL CONDITION]. Goal: Resident will not develop complications related to [MEDICAL CONDITION] . Approaches: Check [MEDICAL CONDITION] each shift and PRN (as needed) for appropriate fit, leakage, and need for emptying. Provide ostomy care per standards . b. Nursing Progress Notes dated 12/23/17 through 12/29/17 contained no documentation of nausea, vomiting or other gastrointestinal (GI) issues. c. An Orders Administration Note dated 12/30/17 at 8:00 a.m. documented, [MEDICATION NAME] Solution 25 mg/ml (milligrams per milliliter) Inject 1 ml intramuscularly every 4 hours as needed for nausea and vomiting per standing orders. Vomited x (times) 1. d. The SBAR (Situation Background Assessment Recommendation) Communication Form dated 12/30/17 at 8:15 a.m. documented, Abdominal / GI Evaluation: .Nausea and / or vomiting . Primary Care Clinician Notified . 12/30/17 (at) 8:15 a.m . Recommendations of Primary Clinicians . SO (standing order) [MEDICATION NAME] 25 mg IM (intramuscularly) every six hours PRN for nausea and vomiting . e. An Orders Administration Note dated 12/30/17 at 3:11 p.m. documented, Elder c/o (complains of) pain all over, PRN Tylenol given, notified (physician), NO (new order) to get flu swab . f. Nursing Hot Rack Charting dated 12/30/17 at 10:08 p.m. documented the following: 1.) 16:15 (4:15 p.m.) Noted to have mod (moderate) amt (amount) of undigested food in emesis . 2.) 17:00 (5:00 p.m.) consumed few sips of tea. Refused soup and crackers . 3.) 19:45 (7:45 p.m.) Noted to have mod amt emesis of undigested food. [MEDICATION NAME] 25 mg IM given at this time. 4.) 20:30 Awake. No further emesis noted . Results of flu swab rec. (received) with results neg (negative) . g. Orders Administration Notes dated 12/31/17 at 5:52 a.m. documented, [MEDICATION NAME] . 25 mg . elder has nausea and vomiting brown emesis . The follow-up note timed at 7:24 a.m. documented, .PRN administration was effective . There was no documentation regarding the odor of the emesis or of a bowel assessment that included bowel sounds, presence or absence of abdominal distention or pain, nor of any notification to the physician regarding any changes at this time or at any time on the 11:00 p.m. to 7:00 a.m. shift; however, the next Nursing Note was dated 12/31/17 at 12:41 p.m. and documented, 11/7 (11:00 p.m. to 7:00 a.m. shift) nurse reported to this nurse that Elder was noted to have emesis with bowel like odor this a.m. (morning). Abdomen noted to be distended and tender to touch. Bowel sounds active in right upper and lower quadrant but noted to be hypoactive in left upper and lower quadrants. (Advanced Practice Nurse (APN)) made aware with new orders to send to ER (emergency room ) with evaluation . 0915 (9:15 a.m.) ambulance here to transport to ER . The resident's transfer to the hospital emergency room occurred approximately 3 hours and 23 minutes after the 11:00 p.m. to 7:00 a.m. shift nurse noted the change in the resident's emesis. There had been no documentation regarding whether [MEDICAL CONDITION] output was present, absent, normal or abnormal at any time since the nausea and vomiting was initially noted on 12/30/17 at 8:00 a.m. h. Hospital #1's Emergency Department Notes dated 12/31/17 documented the following: 1.) 9:31 a.m. - Triage Assessment: Pain: Complains of abdomen pain, currently is 8 out of 10 on a pain scale. At worst was 10 out of 10 on a pain scale. Quality of pain is described as being aching and crampy. Pain began 1 day ago. Abdomen is distended, obese, hard around [MEDICAL CONDITION] left side of abdomen. Bowel sounds present in right upper quadrant, left upper quadrant and right lower quadrant. Abdomen is tender to palpation in left lower quadrant. Reports cramping . 2). 10:30 a.m. - Acute Abdominal Series documented, H/O (history of) abdominal pain. Impression: Marked [MEDICATION NAME] distention of the stomach. Dilated loops of small bowel within the left abdomen with air-filled levels consistent with small obstruction. Fecal residue within the right colon is noted. 3). 2:57 p.m. - NG (nasogastric) tube was inserted, removed 400 ml (approximately 13.5 ounces) of brown liquid. CT (computerized tomography) abdomen and pelvis . Impression: Left lower quadrant [MEDICAL CONDITION] with prostomial hernia containing loop of small bowel which is causing obstructive point with high grade small bowel obstruction. There is some mild thickening of the herniated loop of bowel with stranding and fluid . Report called to doctor in emergency at 17:05 hours (5:05 p.m.). 4). 5:54 p.m. - Disposition: Transfer ordered to (Hospital #2) [DIAGNOSES REDACTED]. Reason for transfer: Surgery - Higher Level of Care . i. Hospital #2's medical records dated 12/31/17 for the resident documented, Emergency Department . 12/31/17 . arrival at 20:42 (8:42 p.m.). Resident was placed on the urology unit . Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. j. On 1/30/18 at 11:40 a.m., the Director of Nursing (DON) was asked for documentation of monitoring of the resident's [MEDICAL CONDITION] output. The DON and Nurse Consultant provided a copy of the resident's [MEDICAL CONDITION] documentation, which consisted of records of changing the [MEDICAL CONDITION] bag and an elimination sheet. There was no documentation of bowel output for the entire month of December 2017. The DON stated, This is all of the documentation that we have for the [MEDICAL CONDITION]. She was asked why no bowel movements were documented for this resident and stated, There were none being documented. The December 2017 Medication Administration Record (MAR), provided by the DON on 1/30/18 documented, [MEDICAL CONDITION] bag to be changed every shift and PRN. There were nurses' signatures documented on the MAR of daily [MEDICAL CONDITION] bag changes, but no documentation of the presence or absence of [MEDICAL CONDITION] output and whether the output was normal or abnormal for the resident. k. On 1/30/18, the following staff members were interviewed regarding the resident's [MEDICAL CONDITION] output: 1.) At 2:30 p.m., Certified Nursing Assistant (CNA) #1 stated, .I worked on that Friday (12/29/17); I don't think she did have a BM (bowel movement). The bag was just flat. I came to work at 6:45 a.m., and it looked like a new bag from night shift changing it. She normally had BMs daily, but she did not have one on that Friday. I checked her about 11:00 a.m., and it ([MEDICAL CONDITION] bag) was flat. I left at 1:00 p.m. 2.) At 2:40 p.m., Licensed Practical Nurse (LPN) #1 stated, Yes. I know she had a big one that Thursday (12/28/17). That Friday (12/29/17), I don't remember changing the [MEDICAL CONDITION] bag. There was not enough in there to change it. When asked if the resident normally had bowel movements via the [MEDICAL CONDITION] daily, the LPN stated, Every day, sometimes several times a day. One day I had to change it ([MEDICAL CONDITION] bag) two times. When asked if the resident was having pain on 12/29/17, the LPN stated, No, she was not having any pain that Friday. 3.) At 2:50 p.m., LPN #1 stated, .I don't believe she did (have a bowel movement on Friday 12/29/17). Her abdomen did not look distended, but I do recall her complaining of general stuff, pain around her side area that she always complained of. She took her ([MEDICAL CONDITION]) bag off that night and I had to put it back on. I gave her some Milk of Magnesia (MOM), but there were no results before I left. I gave it just before 9:00 p.m. The LPN was asked if the resident normally had bowel movements via the [MEDICAL CONDITION] daily and stated, Yes, she normally had BMs. When asked if there was any stool visible in the resident's [MEDICAL CONDITION] bag on Friday, 12/29/17, the LPN stated, No. 4.) At 3:15 p.m., CNA #3 stated, .I don't recall a BM on that day (12/29/17); she could have. l. The facility removed the immediate jeopardy on 12/31/17, and reduced the scope / severity to G, as evidenced by the following: 1.) On 1/31/18 at 12:40 p.m., the DON was asked if the facility had identified the problem with lack of documentation of the resident's [MEDICAL CONDITION] output after the resident was hospitalized . She stated, Yes, we determined there was a problem with the [MEDICAL CONDITION] outputs; there were none documented. She was asked, What did you put in place as a plan of correction for this? She stated, We have put in place for the CNAs to continue forward when they are documenting in the kiosk and go to the output section so that a [MEDICAL CONDITION] output will be documented. This will also alert us to know who hasn't had a BM in 3 days. A clinical alert will show up on the computers. She was asked, How are you monitoring this? She stated, The nursing managers are now monitoring the clinical alerts 5 days a week. 2.) On 1/31/18 at 2:55 p.m., the Medical Director was contacted via phone call and was asked if aware the facility was not monitoring bowel output for a resident with a [MEDICAL CONDITION]. He stated, Yes, I am now. I spoke with the DON, and they are going to start doing them. 3.) On 1/31/18 at 4:00 p.m., the DON provided the facility's written corrective action plan dated 12/31/17, which documented the following: a. On 12/31/17, the facility identified opportunities for improvement specific to the documentation of bowel movements as it relates to [MEDICAL CONDITION] patients. Specifically, omissions in the documentation of bowel movements physical appearance/characteristics were noted from resident's record. b. The facility nursing management team implemented staff documentation specific to the size and form of all bowel movements observed as care is provided by staff. c. An added precaution was implemented linking the facility clinical alert system to any resident lacking a documented bowel movement over a 3 day / 9 shift time span. d. Staff in services were implemented regarding additional follow up by licensed charge nurses and department managers in order to ensure compliance with the above plan. e. Additional assessment requirements implemented at time to ensure all residents with a [MEDICAL CONDITION] receive documented bowel sounds auscultated along with follow up as appropriate findings.

Complaint # (AR 752) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure the care planned level of assistance was provided during a resident's shower and that the proper size shower chair was utilized, to prevent potential falls and injuries for 1 (Resident #4) of 1 case mix resident who was at risk for falls and was care planned for 2-person assistance with showers. The failed practice resulted in past noncompliance at actual harm level for Resident #4, who fell from a shower chair during a shower and sustained a fracture of the femur, and had the potential to cause more than minimal harm to 6 residents who were care planned for 2-person assistance with bathing / showering, according to a list provided by Nurse Consultant on 2/15/17. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/15/16 documented the resident scored 3 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, was totally dependent on two plus people for bathing and had no history of falls. a. A Nursing Admit / Readmit Assessment and Care Plan dated 11/21/16 documented, .History of Falls .Morse Fall Score Total score 50 . A total score of 10 or higher indicate resident is at risk for fall . b. A Care Plan dated as initiated 11/21/16 documented, .Bathing/Showering: The resident requires (specify what assistance) by x (times) 2 staff with (specify: bathing/showering) (Specify Freq) and as necessary . The Care Plan did not address falls. c. The Nursing Assistant Care Plan not dated, located in the resident's closet on 2/14/17 at 1:10 p.m., documented, Bathing D = Dependent or Total Care Required .non ambulatory .Transfer skills (not answered) .mechanical lift with purple trim lift pad X 2 staff . d. A Incident/Accident report dated 1/30/17 at 10:25 a.m. documented, Witnessed Fall; Incident Location: Resident's Room, Person Preparing Report: (Licensed Practical Nurse (LPN) #1) . Incident Description : .Elder on shower floor in fetal position with head against wall naked with noted blood on floor on left side. Elder upon touch screamed out in pain. Immediate action taken . 911 called and sent to ER (emergency room ) . Injuries Observed at Time of Incident: .Left Upper Arm Skin Tear . Other info (information) : CNA was moving elder in shower chair to get dried and dressed, and elder fell forward out of chair, Witnesses: (Certified Nurse Assistant (CNA) #4) .Physician notified and Family Member . e. A Timberlane Health and Rehabilitation Progress Note dated 1/30/17 at 8:11 p.m. and signed by the Assistant Director of Nursing (ADON) documented, .Elder only voiced neck and back pain .Long Term Intervention: Staff to use regular sized wheelchair with safety strap in place . A Timberlane Health and Rehabilitation Progress Note dated 1/30/17 at 11:28 p.m. and signed by LPN #1 documented, .Sent to ER due to hitting head and c/o (complaint of) hip/back pain . f. A hospital record dated 1/30/17 at 10:49 (a.m.) documented, .Presenting complaint: EMS (Emergency Medical Service) states: Pt (patient) fell in the shower and has some skin tears on her arm and hurts head to toe . g. Radiology report was as follows: 1.) A Computed Tomography (CT) of the Head without Contrast results dated 1/30/17 at 10:50 a.m., documented, . Impression:No acute intracranial injury or skull fracture . 2.) A CT of the cervical spine without contrast results dated 1/30/17 at 11:07 a.m., documented, .Bones are osteopenic . no acute cervical spine fracture . 3.) An Anterior-to- Posterior (AP) pelvis radiology results documented, .Bones are osteopenic . no acute fracture of the pelvis or proximal femurs . h. An Emergency note dated 1/30/17 at 12:05 a.m. documented, discharged to home, impression, fall, skin tears left arm, condition stable . i. A Nurses Note dated 1/31/17 at 3:17 a.m. documented, .Elder voices pain in her right leg . j. A Nurses Note dated 1/31/17 at 10:18 a.m. documented, .Elder right knee noted to be swollen with pain noted upon movement. As long as Elder is still, she denies pain but when staff attempts to reposition Elder or to perform ADLs (activities of daily living) care, she complains of pain to right leg. (Physician's) office notified with message left per (LPN #2). Will continue to monitor. k. A Nurses Note dated 1/31/17 at 4:03 p.m. documented, (Physician's) office called with new order given to (LPN #2) to consult ortho (orthopedic) for right knee swelling/pain. Son aware. Will follow-up in a.m. (morning). l. A Nurses Note dated 2/1/17 at 8:35 a.m. documented, (Physician's) office notified at this time regarding Elder's right knee swelling and pain and the new order received yesterday. Right knee x-rays requested as well as prn (as needed) pain medication . m. A Nurses Note dated 2/1/17 at 4:47 p.m. documented, .Office Returned call New orders for right knee x-ray and Tylenol 325 mg (milligrams) give 2 tabs (tablets) po (by mouth) q4hrs (every 4 hours) prn pain and/or increased temp (temperature) . Son notified. n. A Nurses Note dated 2/1/17 at 6:21 p.m. documented, Onsite imaging here at this time collecting x-ray . o. A Radiology Report dated 2/2/17 at 6:12 p.m. documented, .Procedure: Knee AP / LAT (lateral) right . Acute fracture involving the distal shaft of the femur with mild displacement and impaction . p. A Nurses Note dated 2/1/17 at 7:23 p.m. documented, .Physician notified of full Lab / Diagnostic Report . Family notified . Send out to ER for evaluation . q. A hospital Emergency Department (ED) Nurse Note dated 2/1/17 at 8:19 p.m. documented, .presents in ED via EMS -Ground with complaints of fall injury . Pt fell in shower 2 days ago and came to ER and had normal CT head and neck and a normal pelvis x-ray. NH (Nursing Home) said pt (patient) just kept c/o (complaining of) right knee pain so today had an onsite x-ray done of right knee and a fracture was seen so they sent her back to ER. Pt is poor historian and doesn't really talk due to dementia. r. A hospital Imaging Report dated 2/1/17 at 9:24 a.m. documented, .Right femur radiographs . pain in right femur . Impression: Oblique fracture distal diaphysis of femur with posterior and medial displacement of the distal fragment relative to the proximal fragment . s. A Hospital History and Physical Report dated 2/1/17 (not dated) documented, .Plan of Treatment: .Long term prognosis is poor given age, dementia, and immobility after fracture . t. A Hospital Procedure Note dated 2/2/17 at documented, .Procedure performed: Open treatment and internal fixation of a right supracondylar femur fracture with intramedullary nail . u. A Nurses Note dated 2/6/2017 at 6:50 p.m. documented, .Resident returned to facility from (hospital) .via stretcher with surgical nailing of right femur resident with surgical incision to right thigh dry and intact with 5 staples in place right knee surgical incision with 8 staples . v. On 2/14/17 at 11:30 a.m., the Administrator and Director of Nursing were asked if the I/A section for witnessed by indicated only 1 person witnessed the actual fall, and both stated, Yes. w. On 2/14/17, Licensed and Certified Nursing staff was asked how much assistance was required to transfer, bathe, shower, and dress Resident #4, and who was present and providing care for the resident when the 1/30/17 fall in the shower occurred. Their responses were as follows: 1.) At 1:40 p.m., Restorative Certified Nursing Assistant #1 stated, (Resident #4) was a 2 (person) assist for transfers, and total assist of 2 with bathing, showering, and dressing. We have closet care plans. I heard about the fall, but I didn't know anything about the fall until I seen the ambulance here. (CNA #4) was the only one in there showering the resident, and no one else that I know of. I did not see the fall occur. (CNA #4) no longer works here. 2.) At 1:50 p.m., CNA #2 stated, She was assist of 2 with transfers, and I use a gait belt; we have closet care plans. The resident requires 2 assist with showering, bathing, and dressing. I can't remember if I was here the day she had the fall in the shower. I heard that (CNA #4), who works 7-3, was the one in showering the resident when she fell . (CNA #4) no longer works here. 3.) At 1:58 p.m., CNA #3 stated, She was assist of 2 with transfers with a gait belt, 2 with showering and bathing. Yes, I remember that day when she fell in the shower. I helped (CNA #4) transfer her from the bed into the wheelchair and, before showering her, I helped (CNA #4) transfer her from the wheelchair to the shower chair. I told (CNA #4) when she was done showering (Resident #4), to use the call bell and I would come help her, then I walked out (of) the shower room. She never called for me. When I noticed anything, the ambulance was here. (CNA #4) was in alone with the resident during the shower. I did not witness the actual fall. I'm in trouble, because I know I should have stayed in there to help. (Resident #4) could be combative. 4.) At 2:20 p.m., Licensed Practical Nurse #1 (LPN) stated via telephone, She (Resident #4) was assist of 2 with transferring, and 1 assist with showering and dressing. (CNA #4) was the only one in showering the resident. When I got to the shower room, she was lying next to the wall, covered, and the shower chair was away from her, and I can't remember if a wheelchair was in there or not. I can't remember who came and got me to come to the shower room that morning. 5.) At 3:00 p.m., the Director of Nursing stated, She was a 2 (person) assist with transfers and 1 assist with bathing/showering prior to the fall on 1/30/17. The MDS Coordinator we had wasn't good at her job. (CNA #4) was the CNA that was bathing the resident, and I don't believe there was anyone in there assisting her when the fall occurred. I think (CNA #4) was pulling her from the shower out of the stall. The resident was never dressed. No one witnessed the fall, but (CNA #4). (CNA #4) is no longer employed here. x. The facility provided the following evidence of corrective actions taken prior to the survey date: 1.) A Termination Information Sheet dated from 12/1/2016-2/14/17 documented CNA #4 was terminated 01/31/17 and, .Type: voluntary and reason: No Notice Given. 2.) A Quality Assessment / Assurance (QAA) Plan dated 1/30/17 documented the following: On 1/30/17, (Resident #4) sustained a fall to the floor from seated position on a rolling shower chair upon completion of her shower . A facility incident and accident investigation was immediately initiated. The shower chair utilized for (Resident #4) at the time of her fall was removed from resident care and evaluated for operability; no concerns were identified with these safety observations . Incident/Accident investigation reveals (CNA #4) as having assisted (Resident #4) with her shower at the time of the incident. Ongoing investigation including staff interview and reenactment identified that although the resident was appropriately transferred onto a shower chair by two staff members and provided appropriate assistance . potential concerns with the size of the shower chair utilized are raised. (Resident #4) was placed on a large shower chair which may have contributed instability in the seated position causing her to fall forward from chair . 1/31/17 the facility identified all other patients with use of rolling shower chairs via observation rounds and staff interviews. All residents utilizing use of a shower chair were observed to ensure that the size of the shower chair appropriate for the individual was consistently utilized . All residents identified as needing a bariatric shower chair versus standard size shower chair were identified at this time and CNA communication was verified with any clarifications in communication tools made at this time . All facility shower chairs were observed for operability with no safety concerns identified involving the chairs. The facility explored options for additional safety measures to guard against accidents involving the chairs thus opting to order safety bars for use on shower chairs. Showers given utilizing chairs without the safety bar will be assisted with two staff members as well . On 1/30/17 facility administration and nursing management initiated staff retraining on the following topics: Shower chair selection; direct care staff communication of equipment selection. Safety precautions with additional staff members to be implemented until additional safety features can be determined, ordered, delivered and installed. Implementation of alternate safety precautions in the case that a resident were to refuse use of safety bar. Ongoing monitoring to evaluate the effectiveness of re-training will be completed with random daily observation rounds to ensure implementation of standard size shower chairs unless otherwise directed for individual residents as follows: 3 x (three times) weekly x (times) 2 weeks and then ongoing during facility observation rounds until substantial compliance is achieved . 3.) An in-service sheet dated 1/30/17 documented CNAs and LPNs were in-serviced on, Insure (sic) appropriate size shower chair + (and) safety strap is used as indicated . The large (XL (extra large)) shower chairs are not for residents that are not obese. The regular shower chair should be used for most residents. Look at CNA Care Plan should a resident require additional assist (with) actual shower, it will indicate . Only shower chairs with safety bar are to be used (at) this time. Should a resident request that no safety bar be used, then 2 people must be present + assist (with) shower . 4.) A QAA Plan dated 2/3/17 documented the following: On 2/3/17 the care plan and safety assessments for (Resident #4) were reviewed as part of the facility incident / accident investigation of a fall occurring 1/30/17 in which the resident sustained [REDACTED].#4's) comprehensive care plan was identified at this time as having documentation error specific to the number of staff members required to bathe the resident. Staff interviews, medical record reviews and her CNA care plan communication tool have been reviewed in their entirety and accurately reflect (Resident #4) as requiring two persons for transfer and one person for the physically (sic) bathing activity . The facility IDT (Interdisciplinary Team) will proceed with full house plan to ensure accurate documentation on comprehensive care plans as listed below. On 2/3/17 IDT designee(s) initiated observation rounds and staff interviews to determine the level of assistnace specific to the number of staff members required for completing each resident's bathing adl (activity of daily living). On 2/3/17 IDT designee(s) initiated comprehensive care plan audits with clarifications made immediately as needed to ensure comprehensive care plans accurately reflect the number of staff members required to provide physical assistance with each resident's bathing adl. On 2/3/17 IDT designee(s) initiated CNA / direct care staff care communication tools to ensure accurate communication of the number of staff members required for bathing and any clarifications were implemented as needed . Increased monitoring of care plan documentation is being implemented in conjunction with increased IDT review for all comprehensive care plans developed . 5.) An in-service sheet dated 2/3/17 documented the MDS Coordinator was provided with the following training: Comprehensive Care Plan error identified + QAA Plan developed (after) review of (Resident #4). Specifically # (number) of staff required for bathing. The nsg (nursing) admit / re-admit assessment that is completed at the time for ARD must reflect as the safety assmt (assessment), Section B (ADLs) 6g. bathing is completed to reflect level of assistance + the activities of daily living care plan focus. Interventions must be individualized for safety assmt + specific needs including # of staff. MDS section G reflects the highest level of care provided for said resident during the 7 day ARD look back period + should not automatically carry into the comprehensive care plan unless it is appropriate per safety assment .

Complaint # substantiated (all or in part) with these findings: Based on record review and interview, facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for Resident #3, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure staff (Licensed Practical Nurse (LPN) #1 and LPN #2) immediately provided cardiopulmonary resuscitation when resident was found without vital signs for 1 (Resident #3) of 8 (Residents #1, #2, #3, #4, #6, #7, #9, and #10) case mix residents who had full code advance directive. This failed practice resulted in a past Immediate Jeopardy which caused or could have caused death to Resident #3 who had an advance directive for full code and did not have cardiopulmonary resuscitation initiated when resident condition declined. This failed practice had the potential to cause more than minimal harm for 50 residents who had an advance directive of full code according to a list provided by the Director of Nursing on [DATE]. On [DATE] at 3:45 p.m., the facility was informed of the past Immediate Jeopardy. The findings are: 1. On [DATE] at 12:15 p.m., the Director of Nursing (DON) provided a copy of a form " Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) " which documented, " ...Purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel. 2. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times ... General Guidelines 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (no pulse). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA .... 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse ... 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 9. If an individual (resident, ...) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). ... Documentation: 1. Document the following in the resident's medical record (if the victim is a resident): a. The condition in which the resident was found or the witnessed event. b. The sequence of resuscitation efforts, including approximate times. c. The victim's response to resuscitation efforts. d. The approximate time that the EMS (Emergency Medical System) team took over. e. Time of death or time the individual was transported." 2. Resident #3 had [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The "Acknowledgment of Receipt Advance Directive/Medical Treatment Decisions" dated [DATE] and signed by the resident's representative documented, "I, the undersigned, acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue Advance Directives to be followed should I become incapacitated. ...(check mark) I do not choose to formulate or issue any Advance Directives at this time. ..." A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"NOTES/ALERTS FULL CODE" The Resident Admission Care Plan dated [DATE] documented " ...Code Status: Full Code..." b. The Vital Signs & Weight Flow Sheet documented, " ... [DATE]: Blood Pressure ,[DATE] Temperature 97.1 Pulse 55 Respiration 16 Signature/Comments ,[DATE] (11:00 p.m. to 7:00 a.m.) (Certified Nursing Assistant (CNA) #1). " c. Daily Skilled Nurses Note dated [DATE] at 2:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Resp. even (and) unlabored on O2 (oxygen) (at) 2L/M (liters per minute) per N/C (nasal cannula). Voices needs clearly. Cont. (continent) of B (and) B (bowel and bladder) (with) assist of (one) to BR (bathroom). Limited assist (with) ADLs (activities of daily living) (and) transfers. PT/OT (physical therapy and occupational therapy) 5 (times) wk (week) Updrafts as ordered. BS (blood sugar) checks as ordered. No c/o (complaints of) pain/distress. Call light within reach." d. Daily Skilled Nurses Notes dated [DATE] at 6:15 a.m. and signed by LPN #1 documented, "Elder found to be (without) pulse or respirations. (County) Sheriff informed (and) will send coroner. ...When elder was found fingertips (and) hands were cold." e. An " Information for Funeral Home " form provided by the County Coroner documented, "...date of death [DATE] Time of Death 0600 hrs (6:00 a.m. (hours)). Time Pronounced: 0700 hrs (7:00 a.m.). Pronounced by (Deputy Coroner) Place of Death (facility) Manner of Death Natural Cause of Death Pending..."A county Coroner's Office letter dated [DATE] documented, "The death of (Resident #3) ...a resident at (facility) was checked on [DATE] at the facility by (coroner) deputy coroner. The death appears natural in origin and is attributed to cardiopulmonary arrest secondary to [MEDICAL CONDITION], severe hypertension and diabetes. ..." f. A " Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities " (DMS (Division of Medical Services) 762) dated [DATE] documented, "Date Incident Reported to OLTC (Office of Long Term Care) [DATE] Time: 10:06 a.m. Date and Time of Incident (if known): [DATE] Time: 6:15 a.m. Date and Time of Discovery: [DATE] Time: 10:30 a.m. Type of Incident: Neglect (box marked) Name of Involved Resident: (Resident #3) ...Section III-Findings and Actions Taken Please include Resident's current medical condition Findings: Allegation substantiated Investigation results: (Resident #3) admitted to (facility) on [DATE]. Her code status was full code. At 5:15 a.m., (Licensed Practical Nurse (LPN) #1) administered (Resident #3) medications, started her updraft treatment and left her room to continue her medication pass. Approximately 15 minutes later, (LPN #1) returned to (Resident #3) room to remove the updraft. (LPN #1) stated that at this time, (Resident #3) appeared to be sleeping. According to (Certified Nursing Assistant (CNA) #1) sometime between 5:45 a.m. and 6:00 a.m., she checked on (Resident #3) who was unresponsive. (CNA #1) stated she went to (LPN #1) who was now passing medications on the 200 hall and informed her that (Resident #3) was unresponsive. (CNA #1) stated that (LPN #1) continued with her med pass. (CNA #1) then went to co-worker, (CNA #2) and told her that she did not think (Resident #3) was breathing. (CNA #2) accompanied (CNA #1) back to (Resident #3) room, checked and found no pulse and noted that (Resident #3) hands were cold and dark. The two CNAs exited the room and together summoned (LPN #1) who was at the nurse station, to (Resident #3). According to (LPN #1) (Resident #3) had no pulse, no heartbeat, no respirations, no blood pressure, her pupils were fixed, and her hands were cold and blue. (LPN #1) stated that it was obvious to her that (Resident #3) was past the point of resuscitation. According to (LPN #1) and the two CNAs, (LPN #1) approached (LPN #2) at the nurse station and asked her what needed to be done. According to (LPN #1), (LPN #2) told her to call the coroner. The two CNAs stated that (LPN #2) picked up the phone to call someone, but they were unsure of whom. (LPN #1) stated that while she called the coroner, (LPN #2) telephoned (Resident #3) family to make notification. (LPN #2) stated that she has no recollection of any situation involving (Resident #3) or any similar event as described above. Actions taken: (LPN #1) employment at (facility) is terminated for failing to follow nursing standards of practice regarding initiating CPR (Cardio [MEDICAL CONDITION] Resuscitation) on a full code patient. (LPN #2) employment at (facility) is terminated for providing misleading and unreliable testimony during the course of the investigation based on other witness statements. Both nurses have been reported to the (state) Board of Nursing for their involvement in the incident. According to the (county) coroner's office, (Resident #3) died of [MEDICAL CONDITION], secondary to [MEDICAL CONDITION], hypertension, and diabetes." 1) An OLTC Witness Statement Form dated [DATE] at 7:15 a.m. and signed by CNA #1 documented, "I went to check resident (Resident #3) at 5:,[DATE]:00 (5:45 a.m.-6:00 a.m.). I called her name more than once and no response. I notified nurse (LPN #1) and she continued to pass meds. I asked coworker (CNA #2) to help to see if she was okay. She also called her name and checked pulse so we notified nurse again. (LPN #1) checked her pulse and said no response. (LPN #1) left out and notified other nurse (LPN #2) to help her and she called her family. " On [DATE] at 7:15 a.m., surveyors asked CNA #1 what had occurred on the morning of [DATE] with Resident #3 and the CNA stated, "I came in to check her. I saw that she didn't have a response when I called her name." The CNA was asked if the resident could usually hear and respond to her name being called. The CNA stated, "Yes." CNA #1 continued, "I went and notified the nurse (LPN #1) and told her. She continued to pass meds on 200 hall. I went back to the room and went to get help from another CNA (CNA #2). She said to go tell the nurse again. She was at the nurse's station then. She came and checked her finger. She put something on her finger. She (LPN #1) went to the other nurse, (LPN #2) and I heard her ask (LPN#2) what she was supposed to do. She (LPN #2) made a phone call. I went to the room." The CNA was asked what time this occurred and the CNA stated, "About 5:50 a.m." The CNA was asked what time she first went to the resident's room and the CNA stated, "5:45 a.m." The CNA was asked what time the nurse was told that the resident did not respond and the CNA stated, "About 5:50 a.m." The CNA was asked to describe what LPN #1 did after she was notified and had entered the resident's room. CNA #1 stated, "All she did was check her finger. Yes, she called her name." CNA #1 was asked what was to be done if a resident is found unresponsive and the CNA stated, "Yell for help and notify the nurse and do CPR." The CNA was asked if she had checked the resident for a pulse and the CNA stated, "Yes." The CNA was asked if a pulse was found and the CNA stated, "No." The CNA was asked how it is known if the resident is to be coded or not and the CNA stated, "Outside the door there is either a red dot or a green dot. Red dot means they don't want CPR. Green dot means they do. Her door had a green dot." The CNA was asked what is done in the facility if a resident is to be coded and the CNA stated, "Everybody comes from each hall. Some chart the time, some call 911. The nurses do CPR." CNA #1 was asked if the resident had CPR that morning [DATE] and the CNA stated, "No." The CNA was asked if the resident was coded for green for CPR and the CNA stated, "Yes." The CNA was asked what (LPN #1) did when she was told on [DATE] that the resident was unresponsive and the CNA stated, "She passed meds. I don't know what time but she gave her (Resident #3) some medicine. That's what the nurse said." 2) An OLTC Witness Statement Form dated [DATE] (not timed) and signed by CNA #2 documented, "I really don't know the exact time everything occurred but the charge nurse (LPN #1) was on 300 hall 4:30 a.m. doing med pass. She always starts around this time however I started doing my rounds shortly after. When I made it down to (other residents) room all I remembered took place (LPN #1) knocking on (Resident #3) door and entering the room. The door was open and I did hear (LPN #1) call (Resident #3) name a couple of times before I entered (other residents room). Continuing to finish my job, maybe 25 to 30 minutes later (CNA #1) came out the room and said to me, 'can you come see if this lady is breathing ' We hurried into the room and I checked her wrist for a pulse and felt her hands. No pulse and her hands were cold and a little dark. I also yelled her name a few times (no response). I then told (CNA #1) that we have to get the nurse and both of us hurried out the room up to the nurse station to get (LPN #1). By that time another nurse (LPN #2) was up there it was around 6 a.m. or a little after. I told (LPN #1) that (Resident #3) wasn't breathing. I remember seeing (LPN #2) pick up the phone to call someone and (LPN #1) came down to (Resident #3) room. When we entered she called her name a few times while feeling for a pulse. After that I remembered walking out the room. The nurse was still in the room with the CNA." On [DATE] at 7:15 a.m., CNA #2 was asked to describe what had occurred with (Resident #3) on the morning of [DATE] and the CNA stated, "I started rounds by 4:45 a.m. I did remember her (CNA#1) going into her (Resident #3) room a little before 5:00 a.m. I got through the 300 hall and went and checked on the 100 hall. (CNA #1) called my name and asked, 'can you come see if (Resident #3) is breathing? ' About 6:00 a.m., I went down there yelled her name, pulled cover back, checked her radial pulse, no pulse. I even checked carotid." The CNA was asked if the resident had a carotid pulse and the CNA stated, "No." There was oxygen tubing, nasal. I told (CNA #1) we need to go up here and tell the nurse and I was out of the room ahead of her. We told the nurse (LPN #1)." The CNA was asked if there was any other nurse at the desk and the CNA stated, "(LPN #2)" The CNA was asked what the nurse did and the CNA stated, "What I did see (LPN #2) do, she picked the phone up. (LPN #1) came down to the room and all I saw her do was check her pulse and call her name. I was about to cry. I left the room. I remember going to the nurses' station." The CNA was asked if anything was done or code called and the CNA stated, "No." The CNA was asked how it is known what the resident's advance directive is and the CNA stated, "We have stickers and mainly see what is in the chart." The CNA was asked if a resident's advance directive is to be a code is CPR to be done and the CNA stated, "Yes you're supposed to." The CNA was asked what the CNA is to do if a resident is found unresponsive and the CNA stated, "Tell the nurse." 3) An OLTC witness statement form dated [DATE] at 8:30 a.m. and signed by LPN #1 documented, "At approximately 5:15 a.m. on [DATE] I gave (Resident #3) her morning meds, obtained FSBS (Finger Stick Blood Sugar), administered insulin (and) started updraft treatment. I proceeded to give meds to other residents then went back to remove updraft after approx. (approximately) 15 minutes. During giving her meds (medications), she was alert (and) had asked for more water, when I removed updraft she appeared to be sleeping. I continued with my med pass on 300 hall (and) had completed passing meds on 200 hall when a CNA came to me to report that elder was non-responsive (and) not breathing. I went to elder's room (and) found her to be without pulse or respirations, pupils appeared fixed, hands cold to touch. Another LPN, (LPN #2) was present at nursing station. I asked her what I should do, as this was the first death I had encountered while employed here (and) was unsure of facility protocol. She stated that I should call the coroner, which I did (and) he told me that I needed to call the police dept. (department) to report. I then called the police dept. and was told they would send a coroner. While I was doing this, (LPN #2) stated she would inform the family. When I asked (LPN #2) if there was anything else I needed to do she told me to be sure to document how elder was found, i.e.: (for example) no respirations, cold hands, etc. At no time was I made aware of the protocol for withholding CPR or advised by other LPN that CPR should be initiated regardless of above findings (and) at least one hour since she was last observed." As of [DATE], LPN #1 was not available for interview. 4) An Office of Long Term Care (OLTC) Witness Statement Form dated [DATE] at 7:00 p.m. and signed by LPN #2 documented, "Instructions: State in your own words what you witnessed (be very descriptive) and sign below. Entry: I worked ,[DATE] (7:00 a.m. -3:00 p.m.) shift on [DATE] for (staff member). I am pretty sure I clocked in (at) 6 a.m. I was unaware of any situation going on (with) (Resident #3). I am aware that any elder that's found (with) no pulse-that CPR is imitated, unless the elder has a DNR (Do Not Resuscitate) (and) 911 is called. If I had been aware that this elder had been found (without) a pulse, I would have assisted the LPN (with) CPR (and) calling 911." As of [DATE], LPN #2 was not available for interview. g. On [DATE] at 1:53 p.m., the Administrator was asked what prompted the investigation of the events of Resident #3's death and the Administrator stated, "I received a phone call that (Resident #3) daughter wanted to get records." The Administrator was asked who obtains the information for a resident's advance directive and the Administrator stated, "Whoever admits the resident. The day the resident comes in." The Administrator was then asked if the resident was coded and the Administrator stated, "I don't see evidence of a code." On [DATE] the Administrator provided a Quality Assurance form dated [DATE] that documented, "Concern On [DATE], an audit of a closed medical record revealed that CPR was not initiated on a full code patient who expired in the facility on [DATE]. The medical record of this particular resident communicated physician's full code orders to facility clinicians as follows: 1. "Full code" printed in two places on the face sheet-under Alerts/Notes and Advance Directives. 2. "Full Code" printed at the top of the physician's orders [REDACTED]. 4. "Full code" written at the top of all six pages of the resident's admission care plan 5. "Full code" printed under the notes/alerts section of the Treatment Record (TAR) 6. "Full code" printed under the notes/alerts section of all five pages of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." h. An "Employee Memorandum" form dated [DATE] documented, "Employee Name: (LPN #1) Department: Nsg (Nursing)...Date of occurrence: [DATE] Date of Memorandum: [DATE] ...(box marked) Complaint against ... (Instructions) Please give a detailed description of the occurrence: During closed medical record review, the administration could find no documentation that (LPN #1) initiated CPR on an unresponsive resident with full code status. ...Allegation of Neglect...(box marked) Suspension until investigation complete Comment/Explanation: After investigation it will be determined whether or not to continue (LPN #1) employment Employee Response: I was called to elders room approximately one hour after giving her morning meds, insulin (and) updraft. She was found to be not breathing; no pulse (and) pupils appeared fixed. This was the first death I had encountered (at) facility (and) asked an experienced LPN for guidance in what to do. I was never told I should initiate CPR (at) this time. Was told I should call coroner. At no time during my orientation was I made aware of the protocol for withholding CPR." This was signed by LPN #1 and dated [DATE]. An " Employee Memorandum " form dated [DATE] documented, "Employee Name: (LPN #1) ...Date of occurrence: [DATE] Date of Memorandum: [DATE]...(Instructions) Please give a detailed description of the occurrence: Allegation of neglect-investigation completed [DATE]. Findings: Allegation substantiated. (LPN #1) failed to follow nursing standards of practice...Violation of facility policy re (as referenced): initiating CPR on resident with full code physician order. ...Comment/Explanation: Attempt to bring (LPN #1) in on [DATE] to present termination unsuccessful. She states she will be in at 10:00 a.m. on [DATE]." The document was signed by LPN #1 and dated [DATE]. The form indicated that LPN #1 was terminated from employment and no longer worked in the facility. A form entitled (state) Board of Nursing, dated [DATE] documented, "Information about the Nurse Being Reported: ...Description of Complaint: (facility) is submitting this notice to the (state) State Board of Nursing regarding a Licensed Practice Nurse, (LPN #1) whose employment was terminated effect [DATE]. The termination was the result of a recently completed investigation, which stemmed from (LPN #1) failing to initiate CPR to an unresponsive resident with full code resuscitation orders. The facility investigation has been reported to the Office of Long Term Care, as well as the resident's physician, the facility Medical Director, the resident's family, and local law enforcement. i. On [DATE] at 8:12 a.m., LPN #3 was asked how staff knows what the resident's advance directive is and the LPN stated, "It's in the chart. You can look on the MAR (medication administration record), stickers on the door green, red." The LPN was asked what is to be done if a resident is found unresponsive and a full code and the LPN stated, "If found unresponsive, call 911 and initiate CPR." The LPN was asked if she was certified in CPR and the LPN stated, "Yes." The LPN was asked if present or called to Resident #3 room on morning of [DATE] and the LPN stated, "No." The LPN was asked if a Code Blue was called the morning of [DATE] and the LPN stated, "No." j. On [DATE] at 8:55 a.m., the Director of Nursing (DON) was asked how it is known what the resident's advance directive is and the DON stated, "Chart determined on admission, green or red sheet, face sheet, physician order, MAR, Care plan, Resident door will have a green sticker for full code or a red sticker for DNR." The DON was asked if a resident is found unresponsive and is a full code what is to be done and the DON stated, "Do CPR. ...I run a code report sometimes weekly to determine if steps are being followed." The DON was asked what is to be done if the resident has a change in condition and is to be coded and the DON stated, "After nurse makes assessment should call for help, crash cart, chart, if code, starts CPR. ..." The DON was asked what is expected when a CNA finds a resident without a pulse and the DON stated, "If no pulse, respiration, CNA expected to get nurse. Nurse is supposed to immediately check the resident." The DON was then asked if there had been any type of review at the time of Resident #3 death when the resident had an order for [REDACTED]. Outcome of investigation we determined nurses did not perform CPR on the resident that was a full code." The DON was asked what LPN #1's nursing history was and the DON stated, "Nurse of [AGE] years. She had worked 6 months. No other deaths. ...She had been an ADON (Assistant Director of Nursing) in (other state)" At 9:20 a.m., the DON was asked what was done after the investigation and the DON stated, "She (LPN #1) was terminated." The DON was asked when the LPN had last worked and the DON stated, "She was suspended [DATE] and has not worked since." k. On [DATE] at 10:50 a.m., the Director of Nursing (DON) was asked if LPN #1 was certified in CPR and the DON stated, "I believe she (LPN #1) stated, "I had my certification and it's out." The DON was asked if a licensed nurse is required to be certified in CPR to be employed and the DON stated, "They are not required to be certified in CPR upon hire, no. There is 1 nurse on every shift that is certified." The DON was asked what nurse was certified in CPR on the 11:00 p.m.-7:00 a.m. shift the morning of [DATE] and the DON stated, "I believe (LPN #3)." The DON was asked how that nurse would be aware that CPR was needed and the DON stated, "If paged." The DON was asked what protocol would indicate that CPR not be done and the DON stated, "If they have a DNR we do not resuscitate or if rigor and rigidity are developed." The DON was asked what is to be done if the resident is a full code and unresponsive and the DON stated, "Now our policy to start CPR." l. On [DATE] at 6:00 p.m. the Administrator provided an " In-service Education Report " form dated [DATE] thru [DATE] and signed by all staff members that documented, "In-service conducted by:...Title RN DON...Topic: Code Blue Appointment of duties, crash cart arrival, chart arrival-done by any staff, Call to 911, CPR started, Record keeping, Where crash cart is located, who can bring cart, crash cart checks" m. A record review on [DATE] of the licensed nursing staff that had certification in CPR was performed. A document documented, "Healthcare Provider American Heart Association (LPN #2). This card certifies that the above individual has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association BLS (Basic Life Support) for Healthcare Providers (CPR and AED (Automated External Defibrillator) ) program. Issue Date [DATE] Recommended Renewal Date ,[DATE]..." This indicated that LPN #2 who was present when the CNA notified LPN #1 of the resident's condition, was certified in CPR.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for Resident #3, in accordance with the comprehensive assessment, plan of care, and resident 's directive. The facility failed to ensure staff (Licensed Practical Nurse (LPN) #1 and LPN #2) immediately provided cardiopulmonary resuscitation when resident was found without vital signs for 1 (Resident #3) of 8 (Residents #1, #2, #3, #4, #6, #7, #9, and #10) case mix residents who had full code advance directive. The facility failed to identify the staff ' s failure to initiate CPR until [DATE]. This failed practice resulted in a past Immediate Jeopardy which caused or could have caused death to Resident #3 who had an advance directive for full code and did not have cardiopulmonary resuscitation initiated when resident condition declined. This failed practice had the potential to cause more than minimal harm for 50 residents who had an advance directive of full code according to a list provided by the Director of Nursing on [DATE]. On [DATE] at 3:45 p.m., the facility was informed of the past Immediate Jeopardy. The findings are: 1. On [DATE] at 12:15 p.m., the Director of Nursing (DON) provided a copy of a form 'Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS)' which documented, " ...Purpose: The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel. 2. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times ... General Guidelines 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (no pulse). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA .... 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse ...8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 9. If an individual (resident, ...) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). ... Documentation: 1. Document the following in the resident's medical record (if the victim is a resident): a. The condition in which the resident was found or the witnessed event. b. The sequence of resuscitation efforts, including approximate times. c. The victim's response to resuscitation efforts. d. The approximate time that the EMS (Emergency Medical System) team took over. e. Time of death or time the individual was transported." 2. Resident #3 had [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The "Acknowledgment of Receipt Advance Directive/Medical Treatment Decisions" dated [DATE] and signed by the resident's representative documented, "I, the undersigned, acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue Advance Directives to be followed should I become incapacitated. ...(check mark) I do not choose to formulate or issue any Advance Directives at this time. ..." A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"NOTES/ALERTS FULL CODE" The Resident Admission Care Plan dated [DATE] documented " ...Code Status: Full Code..." b. The Vital Signs & Weight Flow Sheet documented, " ... [DATE]: Blood Pressure ,[DATE] Temperature 97.1 Pulse 55 Respiration 16 Signature/Comments ,[DATE] (11:00 p.m. to 7:00 a.m.) (Certified Nursing Assistant (CNA) #1). " c. Daily Skilled Nurses Note dated [DATE] at 2:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Resp. even (and) unlabored on O2 (oxygen) (at) 2L/M (liters per minute) per N/C (nasal cannula). Voices needs clearly. Cont. (continent) of B (and) B (bowel and bladder) (with) assist of (one) to BR (bathroom). Limited assist (with) ADLs (activities of daily living) (and) transfers. PT/OT (physical therapy and occupational therapy) 5 (times) wk (week) Updrafts as ordered. BS (blood sugar) checks as ordered. No c/o (complaints of) pain/distress. Call light within reach." d. Daily Skilled Nurses Notes dated [DATE] at 6:15 a.m. and signed by LPN #1 documented, "Elder found to be (without) pulse or respirations. (County) Sheriff informed (and) will send coroner. ...When elder was found fingertips (and) hands were cold." e. An " Information for Funeral Home " form provided by the County Coroner documented, "...date of death [DATE] Time of Death 0600 hrs (6:00 a.m. (hours)). Time Pronounced: 0700 hrs (7:00 a.m.). Pronounced by (Deputy Coroner) Place of Death (facility) Manner of Death Natural Cause of Death Pending..."A county Coroner's Office letter dated [DATE] documented, "The death of (Resident #3) ...a resident at (facility) was checked on [DATE] at the facility by (coroner) deputy coroner. The death appears natural in origin and is attributed to cardiopulmonary arrest secondary to [MEDICAL CONDITION], severe hypertension and diabetes. ..." f. A " Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities " (DMS (Division of Medical Services) 762) dated [DATE] documented, "Date Incident Reported to OLTC (Office of Long Term Care) [DATE] Time: 10:06 a.m. Date and Time of Incident (if known): [DATE] Time: 6:15 a.m. Date and Time of Discovery: [DATE] Time: 10:30 a.m. Type of Incident: Neglect (box marked) Name of Involved Resident: (Resident #3) ...Section III-Findings and Actions Taken Please include Resident's current medical condition Findings: Allegation substantiated Investigation results: (Resident #3) admitted to (facility) on [DATE]. Her code status was full code. At 5:15 a.m., (Licensed Practical Nurse (LPN) #1) administered (Resident #3) medications, started her updraft treatment and left her room to continue her medication pass. Approximately 15 minutes later, (LPN #1) returned to (Resident #3) room to remove the updraft. LPN #1 stated that at this time, (Resident #3) appeared to be sleeping. According to (Certified Nursing Assistant (CNA) #1) sometime between 5:45 a.m. and 6:00 a.m., she checked on (Resident #3) who was unresponsive. (CNA #1) stated she went to (LPN #1) who was now passing medications on the 200 hall and informed her that (Resident #3) was unresponsive. (CNA #1) stated that (LPN #1) continued with her med pass. (CNA #1) then went to co-worker, (CNA #2) and told her that she did not think (Resident #3) was breathing. (CNA #2) accompanied (CNA #1) back to (Resident #3) room, checked and found no pulse and noted that (Resident #3) hands were cold and dark. The two CNAs exited the room and together summoned (LPN #1) who was at the nurse station, to (Resident #3). According to (LPN #1) (Resident #3) had no pulse, no heartbeat, no respirations, no blood pressure, her pupils were fixed, and her hands were cold and blue. (LPN #1) stated that it was obvious to her that (Resident #3) was past the point of resuscitation. According to (LPN #1) and the two CNAs, (LPN #1) approached (LPN #2) at the nurse station and asked her what needed to be done. According to (LPN #1), (LPN #2) told her to call the coroner. The two CNAs stated that (LPN #2) picked up the phone to call someone, but they were unsure of whom. (LPN #1) stated that while she called the coroner, (LPN #2) telephoned (Resident #3) family to make notification. (LPN #2) stated that she has no recollection of any situation involving (Resident #3) or any similar event as described above. Actions taken: (LPN #1) employment at (facility) is terminated for failing to follow nursing standards of practice regarding initiating CPR (Cardio [MEDICAL CONDITION] Resuscitation) on a full code patient. (LPN #2) employment at (facility) is terminated for providing misleading and unreliable testimony during the course of the investigation based on other witness statements. Both nurses have been reported to the (state) Board of Nursing for their involvement in the incident. According to the (county) coroner's office, (Resident #3) died of [MEDICAL CONDITION], secondary to [MEDICAL CONDITION], hypertension, and diabetes." 1) An OLTC Witness Statement Form dated [DATE] at 7:15 a.m. and signed by CNA #1 documented, "I went to check resident (Resident #3) at 5:,[DATE]:00 (5:45 a.m.-6:00 a.m.). I called her name more than once and no response. I notified nurse (LPN #1) and she continued to pass meds. I asked coworker (CNA #2) to help to see if she was okay. She also called her name and checked pulse so we notified nurse again. (LPN #1) checked her pulse and said no response. (LPN #1) left out and notified other nurse (LPN #2) to help her and she called her family. " On [DATE] at 7:15 a.m., surveyors asked CNA #1 what had occurred on the morning of [DATE] with Resident #3 and the CNA stated, "I came in to check her. I saw that she didn't have a response when I called her name." The CNA was asked if the resident could usually hear and respond to her name being called. The CNA stated, "Yes." CNA #1 continued, "I went and notified the nurse (LPN #1) and told her. She continued to pass meds on 200 hall. I went back to the room and went to get help from another CNA (CNA #2). She said to go tell the nurse again. She was at the nurse's station then. She came and checked her finger. She put something on her finger. She (LPN #1) went to the other nurse, (LPN #2) and I heard her ask (LPN#2) what she was supposed to do. She (LPN #2) made a phone call. I went to the room." The CNA was asked what time this occurred and the CNA stated, "About 5:50 a.m." The CNA was asked what time she first went to the resident's room and the CNA stated, "5:45 a.m." The CNA was asked what time the nurse was told that the resident did not respond and the CNA stated, "About 5:50 a.m." The CNA was asked to describe what LPN #1 did after she was notified and had entered the resident's room. CNA #1 stated, "All she did was check her finger. Yes, she called her name." CNA #1 was asked what was to be done if a resident is found unresponsive and the CNA stated, "Yell for help and notify the nurse and do CPR." The CNA was asked if she had checked the resident for a pulse and the CNA stated, "Yes." The CNA was asked if a pulse was found and the CNA stated, "No." The CNA was asked how it is known if the resident is to be coded or not and the CNA stated, "Outside the door there is either a red dot or a green dot. Red dot means they don't want CPR. Green dot means they do. Her door had a green dot." The CNA was asked what is done in the facility if a resident is to be coded and the CNA stated, "Everybody comes from each hall. Some chart the time, some call 911. The nurses do CPR." CNA #1 was asked if the resident had CPR that morning [DATE] and the CNA stated, "No." The CNA was asked if the resident was coded for green for CPR and the CNA stated, "Yes." The CNA was asked what (LPN #1) did when she was told on [DATE] that the resident was unresponsive and the CNA stated, "She passed meds. I don't know what time but she gave her (Resident #3) some medicine. That's what the nurse said." 2) An OLTC Witness Statement Form dated [DATE] (not timed) and signed by CNA #2 documented, "I really don't know the exact time everything occurred but the charge nurse (LPN #1) was on 300 hall 4:30 a.m. doing med pass. She always starts around this time however I started doing my rounds shortly after. When I made it down to (other residents) room all I remembered took place (LPN #1) knocking on (Resident #3) door and entering the room. The door was open and I did hear (LPN #1) call (Resident #3) name a couple of times before I entered (other residents room). Continuing to finish my job, maybe 25 to 30 minutes later (CNA #1) came out the room and said to me, 'can you come see if this lady is breathing ' We hurried into the room and I checked her wrist for a pulse and felt her hands. No pulse and her hands were cold and a little dark. I also yelled her name a few times (no response). I then told (CNA #1) that we have to get the nurse and both of us hurried out the room up to the nurse station to get (LPN #1). By that time another nurse (LPN #2) was up there it was around 6 a.m. or a little after. I told (LPN #1) that (Resident #3) wasn't breathing. I remember seeing (LPN #2) pick up the phone to call someone and (LPN #1) came down to (Resident #3) room. When we entered she called her name a few times while feeling for a pulse. After that I remembered walking out the room. The nurse was still in the room with the CNA." On [DATE] at 7:15 a.m., CNA #2 was asked to describe what had occurred with (Resident #3) on the morning of [DATE] and the CNA stated, "I started rounds by 4:45 a.m. I did remember her (CNA#1) going into her (Resident #3) room a little before 5:00 a.m. I got through the 300 hall and went and checked on the 100 hall. (CNA #1) called my name and asked, 'can you come see if (Resident #3) is breathing? ' About 6:00 a.m., I went down there yelled her name, pulled cover back, checked her radial pulse, no pulse. I even checked carotid." The CNA was asked if the resident had a carotid pulse and the CNA stated, "No." There was oxygen tubing, nasal. I told (CNA #1) we need to go up here and tell the nurse and I was out of the room ahead of her. We told the nurse (LPN #1)." The CNA was asked if there was any other nurse at the desk and the CNA stated, "(LPN #2)" The CNA was asked what the nurse did and the CNA stated, "What I did see (LPN #2) do, she picked the phone up. (LPN #1) came down to the room and all I saw her do was check her pulse and call her name. I was about to cry. I left the room. I remember going to the nurses' station." The CNA was asked if anything was done or code called and the CNA stated, "No." The CNA was asked how it is known what the resident's advance directive is and the CNA stated, "We have stickers and mainly see what is in the chart." The CNA was asked if a resident's advance directive is to be a code is CPR to be done and the CNA stated, "Yes you're supposed to." The CNA was asked what the CNA is to do if a resident is found unresponsive and the CNA stated, "Tell the nurse." 3) An OLTC witness statement form dated [DATE] at 8:30 a.m. and signed by LPN #1 documented, "At approximately 5:15 a.m. on [DATE] I gave (Resident #3) her morning meds, obtained FSBS (Finger Stick Blood Sugar), administered insulin (and) started updraft treatment. I proceeded to give meds to other residents then went back to remove updraft after approx. (approximately) 15 minutes. During giving her meds (medications), she was alert (and) had asked for more water, when I removed updraft she appeared to be sleeping. I continued with my med pass on 300 hall (and) had completed passing meds on 200 hall when a CNA came to me to report that elder was non-responsive (and) not breathing. I went to elder's room (and) found her to be without pulse or respirations, pupils appeared fixed, hands cold to touch. Another LPN, (LPN #2) was present at nursing station. I asked her what I should do, as this was the first death I had encountered while employed here (and) was unsure of facility protocol. She stated that I should call the coroner, which I did (and) he told me that I needed to call the police dept. (department) to report. I then called the police dept. and was told they would send a coroner. While I was doing this, (LPN #2) stated she would inform the family. When I asked (LPN #2) if there was anything else I needed to do she told me to be sure to document how elder was found, i.e.: (for example) no respirations, cold hands, etc. At no time was I made aware of the protocol for withholding CPR or advised by other LPN that CPR should be initiated regardless of above findings (and) at least one hour since she was last observed." As of [DATE], LPN #1 was not available for interview. 4) An Office of Long Term Care (OLTC) Witness Statement Form dated [DATE] at 7:00 p.m. and signed by LPN #2 documented, "Instructions: State in your own words what you witnessed (be very descriptive) and sign below. Entry: I worked ,[DATE] (7:00 a.m. -3:00 p.m.) shift on [DATE] for (staff member). I am pretty sure I clocked in (at) 6 a.m. I was unaware of any situation going on (with) (Resident #3). I am aware that any elder that's found (with) no pulse-that CPR is imitated, unless the elder has a DNR (Do Not Resuscitate) (and) 911 is called. If I had been aware that this elder had been found (without) a pulse, I would have assisted the LPN (with) CPR (and) calling 911." As of [DATE], LPN #2 was not available for interview. g. On [DATE] at 1:53 p.m., the Administrator was asked what prompted the investigation of the events of Resident #3's death and the Administrator stated, "I received a phone call that (Resident #3) daughter wanted to get records." The Administrator was asked who obtains the information for a resident's advance directive and the Administrator stated, "Whoever admits the resident. The day the resident comes in." The Administrator was then asked if the resident was coded and the Administrator stated, "I don't see evidence of a code." On [DATE], the Administrator provided a Quality Assurance form dated [DATE] that documented, "Concern On [DATE], an audit of a closed medical record revealed that CPR was not initiated on a full code patient who expired in the facility on [DATE]. The medical record of this particular resident communicated physician's full code orders to facility clinicians as follows: 1. "Full code" printed in two places on the face sheet-under Alerts/Notes and Advance Directives. 2. "Full Code" printed at the top of the physician's orders [REDACTED]. 4. "Full code" written at the top of all six pages of the resident's admission care plan 5. "Full code" printed under the notes/alerts section of the Treatment Record (TAR) 6. "Full code" printed under the notes/alerts section of all five pages of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." h. A " Employee Memorandum " form dated [DATE] documented, "Employee Name: (LPN #1) Department: Nsg (Nursing)...Date of occurrence: [DATE] Date of Memorandum: [DATE] ...(box marked) Complaint against ... (Instructions) Please give a detailed description of the occurrence: During closed medical record review, the administration could find no documentation that (LPN #1) initiated CPR on an unresponsive resident with full code status. ...Allegation of Neglect...(box marked) Suspension until investigation complete Comment/Explanation: After investigation it will be determined whether or not to continue (LPN #1) employment Employee Response: I was called to elders room approximately one hour after giving her morning meds, insulin (and) updraft. She was found to be not breathing; no pulse (and) pupils appeared fixed. This was the first death I had encountered (at) facility (and) asked an experienced LPN for guidance in what to do. I was never told I should initiate CPR (at) this time. Was told I should call coroner. At no time during my orientation was I made aware of the protocol for withholding CPR." This was signed by LPN #1 and dated [DATE]. An " Employee Memorandum " form dated [DATE] documented, "Employee Name: (LPN #1) ...Date of occurrence: [DATE] Date of Memorandum: [DATE]...(Instructions) Please give a detailed description of the occurrence: Allegation of neglect-investigation completed [DATE]. Findings: Allegation substantiated. (LPN #1) failed to follow nursing standards of practice...Violation of facility policy re (as referenced): initiating CPR on resident with full code physician order. ...Comment/Explanation: Attempt to bring (LPN #1) in on [DATE] to present termination unsuccessful. She states she will be in at 10:00 a.m. on [DATE]." The document was signed by LPN #1 and dated [DATE]. The form indicated that LPN #1 was terminated from employment and no longer worked in the facility. A form entitled (state) Board of Nursing, dated [DATE] documented, "Information about the Nurse Being Reported: ...Description of Complaint: (facility) is submitting this notice to the (state) State Board of Nursing regarding a Licensed Practice Nurse, (LPN #1) whose employment was terminated effect [DATE]. The termination was the result of a recently completed investigation, which stemmed from (LPN #1) failing to initiate CPR to an unresponsive resident with full code resuscitation orders. The facility investigation has been reported to the Office of Long Term Care, as well as the resident's physician, the facility Medical Director, the resident's family, and local law enforcement. i. On [DATE] at 8:12 a.m., LPN #3 was asked how staff knows what the resident's advance directive is and the LPN stated, "It's in the chart. You can look on the MAR (medication administration record), stickers on the door green, red." The LPN was asked what is to be done if a resident is found unresponsive and a full code and the LPN stated, "If found unresponsive, call 911 and initiate CPR." The LPN was asked if she was certified in CPR and the LPN stated, "Yes." The LPN was asked if present or called to Resident #3 room on morning of [DATE] and the LPN stated, "No." The LPN was asked if a Code Blue was called the morning of [DATE] and the LPN stated, "No." j. On [DATE] at 8:55 a.m., the Director of Nursing (DON) was asked how it is known what the resident's advance directive is and the DON stated, "Chart determined on admission, green or red sheet, face sheet, physician order, MAR, Care plan, Resident door will have a green sticker for full code or a red sticker for DNR." The DON was asked if a resident is found unresponsive and is a full code what is to be done and the DON stated, "Do CPR. ...I run a code report sometimes weekly to determine if steps are being followed." The DON was asked what is to be done if the resident has a change in condition and is to be coded and the DON stated, "After nurse makes assessment should call for help, crash cart, chart, if code, starts CPR. ..." The DON was asked what is expected when a CNA finds a resident without a pulse and the DON stated, "If no pulse, respiration, CNA expected to get nurse. Nurse is supposed to immediately check the resident." The DON was then asked if there had been any type of review at the time of Resident #3 death when the resident had an order for [REDACTED]. Outcome of investigation we determined nurses did not perform CPR on the resident that was a full code." The DON was asked what LPN #1's nursing history was and the DON stated, "Nurse of [AGE] years. She had worked 6 months. No other deaths. ...She had been an ADON (Assistant Director of Nursing) in (other state)" At 9:20 a.m., the DON was asked what was done after the investigation and the DON stated, "She (LPN #1) was terminated." The DON was asked when the LPN had last worked and the DON stated, "She was suspended [DATE] and has not worked since." k. On [DATE] at 10:50 a.m., the Director of Nursing (DON) was asked if LPN #1 was certified in CPR and the DON stated, "I believe she (LPN #1) stated, "I had my certification and it's out." The DON was asked if a licensed nurse is required to be certified in CPR to be employed and the DON stated, "They are not required to be certified in CPR upon hire, no. There is 1 nurse on every shift that is certified." The DON was asked what nurse was certified in CPR on the 11:00 p.m.-7:00 a.m. shift the morning of [DATE] and the DON stated, "I believe (LPN #3)." The DON was asked how that nurse would be aware that CPR was needed and the DON stated, "If paged." The DON was asked what protocol would indicate that CPR not be done and the DON stated, "If they have a DNR we do not resuscitate or if rigor and rigidity are developed." The DON was asked what is to be done if the resident is a full code and unresponsive and the DON stated, "Now our policy to start CPR." l. On [DATE] at 6:00 p.m. the Administrator provided an " In-service Education Report " form dated [DATE] thru [DATE] and signed by all staff members that documented, "In-service conducted by:...Title RN DON...Topic: Code Blue Appointment of duties, crash cart arrival, chart arrival-done by any staff, Call to 911, CPR started, Record keeping, Where crash cart is located, who can bring cart, crash cart checks" m. A record review on [DATE] of the licensed nursing staff that had certification in CPR was performed. A document documented, "Healthcare Provider American Heart Association (LPN #2). This card certifies that the above individual has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association BLS (Basic Life Support) for Healthcare Providers (CPR and AED (Automated External Defibrillator) ) program. Issue Date [DATE] Recommended Renewal Date ,[DATE]..." This indicated that LPN #2 who was present when the CNA notified LPN #1 of the resident's condition, was certified in CPR. n. On [DATE] LPN #1's employee file was reviewed. The " Job Description Charge Nurse/Shift Supervisor " documented, " ...Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the patients, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services to ensure that the highest degree of quality care is maintained at all times. ...As a Charge Nurse/Shift Supervisor, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties. Job Functions ...Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. ...Transcribe physician's orders [REDACTED]. ...Chart all reports of ...incidents involving patients. ...Follow established procedures. ...Report all discrepancies noted concerning physician's orders [REDACTED]. ...Nursing Care Functions ...Review the patient's chart for specific treatments, medication orders, ...etc. as necessary. ...Notify the patient's attending physician ...when there is a change in the patient's condition...Monitor seriously ill patients as necessary. ...Ensure that your nurse's notes reflect that the care plan is being followed when administering nursing care or treatment. ...Communicates with nursing personnel..." The form was signed by LPN #1 and dated [DATE].