Every finding on record at Unity Healthcare and Rehabilitation Center

Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to prevent elopement for one out of three sampled residents as evidenced by; on 08/21/2025 at 6:22 AM Resident # 5, a newly admitted resident who is cognitively intact, exited the building undetected through the door used for the linen delivery that was left open and eventually exited the facility's grounds through the back gate. There were four residents at risk for elopement residing in the facility at the time of the survey. The findings include.Observation on 08/22/2025 at 12:55 PM revealed the door Resident # 5 exited through has an alarm system.Review of a photograph provided by the facility's Administrator revealed Resident # 5 wearing blue short sleeved with horizontal stripes, green cargo pants, black socks and black sandals, exiting the facility at 6:22 AM through the emergency exit door that was wide open.Record review of Resident # 5's medical records revealed the resident was admitted to the facility on [DATE] to a room on the facility's first floor. On 08/21/2025 Resident # 5 eloped. Resident # 5's clinical diagnoses include but not limited to non-Pressure related Chronic Ulcer of Right Heel and Midfoot, adverse effect of other Antipsychotics and Neuroleptics, Schizophrenia unspecified, and other Specified Persistent Mood.Review of Resident #5's Physician orders included: Risperidone 2 milligrams (mg) oral tablet-Give 1 tablet by mouth two times a day related to adverse effect of other Antipsychotics and Neuroleptics, Order dated 8/20/2025 21:00-Valproic Acid 250 mg oral capsule-Give 1 capsule by mouth two times a day related to Specified Persistent Mood.Review of the Social Services Baseline Care Plan documentation indicated: (Mood and Behavior): Resident exhibits a potential for alteration in mood and/or behavior. Resident will maintain current level of mood state and will not exhibit adverse behaviors. Resident will refrain from harming self/others.On 08/22/2025 at 1:14 PM, the Nursing Home Administrator (NHA) revealed, the incident occurred yesterday at approximately 7:00 AM and the patient is alert, oriented and make his own decision. He was admitted on 08/19/ 2025 from [local Hospital] for an arterial wound on the right foot he ambulated through the entire facility, and on 8/21/2025 he woke up at around 6:00 AM asked for towels to take a shower; at 7:13 AM the nurse did a head count and noticed he was not in bed at that point she told the supervisor, and the supervisor called a code green. I was notified by the maintenance we called the relative on file to check if he was with her, at this time we are treating it as a missing person. The last person that saw him was the laundry vendor and he did not know he was resident. The resident went through the back gate after he exited through the laundry room exit. The RCA (Root Cause Analysis): [Staff D, Floor Tech] should have stayed at the door when he opened and disarmed it. The CNA (Certified Nursing Assistant) have at least 11 residents and she was taking care of other residents, so she was not really at fault. Security had a delivery for dietary so he was not able to be at the laundry, and the Floor tech should have stayed and monitor. Floor tech was suspended pending further investigation. Interview on 08/22/2025 at 2:15 PM, Staff A, Certified Nursing Assistant (11:00 PM to 7:00 AM shift) stated: I got to know him for a short period of time before that happened he wanted to know where the front patio and back patio was located this was on the 20th at approximately 2:00 AM he asked if there is a place to go out to have some fresh air I told him it too late to go out on the patio, he said he was hungry and we gave him some apple sauce, he ate the applesauce and he said he was still hungry so the supervisor went to the kitchen got two sandwiches and gave them to him he ate and went to sleep. Before I left at the end of my shift, I changed him and left him in his room. The next day (08/21/2025) when I came in at the start of my shift he was on the back porch with the security guard and other residents, he said he was hungry, and we gave him some apple sauce and he said he was still hungry so he supervisor went with the supervisor to the kitchen, and he got two sandwiches he ate the and went to bed. On the 21st He woke up early in the morning and went to take a shower the nurse was with him, and we gave him towels he dressed himself, about 6:30 AM he went through the double doors, and I continued working with my other patients. The other shift came, and they were asking if we saw [Room Number], I never knew he would leave because he was compliant. Interview on 08/22/2025 at 2:28 PM Staff B, Registered Nurse (RN)- Day Shift stated, On that day the outgoing nurse told me I can do my rounds, and I asked her where he (Resident #5) was, and she told me he may be on the patio. She told me that the last time she saw the resident was about at 6:30 AM. I told her I needed to see the patient because I did not know him. When I went to his room he was not there. I called the supervisor and the DON (Director of Nursing); and the outgoing nurse stayed and helped to look for him, but we did not find him, so they called code green (elopement code). I did not know him, and they showed me his picture when we were searching for him.During a telephone interview on 08/23/2025 at 9:55 AM, Staff C, RN-Night Shift Supervisor revealed: The resident (Resident #5) is very alert, and he is close to the kitchen most of the time and he walks around the facility socializing with everyone. He was not an exit seeking resident and never gave problem. I usually sit downstairs when I finish my rounds, when I did my second round he was in his room the patient (Resident #5) asked for food and security opened the kitchen and I got some sandwiches and gave the food to him (Resident #5) in his room. During my third round at about 7:10 AM the nurse came and told me a resident was missing, and I called a code green. I called maintenance and looked at the camera showing him leaving through the laundry room exit. Interview on 08/23/2025 at 9:58 AM, the Risk Manager revealed the elevators are not equipped with [wander alert system] . the exit doors are alarmed and will sound when approached. Resident #5 was alert, did not have and did not have a [wander alert system] in place. He eloped during a laundry delivery through the back door after asking for food. The resident has a known history of elopement and has not yet been located. Interview on 08/23/2025 at 10:03 AM the Maintenance Director revealed all exit doors on the first floor are equipped to detect the [wander alert] and will alarm when triggered. If the door is pushed, it must be held for 15-30 seconds before a loud alarm will sound. A key is required by maintenance staff to reset the stairwell alarms.Telephone interview with translation assistance by the NHA on 08/23/2025 at 10:05 AM, Staff D, Floor Tech revealed, on 08/21/2025 around 6:00 AM to 6:15 AM the security called and asked him to open the laundry door because he was dealing with another delivery in the kitchen. Staff D, Floor Tech revealed unlocked and disarmed the door and did not stay during the delivery because he went to pick up the soiled linen. Staff D, Floor Tech revealed he does not remember shutting and locking the door and gate and did not see the resident leaving.On 08/23/2025 at 10:41 AM Staff E, Certified Nursing Assistant (7:00 AM to 3:00 PM shift) stated: I remember the resident, he is alert and like to walk around the facility. Wednesday (8/20/2025) was the first time I worked with him. After I changed him that afternoon, he asked for food around 2:00 PM and he sat on the patio where they smoked, and I left at about 3:15 PM. On Thursday (8/21/2025) at the start of my shift when I did my rounds I did not see him in his room so I asked the nurse where is my resident because he was not in bed; the nurse said he just had a shower and because he is always walking back I went looking for him and did not see him so I tell the nurse and the nurse told the supervisor then they called a code green and we searched for him, I drove in my car all the way past [streets] and around but did not find him we kept searching the police came and still not find him. Telephone interview on 08/23/2025 at 10:50 AM Staff F, Licensed Practical Nurse (7:00 PM t0 7:00 AM shift) revealed, on 08/20/2025 to 08/21/2025 I worked with him he is alert he followed instruction; I administered medication to him, and he took them one by one. Around 2:00 AM, he was walking back and forth and was given two sandwiches after he ate, he went back to bed. Around 6:00 AM He showered himself and after his shower when I did rounds, he was in his room in the bed. During shift transfer we did not see him I told the supervisor, and a code green was called.On 08/23/2025 at 11:41 the DON revealed: On Thursday (08/21/2025) I got a call that there was a missing resident. I told them he always goes to sit on the patio, the code green was already started and once I got here we created a command center. Record Review of the facility's policy titled: Safety and Supervision of Residents indicate:Policy StatementOur facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation Facility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.

Based on observations, interviews and record review, the facility failed to ensure medications were stored in accordance with professional standards, as evidenced by unsecured medications observed at the bedside in one out of eight sampled residents. There were 257 residents residing in the facility at the time of the survey. The findings included: Observation on 06/23/2025, at 9:59 AM, Resident #97 was observed lying in bed, there was a bottle labeled for congestion treatment on the window ledge and an unlabeled transparent medication bottle containing an unidentified tablet at the resident's bedside. Observation on 06/23/2025, at 12:06 PM and 06/24/2025 at 2:11 PM in Resident #97's room revealed the bottle labeled for congestion treatment on the window ledge and the unlabeled transparent medication bottle containing an unidentified tablet remained on the shelf at the resident's bedside. Record review revealed Resident #97 was admitted on [DATE]; the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact and requires staff assistance with activities of daily living, Review of the care plan revealed no documentation indicating Resident #97 was assessed or authorized to self-administer medications. Interview on 06/24/2025 at 2:17 PM, Staff A, Registered Nurse (RN) revealed residents are not permitted to keep medications in their rooms. Staff are expected to remove any medications found and store them properly. On 06/25/2025, at 2:58 PM, Staff B, RN reported it is unsafe for residents to keep medications in their rooms and revealed the resident's wife routinely brings in unauthorized items, including medications. Review of the facility's policy titled Medication Labeling and Storage indicates: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

On [DATE] at 10:48 AM, observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care for Resident #243 performed by Staff M, Registered Nurse (RN). Staff M, Registered Nurse gathered peg tube supplies, knocked on Resident #243's door provided privacy, explained the care that will be provided, provided privacy, washed hands, put on gloves, gown and face mask. Staff A removed the old peg tube dressing dated [DATE] and discarded it in a red biohazard bag, removed soiled gloves and put on a new pair of gloves; cleaned the skin around the peg site three times and discarded the soiled gauzes. Staff A, RN removed soiled gloves, put on a new pair of gloves, and applied new peg tube dressing; Staff A, RN removed the gloves, gown and face mask and discarded them in the red biohazard bag . Review of Resident #243's clinical records revealed the resident was admitted to the facility on [DATE]; medical diagnoses included but not limited to Gastronomy Status and Dysphagia. Review of Resident # 243's Physician Orders for [DATE] revealed an order for enteral feeding every 24 hours . Review of Care Plan for Resident #243 dated [DATE] revealed the resident is at high nutritional and hydration risk .with diagnosis and past medical history of dependence for enteral nutrition. Goals include providing local care to tube site as ordered and monitoring signs and symptoms of infection. Registered dietitian consult as needed. Interview on [DATE] at 11:07 AM, Staff M, RN stated: After removing gloves during care, I must wash my hands and then put on new gloves anytime you are changing gloves, hand hygiene is very important. On [DATE] at 03:10 PM, the Nursing Supervisor revealed: Staff always needs to wash hands or use hand sanitizer after removing soiled gloves and before donning new ones . Interview on [DATE] at 10:11 AM, Staff O, Certified Nursing Assistant (CNA) revealed Hand hygiene should be done frequently. It should be done before and after one is in contact with a patient, and when changing gloves. It is essential in our work to prevent any type of infection . On [DATE] at 09:25 AM during a facility tour an empty antibiotic intravenous (IV) bag with uncapped tubing hanging on IV pole was observed in a resident's room on the first floor of the North Wing unit (photographic evidence). On [DATE] at 12:18 PM another facility tour the empty antibiotic IV bag with uncapped tubing was observed hanging on IV pole in the same resident's room on the first floor North Wing (Photographic evidence). On [DATE] at 05:37 PM, a third facility tour was conducted and the empty antibiotic IV bag with uncapped tubing was observed hanging on IV pole in the same resident's room on the first floor's North Wing unit (Photo evidence). Interview on [DATE] at 02:22 PM, the Director of Nursing (DON) revealed: When IV bags are empty, they should be discarded immediately along with the IV tubing as well. IV tubing should be dated, and tubing port should be capped when not in use. Interview on [DATE] at 09:18 AM, Staff N, Licensed Practical Nurse (LPN) revealed: I would follow hand hygiene any time before and after touching a resident and before and after using gloves. We should also make sure to always use aseptic technique when handling IV bags and tubing. IV tubing ports should always be capped when not in use or thrown away upon completion or when they are expired. Review of the facility's policy titled: Infection Prevention and Control Program dated 12/2023 Policy states: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 7. Prevention of Infection a. Important facets of infection prevention include: 1. identifying possible infections or potential complications of existing infections. 2. instituting measures to avoid complications or dissemination. 3. educating staff and ensuring that they adhere to proper techniques and procedures. 4. communicating the importance of standard precautions and respiratory hygiene to visitors and family members. 7. implementing appropriate enhanced barrier and transmission-based precautions when necessary. Based on observations reviewed and interview, the facility failed to implement infection prevention and control practices as evidence by respiratory equipment left exposed next to a rat trap and other non-clinical items on a chair in Resident #97's room and staff failure to perform hand hygiene between glove changes. These deficient practices potentially increases the risk for contracting and spreading diseases. There were 257 residents residing in the facility at the time of the survey. The findings included: On [DATE] at 9:59 AM, Resident #97 was observed in bed, a pungent fecal like odor was noted in the room, a nebulizer machine with tubing and mask, was observed uncovered beside a rat trap on a chair. Observations on [DATE] at 12:06 PM, the resident remained in bed the uncovered nebulizer equipment remained on the chair in the same location next to the rat trap. Review of Resident #97's clinical records revealed the resident was admitted on [DATE]; clinical diagnoses include Chronic Obstructive Pulmonary Disease (COPD). Review of physician's order for [DATE] revealed an order dated [DATE] for Ipratropium-Albuterol Inhalation Solution, to be administered via nebulizer every 6 hours as needed. Review of the Annual Minimum Data Set (MDS) dated [DATE] indicate the resident is cognitively intact, requires assistance for hygiene care and transfers. Review of Resident # 97's care plan with start date [DATE] and completion dated [DATE] indicate: Administer nebulizer treatments as ordered, monitor effectiveness and potential side effects, observe signs of respiratory infection or distress, and maintain oxygen saturation monitoring and proper positioning. Interview [DATE] at 2:17 PM, Staff A, Registered Nurse (RN) reviewed the photographic evidence and revealed the respiratory supplies should be kept in a labeled, closed bag and must be dated. On [DATE] at 2:58 PM, Staff B, RN supervisor acknowledged the identified concerns and revealed the nebulizer supplies must not be left uncovered on furniture and must be stored properly to prevent contamination. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment classifies respiratory therapy equipment as semi-critical and requires cleaning and disinfection per CDC (Centers for Disease Control and Prevention) and OSHA (Occupational Safety and Health Administration) standards. The policy mandates that these items must be stored and maintained in a manner that prevents cross-contamination and microbial growth.

Based on observations, interviews, and record review the facility failed to ensure the essential patient care equipment was in safe operating condition for three out of three residents who used mechanical lifts for transfer (Residents # 25, #464, and #129). The mechanical lift used to transfer the residents who required total assistance from the bed to the chair was not working. The findings included: Observation on 02/21/2024 at 07:25 AM revealed that on the second floor there were six (6) mechanical lifts working to take care of 91 residents who were totally dependent on the equipment. On the first floor five mechanical lifts worked to take care of 71 residents who were totally dependent on the equipment. In total the facility had five mechanical lifts broken. On 02/20/2024 at 11:20 AM, during an interview with Resident #25 the resident revealed that he needs assistance to be transferred from his bed to the wheelchair and assistance is provided using the mechanical lift. He has to wait for a long time because on the first floor there are only a few mechanical lifts working for all the residents that need them. The other ones had been broken for a long time. Record review of the Quarterly Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 01/29/2024 for Resident #25 revealed in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) a score of 15 out of 15 indicating Resident # 25 is cognitively intact. Section GG for Functional Abilities and Goals indicated upper and lower extremity impairment on both sides and noted for Wheelchair (manual or electric)-Yes. On 02/21/2024 at 01:47 PM Resident #464 stated that she has been in the facility since February 1, 2024. They take me out every single day but, it takes very long time for them to get me out of the bed. Usually by 12:00 PM is when they get around to get me out of bed. Every single day they don't get me out of bed until 12:00 PM. Record review of the Admission Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 02/08/2024 for Resident #464 documented in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) a score of 12 out of 15 that suggests the resident is moderately impaired. Section GG for Functional Abilities and Goals indicate in ADL (activities of daily living) that the resident is dependent in all areas. On 02/21/2024 at 01:59 PM Resident #129 stated: I have been in this facility for a long time, I like to get out of my bed every day, but they take too long for them to take me out of my bed to my wheelchair. Record review of the Modification of Annual Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 12/22/2023 for Resident #129 revealed in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 12 out of 15 to suggest the resident is suggests the resident moderately impaired. Section GG for Functional Abilities and Goals indicate functional limitation in range of motion and impaired in both sides, Wheelchair (manual or electric)-Yes. On 02/21/2024 at 08:15 AM during an interview the Maintenance Director stated that at the moment the facility has three mechanical lifts on the second floor working and five on the first floor. The facility has 12 Mechanical Lifts and 3 to stand up, in total 15. On 02/21/2024 at 08:12 AM during an interview with The Administrator revealed that the vendor that fixes the mechanical lifts came on 02/14/2024 to check on them and the facility has 15 of them, out of those 15, only 4 are not working, parts need to be replaced, and two of them need to be complete replaces. The parts were ordered, and they were expecting to receive then in the next few weeks. Record review of the order purchase of equipment revealed that the facility placed the order on 02/21/2024 at 10:06 AM, after it was brought to the administrator attention that there was some equipment not working. Record review of the Assistive Devices and Equipment Policy Statement documented: Our facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. they may include (but not limited to): a) safety devices (grab bars, toilet rises, bedside commodes, etc.); and mobility devices (wheelchairs, walkers, and canes). Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. Device condition - devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired.

Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 263) out of one resident MDS assessment that was reviewed at the time of survey. There were 266 residents residing in the facility at the time of survey. The findings included: Review of Resident #263's Admission Record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Medical diagnosis included, but not limited to, Diabetes mellitus (DM), chronic obstructive pulmonary disease and cerebral infarction. Review of Discharge Return not Anticipated Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to Short-term/General Hospital. Review of the Care Plan initiated on 07/07/2023 with revision dated 01/02/2024 indicated: [Resident #263] is here for long term placement due to resident/representative desire to remain in long term facility. Goal: Resident's Psychosocial needs will be met daily with assistance from staff through the next review. Interventions: Encourage socialization with peers in the facility. Review of Social Services progress note dated 11/22/2023 and time stamped documented: Discharge Activity Planning: Resident and daughter are requesting discharge to an Assisted Living Facility (ALF). Resident requested to be discharged after Thanksgiving. Resident will be provided medication scripts and discharge folder on discharge date . Review of Discharge Summary progress note dated 11/24/2023 time stamped 12:49 documented: Resident is discharged from the facility to an Assisted Living Facility (ALF) in stable condition with all her belongings and regular medications accompanied by two family 's members with good attitude. Skin is intact, no edema. Vitals are in normal limit. During an interview on 02/21/2024 at 12:20 PM, the MDS Coordinator stated she has been in charge of MDS for [AGE] years. Oh my God, I see this was my mistake, I will fix it, I'm sorry. Review of the facility's MDS Policy and Procedure revealed: Resident assessment Policy Statement A complete assessment of every resident's needs is made at intervals designed by Omnibus Budget Reconciliation Acts (OBRA), and Palliative Performance Scale (PPS) requirements. Policy Interpretation and Implementation: OBRA-Required Assessments - Are Federally Mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing home. PPS Assessments - Provide information about the clinical condition of beneficiaries receiving part A Skilled Nursing Facility (SNF)-level care in order to be reimbursed under SNF PPS for both SNFs and Swing Bed providers. OBRA required assessments conducted for all residents in the facility: Discharge Assessment (return anticipated and return not anticipated). The interdisciplinary team uses the Minimum Data Set (MDS) from currently mandated by federal and state regulations to conduct the resident assessment. All persons who have completed any portion of MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observations, interviews, and record reviews, it was determined that the facility failed to provide a clean environment and housekeeping services for resident's equipment (Resident #258 and Resident #158). There were 266 residents residing in the facility at the time of the survey. The findings include: On 02/19/2024 at 10:09 AM. It was observed that Resident #258's feeding pump had dried enteral liquid on the feeding pump and pole. (see photo evidence) On 02/19/2024 at 11:24 AM. Observation revealed Resident #182 feeding pump had dried enteral liquid and dark matter on the floor. (See photo evidence) On 02/19/2024 at 12:03 PM. In room [ROOM NUMBER], it was observed that the oxygen concentrator was on and covered with dust with no nasal cannula attached. (see photo evidence) On 02/19/2024 at 05:24 PM. In room [ROOM NUMBER], it was observed that the oxygen concentrator was on, covered with dust, and no nasal cannula tubing attached. On 02/20/2024 at 09:21 AM. It was observed that Resident #182's floor had dark substance on the floor. On 02/21/2024 at 08:30 AM. It was observed that Resident #182's feeding pump had dried enteral liquid and dark matter on the floor. On 02/21/2024 at 08:33 AM. In room [ROOM NUMBER], it was observed that the oxygen machine was on and was covered with dust. On 02/21/2024 at 08:49 AM. It was observed that Resident #258's feeding pump had dried enteral feeding liquid (See photo evidence) Record review of Resident #258's physician orders revealed an order for enteral feeding liquid via feeding tube at 50 milliliters ml an hour with water flush at 30 milliliters an hour. Record review of Resident #182's physician orders revealed an order for enteral feeding liquid at 70 milliliters an hour and water flush at 30 milliliters an hour. Record review of Residents #143's and Resident #146's physician orders revealed no physician orders for oxygen therapy. On 02/21/2024 at 10:40 AM. In an interview with the Environmental Services Director was asked: What is the routine for housekeeping services for cleaning resident rooms, enteral pumps and equipment? The Environmental Services Director stated Every day the pumps and poles are to be checked with daily cleaning. We have a multi-surface cleaner to clean them. We did an in-service on 2/14/2024 about environmental cleaning techniques. Basically, cleaning techniques for how to clean the room from cleanest to dirtiest. On 02/21/2024 at 11:09 AM. In an interview Staff E, LPN (Licensed Practical Nurse) was asked if the oxygen concentrator was on or off, and which resident has orders for oxygen? Staff E, LPN stated: The oxygen concentrator is on and working. It's dusty and it needs to be cleaned. Staff E LPN reviewed the medical chart for Resident #143 and Resident #146 and stated: Both residents do not have physician orders for oxygen. On 02/21/2024 at 11:29 AM. In an interview Staff A, Nurse Manager, was asked about the two enteral feeding pumps that were found with dried enteral liquid in room [ROOM NUMBER], the dirty oxygen concentrator that was on but there were no orders for either of the residents. When Staff A was asked what the routine for cleaning enteral feeding pumps and oxygen concentrator. Staff A stated: These medications and feeding liquid can be so sticky. I will discuss this with the Housekeeping Director. Sometimes, the resident is on as-needed oxygen for three days and the order expires. The nurse is to remove the nasal cannula tubing and the oxygen concentrator from the room. A safe environment is for everyone. I'm going to do an in-service with nurses and certified nursing assistants. If you see something, you need to report it. So, the job can be done. I will talk with all of them. Review of document titled general environmental cleaning techniques. The identification of high touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures as theses will often differ by room and facility. Perform assessment and observations of workflow in consultation with clinical staff in each patient care area to determine key high touch areas. Common high touch surfaces include, iv poles, counters where medications and supplies are prepared, patient monitoring equipment. Review of document titled; Spot check of staff revealed a checklist of steps: proper cleaning chemicals uses and areas to clean in the room. Sprays down appropriate areas to clean and lets the chemical sit for at appropriate time. Wipe dry all chemically treated areas. Floor is mopped thoroughly with fresh disinfectant. Review of facility policy titled Cleaning and disinfecting residents room. Revised August 2013. The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. In the section titled general guidelines: 1) housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. 2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled. 3) Manufacturer's instructions will be followed for proper use of disinfecting products. Review of facility's policy titled Cleaning and disinfection of resident care items and equipment. The policy statement stated resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. In section titled policy interpretation and implementation. B) Semi critical items consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. C) Noncritical items are those that come in contact with intact skin but not mucous membranes. 2) Non -critical environmental include surfaces bed rails, bedside table. 3) Non-critical items require cleaning followed by either low or intermediate level disinfection following manufacturer's instructions.

Based on observations, interviews, and record review the facility failed to provide devices for an accident-free environment for one out of nine sampled residents (Resident#32). There were 266 residents residing in the facility at the time of survey. The findings included: On 02/19/2024 at 8:28 AM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat was located on the right side of the bed. (see photo evidence) On 02/20/2024 at 9:18 AM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat was located on the right side of bed. (see photo evidence) On 02/21/2024 at 3:03 PM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat located on right side and left side of bed. Record review of demographic face sheet revealed Resident #32 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis affecting left dominant side, Seizure, and Glaucoma. Record review of Resident #32's Quarterly Minimum Data Set (MDS) dated [DATE], section C for cognitive patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 on a scale of 0-15, indicated no cognitive impairment. Section E for Behaviors revealed no potential indicators of psychosis, no behavioral symptoms or rejection of care. Section GG for Functional Status revealed Resident #32 required substantial assistance for transferring and rolling from left to right on the bed. Section J for Pain Management revealed Resident#32 had one fall since admission. Review of Resident #32's Care Plan with initial date of 3/31/2022 and revision date of 12/5/2023 for risk for falls related to weakness. Interventions included: Bilateral floor mats. PT (Physical Therapy) screen: Currently on therapy caseload, will reassess functional mobility, maintain bilateral floor mats. Keep bed in low position and locked position. Keep call bell in reach when in room. Perform frequent checks of resident. Review of physician orders revealed orders to keep bed in lowest position and bilateral mats to floor when resident is in bed dated 10/19/2023. Review of the Incident Log, listed Resident #32 on 10/19/2023. Review of Nursing Note dated 10/19/2023 indicated [Resident #32] was observed next to his bed sitting on the floor pad, he was able to verbalize I slid from the bed. no apparent injury noted. On 02/20/2024 at 9:35 AM, Registered Nurse (RN), Staff A revealed Resident #32 has an order for bilateral floor mats. She is not sure why only one floor mat was present, and she will follow up with rehab to reevaluate Resident #32. On 02/21/2024 at 4:55 PM Staff C, Certified Nursing Assistant (CNA) stated: I am not aware that [Resident #32] needs floor mats. [Resident #32] is a good resident and follows direction. On 02/21/2024 at 5:15 PM, Staff B, RN stated that she is aware that the resident has a physician order for bilateral floor mats when in bed for fall precaution. I do rounds to ensure floor mats are in place and if I notice a floor mat is missing, I notify housekeeping to bring a floor mat. I will reinforce with [Staff C] that [Resident #32] requires floor mats on each side of bed for safety. On 02/21/2024 at 5:45 PM the Director of Nurses (DON) stated: Floor mats are for resident's safety and to prevent injuries. we are not following orders when a resident's order says bilateral floor mats and there is only one floor mat in place. I will investigate to find the reason why only one floor mat was in place. Moving forward I will complete an in-service with licensed staff about following doctor's orders for floor mats and the reason for using floor mats. I will speak to housekeeping to ensure if they remove floor mats for cleaning that they replace them. Review of the facility's Policy and Procedure entitled, Falls and Fall Risk, Managing revised March 2018. Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Review of Policy and Procedure entitled, Safety and Supervision of Residents revised July 2017 Policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: Individualized, Resident-Centered Approached to safety: 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communication specific intervention to all relevant staff; d. Ensuring that interventions are implemented.

Based on record review and interview and the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe, Clean, Comfortable, Homelike Environment, F689 Free of Accident Hazards, Supervision, Devices, F695 Respiratory/Tracheotomy Care and Suctioning. These repeated deficiencies have the potential to affect 266 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 11/18/2022, F584 Safe, Clean, Comfortable, Homelike Environment, F689 Free of Accident Hazards, Supervision, Devices, F695 Respiratory/Tracheotomy Care and Suctioning. were cited. Interview with Administrator and the Director of Nursing on 02/22/2024 at 01:40 PM. The Administrator and DON stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held every month with the attendees are the Risk Manager, Social services, Medical Director, Complaint Officer, Infection Control, MDS coordinator and Activity Director. QAPI review of the plan that was provided by the facility indicated: Vision A Vision statement is sometimes called a picture of your organization in the future; it is your inspiration and the framework for your strategic planning. The vision of the facility is to create an environment where people are loved, valued, and dignified. Mission or Cores Principles are: Superior Quality of Care Exceptional Quality outcomes and Service delivery Caring and top performing staff Outstanding Resident and Family Satisfaction It provides the framework or context within which the company's strategies are formulated. The Facility is each resident's home. We are committed to enhancing quality of life by nurturing individuality and independence. We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationship with all whose lives we touch. Performance Improvement Projects (PIPs): The QAPI Committee annually prioritizes activities, endorses, or re-endorses policies and procedures, and continually monitor for improvement through the use of QAPI self-assessment. In addition, the QAPI Steering Committee will implement any PIP topics indicated by date analysis. Quality improvement activities are also developed in collaboration with the support of providers, residents, and staff. PIPs are implemented in accordance with CMA protocol for conducting PIP's including: 1. Measurement of performance using objective quality indicator. 2. Implementation of system interventions to achieve improvement in quality. 3. Evaluation of the effectiveness of the interventions 4. Plan and initiation of activities for increasing or sustaining improvement. Implementation of new PIPs or any significant changes proposed to existing PIPs will be subject to approval. As such, reports reflecting new or charging PIPs will be submitted to the corporation and/or the Upper Management. Peer Reviews: The facility monitors provider and facility adherence to quality standards via site visits and ongoing review of complaints, adverse events, and sanctions and limitations on licensure. The purpose of the peer review program is to monitor accessibility, quality, adequacy, and outcomes of services delivered. The facility performs audits of providers to review clinical and administrative policies and procedures, clinical record's against standards, adherence to timely access to care requirements, and administrative practices for the purpose of monitoring compliance with best practice for the purpose of monitoring compliance with the facility and Rehab Center contact, including state and federal requirements.

Based on observation, record review and interview the facility failed ensure accuracy in the reconciliation in the accounting of all controlled substances for 2 out of 2 residents whose narcotic records were reviewed (Resident#150 and Resident#76). There were 262 residents residing in the facility at the time of survey. The findings included: Observation on 02/21/2024 at 12:30 PM on the second-floor south station, cart 2. During Controlled Substance count with Staff D, Registered Nurse (RN), it was revealed during the counting of the controlled substances sheet for Resident #76's, Medication: Methadone, Dosage: 5 mg (milligram) tablet; indicated on the last line of sheet that the person giving the medication: Staff D, Date: 2/20/2024, Time: 5:00PM, Amount on hand: 22, Amount given: 1, Amount remaining: 21. (see photo evidence). Review of the physical bingo card for the Methadone 5 mg for Resident #76, count was 20. Observation on 02/21/2024 at 12:32 PM on the second-floor south station cart 2. Controlled substances count with Staff D, Registered Nurse (RN) revealed the controlled substances sheet for Resident#150 Lorazepam, Dosage: 1mg tablet. Noted on the Last line of the sheet indicated the Person giving: Staff D, Date: 2/20/2024, Time: 5:00 PM, Amount on hand: 14, Amount given: 1, Amount remaining: 13. (see photo evidence). Review of the physical bingo card for Resident #150 indicated the count was 12. On 02/21/2024 at 12:35 PM Staff D, RN stated she administered the narcotics at 9:00 AM and did not reconcile narcotics because she was busy. She is aware she should sign out narcotics at the time she administers it to the resident. On 02/21/2024 at 4:29 PM the Director of Nursing (DON) stated: Before a nurse administers a narcotic, the nurse verifies the physician order and then reconciles the narcotic administered on the counting-controlled substances sheet. It is not appropriate for a nurse to administer a narcotic at 9:00 AM and sign-out the narcotic at 12:30PM on the counting-controlled substances sheet. I will investigate this situation and complete an in-service with all nursing staff to reinforce the time frame for signing out narcotics. It is important to sign out narcotics at the time of administration because we must make sure we are following doctor's orders to meet the resident's needs and to make a nurse is not diverting medication. Review of the facility's Policy and Procedure entitled Controlled Substances revised April 2019. Policy Statement: The Facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication; (2) Name, strength, and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication. (in a timely manner)

Based on observations, records reviewed, and interviews. The facility failed to obtain physician's orders for oxygen treatment for Resident #211. This practice could affect 266 residents who were residing at the facility at the time of the survey. The findings include: On 02/19/2024 at 12:18 PM. In an observation and interview of Resident #211. It was observed that the resident was on two liters of oxygen via nasal cannula. (See photo evidence). Resident #211 stated the nurse from the night shift had changed the nasal cannula tubing earlier that morning. Observation on 02/20/2024 at 09:43 AM, revealed Resident #211 was not in the room but the nasal cannula tubing was on the bed and the oxygen concentrator was on at two liters. Record review of physician orders revealed no orders for oxygen therapy for Resident #211. On 02/21/2024 at 11:21 AM. In an interview with Staff F, LPN (Licensed Practical Nurse). When Staff F was asked where Resident #211 was and if the resident had physician orders for oxygen treatment. Staff F stated, [Resident #211] is downstairs at Bingo. Sometimes [Resident #211] will place the oxygen on or off per request. Staff F reviewed the medical chart and stated: I'm not seeing any oxygen orders for [Resident #211]. On 02/21/2024 at 11:51 AM. In an interview with the Staff A, Nurse Manager. When asked, When residents are on oxygen do they need physician orders. Are there any physician orders for oxygen for [Resident #211]? Staff A stated: Yes, and reviewed Resident #211's medical chart. The Nurse manager stated: I will talk to the resident's physician to receive an order for oxygen. On 02/21/2024 at 02:09 PM. In an interview with the Nurse Manager, it was stated I talked to the nurse who put the oxygen orders in, and they said it was in the medical record. I told the nurse it wasn't there. I received an order from the physician for oxygen at two liters and the pulse oxygen machine as needed for oxygen saturation lower than 92% Record review of Resident #211 medical diagnosis revealed cerebral infarction (Stroke). Record review of physician orders revealed no orders for oxygen administration except to change the oxygen cannula every Sunday and as needed. Review of the care plan revealed Resident #211 had potential for complications of respiratory distress related to the diagnosis of episode of shortness of breath. Interventions were oxygen saturation as ordered. Administer oxygen as ordered. Goal was Resident #211 will remain free from signs and symptoms of respiratory distress through the next review. Record review of Minimum Data Set, dated dated dated [DATE] revealed in section C: Cognitive patterns, the brief interview of mental status was a 15 suggesting Resident #211 was cognitively intact. In section J: Health conditions, no to shortness of breath. In section O: Special treatments, procedures, and programs No to oxygen therapy. Review of facility's policy titled oxygen administration with revision date of October 2010 documented: The purpose of this procedure is to provide guidelines for safe oxygen administration. In section titled preparation, 1.) verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Class III

Based on interview and record review, the facility failed to implement their policy and procedures on abuse for one (Resident #1) out of one sampled resident whose abuse report was reviewed. This facility practice had the potential to have a negative impact on the health and safety of all 263 residents residing in the facility at the time of the survey. The findings included: Review of the facility's Abuse Reporting Timeline Audit revealed an abuse of unknown injury or fracture occurred on 09/25/2023. Review of Immediate Federal Report revealed the Immediate Report was completed and filed on 09/27/2023 at 8:28 PM while the administrator was notified on 09/25/2023 at 10:30 AM. Interview with the Director of Nursing (DON) on 10/05/2023 at 01:55 PM, the DON confirmed that the initial report was filed about 2 days after the alleged abuse first reported. The DON stated, The procedure is to report the incident right away. I had a case where they sent the resident to the hospital without bruises or redness. After they told me there was a fracture, I did the report. It was a teachable moment. The day I received the result that the resident had a fracture, I reported it right away, and I did a QAPI (Quality Assurance and Performance Improvement) to explain my report. We did the PIP (Performance Improvement Plan). The staff sent the resident to the hospital without mentioning it to me. Yes, the alleged abuse was on September 25, 2023 and I filed the report on September 27, 2023, but that's when I received the x-ray report. The DON reported, one of our nurses reported it to the administrator. The administrator then told our charge nurse, but she forgot to tell me. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Policy and Procedure dated September 2022 revealed: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (Where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. Within two hours of an allegation involving abuse or result in serious bodily injury; or b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance and review of the facility's policy, the facility failed to implement their policy by ensuring all staff were either fully vaccinated against COVID-19, had an approved exemption from the vaccination, or temporarily delayed from the vaccination prior to working in the facility. Specifically, the facility approved a medical exemption for a staff member for a clinical contraindication not recognized by CDC. This resulted in a facility compliance rate of 99.6%. Findings include: Review of the facility's undated policy titled, COVID-19 Vaccination Mandate Policy, revealed PURPOSE .To provide and maintain a healthy workplace and safeguard the health of our staff and their families, our patients and visitors and the community at large from the COVID-19 virus. POLICY .This policy applies to all personnel as follows: employees, volunteers, students, interns, independent contractors, licensed independent contractors, and contract personnel . [name of facility] is committed to provide and maintain a workplace that is free from COVID-19. In accordance with Centers for Disease Control and Prevention (CDC), Center for Medicare & Medicaid Services (CMS), Florida Department of Health (DOH), and the Agency for Health Care Administration initiatives, the Facility will follow comprehensive infection prevention and control guidelines for COVID-19. PROCEDURE .The following procedures will be implemented for Covered Individuals to receive a vaccine for COVID-19 or for employees to seek an exemption from the vaccination mandate .A. Compliance Dates for COVID-19 Vaccination: .2. By December 5, 2021, all current or new employees must receive their first dose of the COVID-19 vaccination or request an exemption to the vaccination requirement .4. All employees must receive their second dose of COVID-19 vaccination or have been granted an exemption no later than January 4, 2022. 5. By January 18, 2022, all employees, contractors, licensed independent practitioners, contract personnel, volunteers, and students must be Fully Vaccinated against COVID-19 or eligible employees must receive an exemption .B. Policy Compliance Requirements: .3. Obtain a religious or medical exemption granted by the facility .Exemption and Accommodation Instructions .A. to assist an employee or contractor with a religious or medical accommodations, the Facility will engage in an interactive process to determine if a reasonable accommodation can be provided without imposing an undue hardship for the Facility or creating a direct threat to the health and safety of our patients or other employees. B. The Facility will only provide an exemption to the vaccine mandate for religious or medical reasons. To request an accommodation, an employee or contractor must provide written documentation from a licensed physician or ordained clergy member to the Facility .D. If the immunization is medially contradicted, per CDC's Summary Document for Interim Clinical Considerations for Use of Covid-19 Vaccines Currently Authorized in the United States, staff may apply for a medical exemption or delay. For medical exemption requests, employees or contractors must provide a note on letterhead from a licensed physician. The written letter from the physician should state the medical reason why it is inadvisable for the employee to be vaccinated against COVID-19 due to a recognizable medical condition . Review of the CDC's Summary Document for Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized or Approved in the United States revised 12/06/22 revealed .Persons who are pregnant, breastfeeding, trying to get pregnant, or might become pregnant in the future are recommended to be vaccinated according to the recommended schedule . https://www.cdc.gov/vaccines/covid-19/downloads/summary-interim-clinical-considerations.pdf Review of the facility's undated and untitled COVID-19 vaccination tracking document revealed the Director of Admissions (DOA) was documented as having a medical exemption from the COVID-19 vaccination. Review of the untitled and undated staff listing document revealed the DOA was hired by the facility on 06/09/21. Review of the DOA's Medical Exemption From COVID-19 Vaccination form dated 11/30/21 revealed .Please select yes if this exemption is on the basis of pregnancy or anticipated pregnancy. Yes was selected. Continued review of the form revealed .It is in my professional opinion as a physician or physician assistant who holds a valid, active license under chapter 458 or chapter 459, Florida Statues, or an advance practice registered nurse who holds a valid, active license under chapter 464, Florida Statues, that COVID-19 vaccination is not in the best medical interest of the employee. The form was signed by one of the medical provider types listed. During an interview on 12/27/22 at 8:48 PM, the Administrator stated it was his expectation that everyone at the facility comply with federal and state regulations. The Administrator confirmed the medical exemption for the DOA was approved on the basis of pregnancy. The Administrator stated the facility utilized the form that was provided by the Florida Department of Health, which indicated that pregnancy was a reason for medical exemption. The Administrator also stated he was not aware that the CDC did not recognize pregnancy as a clinical rational to be exempt from the COVID-19 vaccination. The Administrator verified that the DOA was actively working in the building. During an interview on 12/27/22 at 8:56 PM, the Director of Nursing (DON) stated she was not aware that pregnancy or attempting to get pregnant was not a contraindication for the COVID-19 vaccine. The DON also stated the facility used the form provided by the Florida Department of Health which indicated pregnancy was a clinical rational to be exempt.

Based on observations, interviews, and record review, it was determined that the facility failed to follow the resident's approved menu for the Regular diets (Resident #189 and Resident #92). This could affect all residents receiving Regular, consistency diets (145 residents). The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular Diet consistency had 3 ounces of honey-glazed ham,4 ounces of red cabbage, and 4 ounces of seasoned roasted potatoes. The Diet Type Report provided by the facility showed that 145 residents are on a Regular diet consistency. In an observation conducted on 11/15/22 at 1:40 PM, Resident #189 was noted in his room with the lunch tray at his bedside. Closer observation showed a lunch meal that had the following: a slice of glazed ham, purple cabbage, and roasted potatoes. In this observation, Resident #189 stated that the ham is so small that he is not sure that it weighs 3 ounces. A chart review showed that Resident #189 was admitted on [DATE] with type 2 diabetes and sleep apnea diagnoses. An order was noted for a Regular texture diet dated 08/11/21. The Minimum Data Set (MDS) dated [DATE] showed that Resident #189 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. A chart review showed that Resident #92 had an order for a Regular texture diet dated 11/09/21. In an observation conducted on 11/15/22 at 1:50 PM, Resident #92's lunch tray was observed with the following: a piece of glazed ham with a slice of pineapple on top, purple cabbage, and roasted potatoes. Closer observation showed a small thin slice of the glazed ham that did not look like it was 3 ounces in size. Surveyor then asked to take the weight of the sliced ham using the facility's food scale. The facility's Food Service Director asked Surveyor if she could put the sliced pineapple with the ham before taking the weight. Surveyor explained that pineapple is not considered a protein food. The Food Service Director placed the sliced ham on the scale, which showed a weight of 1 ounce. In this observation, she was asked if the glazed ham that was served for lunch today was sliced and measured before serving to ensure that it was 3 ounces per slice; she said no. she stated that she did not take the weight of each sliced glazed ham before placing them on the tray line. The Food Service Director stated that she used the food slicer to cut the glazed ham, and it was set at number 3 for three ounces. She was under the impression that the number 3 was used for a 3-ounce measuring size. The Food Service Director reported that all the sliced ham that was served for lunch on 11/15/22 was sliced using the number 3 on the slicer.

Based on observations, interviews, and record review, the facility failed to ensure resident's rooms are designed and equipped for adequate nursing care, comfort, and privacy of residents in a safe manner. Semi-private resident rooms measured under the required 80 square feet per resident and multiple residents complained to the surveyors of their rooms being cramped and cluttered. The findings included: Review of a Memo provided to the surveyors by the facility's Administrator revealed the following: 81 rooms in the facility are semi-private rooms. Of these, 58 measure 157 square feet-which equates to less than the required 80 square feet per resident. These measurements do not include the bathroom or closet storage space in the rooms. During a tour of the facility conducted on 11/16/22 at 11:00 AM, it was noted by the surveyors that a number of the facility's semi-private rooms appeared to be small. It was noted in room [ROOM NUMBER] that a wheelchair between the beds was touching the side rails of each bed, indicating the space between the beds was minimal. On 11/16/22 at 11:23 AM, after obtaining consent from the Resident, the surveyors measured room [ROOM NUMBER]. The surveyors measured the room to be 153 inches long by 144 inches deep. There were 2 bedside tables present in the room which measured 19 inches by 19 inches. Taking into account the size of the bedside tables, the surveyors calculated 150.5 square feet for the room space. On 11/16/22 at 11:30 AM, the surveyors measured room [ROOM NUMBER] with the AHCA Life Safety Surveyor. The surveyors measured the room to be 12 feet by 12 feet. Taking into account the size of the bedside tables, the surveyors calculated 141.5 square feet for the room space. On 11/16/22 at 11:35 AM, the surveyors measured room [ROOM NUMBER] with the AHCA Life Safety Surveyor, the facility's Maintenance Director and the facility's Administrator. The measurements taken were 155 inches by 145 inches. Taking into account the size of the bedside tables, the surveyors calculated 154.5 square feet for the room space. All parties involved agreed these measurements do not equate to the required 80 square feet of space for each resident in a double-occupancy room. The Life Safety Surveyor explained to the Maintenance Director and the Administrator that the rooms being cluttered with belongings and wheelchairs is hazardous for the residents and the staff. When asked how many rooms in the facility have the same layout as room [ROOM NUMBER], the Maintenance Director stated all 19 rooms on the wing (152-172) have this layout, but that there may be more in the facility. Of the 19 rooms on the wing (152-172), the surveyor noted that 2 of the rooms (164 and 166) are single occupancy rooms. The surveyors asked for a map of the facility to count how many rooms have this layout throughout the facility. An interview was conducted on 11/16/22 at 11:25 AM with Resident #100. Resident #100 stated he did feel that his room was cramped and cluttered. (Photographic evidence obtained). Resident #100 stated he had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) completed 09/30/22 revealed Resident #100 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates he was mentally intact. For functional status, he required extensive assistance for bed mobility, dressing, toilet use, personal hygiene; total dependence of 2 staff for transfers. An interview was conducted on 11/16/22 at 12:03 PM with Resident #152. Resident #152 stated she did feel that her room was cramped and cluttered. ( Photographic evidence obtained). Resident #152 had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She also required the use of a wheeled walker for ambulation. A Quarterly MDS done 11/09/22 showed Resident #152 had a BIMS score of 15, which indicates she was mentally intact. For functional status, she required supervision assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. An interview was conducted on 11/16/22 at 12:09 PM with Resident #157. Resident #157 stated he did feel that his room is cramped and cluttered. ( Photographic evidence obtained). Resident #157 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS done on 09/29/22 showed Resident #157 had a BIMS score of 3, which indicates severe cognitive impairment. However, Resident #157 was able to answer all the surveyor's questions without difficulty. For functional status, he required total dependence of 2 staff for bed mobility, transfers, toilet use; total dependence of 1 staff for dressing, eating, personal hygiene.

Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the Mechanical Soft Diets for 2 of 2 residents during dining observations (Resident #10 and Resident #167). This has the potential to affect 38 residents on the Mechanical Soft diet. The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular diet consistency had honey-glazed ham, red cabbage, and seasoned roasted potatoes. The Mechanical soft diet had ground honey-glazed ham, red cabbage, and mashed potatoes. The Diet Type Report provided by the facility showed that 38 residents are on a Mechanical soft consistency diet. In an observation conducted on 11/15/22 at 8:45 AM, Resident #10 was noted in the room with her breakfast tray in front of her. Closer observation showed a breakfast meal with a large piece of bread approximately 3 inches long that was untoasted and hard to the touch. It also had a ground sausage patty and scrambled eggs. The meal ticket on the tray showed that Resident #10 was on a Mechanical soft diet. In an observation conducted on 11/15/22 at 1:30 PM, Resident #10 was noted eating her lunch in her room. Closer observation showed a tray that had the following: ground glazed ham, purple cabbage, and roasted potatoes that were about 2 inches in size and hard to the touch. The meal ticket on the tray showed that Resident #10 was on a Mechanical soft diet. In an observation conducted on 11/15/22 at 9:10 AM, Resident #167 was noted in his room waiting on the breakfast meal. The tray arrived with the following foods: a large piece of bread approximately 3 inches long that was untoasted and hard to the touch. It also had a ground sausage patty and scrambled eggs. In an interview conducted on 11/17/22 at 9:28 AM with Staff Y, the Speech Therapist stated that a Mechanical soft diet consistency needs to have ground meat and maybe a smooth texture like mashed potatoes. If any vegetables are served, they need to be cut and chopped and soft to the touch. She also said that if potatoes are served on a Mechanical diet, they need to be soft to the touch and cut easily through with a fork. When asked about the large piece of bread that was observed on some of the trays, she stated that the bread needs to be soft and easy to chew. Staff Y further reported that they only have one type of Mechanical soft diet in this facility. When asked if she participated in the menu selection for the different diet consistencies, she said no. During an interview conducted on 11/18/22 at 10:03 AM, the facility's Food Service Director stated that she recently made changes to the menu selection and that they are in the process of making changes. the facility's Food Service Director also reported that the Speech Therapist must tell them which level of mechanical soft they need to give certain residents and that any special modifications will be put under the note section of the meal ticket. When asked why all residents on the Mechanical soft diet on 11/15/22 received roast potatoes with honey glazed ham and not the mashed potatoes specified under the Mechanical soft diet, the facility's Food Service Director revealed that she did not know. She further acknowledged that she did not know that mashed potatoes was noted under the Mechanical soft diet section.

Based on observation, interview and record review, the facility failed to assess for safety of smoking for 1 of 2 sampled residents (Resident #217). The findings included: A review of the facility's policy Safe Smoking, dated 10/01/2004, and revised 03/27/21, documented: Electronic vapor cigarettes will be addressed and accommodated per the same guidelines as for actual cigarettes. A safe Smoking Screen is performed on admission for a resident who wishes to smoke. Resident #217 was admitted to the facility on [DATE]. An admission comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required limited to extensive one to two-person assist with activities of daily living. The assessment further documented the resident did not use tobacco. Record review revealed a care plan dated 11/15/22, documented Resident #217 desires to smoke. Resident has been assessed as able to smoke independently. A review of a Smoking Evaluation form dated 11/14/22 revealed the document was not completed/blank for Resident #217. An interview was conducted with Resident #217 on 11/18/22 at 9:00 AM. The resident stated will go out to smoke around 11:00 AM. An interview was conducted with the Unit Manager (UM) on 11/18/22 at 9;30 AM. Surveyor questioned the UM if Resident #217 was evaluated for safe smoking. The UM stated he would get back to me. On 11/18/22 at 12:00 PM, the UM approached surveyor and stated Resident #217 did not smoke. Surveyor, accompanied by the UM went to the patio. Resident #217 was observed smoking an electronic cigarette.

Based on interviews, observations, and record review, the facility failed to provide fingernail grooming (Resident #10 and Resident #94) to assist with dining (Resident #94) and failed to provide care and services to prevent a decline in the range of motion (Resident #117, Resident #231, and Resident #225) for 5 of 5 sampled residents for Activities of Daily Livings (ADLs). The findings included: A review of the facility's policy titled ADL Care and Assistance, revised on 03/27/21, showed that the following: each Resident will be assessed/evaluated upon admission or shortly after for their level of resident ability/function and staff assistance required to perform ADLS safely. The Minimum Data Set (MDS) assessment is an example of an assessment/evaluation of the level of resident ability/function and staff assistance required to perform ADLs. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the Resident while ensuring the needs and desired goals. ADL assistance needs should be reflected in the person-centered plan of care. 1. In an observation conducted on 11/15/22 at 9:30 AM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/15/22 at 2:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 2:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 4:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] showed that Resident #10 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. Section G for eating showed that Resident #10 needed total assistance and one person's assist. The care plan showed that Resident #10 has a self-care deficit with dressing, grooming, and bathing, as evidenced by the need for assistance with personal care tasks and mobility skills. Cognitive deficit related to dementia, impaired mobility, and generalized weakness. The Resident participates with ADLs with cues from staff. It further showed to provide hands-on assistance with dressing, grooming, and bathing as needed. 2. In an observation conducted on 11/15/22 at 1:07 PM, the lunch tray arrived for Resident #94 and was placed on her side table. Staff left the tray at the bedside and walked out to help pass other lunch trays. At 1:15 PM, Resident #94's tray was about 5% consumed, and no staff was noted in the room assisting her with the lunch meal. Continued observation at 1:29 PM showed that Resident #94's tray was left 95% untouched. In an observation conducted on 11/15/22 at 1:07 PM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/17/22 at 9:10 AM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room with the breakfast tray in front of her. She was observed eating one tablespoon of the eggs, but everything else on the tray was untouched. The closer observation did not show any staff in the room assisting her with her breakfast meal. At 9:50 AM, the tray was taken out of her room. In an observation conducted on 11/17/22 at 9:10 AM, Resident #94 was noted in her room with the breakfast tray on the side table, and the Resident was noted asleep. At 9:30 AM, Resident #94 was awake, but the breakfast tray was untouched. A review of the chart showed that #94 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #94 is cognitively severely impaired. Under section G for eating, it showed that Resident #94 is for supervision with set up only. The care plan showed that Resident #94 has a self-care deficit with dressing, grooming, and bathing, as evidenced by the need for assistance with personal care tasks and mobility skills. Cognitive deficit related to impaired mobility, generalized weakness, and limited endurance. It further showed to assist with nail shaping, keep nails short and clean and provide hands-on assistance with dressing, grooming, and bathing as needed. In an interview conducted on 11/17/22 at 11:43 AM, Staff F, a Licensed Practical Nurse (LPN), stated that the fingernail grooming is done by the Certified Nurse Assistance that is assigned to the Resident. It is usually done during daily care or as needed. In an interview on 11/17/22 at 11:46 AM, Staff G, a Certified Nursing Assistant, stated that activities usually involve fingernail grooming. If the Resident stays in bed and does not attend activities, she will do the fingernail grooming as needed as part of her daily care. In this interview, the surveyor asked Staff G to accompany her to Resident #94's room. Staff G was asked if she thinks Resident #94's fingernails needed grooming and cleaning, and Staff G said yes. When asked why it was not done, Staff G stated that Resident #94 does not like her fingernails trimmed. When asked if it is documented in the electronic charting or in the daily care notes, Staff G said no. Staff G then stated, let me do it now and see if Resident #94 will let me trim and clean her fingernails. Continued observation showed that with some encouragement, Resident #94 allowed Staff G to trim and cut her fingernails. 3. A review of the facility's policy Standards and Guidelines: Restorative Nursing Program, dated 12/01/16, and revised 03/27/21, documented: It will be the standard of this facility to provide restorative nursing services to residents that require them to attempt to maintain or improve function or as ordered by the physician. Restorative Programs include Range of motion (active and passive), splint or brace assistance, bed mobility, transfers, walking, dressing and/or grooming, communication, amputation/prosthesis care, or eating and/or swallowing. Record review revealed Resident #225 was admitted to the facility on [DATE]. A comprehensive assessment, dated 10/15/22, documented the resident was cognitively intact, and required extensive one-person assist with bed mobility. The assessment further documented transfers out of bed did not occur. Resident #225 was care planned for participating in restorative nursing program. Interventions included to provide restorative programs/interventions as ordered/indicated and refer to therapy as necessary. Resident #225 was further care planned for at risk for falls related to weakness, immobility, and generalized muscle weakness and impaired balance related to muscle wasting. Interventions included staff to assist with transfers, and to utilize mechanical lift with assist of 2 for transfers. A review of Resident #225's orders revealed an order dated 07/08/22; May participate in restorative program as needed and as tolerated. An interview was conducted with Resident #225 on 11/17/22 at 9:00 AM. Resident #225 stated he does not get therapy. Resident #225 further stated he does not get out of bed. He was told he could not get out of bed due to the wounds on his buttocks. A review of Resident #225's records did not reveal any documentation of the resident need to stay in bed. A review of the resident's wound care notes documented the resident up to chair with cushion. An interview was conducted with Staff T, a Registered Nurse, on 11/17/22 at 1:00 PM. Staff T stated she was not aware Resident #225 did not get out of bed. Staff T further stated the resident's wounds were improved. A side-by-side interview was conducted with Resident #225 by Staff T and surveyor on 11/17/22 at 1:30 PM. Resident #225 stated he had not been out of bed to a chair since admission to the facility. Resident #225 further stated he was going out of his mind just lying there. An interview was conducted with the Director of Rehabilitation on 11/18/22 at 9:00 AM. The Director stated Resident #225 had received occupational therapy from 09/14/22-10/12/22, working on bed mobility. The Director stated he was told verbally by wound care not to get Resident #225 up to chair. The Director acknowledged no documentation for the resident to not get up to chair. The Director further acknowledged the weekly wound care notes for Resident #225 documented up to chair with cushion. An interview was conducted with Staff E, Restorative Aid, on 11/18/22 at 10:00 AM with the Director of Rehabilitation present. Staff E stated Resident #225 refused restorative therapy. Staff E acknowledged there was no documentation of resident #225 refusing restorative care. An interview was conducted with Resident #225 on 11/18/22 at 10:30 AM with the Director of Rehabilitation and Staff E. Resident #225 again stated he had not received any kind of therapy and was just wasting away in bed. The Director of Rehabilitation stated they would get Resident #225 out of bed to a chair and would evaluate for therapy services. An observation of Resident #225 was conducted on 11/18/22 at 12:00 PM. Resident #225 was observed sitting up in a high back chair in his room. Resident #225 looked at surveyor and said: Thank you, thank you.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 9 out of 36 sampled residents (Residents #11, #27, #63, #105, #129, #146, #203, #255, #459). Review of the facility's policy titled Work Orders, Maintenance with no date included the following: To establish priority of maintenance service, work orders must be filled out electronically using an online application such as TELS and forward to the Maintenance Director. It shall be the responsibility of the department directors and employees to fill out and submit work orders to the Maintenance Director. Work orders are reviewed daily. Emergency or critical work orders would be called in to the Maintenance Director. Emergency requests will be given priority. On 11/15/22 at 9:54 AM an observation of vent with missing slats coated with dust across from the shower room near the 2 South Nursing Station. On 11/15/22 at 10:15 AM an observation was made in Resident # 203's room of the floor under the air conditioning unit was black and the baseboard next to the air-conditioning unit was pushed in (Photographic Evidence Obtained), ceiling tiles near the window had stains, the main light for the room had a burnt out light bulb, the bathroom had plaster above the sink and 3 areas of mismatched paint on the walls, and part of the linoleum next to the shower was missing and concrete was showing. On 11/15/22 at 10:30 AM an observation was made in the shower room located near the 2 South Nursing Station that had black mold-like substance on the tile on the walls, loose tiles, and a hole near the shower faucet. On 11/15/22 at 10:50 AM an observation was made in Resident #105's room of the air conditioning vent dusty, and dirty with a black mold-like substance (Photographic Evidence Obtained), ceiling tiles in the bathroom stained, and just outside of the room on both sides of the door the bumper guard near the floor was missing the end piece and had sharp edges exposed. On 11/15/22 at 10:53 AM an observation was made in Resident #459's room of mismatched paint/plaster above sink and the light over the sink had no light switch or pull cord. On 11/15/22 at 10:55 AM an observation of Resident #129's room air conditioning vent was dirty and soiled with debris and dust (Photographic Evidence Obtained),baseboard located by the window were coming away from the wall (Photographic Evidence Obtained), multiple areas on the walls had plaster and mismatched paint the areas were as follows: above the head of the bed, across from the foot of the bed, and under the window (Photographic Evidence Obtained), the bathroom had stained ceiling tiles (Photographic Evidence Obtained), the floor next to the tub was missing flooring and appeared to be down to concrete (Photographic Evidence Obtained), and mismatched paint above the sink (Photographic Evidence Obtained) On 11/15/22 at 11:00 AM an observation was made in Resident #146's room of an overwhelming pungent musty mildew-like smell upon entering the room, the air conditioning vent was dirty with a black mold-like substance (Photographic Evidence Obtained), and ceiling tiles in the corner by the window were stained. On 11/15/22 at 11:35 AM an observation was made of Resident #63's bathroom with the tile around the tub having a yellow mold-like substance. On 11/15/22 at 2:08 PM an observation of ceiling vent covered with dust and debris in the hallway next to room 225. On 11/15/22 at 4:57 PM an observation of Resident #225's room with a large gap between the air conditioning vent and the wall. On 11/16/22 at 9:00 Am an observation at 1 South Nursing Station of missing corner paneling on desk. On 11/16/22 at 11:40 AM an observation of dripping ceiling air conditioning vent by 1 South Nursing Station. On 11/16/22 at 11:45 AM an observation of broken floor near the exit door located by room 153. On 11/16/22 at 12:00 PM an observation of dirty door that leads to the smoking patio near 1 South Nursing Station. On 11/16/22 at 1:20 PM an observation of broken door molding across from the Admissions Office near the 1 North Nursing Station. On 11/17/22 at 8:30 AM an observation was made in Resident #11's room of a missing ceiling tile behind the entrance door (Photographic Evidence Obtained), and caution tape across the shower entrance into the shower and the ceiling above the shower has a hole around a possible old light fixture with capped wires coming out (Photographic Evidence Obtained). On 11/17/22 at 8:50 AM an observation was made in Resident #27's room of a greenish-gray mold-like substance on the wall by the window (Photographic Evidence Obtained), air conditioning vent has black mold-like inside the vent (Photographic Evidence Obtained), and 2 stuffed animals on top of overbed light. During an interview conducted on 11/15/22 at 10:20 AM with Staff S Certified Nursing Assistant (CNA) when asked how long the walls have been with plaster and mismatched paint in Resident #203's room he said they were working on it this weekend. During an interview conducted on 11/15/22 at 10:23 AM with Staff W Environmental Services Housekeeper, when asked how often each room is cleaned, she stated 3-4 times a day sometimes more. When asked how often the floors are mopped, she replied at least once a day. When asked how long the linoleum has been missing from the floor in the bathroom next to the shower in Resident #203's bathroom, she said about 3 or 4 months ago when they replaced the tub with a shower. During an interview conducted on 11/17/22 at 9:00 AM with Resident #27 when asked how long the wall under the window has been discolored, she stated it started about a month ago and gets worse every time it rains. During an interview conducted on 11/17/22 at 11:05 AM with the Director of Maintenance, when asked how long he has been with the facility, he replied, he has been with the facility for 3.5 years. The maintenance department consists of himself, 2 painters and 3 maintenance staff members. He stated that all routine maintenance issues/concerns go through the TELS system (computerized reporting for maintenance issues), and all staff have access to the TELS system. They have had the TELS system since before he started working with the facility. The facility does not keep records or have access to a work order history, it will only show what issues are open. They Keep a schedule of refurbishing program for the entire facility including what has been completed each room and what needs to be done for each room. During a tour of the facility conducted on 11/18/22 at 9:00 AM with the Director of Maintenance he stated that some of the issues identified, he was not aware of. He explained that he was checking on one of his painters and discovered that they were painting rooms with mismatched paint and told the painter to stop until they had the correct color of paint to match the existing paint on the walls. During an interview conducted on 11/18/22 at 9:45 AM with the Director of Maintenance, he stated they have a restoration refurbishing program that has been in progress for 1 year, they started with the more common areas first and this included changing out the ceiling lights, ceiling tiles and painting, the rehab gym. He estimates that approximately 45-50 rooms are completed including changing tubs to flat showers, but the floors next to the new showers are not completely restored. In the process of covering the walls in the dining rooms with a paneling (FRP boards a type of paneling). He may have an issue with a maintenance staff member that needs to be a little more detailed. He stated he thinks he may need additional staff beside the 2 they just hired recently. He is the only maintenance staff that goes into the TELS system, he will assign the various issues/concerns to specific maintenance staff and prints out sheets for each individual maintenance staff member. The staff member hands this into the Director of Maintenance daily so he can keep track of what is completed and what is still outstanding. He said some staff are not computer literate and will hand him slips of paper with identified maintenance issues/concerns, he then enters them into the TELS system.

Based on observation, interview, and record review, the facility failed to assist with resident's right to vote for 1 of 1 sampled residents (Resident #225). The findings included: Record review revealed Resident #225 was admitted to the facility on [DATE]. A comprehensive assessment, dated 10/15/22, documented the resident was cognitively intact, and required extensive one-person assist with activities of daily living. An interview was conducted with Resident #225 on 11/15/22 at 12:00 PM. Resident #225 stated he had been trying to get in touch with social services for approximately two months in order to assist in voting. Resident #225 further stated he was not able to vote this past election. Resident #225 stated he was very upset, as he has not ever not voted. Resident #225 stated this needed to be fixed so as it does not happen again. A subsequent interview was conducted with Resident #225 on 11/17/22 at 9:00 AM. Resident #225 stated he had called the receptionist at the front desk several times to request to speak with social services. An interview was conducted with the receptionist on 11/17/22 at 9:15 AM. The receptionist stated residents frequently call her at the front desk in order to get in touch with dietary, a nurse, a nurse aid, or if something was broken. On admission, the residents are told to call the receptionist if they needed anything. They forward the phone call to the appropriate department or take a message. The receptionist stated she was familiar with Resident #225, as he had called before. The receptionist stated she did not recall what Resident #225 had called for. An interview was conducted with the Social Services Director and social services assistant on 11/17/22 at 10:00 AM. The Social Services Director stated the activities department was in charge of assisting residents to vote. The social services assistant stated she was not aware of Resident #225 trying to get in touch with her. The social services assistant provided documentation of last interaction with Resident #225 dated 09/08/22, concerning therapy and dietary needs. An interview was conducted with the Activities Director on 11/17/22 at 10:30 AM. The Activities Director stated she went around and asked residents who were interested in voting. The Activities Director stated the election office usually come to the facility to assist residents in voting, such as, to register, address changes, anything needed for voter registration. The Activities Director stated she called the election office and they said it was too late to come out to the facility. The Activities Director stated she was not aware of the deadline. The only way a resident could vote was by absentee ballot. If residents did not receive an absentee ballot, they weren't able to vote. The Activities Director stated Resident #225 was a resident that had expressed interest in voting. The Activities Director stated she was not aware of which residents received an absentee ballot. The Activities Director stated she assisted one resident who had received an absentee ballot who requested assistance. She did not inquire if any of the residents wanted/needed assistance with absentee ballots.

Based on observation, interviews and policy review, the facility failed to provide showers per resident request for 1 of 251 sampled residents screened in the initial pool (Resident #121). The findings included: The facility's policy titled Standards and Guidelines: SG Showers/Bathing issued 03/08/10 and revised 03/27/21 revealed It will be the standard of this facility to assure that showers/bathing are offered to residents at least 2 times weekly or per resident/representative preference unless specifically ordered otherwise by the physician or care planned otherwise. Refusals for showers/bathing should be reported to the licensed nursing staff . On 11/15/22 at 11:29 AM, Resident #121 was interviewed during the initial screening process. Resident #121 was observed in a hospital type gown, lying in bed. The resident stated that he would like to get dressed when he got out of bed. He also stated that he never got a shower. He was given a bed bath but would like a shower ideally everyday. Resident #121 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His quarterly Minimum Data Set with an assessment reference date of 09/04/22 revealed his Brief Interview for Mental Status was 14 out of 15 which indicated he was cognitively intact. On 11/18/22 at 10:26 AM the resident was again observed in bed in a hospital type gown. He stated he had not had a shower since he was last interviewed and would still like to be showered. On 11/15/22 at 10:35 AM, Staff K, a Certified Nursing Assistant (CNA) was asked about the shower schedule for Resident #121. She stated that he is scheduled for a shower twice a week and she has given him showers. She also stated that if he refused, she would give him a bed bath. On 11/18/22 at 12:25 PM, this surveyor entered the resident's room with Staff H, a Licensed Practical Nurse (LPN). This surveyor asked Resident #121 with Staff H present if he had been given showers. Resident #121 stated that he has not had a shower and would like one everyday if he could. Resident #121 stated that he is fine being in bed with a hospital gown on, but when he is going to an activity he would like to be dressed. Staff H stated that she was unaware that the resident wanted a shower but was not given one. On 11/18/22 at 12:35 PM, during an additional interview, Staff K stated that she did not know that she is supposed to inform the nurse if a resident refuses a shower.

Based on observation, interviews and records review the facility failed to provide proper care and supervision to prevent falls for one resident (Resident #1) out of three sampled residents that were reviewed for accidents and falls during a complaint investigation survey. Resident #1 a vulnerable resident with known wandering behaviors required a wheelchair as mobility device. While unsupervised on the second floor approximately 300 feet away from his unit, Resident #1 pushed open the fire exit door, exited through the fire exit door, and descended the first flight of stairs (7 steps) to the landing below, where he was found by staff. His fall resulted in major injuries that included acute nondisplaced fracture of the right frontal process of the maxilla and Acute nondisplaced fracture of the left frontal bone. This practice has the potential to negatively affect the safety and well-being of 24 residents of which 10 reside on the facility's second floor that were identified to ambulate with assistance or assistive device. The facility's failure for adequate supervision of Resident #1 resulted in Immediate Jeopardy. The Immediate Jeopardy started on October 31, 2021 and was removed on December 14, 2021. The scope and severity for F 689 was lowered to a (D) for no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy as of December 14, 2021. The Findings Included: Observation and interview on 11/08/2021 at 9:35 AM, revealed Resident # 1 was in his room in bed. Staff A, Certified Nursing Assistant, (CNA) was also in the room and reported she provided one to one supervision for Resident #1 because the resident had periods of confusion and continuously attempted to get up and walk. the interview was interrupted when Resident #1 attempted to get up. Resident #1 was able to respond to his name. but cognitively unable to respond during the interview. When asked, can you tell me about your fall? Resident #1 reported in Spanish', That was nothing! Resident #1 could not provide details about his fall and only reported that he was going to go get some clothes and he fell . Record review of the Face Sheet for Resident #1 revealed, Resident #1 was first admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: anxiety disorder, unspecified convulsions, altered mental status and psychotic disorder with delusions. Review of the Comprehensive Minimum Data Set (MDS) for Resident #1 dated 09/12/2021 revealed, Resident #1 sometimes made self-understood and was sometimes able to understand others. He had a score of 99 on the Brief Interview for Mental Status (BIMS) indicating the resident was unable to complete the interview. Section G for Functional Status documented the resident requires supervision for bed mobility and transfer. For how the resident walks between locations in his room, walk in corridor or on unit and locomotion on and off the unit a coding of 1 and documented that the resident is able self-perform with supervision, oversight , encouragement, and cueing. Section E for Behavior - Section E 0900 for wandering-Presence and frequency-in response to the question Has the resident wandered ? indicate a coding of 0 (zero)) meaning -Behavior not exhibited. for section E1100. Change in Behavior or Other Symptoms. How does resident's current behavior status, care rejection, or wandering compared to prior assessment coded 0. Same. Review of the medication administration records for 10/01/2021 to 10/31/2021 revealed Resident #1 was receiving medications with side effects that included dizziness. The ordered medications included but were not limited to : [MEDICATION(S)] tablet 10 milligrams one tablet to be given by mouth one time a day for mood and anxiety to be administered at 9:00 AM. [MEDICATION(S)] tablet 10 milligrams one tablet to be given by mouth two times a day related to anxiety disorder; to be administered at 9:00 AM and 5:00 PM. [MEDICATION(S)] tablet 0.5 milligram one tablet to be given by mouth two times a day for anxiety; to be administered at 9:00 AM and 9:00 PM. [MEDICATION(S)] 150 milligram tablet one tablet to be given by mouth 2 times a day related to unspecified convulsions; to be administered at 9:00 AM and 5:00 PM. [MEDICATION(S)] tablet 50 milligrams one tablet to be given by mouth two times a day for [CONDITION(S)]/sleep; 9:00 AM and 5:00 PM. Review of the comprehensive care plans for Resident #1 revealed, care plan initiated on 03/23/2016 with Focus: The resident is at risk for falls related to medication use, limited mobility, [CONDITION(S)] disorder and dementia. The goal noted: The resident will not sustain a fall related injury by utilizing fall precautions through the review date. Interventions included but not limited; anticipate resident's needs, PRN (as needed). Review of nurses notes dated 10/31/2021 time stamped 15:27 revealed: During rounds noted member lying on his left side to midway landing of 2 east stairwell with his seat cushion under his head and wheelchair next to him on his right side. Elite response activated. Member awake, alert and responsive to verbal and tactile stimuli. Left forehead and eye swollen, with purplish discoloration, small amount of blood noted to face. Cold compress applied . Unable to obtain blood pressure as member removed the cuff. VS (vital signs) T (temperature)-97.2, O2 sat( oxygen saturation).-97%, BS (Blood Sugar)-190, R (respirations)-20. Nursing supervisor at the site and aware of situation. Rescue called. 3:49 PM-Rescue Team 5 to facility and evaluated member and took him to [local hospital] - 4:01 PM - Call placed to ARNP (Advanced Registered Nurse Practitioner) by a staff nurse and notified him .4:12 PM -Call placed to [Guardianship] and message left to voice mail . Return call pending. Record review of hospital's final report dated 11/04/2021 revealed the follow traumatic findings: 1. Small intraparenchymal hemorrhagic (Intracerebral hemorrhage (ICH) is when blood suddenly bursts into brain tissue, causing damage to your brain) contusion in the left anterior frontal lobe measuring 1 x 1.2 cm (centimeters) . 2. Acute nondisplaced fracture of the right frontal process of the maxilla (upper jaw). Acute nondisplaced fracture of the left frontal bone. 3. Left anterior frontal subgalea hematoma (a solid swelling of clotted blood within the tissues) associated with left preorbital ( situated in front of the orbit or eye socket) soft tissue swelling and hematoma. Interview on 11/08/2021 at 11:10 AM with the Nursing Home Administrator (NHA)and the Director of Nursing (DON) revealed, the DON also served as the Risk Manager and worked with the Administrator in the investigation and reporting process of incidents. They explained their investigative finding for the above mentioned incident. The last incident that we had to investigate was a fall that occurred on 10/31/2021 at approximately 3:00 PM. We were not here. We do not have video surveillance. [the DON] received a call from [Staff F], a LPN (Licensed Practical Nurse) that was taking care of Resident #1. She called me at 3:10 PM. She told me that [Resident #1] fell in the back stairs. She explained that he pushed the push bar on the fire exit door in 2 East, by the elevator.[Resident #1's] room is located in 2 North. After 15 seconds of holding it, the fire door opened. She found him midway, of the stairs, he was found with his cushion under his head, the wheelchair on his right side upright. We noted a little bit of blood on midway landing floor. We think he tripped or missed a step. The DON explained that Resident #1 has resided in the facility for 9 years. He never tried the elevator or door. He only had a fall in August in front of his room. The next step was to call 911, the elite response code was initiated, and we applied first aid, cold compress, applied. Paramedics got here around 3:10 PM transferred to [ local hospital] at 3:30 PM; and at 4:00 PM the physician and responsible party (guardian) notified. The DON explained that the Resident suffered all injuries on the left side of his face. The residents' injuries included a line fracture in his mandibular. Nondisplaced maxilla fracture and nondisplaced frontal bone fracture. He had a hematoma and frontal bone fracture as well as preorbital swelling. The Administrator explained that his first steps included communication with staff and security guard to ensure each exit door was working properly. The facility's Security Guard, Maintenance Staff and the Fire Alarm company checked all the doors and verified that each door was working properly. As part of the investigation, the facility's Risk Management team interviewed and documented statements from staff including the Security Guard, Staff F LPN, Staff C a Registered Nurse ( RN), and Staff E a CNA. The investigation was in progress, with more witnesses and staff statements pending. The Administrator later explained and presented copy of referral information form dated 11/04/2021 times stamped 11:02 AM and he completed the immediate report once he received this notification from the hospital on 11/04/2021 that Resident #1 suffered major injuries on 11/4/2021, four days after the incident. He explained that at the time of the incident, the resident reported no pain and did not want to transfer to the hospital. The DON added that Resident #1 did not show exit seeking behavior. During an interview on 11/08/2021 at 12:50 PM Staff B, a CNA revealed she was familiar with Resident #1 for many years and cared for him at times. Staff B reported that Resident #1 resides on her assigned unit which is second floor 2 North. He likes to be wander around on the floor; from one end to another sometimes, you have to go find him to get him to eat lunch, even breakfast, but they know him, in 2 East, many times they know to bring him to us. Staff B explained that Resident #1 was aggressive at times. Other times he appeared confused. Staff B and other staff observed Resident #1 attempted to exit and or followed facility staff as they exited or entered the second floor. Staff B reported she was cautious and sometimes reminded staff to ensure all doors were locked. Staff B stated that she reported Resident #1's behaviors to the floor nurse, but all the staff were aware. Staff B stated: I have seen him before trying to open the door. I have told staff to make sure they close the door and watch out for him. We all knew that he attempted to exit everyone know he's always walking around, even people in the office (pointed to office staff located on the second floor, near the exit door), they've seen him try to exit. Review of behavior notes from July 27, 2019, through October 31, 2021, showed that Resident #1 had a history of wandering and aggressive behavior. There was no documentation noted note that addressed Resident #1's exit seeking behavior. Behavior note dated 8/19/2021 time stamped 01:36; documented : Member refused to stay to his room, walking in the hallway unsteady gait, attempted to assist him back to his room, became very aggressive and combative. Closely monitoring for fall and continue to monitor. Behavior note dated 5/7/2020 time stamped 00:45; documented: Member is awake, alert, and responsive to verbal and tactile stimuli, no acute distress noted, denied pain and discomfort. Member is wandering going on all the floors and going to every other member's room. Attempted to redirect him to his room, tried to put him to bed, he became very combative and aggressive. One to one is initiated at this moment . Interview with Staff C, a Registered Nurse (RN) on 11/08/2021 at 1:04 PM revealed, Staff C normally worked the 2 North unit and was familiar with Resident #1. Staff C acknowledged that Resident #1 had diagnoses of anxiety, denied he was aggressive at times but had periods of confusion. Staff C explained that in his confusion as he wandered around, he would state that he was going to [NAME]. He was always going around in his wheelchair. It was normal to see him wandering around the facility. When asked if he ever attempted to exit Staff C reported: No one ever communicated to me that he attempted to open the door. Interview on 12/13/2021 at 9:33 AM with Staff G, CNA revealed, Staff G was familiar with Resident #1 and cared for him often. Staff G, CNA explained: I know he liked to move everywhere. Sometimes he listens, sometimes he don't. I would tell him 'don't do that papa' when he had his cup and touch things like other patient chairs and the doors. Staff G reported that Resident #1 got aggressive at times, when he touched something She added that Resident #1 continues to need the same level of assistance to transfer from his bed to his wheelchair. Resident #1 loses his balance if he attempts to walk. Staff G, CNA reported that she took care of Resident #1 on the day of the incident. She reported; I leave at 3:30 PM I was here when he fell . We don't know when he fell . I remember it was in the afternoon, we were making rounds and we did not see him. We could not find him, with the 3:00 PM to 11:00 PM staff. He kept going around earlier, and we saw him by the nurses' station going round and round as usual. Then in the afternoon we did not see him, we started looking for him, then we found him down the stairs the wheelchair was next to him. When he finished lunch, he was going around with his coffee. I found him with the coffee next to him. The nurse was with him already. Observation of the area of the facility leading to where Resident #1 exited through the emergency exit door revealed the exit door was located at the end of the hallway and no nursing station located in the area. Review of the facility's policy titled Elopement Assessment and ID issued February 1st, 2002, revised April 1st, 2016, and June 1, 2017, indicated: Standard: It will be the standard of this facility to identify residents admitted to the facility who have a potential to leave actual or attempted the premise is either per their own choice or due to impaired cognitive awareness of their actions. Guidelines: Item 1. All residents will be assessed upon admission quarterly and as needed for risk of elopement if they display history of wandering moderate to severe cognitive impairment with the ability to self-propel or ambulate, express desire to exit the facility or are noted attempting to exit the facility. The facility's Immediate Jeopardy removal Plan included the following immediate actions which were verified by the surveyor: On 10/31/21, the Director of Nursing conducted a quality review of residents who had incidents within the facility over the past 60 days to ensure the no other resident were affected and intervention were followed; no concerns noted. On 10/31/21, facility initiated on-going staff re-education to enhance staff's ability to supervise residents exhibiting wandering behavior by assessing/screening upon new admission or with any changes in behavior by reviewing the following information: o Review resident's medical diagnosis o Resident's mobility o Cognitive status Competency for making decisions o Wandering behavior o Exit seeking behavior o History of unsafe wandering or exiting a home/facility without supervision o Does the resident accept their current residency in the facility? o Does the resident verbalize a desire to leave facility? o Exhibiting restlessness and/or agitation If staff determine resident at risk of unsafe wandering behavior, they will notify patients nurse, Unit Supervisor, ADON and DON to discuss immediate interventions for plan of care. Once a resident is identified to be a wander risk, they will be added to our list of wander risk binder which are located at the nurse's station. Care plan and Kardex will be updated according to enhance staff ability to care for patients with wandering behaviors. Other education items that were reviewed are: o Prevention of Accidents, including falls o ANEMMI (Abuse, Neglect, Exploitation ) with indicators of neglect o Risk Management o Reporting of incidents o Residents Rights ***(Staff will not work without receiving this education) ***(Newly hired employees will receive education on the above in orientation) On 10/31/21, the facility initiated MOCK code drills relating to responding to codes/alarms and checking all egress doors until all staff received re-education. On 11/04/21, Resident #1 returned to the facility with a diagnosis of an acute non-displaced fracture of the right frontal maxilla and left frontal bone and the resident was placed on under 1:1 supervision. On 11/04/21, the Interdisciplinary Team assessed the resident and additional interventions were set in place for fall precautions and wandering behavior which included. o Wander guard placement on left ankle. o Increase frequency of patient/resident observation rounds, including one to one (staff supervision ) and/or 15 minutes checks o Follow up with specialists including neurologist for patient disease management o Weekly visit by Psychiatrists to monitor disease process of [CONDITION(S)] o Reinforce safety precaution with resident. o Anticipate and meet resident needs o Be sure the call light is within reach, when in his room, and encourage resident to use it for assistance. o Provide clutter free environment with adequate lighting o Provide diverse activities that correspond with past lifestyle/preferences o Small Group Activities during key risk times o Keep resident room close to nursing station for easy observation o Monitor for pain Monitor for any new behaviors o Monthly Medication Review On 11/04/21, after first learning about the resident's diagnosis the facility filed immediate federal report related to potential neglect for Resident #1. Department of Children and Families ([the Florida state agency responsible for investigating adult abuse and neglect) and City of Miami Police Department were notified. On 11/05/21, the facility initiated an Adverse Incident Investigation related to this incident. On 11/05/21, the Director of Nursing screened and reviewed residents with wandering behaviors and/or underlying mental health diagnosis and will maintain a log to continue supervision, surveillance and monitoring of these residents. On 11/05/21, the Director of Nursing/designee initiated a facility-wide audit of residents with wandering behaviors. The audit includes review of resident records, resident assessment, and systems. Including reviews of the following: o Wandering Behaviors o Prevention of Accidents, including falls o ANEMMI with indicators of neglect o Risk Management o Reporting of incidents o Residents Rights o Care plans and interventions Based on the findings and record reviews, no other residents were affected by this practice. On 11/05/21, during our Ad Hoc QA (Quality Assurance) Meeting , including our Medical Director, criteria to place residents on 1:1 were discussed on how to ensure proper use, including termination, of one to one and/or frequency monitoring residents with wandering behavior. Criteria includes the following: o Is environment safe for resident, including all exit doors/alarms? o Increase participation of daily activities? o Evaluation by Medical Doctor/Psychiatrists to determine one to one staff supervision need for resident o Evaluation of effectiveness of medications On 11/08/21, Advantage Tech, a door repair company, inspected all exit doors and determined they were all in working properly. In addition, a secondary audible alarm to 2 North exit door, 2 East Exit were placed. Furthermore, a work order was initiated for additional installation of wander guard. On 11/08/2021, the in-house Psychiatrist, evaluated resident, adjusted medications, and recommended close supervision of resident. On 11/10/2021, a special interdisciplinary care plan in-person conference was held with legal guardian were care plans and interventions were discussed and reviewed. Legal guardian was in agreement with plan of care and interventions and stated, I am happy to have the resident back to Unity and I know this was an accident. On 11/13/21, Adverse Incident was completed and submitted to the Agency of Health Care Administration. Monitoring will be ongoing: o The Director of Nursing/designee will conduct a daily review of new residents during clinical meeting with a special focus for residents with wandering behaviors and/or underlying mental health diagnosis utilizing the revised Fall Prevention and Wandering Behavior Tracking Tool to ensure process is functioning as designed. o The facility DON/ designee will conduct a weekly quality review of at least 5 residents on each unit weekly for 4 weeks and then every 2 weeks for 2 months to ensure fall preventions and wandering behaviors preventions are in place. o Findings of these quality reviews will be reported to the facility QA/Risk Management meeting until such time as substantial compliance has been determined and recommends on-going monitoring by the facility Clinical Consultant when conducting facility visits and quality systems reviews. o On 11/01/2021, an Ad Hoc QA Meeting was convened to review the above plan and IJ Removal and the QA members, including the Medical Director, reviewed and approved the plan related to Prevention of Accidents and Wandering Behaviors. o The Administrator and facility leadership team will hold daily Meetings until such time as the immediacy has been removed and will then conduct weekly QA Meetings until such time as substantial compliance has been determined. On 12/14/2021 at 3:00 PM, the DON/ Risk Manager revealed during record review of the audit logs and clinical records for each sampled resident the DON/ Risk Manager explained the care-planned interventions in place for each resident at risk. It was revealed that each resident was appropriately assessed. Appropriate care and interventions noted after each fall. The records reviewed showed only one sampled resident (Resident #1) wandered throughout the facility. On 12/14/2021 at approximately 3:20 PM, observations of Resident #1 revealed wander monitoring device in place and Resident #1 remained on one to one supervision while propelling himself in his wheelchair. On 12/14/2021 verification of the removal plan included interviews with staff that worked across all shifts included a total of 14 CNAs, 8 LPNs and 10 RNs, 1 Maintenance staff, Security and Human Resources Staffing Coordinator; it was revealed that in-services were completed, revealed re-education related to prevention of accidents/wandering behaviors including prevention of falls were completed and verified on the sign in sheet and attendance log for training titled: Wandering behavior, prevention of accidents including fall, risk management reporting of incident, door alarm and responding to alarms. The in-services documentation revealed all staff received 30 minutes training sessions on each topic that took place on 10/31/21, 11/5/21, 11/4/21, 11/7/21, 11/12/21, 11/24, 11/23/21, 11/25/21,12/12/21 and 12/13/21.

Based on record review and interview, the facility failed to follow their policies to implement advanced directives. The facility staff failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) on a resident (#1) with a full code status order of the six residents reviewed. There were 200 residents residing in the facility with full code status orders. There were 255 residents residing in the facility at the time of the survey. Resident #1 was full code and receiving Hospice services. On [DATE], a Licensed Practical Nurse (LPN) found Resident #1 unresponsive with no vital signs. The LPN failed to implement the resident's advance directives to be resuscitated. The resident died . This situation resulted in Immediate Jeopardy. Cross reference: F 600, F 678 and F 835 The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 3, 2020. The immediate jeopardy began on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. The findings included: The facility policy and procedure titled Resident Rights, Dignity and Visitation Rights revised [DATE] revealed: Standard: The facility promotes the exercise of rights for each resident, including those who face barriers (communication and hearing problems and cognitive limits) in the exercise of these rights. Guidelines include: 8. The right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate advance directives. The facility policy and procedure titled Advance Directives revised ,[DATE] revealed: Standard: It will be the standard of this facility that the resident has the right to request, refuse and/or discontinue treatment and to formulate an advance directive and participate in advance directive care planning. Advance Directives/Advanced Care Planning designations will be respected in accordance with state law and facility policy. The facility policy and procedure titled Code Blue and CPR revised ,[DATE] revealed : Standard : the facility will honor the resident/resident representative wishes regarding either the provision or withholding of Cardio [MEDICAL CONDITION] Resuscitation (CPR ). In the event a resident experiences [MEDICAL CONDITION] (cessation of pulse and or respirations) CPR will be provided in the absence of a valid physician's orders [REDACTED].CPR will be initiated and will continue until the arrival of EMS (emergency medical services) or until the discovery of a valid DNR. Record review revealed resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review revealed resident #1 expired in the facility [DATE]. The physician's orders [REDACTED]. There was an order dated [DATE] for a hospice evaluation. The Health Care Proxy Designation Form revealed resident #1's grandson signed as designated health care proxy on [DATE]. The Advanced Directive/Medical Treatment Decisions Acknowledgement of Receipt form signed by the health care proxy on [DATE] revealed advance directives included healthcare proxy designation only. The nursing progress notes revealed: [DATE] at 06:20: Received member in bed with eyes closed, respiration even and non-labored. O 2 3 L/M via NC (oxygen at 3 liters/minute via nasal cannula) in progress. O 2 sats (saturation) ,[DATE]%. Blood sugar check done with insulin coverage provided. All other AM medications tolerated well by member, she was also medicated for fever with liquid Tylenol which was effective. Total assistance on AM care provided by staff. Aspiration and [MEDICAL CONDITION] precautions observed. Comfort measures maintained . [DATE], 09:09: Total AM care given. Position for comfort. Tolerating feeding via PEG (Percutaneous Endoscopic Gastrostomy) tube. [DATE], 07:20 : Member in bed in no apparent distress. Skin warm and dry to touch. Abdomen soft non-tendered, non-distended. Bowel sounds present x 4 quadrants. Enteral feeding infusing well via pump. Due medications administered via PEG and tolerated well. Blood sugar monitored. Coverage given as ordered. No signs of hyper/hypoglycemic reaction noted. Aspiration precautions maintained. Total assistance on AM care rendered by staff. Safety and comfort measures provided. Call light within reach. [DATE] 08:09: Total am care given. Position for comfort, tolerating feeding via PEG tube. [DATE] 08:25 : Upon rounds member noted in bed sleeping but responded to tactile stimuli. Skin warm to touch. Temperature 98.9. Tolerating feeding well via PE[NAME] [DATE] 09:44 : Member in bed. Responsive to tactile stimuli. Medication administered as scheduled via PEG tube. PEG tube site intact, no redness noted. HOB (head of bed) elevated. Safety measures in place. [DATE] 10:25 : Discharge Summary: Report given upon rounds member was noted in bed sleeping, but responsive to tactile stimuli. Skin warm to touch. Member was tolerating feeding via PEG tube. Medications administered as scheduled via PEG tube. PEG tube site intact. No redness noted. HOB elevated. Safety measures in place. Report given that hospice C N A (Certified Nursing Assistant) was in the room completing the ADL (activities of daily living) care and pulling the curtain for privacy after taking care of the first bed. Went to check and see member and noted member unresponsive to tactile stimuli and sternal chest rub. Report received that no vital signs were apart at this time. Family member notified as per hospice nurse. MD (medical doctor) notified by Unit Charge Nurse. Body was released to funeral home. Mortician arrived at facility and left facility with body at 2:56 PM. Orders discontinued. [DATE] 12:49 : Upon rounds at 10:25 AM, noted hospice C N A in room completing ADL care and pulling the curtain for privacy. After I took care of bed one, I pulled the curtain to see member and noted member unresponsive to tactile stimuli and external rub. Unable to find pulse. Hospice nurse made aware and took over by calling the family and funeral home. Doctor was notified. [DATE] 14:50 Member expired. [DATE] Discharge Summary: Call placed to grandson who stated that his grandma has been declining since admission and has not been responding to any of the family members. He stated he cannot thank the facility enough and stated that the staff treated her like family. Interview with the Director of Nursing (DON) on [DATE] at 11:00 AM revealed- this resident was on hospice for one day. She was placed on hospice [DATE]. The Hospice [DIAGNOSES REDACTED]. She never responded, she was in a vegetative state. The nurse walked in and found the resident had no pulse. She went to the desk and she called the hospice people to notify them. The hospice nurse came in and took over by calling the family to inform them that the patient had passed. The code status at that time was full code. It was a big question why CPR was not administered. The Nurse was suspended right away. We contacted the family to tell them we did not initiate CPR. We explained to the family that we did not follow their wishes because we did not start CPR. Her grandson stated my grandma has been declining since admission and did not respond to anyone since day one. He stated he was aware that CPR was not completed on his loved one, but stated he had no concerns with the resident treatment at the facility. The DON stated the grandson was the healthcare proxy, but he did not feel comfortable making the decision to sign a DNR (Do Not Resuscitate). The DON stated the facility policy if a resident does not have a DNR is to start CPR. We did not have the residents advance directives. DCF (Florida Department of Children and Families) was called on [DATE] the Immediate Federal report was submitted to AHCA (Agency for Health Care Administration) on [DATE]. The LPN (Licensed Practical Nurse) was removed from the schedule pending investigation. When the nurse was interviewed, she said when she found the resident expired, she said in her mind she thought the resident was on hospice and she did not go and check the chart for code status. In the event of a code, the staff must access the resident's chart in PCC (point click care). The code status is listed in PCC as soon as you open the electronic record and in the physician's orders [REDACTED]. This is constantly updated and must be maintained in the event that PCC is down. We did not have the residents advance directives. We gave the LPN all the tools needed, but she just did not follow the protocol. The LPN was suspended due to the severity of the matter, she will be reported to the Florida Board of Nursing. Interview with the Registered Nurse (Registered Nurse) Supervisor (staff A) on [DATE] at 3:11 PM revealed, I was the Supervisor on [DATE] and present in the facility when resident #1 expired. I was in the morning meeting from 9:00 AM to 10:00 AM. When I arrived on the unit, the nurse informed me that one of the patients just expired. I checked the computer and found that the patient was a full code. I asked the LPN why she did not call a code blue and she told me the resident was on hospice. The hospice nurse was also present in the facility at this time. I asked the hospice nurse if they had initiated the DNR and if a DNR was signed. The hospice nurse stated they were attempting to educate the family regarding DNR, but they did not have a signed DNR at this time. I told the nurse I had to call the DON because this was an error. She failed to initiate the protocol. This is neglect. She was confused and stated she thought because the patient was on hospice that she was a DNR. She told me when she went into the room, she saw the patient unresponsive and not breathing. She called the hospice nurse to the room. The hospice nurse did an assessment and called the hospice physician who pronounced the patient. The nurse should have initiated the code blue protocol that we have in place and she should have initiated CPR. Interview with the Nursing Home Administrator (NHA) on [DATE] at 4:10 PM revealed, the LPN that found the resident unresponsive, should have checked the residents code status in PCC. In the event that PCC is not working, we have a backup to check code status. We maintain a book at each nursing station with a copy of all DNR's in the event they cannot check the face sheet in the electronic system. If there is no DNR in the book, they should be considered full code. As far as the nurse, the resident was under hospice care and I understand she assumed the resident was DNR since she was on hospice. Through the investigation it was determined that CPR should have been administered. The LPN involved was suspended pending investigation. We contacted the family and physician right away. Interview with the attending physician for resident #1 (Staff B) on [DATE] at 4:27 PM revealed she was the primary care physician for resident #1. Her advanced directives indicated she was full code status. The expectation when she was found to be unresponsive was to respond by initiating CPR. I was made aware the resident expired the same day. I was informed the resident expired and I was also made aware that CPR was not initiated. The family was also notified. My expectation is that CPR would have been initiated. Regardless if a patient is on hospice, if there is no DNR, CPR must be done. Interview with the Licensed Practical Nurse (Staff C) via telephone on [DATE] at 11:34 AM revealed, when she arrived at work on [DATE], resident #1 was her usual self. She was non-verbal and kept her eyes closed most of the time. She would open her eyes when touched. At the beginning of the shift she was breathing. Her skin was a little warm, so I checked her temperature and she did not have a fever. Her feeding was running via the PEG tube. A little while later about 9:,[DATE]:40 AM, I administered her medications via the PE[NAME] At that time, she was calm with no signs of distress. She was responsive to touch when I accessed the PEG tube. The next time I saw her was around 10 something. The resident in the same room in bed one put the light on so I answered the light for this resident. When I arrived in the room the hospice C N A was in the room finishing up ADL(activities of daily living) care for resident #1. The hospice C N A pulled the curtain and asked me to sign her board for the care she had provided. Since I was in the room, I decided to check on resident #1. When I pulled the curtain back to check her, I saw that her eyes were open with a stare. I checked her vital signs and she had no pulse or respirations. Since I did not get a pulse or respiration, I left the room and called hospice. I am not sure if they were already in the building, but responded quickly. The hospice nurse assisted by calling the family and the doctor and making the arrangements with the funeral director. The facility protocol if a resident is found unresponsive is to first check for the code status and start CPR if the resident did not have a DNR. At that moment, I did not check the code status for this resident. I was told weeks before this by the hospice nurse, that they were working on getting a DNR signed but I did not actually see the DNR or check the code status. In the event that a resident is on hospice, it is not automatic that they have a DNR. CPR should have been initiated for this resident. I was just going on what I was told by hospice. To my knowledge, nobody checked to see if this resident had a DNR. I provided a statement to the facility about what happened. The RN Supervisor came after the event and I reported to her that the patient had no vital signs. The protocol would have been to check the code status, but this just did not happen. I assumed over a two weeks period that the DNR would have been in place. I should have checked the book or checked in the computer to see what the code status was. I was told by hospice resident was getting a DNR and it never happened. The facility's immediate jeopardy removal plan included: -On [DATE], the resident was identified with the absence of vital signs. CPR was not initiated. Family and physician were notified. -On [DATE], the attending physician, Hospice, and resident representative were notified the resident expired. -On [DATE], the Licensed Practical Nurse involved was interviewed, re-educated related to identification of code status, resident's rights to formulate advance directives, following physician's orders [REDACTED]. -On [DATE], the Director of Nursing (DON) /designee initiated a house wide full chart review of resident records and system reviews including: - Cross checking DNR(do not resuscitate)/advance directives with the Social Service list -Ensured DNR orders with the EHR (Electronic Health Record) reflect current resident status -DNR books updated and reflect physician's orders [REDACTED].> -Accuracy of physician's orders [REDACTED]. -Yellow DNRO form scanned into resident records and appropriately signed by resident/resident representative. -Documentation in record if verbal order was obtained for a DNR, including that 2 nurses witnessed the order. -DNR book and advance directive list is accurate and validated. -Care plan and advanced directive care plan tracking form accurate. -On [DATE], the DON conducted a quality review of resident who expired in the facility in the past 60 days to ensure resident's documented wishes were carried out, no identified concerns. -On [DATE], the facility initiated on-going licensed nurses re-education related to Resident Rights, Advance Directives, and polity regarding code status determination. -On [DATE], the facility initiated on-going facility staff re-education related to Resident Rights and Advance Directives. -On [DATE], education materials were mailed to 365 of 365 facility staff members. One to one education to be provided as staff return to work. As of [DATE], 78 of 90 licensed nurses and 259 of 365 facility staff had been educated in person. -Systematic changes: Staff re-education, initiation of an Advance Directive Compliance Tracking Tool used daily. -Ongoing Monitoring -Beginning [DATE], daily QAA (Quality Assurance and Assessment) meeting until immediacy removed, then weekly. -On [DATE] and [DATE], Ad Hoc QA meetings were convened. On [DATE], the information in the facility's removal plan was verified as completed. The immediate jeopardy was removed on [DATE] at 2:34 PM

Based on record review and interview, the facility failed to ensure residents were free from neglect by failing to provide emergency medical services in accordance with the residents advance directive by not initiating cardio-pulmonary resuscitation (CPR) on a resident (R#1) with a full code status order for one of six residents reviewed. There were 200 residents residing in the facility with full code status orders. There were 255 residents residing in the facility at the time of the survey. Cross reference: F 578, F 678 and F 835. On [DATE], a Licensed Practical Nurse (LPN) found Resident #1 unresponsive with no vital signs. Resident #1 was a full code and receiving hospice services. The LPN failed to check the resident's code status and failed to initiate CPR. The failure to provide emergency care for resident #1 resulted in medical neglect. The resident died . This situation resulted in immediate jeopardy. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 3, 2020. The immediate jeopardy began on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. The findings included: Review of the facility policy and procedure titled ANE and Investigations revised [DATE] revealed: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review revealed the facility reported the incident to the state agency as neglect. Record review revealed resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated [DATE] Advance Directive: Full Code. There was an order dated [DATE] for a hospice evaluation. Review of the Health Care Proxy Designation Form revealed resident #1's grandson signed as designated health care proxy on [DATE]. Review of the Advanced Directive/Medical Treatment Decisions Acknowledgement of Receipt form signed by the health care proxy [DATE] revealed advance directives included healthcare proxy designation only. Review of the nursing progress notes revealed: [DATE] 10:25 Discharge Summary-Report given upon rounds member was noted in bed sleeping, but responsive to tactile stimuli. Skin warm to touch. Member was tolerating feeding via PEG tube. Medications administered as scheduled via PEG tube. PEG tube site intact. No redness noted. HOB elevated. Safety measures in place. Report given that hospice C N A (Certified Nursing Assistant) was in the room completing the ADL (Activities of Daily Living) care and pulling the curtain for privacy after taking care of the first bed. Went to check and see member and noted member unresponsive to tactile stimuli and sternal chest rub. Report received that no vital signs were apart at this time. Family member notified as per hospice nurse. MD (medical doctor) notified by Unit Charge Nurse. Body was released to funeral home. Mortician arrived at facility and left facility with body at 2:56 PM. Orders discontinued. [DATE] 12:49 :Upon rounds at 10:25 AM, noted hospice CNA in room completing ADL care and pulling the curtain for privacy. After I took care of bed one, I pulled the curtain to see member and noted member unresponsive to tactile stimuli and external rub. Unable to find pulse. Hospice nurse made aware and took over by calling the family and funeral home. Doctor was notified. [DATE] 14:50: Member expired. [DATE] Discharge Summary: Call placed to grandson who stated that his grandma has been declining since admission and has not been responding to any of the family members. He stated he cannot thank the facility enough and stated that the staff treated her like family. Interview with the Director of Nursing (DON) on [DATE] at 11:00 AM revealed, this resident was on hospice for one day. She was placed on hospice on [DATE]. The Hospice [DIAGNOSES REDACTED]. She never responded, she was in a vegetative state. The nurse walked in and found the resident had no pulse. She went to the desk and she called the hospice people to notify them. The hospice nurse came in and took over by calling the family to inform them that the patient had passed. The code status at that time was full code. It was a big question why CPR was not administered. The Nurse was suspended right away. We contacted the family to tell them we did not initiate CPR. We explained to the family that we did not follow their wishes because we did not start CPR. Her grandson stated my grandma has been declining since admission and did not respond to anyone since day one. He stated he was aware that CPR was not completed on this loved one, but stated he had no concerns with the resident treatment at the facility. The DON stated the grandson was the healthcare proxy, but he did not feel comfortable making the decision to sign a DNR (Do Not Resuscitate). The DON stated the facility policy if a resident does not have a DNR is to start CPR. We did not have the residents advance directives. DCF ( Florida Department of Children and Families) was called on [DATE] the Immediate Federal report was submitted to AHCA (Agency for Health Care Administration) on [DATE]. The LPN (Licensed Practical Nurse) was removed from the schedule pending investigation. When the nurse was interviewed, she said when she found the resident expired, she said in her mind she thought the resident was on hospice and she did not go and check the chart for code status. In the event of a code, the staff must access the resident's chart in PCC (point click care). The code status is listed in PCC as soon as you open the electronic record and also in the physician's orders. We also have a yellow DNR binder at each nurse's station. This is constantly updated and must be maintained in the event that PCC is down. We did not have the residents advance directives. We gave the LPN all of the tools needed, but she just did not follow the protocol. The LPN was suspended and due to the severity of the matter, she will be reported to the Florida Board of Nursing. Interview with the Registered Nurse (Registered Nurse) Supervisor (Staff A) on [DATE] at 3:11 PM revealed, I was the Supervisor on [DATE] and present in the facility when resident #1 expired. I was in the morning meeting from 9 AM to 10 AM. When I arrived on the unit, the nurse informed me that one of the patients just expired. I checked the computer and found that the patient was a full code. I asked the LPN why she did not call a code blue and she told me the resident was on hospice. The hospice nurse was also present in the facility at this time. I asked the hospice nurse if they had initiated the DNR and if a DNR was signed. The hospice nurse stated they were attempting to educate the family regarding DNR, but they did not have a signed DNR at this time. I told the nurse I had to call the DON because this was an error. She failed to initiate the protocol. This is neglect. She was confused and stated she thought because the patient was on hospice that she was a DNR. She told me when she went into the room, she saw the patient unresponsive and not breathing. She called the hospice nurse to the room. The hospice nurse did an assessment and called the hospice physician who pronounced the patient. The nurse should have initiated the code blue protocol that we have in place and she should have initiated CPR. Interview with the Nursing Home Administrator (NHA) on [DATE] at 4:10 PM revealed, the LPN that found the resident unresponsive, should have checked the residents code status in PCC. In the event that PCC is not working, we have a backup to check code status. We maintain a book at each nursing station with a copy of all DNR's in the event they cannot check the face sheet in the electronic system. If there is no DNR in the book, they should be considered full code. As far as the nurse, the resident was under hospice care and I understand she assumed the resident was DNR since she was on hospice. Through the investigation it was determined that CPR should have been administered. The LPN involved was suspended pending investigation. We contacted the family and physician right away. Interview with the attending physician on [DATE] at 4:27 PM revealed she was the primary care physician for resident #1. Her advanced directives indicated she was full code status. The expectation when she was found to be unresponsive was to respond by initiating CPR. I was made aware the resident expired the same day. I was informed the resident expired and I was also made aware that CPR was not initiated. The family was also notified. My expectation is that CPR would have been initiated. Regardless if a patient is on hospice, if there is no DNR, CPR must be done. Interview with the Licensed Practical Nurse (Staff C) via telephone on [DATE] at 11:34 AM revealed when she arrived at work on [DATE], resident #1 was her usual self. She was non-verbal and kept her eyes closed most of the time. She would open her eyes when touched. At the beginning of the shift she was breathing. Her skin was a little warm, so I checked her temperature and she did not have a fever. Her feeding was running via the PEG tube. A little while later about 9:,[DATE]:40 AM, I administered her medications via the PE[NAME] At that time, she was calm with no signs of distress. She was responsive to touch when I accessed the PEG tube. The next time I saw her was around 10 something. The resident in the same room in bed one put the light on so I answered the light for this resident. When I arrived in the room the hospice C N A was in the room finishing up ADL care for resident #1. The hospice C N A pulled the curtain and asked me to sign her board for the care she had provided. Since I was in the room, I decided to check on resident #1. When I pulled the curtain back to check her, I saw that her eyes were open with a stare. I checked her vital signs and she had no pulse or respirations. Since I did not get a pulse or respiration, I left the room and called hospice. I am not sure if they were already in the building, but responded quickly. The hospice nurse assisted by calling the family and the doctor and making the arrangements with the funeral director. The facility protocol if a resident is found unresponsive is to first check for the code status and start CPR if the resident did not have a DNR. At that moment, I did not check the code status for this resident. I was told weeks before this by the hospice nurse, that they were working on getting a DNR signed but I did not actually see the DNR or check the code status. In the event that a resident is on hospice, it is not automatic that they have a DNR. CPR should have been initiated for this resident. I was just going on what I was told by hospice. To my knowledge, nobody checked to see if this resident had a DNR. I provided a statement to the facility about what happened. The RN Supervisor came after the event and I reported to her that the patient had no vital signs. The protocol would have been to check the code status, but this just did not happen. I assumed over a two weeks period that the DNR would have been in place. I should have checked the book or checked in the computer to see what the code status was. I was told by hospice resident was getting a DNR and it never happened. The facility's immediate jeopardy removal plan included: -On [DATE], the resident was identified with the absence of vital signs. CPR (Cardio [MEDICAL CONDITION] Resuscitation) was not initiated. Family and physician were notified. -On [DATE], the attending physician, Hospice, and resident representative were notified the resident expired. -On [DATE], the Licensed Practical Nurse involved was interviewed, re-educated related to identification of code status, resident's rights to formulate advance directives, following physician's orders and she was removed from the schedule pending investigation. -on [DATE], the facility filed an immediate federal report related to neglect and initiated a full investigative process. Florida Department of Children and Families was notified. -On [DATE], the DON) /designee initiated a house wide full chart review of resident records and system reviews including: - Cross checking DNR(Do Not Resuscitate)/advance directives with the Social Service list -Ensured DNR orders with the EHR reflect current resident status -DNR books updated and reflect physician's orders -Accuracy of physician's orders as it pertains to code status/advance directives -Yellow DNRO form scanned into resident records and appropriately signed by resident/resident representative. -Documentation in record if verbal order was obtained for a DNR, including that 2 nurses witnessed the order. -DNR book and advance directive list is accurate and validated. -Care plan and advanced directive care plan tracking form accurate. -On [DATE], the DON conducted a quality review of resident who expired in the facility in the past 60 days to ensure resident's documented wishes were carried out, no identified concerns. -On [DATE], the facility initiated on-going licensed nurses re-education related to Abuse, Neglect, and Exploitation with indicators of neglect, Resident Rights, Advance Directives, following Physician orders, polity regarding code status determination, completing verbal orders, location of DNR with the EHR, location of DNR binders, performing a code blue, paging overhead during a code, crash cart process, AED (Automated External Defibrillator) process and identification and response to a resident found to be unresponsive. -On [DATE], the facility initiated on-going facility staff re-education related Abuse and Neglect, Resident Rights, and Advance Directives. -On [DATE], education materials were mailed to 365 of 365 facility staff members. One to one education to be provided as staff return to work. As of [DATE], 78 of 90 licensed nurses and 259 of 365 facility staff had been educated in person. -Systematic changes: Staff re-education, initiation of an Advance Directive Compliance Tracking Tool used daily. -Ongoing Monitoring -On [DATE], education was completed with the Executive Director and The DON to review job descriptions, how to conduct an investigation, risk management, and conducting daily meetings. -Beginning [DATE], daily QAA (Quality Assurance and Assessment) meeting until immediacy removed, then weekly. -On [DATE] and [DATE], Ad Hoc QA meetings were convened. On [DATE], the information in the facility's removal plan was verified as completed. The immediate jeopardy was removed on [DATE] at 2:34 PM

Based in record review and interview, the facility failed to ensure emergency medical care and services such as Cardio-Pulmonary Resuscitation (CPR), were provided in accordance with resident's advance directives and physician's orders [REDACTED].#1) who was found unresponsive with a full code status order of six residents reviewed. There were 200 residents residing in the facility with full code status orders. There were 255 residents residing in the facility at the time of the survey. Cross reference: F 578, F 600 F, F 678 and 835 On [DATE], a Licensed Practical Nurse (LPN) found Resident #1 unresponsive with no vital signs. Resident #1 was a full code and receiving hospice services. The LPN failed to check the resident's code status and failed to initiate CPR. The failure to provide emergency care for resident #1 resulted in medical neglect. The resident died . This situation resulted in immediate jeopardy. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 3, 2020. The immediate jeopardy began on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE]. The findings included: The facility policy and procedure titled Code Blue and CPR revised ,[DATE] revealed: Standard: The facility will honor the resident/resident representatives wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). In the event a resident experiences [MEDICAL CONDITION] (cessation of pulse and or respirations), CPR will be provided in the absence of a valid physician's orders [REDACTED]. Guideline: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: -Remain calm. Remain with the resident. -Call out for help. -Licensed Nurse will assure command of the scene and will direct other personnel in the effort. -Direct a staff member to announce the emergency per facility protocol (i.e. Code Blue and room number three times) and direct staff to bring emergency equipment cart and AED (Automated External Defibrillator) machine to the scene. -A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the EHR (Electronic Health Record), e-MAR(Electronic Medical Records) or point of care kiosk. At that point provision or withholding of resuscitative efforts may begin. -In the event the EHR is unavailable code status may be validated using a secondary check of the code binder via presence of a physician order [REDACTED]. If DNR status is validated and or obvious clinical signs of irreversible death are present, do not initiate CPR. If CPR/Code Status is undefined (absence of DNR, Advance Directive, documented verbal wishes or resident/representative or physician order) CPR will be initiated and will continue until the arrival of EMS (Emergency Medical Services) or until the discovery of a valid DNR. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1 expired in the facility on [DATE]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed resident #1's communication status was coded to indicate she was rarely or never understood and sometimes understands. The resident's cognitive status was coded for impaired short and long term memory and moderately impaired cognitive skills for daily decision making. Resident #1 required total dependence for activities of daily living. Special treatment included oxygen therapy and skilled speech therapy, occupational therapy and physical therapy. Resident #1's care plan revealed: Resident has advanced directive on record. Health Care Proxy (appointed by facility). Resident is not capable of making informed consent regarding health care decisions. physician's orders [REDACTED]. There was an order dated [DATE] for a hospice evaluation. The Health Care Proxy Designation Form revealed resident #1's grandson signed as designated health care proxy on [DATE]. The Advanced Directive/Medical Treatment Decisions Acknowledgement of Receipt form signed by the health care proxy [DATE] revealed advance directives included healthcare proxy designation only. The nursing progress notes revealed: [DATE] 10:25: Discharge Summary. Report given upon rounds member was noted in bed sleeping, but responsive to tactile stimuli. Skin warm to touch. Member was tolerating feeding via PEG tube. Medications administered as scheduled via PEG tube. PEG tube site intact. No redness noted. HOB elevated. Safety measures in place. Report given that hospice C N A (Certified Nursing Assistant) was in the room completing the ADL (activities of daily living) care and pulling the curtain for privacy after taking care of the first bed. Went to check and see member and noted member unresponsive to tactile stimuli and sternal chest rub. Report received that no vital signs were apart at this time. Family member notified as per hospice nurse. MD (medical doctor) notified by Unit Charge Nurse. Body was released to funeral home. Mortician arrived at facility and left facility with body at 2:56 PM. Orders discontinued. [DATE] 12:49: Upon rounds at 10:25 AM, noted hospice C N A in room completing ADL care and pulling the curtain for privacy. After I took care of bed one, I pulled the curtain to see member and noted member unresponsive to tactile stimuli and external rub. Unable to find pulse. Hospice nurse made aware and took over by calling the family and funeral home. Doctor was notified. [DATE] 14:50 Member expired. [DATE] Discharge Summary: Call placed to grandson who stated that his grandma has been declining since admission and has not been responding to any of the family members. He stated he cannot thank the facility enough and stated that the staff treated her like family. Interview with the Director of Nursing (DON) on [DATE] at 11:00 AM revealed, this resident was on hospice for one day. She was placed on hospice on [DATE]. The Hospice [DIAGNOSES REDACTED]. She never responded, she was in a vegetative state. The nurse walked in and found the resident had no pulse. She went to the desk and she called the hospice people to notify them. The hospice nurse came in and took over by calling the family to inform them that the patient had passed. The code status at that time was full code. It was a big question why CPR was not administered. The Nurse was suspended right away. We contacted the family to tell them we did not initiate CPR. We explained to the family that we did not follow their wishes because we did not start CPR. Her grandson stated my grandma has been declining since admission and did not respond to anyone since day one. He stated he was aware that CPR was not completed on this loved one, but stated he had no concerns with the resident treatment at the facility. The DON stated the grandson was the healthcare proxy, but he did not feel comfortable making the decision to sign a DNR (Do Not Resuscitate). The DON stated the facility policy if a resident does not have a DNR is to start CPR. We did not have the residents advance directives. DCF ( Florida Department of Children and Families) was called on [DATE] the Immediate Federal report was submitted to AHCA (Agency for Health Care Administration) on [DATE]. The LPN (Licensed Practical Nurse) was removed from the schedule pending investigation. When the nurse was interviewed, she said when she found the resident expired, she said in her mind she thought the resident was on hospice and she did not go and check the chart for code status. In the event of a code, the staff must access the resident's chart in PCC (point click care). The code status is listed in PCC as soon as you open the electronic record and also in the physician's orders [REDACTED]. This is constantly updated and must be maintained in the event that PCC is down. We did not have the residents advance directives. We gave the LPN all of the tools needed, but she just did not follow the protocol. The LPN was suspended and due to the severity of the matter, she will be reported to the Florida Board of Nursing. Interview with the Registered Nurse (Registered Nurse) Supervisor (Staff A) on [DATE] at 3:11 PM revealed, I was the Supervisor on [DATE] and present in the facility when resident #1 expired. I was in the morning meeting from 9 AM to 10 AM. When I arrived on the unit, the nurse informed me that one of the patients just expired. I checked the computer and found that the patient was a full code. I asked the LPN why she did not call a code blue and she told me the resident was on hospice. The hospice nurse was also present in the facility at this time. I asked the hospice nurse if they had initiated the DNR and if a DNR was signed. The hospice nurse stated they were attempting to educate the family regarding DNR, but they did not have a signed DNR at this time. I told the nurse I had to call the DON because this was an error. She failed to initiate the protocol. This is neglect. She was confused and stated she thought because the patient was on hospice that she was a DNR. She told me when she went into the room, she saw the patient unresponsive and not breathing. She called the hospice nurse to the room. The hospice nurse did an assessment and called the hospice physician who pronounced the patient. The nurse should have initiated the code blue protocol that we have in place and she should have initiated CPR. Interview with the Nursing Home Administrator (NHA) on [DATE] at 4:10 PM revealed, the LPN that found the resident unresponsive, should have checked the residents code status in PCC. In the event that PCC is not working, we have a backup to check code status. We maintain a book at each nursing station with a copy of all DNR's in the event they cannot check the face sheet in the electronic system. If there is no DNR in the book, they should be considered full code. As far as the nurse, the resident was under hospice care and I understand she assumed the resident was DNR since she was on hospice. Through the investigation it was determined that CPR should have been administered. The LPN involved was suspended pending investigation. We contacted the family and physician right away. Interview with the attending physician on [DATE] at 4:27 PM revealed she was the primary care physician for resident #1. Her advanced directives indicated she was full code status. The expectation when she was found to be unresponsive was to respond by initiating CPR. I was made aware the resident expired the same day. I was informed the resident expired and I was also made aware that CPR was not initiated. The family was also notified. My expectation is that CPR would have been initiated. Regardless if a patient is on hospice, if there is no DNR, CPR must be done. Interview with the Licensed Practical Nurse (Staff C) via telephone on [DATE] at 11:34 AM revealed when she arrived at work on [DATE], resident #1 was her usual self. She was non-verbal and kept her eyes closed most of the time. She would open her eyes when touched. At the beginning of the shift she was breathing. Her skin was a little warm, so I checked her temperature and she did not have a fever. Her feeding was running via the PEG tube. A little while later about 9:,[DATE]:40 AM, I administered her medications via the PE[NAME] At that time, she was calm with no signs of distress. She was responsive to touch when I accessed the PEG tube. The next time I saw her was around 10 something. The resident in the same room in bed one put the light on so I answered the light for this resident. When I arrived in the room the hospice C N A was in the room finishing up ADL care for resident #1. The hospice C N A pulled the curtain and asked me to sign her board for the care she had provided. Since I was in the room, I decided to check on resident #1. When I pulled the curtain back to check her, I saw that her eyes were open with a stare. I checked her vital signs and she had no pulse or respirations. Since I did not get a pulse or respiration, I left the room and called hospice. I am not sure if they were already in the building, but responded quickly. The hospice nurse assisted by calling the family and the doctor and making the arrangements with the funeral director. The facility protocol if a resident is found unresponsive is to first check for the code status and start CPR if the resident did not have a DNR. At that moment, I did not check the code status for this resident. I was told weeks before this by the hospice nurse, that they were working on getting a DNR signed but I did not actually see the DNR or check the code status. In the event that a resident is on hospice, it is not automatic that they have a DNR. CPR should have been initiated for this resident. I was just going on what I was told by hospice. To my knowledge, nobody checked to see if this resident had a DNR. I provided a statement to the facility about what happened. The RN Supervisor came after the event and I reported to her that the patient had no vital signs. The protocol would have been to check the code status, but this just did not happen. I assumed over a two weeks period that the DNR would have been in place. I should have checked the book or checked in the computer to see what the code status was. I was told by hospice resident was getting a DNR and it never happened. The facility's immediate jeopardy removal plan included: -On [DATE], the resident was identified with the absence of vital signs. CPR (Cardio [MEDICAL CONDITION] Resuscitation) was not initiated. Family and physician were notified. -On [DATE], the attending physician, Hospice, and resident representative were notified the resident expired. -On [DATE], the Licensed Practical Nurse involved was interviewed, re-educated related to identification of code status, resident's rights to formulate advance directives, following physician's orders [REDACTED]. -on [DATE], the facility filed an immediate federal report related to neglect and initiated a full investigative process. Florida Department of Children and Families was notified. -On [DATE], the DON) /designee initiated a house wide full chart review of resident records and system reviews including: - Cross checking DNR(Do Not Resuscitate)/advance directives with the Social Service list -Ensured DNR orders with the EHR reflect current resident status -DNR books updated and reflect physician's orders [REDACTED].> -Accuracy of physician's orders [REDACTED]. -Yellow DNRO form scanned into resident records and appropriately signed by resident/resident representative. -Documentation in record if verbal order was obtained for a DNR, including that 2 nurses witnessed the order. -DNR book and advance directive list is accurate and validated. -Care plan and advanced directive care plan tracking form accurate. -On [DATE], the DON conducted a quality review of resident who expired in the facility in the past 60 days to ensure resident's documented wishes were carried out, no identified concerns. -On [DATE], the facility initiated on-going licensed nurses re-education related to Abuse, Neglect, and Exploitation with indicators of neglect, Resident Rights, Advance Directives, following Physician orders, polity regarding code status determination, completing verbal orders, location of DNR with the EHR, location of DNR binders, performing a code blue, paging overhead during a code, crash cart process, AED (Automated External Defibrillator) process and identification and response to a resident found to be unresponsive. -On [DATE], the facility initiated on-going facility staff re-education related Abuse and Neglect, Resident Rights, and Advance Directives. -On [DATE], education materials were mailed to 365 of 365 facility staff members. One to one education to be provided as staff return to work. As of [DATE], 78 of 90 licensed nurses and 259 of 365 facility staff had been educated in person. -Systematic changes: Staff re-education, initiation of an Advance Directive Compliance Tracking Tool used daily. -Ongoing Monitoring -On [DATE], education was completed with the Executive Director and The DON to review job descriptions, how to conduct an investigation, risk management, and conducting daily meetings. -Beginning [DATE], daily QAA (Quality Assurance and Assessment) meeting until immediacy removed, then weekly. -On [DATE] and [DATE], Ad Hoc QA meetings were convened. On [DATE], the information in the facility's removal plan was verified as completed. The immediate jeopardy was removed on [DATE] at 2:34 PM

Based on record review and interview, the facility's administration failed to use its resources effectively to ensure resident's rights were honored related to advanced directives, failure to ensure residents were free from neglect, Ensuring that the facility's policy addressing advance directives was followed and failure to ensure coordination of care with contracted hospice services in the facility. These actions affected the care for resident #1. There were 200 residents residing in the facility with full code status orders and thirty four residents residing in the facility receiving hospice services. There were 255 residents residing in the facility at the time of the survey. Cross reference: F 578, F 600 and F 678 On [DATE], a Licensed Practical Nurse (LPN) found Resident #1 unresponsive with no vital signs. Resident #1 was a full code and receiving hospice services. The LPN failed to check the resident's code status and failed to initiate CPR. The failure to provide emergency care for resident #1 resulted in medical neglect. The resident died . This situation resulted in immediate jeopardy. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 3, 2020. The immediate jeopardy began on [DATE] and was removed on [DATE]. The scope and severity was decreased to D, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of [DATE] The findings included: The job description for the job title Administrator (undated) revealed: General Purpose: Manage, lead and direct overall operations of the facility in accordance with customer needs, regulations, and company policy. Essential Job Functions: B. Facility Management: Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility, moral of staff and ensures resident needs are being addressed. Compliance Management: Develops and maintains written policies and procedures that govern efficient day to day operation of the facility. Maintain a working knowledge of and ensure compliance with all governmental regulations. I. Resident Rights: Understand, comply and promote all rules and regulations regarding resident's rights. The Job Description for the Director of Nursing (undated) with Division/Department, Job Title revealed General Description : Responsible for planning, coordination, implementation, evaluation and supervision of the nursing services. The Director of Nursing Service is responsible for maintaining consistent, safe effective nursing practices and the management of the overall operation of the nursing department in accordance with policies, standards of nursing practices and regulatory requirements. Establish processes that are outcome focused as to maintain the highest possible level of care and services for each resident, while achieving the facility's business objectives. The facility policy and procedure titled Resident Rights, Dignity and Visitation Rights revised [DATE] revealed: Standard: The facility promotes the exercise of rights for each resident, including those who face barriers (communication and hearing problems and cognitive limits) in the exercise of these rights. Guidelines include: 8. The right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate advance directives. The facility policy and procedure titled Advance Directives revised ,[DATE] revealed: Standard: It will be the standard of this facility that the resident has the right to request, refuse and/or discontinue treatment and to formulate an advance directive and participate in advance directive care planning. Advance Directives/Advanced Care Planning designations will be respected in accordance with state law and facility policy. The facility policy and procedure titled ANE (Abuse Neglect and Exploitation)and Investigations revised [DATE] revealed: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's report of Neglect Incident to stat agency neglect incident was submitted on [DATE]. The facility policy and procedure titled Code Blue and CPR revised ,[DATE] revealed: Standard: The facility will honor the resident/resident representatives wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). In the event a resident experiences [MEDICAL CONDITION] (cessation of pulse and or respirations), CPR will be provided in the absence of a valid physician's orders [REDACTED]. Guideline: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: -Remain calm. Remain with the resident. -Call out for help. -Licensed Nurse will assure command of the scene and will direct other personnel in the effort. -Direct a staff member to announce the emergency per facility protocol (i.e. Code Blue and room number three times) and direct staff to bring emergency equipment cart and AED (Automated External Defibrillator) machine to the scene. -A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the HER (electronic health record), e-MAR or point of care kiosk. At that point provision or withholding of resuscitative efforts may begin. -In the event the EHR is unavailable code status may be validated using a secondary check of the code binder via presence of a physician order [REDACTED]. If DNR status is validated and or obvious clinical signs of irreversible death are present, do not initiate CPR. If CPR/Code Status is undefined (absence of DNR, Advance Directive, documented verbal wishes or resident/representative or physician order) CPR will be initiated and will continue until the arrival of EMS (emergency medical services) or until the discovery of a valid DNR. On [DATE] the DON stated, I am responsible for the competency evaluation and the performance evaluations for the Licensed Nurses and C N [NAME] They are done annually scheduled around the anniversary. This is all done electronically, and I receive an e-mail a month in advance so they can be completed timely. I get feedback from the Charge Nurses for the C N A, and the Unit Managers for the Licensed Nurses. I also have the ADON assist in these annual evaluations. Once completed, they are filed in the personal record. Corporate tracks the CPR Certification and Licenses - all Nurses and C N A's are CPR certified. We have an individual come in to conduct the CPR training. We conduct skills training which is hands own. We cover all the required trainings both electronically and every 6 months hands on during our skills training. The DON stated she has input in the clinical portion of the facility assessment; especially related what type of resident can be admitted . I am also involved in the staffing projection portion of the facility assessment. The physician's orders [REDACTED]. There was an order dated [DATE] for a hospice evaluation. The Health Care Proxy Designation Form revealed resident #1's grandson signed as designated health care proxy on [DATE]. The Advanced Directive/Medical Treatment Decisions Acknowledgement of Receipt form signed by the health care proxy [DATE] revealed advance directives included healthcare proxy designation only. The nursing progress notes revealed: [DATE] 10:25 Discharge Summary. Report given upon rounds member was noted in bed sleeping, but responsive to tactile stimuli. Skin warm to touch. Member was tolerating feeding via PEG tube. Medications administered as scheduled via PEG tube. PEG tube site intact. No redness noted. HOB elevated. Safety measures in place. Report given that hospice C N A (Certified Nursing Assistant) was in the room completing the ADL (activities of daily living) care and pulling the curtain for privacy after taking care of the first bed. Went to check and see member and noted member unresponsive to tactile stimuli and sternal chest rub. Report received that no vital signs were apart at this time. Family member notified as per hospice nurse. MD (medical doctor) notified by Unit Charge Nurse. Body was released to funeral home. Mortician arrived at facility and left facility with body at 2:56 PM. Orders discontinued. [DATE] 12:49: Upon rounds at 10:25 AM, noted hospice C N A in room completing ADL care and pulling the curtain for privacy. After I took care of bed one, I pulled the curtain to see member and noted member unresponsive to tactile stimuli and external rub. Unable to find pulse. Hospice nurse made aware and took over by calling the family and funeral home. Doctor was notified. [DATE] 14:50: Member expired. [DATE] Discharge Summary: Call placed to grandson who stated that his grandma has been declining since admission and has not been responding to any of the family members. He stated he cannot thank the facility enough and stated that the staff treated her like family. Interview with the Director of Nursing (DON) on [DATE] at 11:00 AM revealed this resident was on hospice for one day. She was placed on hospice on [DATE]. The Hospice [DIAGNOSES REDACTED]. She never responded, she was in a vegetative state. The nurse walked in and found the resident had no pulse. She went to the desk and she called the hospice people to notify them. The hospice nurse came in and took over by calling the family to inform them that the patient had passed. The code status at that time was full code. It was a big question why CPR was not administered. The Nurse was suspended right away. We contacted the family to tell them we did not initiate CPR. We explained to the family that we did not follow their wishes because we did not start CPR. Her grandson stated my grandma has been declining since admission and did not respond to anyone since day one. He stated he was aware that CPR was not completed on this loved one, but stated he had no concerns with the resident treatment at the facility. The DON stated the grandson was the healthcare proxy, but he did not feel comfortable making the decision to sign a DNR (Do Not Resuscitate). The DON stated the facility policy if a resident does not have a DNR is to start CPR. We did not have the residents advance directives. DCF (Florida Department of Children and Families) was called on [DATE] the Immediate Federal report was submitted to AHCA (Agency for Health Care Administration) on [DATE]. The LPN (Licensed Practical Nurse) was removed from the schedule pending investigation. When the nurse was interviewed, she said when she found the resident expired, she said in her mind she thought the resident was on hospice and she did not go and check the chart for code status. In the event of a code, the staff must access the resident's chart in PCC (point click care). The code status is listed in PCC as soon as you open the electronic record and in the physician's orders [REDACTED]. This is constantly updated and must be maintained in the event that PCC is down. We did not have the residents advance directives. We gave the LPN all of the tools needed, but she just did not follow the protocol. The LPN was suspended and due to the severity of the matter, she will be reported to the Florida Board of Nursing. Interview with the Registered Nurse (Registered Nurse) Supervisor (Staff A) on [DATE] at 3:11 PM revealed, I was the Supervisor on [DATE] and present in the facility when resident #1 expired. I was in the morning meeting from 9 AM to 10 AM. When I arrived on the unit, the nurse informed me that one of the patients just expired. I checked the computer and found that the patient was a full code. I asked the LPN why she did not call a code blue and she told me the resident was on hospice. The hospice nurse was also present in the facility at this time. I asked the hospice nurse if they had initiated the DNR and if a DNR was signed. The hospice nurse stated they were attempting to educate the family regarding DNR, but they did not have a signed DNR at this time. I told the nurse I had to call the DON because this was an error. She failed to initiate the protocol. This is neglect. She was confused and stated she thought because the patient was on hospice that she was a DNR. She told me when she went into the room, she saw the patient unresponsive and not breathing. She called the hospice nurse to the room. The hospice nurse did an assessment and called the hospice physician who pronounced the patient. The nurse should have initiated the code blue protocol that we have in place and she should have initiated CPR. Interview with the Nursing Home Administrator (NHA) on [DATE] at 4:10 PM revealed the LPN that found the resident unresponsive, should have checked the residents code status in PCC. In the event that PCC is not working, we have a backup to check code status. We maintain a book at each nursing station with a copy of all DNR's in the event they cannot check the face sheet in the electronic system. If there is no DNR in the book, they should be considered full code. As far as the nurse, the resident was under hospice care and I understand she assumed the resident was DNR since she was on hospice. Through the investigation it was determined that CPR should have been administered. The LPN involved was suspending pending investigation. We contacted the family and physician right away. Interview with the attending physician on [DATE] at 4:27 PM revealed she was the primary care physician for resident #1. Her advanced directives indicated she was full code status. The expectation when she was found to be unresponsive was to respond by initiating CPR. I was made aware the resident expired the same day. I was informed the resident expired and I was also made aware that CPR was not initiated. The family was also notified. My expectation is that CPR would have been initiated. Regardless if a patient is on hospice, if there is no DNR, CPR must be done. Interview with the Licensed Practical Nurse (Staff C) via telephone on [DATE] at 11:34 AM revealed when she arrived at work on [DATE], resident #1 was her usual self. She was non-verbal and kept her eyes closed most of the time. She would open her eyes when touched. At the beginning of the shift she was breathing. Her skin was a little warm, so I checked her temperature and she did not have a fever. Her feeding was running via the PEG tube. A little while later about 9:,[DATE]:40 AM, I administered her medications via the PE[NAME] At that time, she was calm with no signs of distress. She was responsive to touch when I accessed the PEG tube. The next time I saw her was around 10 something. The resident in the same room in bed one put the light on so I answered the light for this resident. When I arrived in the room the hospice C N A was in the room finishing up ADL care for resident #1. The hospice C N A pulled the curtain and asked me to sign her board for the care she had provided. Since I was in the room, I decided to check on resident #1. When I pulled the curtain back to check her, I saw that her eyes were open with a stare. I checked her vital signs and she had no pulse or respirations. Since I did not get a pulse or respiration, I left the room and called hospice. I am not sure if they were already in the building, but responded quickly. The hospice nurse assisted by calling the family and the doctor and making the arrangements with the funeral director. The facility protocol if a resident is found unresponsive is to first check for the code status and start CPR if the resident did not have a DNR. At that moment, I did not check the code status for this resident. I was told weeks before this by the hospice nurse, that they were working on getting a DNR signed but I did not actually see the DNR or check the code status. In the event that a resident is on hospice, it is not automatic that they have a DNR. CPR should have been initiated for this resident. I was just going on what I was told by hospice. To my knowledge, nobody checked to see if this resident had a DNR. I provided a statement to the facility about what happened. The RN Supervisor came after the event and I reported to her that the patient had no vital signs. The protocol would have been to check the code status, but this just did not happen. I assumed over a two weeks period that the DNR would have been in place. I should have checked the book or checked in the computer to see what the code status was. I was told by hospice resident was getting a DNR and it never happened. The clinical record revealed resident #1 had an order for [REDACTED]. There were no consent forms, certification, initial admission assessment, plan of care or visit notes. Interview with the DON on [DATE] at 2:15 PM revealed; the facility has been having difficulty receiving the paperwork from this hospice provider. Resident #1 was officially placed on hospice services on [DATE]. The resident expired on [DATE] and we still do not have any paperwork from hospice. We do not have a certification or an admission assessment. I have been trying to call them to get the documentation. This has been an ongoing problem with this hospice provider. Interview with the DON on [DATE] at 4:38 PM revealed; we are having a problem with this hospice service. We had stopped allowing them to accept patients here. They were not coming to the care plan meetings and they were not providing us with their documentation. We just recently started to contract with this provider again. We do not have any of the paperwork for resident #1. They told me they did the initial evaluation for this resident on [DATE]. Due to some financial issues, resident #1 was not receiving hospice services until [DATE]. Our admission department or Social Services needs to make sure we have the certification and the consent forms. Hospice staff should not be providing services unless we have the paperwork. I just received an e-mail that they forwarded all the documents today. The nurse should have made sure we had we had an initial nursing assessment. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:15 PM revealed, when a patient is admitted , and they are on hospice we check for the consent forms and check for DNR (Do Not Resuscitate) forms. Also, Social Services is involved. If there is any change in condition, we also communicate to coordinate care with hospice. In the event that a resident is placed on hospice after admission, the nurse manager is the person who will ensure the consents and paperwork are in place. We have to ensure the necessary consent forms and hospice assessments are completed and filed in the hospice binder. Interview with the RN Supervisor/Nurse Manager (Staff A) on [DATE] at 2:23 PM revealed, when a resident is place on hospice, Social Services coordinates with the family members to set up hospice services. Once the family member elect's hospice, Social Services coordinates with Nursing to receive an order for [REDACTED]. Once admitted , I would need the admission [DIAGNOSES REDACTED]. I was not aware resident #1 was on hospice. It was my understanding that the admission to hospice was still in progress. They did take over the care of resident #1 and they hospice sent a nurse and an aide to care for the resident. Once received, the documents are also scanned into the [NAME] H R. Of course, if we have hospice staff providing care for one of our residents, we would have to make sure we have all the proper consents and documents. Interview with the Director of Social Services (Staff D) on [DATE] at 12:52 PM revealed; Social Services oversees the advance directives. We discuss hospice as applicable. This is part of the initial assessment process. We also work with various hospice contractors. We oversee to make sure the paperwork is uploaded in the electronic health record. We also invite them to care plans. The expectation is to have the paperwork in place before the hospice service starts to see the resident. Interview with the Director of Social Services (Staff E) on [DATE] at 12:57 PM revealed, when a resident is on hospice, we work with nursing and the business office to get the necessary paperwork. A lot of resident comes in with that paperwork but if the order is driven by the physician here, we will assist with carrying out the order. We have a point of contact person here who acts as the liaison between the facility and the hospice providers. This person is the ADON. The hospice documentation received from the DON on [DATE] at 5:35 PM revealed the documents had been faxed to the facility on [DATE] at 3:05 PM. The documents included a visit note report dated [DATE]. Visit type: Hospice RN start of care. Additional documents signed by resident #1's legal representative and the hospice representative on [DATE] included and Informed Consent/Election of Benefits, a Notice of Advance Directive form indicated I do not have an advance directive for health care, Patient's Rights, Notice of Privacy, Costs/Responsibilities, Appointment of Designated Representative, Medicaid Hospice Benefit Election, Health Care Surrogate/Proxy Statement, and the Facility Notice of Hospice Care. Interview with the DON on [DATE] at 5:35 PM revealed the hospice documents were faxed to the facility today. There were no hospice documents provided at the time of admission. The DON again stated that resident #1 was admitted to hospice on [DATE], not [DATE] due to some financial problem that needed to be clarified. Interview with RN employed by the hospice provider via telephone on [DATE] at 2:48 PM revealed ; when a resident has an order for [REDACTED]. The facility should get a copy placed in the chart the same day or within 24 hours. The protocol is to make sure all consents are provided to the facility and placed on file in the facility. As soon we do the case presentation the facility receives the CTI (Certificate of Terminal Illness), the initial plan of care signed by our Medical Director and the attending physician. This must be sent to the facility. The RN requested that the surveyor contact the Director of Clinical Services for clarification of the process. On [DATE] at 3:42 PM the DON and NHA revealed administration will be using an audit tool that will to will be reviewed in morning meeting. The administrator revealed that they will review if the patient status is DNR and verify information with resident and or representative. The DON explained that in the event a resident is incapacitated they will be making sure a surrogate or guardianship is in place. The DON stated that in order to Identify and prioritize deviations from performance and other problems and issues they will continue with the audits and ongoing education including updates with orientation process to cover new hire. During a follow up interview via telephone hospice provider's Director of Clinical Services (Staff G) [DATE] at 10:30 AM, he revealed resident #1 was officially admitted to hospice on [DATE]. The communication with the facility with this admission was not appropriate. First, the nursing home notifies us of a referral. When we admit the patient, we leave a copy of all consents in the facility. These consents should be given to the facility on the same day of admission. Once we have an order for [REDACTED]. Once the evaluation is done, the nurse calls the medical director to confirm that the patient is appropriate for hospice. Once approved, we proceed to call the attending physician to confirm the orders, discuss condition, medications and the plan of care. Once all of this is done, we leave the consents in the facility. We prioritize by leaving the consents and the facility notification forms in the facility on the day of admission. This is the proof that the resident has been admitted . We also verify if there is a DNR on the day of admission. This is done immediately. In this case, the patient was admitted on [DATE]. We also leave a copy of the Nursing Comprehensive Admission Assessment at the facility. We replace this with a signed copy once we have our meeting and it is signed by the medical director along with the signed plan of care. This patient was admitted on [DATE]. The order for the evaluation was [DATE]. The next day she was discontinued from hospice because she was seeking some skilled therapy services in the facility. This is considered aggressive treatment since the facility was pursuing skills services. She was not readmitted for services. In order for the patient to be readmitted , we would have had to start the process all over again. She was officially discharged from hospice on [DATE] and not readmitted .

Based on observation, interview and record review the facility failed to ensure 1 of 4 residents (#258) observed for wound care treatment was appropriately monitored and re-assessed for pain management. The facility assessed the resident's crying for anxiousness and not pain. There were 34 residents with pressure ulcers at the time of survey. The findings include: Review of the medical record revealed resident #258 was re-admitted on [DATE] with a stage 4 pressure ulcer to the sacrum and stage 3 pressure ulcers to the to right ankle and the left heel. Record review of resident #258's care plan for pain revealed the potential for pain as evidenced by crying/moaning, facial grimace, guarding, observed non-verbal behavior cues of pain, and guarded movement related to a left heel ulcer. Observation on 05/16/2013 at 7:39 am revealed resident #258 in bed on her left side. Review of May 2013 physician order [REDACTED]. There was an additional order to cleanse the right ankle and the left heel with normal saline, apply [MEDICATION NAME] spray and secure with kerlix every other day (dated 5/3/2013). Observation of the sacral pressure ulcer wound treatment on 05/16/2013 at 10:32 am revealed LPN #1 would complete the wound treatment with the aid of RN #1. RN #1 placed the barrier between the resident and the sheets. LPN #1 attempted to remove the dressing from the sacrum. Resident #258 started to cry and had a grimaced facial expression. She used her right hand to push away the LPN's hands. The LPN said the resident always behaved in that manner because she was anxious. The RN asked the resident if she was in pain and the resident said, "yes." The RN also informed the LPN that the resident had requested that she remove the dressing slowly. The LPN tried to remove the dressing from the sacrum several times amidst the resident saying she was feeling pain. Observation on 05/16/2013 at 10:42 am revealed the LPN attempted to touch resident #258's right ankle in an effort to remove the dressing. The resident grimaced and cried while attempting to guard her leg. The RN again asked the resident if she was in pain and the resident said, "yes." The RN explained that the resident had a [DIAGNOSES REDACTED]. The LPN was determined to continue the wound treatment but the RN told her not to continue and the physician would be notified. The RN confirmed the resident had been administered regular Tylenol. The resident's left heel was not observed. Observation of the right ankle wound treatment on 05/16/2013 revealed the resident only voiced she was experiencing pain when the LPN touched her ankle. The resident had stopped crying when the surveyors left the room. During the review of the MAR indicated [REDACTED]. The wound care nurses came out of the room and the surveyor requested a second observation of the right ankle. Observation of the right ankle on 05/16/2013 at 10:49 am with assistance of the RN confirmed the wound care nurses had proceeded to apply the wound treatment [MEDICATION NAME] to the right ankle and a dry dressing to cover the ankle after the surveyors left the room. Review of the pain management flow sheet revealed the resident had routinely been administered Tylenol 325 mg 2 tablets by mouth for pain in her legs at a pain rating scale of 7-8. Interview with LPN #2 assigned to the resident on 05/16/2013 at 10:52 am confirmed the resident had not been re-assessed for pain and the physician had not been notified of the resident's pain frequency. The LPN's response was that she did not know if anyone had called the physician concerning the pain. Interview with the Director of nursing (DON) on 5/17/2013 at approximately 10:30 am confirmed that the facility decided to re-assess the resident ' s pain frequency on the day of the scheduled wound care treatment. A reassessment form was completed and the physician was notified. The physician's orders [REDACTED].