Every finding on record at Viera Healthcare and Rehabilitation Center

Based on observation, and interview, the facility failed to maintain the refuse storage area in a sanitary condition to prevent the development of odors and the attraction of pests for 2 of 2 dumpsters observed in the exterior kitchen refuse area.Findings: During the initial tour of the facility kitchen on 2/09/26 at 10:31 AM, observation of the exterior refuse area revealed two large waste dumpsters with lids not tightly closed. Plastic trash was protruding from the top of the dumpsters, preventing full lid closure. The surrounding ground surface contained scattered refuse debris, including four plastic gloves. Photographic evidence was obtained. The Certified Dietary Manager and the Maintenance Director acknowledged the findings at the time of the tour. On 2/11/26 at 3:40 PM, the Maintenance Director stated kitchen, housekeeping and maintenance staff disposed of trash in the dumpsters and were responsible for ensuring garbage was contained, debris was not left on the ground, and lids were kept closed, to prevent vermin. He stated he did not know where the discarded gloves originated. He further stated he was not present on weekends, and garbage was not collected on Sundays.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and maintained in a safe and sanitary manner to prevent the potential for foodborne illness in the main kitchen and 1 of 2 nourishment rooms. Findings: During the initial tour of the facility kitchen on 2/09/26 at 10:11 AM, the following concerns were observed: *Multiple lids were stored on a rolling storage rack with visible food debris and residue present on the shelving surfaces and rack bars. The rack was soiled, with dried food particles noted on the horizontal supports. *The kitchen ceiling above the dishwashing area revealed multiple ceiling tiles with visible dark spots, stains, and discoloration. *Multiple baking pans contained dried food residue. Photographic evidence was obtained. The Certified Dietary Manager (CDM) validated the above findings and did not provide an explanation for why the items were in this condition. On 2/10/26 at 9:52 AM, the Regional Dietary Consultant stated the kitchen and baking pans were cleaned the previous night. Observation of approximately 20 baking pan trays revealed continued staining and residue. He acknowledged the baking pans needed to be replaced. 2. On 2/11/26 at 4:46 PM, a tour of the nourishment room in the Residential Care Unit (RCU) was conducted with Certified Nursing Assistant (CNA) I. The following concerns were observed: *A sandwich wrapped in aluminum foil was observed in the refrigerator door and was not labeled with a resident name, room number, or date. *A bag of lemon sugar cookies was observed in the refrigerator door with no name, room number, or date indicated. *A Styrofoam cup containing ice was observed in the refrigerator door and was not labeled with a resident name, room number, or date. CNA I discarded the cup and stated it was likely from a resident who liked to save cups of ice. *A Styrofoam cup containing liquid was stored inside the top rack of the refrigerator. The cup was labeled with a staff member's name and the letters CNA. CNA I stated the staff member worked the 7:00 AM to 3:00 PM shift and was not present at that time. She indicated staff were instructed to store food and beverages in the staff break room refrigerator and not in the nourishment room refrigerator. CNA I discarded the cup at that time CNA I stated resident food items were required to include the resident's name or room number and the date received. She indicated items were kept for up to three days and discarded after that time. On 2/11/26 at 4:59 PM, the RCU Unit Manager (UM) confirmed the nourishment room refrigerator was designated for resident food items only. She indicated resident items must include a name or room number and the date, and items were discarded after 72 hours. The UM acknowledged the unlabeled items should be discarded because their ownership and date could not be verified. On 2/12/26 at 11:34 AM, the Administrator stated staff beverages should not be stored in the nourishment room refrigerator and resident food items must be labeled with a name or room number and date. Review of the facility's policy and procedure titled Food Brought in From the Outside, issued on 4/01/22, revealed the facility intended to provide safe and sanitary storage and handling of all food and beverages brought into the facility. The policy stated nursing staff were to label containers with the food item name and date received.

Based on observation, interview, and record review, the facility failed to provide written notice, including the reason for the change, prior to changing the resident's room for 3 of 5 residents reviewed for choices, of a total sample of 42 residents, (#2, #6, and #79).Findings: 1. Review of the medical record revealed resident #2, a [AGE] year-old female was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included chronic pain syndrome, muscle spasm, right side lumbago (low back pain) with sciatica (pain along sciatic nerve), and generalized anxiety disorder. The most recent Comprehensive Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/15/26 indicated resident #2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The Care Plan Report noted on 1/16/25, resident #2 had alteration in mood/psychosocial well-being related to anxiety with an intervention to provide a calm environment. On 2/10/26 at 11:57 AM, resident #2 said she did not like being in a room with her current roommate and stated, it's terrible. Review of resident #2's Electronic Health Record (EHR) showed room changes were made on 11/01/25 and 1/03/26. Resident #2's progress notes did not include any information about informing the resident/representative about the two room changes. On 2/12/26 at 11:19 AM, the Social Services Director said the facility's practice was obtaining resident/representative consent prior to room changes. She checked resident #2's medical record and said she was unable to find any notes or documentation about the resident's consultation or consent for two room changes. She said she was not involved in resident #2's room changes and she was recently made aware of an electronic form available to document proper protocols and consent. She checked the medical record and found a progress note that showed the resident had recently requested a transfer to another facility and conveyed it was possible she wanted to transfer because she was unhappy with her room assignment. 2. Review of resident #79's medical record revealed he was admitted to the facility on [DATE] with diagnoses including pericardial effusion (fluid around the heart), chronic obstructive pulmonary disease, and congestive heart failure. Review of the MDS admission assessment with ARD of 1/15/26 revealed resident #79 had a BIMS score of 15 out of 15 which indicated he was cognitively intact. The MDS assessment indicated it was very important to him to have his family or a close friend involved in discussions about his care. Review of residents #79's medical record revealed no documentation that written notice, including the reason for the change, was provided to the resident or his representative regarding a room change. Review of a Plan of Care Note dated 2/03/26 revealed the interdisciplinary team (IDT) met for a Care Plan Review Meeting on that date, which was attended by resident #79 and his sister. The note indicated the resident's plan of care was reviewed and discussed during the meeting, including ongoing discharge plans. On 2/09/26 at 12:15 PM, resident #79 stated he was told earlier that day he was being moved to another room, but he was not told the reason. He indicated he would like to remain in his current room. He indicated his sister was his Power of Attorney (POA) and stated he did not receive written notification of the change. On 2/12/26 at 9:58 AM, during a telephone interview, resident #79's POA stated she learned about the room change when resident #79 called her while she was on her way to the facility. She stated no one from the facility notified her of the change prior to it occurring. On 2/11/26 at 3:02 PM, Certified Nursing Assistant L stated the Unit Manager (UM) informed staff about the room changes, but he did not know who informed the residents. 3. Review of resident #6's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute embolism and thrombosis of the left calf muscular vein, difficulty walking, muscle weakness, and major depressive disorder. Review of the MDS admission assessment with ARD of 12/16/25 revealed resident #6 had a BIMS score of 12 out of 15 which indicated she had moderate cognitive impairment. A subsequent BIMS evaluation completed on 1/08/26 revealed a score of 15 out of 15, indicating intact cognition. Review of residents #6's medical record revealed no documentation that written notice, including the reason for the change, was provided to the resident or her representative prior to the room change. On 2/09/26 at 3:50 PM, resident #6 stated she was informed of the move while she was outside in the courtyard and when she returned inside, her belongings had already been moved. She indicated she did not understand why she was moved and was told the room was needed for two male admissions. She stated she was upset about the situation. On 2/11/26 at 5:28 PM, the Social Services Director stated residents did not sign documentation for room changes, and discussions should be documented in the medical record. On 2/12/26 at 11:22 AM, the Administrator stated it had not been the practice of the facility to provide residents with a form to sign for room changes and there was no formal written notification process. He stated room changes were typically handled verbally. On 2/12/26 at 1:34 PM, the Transitional Care UM stated she could not identify who informed resident #6 of the room change. Review of the facility's policy and procedure titled Room Changes, issued on 4/01/22, read, The resident has a right to receive written notice, including reason for the change, before the resident's room or roommate in the facility is changed. The policy further stated when a resident is being moved at the request of facility staff, the resident and/or resident representative must receive an explanation in writing of why the move is required.

Based on observation, interview, and record review, the facility failed to maintain complete and accurately documented clinical records for medication administration, in accordance with accepted professional standards and practices, for 1 of 7 residents observed for medication administration, of a total sample of 42 residents, (#33).Findings:Resident #33 was admitted on [DATE] with diagnoses that included cellulitis of the left lower limb, respiratory failure, peripheral vascular disease and rash. Review of the admission Minimum Data Set assessment with reference date 11/30/25 revealed resident #33's cognition was intact with a brief interview of mental status score of 15 out of 15. Review of resident #33's plan of care showed the resident had the following skin impairments: rash in right lower quadrant of the abdominal folds, scalp seborrheic dermatitis, right dorsal hand wound and stasis dermatitis on bilateral lower legs. Interventions included instruction for nurses to perform wound care treatments as ordered. Physician's orders included Urea External Cream 40% (Urea), applied to bilateral lower legs topically every day shift for stasis dermatitis) for six months, Hibiclens External Solution 4% (Chlorhexidine Gluconate) applied to lower legs topically every day for stasis dermatitis and Ketoconazole External Shampoo 2% (Ketoconazole (Topical)) applied to scalp topically every day shift for seborrheic dermatitis. On 2/10/25 at between 9:00 AM and 9:30 AM, Licensed Practical Nurse (LPN) C, was observed during medication administration for resident #33. LPN C administered five oral medications. A short time later, during medication reconciliation, a review of the Medication Administration Record (MAR), revealed the resident received Hibiclens External solution, Ketoconazole External Shampoo and Urea external cream in addition to the five oral medications observed. A further review of the medication administration audit report showed LPN C administered Hibiclens External Solution at 8:57 AM, ketoconazole external shampoo at 9:16 AM, and Urea External cream at 9:16 AM. On 2/10/26 at 1:24 PM, resident #33 was sitting up in his wheelchair and said no creams or other topical medicine were applied to his legs today nor did he receive the shampoo to his scalp. The resident explained sometimes he got the creams in the afternoon but said he didn't ask for the medications when he did not get them. On 2/10/26 at 1:33 AM, LPN C explained he documented after providing treatment or after giving medication and not before. LPN C acknowledged he documented the medications were given before they were actually administered to the resident. He confirmed he should have documented after the treatment was applied not prior but could not say why he did. At that time, the Director of Nursing (DON) who was standing next to LPN C at the nurse's station, was told that resident #81's topical medications were documented as performed when they had not actually been given. The DON acknowledged the MAR was inaccurate because it showed the treatment was applied, when it was not. She stated her expectation was for nurses to document immediately after medications were administered or treatment were applied, not beforehand. The facility's policy on Medication Administration dated 4/01/22 indicated medications were administered in a timely manner and as prescribed by the physician unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. In section 12, the policy described, Should a drug be withheld, refused or given other than the scheduled time, the individual administering the medication will document this in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure hearing aid assistance was provided for 1 of 2 residents reviewed for Communication/Sensory, of a total sample of 42 residents, (#81).Findings: Review of the medical record revealed resident #81, a [AGE] year-old female was admitted to the facility from an acute care hospital on 6/04/23 with diagnoses that included adjustment disorder with mixed anxiety and depressed mood, dementia, recurrent major depressive disorder, retinopathy (damage to retina of the eyes), and generalized muscle weakness. Review of the most recent Comprehensive Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/30/25 documented the Preferences for Routine & Activities interview completed with the resident/family member indicated it was very important to resident #81 to listen to music she liked, keep up with the news, do things with groups of people, do favorite activities, and participate in religious services. The most recent Quarterly MDS assessment with an ARD of 12/31/25 noted during the look-back period, the resident scored 8 out of 15 on the Brief Interview for Mental Status that indicated she was moderately cognitively impaired and wore a hearing aid that provided adequate hearing ability if normally used. Review of the Care Plan Report included a care plan dated 1/13/25, for self-care deficits with dressing, grooming, dementia, generalized weakness, and cognitive deficits that noted the resident participated with cues from staff with interventions to assist the resident. The care plan noted (10/21/25) resident #81 was often observed in the hallway people watching and socializing with peers; enjoys group programs and had potential for alteration in communication; hearing was adequate with bilateral hearing aids with interventions (10/21/25). Resident #81 had a care plan focus for hearing aids to bilateral ears. Interventions included, in AM assist resident to put her hearing aids in; evening assist resident to remove hearing aids daily, and on 7/22/25 an intervention that read, hearing aids to both ears, change battery every 10 days. On 2/09/26 at 12:14 PM, resident #81 was observed sitting in a wheelchair eating lunch with her daughter in the nursing unit's common area. The resident was not wearing hearing aids and was unable to hear without speaking within a few inches of her ear. The resident's daughter explained that her mother was very hard of hearing and had been fitted for hearing aids however, even though she had complained to management that staff were not assisting with putting the hearing aids in, they never followed up and staff were still not putting them in. She said her mother enjoyed activities like socializing and stated, if she wore them, they would improve her quality of life; more people would talk to her. Review of a Plan of Care Progress Note on 1/21/26 noted resident #81's daughter participated with her in a Care Plan review meeting. It was noted that the resident enjoyed interactions with staff and other residents. The note indicated hearing services were discussed. The Grievance/Complaint Log showed on 1/21/26, a complaint was reported by resident #81's daughter concerning hearing aid placement. On 2/11/26 at 11:08 AM, resident #81 was observed near the nurse's station when she propelled herself from the activities room towards her room. Her hearing aids were not on. On 2/11/26 at 11:26 AM, Certified Nursing Assistant (CNA) A said she was aware resident #81 needed assistance to wear her hearing aids. She said she checked them the same day and there was no sound. She explained she informed the nurse the previous day and the hearing aid specialist checked them once a month. On 2/11/26 at 10:56 AM, Licensed Practical Nurse (LPN) B said she was familiar with resident #81 who was frequently included in her assignments. The nurse explained that CNAs were responsible for assisting residents to put hearing aids in, they were kept in the resident rooms, and the task was included in their documentation. The LPN stated she was unaware of any issues about resident #81's hearing aids malfunctioning. Review of the Audiologist's (hearing specialist) Chart Note on 12/09/25 indicated upon examination, the resident was not wearing her hearing aids, and her ear canals were clear. The note mentioned the nurse was reminded to assist the resident to place her hearing aids on in the morning, and remove them at night and read, The request for assistance was reinforced. No batteries were left since the resident already had some. The Audiologist's Chart Note dated 1/22/26 noted resident #81 was checked and found with good device functioning and sound quality with new replacement batteries also provided. The note indicated the resident frequently reported that no one helped her place the hearing aids, which the Audiologist reported to the Social Services Director. On 2/12/26 at 10:40 AM, the Social Services Director checked the grievance records and said on 1/21/26, resident #81's daughter submitted a complaint that staff were not assisting the resident to put her hearing aids in. She said the record indicated CNAs were provided re-education on 1/27/26 about assisting the resident to put the devices in and ensuring the batteries were charged. Review of the CNA Task records from 1/14/26 to 2/12/26 included, Hearing Aid, offer and assist in morning putting in, and evening taking out. Nineteen of thirty entries were marked No. The entry on 2/12/26, the last day of the survey at 12:01 PM was marked, Yes. On 2/12/26 at 12:00 PM, resident #81 was observed sitting in her wheelchair in the main dining room amongst other residents eating lunch. The resident was not wearing hearing aids and was unable to hear without speaking within a few inches of her ear. On 2/12/26 at 12:30 PM, the Unit Manager said she expected CNAs to assist residents with applying hearing aids and if there was anything missing or problems, they notified the nurse and/or Unit Manager. She explained CNAs documented on the tasks record when it was done or not. She said she was unaware of any issues with resident #81's hearing aids. Review of the facility's undated standards and guidelines titled Nursing Home Resident's Rights in Florida included the right to encouragement and assistance from the facility staff to the fullest possible extent, and the facility must continue to provide services in accordance with the resident's care plan. The Facility assessment dated [DATE] noted the facility provided person-centered/directed care and services for residents with hearing loss.

Based on observation, interview, and record review, the facility failed to ensure prompt resolution of grievances for 1 of 5 residents reviewed for choices, of a total sample of 42 residents, (#94).Findings:Resident #94 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, chronic obstructive coronary disease, unspecified dementia and major depressive disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed resident #94 was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15, meaning he was cognitively intact. The assessment indicated he did not have any behaviors nor refused care. On 2/11/26 at 3:05 PM, resident #94 was up in his wheelchair with his wife at the bedside. He stated this was the first time he had been out of bed in a very long time. He explained the reason he had to get up was to attend the care plan meeting. Both the resident and his wife said they had voiced a lot of issues to the facility, but the concerns did not seem to be addressed. Resident #94's wife said she had even filed a grievance last month but had not heard anything back. She said she often spoke to the resident care unit (RCU) Unit Manager (UM), but felt she often talked around her issues. The wife said she did not think anything had been resolved, I do not remember signing the grievance or having a discussion that there was any resolution to my concerns. Resident #94 stated he wanted to be taken out of bed more often and had been asking for a long while, but staff often reported that he refused whenever his wife would ask. On 2/11/26 at 3:30 PM, Certified Nursing Assistant (CNA) E said she had never assisted resident #94 out of bed nor ever put him back to bed. She heard from other staff that he often refused but recalled she once saw him out of bed for a doctor's appointment. Assigned CNA D said that today was the first time in a long time she saw resident #94 out of bed and had thought he only got out of bed for showers. On 2/11/26 at 3:54 PM, the Social Services Director (SSD) said she was also the Grievance Officer and whenever she received a grievance, based on the issue, it was often forwarded to the department responsible for a resolution. She explained that it usually takes them about two weeks to resolve. The SSD was asked to review the grievance filed on behalf of resident #94 and retrieved it from her binder. She explained it was filed on 1/21/26 by and did not appear to be resolved. She continued to explain that this would have been handled by the RCU UM and the Assistant Director of Nursing (ADON) and they would have information about it. On 2/11/26 at 4:27 PM, the RCU UM said she did not know anything about the grievance filed on behalf of resident #94 and the only reason it might have taken longer than two weeks was because they might not have been able to contact the family. The RCU UM explained that during that time, she was on vacation and the ADON was handling the grievances. On 2/11/26 at 4:47 PM, the ADON provided a copy of the grievance and stated she remembered it was resolved over the phone with resident #94's wife. A review of the actions taken for the resident wanting to be shaved was the task was included it in the CNA Kardex. Their investigation showed that resident #94 refused to get out of bed, and explained they were honoring his right to refuse. There was no mention about the resident wanting a private room nor an explanation given about the roommate having the TV too loud. A review of the grievance form did not indicate if the grievance was resolved. The form did not contain any signatures or dates for when the grievance was resolved. On 2/12/26 at 10:15 AM, the SSD said she could not answer why the grievance had not been resolved since the same issues were brought up in the Care Plan meeting yesterday. She said that nursing was still working on it. The facility's policy on grievances issued 4/01/22 indicated the facility would provide residents, resident representatives, family and visitors with methods of sharing grievances and/or concerns with the facility and the facility would make prompt efforts to resolve grievances. The procedure listed in section 4, The individual filing the grievance has the right to a reasonable expected time frame for completing the review of the grievance, being kept apprised of the progress toward a resolution and a right to obtain a written decision regarding his or her grievance.

Based on interview, and record review, the facility failed to promote resident rights related to the choice of the type of wheelchair used for 1 of 5 residents reviewed for choices, of a total sample of 42 residents, (#104).Findings: Review of resident #104's medical record revealed she was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare, displacement of internal fixation device of vertebrae, hemiplegia and hemiparesis (partial paralysis and weakness) following cerebral infarction affecting her left non-dominant side, and difficulty in walking. Review of the Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 1/27/26 revealed resident #104 had a Brief Interview for Mental Status score of 15 out of 15, indicating she was cognitively intact. The MDS assessment indicated she did not reject evaluation or care needed to achieve her goals for health and well-being. The MDS assessment noted she used a manual wheelchair and was able to independently propel at least 150 feet. Review of resident #104's comprehensive care plan dated 1/27/26 revealed she was there for a short stay and clearly expressed desire to discharge from the facility. She anticipated returning home where she lived alone. Review of a PT (Physical Therapy) Evaluation and Plan of Treatment form dated 1/21/26 revealed that prior to admission resident #104 used a large electric wheelchair primarily for mobility in the home and community; and was independent with transfers. Documentation also indicated she had a smaller foldable electric wheelchair she used for community outings. On 2/09/26 at 1:13 PM, resident #104 stated the facility did not allow her to use her own wheelchair. She shared she was required to use a facility wheelchair. She reported she had used her electric wheelchairs for approximately five years and had traveled with them. She stated the facility did not test her ability to use the wheelchair in manual mode and did not assess her ability to safely operate it. On 2/11/26 at 1:42 PM, Occupational Therapy Assistant (OTA) G stated resident #104 had expressed her desire to use her electric wheelchair in the facility. OTA G indicated electric wheelchairs were not allowed due to safety concerns. On 2/12/26 at 12:20 PM, the Director of Rehabilitation (DOR) stated resident #104 informed therapy of her preference to bring her power chair. The DOR indicated electric wheelchairs were not generally used in the facility due to safety concerns for residents and staff. The DOR stated therapy would not be working with the electric wheelchair during treatments. She further stated she was not aware of a specific motorized wheelchair policy. On 2/12/26 at 12:45 PM, Physical Therapy Assistant F stated staff were aware resident #104 wanted to use her electric wheelchair and that he was told electric wheelchairs were not allowed in the facility. On 2/12/26 at 3:16 PM, the Administrator stated the facility historically did not use motorized wheelchairs; however, near discharge, therapy may request families bring them in for assessment in preparation for return to the community. Review of the medical record revealed no documentation that therapy or nursing assessed resident #104's ability to safely use her motorized wheelchair in the facility. Review of the facility's policy and procedure titled Motorized Wheelchairs revised 4/01/22 revealed an intent to allow and assist residents who can safely and competently utilize motorized wheelchair to do so. The procedure stated therapy and/or nursing would determine the need for a motorized wheelchair based on assessment of the resident's capability and safe operation while in the facility. An addendum to this policy titled Resident Use of Motorized Wheelchairs/Scooters indicated the use of electric wheelchairs and scooters was discouraged in the facility. Review of the facility's policy and procedure titled Resident Rights, Dignity, and Visitation Rights, issued on 4/01/22, stated the facility would ensure residents could exercise their rights without interference and would observe resident's choices whenever able.

Based on interview and record review, the facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for 1 of 5 residents reviewed for medications, out of a total sample of 10 residents, ( #3). Findings: Cross Reference F698 Review of the medical record revealed resident #3 was admitted to the facility on [DATE]. Her diagnoses included aneurysm of artery of upper extremity, end-stage renal disease (ESRD), and rapidly progressive nephritic syndrome with diffuse crescentic glomerulonephritis. According to the National Library of Medicine, Rapidly progressive glomerulonephritis (RPGN) is a clinical syndrome manifested by features of nephritic syndrome and rapid loss of the kidney function over a period of a few weeks to months. (Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC4720204/ on 2/21/25). Review of resident #3's physician orders revealed an order dated 2/04/25 for Sevelamer Carbonate 800 milligrams (mg) 3 tables before meals for hypocalcemia related to ESRD. Sevelamer administration was scheduled for 6:30 AM, 11:30 AM, and 4:30 PM daily. Review of resident #3's MAR showed Sevelamer was administered on 2/05/25 at 6:30 AM, 2/06/25 at 6:30 AM and 4:30 PM, 2/07/25 at 6:30 AM, and 2/10/25 at 6:30 AM, 11:30 AM and 4:30 PM for a total of 7 doses. Review of the Progress Note revealed Sevelamer was not available to resident #3: *2/05/25 at 6:06 PM - on order, awaiting for pharmacy and the physician was aware. *2/06/25 at 12:17 PM - pending pharmacy delivery. *2/07/25 at 5:17 PM read, Medication is not available, Medication has been reordered from pharmacy. Awaiting delivery from pharmacy. MD (physician) notified. * 2/08/25 at 7:47 AM read, Medication is not available. Contacted pharmacy. Awaiting approval. *2/08/25 at 10:40 AM read, Pharmacy states they have to go through dialysis to send pill, awaiting delivery. *2/09/25 at 6:29 AM read, Medication is not available. Contacted pharmacy. Awaiting approval. *2/09/25 at 11:03 AM read, Awaiting pharmacy delivery. *2/10/25 at 8:08 AM read, Waiting arrival from pharmacy. *2/10/25 at 4:41 PM read, Dialysis to give. *2/11/25 at 6:39 AM read, Dialysis to give. *2/11/25 at 12:36 PM read, Awaiting delivery. MD aware. *2/11/25 at 3:40 PM read, Waiting on pharmacy. *2/12/25 at 12:53 PM read, Medication to be administered at dialysis. Review of resident #3's Baseline Care Plan initiated on 2/04/25 read, Resident needs dialysis. Interventions included, Administer any physician ordered medications for renal functioning. Monitor for side effects. Communicate and collaborate with dialysis center regarding weights, medication, diet, and lab results. On 2/12/25 at 1:35 PM, the Transitional Care Unit Manager (UM) stated she called their pharmacy yesterday because dialysis did not have Sevelamer. She shared she called dialysis every single day and informed the physician, but she did not document it in resident #3's medical record. She explained they recently received corporate approval for a 5-day supply of Sevelamer and it was received yesterday morning. Later at 2:18 PM, the UM stated she reviewed the documentation for resident #3 and could not find evidence that Sevelamer was in the facility before this morning. She stated she spoke with the nurses who documented the administration of Sevelamer when the medication was not available, and she said they did not have an answer. She mentioned one of the nurses confirmed he did not give the medication but documented he gave it and could not explain why he did that. Review of the Pharmacy Packing Slip dated 2/11/25 revealed resident #3's Sevelamer was included. The Signature, Date Signed, and Time Signed sections of the form were blank. On 2/12/25 at 2:54 PM, the Director of Nursing (DON) stated she expected the nurses to document accurately in the medical record. She indicated if a medication was not given, the physician needed to be informed, and the communication documented in the medical record. She mentioned she was not sure of the steps the facility's UMs took to communicate with the dialysis centers regarding the unavailability of Sevelamer or if they documented their efforts. She said, We do the best we can, do I document every single conversation I have with a physician or family? I cannot and I do not. She shared she had spoken to 3 physicians today and had not documented any of those conversations. Review of the policy titled Resident Identifiable Information / Medical Records dated 4/01/22 revealed the intent to maintain a medical record for each resident in accordance with federal and state guidelines. The document read, Medical records on each resident will be accurately documented; readily accessible; and systematically organized.

Based on observation, interview, and record review, the facility failed to adhere to proper hand hygiene and use of personal protective equipment (PPE) practices per infection control standards when handling soiled linens in 1 of 2 units. Findings: On 2/12/25 at 10:43 AM, Certified Nursing Assistant (CNA) C was observed leaving room [ROOM NUMBER] with a bag of dirty linens in a plastic bag and wearing a glove on her right hand. While holding the bag and wearing the glove, CNA C entered room [ROOM NUMBER], asked the resident if everything was okay, removed the glove in her right hand and kept it in her hand, then grabbed a couple of hospital gowns that were lying on a chair in room [ROOM NUMBER] with her other hand. CNA C left room [ROOM NUMBER] and re-entered room [ROOM NUMBER], placed the bag on the floor, touched the bed sheet and left the room without performing hand hygiene. On 2/12/25 at 1:45 PM, CNA C acknowledged she left room [ROOM NUMBER] with soiled linens in a plastic bag while wearing a glove on her right hand when she entered room [ROOM NUMBER]. She stated she was taking trash, gowns and things patients no longer needed to the soiled utility room. She indicated she was assigned 12 residents who had to be ready for therapy and appointments and she was only one and did not always have time to go around for all the tasks she was assigned to do. She said, The correct way, politically, I was supposed to dispose the bag in the soiled utility room. She stated she was just trying to do so many things at one time. I do the best I can. She validated bringing a bag of soiled linens from one room to another was an issue. She indicated she was not supposed to have gloves on in the hallway because of infection control. She added when she removed gloves, she was supposed to wash her hands and confirmed she did not perform hand hygiene. She confirmed she grabbed the hospital gowns on the chair and removed them from the room without placing them in a plastic bag. She stated she left them in the soiled utility room. She asked, What do I do if I am carrying soiled items and a call light is on or a resident fell , what am I supposed to do? She then stated she was supposed to take it to the soiled utility room when done with patient care. She indicated she received Infection Control training during her orientation in September 2024. Review of a Certificate of Completion for Infection Control: Comprehensive Review dated 1/03/25 revealed satisfactory completion by CNA C. Review of Certificates of Completion for Donning and Doffing PPE and Principles of Infection Control and Asepsis revealed satisfactory completion by CNA C on 9/03/24. On 2/12/25 at 3:11 PM, the Direct of Nursing (DON) stated staff could not bring soiled linens into another resident's room or wear gloves in the hall. She stated CNA C was not following their policy. Review of the facility's policy titled Standard Precautions for Infection Control dated 4/01/22 read, It will be the policy of this facility to assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. The document revealed hand hygiene was considered the primary means of preventing the transmission of infection. The policy instructed staff to remove and discard PPE before leaving the resident's room.

Based on interview, and record review, the facility failed to provide care and services to promote healing of a sacral pressure ulcer (PU) as ordered by the physician for 1 of 1 residents reviewed for pressure ulcers, of a total sample of 10 residents, (#9). Findings: Review of the medical record revealed resident #9 was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, type 2 diabetes, heart disease and glaucoma. Review of the Admission Summary Progress Notes dated 1/29/25 revealed resident #9 required assistance with activities of daily living including bed mobility, transfers, ambulation, dressing, bathing, and toileting. Review of resident #9's Admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 2/05/25 revealed she had a Brief Interview for Mental Status score of 12 out of 15 which indicated moderate cognition impairment. The MDS assessment noted no rejection of care necessary to obtain goals for her health and well-being. The MDS assessment showed resident #9 was identified at risk of developing PU/injuries, she had a stage 3 PU and a surgical wound. The National Pressure Injury Advisory Panel defines a pressure injury or decubitus ulcer as localized damage to the skin and underlying soft tissue usually over a bony prominence.The injury can present as intact skin or an open ulcer and may be painful (retrieved on 2/21/25 from www.npiap.com). Review of resident #9's medical record revealed a PRN (as needed) Skin Check form dated 2/01/25. The form read, New skin impairment(s) that have not been previously noted - yes. Open area. Treatment in place. Wound dr. (physician) to evaluate. Review of resident #9's medical record revealed a Change in Condition Evaluation dated 2/02/25 read, Resident stated her bottom was hurting. Assessed the area and noted an open wound between the cheeks of her buttocks. The document indicated the physician was notified, and treatment orders and a consultation to the wound care physician were obtained. Review of resident #9's physician orders revealed an order dated 2/02/25 to cleanse the sacrum with normal saline, apply calcium alginate, and cover with bordered gauze dressing daily and as needed if the dressing was soiled or dislodged. Review of resident #9's Treatment Administration Record (TAR) and Progress Notes for February 2025 revealed wound care was not performed on 2/04/25 and 2/09/25. Review of resident #9's medical record revealed a care plan for skin impairment of a surgical wound to the right knee and PU to coccyx initiated on 2/10/25. The goal was the resident would demonstrate healing without complications. The interventions included, Perform wound treatments as ordered. Review of an Initial Wound Evaluation & Management Summary form dated 2/05/25 by the Wound Care Physician revealed a stage 3 pressure wound coccyx full thickness which measured 2.0 x 2.2 x 0.3 centimeters with moderate serous exudate, 75% granulation tissue, and 25% subcutaneous tissue. The dressing treatment plan was to apply alginate calcium, a gauze island with border and skin prep on the peri wound daily. The physician's recommendations included a Multivitamin daily, Vitamin C 500 milligrams (mg) twice daily and Zinc Sulphate 220 mg daily for 14 Days. Review of resident #9's physician orders did not include a Multivitamin daily, Vitamin C 500 milligrams (mg) twice daily or Zinc Sulphate 220 mg daily for 14 Days. On 2/12/25 at 11:55 AM, Licensed Practical Nurse (LPN) A stated he, along with another nurse, performed wound care to residents with wounds in the facility 7 days a week. He indicated the other wound care nurse rounded most often with the wound care physician but whenever he did it, he removed the dressing and cleaned the resident's wound, and redressed the wound after the wound care physician was done. He indicated he asked the wound care physician if there were any new orders when he finished with each resident. He explained after the wound care physician left the facility, they received their progress notes, usually within 3 to 4 hours, on the same day. He indicated if he felt he was lacking information, he referred to the progress note but not often. LPN A reviewed the Initial Wound Evaluation & Management Summary form dated 2/05/25 and validated the Multivitamin, Vitamin C and the Zinc Sulphate were not added to resident #9's orders. He mentioned if the wound care physician did not mention any new orders, he did not check the notes, so that is on me, but I will be doing it going on apparently. He explained he documented whenever he performed wound care. He stated he did not work on 2/04/25 or 2/09/25 and could not explain why wound care was not done those days. On 2/12/25 at 12:57 PM, the Director of Nursing (DON) explained the facility had 2 nurses who performed wound care regularly, but they had a back up if those nurses were out. She indicated her expectation for the wound care nurses was to perform wound care to any pressure wounds or surgical incisions and document it. She shared there was someone assigned to perform wound care 7 days a week. She expected the nurse performing wound care to either enter a progress note or sign off the TAR when wound care was done. She stated the wound physician should give new orders at time of rounding. She indicated the wound care nurse should review the note from the wound physician when received and update the wound log each Friday. She stated she expected the nurse who updated the log to follow up on the physician's recommendations. She indicated if a recommendation was discovered during review of the note, the primary physician would be contacted. The DON explained if the primary physician agreed with the recommendations, the wound care nurse would enter the orders. The DON stated it did not appear the wound care nurse followed through with the wound care physician's recommendations for resident #9. When asked why wound care was not performed on 2/04/25 and 2/09/25 for resident #9, the DON response was she knew who the nurse was those days, and that nurse always documented. She validated she did not see a progress note and the TAR was blank on 2/04/25 or 2/09/25. Review of the facility's policy and procedure titled Wound Care dated 4/01/2022 read, Wound care procedures and treatments should be performed according to the physician orders. The policy included to document in the clinical record when treatment was performed.

Based on interview and record review, the facility failed to maintain effective communication between nursing staff and medical providers and failed to collaborate with a dialysis center to promote adequate treatment, monitoring, and continuity of care for 2 of 4 residents reviewed for dialysis care and services, out of a total sample of 10 residents, (#3 and #4). Findings: Cross Reference F842 1. Review of the medical record revealed resident #3 was admitted to the facility on [DATE]. Her diagnoses included aneurysm of artery of upper extremity, end-stage renal disease (ESRD), and rapidly progressive nephritic syndrome with diffuse crescentic glomerulonephritis. According to the National Library of Medicine, Rapidly progressive glomerulonephritis (RPGN) is a clinical syndrome manifested by features of nephritic syndrome and rapid loss of the kidney function over a period of a few weeks to months. (Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC4720204/ on 2/21/25). Review of resident #3's physician orders revealed an order dated 2/04/25 for Sevelamer Carbonate 800 milligrams (mg) 3 tables before meals for hypocalcemia related to ESRD. Sevelamer administration was scheduled for 6:30 AM, 11:30 AM, and 4:30 PM daily. Review of resident #3's Medication Administration Record (MAR) showed Sevelamer was administered on 2/05/25 at 6:30 AM, 2/06/25 at 6:30 AM and 4:30 PM, 2/07/25 at 6:30 AM, and 2/10/25 at 6:30 AM, 11:30 AM and 4:30 PM for a total of 7 doses. Review of the Progress Note revealed Sevelamer was not available to resident #3 from 2/4/25 to 2/12/25: *2/05/25 at 6:06 PM - on order, awaiting for pharmacy, physician aware *2/06/25 at 12:17 PM - pending pharmacy delivery *2/07/25 at 5:17 PM read, Medication is not available, Medication has been reordered from pharmacy. Awaiting delivery from pharmacy. MD (physician) notified. * 2/08/25 at 7:47 AM read, Medication is not available. Contacted pharmacy. Awaiting approval. *2/08/25 at 10:40 AM read, Pharmacy states they have to go through dialysis to send pill, awaiting delivery. *2/09/25 at 6:29 AM read, Medication is not available. Contacted pharmacy. Awaiting approval. *2/09/25 at 11:03 AM read, Awaiting pharmacy delivery. *2/10/25 at 8:08 AM read, Waiting arrival from pharmacy. *2/10/25 at 4:41 PM read, Dialysis to give. *2/11/25 at 6:39 AM read, Dialysis to give. *2/11/25 at 12:36 PM read, Awaiting delivery. MD aware. *2/11/25 at 3:40 PM read, Waiting on pharmacy. *2/12/25 at 12:53 PM read, Medication to be administered at dialysis. A Progress Provider Note entered by the Physician Assistant on 2/06/25 revealed there were no concerns shared by the nursing staff. Review of resident #3's Baseline Care Plan initiated on 2/04/25 read, Resident needs dialysis. Interventions included, Administer any physician ordered medications for renal functioning. Monitor for side effects. Communicate and collaborate with dialysis center regarding weights, medication, diet, and lab results. On 2/12/25 at 1:30 PM, the Director of Nursing (DON) stated a new regulation from Centers for Medicare and Medicaid Services as of January 1st, 2025, specified dialysis centers were responsible for providing the phosphate binders which included Sevelamer. She explained they requested a 5-day supply of Sevelamer from their pharmacy for resident #3. The DON shared she expected dialysis to provide Sevelamer within 24 hours, but this was a brand-new rule, and everyone was struggling with it. She stated the Transitional Care Unit Manager (UM) placed multiple phone calls yesterday with dialysis. On 2/12/25 at 1:35 PM, the UM stated she called their pharmacy yesterday because dialysis did not have Sevelamer. She explained she had called dialysis every single day and informed the physician, but she did not document it in resident #3's medical record. She explained they recently received corporate approval for a 5-day supply of Sevelamer and it was received yesterday morning. She did not recall if she mentioned to dialysis that resident #3 had not had one dose of Sevelamer since admission. At 2:18 PM, the UM stated she reviewed the documentation for resident #3 and could not find evidence that Sevelamer was here before this morning. She stated she spoke with the nurses who documented administration of Sevelamer when the medication was not available and she said they did not have an answer. She mentioned one of the nurses confirmed he did not give the medication but documented he gave it and could not explain why he did that. Review of the Pharmacy Packing Slip dated 2/11/25 revealed resident #3's Sevelamer was included. The Signature, Date Signed, and Time Signed sections of the form were blank. 2. Review of the medical record revealed resident #4 was admitted to the facility on [DATE]. His diagnoses included alcohol abuse with intoxication, acute kidney failure, and coronary artery disease. Review of a Provider Progress Note dated 2/11/25 revealed a diagnosis of acute kidney injury on hemodialysis. According to the National Kidney Foundation, Dialysis is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to. By performing some of the kidney's usual duties, dialysis helps to maintain safe levels of minerals in your blood, such as potassium, sodium, calcium, and bicarbonate. The organization's website indicated it was important to complete dialysis treatments according to the prescribed schedule and inform the dialysis provider about medications and supplements taken. (Retrieved on 2/21/25 from https://www.kidney.org/atoz/content/dialysisinfo). Review of resident #4's Baseline Care Plan initiated on 2/04/25 read, Resident needs dialysis. Interventions included, Communicate and collaborate with dialysis center regarding weights, medication, diet, and lab results. Resident goes out to dialysis. Check with nurse for the schedule and assist the resident to be ready to go on time. A bag of lunch may be needed, help ensure the resident has it with them. Review of resident #4's physician orders revealed an order dated 2/07/25 which indicated dialysis center on Tuesday, Thursday and Saturday, with chair time at 7:30 AM and pick up at 6:15 AM. On 2/12/25 at 10:31 AM, resident #4 explained he received dialysis 3 times per week. He indicated this was temporary and yesterday was his 4th time. A binder was noted at his bedside table and the cover had the name of the dialysis center where he received his treatments. Resident #4 said he brought the binder from his treatment yesterday and it was left in his room. Review of the binder revealed 2 Dialysis Transfer Forms dated 2/08/25 and 2/11/25. The top and middle sections were completed, but the bottom, Post-Dialysis Treatment section, was blank on both forms. Resident #4 shared he did not get a snack nor breakfast yesterday when he left for dialysis, but he ate lunch upon his return to the facility. Review of the Dialysis Transfer Form, given to residents who went to dialysis on each visit, revealed the document included 3 sections. The top and bottom sections were to be completed by the facility's nurses and the middle section by the dialysis nurse. Resident #4's form dated 2/08/25 included a message from dialysis that read, Please place hoyer pad under patient for transfer. The dialysis nurse also wrote resident #4 was late for treatment and received an abbreviated treatment. There was no evidence in resident #4's medical record the note was clarified or addressed by the facility. On 2/12/25 at 10:50 AM, Licensed Practical Nurse (LPN) B stated resident #4's dialysis treatment was in the early morning. She explained they gave him a binder with the transfer form and lunch to take with him. She recalled resident #4 left for dialysis yesterday at approximately 7:30 AM and he was by the nurses station when she started her shift at 7:00 AM. She mentioned when he returned from dialysis before the end of her shift, she took his vital signs, and he ate lunch. She stated she reviewed the binder from dialysis and completed the section at the bottom. She indicated she documented the vital signs on the form also, as she did not enter a note in the Electronic Medical Record (EMR). She stated they kept the binder by the nurses station, not in the resident's room. At 10:56 AM, the nurse walked into resident #4's room and the UM was in the room holding the binder in her hands. On 2/12/25 at 11:00 AM, the UM explained any information they would like to communicate to dialysis was included in the dialysis binder. She stated when a resident returned from dialysis, transportation staff took the resident to his room, and they were expected to hand the binder to the nurse. She indicated the binder was not left in the resident's room. She shared she expected the nurse to take the vital signs, observe the dialysis port site, and document it on the transfer form. She indicated she was not sure if the assessment was also documented in the EMR or not. The UM looked in resident #4's EMR and stated there was documentation of the vital signs for Saturday 2/08/25 at 2:23 PM but not for yesterday. She indicated she did not see a progress note entered for 2/08/25 or 2/11/25 after the resident returned from dialysis. She validated the forms dated 2/08/25 and 2/11/25 in resident #4's binder were not completed after he returned to the facility from dialysis. She mentioned at times binders were left at the dialysis center and she was looking for resident #4's binder this morning but could not locate it. She said she was not aware resident #4 did not get breakfast or snacks before going to dialysis but she was aware of an issue with transportation yesterday. She indicated she had not seen the note added by the dialysis nurse on 2/08/25. She noted the expectation was for the nurses to review the transfer form and address any questions or concerns by the dialysis team. On 2/12/25 at 12:31 PM, the Director of Nursing (DON) stated their practice was to chart when there is something to chart about. She indicated an assessment was done by the nurse upon the resident's return from dialysis based on the documentation on the Treatment Administration Record (TAR). She explained the TAR showed a check mark when the nurses assessed the resident's dialysis catheter every shift. She stated the Dialysis Transfer Form was a tool to communicate with the dialysis center and nurses were expected to review it when residents returned from dialysis. Review of the agreement between the dialysis center for resident #3 and the facility dated 6/19/24 read, Emergency and non-emergency changes in a resident's medical condition will be immediately communicated by the party having primary knowledge of the change to the other party. Center will communicate with Nursing Facility via Dialysis Communication Form, including when a resident refuses scheduled medical management or non-compliance with medical management relating to dialysis treatment (i.e. diet, fluid restriction and medications). Center will also provide Nursing Facility with a Patient Plan and Progress Report for each resident served.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents reviewed for Care Planning were offered participation in plans or revisions to their care, of a total sample of 40 residents, (#65). Findings: Review of the medical record revealed resident #65, a [AGE] year old female was admitted to the facility on [DATE], and readmitted from an acute care hospital on 5/26/24 with diagnoses of malnutrition, type 2 diabetes mellitus, adjustment disorder with anxiety and depressed mood, gastrostomy (feeding tube) status, and acute duodenal (intestine) ulcer with perforation. The most recent Minimum Data Set (MDS) Admission 5-day Assessment with an Assessment Reference Date (ARD) of 6/02/24 noted during the look back periods, the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated her cognition was moderately impaired. There were no signs and symptoms of delirium or rejection of care necessary to achieve health and well-being goals. The resident scored 13 out of 27 on the PHQ-2 to 9(C) (Resident Mood Interview) that indicated moderate depression, and she felt down, depressed, or hopeless nearly every day. The assessment showed the resident's customary routines and activities preferences were very important to her, and she required a feeding tube to sustain nutrition and hydration. The Order Summary Report included active physician's orders for nothing by mouth (NPO) diet, regular diet, regular texture, thin consistency, meat cut into bite size, sandwiches with lunch/dinner, no straw, and J (small intestine) tube/surgical site care. On 8/12/24 at 10:53 AM, resident #65 was observed sitting in a wheelchair in her room while her family representative visited. The resident was visibly upset when she said although she had asked staff on multiple occasions, they hadn't kept her updated about having her feeding tube removed. She stated, Maybe it's going to happen on Wednesday. Review of the Comprehensive Care Plan included focuses, goals, and interventions that included nutrition and hydration with a mechanically altered diet and tube feeding. The care plan showed resident #65 was at the facility for short term placement, and the resident/representative clearly expressed a desire to discharge from the facility. It was noted the resident had an alteration in mood as evidenced by adjustment disorder with mixed anxiety and read, endorses depressed mood. During an interview on 8/12/24 at 10:54 AM, the resident's representative conveyed the resident had been anxiously awaiting having the feeding tube removed as she had greatly improved and was eating regular food again. She stated, We need to know when it's happening. Review of the Care Plan Calendar Schedule provided by the MDS Coordinator documented a Care Plan Meeting had been scheduled for the resident on 5/21/24 and noted the resident had been discharged on [DATE]. On 8/15/24 at 10:59 AM, the MDS Coordinator checked the care plan meeting schedule and explained that resident #65 had been scheduled for a care plan meeting on 5/21/24 however, she was discharged to the hospital before the meeting was held. She said when the resident returned on 5/26/24, a meeting to include the resident and/or her representative wasn't rescheduled and she stated, She should have been put back on the schedule and she was missed; we just missed it. On 8/15/24 at 2:38 PM, the Director of Nursing (DON) explained the MDS department was responsible for scheduling regular care plan meetings. She said it was important to include the resident and representative so the facility could ensure their needs were met and they understood their plan of care and discharge plans. The DON stated, It's an opportunity for us to all meet together so they understand what's going on; it can cause depression and anxiety and it's important for everybody to feel like they're heard, and things change; it's an opportunity for those to be shared. Review of the facility's standards and guidelines titled Comprehensive Assessments and Care Plans dated 4/01/22 read, . the plan of care should be created in consultation with the resident and the resident's representative (s)- (i) The resident's goals for admission and desired outcomes. (ii) The resident's preference and potential future discharge. (iii) . The facility shall maintain the right to participate in the development and implementation of his or her person-centered plan of care.

Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff maintained a secure environment and implemented measures to mitigate the risks to prevent elopement for 1 of 9 residents reviewed for elopement, of a total sample of 10 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, impairment, and/or death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, accosted by a stranger, or been hit by a vehicle. The facility neglected to identify the need for adequate supervision and ensure a secure environment that contributed to resident #1's elopement and placed all residents at risk for elopement at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE] after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies were decreased to a D, no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy. There were a total of 9 current residents at risk for wandering/elopement identified at the time of the survey. Findings: Cross reference F689 On [DATE] at approximately 6:05 PM, the facility's Weekend Supervisor unlocked the door for a visitor to leave and neglected to ensure no residents followed behind the visitor. Resident #1, a vulnerable, severely cognitively impaired male followed the visitor and exited the facility unnoticed and unsupervised. Resident #1 was allowed to exit the building and walked outside on the hot, 90 degree Fahrenheit evening for approximately 30 minutes (retrieved on [DATE] from www.wunderground.com). He traveled approximately 1.1 miles away from the facility until an off-duty staff nurse noticed him and stopped to call the facility to inquire about him being missing. Resident #1 was admitted to the facility on [DATE], with diagnoses to include right femur fracture, difficulty walking, dementia, anxiety, major depressive disorder, and psychotic disorder with delusions. The Minimum Data Set (MDS) Admission assessment with reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated he had severe cognitive impairment. The assessment revealed he received antipsychotics, antianxiety, antidepressant, and antibiotic medications, but did not show any documentation of behaviors towards others or rejection of care. Review of the medical record revealed resident #1 had a physician's order for an electronic wander monitoring bracelet to be applied beginning [DATE]. Review of resident #1's medical record revealed he had a care plan for potential for elopement related to his behaviors such as wanders, ambulatory, has confusion, and exit seeking initiated on [DATE]. The goal described the resident would remain safe and would refrain from leaving the facility unsupervised was initiated on [DATE] and revised on [DATE]. Interventions included enhanced supervision, initiated on [DATE], provide redirection when observed going towards exit doors, initiated on [DATE]. A revision was added to the care plan on [DATE] which indicated resident #1 had eloped from building. On [DATE] at 11:48 AM, the Weekend Supervisor stated the receptionist was on duty until 5:00 PM on the weekends and after hours any staff could let visitors in or out. She said she was the on-duty supervisor the day resident #1 eloped. The Weekend Supervisor stated she was sitting at receptionist desk charting assessments sometime after 5:00 PM on Saturday, [DATE] when a visitor approached the door to leave the facility. The Weekend Supervisor said she unlocked the door with a remote electronic key fob from where she was sitting, the visitor then pushed the door open and walked out. The Weekend Supervisor stated she did not see resident #1 behind the visitor nor see him exit out the door. The Weekend Supervisor explained no one realized resident #1 was missing from the facility until about 30 minutes later when she received a phone call from an off-duty nurse at 6:35 PM, who asked if he was a resident at the facility. On [DATE] at 1:05 PM, the Administrator shared a video on his cell phone he made of the incident from the facility's video system when he arrived to the facility the evening of [DATE]. The video from the same date, [DATE], showed the visitor pause at the door, while the Weekend Supervisor unlocked the door with the remote key at 6:05 PM, the visitor then pushed the door handle and opened the door. The Weekend Supervisor was seen lowering her head back to look at her computer and resident #1 came a few seconds later behind the visitor and exited out the door. The video showed him returning to the facility at 6:49 PM. On [DATE] at 2:26 PM, Licensed Practical Nurse (LPN) G said she worked the day shift at the facility on [DATE]. She explained that evening she went to the store with her husband and as they were leaving the parking lot, she noticed an older gentleman walking down the street because he kept looking toward the back of him as if he was looking for a ride from someone. He was walking east on the opposite side of the highway from her. LPN G recalled she asked her husband to make a U-turn because it looked like the man had an electronic wander monitoring bracelet on. LPN G explained that they caught up with the man in front of a jewelry store. She said they pulled over on the side of the road, then she got out of the car and asked the man if he needed a ride. He said yes and she asked where he was going? He replied he was going to the [military] base. LPN G recounted the man was not familiar to her, so she asked his name, which sounded familiar. She described it was hot, so she asked him to sit in the shade while she made a phone call, and he agreed. She called the Weekend Supervisor to check if he was a resident of the facility. She said a sheriff's department vehicle pulled up at this time and inquired about resident #1. Another officer arrived and both stayed until the supervisor came. LPN G stated resident #1 did not recognize her, but when the supervisor came, she thought he recognized her. The supervisor got out and talked to him and he walked to the car with her. On [DATE] at 3:20 PM, LPN B stated she was familiar with resident #1. She said she went with the supervisor to pick him up the day he eloped. She said she thought they were keeping a close eye on him that day due to his behaviors. LPN B said, He was sitting on the sidewalk on the curb with a police officer talking to him near the jewelry store. She stated when she got out of the car resident #1 was apologetic and said he knew he did something he should not have done. The LPN said resident #1 could not recall when or why he left. She explained, he told me he drove himself from the facility in a car. On [DATE] at 3:53 PM, by telephone, Certified Nursing Assistant (CNA) C stated she worked a double shift from 3:00 PM to 7:00 AM, on the day resident #1 eloped. She said that day was not unusual that he was wandering around and was asking questions about when he was going to leave and could he go home. What was different was the frequency in which he asked. CNA C said usually he would ask the questions about his wife maybe every few hours or so, but the day he eloped he kept asking about every 10 minutes. She said resident #1 also packed his bags about an hour and a half into her shift and asked why his wife left him there. CNA C explained he was walking around the facility with his bag, carrying a picture of his wife. She recalled the staff knew what he was doing that day, they had to frequently redirect him. The CNA stated everyone knew he had increased behaviors and was more persistent that day. She recounted resident #1 went up to LPN E who was at her medication cart, and talked to her, then she saw him drop his bag on her medication cart. CNA C said she let the other CNAs on the unit, and his nurse know to redirect his behaviors. The CNA said he even asked her where [city where he previously lived] was. CNA C said the supervisor called her around 5:00 PM to come and get resident #1 from the front lobby. She explained resident #1 was sitting next to the supervisor at the front desk, with his bag and a picture of his wife in his hand when she arrived at the lobby. The CNA said the supervisor asked her to take him back to his unit and keep him distracted until dinner. CNA C said she took resident #1 back to the nurse's station and stayed until she had to help deliver dinner trays which was the last time she saw him until after he returned to the facility. On [DATE] at 4:35 PM, LPN D stated she usually took care of resident #1. She said he was very forgetful, and you had to remind him over and over where he was. The LPN stated she would call his wife, and he would talk to her but forget that he talked to her shortly after. She said, He was physically independent but very forgetful, only oriented to himself. LPN D stated resident #1 was eating in his room when she went to give him his medications around 5:30 PM. The LPN said resident #1 had come to the nurse's station earlier and asked for her to call his wife. LPN D said she would call later, but he came back asking her again to call his wife. The LPN stated when she administered his medications, she told him she would call his wife before he went to bed, and he said okay. She explained resident #1 usually walked around the building, but she did not see him again that night after he got his medications. LPN D stated another staff told her resident #1 had gotten outside, but they were not sure how he got out. She said when he returned, she asked him how he got out of the building and he said, I was very careful, and asked her if he was going to get in trouble. On [DATE] at 5:04 PM, LPN E stated she worked on the day resident #1 eloped but was not his nurse. She said she had taken care of him in the past. The LPN said he wandered a lot, and he asked the same questions over and over, Why is my wife not here? She explained even when his wife had just left, he would ask about her. She continued, we would tell him his wife just left, and he would not remember she was just there. LPN E said she saw resident #1 earlier that evening and he put a bag of garbage on her medication cart, and she told him not to put trash on her cart. I think it was trash, I thought I saw a brief in it. I did not look in the bag. The LPN stated resident #1's CNA came to get him, and she was not aware he thought the bag was his belongings he was taking with him to go home. On [DATE] at 5:55 PM, the Administrator stated when he arrived at the facility that night, he started watching the videos. He said he watched a couple hours prior to the elopement and saw resident #1 wandering down the hall. The Administrator explained not all the cameras were live, some were dummies, and were not in all of the hallways. He said he saw CNA C walk resident #1 back to his room for dinner. The Administrator confirmed resident #1 came out of his room shortly after and came straight back to the front hall. He acknowledged the front hall did not have a live camera, but shortly after resident #1 was seen on video going out the front door. The Administrator stated the video showed the Weekend Supervisor returned to working on her computer and did not look up when resident #1 left the building behind the departing visitor. He said he saw the Weekend Supervisor was still at the desk when she received the phone call about resident #1 being out of the building. Review of resident #1's medical record revealed limited nursing progress notes describing resident #1's behaviors until a week before his elopement. These progress notes revealed escalating exit seeking behaviors in the week preceding the elopement. A nursing progress note dated [DATE], read, The resident removed the electronic wander monitoring bracelet on his right ankle. The bracelet was located [in] the trash can in his room. New bracelet applied on the left ankle. A nursing progress note the next day, [DATE] documented the resident was wandering up and down the unit, packed his belonging and told others he was going home. The nurse charted she notified the charge nurse and the as needed anti-anxiety medication was given. On the day he eloped, [DATE], the nurse documented the resident's behavior remained unchanged. He continued to wandering the unit, and she noted resident #1, constantly needs to be redirected without success. The nurse indicated resident #1 was again medicated for anxiety. Review of the Medication Administration Record (MAR) dated for [DATE] revealed resident #1 had an as needed (prn) order for anti-anxiety medication every 8 hours for restlessness/agitation that was in effect for 14 days starting on [DATE]. The resident received the medication one time on [DATE], once on [DATE] and again once on [DATE]. The order was not renewed, and it was discontinued after the 14 days were completed. On [DATE], the day after resident #1 cut off his electronic wander monitoring bracelet the nurse noted in the progress notes he was wandering up and down the unit and an anti-anxiety prn medication was given. This medication was restarted that same day, [DATE] as a renewal of the previous 14-day as needed anti-anxiety medication that had expired on [DATE]. Over the course of the week before the elopement resident #1 received one dose of the as needed anti-anxiety medication on [DATE], two doses on [DATE], a dose on [DATE], a dose on [DATE] and another dose on [DATE] both prior to and after the elopement. On [DATE] at 1:58 PM, the 200 Unit Manager (UM) acknowledged the prn anti-anxiety medication was restarted on [DATE] after resident #1 cut his electronic wander monitoring bracelet off the previous day. She was asked why resident #1 did not have additional interventions added to his care plan when this occurred, and his behaviors escalated the days prior to the elopement. The UM could not answer but acknowledged again the resident took his wander monitoring bracelet off on Sunday [DATE] and placed it in the garbage. She continued the bracelet was replaced on the other limb. The UM said she was notified of the incident when she came to work on Monday. She was sure it would have been discussed in morning meeting but could not answer why the interdisciplinary team (IDT) did not add interventions at that time. The 200 UM was unable to say whether psychiatric services was consulted when resident #1 was having increased episodes of behaviors and anxiety that warranted use of the prn anti-anxiety medication, and after she was given the opportunity to check the electronic record she still did not answer the inquiry. The 200 UM was not able to say why no additional interventions were put in place for resident #1 after the incident when he cut off his wander monitoring bracelet, increase in anxiety and unsuccessful attempts at redirection by staff. The UM said, There is a behavior documentation tool on the MAR and the nurse should be documenting the behavior if [prn anti-anxiety medication] was given. Review of the behavior documentation on the MAR for [DATE] revealed no behaviors documented. On [DATE] the resident received the prn anti-anxiety medication at 12:07 PM, with no behavior documented, he received it again at 9:01 PM with screaming behavior noted. He received it again on [DATE], [DATE], and in the afternoon of [DATE] with no behaviors documented by nursing staff. On [DATE] at 3:00 PM, the Administrator acknowledged he was the Risk Manager for the facility. He stated the clinical team met every morning, and discuss abnormal situations then add any interventions needed. He said he would expect the IDT team to inform him of events like when resident #1 removed his electronic wander monitoring bracelet. He said he would expect them to add some new or more effective interventions if there was a change in the resident like increased behaviors. He stated interventions were primarily the responsibility of the MDS team. On [DATE] at 4:29 PM, the MDS Coordinator stated she attended the clinical meetings in the morning. She said the team discussed risks, like falls, reviewed events that happened the day before, and the 24-hour report sheet. She stated the team decided what interventions needed to be added or updated and then they would add the interventions to the care plan. She recalled the team did speak about resident #1 wearing a wander guard and said he was usually easily redirected. The MDS Coordinator added that changes in behavior also should be reported to the physician. She acknowledged resident #1 should have had a new intervention in his care plan after cutting off his wander monitoring bracelet. The MDS Coordinator said, I was not aware he cut off his wander guard, this is the first time I am hearing this. The MDS Coordinator explained if there was a new behavior whoever was in the meeting should update the care plan. She explained that enhanced supervision meant basically to supervise resident #1 so staff always knew where he was. In a telephone interview on [DATE] at 3:33 PM, resident #1's wife stated she was notified of her husband's elopement on [DATE] between 9:00 and 9:30 PM when facility staff called her. She said they called her after he was back in the facility. She said, I was kind of upset because he had a bracelet on his leg, and he still got out. She said they told her the bracelet was put on her husband so he would not leave the facility. Resident #1's wife stated he has Alzheimer's Dementia. She said the day he got out of the nursing home their son who lives in another state came to visit her husband. She stated they brought her husband lunch and were able to eat with him. She wondered if it triggered her husband when they left the facility after lunch, because he had seen his son earlier that day and had been told he was only visiting for the day. She cried and said, My heart almost fell out of my chest when they said he was on [highway name] when they found him. Resident #1's wife said it was very scary to think that he walked that far and was on that busy road alone. On [DATE] at 12:35 PM, the Director of Nursing stated neglect was if a resident's needs were not met by the facility. She gave examples of neglect such as if residents were not bathed, not given hydration or not supervised appropriately, and said all of these things were neglect. Review of the facility policy and procedure for Abuse, Neglect Exploitation, and Investigations dated [DATE] revealed the facility would honor the resident's rights by addressing with employees the seven components including neglect in accordance with Federal law. The policy defined neglect as the failure of the facility, or its employees to provide services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], Resident #1 was returned to the facility and re-evaluated by the licensed nurse. Full body assessment of resident completed. One to one supervision initiated. Physician and resident representative notified of event. *On [DATE], the facility filed an immediate federal report related to allegation of neglect of resident #1 to Agency for Healthcare Administration, notified Department of Children and Families and initiated a full investigation. Physician and resident representative notified. *On [DATE], the Elopement Risk Alert Binder was reviewed to ensure the resident's picture and demographics were in place. Plan of care and Kardex was reviewed to ensure accuracy of resident's current condition. Increased monitoring related to exit seeking behaviors verified in place. *On [DATE], Risk Evaluation related to elopement was conducted for resident #1. *On [DATE], facility conducted head count of residents currently residing in the facility; all were accounted for and safe. *On [DATE], doors were assessed by Administrator and Maintenance Director to ensure proper functioning; no issues or concerns were identified. It was identified through Root Cause Analysis (RCA) process that the electronic wander monitoring alarm was deactivated during the remote door opener activation to allow visitors out. Systemic changes listed below to prevent occurrence. *By [DATE], residents residing in the facility were re-evaluated/reviewed for elopement risk. *By [DATE], residents identified at risk for elopement were reviewed by Unit Managers/designee for: Elopement Screen, Car plan in place related to wandering risk, CNAs Kardex reflective of resident status and Resident(s) present in Elopement Binder. *On [DATE], the Director of Nursing (DON) /designee reviewed elopement binders to ensure residents at risk for elopement were present and identified. *On [DATE], Resident #1 was evaluated by psychiatry. *On [DATE], DON/designee educated staff on: a. Components of the regulation: F689 b. Elopement Policy and Procedure c. 1:1 supervision d. Door/Egress checks e. Responding to an alarm f. Response to a missing resident g. Elopement Triggers h. Proactive interventions for residents at risk for wandering/elopement i. In an abundance of caution, abuse and neglect education completed. *On ,d+[DATE], DON/designee carried out elopement drills. Education provided as indicated based on Elopement Drill findings. the facility has completed 35 elopement drills that includes 185 staff members out of 186 (the staff member not included is out of the State). *By [DATE], ,d+[DATE] facility staff members were re-educated. *By [DATE], ,d+[DATE] facility staff members were re-educated, no staff worked without receiving in-person education. Newly hired employees will receive education on above in orientation. *On [DATE], the facility removed the automatic door opener. *On [DATE], the facility adjusted the alarm delay from 15 seconds to 5 seconds to prevent tailgating. *Beginning [DATE], the facility Administrator/designee/DON/designee will ensure the safety and well-being as it relates to elopement is maintained by continued participation, evaluation, and intervention through: a. Clinical standup review of the 24-hour report to identify change in condition. b. Monitoring of egress systemic changes c. Maintaining QA/PI process. *On [DATE], anti-tailgate device was added to the front door along with antennae moved to improve field of frequency. *Beginning [DATE], the facility Administrator/designee, and the DON/designee will ensure the components of F600 compliance with an emphasis on neglect to include monitoring of facility systems during administrative/clinical standup and standdown to identify areas that may rise to the level of investigating ANEMMI to ensure residents receive the necessary care and services. Areas of service include: *Review of Concern/Grievance log *Review of ,d+[DATE] hour report log *Resident/Family Council Meeting(s) *Facility Compliance/Complaint Line *Skin integrity review for any trending *Risk Management Portal *Electronic Health Record (Point Click Care) Alert Reporting-e.g. SBAR, Stop and Watch. *By [DATE], skin evaluations for residents with a BIMS score of 11 or lower were evaluated to identify abuse or neglect. *By [DATE], residents with a BIMS score of 12 or higher were interviewed to identify abuse or neglect. From [DATE] to [DATE], interviews were conducted with 28 staff members who represented all shifts. Staff included 8 CNAs, 8 LPNs, 4 RNs, 2 Housekeepers, 1 Receptionist, 1 MDS Coordinator, 2 Dietary personnel, 1 Maintenance Director, and 1 Physical Therapy Assistant who verbalized their understanding of the education provided. The resident sample was expanded to include all 8 additional residents identified as at risk for elopement/neglect. Interviews with 3 alert and oriented residents regarding interviews conducted by facility staff regarding feeling safe and no neglect and chart reviews for 9 residents to ensure elopement risk evaluations and skin checks were completed on [DATE]. Observations, interviews, and record reviews revealed no concerns related to elopement for the expanded sample residents.

Based on observation, interview, and record review, the facility failed to maintain a secure environment and provide adequate supervision to prevent a severely cognitively impaired resident to exit unauthorized, and unsupervised from the facility and the safety of its property, for 1 of 9 residents reviewed for elopement risk, of a total sample of 10 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, impairment, and/or death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, accosted by a stranger, or been hit by a vehicle and died . The facility's failure to identify and provide adequate supervision and ensure a secure environment contributed to resident #1's elopement and placed all elopement risk residents at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE] after verification of the immediate actions by the facility. The scope and severity of the deficiencies were decreased to a D, no actual harm with a potential for more than minimal harm, that is not an Immediate Jeopardy. There were a total of 9 current residents identified at risk for wandering/elopement. Findings: Cross reference F600 On [DATE] at approximately 6:05 PM, the facility's Weekend Supervisor unlocked the door for a visitor to leave and neglected to ensure no residents followed out behind the visitor. Resident #1, a vulnerable, severely, cognitively impaired male, followed behind the visitor and exited the safety of the facility unnoticed and unsupervised. Resident #1 was allowed to exit the building and walked outside on the hot, sunny 90 degree Fahrenheit evening for approximately 45 minutes, traveling approximately 1.1 miles away from the facility, (retrieved on [DATE] from www.wunderground.com). Along the route it was noted to have uneven, sloped terrain/pavement, curbs and multiple open retention ponds. He would have crossed a heavily trafficked, six lane highway with speed limit of 40 miles per hour to reach the location where an off-duty staff member spotted him. The facility was unaware of resident #1's whereabouts until 6:35 PM when an off-duty staff member happened to see the resident walking down the street with a wander prevention bracelet and called the supervisor. Resident #1 was admitted to the facility on [DATE], with diagnoses to include right femur fracture, difficulty walking, dementia anxiety, major depressive disorder, psychotic disorder with delusions. The Minimum Data Set (MDS) Admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of ,d+[DATE] which indicated he had severe cognitive impairment. The assessment indicated he received antipsychotic, antianxiety, antidepressant, and antibiotic medications. Review of the medical record revealed resident #1 had a physician order for an electronic wander monitoring bracelet to be applied beginning [DATE]. Review of resident #1's medical record revealed he had a care plan for potential for elopement related to his behaviors such as wandering, ambulatory, has confusion, and exit seeking initiated on [DATE]. The goal described the resident would remain safe and would refrain from leaving the facility unsupervised was initiated on [DATE] and revised on [DATE]. Interventions included enhanced supervision, initiated on [DATE], provide redirection when observed going towards exit doors, also initiated on [DATE]. A revision was added to the care plan on [DATE] which indicated resident #1 had eloped from building. On [DATE] at 1:05 PM, the Administrator shared a video from his cell phone recorded on [DATE] from the facility's video monitoring system. The video which started at approximately 6:05 PM, showed a visitor paused at the door, while the weekend supervisor used a remote control to open the front door to exit the facility. The visitor pushed the door handle and opened the front door exiting the facility lobby. Six seconds later resident #1 went out the door after the resident. The weekend supervisor was seen seated at the receptionist desk with her head down, on the computer, totally unaware of resident #1 tailgating behind the visitor she had let out moments before. The video then showed resident #1 returning to the facility at 6:49 PM. The Administrator stated the video camera was positioned above the receptionist desk, and ran on a loop, so he had recorded the video portion of resident #1 leaving the facility on his phone but had no other record of his actions from that day. On [DATE] at 11:48 AM, the Weekend Supervisor stated the receptionist hours were Monday- Friday 8 AM-8 PM and Saturday and Sunday from 8 AM-5 PM. The Weekend Supervisor stated she worked most weekends and confirmed she was the supervisor in charge [DATE], the day resident #1 eloped. She stated she had been sitting at the receptionist desk charting assessments after the receptionist left the facility. She said she saw the visitor approach and pushed the button on the remote to unlock the door to let her out. She stated she did not see resident #1 follow behind the visitor. The supervisor explained how she had opened the door from where she was seated at the desk using the remote without having to actually get up from her position. She explained no one at the facility knew resident #1 was missing until she received a phone call from off duty Licensed Practical Nurse (LPN) G at 6:35 PM, who asked if [name of resident #1] was a resident at the facility. On [DATE] at 2:26 PM, LPN G said she worked the day shift at the facility on [DATE] then later that evening she went to pick up food at a restaurant not far from the facility with her husband. She explained as they left the parking lot, she noticed an older gentleman walking down the street who kept looking behind him as if he needed a ride or was looking for someone to pick him up. She stated the man was headed east on the sidewalk along the highway, across the intersection from where she had been parked. LPN G recounted it looked like the man had an electronic wander monitor bracelet on his leg and she asked her husband to make a U-turn so she could get a closer look. She explained they caught up with him further down the road in front of another store, so they pulled to the side of the road, and she got out of the car. She asked the gentleman if he needed a ride and where he was going. To which he replied, yes and he was going to the base. LPN G stated she did not know him, so she asked him his name, which sounded familiar. She instructed him to sit in the shade and she called her supervisor at the facility to check to see if the man was ours. Around that time a sheriff's officer pulled up and asked resident #1 where he lived, and she told him he was from the facility and a supervisor was on the way to get him. LPN G said she stayed with him until the Weekend Supervisor and another staff arrived at her location. She explained resident #1 did not recognize her but when the supervisor came, it appeared he recognized her. The supervisor got out of her car and talked to him, then he walked to the car with her. On [DATE] at approximately 7:25 PM and on [DATE] at 9:18 AM, the likely route was toured by car and by foot (see photo evidence). Per interview the resident left his room on the 200 hall and walked toward the front of the building to the lobby approximately 267 feet away. From there he exited the building through the front door and likely walked approximately 298 feet through the parking lot down a short drive to the sidewalk adjacent to a minimally busy two-lane road. On the short road adjacent the parking lot there were two open retention ponds directly across from the facility. At the sidewalk he would have turned right and walked .3 miles over uneven pavement passing multiple business entrances to where that road intersected a moderately trafficked four lane road and turned left. He continued another 0.4 miles on the moderately trafficked road passing five business entrances, the driveway for a fire station and four unsecured retention ponds. At this point there was a large intersection with busy restaurants/convenience store on three of the four corners of the intersection. Resident #1 then turned left onto the highway which was 6 lanes across at that point with traffic coming from the nearby interstate and busy shopping area a short distance away. He walked another 0.1 miles before he was stopped by LPN G and her husband at the jewelry store. On [DATE] at 3:20 PM, LPN B stated she was familiar with resident #1. She said she went with the Weekend Supervisor to pick him up the day he eloped. The LPN stated she went along with the supervisor to retrieve resident #1 from where LPN G found him in case she needed assistance with him due to possible behavior. LPN B said, He was sitting on the sidewalk on the curb with a police officer talking to him near the jewelry store. She stated when she got out of the car resident #1 was apologetic and said he knew he did something he should not have. The LPN said resident #1 could not recall when or why he left. She said he told her he drove himself from the facility in a car. On [DATE] at 3:53 PM, via telephone, Certified Nursing Assistant (CNA) C stated she worked a double shift from 3 PM to 7 AM on the day resident #1 eloped. She recalled he had wandered around that day, asking questions about every 10 minutes like, when he was going to leave? and could he go home? She said resident #1 packed his bags about an hour and a half into her shift and asked her why his wife had left him there. She recounted all the staff knew of his behaviors that day, and they needed to frequently redirect him. She expressed that everyone knew he had increased behaviors and had been hard to redirect that day. CNA C said she let the other staff, and his nurse know what he was doing so they could redirect him. She said he asked her where [the name of the city where he used to live] was. CNA C explained the Weekend Supervisor called her around 5:00 PM and asked her to come get resident #1 from the front. CNA C explained that resident #1 was sitting next to the supervisor at the front desk, with his bag and a picture of his wife in his hand when she arrived. The CNA said the supervisor asked her to take him back to his unit and keep him distracted until dinner. CNA C said she took resident #1 back to the nurse's station but shortly after the dinner trays arrived and the CNAs had to deliver them to the residents. CNA C stated she left resident #1 and went to deliver the trays and did not see him again until he was returned to the facility with the Weekend Supervisor. On [DATE] at 4:35 PM, LPN D stated she was assigned to care for resident #1 frequently. She recalled he was very forgetful, and staff had to remind him over and over where he was. The LPN stated she would call his wife for him; he would talk to her and only a few minutes later he would already forget that he had just talked to her. She said, He was physically independent but very forgetful, only oriented to himself. LPN D stated resident #1 was eating in his room when she went to give him his medications around 5:30 PM. She said resident #1 had come to the nurse's station earlier and asked her to call his wife, but she told him she would call her later. He came back asking for her to call his wife again. LPN D said when she gave him his medications, she promised him she would call his wife before he went to bed, and he said okay. She explained resident #1 usually walked around the building, but she did not see him that night after she gave him his medications. LPN D stated another staff told her resident #1 had left the building, but they were not sure how he got out. She said when resident #1 returned to the facility, she asked him how he got out of the building and he said, I was very careful. The LPN said he then asked her if he was going to get in trouble. On [DATE] at 5:21 PM, in a second interview, the Weekend Supervisor said, When [resident #1] was talking to me before the elopement, he had a picture of his wife, but I do not recall him having a bag. She said she had seen the picture in his room but did not recall seeing him carry it around with him in the past. The supervisor stated she let him sit with her and talk a little bit because she knew he was an elopement risk, and it would give him a change of scenery. She stated if she knew he was exit seeking she would have put him on one-to-one supervision. She acknowledged it was not likely he would have eloped if he had more supervision such as one to one. She stated she had not been aware his behavior was different that day. Review of resident #1's medical record revealed limited nursing progress notes describing resident #1's behaviors until a week before his elopement. These progress notes revealed escalating exit seeking behaviors in the week preceding the elopement. A nursing progress note dated [DATE], read, The resident removed the electronic wander monitoring bracelet on his right ankle. The bracelet was located [in] the trash can in his room. New bracelet applied on the left ankle. A nursing progress note the next day, [DATE] documented the resident was wandering up and down the unit, packed his belonging and told others he was going home. The nurse charted she notified the charge nurse and the as needed anti-anxiety medication was given. On the day he eloped, [DATE], the nurse documented the resident's behavior remained unchanged. He continued to wandering the unit, and she noted resident #1, constantly needs to be redirected without success. The nurse indicated resident #1 was again medicated for anxiety. Review of the Medication Administration Record (MAR) dated for [DATE] revealed resident #1 had an as needed (prn) order for anti-anxiety medication every 8 hours for restlessness/agitation that was in effect for 14 days starting on [DATE]. The resident received the medication one time on [DATE], once on [DATE] and again once on [DATE]. The order was not renewed, and it was discontinued after the 14 days were completed. On [DATE], the day after resident #1 cut off his electronic wander monitoring bracelet the nurse noted in the progress notes he was wandering up and down the unit and an anti-anxiety prn medication was given. A renewal order for the same as needed anti-anxiety medication every 8 hours for restlessness/agitation was documented as restarted in the record. Over the course of the week before the elopement resident #1 received one dose of the as needed anti-anxiety medication on [DATE], two doses on [DATE], a dose on [DATE], a dose on [DATE] and another dose on [DATE] both prior to and after the elopement. On [DATE] at 1:58 PM, the 200 Unit Manager (UM) acknowledged the prn anti-anxiety medication was restarted on [DATE] after resident #1 cut his electronic wander monitoring bracelet off the previous day. She was asked why resident #1 did not have additional interventions added to his care plan when this occurred, and his behaviors escalated the days prior to the elopement. The UM could not answer but acknowledged again the resident took his wander monitoring bracelet off on Sunday [DATE] and placed it in the garbage. She continued the bracelet was replaced on the other limb. The UM said she was notified of the incident when she came to work on Monday. In a telephone interview on [DATE] at 3:33 PM, resident #1's wife stated she was notified by staff of her husband's elopement on [DATE] around 9:00 PM after he was returned to the facility. She said, I was kind of upset because he had a bracelet on his leg, and he still got out. She said they told her the wander monitoring bracelet was put on her husband so he would not leave the facility. Resident #1's wife stated her husband has Alzheimer's Dementia. She said the day he got out of the nursing home their son who lived in another state came to visit her husband. She stated they brought her husband lunch and were able to eat with him. She wondered if it triggered her husband when they left the facility after lunch, because he had seen his son earlier that day and had been told he was only visiting for the day. She cried and said, My heart almost fell out of my chest when they said he was on [highway name] when they found him. Resident #1's wife said it was very scary to think about what could have happened since he walked that far away and was on that busy road alone. Review of the facility's corrective actions were verified by the survey team and included the following: * On [DATE], Resident #1 was returned to the facility and re-evaluated by licensed nurse. Full body assessment of resident completed. One to one supervision initiated. Physician and resident representative notified on event. * On [DATE], the facility filed an immediate federal report related to allegation of neglect of resident #1 to Agency for Healthcare Administration, notified Department of Children and Families and initiated a full investigation. Physician and resident representative notified. * On [DATE], the Elopement Risk Alert Binder was reviewed to ensure resident's picture and demographics were in place. Plan of care and Kardex reviewed to ensure accuracy of resident's current condition. Increased monitoring related to exit seeking behaviors verified in place. * On [DATE], Risk Evaluation related to elopement was conducted for resident #1. * On [DATE], Facility conducted head count of residents currently residing in the facility; all were accounted for and safe. * On [DATE], Doors were assessed by Administrator and Maintenance Director to ensure proper functioning; no issues or concerns were identified. It was identified through Root Cause Analysis (RCA) process that the electronic wander monitoring alarm is deactivated during the remote door opener activation to allow visitors out. Systemic changes listed below to prevent occurrence. * By [DATE], Residents residing in the facility were re-evaluated/reviewed for elopement risk. * By [DATE], Residents identified at risk for elopement were reviewed by Unit Managers/designee for: Elopement Screen, Care plan in place related to wandering risk, CNAs Kardex reflective of resident status and Resident(s) present in Elopement Binder. * On [DATE], the Director of Nursing (DON) /designee reviewed elopement binders to ensure residents at risk for elopement were present and identified. * On [DATE], Resident #1 was evaluated by psychiatry. * On [DATE], DON/designee educated staff on: a. Components of the regulation: F689 b. Elopement Policy and Procedure c. 1:1 supervision d. Door/Egress checks e. Responding to an alarm f. Response to a missing resident g. Elopement Triggers h. Proactive interventions for residents at risk for wandering/elopement i. In an abundance of caution, abuse and neglect education completed. * On [DATE], DON/designee carried out elopement drills. Education provided as indicated based on Elopement Drill findings. The facility has completed 35 elopement drills that includes 185 staff members out of 186 (the staff member not included is out of the State). * By [DATE], ,d+[DATE] facility staff members were re-educated. * By [DATE], ,d+[DATE] facility staff members were re-educated, no staff worked without receiving in-person education. Newly hired employees will receive education on above in orientation. * On [DATE], the facility removed the automatic door opener. * On [DATE], the facility adjusted the alarm delay from 15 seconds to 5 seconds to prevent tailgating. * Beginning [DATE], the facility Administrator/designee/DON/designee will ensure that the safety and well-being as it relates to elopement is maintained by continued participation, evaluation, and intervention through: a. Clinical standup review of the 24-hour report to identify change in condition. b. Monitoring of egress systemic changes c. Maintaining QAPI process. * On [DATE], anti-tailgate device was added to the front door along with antennae moved to improve field of frequency. From [DATE] to [DATE], interviews were conducted with 28 staff members who represented all shifts. Staff included 8 CNAs,8 LPNs, 4 RNs, 2 Housekeepers, 1 Receptionist, 1 MDS Coordinator, 2 Dietary personnel, 1 Maintenance Director, and 1 Physical Therapy Assistant who verbalized their understanding of the education provided. The resident sample was expanded to include all eight residents identified as at risk for elopement currently in the facility. Interviews with three alert and oriented residents regarding interviews conducted by facility staff regarding feeling safe and no neglect and chart reviews for the other 8 residents to ensure elopement risk evaluations and skin checks were completed on [DATE]. Observations, interviews, and record reviews revealed no concerns related to Elopement.

Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted/completed in response to possible neglect for a resident elopement for 1 resident of 9 residents reviewed for elopement, of a total sample of 10 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE], with diagnoses to include right femur fracture, difficulty walking, dementia, anxiety, major depressive disorder, and psychotic disorder with delusions. The Minimum Data Set Admission assessment with assessment reference date of 6/24/24 revealed resident #1 had a Brief Interview for Mental Status score of 03/15 which indicated he had severe cognitive impairment. The assessment read he received the following medications, antipsychotics, antianxiety, antidepressant, and antibiotics. On 8/03/24 at 11:48 AM, the Weekend Supervisor stated she was sitting at the receptionist desk on Saturday, 7/20/24 sometime after 5:00 PM, charting assessments when a visitor came to the door to leave. The supervisor said from where she was seated, she unlocked the door with the remote, the visitor pushed the bar on the door, opened the door and walked out. The supervisor stated she returned to her work and did not see anyone behind the visitor go out the door. She explained no one knew resident #1 was missing from the facility until she got a phone call from an off-duty nurse at 6:35 PM, who asked if he was a resident and explained she has seen him walking down a busy highway about a mile away from the facilty. On 8/03/24 at 1:05 PM, the Administrator shared video footage of the incident from his cell phone taken on 7/20/24 after resident #1's elopement. According to the video, at 6:05 PM, a visitor was seen paused at the door, while the Weekend Supervisor pushed the button, a few seconds later the visitor pushed the door handle and opened the door. Resident #1 came behind the visitor and went out the door 6 seconds later. The video showed him returning to the facility at 6:49 PM. On 8/03/24 at 3:53 PM, via telephone, Certified Nursing Assistant (CNA) C stated she worked a double shift from 3:00 PM to 7:00 AM the day resident #1 eloped. She recalled the day he eloped he had been wandering around, and asked more frequently questions like when he was going to leave and could he go home, about every 10 minutes. She recounted resident #1 packed his bags about an hour and a half into her shift and asked why his wife had left him there. CNA C stated the staff had to redirect him frequently that day because he had increased behaviors and was more persistent with them. She remembered she let the other CNAs, and his nurse know so they could also redirect him. She said he asked her where [his home] was. CNA C explained the Weekend Supervisor called her around 5:00 PM and asked her to come get him from the front desk and keep him occupied after he wandered up there and set the wander prevention alarm off. CNA C explained when she arrived to the lobby resident #1 was sitting next to the supervisor at the front desk, with his bag and a picture of his wife in his hand. CNA C said she took resident #1 back to the nurse's station and stayed near him until she had to help deliver trays for dinner. She added if resident #1 had been on 1:1 supervision she did not think he would have gotten out. She explained she wrote a statement afterwards and got education for elopement, abuse and neglect. On 8/03/24 at 7:08 PM, CNA F stated she was working on the 200 unit the night resident #1 eloped. She stated was not resident #1's assigned CNA that evening, but she knew him as being confused and needing redirection and supervision sometimes. She recalled resident #1's behavior caught her attention when she arrived to her shift on that Saturday as he kept walking up the hallway in the front of the 200 unit toward the lobby, which was not usual for him. She explained he carried around a bag and a picture of his wife, was carefully watching the staff watching him, and had told her he was leaving and had been doing these type of things all week. CNA F recalled while her and CNA C were passing dinner trays resident #1 approached them and the redirected him back to his room. She stated she told CNA C that resident #1 needed to be on 1 to 1 supervision because of the way he was acting, and CNA C told her he was okay. CNA F explained she did not write a statement after the elopement incident, nor did anyone follow up to interview or ask her questions about what she saw or what happened that evening, nor did she voluntarily go to Supervisory staff to volunteer information about what happened. CNA F stated she told CNA C after the elopement, I told you he needed to be on 1 to 1 [supervision]. On 8/03/24 at 4:34 PM, Licensed Practical Nurse (LPN) D stated she was assigned to resident #1 the night he eloped. She said she was not aware his CNA had to retrieve him from the lobby area. LPN D said she was surprised when the supervisor told her he got out of the building. She said when he returned, she asked him how he he left and he said, I was very careful. The LPN said he then asked her if he was going to get in trouble. LPN D stated the staff got education when the administrative team got to the facility that evening, and she wrote a statement. She explained she talked with the Director of Nursing (DON) that evening about the event, but no one inquired about resident' #1's behaviors that shift. On 8/04/24 at 1:58 PM, the 200 Unit Manager (UM) stated she did not think resident #1 had any new behaviors although she acknowledged nurses needed to reinstate an as needed anti anxiety medication order that week, which he received multiple times. The UM stated he needed the medication because he was more anxious, but did not elaborate further. When asked why he was given the as needed anti-anxiety medication when he cut off his wander monitoring bracelet, packed his clothes to leave and staff were not able to redirect him as these were more behaviors than anxiety, she again stated he got the medication for anxiety not behaviors. The UM stated all of the staff who worked that night were interviewed on the night of the elopement by the DON, UMs, and Assistant DON. She was unable to say who was interviewed, nor how did they know if all of the staff were interviewed. The 200 UM stated they did not have documentation of which staff were interviewed, or what was said during those interviews. On 8/03/24 at 5:55 PM, in joint interviews with the Director of Nursing (DON), the Administrator, the [NAME] President of Clinical Services and the Regional Nurse, the DON stated on the evening of the elopement, she asked all staff in the facility to write a statement regarding interactions with resident #1. She read statements including, LPN E's statement read, The last time I saw resident was at 6:19 PM. CNA J's statement read, he saw him while was passing trays in his room at approximately 5:30 PM. CNA C's statement from 7/20 read, [resident #1's name] left saw him between 6-6:30 PM. The DON acknowledged that two of the staff statements said they saw the resident when he was not in the building per the facility video timeline. The DON stated she did not interview or speak to the staff again personally after she received their statements to clarify or add additional information to her investigation of the incident. She stated she asked for written statements then she and the managers provided verbal education to the staff. The DON could not say why she did not further investigate by clarifying or asking for additional details from staff when some statements were vague or incorrect only saying she did not want to change them. She confirmed the facility had no further written documentation showing further investigation with the staff, and explained she had talked to staff throughout that evening and no one mentioned resident #1's behavior. The Regional Nurse explained, because there was actual video footage that showed what happened they did not feel they needed additional information from the staff. On 8/04/24 at 4:53 PM, the [NAME] President of Clinical Services and the Regional Nurse confirmed the facility did not have a statement documented from CNA F or an interview from 7/20/24, the night of the elopement. They presented a verbal statement signed by CNA F and transcribed on 8/03/24 in which CNA F stated, I felt something wasn't right. On 8/04/24 at 3:01 PM, the Administrator stated he was the Risk Manager for the facility. He explained interviews were part of the investigation process for abuse or neglect allegations as well as taking statements from staff or witnesses. He was unable to say how the facility would know if they had interviewed all of the pertinent players or what had been said if there was no documentation for it. Review of the facility Abuse, Neglect, Exploitation and Investigation policy and procedure issued 4/01/22, read, The facility will conduct their own internal investigation including but not limited to staff.resident, and family/resident representative interviews, medical records.

Based on interview and record review, the facility failed to ensure 1 of 5 employees were adequately screened prior to hire and failed to thoroughly investigate and report to the State licensing authority knowledge regarding the restriction of a Registered Nurse's (RN) professional license. Findings: Review of the Department of Health (DOH) License revealed an Emergency Restriction Order was filed against RN A's license on 3/09/22. The order indicated the RN was evaluated by a physician specializing in addiction medications, and documented his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's recommendations were for RN A to engage in a residential treatment program or partial hospitalization program. Engage in a psychiatric and Neurocognitive evaluation, and to enter an [MEDICATION(S)] Project for Nurses (IPN) monitoring contract with routine toxicology testing. Intervention Project for Nurses (IPN), a program that contracts with the Board of Nursing to evaluate and monitor nurses needing rehabilitation or treatment because of impairment due to drugs, alcohol, mental health or physical conditions. (Nurse Practice Act-copyright 2008 by Nursing Law Manual) RN A failed to engage in the recommended treatment or enter the IPN monitoring contract, and The Florida Board of Nursing imposed discipline which was signed and dated 3/25/22, and indicated the RN was Unable to practice Nursing with reasonable skills and safety to patients due to moderate opioid use disorder, and moderate benzodiazepine use disorder. On 8/09/22 at 4:15 PM, in a telephone interview, RN A stated he was hired by the facility around the first of the year, but he was not sure of the dates. He verbalized he stopped working at the facility a couple of months ago, and stated he was taken off the facility's schedule because he had a stipulation on his license. RN A said he was told by the previous Administrator and previous Director of Nursing (DON) C he needed to get the stipulation removed before he could work at the facility again. RN A stated the facility was not aware he had a stipulation against his license, they wanted an update of his license and that's when they found out about the stipulation. On 8/09/22 at 4:30 PM, the facility's previous Human Resource (HR) Director B stated that on 4/29/22 she reviewed all the RNs licenses electronically and RN A's license was flagged. HR B verbalized she printed the documentation from the DOH website, which revealed the RN was unable to pass medications without supervision, and gave the documentation to DON C. HR B said she discussed the situation with the previous Administrator, and DON C, and they were going to call the RN to question him about the situation. HR B stated the DOH court document showed an effective date of 3/09/22, and she discussed with DON C, that since the RN was still working while he was under suspension/restricted license for over a month, the incident should be reportable. HR B verbalized the DON called her and reported she spoke with the Corporate Senior Director of Clinical Operations and was told it was not reportable since the incident was not within a certain timeframe. HR B stated nothing more was said or done about the incident, and added, he just disappeared. HR B stated reference checks were done by HR prior to hire. She said she called RN A's last workplace but did not recall hearing back from that facility regarding his references. She stated she would usually document the encounter. Review of RN A's employee file revealed no documentation regarding references. The Employment Application completed on 10/14/21 revealed the Employment History was blank, and the Reference check form was not completed as required: Specific duties, reason for leaving, dates from-to, supervisor's name and title were missing. The portion For office use only checked yes that the company contact was reached and indicated verified dates of employment was from 4/21 to current. The answer for Reason given for termination was still current. However, documentation by the State of Florida Department Of Health regarding the restriction of RN A' s license revealed the RN was terminated by his previous employer on 10/01/21, 14 days prior to the partial completion of RN A's employment application. On 8/09/22 at 5:17 PM, the Regional Director of Operations (RDO) who was the facility's previous Administrator, stated RN A was hired at the facility on 10/21/21, and was terminated on 4/29/22, when he was informed by HR B the RN had something wrong with his license. The RDO verbalized the facility's Corporate body required Agency For Health Care Administration (AHCA) Background Screening (BGS) be done every Friday, to identify discipline / restriction on licenses, and any issues would be reported to the DON. The RDO could not provide any documentation to indicate the BGS was reviewed for RN A every Friday from 3/09/22 until the RN was terminated on 4/29/22. He stated the facility's Corporate Office was made aware of the concerns and recommended that a 30 day look back be conducted on residents' charts, with focus on medications. The RDO stated he was given a verbal report by DON C that the medication cart of RN A on the Transition Care Unit (TCU) was checked, and nothing flagged. He said in my professional opinion the RN showed up to work healthy, not impaired. The RDO said the nursing team reported to him, and the decision not to do an ACHA immediate report was made by him. He verbalized the facility did not report the issue with RN A's license to the DOH. On 8/09/22 at 7:09 PM, DON C stated that when the facility found out about the RN's license on 4/29/22, the following actions were taken: * the HR Director pulled all RNs and LPNs licenses to verify licenses were current/active/clear, and no concern/issues were identified. * DON C and the RDO/Previous Administrator called RN A who told them he had no Known Knowledge that there was a restriction on his license. The facility informed him he was terminated effective that day (4/29/22). *On 4/29/22 a systemic review of residents on the hallways RN A worked was conducted and audits were conducted on residents from the beginning of April until 4/29/22. Narcotic counts were reviewed, and no diversion was identified. The RDO and DON C could not provide any audits/documentation regarding the review of licenses of the facility's licensed employees. A list provided by the facility titled Resident reviewed (verbal/non-verbal) 04-29-22 had two questions: 1. Is your pain currently being managed? (Y/N) 2. Are you having any issues with receiving pain medication? (Y/N). The list had the names of 110 residents from both units, but there was no documentation to indicate the questions were addressed with the residents/representatives. Five of five medication carts audited to ensure all narcotics were accounted for was completed/signed by DON C and was dated 4/29/22. Responses were typed and all five audits had comments that read: Pain medication effectiveness documentation on MAR [Medication Administration Record] needs further nursing education. The RDO and DON C verbalized a review of the facility's hiring process was not done. The RDO stated RN A's file was reviewed, and he was not someone that appeared impaired while at work. They confirmed the Department of Children and Family (DCF) was not notified. The RDO stated the facility did not find deviation, and there were no concerns from residents, family, or staff regarding RN A. They also confirmed the nurse was not reported to DOH by the facility as required, and a report was not made to ACHA. As per the RDO, an Immediate and 5-day Reportable was not done because nothing was identified to trigger abuse and neglect. On 8/10/22 at 9:22 AM, in another interview with the RDO and current DON, the RDO stated the facility's hiring process was tight. RN A's employment application, and references, were reviewed with the RDO. He confirmed the application was not completed and reference checks were not followed up. He stated the hiring process could have been better and should have had reference checks. He noted the facility's Corporate policy was for BGS to be run every Friday, and verbalized he was under the impression BGS was run for RN A, which identified the issue on 4/29/22. The facility could not identify a log to indicate BGS were reviewed every Friday from 3/11/22 until 4/29/22. He stated BGS checks were done to catch incidents like this. On 8/10/22 at 10:26 AM, in a telephone interview, HR B stated that when she looked at BGS every Friday, she was usually reviewing for the Agency for Health Care Administration Eligibility, and license would not be printed unless an issue was identified. HR B explained she pulled RNs licenses randomly, in April and July, since RN licenses were due for re-licensure those months. On 4/29/22 the restriction showed up on RN A's license. She verbalized she then reviewed the ACHA BGS, and the restriction was noted there also. When asked if BGS were reviewed on the Fridays after 3/09/22, she replied yes stating the restriction could have been there, but she did not usually scroll down to the section with the Department of Health Licensure Status. On 8/10/22 at 5:33 PM, an interview was conducted with the facility's corporate Chief Nursing Officer (CNO), the RDO, current Administrator and the current DON. The CNO stated that during a review conducted by the facility on 4/29/22, it was identified that RN A had a restriction on his professional license. She said she provided DON C with an audit tool and directed DON C to do Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNO explained that at the time of the identification, the facility was focused, and wanted to make sure there were no discrepancies related to Narcotics. She said a formal Performance Improvement Project (PIP) was not in place. The CNO verbalized there was a gap in timeframe and she would have directed the facility to report the RN to DOH. She stated she understood why this was not done since the RN had a court hearing but added this would not have absolved the facility from reporting to DOH. She said the facility should have filed a practitioner complaint and these actions were not done. The Facility's Recruitment And Employment form read, An application form must be completed before any employment offer can be extended. Any misrepresentation . material omissions in any information contained in the application is grounds for removal from consideration for employment. The facility's policy ANE [Abuse, Neglect, Exploitation] and Investigations issued 4/01/2022 read, The facility will screen all potential employees .The facility shall request work references on the prospective employee and the facility will make effort to contact those references in regard to work performance and background .The facility must take all necessary corrective actions depending on the results of their investigation and must notify the proper agencies as well as licensing authorities any incidents that would indicate an employee is unfit for service. The facility must analyze the occurrences to determine what changes are needed, if any to the .policies and procedures to prevent further occurrences.

Based on interview and record review, the facility failed to ensure professional staff were licensed, in accordance with applicable State laws for 1 of 5 employees reviewed for Background Screening, (Registed Nurse A). Findings: Review of the Department of Health (DOH) License revealed an Emergency Restriction Order was filed against Registered Nurse (RN) A's license on 3/09/22. The order indicated the RN was evaluated by a physician specializing in addiction medications, and documented his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's recommendations were for RN A to engage in a residential treatment program or partial hospitalization program, engage in a psychiatric and Neurocognitive evaluation, and to enter an [MEDICATION(S)] Project for Nurses (IPN) monitoring contract with routine toxicology testing. RN A failed to engage in the recommended treatments or enter the IPN monitoring contract, and the Florida Board of Nursing imposed discipline which was signed and dated 3/25/22, and indicated the RN was Unable to practice Nursing with reasonable skills and safety to patients due to moderate opioid and benzodiazepine use disorder. Intervention Project for Nurses (IPN), a program that contracts with the Board of Nursing to evaluate and monitor nurses needing rehabilitation or treatment because of impairment due to drugs, alcohol, mental health or physical conditions. (Nurse Practice Act-copyright 2008 by Nursing Law Manual). Review of the facility's employees personnel files revealed RN A was hired by the facility on 10/19/21. RN A's file revealed no documentation regarding references. The Employment Application completed on 10/14/21 revealed the Employment History was blank, and the Reference Check form was not completed as required: Specific duties, reason for leaving, dates of previous work, supervisor's name and title were missing. The portion For office use only checked yes that the company contact was reached and indicated verified dates of employment was from 4/21 to current. The answer for reason given for termination was still current. However, documentation by the State of Florida Department Of Health regarding the restriction of RN A' s license revealed the RN was terminated by his previous employer on 10/01/21, 14 days prior to the partial completion of RN A's employment application. On 8/09/22 at 5:17 PM, the Regional Director of Operations (RDO) who was the facility's previous Administrator, stated RN A was hired by the facility on 10/21/21, and was terminated on 4/29/22 when he was informed by Human Resources (HR) staff B the RN had something wrong with his license. The RDO verbalized the facility's Corporate body required the Agency For Health Care Administration (AHCA) Background Screening (BGS) be reviewed for employees every Friday, to identify discipline/restriction on licenses, and any issues reported to the Director of Nursing (DON). The RDO could not provide any documentation to indicate the BGS was reviewed for RN A every Friday from 3/09/22 when the restriction was filed against the RN's license until 4/29/22 when RN A was terminated. On 8/10/22 at 10:26 AM, in a telephone interview the previous HR Director B stated when she ran BGS every Friday, she was usually reviewing for the Agency for Health Care Administration Eligibility, and the license would not be printed unless an issue was identified. HR B explained she pulled RNs licenses randomly, in April and July, since RN licenses were due for re-licensure those months. She stated that on 4/29/22 the restriction showed up on RN A's license. She verbalized she then reviewed the ACHA BGS, and the restriction was noted there also. When asked if BGS was ran every Friday from 3/09/22 to 4/29/22 she replied yes stating the restriction could have been there, but she did not usually scroll down to the section with the Department of Health Licensure Status. The Florida Nurse Practice Act And The Scope Of Nursing Copyright 2008 by Nursing Law Manual, Chapter 6 documented that the Florida Nurse Practice Act, Chapter 464, Florida Statutes, was enacted to ensure that every nurse practicing in Florida meets minimum requirements for safe practice. A nurse who falls below the minimum competency or who otherwise present a danger to the public shall be prohibited from practicing in Florida.

Based on interview and record review, the facility failed to use its resources effectively to ensure the employee hiring process followed regulatory requirements and the facility's policy, and failed to identify, initiate, and implement appropriate interventions to correct concerns regarding the facility's hiring process and review of licensed employees for 1 of 5 sampled licensed staff, (Registered Nurse A). Findings: Review of the Department of Health (DOH) License revealed an Emergency Restriction Order was filed against Registered Nurse (RN) A's license on 3/09/22. The order indicated the RN was evaluated by a physician specializing in addiction medications, and documented his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's recommendations were for RN A to engage in a residential treatment program or partial hospitalization program. Engage in a psychiatric and neurocognitive evaluation, and to enter an [MEDICATION(S)] Project for Nurses (IPN) monitoring contract with routine toxicology testing. RN A failed to engage in the recommended treatment or enter the IPN monitoring contract, and the Florida Board of Nursing imposed discipline which was signed and dated 3/25/22, and indicated the RN was Unable to practice Nursing with reasonable skills and safety to patients due to moderate opioid use disorder, and moderate benzodiazepine use disorder. Intervention Project for Nurses (IPN), a program that contracts with the Board of Nursing to evaluate and monitor nurses needing rehabilitation or treatment because of impairment due to drugs, alcohol, mental health or physical conditions. (Nurse Practice Act-copyright 2008 by Nursing Law Manual) Interviews were conducted with the Regional Director of Operations [RDO] who was the facility's previous Administrator, on 8/09/22 at 5:17 PM, and on 8/10/22 at 9:22 AM, and with the previous Director of Nursing (DON) C on 8/09/22 at 7:09 PM. The RDO stated RN A was hired at the facility on 10/21/21, and was terminated on 4/29/22, when he was informed by Human Resources (HR) personal B that the RN had something wrong with his license. He verbalized the facility's Corporate body required the Agency For Health Care Administration (ACHA) Background Screening (BGS) be done every Friday, to identify discipline/restriction on licenses, and any issues would be reported to the DON. However, the RDO could not provide any documentation to indicate the BGS was reviewed for RN A every Friday from 3/09/22 until the RN was terminated on 4/29/22. He explained the decision not to do an ACHA immediate report was made by him, and he indicated the facility did not report the issue with RN A's license to the DOH. DON C stated the following actions were taken by the facility: * the HR Director pulled all RNs and Licensed Practical Nurses (LPNs) licenses to verify licenses were current/active/clear, and no concern/issues were identified. * DON C and the RDO/Previous Administrator called RN A who told them he had no Known Knowledge that there was a restriction on his license. The facility informed him he was terminated effective that day (4/29/22). *On 4/29/22 a systemic review of residents on the hallways RN A worked was conducted and audits were conducted on residents from the beginning of April until 4/29/22. Narcotic counts were reviewed, and no diversion was identified. The RDO and DON C could not provide any audits/documentation regarding the review of licenses of the facility's licensed employees. A list provided by the facility titled Resident reviewed (verbal/non-verbal) 04-29-22 had two questions: 1. Is your pain currently being managed? (Y/N) 2. Are you having any issues with receiving pain medication? (Y/N). The list had the names of 110 residents from both units, but there was no documentation to indicate the questions were addressed with the residents/representatives. Five of five medication carts audited to ensure all narcotics were accounted for was completed/signed by DON C dated 4/29/22. Responses were typed and all five audits had comments that read: Pain medication effectiveness documentation on MAR (Medication Administration Record) needs further nursing education The RDO and DON C verbalized a review of the facility's hiring process was not done. The RDO stated RN A's file was reviewed, and he was not someone that appeared impaired while at work. They confirmed the Department of Children and Family (DCF) was not notified. The RDO stated the facility did not find deviation, and there were no concerns from residents, family, or staff regarding RN A. They also confirmed the nurse was not reported to DOH by the facility as required, and a report was not made to ACHA. As per the RDO, an Immediate and 5-day Reportable was not done because nothing was identified to trigger abuse and neglect. The RDO indicated the Root Cause Analysis (RCA) was the employee failed to inform the facility of his restricted license. He verbalized no other RCA was identified. He stated a Quality Assurance Performance Improvement (QAPI) meeting was conducted on 5/26/22 for the month of April with the Medical Director, Administrator, DON, and Department heads, and the meeting included discussion regarding re-running all nurses licenses and BGS. However, a Performance Improvement Project (PIP) was not initiated/implemented to address any corrective measures the facility identified and would implement. This was confirmed by the corporate Chief Nursing Operator (CNO) on 8/10/22 at 5:33 PM. On 8/10/22 at 2:18 PM, in a telephone interview, the Regulatory Specialist II at the DOH, stated RN A had an Emergency restriction on his license to practice as an RN in the state of Florida. She stated the RN was recommended to enter IPN, but he refused, and his license was suspended. She verbalized RN A could not practice as a nurse in Florida until he entered IPN program. The Regulatory Specialist II stated the RN's license status would be reflected on the DOH website immediately, and if the license was reviewed on 3/10/22, the restriction would be identified on the license. The facility failed to conduct a thorough investigation after they were made aware of the restriction on RN A's license. They did not identify omissions in the hiring process related to completion of the employee application, obtaining of references from the employee's previous employer, and the failure to perform a comprehensive review of the ACHA BGS of licenses reviewed weekly as directed by the facility's corporate entity. Witness statement obtained from RN A via telephone, documented by DON C, dated 4/29/22 was not timed. The notice of disciplinary action dated 4/29/21, was not timed. HR personnel did not receive in-service regarding the hiring process. On 8/10/22 at 9:22 AM, the RDO stated a verbal in-service was done with HR. However, documentation could not be provided to support this. He then explained HR was not a part of the RCA. In a telephone interview with HR B on 8/10/22 at 10:26 AM, she verbalized she did not receive any in-service regarding the issues identified on 4/29/22. Resident audits were not conducted as indicated, and there was no follow-up by the QAPI committee. Narcotic audits conducted on five of five medication carts were dated and signed as completed by DON C, but a second signature was not included as per best practice for narcotics. On 8/11/22 at 1:21 PM, the Consultant Pharmacist stated he was neither aware not notified of medication cart audits conducted on 4/29/22. He stated that he would have participated if he was made aware. He verbalized that he felt a second signature should have been on the narcotic audit sheet and said the Consultant Pharmacist should have been notified as a matter of process. The job description of the Administrator with revision date of 1/01/2015 revealed the Administrator should Ensure that appropriate employment identification and work documents are presented prior to employment of personnel and that appropriate documentation was filed in the employee's personnel record in accordance with current regulations mandating such documentation. The job description of the Human Resources Director with revision date of 1/01/2015 indicated the duties and responsibilities of the HR Director included, maintaining job applications for personnel eligible to work in the Facility. (e.g., job applications, resumes, reference checks, etc.Ensure hiring and discharge procedures comply with established policies and procedures. The Facility Assessment updated 7/21/22 read, The Facility must conduct a facility based and community risk assessment .issues should be identified and adapted to QAPI [Quality Assurance Performance Improvement] programs.

Based on observation, interview, and record review, the facility failed to maintain safe and sanitary conditions for food storage in 1 of 2 nutrition rooms, (Residential Care Unit). Findings: On 6/30/22 at 11:40 AM, during a tour of the Residential Care Unit (RCU) nutrition room with Registered Nurse B and the Transitional Care Unit (TCU) Unit Manager (UM), the following concerns were identified: * One 28 ounce (oz) undated plastic container one-quarter full of cheeseballs on top of microwave. * Two 12 oz. cans of opened, undated warm soda pop in the upper left cabinet. * Two 32 oz. empty plastic drink containers with straws and dried residue in the middle upper cabinet. * Cabinets and drawers were dirty with gray dust inside and on the edges of drawers. * Miscellaneous items in the cabinets and drawers were disorganized including an empty plastic cup, lids, condiments, crackers, cookies, crumpled plastic bags and aluminum foil. * The cabinets and drawers were noted to be in poor repair, with some coming off the hinges. * The microwave had three rusted areas, each approximately 1 inch diameter, that appeared to have rusted completely through the ceiling of the appliance. The following concerns were observed with the refrigerator: * The floor around the refrigerator was dirty and in poor repair with holes and cracks noted in the extremely worn laminate flooring material. There was a brown, chunky substance visible underneath the refrigerator. * A yellow/brown substance was noted under the vegetable/fruit drawers and in between the bottom glass shelf and plastic bins. * The seal on the bottom door of the refrigerator was lifting away from the door and there was a black substance present on the seal. * The freezer contained an undated 500 milliliter bottle of soda, and there was a dried, red/brown substance on the bottom of the freezer compartment. The TCU UM stated she did not know who was assigned to keep the nutrition room clean and organized. She explained the sodas belonged to staff and should not be stored in the nutrition room. She explained any staff member could have reported the concerns regarding the rusted areas inside microwave to Maintenance department staff. The TCU UM stated the nutrition room could use a new microwave, refrigerator, and cabinets. On 6/30/22 at 2:05 PM, the Certified Dietary Manager verified staff were not to store food and/or drink in the nutrition rooms. She stated she did not think kitchen staff were responsible for cleaning nutrition rooms. On 6/30/22 at 3:45 PM, the Nursing Home Administrator (NHA) was informed of the concerns identified in the RCU nutrition room. He stated all staff were responsible for reporting any maintenance issues in the nutrition rooms through the facility's electronic reporting system. The NHA explained maintenance staff would inspect the reported area or issue and if unable to fix it, they would request a replacement. The NHA added that kitchen and housekeeping staff were responsible for cleaning the nutrition rooms at least once daily. Review of the facility's policy for Cleaning and Sanitizing of Food and Non-Food Contact Surfaces revised 3/04/21 read, Food and contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth. Review of the facility's policy and procedure for Environmental Services Cleaning Guideline, issued 4/01/22 read, It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning decontamination based on the area of the facility. Purpose: It is important that clean, safe, and sanitary environment is maintained for our residents.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected health conditions related to falls for 1 of 5 residents reviewed for accidents (#608), and respiratory status for 1 of 3 residents reviewed for respiratory care (#51), out of a total sample of 44 residents. Findings: 1. Review of the medical record revealed resident #608 was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22 at 4:20 PM, the resident was seated in a wheelchair across from the nurses' station with obvious bruising noted left side of her face. Personal Care Attendant D stated the resident's bruising resulted from a fall 3 to 4 days ago. Initial review of the incident log showed since her admission, the resident had falls on 6/19/22, 6/23/22 and 6/25/22. Review of nursing documentation dated 6/17/22 read, Upon assessment patient state 'I fell last night when I was going to bathroom.' A knot is noted on the left side of patient forehead. Progress notes for resident #608 showed post-fall Interdisciplinary Plan of Care (IPOC) meetings were held on 6/19/22, 6/24/22 and 6/27/22. There was no documentation an IPOC meeting transpired to discuss the resident's fall on 6/17/22. The 6/19/22 meeting discussion referred to fall on 6/19/22; the 6/24/22 meeting discussion was for the fall on 6/23/22; and the 6/27/22 meeting discussed the fall on 6/25/22. On 6/30/22 at 9:37 AM, the Director of Nursing (DON) reviewed the facility incident documentation for the resident's fall on 6/17/22 at approximately 5:05 AM. The DON explained resident #608's fall did not show up on their incident list provided as it was entered in the category of other instead of as a fall. The DON stated the resident was found on the floor mat adjacent to bed by the night nurse and was noted with new redness to her forehead post fall. Review of the 5-day MDS assessment with assessment reference date (ARD) of 6/22/22 revealed in Section J Health Conditions .J1900. Any Falls Since Admission or Prior Assessment, whichever is More Recent resident #608 was assessed as having one fall without injury. On 6/30/22 at 2:13 PM, Registered Nurse (RN) MDS Coordinator and Licensed Practical Nurse (LPN) MDS Coordinator acknowledged the 5-day MDS dated [DATE] did not reflect resident #608's fall on 6/17/22. The RN MDS Coordinator said that question J1900B should have bed marked 1 to indicated resident had a fall with minor injury in the 7-day look back period. The MDS Coordinators added they were not aware of the resident's fall on 6/17/22 as it was not documented in the medical record and they did not remember hearing about it at the daily clinical meeting. The Centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual dated October 19, 2019 read, .J1900: Number of Falls Since Admission/Entry .B. Injury (except major)-skin tears, abrasions, lacerations, superficial bruises .Falls are a leading cause of morbidity and mortality among nursing home residents .Identification of residents who are at high risk of falling is a top priority for care planning .It is important to ensure the accuracy of the level of injury resulting from a fall. Since injuries can present themselves later than the time of the fall .Coding Instructions for J1900B, Injury Except Major) .Code 1, one: if the resident had one injurious fall (except major) since admission/entry. 2. Clinical record review revealed resident #51 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS Quarterly assessment with ARD of 5/18/22 revealed Section O required documentation of Special Treatments, Procedures, and Programs performed during the last 14 days. However, resident #51's oxygen therapy was not checked. Review of the resident's Treatment Administration Record (TAR) for the period reviewed for the assessment revealed the resident received oxygen during the 7 days look back period. On 6/30/22 at 12:58 PM, the RN MDS Coordinator stated the MDS assessment was completed by doing a 7-day look back, and included observations, interviews with the resident and staff, and review of the resident's clinical records. During review of resident #51's MDS Quarterly assessment with the RN MDS Coordinator, she validated the assessment was not coded to indicate the use of oxygen. The RN MDS Coordinator reviewed the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review and interview, the facility failed to provide supervision and secure environment for a resident with previous attempts and verbalization to exit the facility for 1 of 4 sampled residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a high likelihood he could have fallen, drowned, remained lost or been hit by a car. On 10/9/20 at approximately 9:00 AM, the facility failed to prevent resident #1, a cognitively impaired resident from exiting the facility unsupervised. Resident #1 exited the facility through the lobby's unlocked sliding glass door. He walked 0.3 miles past several retention ponds, filled with water and continued into a wooded area. A staff member from a nearby sleep study clinic notified law enforcement of a man standing on the sidewalk. At 9:45 AM, law enforcement contacted the facility to inform that resident #1 was found. The resident was returned to the facility at 9:50 AM-9:55 AM, approximately one hour after he exited the facility. The facility was unaware the resident was missing until notified by law enforcement. The facility's failure to provide adequate supervision and secure environment resulted in Substandard Quality of Care. Past Non Compliance at the Immediate Jeopardy level was identified as occurring from 10/9/20 to 10/16/20. Findings: Cross Reference to F600 Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was discharged to an Assisted Living Facility's secure unit on 11/9/2020. The quarterly Minimum Data Set ((MDS) dated [DATE] showed resident #1 had severe cognitive impairment, long term memory problems and moderately impaired cognitive skills for decision making. The MDS also noted the resident was able to ambulate without an assistive device, but his balance was not steady. The initial Nursing Admission assessment dated [DATE] noted the resident was not at risk for elopement. Quarterly risk assessments dated 2/19/20, 6/5/20 and 10/02/20 indicated the resident was at low risk for elopement. A nursing progress note by Registered Nurse (RN) A dated 10/5/20 at 11:36 PM read, pt very restless this evening-attempting to exit building for approximately 3 hours-outside in enclosed patio attempting to find a way out -pt (resident #1) found at various exits attempting to open doors-voiced that he wanted to go home-to go outside to his car-attempts to reorient pt unsuccessful-pt became aggressive raising fist to female staff and threatening to hit them-male staff finally able to convince pt to return to his room for the night-pt has on occasion refused meds-verbally abusive at times with female staff-will monitor closely to avoid elopement. Further review of RN A's progress note revealed the RN did not reassess the resident for elopement risk. She failed to contact the physician or the Director of Nursing (DON) of resident #1's change in condition and elopement attempts. RN A also failed to initiate an elopement care plan with approaches for increased supervision and safety which would have prevented resident's elopement. On 11/27/20 at 4:29 PM, the MDS Coordinator stated that all residents were reviewed at the morning clinical meeting. She stated that a 24 hour report was generated for the morning meetings which identified any occurrences from the past 24 hours. The MDS Coordinator stated that resident #1's elopement attempts on 10/5/20 were not documented on the 24-hour report as RN A did not complete the required form. She added that RN A failed to do this and the elopement attempts were not reviewed at the morning clinical meeting. She noted that as a result of this failure, the resident was not identified as an elopement risk, care plan approaches for elopement were not implemented and the resident actually eloped from the facility, 4 days, after his prior attempts. On 11/17/20 at 11 AM, the DON explained that the facility had a process in place for residents exhibiting elopement behaviors. She stated the process included notifying the physician for the resident's change of condition and obtaining new orders based on the resident's needs. She said the process also included notifying herself to ensure care and service and interventions were implemented for safety and to prevent the resident from exiting the facility. A wander guard monitoring device would be placed on the resident for safety, an elopement risk assessment was to be completed, an electronic E-Interact (change of condition form) was to be completed and the resident was to be placed on 1:1 supervision to prevent elopement. When the E-Interact form is completed in the computer, I am able to run a 24-hour report the next morning. I then review for changes in a resident's condition such as exit seeking behaviors. The event is then reviewed at the clinical nursing meeting the following morning to ensure all interventions and plan of care are in place. The DON stated that RN A had failed to follow the facility process for elopement. Because she had not called to notify me of his exit seeking behaviors and she had not completed the E-Interact form, resident #1's exit seeking behaviors on 10/05/20 were missed. RN A also failed to put in place interventions to prevent his elopement on 10/09/20. The DON noted that RN A was hired in 2018 and her orientation included education and working knowledge of the facility's process for elopement. The DON did not explain why RN A had not followed the facility's process for residents displaying elopement behaviors. She said, As a result, RN A was terminated on 10/16/20 for neglect and failure to follow the facility's elopement policy/procedures. Review of the facility's investigation, noted that resident #1 exited the facility through the front lobby, undetected, at approximately 9 am. On 11/17/20 at 11:33 AM, the front lobby area was observed with the facility's Administrative Staff. The staff explained that due to the Coronavirus 2019 (COVID 19) pandemic, the facility instituted a one way in/out of the facility. The automatic sliding doors were to be locked and staff/visitors would enter/exit through the emergency fire door. The receptionist conducted COVID-19 screening of all staff and visitors upon entrance to the facility. The receptionist's desk was located approximately 15 feet from the emergency door. The Maintenance Director stated that after the resident exited the facility on 10/9/20, he discovered the sliding glass door was not locked. He added that the cylinder lock was not engaged and the sliding door opened when someone stood in front of it. He explained the cylinder lock used to be a manual lock twisted by thumb/hand. He stated the cylinder lock was changed to a key lock after resident #1 had eloped. The Director of Nursing (DON) explained that only the receptionist was in the front lobby at the time resident #1 exited the facility on 10/9/20 at 9:00 AM. The facility determined the receptionist may have been distracted with her duties which allowed the resident to exit the facility unnoticed and unsupervised. The facility did not determine who or how the sliding door was unlocked. On 11/16/20 at 4:15 PM, the receptionist stated that she was at her desk in the front lobby on 10/9/20. She stated the only time she left her desk was to make copies between 7-7:15 AM for 10 minutes. She said she had not seen resident #1 but acknowledged she was not aware what the resident looked like. The receptionist looked at resident #1's picture and information on the computer but did not recognize the resident. On 11/17/20 at 10:00 AM, the receptionist's written statement was reviewed with the DON. There was a busy time (screening people) between 6:45 am and 7:15 am and then it slowed down. There was 1 family visitor scheduled for 9:30 AM on 10/9/20. The receptionist noted that she had taken her first break at 9:30 AM and she did not see resident #1 in the front lobby. Based on the receptionist's previous interview, there was no indication the receptionist would have recognized resident #1 if he was in the front lobby. On 11/17/20 at 11:33 AM, resident #1's elopement route was retraced from the facility to the sleep study clinic where he was rescued by law enforcement. The resident exited through the unlocked sliding glass door at the facility's front lobby. Once out of the facility, the resident turned left and walked approximately 250 feet across the paved parking lot out of the facility entrance to the street. He passed a large retention pond filled with water which was on the right side of the parking lot. He then turned left and walked along an uneven sidewalk which was adjacent to a heavily trafficked 2 lane road. He continued straight past a thickly wooded area until he reached the sleep center 0.3 miles from the facility. He was observed by an employee of the sleep center as she was coming to work. The employee called called law enforcement to report an elderly man standing near a thickly wooded area. At 9:45 AM, law enforcement contacted the facility to inform that resident #1 was found. The resident was returned to the facility at 9:50 AM-9:55 AM, approximately one hour after he exited the facility. On 11/17/20 at 5:23 PM, Certified Nursing Assistant (CNA) B stated she was not usually assigned to resident #1 but was assigned to him on 10/9/20. She said the resident was pleasant but confused and on 10/9/20 he followed his normal routine. CNA B stated she observed the resident coming out of his room after breakfast on 10/9/20 at 8:50 AM. She added that he usually sat outside in the patio near the soda machine. She noted she last saw resident #1 sitting in the patio at about 9:15 AM, when she purchased a soda from the machine. She stated later that day, around 10:00 AM, the unit manager told her that resident #1 had eloped from the facility. She stated she gave resident #1 a shower after he was returned to the facility. CNA B described the resident as being dirty and wet. His shoes and socks were soaking wet and the knees of his pants were dirty and grass stained. I think the resident fell on his knees while he was out of the facility and I was told the resident was in the swamp. The resident never said why he was out of the facility, he just seemed very scared and terrified when he returned. CNA B voiced that she and other staff believed that the receptionist was busy and did not see him when he exited by the sliding door. Review of the corrective measures implemented by the facility revealed the following: On 10/09/20: Resident #1 was reassessed after he was returned to the facility and deemed to be an elopement risk. The facility obtained a physician order [REDACTED]. The Pharmacy Consultant completed a medication review and he was seen by his physician. The facility completed a count of all resident with no issues identified. All residents in the facility were re-evaluated for elopement risk with no issues identified. All 3 elopement binders were reviewed with no issues identified. All residents with wander guard monitoring devices were checked for proper placement and validated for proper functioning. Monitoring devices were being checked every shift and care plans were in place. Interviews and handwritten statements were obtained from all staff for knowledge related to the elopement event. A 24-hour door watch was initiated immediately for observations of the sliding glass doors until the turnkey cylinder lock could be replaced. The Administrator checked the staffing and staffing ratios with no issues identified. The Maintenance Director checked all facility doors and the door codes were changed. All exit doors were checked to verify proper functioning of the wander guard monitoring device transponder system with no issues identified. The Interdisciplinary team met to investigate the elopement event, initiate interventions, and identify timeline of events. The DON initiated daily clinical review of new admissions/re-admissions and residents with change of condition that required increased supervision or elopement risk evaluation, appropriate interventions and care plans updated as indicated. On admission all residents identified through evaluation or risk screen for elopement. The staff would immediately notify the DON and follow protocol. The DON completed a review and audits of all new residents and/or risk assessments during morning and afternoon meetings to ensure processes were functioning as designed. The Regional Director of Clinical Operations provided the Administrator, DON and Clinical Managers with re-education related to elopement, supervision and accident prevention/safety. The Regional Director of Operations provided the Administrator, Maintenance Director and maintenance staff with education on the importance of checking all doors to verify proper functioning of doors and transponder for wander guard monitoring systems. Ongoing compliance to be maintained, and concerns to be reported to the Administrator. An Ad Hoc Quality Assessment and Performance (QAPI) meeting was held on 10/09/20 with the Administrator, DON and Medical Director to discuss the elopement, action plan, investigation, interventions, education, elopement drills and root cause analysis. On 10/12/20: Social Services evaluated resident #1 for psychosocial changes for a period of 72 hours. The sliding glass door turnkey cylinder lock was replaced by the Maintenance Director. The DON/designee completed education with 100% of the licensed nurses regarding the identification of a change of condition, recognition and response to include intervention on exit seeking behaviors, admission assessment, accuracy of assessments, elopement screening, interventions, elopement standards and guidelines. The Clinical Educator provided education to 100% of facility staff. Staff were not permitted to work until they received education on elopement standards and guidelines, elopement triggers, initiating interventions, review of the facility's 4 point action plan, 1:1 resident supervision, Abuse/Neglect policy and procedure, alarm response, wander guard device monitoring, placement and functioning, staff to notify DON when placing wander guard device, elopement assessment and wander guard orders. Review of the in-service attendance sheets revealed education was initiated on 10/09/20 and completed with all staff on 10/12/20. Interviews completed with 1 Registered Nurse, 5 Licensed Practical Nurses, 5 Certified Nursing Assistants and 1 housekeeping/laundry staff on 11/18/2020 from 11:00 AM-4:00 PM revealed staff were knowledgeable of the elopement procedures, supervision of residents at risk for elopement, response to door alarms and proper search procedures. Elopement drills were initiated on 10/09/20 until 100% of staff had completed on 10/12/20. Review of elopement attendance sheets revealed elopement drills were initiated on 10/09/20 and completed with all staff on 10/12/20. An outside vendor checked and ensured proper functioning of doors/egress with no issues identified. On 10/16/20 a QAPI meeting was held with the Administrator, DON and Medical Director and management staff to review and evaluate the facility's plan. Additions were made to include elopement education/triggers to the new employee orientation. The Facility Assessment was updated to include under Other-physical plant needs-Replacement of the lobby automatic entrance door thumb turn lock cylinder to key only inside and outside. Replacement of all emergency exit door keylocks to re-key for only General Master (GM) access and 24-hour door watch to facility lobby. The Medical Director reviewed and approved the facility's plan. The sample was expanded to include 3 other residents assessed as high wander/elopement risk with wander guard monitoring devices in place. Observations and record reviews revealed no concerns related to elopement risk assessment, care plans and placement of the wander guard monitoring devices for resident #3, #5 and #7.

Based on observation, interview and record review, the facility failed to provide care and services and failed to follow facility processes for residents identified with exit seeking behaviors to prevent elopement for 1 of 4 residents reviewed for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a high likelihood he could have fallen, drowned, remained lost or been hit by a car. On 10/05/20 during the 3 PM-11 PM shift, resident #1 verbalized he wanted to leave the facility and actively attempted to open facility doors to exit the facility. The facility nurse failed to notify the physician and Director of Nursing (DON) of his change in condition and failed to follow established facility processes for wandering/elopement behaviors to prevent his elopement. On 10/9/20 at approximately 9:00 AM, resident #1 exited the facility through the lobby's unlocked sliding glass door. He walked 0.3 miles past several retention ponds filled with water and continued into a wooded area. A staff member from a nearby sleep study clinic notified law enforcement of a man standing on the sidewalk. At 9:45 AM, law enforcement contacted the facility to inform that resident #1 was found near the clinic. The resident was returned to the facility at 9:50 AM-9:55 AM, approximately one hour after he exited the facility. The facility was unaware the resident was missing until notified by law enforcement. The facility's failure to provide the required care and services for wandering/elopement behaviors resulted in Substandard Quality of Care. Past Non-Compliance at the Immediate Jeopardy level was identified as occurring from 10/09/20 to 10/16/20. Findings: Cross Reference to F689 Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The hospital transfer form, AHCA Form 5000-3008 dated 07/03/19 revealed resident #1 did not have a risk alert for elopement. The document indicated he was alert, disoriented but could follow simple instructions. The Admission/Re-Admission Nursing Note dated 07/03/19 documented he was oriented to person, place and time. The elopement screen indicated he was not an elopement risk. The Admission Minimum Data Set ((MDS) dated [DATE] documented he had moderate impaired cognition, required supervision with activities of daily living (ADL) and ambulated independently without assistive device. The quarterly MDS assessment dated [DATE] revealed he now had short-term and long-term memory problems and moderately impaired cognitive skills for decision making (decisions poor; cues/supervision required). Review of the physician orders [REDACTED]. The Risk Screen for elopement dated 02/19/20, 06/05/20 and 10/02/20, documented resident #1 was at low risk for elopement and did not have a care plan for safety/elopement. A nursing progress note dated 10/05/20 at 11:36 PM, by Registered Nurse (RN) A, revealed, Resident #1 had been very restless during the evening shift and had attempted to exit the facility for 3 hours. He was observed at various exit doors trying to open the doors to exit the facility. He stated that he wanted to go home and go outside to his car. When staff attempted to intervene, he became aggressive, raised his fists and verbally threatened the staff. Further review of the nurse's note revealed that RN A had not notified the physician, responsible party or Director of Nursing (DON) of resident #1's change in condition and attempts to exit the facility. RN A had also failed to ensure interventions and/or increased supervision were put in place for safety to prevent his elopement. Review of the October 2020 Medication Administration Record [REDACTED]. On 11/17/20 at 11 AM, the DON explained that the facility had a process in place for residents exhibiting elopement behaviors. She stated the process included notifying the physician for the resident's change of condition and obtaining new orders based on the resident's needs. She said the process also included notifying herself to ensure care and service and interventions were implemented for safety and to prevent the resident from exiting the facility. A wander guard monitoring device would be placed on the resident for safety, an elopement risk assessment was to be completed, an electronic E-Interact (change of condition form) was to be completed and the resident was to be placed on 1:1 supervision to prevent elopement. When the E-Interact form is completed in the computer, I am able to run a 24-hour report the next morning. I then review for changes in a resident's condition such as exit seeking behaviors. The event is then reviewed at the clinical nursing meeting the following morning to ensure all interventions and plan of care are in place. The DON stated that RN A had failed to follow the facility process for elopement. Because she had not called to notify me of his exit seeking behaviors and she had not completed the E-Interact form, resident #1's exit seeking behaviors on 10/05/20 were missed. RN A also failed to put in place interventions to prevent his elopement on 10/09/20. The DON noted that RN A was hired in 2018 and her orientation included education and working knowledge of the facility's process for elopement. The DON did not explain why RN A had not followed the facility's process for residents displaying elopement behaviors. She said, As a result, RN A was terminated on 10/16/20 for neglect and failure to follow the facility's elopement policy/procedures. On 11/16/20 at 1:10 PM, a review of the facility's investigation was conducted with the DON. The elopement incident timeline revealed that resident #1 was last observed in the facility at 9 AM on 10/9/2020. At 9:45 AM, law enforcement contacted the facility to notify that resident #1 was found approximately 0.3 miles from the facility. He was found standing on the sidewalk next to a thick wooded area by a nearby sleep study clinic staff. Resident #1 was then returned to the facility at 9:50 AM-9:55 AM approximately 1 hour after he left the facility unsupervised. The facility had determined the root cause for the elopement was an unlocked main entrance sliding door. This sliding door was to remain locked at all times. The facility was not able to determine how or who had unlocked the door. During the time the resident exited the facility at approximately 9 AM, the receptionist was at her desk about 15 feet from the sliding glass door. At that time, the receptionist was responsible for clerical duties as well as Coronavirus 2019 (COVID-19) screening of all individuals entering the facility. The facility determined the receptionist may have been distracted with her duties which allowed the resident to exit the facility unnoticed and unsupervised. On 11/17/20 at 10:20 AM, Licensed Practical Nurse (LPN) C stated she was assigned to resident #1 on 10/09/20, the day he exited the facility. She described the resident as soft spoken, and able to make his needs known. She said he walked independently and spent a lot of time outside in the courtyard. On 10/09/20 at 8:50 AM, I was in the hallway with my medication cart preparing my medication administration. Resident #1 walked up to the medication cart and I explained to him that it was time for his medications. The resident said he wanted to take his medications last, and he went out to the courtyard. A short while later the Resident Care Unit (RCU) manager asked me if I had seen resident #1. I told her that he was out in the courtyard. The RCU Manager then informed me that the resident had exited the facility. Resident #1 was returned to the facility at about 10 AM and his assigned Certified Nursing Assistant (CNA) and I assisted him with a shower. He did not explain why he left the facility. His shoes and socks were wet and the knees of his pants had grass stains. His fingernails had dirt under them. The resident's physician and responsible party were notified. The RCU Manager completed the elopement assessment, a wander guard monitoring device was placed on his ankle and he was placed on 1:1 supervision. On 11/17/20 at 5:50 PM, Certified Nursing Assistant (CNA) B stated she was assigned to resident #1 on 10/09/20 on the 7 AM-3 PM shift. He was confused and was always walking around. He spent most of his time outside in the courtyard sitting on the bench or by the soda machine. Pre COVID-19 I had seen the resident in the front lobby, but he never went to the front doors or attempted to leave the facility. On 10/09/20 at 8:55 AM, I was picking up the resident's breakfast trays. I saw resident #1 sitting outside in the courtyard by the soda machine. It was not until 10 AM when the RCU Manager asked me if I had seen resident #1. A few minutes late, law enforcement brought resident #1 back to the facility and I assisted the nurse with his shower. CNA B described the resident as being dirty and wet. His shoes and socks were soaking wet and the knees of his pants were dirty and grass stained. I think the resident fell on his knees while he was out of the facility and I was told the resident was in the swamp. The resident never said why he was out of the facility, he just seemed very scared and terrified when he returned. Review of the facility's Abuse and Neglect Policy and Procedure, dated 10/17/19, read, . 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 Review of the Facility Assessment updated and reviewed by the Quality Assessment and Performance Improvement (QAPI) committee on 10/09/20, revealed the facility is able to meet the needs of residents with [MEDICAL CONDITION], Impaired Cognition, Mental Disorders, Depression, [MEDICAL CONDITION] Disorder, Anxiety Disorder, [MEDICAL CONDITION], and Wandering Behaviors. Review of the corrective measures implemented by the facility revealed the following: On 10/09/20: Resident #1 was reassessed after he was returned to the facility and deemed to be an elopement risk. The facility obtained a physician order [REDACTED]. The Pharmacy Consultant completed a medication review and he was seen by his physician. The facility completed a count of all resident with no issues identified. All residents in the facility were re-evaluated for elopement risk with no issues identified. All 3 elopement binders were reviewed with no issues identified. All residents with wander guard monitoring devices were checked for proper placement and validated for proper functioning. Monitoring devices were being checked every shift and care plans were in place. Interviews and handwritten statements were obtained from all staff for knowledge related to the elopement event. A 24-hour door watch was initiated immediately for observations of the sliding glass doors until the turnkey cylinder lock could be replaced. The Administrator checked the staffing and staffing ratios with no issues identified. The Maintenance Director checked all facility doors and the door codes were changed. All exit doors were checked to verify proper functioning of the wander guard monitoring device transponder system with no issues identified. The Interdisciplinary team met to investigate the elopement event, initiate interventions, and identify timeline of events. The DON initiated daily clinical review of new admissions/re-admissions and residents with change of condition that required increased supervision or elopement risk evaluation, appropriate interventions and care plans updated as indicated. On admission all residents identified through evaluation or risk screen for elopement. The staff would immediately notify the DON and follow protocol. The DON completed a review and audits of all new residents and/or risk assessments during morning and afternoon meetings to ensure processes were functioning as designed. The Regional Director of Clinical Operations provided the Administrator, DON and Clinical Managers with re-education related to elopement, supervision and accident prevention/safety. The Regional Director of Operations provided the Administrator, Maintenance Director and maintenance staff with education on the importance of checking all doors to verify proper functioning of doors and transponder for wander guard monitoring systems. Ongoing compliance to be maintained, and concerns to be reported to the Administrator. An Ad Hoc Quality Assessment and Performance (QAPI) meeting was held on 10/09/20 with the Administrator, DON and Medical Director to discuss the elopement, action plan, investigation, interventions, education, elopement drills and root cause analysis. On 10/12/20: Social Services evaluated resident #1 for psychosocial changes for a period of 72 hours. The sliding glass door turnkey cylinder lock was replaced by the Maintenance Director. The DON/designee completed education with 100% of the licensed nurses regarding the identification of a change of condition, recognition and response to include intervention on exit seeking behaviors, admission assessment, accuracy of assessments, elopement screening, interventions, elopement standards and guidelines. The Clinical Educator provided education to 100% of facility staff. Staff were not permitted to work until they received education on elopement standards and guidelines, elopement triggers, initiating interventions, review of the facility's 4 point action plan, 1:1 resident supervision, Abuse/Neglect policy and procedure, alarm response, wander guard device monitoring, placement and functioning, staff to notify DON when placing wander guard device, elopement assessment and wander guard orders. Review of the in-service attendance sheets revealed education was initiated on 10/09/20 and completed with all staff on 10/12/20. Interviews completed with 1 Registered Nurse, 5 Licensed Practical Nurses, 5 Certified Nursing Assistants and 1 housekeeping/laundry staff on 11/18/2020 from 11:00 AM-4:00 PM revealed staff were knowledgeable of the elopement procedures, supervision of residents at risk for elopement, response to door alarms and proper search procedures. Elopement drills were initiated on 10/09/20 until 100% of staff had completed on 10/12/20. Review of elopement attendance sheets revealed elopement drills were initiated on 10/09/20 and completed with all staff on 10/12/20. An outside vendor checked and ensured proper functioning of doors/egress with no issues identified. On 10/16/20 a QAPI meeting was held with the Administrator, DON and Medical Director and management staff to review and evaluate the facility's plan. Additions were made to include elopement education/triggers to the new employee orientation. The Facility Assessment was updated to include under Other-physical plant needs-Replacement of the lobby automatic entrance door thumb turn lock cylinder to key only inside and outside. Replacement of all emergency exit door keylocks to re-key for only General Master (GM) access and 24-hour door watch to facility lobby. The Medical Director reviewed and approved the facility's plan. The sample was expanded to include 3 other residents assessed as high wander/elopement risk with wander guard monitoring devices in place. Observations and record reviews revealed no concerns related to elopement risk assessment, care plans and placement of the wander guard monitoring devices for resident #3, #5 and #7.

Based on observation, interview and record review, the facility failed to prevent the development of 2 avoidable pressure ulcers to the coccyx area for 1 of 4 sampled residents (#66). Findings: On 4/02/18 at 1:15 PM, resident #66 sat in his wheelchair in his room. He complained of pain to his buttock area and shifted from side to side to relieve the pressure. He stated that he sat for over 4 hours and needed to rest in bed. He asked to be assisted to bed. Licensed practical nurse (LPN) F was notified of resident's complaints of pain to his bottom. She stated that perhaps he was sitting for too long, and that she will have the certified nursing assistant (CNA) assist him to rest in bed. On 4/02/18 at approximately 3 PM, the resident was resting on top of the covers of his bed. He was fully dressed. On 4/03/18 at 11 AM, the resident sat in his wheelchair in his room and stated that his buttock area was hurting and burning. He stated, I don't know why no one is doing anything about the sores. He stated that the pain and burning was getting worse and not better. LPN F was informed that the resident complained of pain. She stated that she would take care of it. When she was asked about any pressure ulcers or skin issues, she stated that he did not have any sores on his bottom. The resident sat in his wheelchair in his room on 4/03/18 at 2:07 PM. He stated that he was okay. He said he had been toileted, and the CNA had applied cream to his bottom. The resident had a black cushion on his wheelchair but he stated that it was not very comfortable. He had been sitting in his wheelchair for over 5 hours. On 4/04/18 at 10:40 AM, the resident sat in his chair in his room. He stated that the pain to his buttocks was still bad and he shifted his weight from side to side in his chair to relieve the pressure. He stated that he was going to an assisted living facility today and his daughter-in-law was here to help pack up his belongings. He said that, the girl who cleaned me up yesterday told me there were two sores on my bottom, and that is why it hurts. With the resident's permission to observe his buttocks, the assistant director of nursing (ADON) and LPN F assisted the resident to bed. After the resident was provided incontinence care, he was noted with redness to the coccyx and buttocks and two open areas, one on each inner buttock. The open areas were round and approximately 1 centimeter (cm.) by 1 cm in size. The ADON and LPN F stated that they were not aware of the two open areas. The ADON stated that they appeared to be stage II pressure ulcers. A review of the resident's care plan dated 3/14/18 for pressure ulcers noted that he was admitted with deep tissue injury to his right heel and toes. The care plan was revised on 3/15/18 including that the resident was at risk for developing a pressure ulcer - incontinence, limited mobility. Interventions included assistance as necessary to reposition/shift weight to relieve pressure; assistance with turning and positioning if resident is unable, minimize pressure over bony prominence, notify nurse immediately of any new areas of skin breakdown, during bathing or daily care, and provide incontinence care, apply barrier cream as needed. There were no interventions listed for a either a specialty mattress or time limits of how long the resident should be sitting in his chair. The weekly skin integrity review, dated 4/03/18, noted the resident had slight red blanchable area to coccyx, and right heel deep tissue injury. The right heel was noted as pressure, measuring 1.1 cm. by 1.5 cm. by 1.1 cm. with 100% eschar. Eschar is dead tissue that sheds or falls off from healthy skin occurs in pressure wounds (healthline.com). The nurses' progress notes from 3/28/18-4/03/18 at 11:23 AM did not contain any documentation of the resident's discomfort to his buttock area. After LPN F was notified of the resident's complaint of pain to his buttocks, she wrote a progress note on 4/03/18 at 11:49 AM. However, an assessment of the resident's skin was not completed at that time. The 14-day minimum data set (MDS), dated [DATE], showed the resident required extensive assistance of 2 persons for bed mobility, transfers from bed to wheelchair, and toilet use. He required extensive assistance of 1 person for personal hygiene. An interview with CNA G on 4/04/18 at 2:20 PM revealed that she had cared for the resident today during the 7 AM to 3 PM shift. She stated she had not seen any open areas on resident's sacral or buttock area. She stated that she had toileted the resident this morning and given him peri care but had not noticed the open areas because he was standing when she provided care. She stated that the open areas would have been difficult to see because of their location on the inner buttocks. She stated that the resident had been sitting up since after breakfast, almost six hours. On 4/04/18 at 3:45 PM, the director of nursing (DON) stated that the facility was doing what they were suppose to do. She stated that the blanched area to the coccyx was identified and it was being treated with barrier cream. She stated that the open areas probably showed up this morning. She said it probably happened when they were cleaning the barrier cream off his skin. On 4/05/18 at 9:04 AM, the physician wrote under diagnoses, Coccyx ulcer stage II non infected. The previous physican/s note, dated 4/03/18, did not mention a stage II coccyx ulcer. On 4/05/18 at 9:45 AM, CNA H stated that she provided care to the resident on 4/03/18 from 7 AM to 3 PM. She stated she had not seen any open areas on his bottom. She said he complained of pain but she figured it was from sitting too long, so she assisted him to bed to rest. She could not provide an answer when questioned as to how long the resident should sit up in the chair. A telephone interview with CNA I on 4/05/18 at 1:15 PM revealed that she had cared for the resident on 4/03/18 on the 3-11 PM shift. She stated that she remembered looking after the resident and gave him care at about 7 PM. She said that she had provided incontinence care while he was in bed, and noticed 2 open areas. She said he kept complaining of pain and when she looked, she noticed 2 small open areas on each inner buttock. She stated that they were difficult to detect because they were on the inner aspect of the buttocks. She said she applied barrier cream to the open areas. She said she could not understand why he kept saying it was burning until she found the open areas, and stated, Of course, that is what was hurting him. She said she informed the nurse who was in the hallway but could not remember which nurse it was. She did not indicate if she had documented the open areas in the resident's medical record. The facility policy and procedure (P&P) for wound care, dated (YEAR), reflected the following for stage II pressure injury: for No or Minimal Drainage, apply Derma View II Transparent film or DermaFilm [MEDICATION NAME] dressing, change every 3 to 5 days/PRN (as needed); for Area exposed to incontinence, cleanse with PeriFresh perineal cleanser/pat dry, apply DermaMed Ointment, repeat above after each episode of incontinence. Barrier cream, the treatment used for resident #66, was to be used for stage I pressure injury only. This wound care P&P for stage II pressure ulcers was not followed. On 4/05/18 at 2:30 PM, the unit manager (UM) stated that he worked as the floor nurse on the 3-11 PM shift on 4/03/18 on the hallway where resident #66 resided. He stated that he was not informed of any open areas to the resident's buttocks. He presented a statement after the pressure ulcers were discovered, dated 4/04/18, which reflected that he had assessed the resident's coccyx on 4/03/18 at 3:38 PM. The statement read, resident observed to have red blanchable area noted to coccyx region. Resident had barrier cream applied, no open area was noted. Resident stated he had no pain to nurse. Resident turned and repositioned. The UM could not provide an answer when he was asked on 4/04/2018 at 3:45 PM why he had not documented this information in the progress note when it occurred. He also could not provide an answer as to how the open areas appeared 3 hours after he assessed the resident. A telephone interview with the resident's daughter-in-law on 4/05/18 at 12:30 PM revealed that the resident's discharge plans were put on hold because of the newly acquired pressure ulcers. She stated that she did not know why the staff had not addressed this before as he had been complaining of pain to his bottom for days. She said she told the staff about the pain but was told by the UM on the evening of 4/03/18 that there was nothing there. She said a few hours after she left the faciity on [DATE], the resident called her and said, I told you so. I knew something was wrong. The girl that put me to bed told me I had 2 sores on my bottom. That's what was hurting me. The daughter-in-law stated, I don't think they checked him carefully when he complained of pain.

Based on interview and record review, the facility failed to follow their process to honor an advance directive to withhold cardiopulmonary resuscitation for 1 of 6 residents reviewed with do not resuscitate (DNR) orders, (resident #1). Resident #1 was found unresponsive in bed at approximately 5:15 AM on [DATE]. The registered nurse, (RN) A initiated chest compressions without first determining the resident's code status and continued intermittent, ineffective resuscitative measures even after receiving verification of the resident's DNR order. The facility's actions to perform cardiopulmonary resuscitation (CPR) against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. This resulted in substandard quality of care and Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. Cross Reference: F223, F281, F353, F490, F520 Findings: Resident #1 was [AGE] years old and was admitted to the facility on [DATE] from the hospital for short-term rehabilitation. While in the hospital, resident #1 had a discussion with his physician about his advance directives and made his wishes clear as per the Do Not Resuscitate (DNR) order. A review of the State Do Not Resuscitate Order read, Based upon informed consent, I .direct that CPR be withheld or withdrawn. The physician's statement on the form read, I, am the physician of the patient. I direct the withholding or withdrawing of CPR (artificial respiration, cardiac compression .from the patient in the event of the patient's cardiac or respiratory arrest. This form was signed by the resident and his physician prior to admission to the facility on [DATE]. The facility admission note read that the resident was alert, oriented, and able to verbalize his needs. He was able to use a bedside urinal and utilize the call light for assistance. A review of the facility's Resident Rights form read that the resident had a right to participate in his treatment including right to formulate advance directives and the right to exercise his rights at the facility. The facility must protect and promote the rights of the resident. A review of the DNR status policy revised ,[DATE], noted that when a resident is admitted with a completed DNR form, the attending physician will be notified so that the facility required DNR order will be obtained and entered into the electronic health record under CODE STATUS. The yellow DNR form will be placed under the medical record. The social service director will ensure that the three yellow indicator dots are in the following locations: the resident's nameplate, yellow name band or yellow dot inside the name band to indicate DNR and on the resident's medical record/binder. A review of the resident's hospital records submitted to the facility at the time of admission on [DATE] showed that the transfer form included, Do Not Resuscitate. The yellow Florida DNR form was included in the hospital records. A telephone interview with registered nurse (RN) A on [DATE] at 10 AM revealed, on [DATE] at approximately 5:15 AM, 13 hours after admission, the resident was found unresponsive in bed by the lab technician. The registered nurse, (RN) A assessed the resident's radial pulse and thought it questionable as was not certain if she was feeling her own pulse. She stated that she panicked and she started chest compressions by herself without the use of a backboard, or a resuscitator bag to assist ventilation for artificial respirations, and without ascertaining the resident's code status. She then stopped compressions, left the resident's room, and called out for help from LPN B, the other nurse on the unit. She then went back to the resident and resumed chest compressions by herself. She again stopped compressions, left the resident and went to the nurse's station as LPN B was still at the nurse's station because she was not able to quickly confirm the code status. The electronic record did not contain the DNR order and the Florida DNR form was not in the required yellow DNR binder. The DNR form was then located within an envelope containing the resident's hospital records. The RN A then called emergency services (911), and instructed them to come to the facility despite verification of the DNR order. She stated that she thought, nothing to lose, might as well save a life if he can be resuscitated. While still at the nursing station, she called the Nurse Practitioner who instructed her to verify the resident's code status and continue CPR until paramedics arrived. A telephone interview with RN A on [DATE] at 11:00 AM revealed that she was not aware of the resident's code status. An event note dated [DATE] at 5:28 AM revealed that RN A performed CPR until the ambulance personnel came in to the room and checked the resident. The resident was pronounced deceased by the paramedics at 5:28 AM on [DATE]. An interview with the admissions coordinator on [DATE] at 4:15 PM noted that a resident's DNR order comes with them from the hospital. She stated that social services and the admitting nurse check for the DNR status when the resident arrives at the facility. An interview with the social service director on [DATE] at 4:38 PM revealed that the yellow DNR status bracelet is placed on the resident at admission and a yellow sticker is placed on the nameplate of the door by the concierge. The next morning my staff verify the code status with the resident/family. An interview with concierge, CNA D on [DATE] at 5:15 PM revealed that the admitting nurse informs the concierge if the resident has a DNR order. The concierge is responsible for placing the yellow bracelet on the resident's wrist and the yellow sticker on the nameplate of the door. She stated that if the concierge is not available, any other staff person could apply the yellow bracelet and the yellow dot on the nameplate. Regarding resident #1, she stated, I cannot remember if I put sticker or yellow bracelet on the resident or his door; I just don't remember. A telephone interview with LPN B on [DATE] at 11:00 AM revealed that she was not aware of the resident's code status. She did not see a yellow bracelet or yellow dot on the bracelet or a yellow dot on the nameplate on the door. She said that since the resident was newly admitted , all his orders were not in the electronic medical record. She could not remember exactly where she found the DNR form, but thought it was in an envelope with his hospital records, and not in the DNR binder where it should have been. An interview with the certified nursing assistant (CNA) G on [DATE] at 4:00 PM revealed that she had cared for the resident in the early morning of [DATE]. She stated that the resident was scared and lonely as he was away from his family and was in a new, unfamiliar setting. He rang his call light several times during the night as he wanted a drink and assistance with repositioning. She stated, I think he was lonely and wanted some support and reassurance. She stated that she was aware that the lab technician came at approximately 5:15 AM and said he was not breathing. It was very confusing after that, as nursing staff did not know what to do. They should not have done chest compressions if he was a DNR. A review of the resident's physician orders [REDACTED]. An interview with the director of nursing (DON) on [DATE] at 1:40 PM noted that she was not aware that the resident's DNR order had not been entered into the electronic medical record until after he deceased on [DATE] at 1:11 PM. She did not offer an explanation, but stated that she would have to contact the information technology (IT) department. She could not explain why the resident's DNR wishes and directive were violated by repeated ineffective and intermittent compressions to his chest. She stated that the nurse, RN A panicked and did not know what to do. It was an emotional knee jerk reaction by the nurse. She said she gave an in-service to RN A via telephone and then again in person, but she could not provide any documentation of the education. She said she also gave an in-service on [DATE], one day following the incident. She reviewed the DNR policy with staff and made copies of the policy available for the staff. A review of the in-service attendance record showed the topic was: DNR, full code, and toileting. There were 22 signatures on the record. Three of the 22 staff that had attended the in-service were no longer working at the facility. The current staff who attended the in-service included 2 RNs, 1 LPN, 13 CNAs, 2 unit clerks and the staffing coordinator. There were no times indicated on the form as to how long the in-service was and no attachments describing the agenda or policies/procedures for the topics discussed. The DON could not explain why toileting was included in the in-service especially after a serious incident. There was no further documentation identifying re-education to all staff for resident rights related to advance directives and DNR orders, which meant that out of 175 current staff members, only 19, had received education. The DON could not provide an answer when questioned as to why only 19 of the 175 current staff received the in-service. An interview with RN J on [DATE] revealed that the in-service given on [DATE] was a quick 5 minute in-service which consisted of reading the DNR policy and signing the attendance record. Interviews done with 33 facility staff (CNA, LPN, RN) from ,[DATE]-[DATE] revealed that they received a brief computer-based in-service on advance directives during orientation and then annually. The DON confirmed that there was no hands on training such as drills or mock codes done at the facility. She stated that staff obtained Basic Life Support training every 2 years on their own, but the facility had not tracked the staff's current certification until it was requested during the survey. When the DON was questioned regarding staff competency on CPR, DNR directives and what to do in real life scenarios, she stated that she was not aware of any competency assessments done at the facility.

Based on interview and record review, the facility failed to meet professional nursing standards of quality by failing to determine the code status, failing to follow a physician's orders [REDACTED].#1). Resident #1 was found in bed, unresponsive, on [DATE] at approximately 5:15 AM. Registered Nurse (RN) A initiated CPR without determining resident #1's code status, and performed intermittent, ineffectual resuscitation efforts before and after receiving verification of his DNR status. The facility's actions to perform cardiopulmonary resuscitation (CPR) against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. This resulted in substandard quality of care and Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. Cross-reference F155, F223, F353, F520. Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. Review of the facility's Registered Nurse (RN) and Licensed Practical Nurse (LPN) job descriptions (no dates), revealed general descriptions of Delivery and administration of nursing care as directed by physician orders, regulations and standards of practice to meet the needs of the residents. The duties of RNs and LPNs included utilize professional and sound judgement in delivery of care, and understand, comply with, and promote compliance regarding residents' rights. The facility's policy and procedure for Determination of DNR Status issued ,[DATE] and revised ,[DATE], ,[DATE] and ,[DATE] read, The resident's DNR Status will be determined by a physician's orders [REDACTED].#DH1896) being in place. The guidelines instructed staff to rely on a yellow arm band or the yellow indicator dot on the resident's door as indicators of DNR status, not initiate CPR, and obtain confirmation from the medical record. If the resident did not have a yellow armband or indicator dot, the resident should receive full resuscitation efforts until verified otherwise by a DNR order and/or the yellow form. The policy listed the areas in the medical record where DNR status could be confirmed, including physician's orders [REDACTED]. Review of the facility's policy and procedure Code Guidelines issued on ,[DATE] with no revision date, revealed CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by physician on their medical records. The procedure instructed 1. When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident's code status . Confirm DNR status with the physician's written order. If the resident was identified as a selecting full resuscitation efforts, and the staff member present was trained in CPR, a call for help should be followed by initiating CPR. Staff responding to the call for help were expected to call Code Blue over the intercom 3 times, summon emergency equipment to the room and activate the emergency medical system. Resident #1, a [AGE] year-old male, was admitted to the facility for short-term rehabilitation on [DATE], with [DIAGNOSES REDACTED]. On admission, resident #1 had a signed State of Florida Do Not Resuscitate Order (DH Form 1896) that read, Based on informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. The physician's statement, signed on [DATE], directed .the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. Review of an Event Note, dated [DATE] at 5:28 AM, revealed a laboratory technician entered resident #1's room, was not able to arouse him and called for a nurse. Registered Nurse (RN) A documented that she checked resident #1 and discovered he was unresponsive, had no pulse, no respirations and an oxygen saturation level of 0%. The note read, Performed CPR and Crash cart obtained, used ambubag trying to resuscitate patient. AMBU is a trademark Artificial Manual Breathing Unit for a resuscitator bag used to assist ventilation. http://medical-dictionary.thefreedictionary.com/Ambu+bag. RN A documented that another nurse called 911, and even though she was aware that Patient is a DNR, performed CPR until the ambulance personnel came in to the room and checked the patient. Review of narrative documentation by 911 emergency medical personnel revealed on [DATE] at 5:29 AM, resident #1 was assessed to be pulseless and not breathing as a result of [MEDICAL CONDITION], or a sudden stop of heart function (https://www.merriam-webster.com/dictionary/cardiac%20arrest). The note read, Patient has a DNR which was provided shortly after arrival. In an interview conducted on [DATE] at 10:00 AM, RN A stated she saw resident #1 on [DATE] at about midnight, and again a few hours later on [DATE] between 4:00 AM and 4:15 AM. RN A stated resident #1 expressed no concerns during those interactions. She stated she was surprised when the laboratory technologist reported resident #1 was not arousable. RN A stated she rushed into the room and observed resident #1 resting with his eyes closed, mouth slightly open and looked like he was sleeping. She stated she then checked for resident #1's pulse on his left wrist and felt a faint pulse, but was not sure. She said, Maybe it was my pulse. RN A confirmed she initiated CPR by starting chest compressions, realized she needed assistance, rushed to the nurses' station and shouted for help then returned to the room and resumed CPR on resident #1. She explained her efforts to resuscitate resident #1 were ineffective as the bed was too soft and he was sinking into the mattress. RN A explained she did not have a backboard to provide a firm surface. She stated licensed practical nurse (LPN) B arrived within a few minutes, and she asked her to verify resident #1's advance directives. RN A stated she got tired of waiting for LPN B to return, and CPR was not having a positive effect anyway, so she stopped attempting to provide chest compressions and returned to the nurses' station where LPN B was still searching for a DNR form or order. RN A called 911 and during the phone call was informed by LPN B that resident #1 had a DNR order. Despite verification of the DNR status, RN A told the 911 operator to send a team to the facility as there was nothing to lose; might as well save a life if he can be resuscitated. RN A stated she then spoke to the advanced registered nurse practitioner (ARNP) to inform her resident #1 did not have a pulse and 911 had been called, and the ARNP instructed her to continue compressions. RN A stated she returned to resident #1's room and felt bad that he had to go through this. In an interview on [DATE] at 12:09 PM LPN B stated she entered resident #1's room on [DATE] and observed RN A performing chest compressions on him. LPN B stated resident #1 had an ashen color and no pulse, and she left RN A in the room to go to the nurses' station to verify resident #1's advance directives. LPN B explained she did not follow the procedure to announce the code blue by overhead page as sometimes the intercom did not work. LPN B confirmed RN A stopped chest compressions and left resident #1's room to join her at the nurses' station while she searched for the yellow DNR form. In an interview on [DATE] at 4:00 PM, certified nursing assistant (CNA) G stated she went to resident #1's room on [DATE] shortly after the laboratory technician alerted them he was not breathing at 5:15 AM. CNA G confirmed RN A was doing chest compressions on resident #1 when she entered the room. She confirmed RN A left the resident's room and then went back into the room several minutes later to resume chest compressions. On [DATE] at 4:40 PM, the ARNP confirmed she received a telephone call on [DATE] from a panicking and confused RN A, who informed her she was doing CPR on resident #1, and thought he was a DNR. The ARNP stated she informed RN A she needed to confirm the code status, but continue CPR until emergency personnel arrived. The 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), instructed Rescuers should attempt to minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute. The Summary of High Quality CPR Components included Limit interruptions of chest compressions to less than 10 seconds. The AHA recommended healthcare providers call for nearby help upon finding the unresponsive victim, and activate the emergency response system before starting CPR. The pulse should be checked on the side of the neck over the carotid artery in preference to the radial artery in the wrist. (http://eccguidelines.heart.org/wp-content/uploads/[DATE]-AHA-Guidelines-Highlights-English.pdf) Review of the medical record revealed an Admission Summary note on [DATE] at 6:43 PM written by RN F, and a head-to-toe evaluation completed by LPN H. physician's orders [REDACTED]. However, the order for Advance Directive: DNR was not entered by RN F until [DATE] at 1:11 PM, approximately 21 hours after admission, and 8 hours after his death. In an interview on [DATE] at 1:41 PM the director of nursing explained entering admission orders [REDACTED]. In addition to omitting the DNR order from the electronic medical record, nursing staff failed to follow the facility's policy and procedure by neglecting to place a wristband on resident #1 and a yellow sticker at his door to indicate his DNR code status. This failure to follow policy and procedure was compounded by nurses neglecting to place the yellow DNR order in the advance directive binder where it would have been accessible to staff in the event of an emergency. When RN A found resident #1 to be unresponsive, she checked for a radial rather than carotid pulse, and initiated CPR with chest compressions. RN A began resuscitation efforts prior to calling for assistance, and had to stop compressions and leave the room to alert other staff members including LPN B. She returned to the room and resumed ineffective chest compressions without a backboard to provide a hard surface under resident #1. LPN B left the room to check for resident #1's code status, and did not use the intercom to call a Code Blue. After a few minutes, RN A again ceased compressions and went to the nurses' station to verify resident #1's code status as LPN B had not returned. RN A called 911 and received verification of resident #1's DNR status from LPN B while on the telephone. RN A instructed emergency response personnel to come to the facility and she returned to resident #1's room to continue resuscitation efforts despite the presence of DNR advance directive. The Event Note, dated [DATE] at 5:28 AM, documented by RN A indicated she Performed CPR and Crash cart obtained, used ambubag trying to resuscitate patient. Interviews with RNA on [DATE] at 10 AM revealed she was not able to explain how she was able to perform chest compressions, retrieve the crash cart, obtain the resuscitator bag used to assist ventilation, and provide artificial respirations by herself as indicated by her documentation in the medical record.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program to ensure the facility maintains compliance with advanced directives, neglect, standards of nursing practice and sufficient nursing staff to ensure that cardiopulmonary resuscitation (CPR) was not initiated for 1 of 6 residents with advanced directives for Do Not Resuscitate, (DNR), (resident #1). Resident #1 was a [AGE] year-old male who had a Do Not Resuscitate order at admission on [DATE] at 4:17 PM. On [DATE] at approximately 5:15 AM, the resident was found unresponsive in bed. The registered nurse, (RN) A started chest compressions by herself without ascertaining the resident's code status. She then stopped compressions, left the resident to step out of the room to call out for help from licensed practical nurse, (LPN) B. She went back into the room, resumed chest compressions by herself and then stopped compressions again, to go to the nurse's station, as LPN B was not able to quickly confirm the code status. The DNR form was located within an envelope containing the hospital records. The RN A then called emergency services (911), informed them that the resident had a DNR order and instructed them to be come to the facility. The resident was pronounced deceased by the paramedics at 5:28 AM on [DATE]. The facility's QAA committee failed to identify quality deficiencies by not identifying the root cause of the incident and failed to evaluate and analyze the risk once the incident had occurred. The facility failed to thoroughly investigate the incident, failed to recognize that there was confusion regarding following advance directives, failed to follow the facility process for determination of DNR status, failed to identify that staff did not know how to make the decision of when to initiate or not initiate CPR, and failed to provide adequate education. The facility's actions to perform CPR against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. Cross reference: F155, F223, F281, F353, F490 Findings: The facility policy on DNR status revised ,[DATE] read, In the event of a Cardio/Pulmonary arrest .staff will NOT initiate CPR but will require DNR confirmation from the resident's medical record. An interview with the administrator, director of nursing (DON), clinical regional director, and the regional director of operations on [DATE] at 1:40 PM revealed that they identified the failure of not honoring the resident's DNR directive by initiating compressions as a serious event, but they did not convene for an immediate QAA meeting. The DON stated that she spoke to the medical director on [DATE] and informed him about the incident. A telephone interview with the medical director on [DATE] at 1:30 PM revealed that the facility did not have a QAA meeting since the incident. He said that he was informed that resident #1 was found unresponsive and received chest compressions despite having a DNR order. He stated that he was informed by telephone and directed that all staff be re-educated on the DNR policy. The DON on [DATE] at 1:40 PM stated that she provided an in-service to the nurse who was involved in the incident, RN A via telephone, and then again in person, but could not provide documentation of the in-service. An interview with RN A on [DATE] at 11:00 AM noted that she remained unclear about DNR orders. She stated that, DNR meant not to resuscitate but when? What if the resident still had a weak pulse? I am still confused about this. I had an in-service which was only a few minutes long and I was asked to sign the attendance record. There was no time to ask questions. The DON on [DATE] at 1:40 PM stated that she started in services on [DATE], one day after the incident. She reviewed the DNR policy with the staff and made copies of the policy available for staff. A review of the in-service attendance sheet noted that topics included, DNR, Full Code and toileting. There were 22 signatures on the attendance form and 3 of the 22 were no longer working at the facility. The staff who attended this in-service included 13 certified nursing assistants (CNA), 2 unit clerks, 1 staffing coordinator, 2 RNs and 1 LPN. The DON could not provide an answer when asked why only 19 of the 175 current staff received the in-service. An interview with RN J on [DATE] revealed that the in-service given on [DATE] was a quick 5 minute in-service which consisted of reading the DNR policy and signing the attendance record. Interviews done with 33 facility staff (CNA, LPN, RN) from ,[DATE]-[DATE] revealed that they received a brief computer based in-service on advance directives during orientation and then annually. The DON confirmed that there was no hands on training such as drills or mock codes done at the facility. She stated that staff obtained Basic Life Support training every 2 years on their own but the facility had not tracked the staff's current certification until it was requested during the survey. When the DON was questioned regarding staff competency on CPR, following DNR directives and what to do in real life scenarios, she stated that she was not aware of any competency assessments done at the facility. Although the failure of not honoring the resident's Do Not Resuscitate directive was serious, the facility failed to investigate the incident and failed to recognize the root cause. The facility did not focus on the incident as a system failure, but rather an, emotional, knee jerk reaction by the nurse. The DON on [DATE] stated that she had investigated the incident by speaking to the nurse and CNA involved in the incident, RN A and CNA C. It was pointed out to the DON that there was another nurse involved in the incident, LPN B. LPN B was called to the incident to assist and had assessed the resident and was sent by RN A to ascertain the resident's code status in the medical record. The DON replied that she was not aware that LPN B was involved and had not spoken to her. She could not provide an answer as to how an investigation was done if she was not aware of which staff were involved in the incident. She stated that she reviewed the DNR policy with RN A and asked her several times if she had any questions regarding the policy. She stated that the resident had a Do Not Resuscitate directive at admission that should have been followed. She stated it was not a systems failure but RN A panicked and did not know what to do. The DON confirmed that their decision on the root cause was that RN A panicked and wanted to save the resident. She said that during her review, she did not consider the nursing staff inability to perform CPR effectively as a focus for the QAA committee. A review of the DNR status policy revised ,[DATE] read, 9. When a resident is admitted with a completed DNR form, the attending physician will be notified so that the facility required DNR order would be obtained and entered into the electronic health record under CODE STATUS. The yellow DNR form will be placed under the Advanced Directive tab in the medical record. The social service director/designee will ensure that the three yellow indicator dots are in the following locations: 1. Yellow indicator dot on resident's nameplate. 2. Yellow name band or yellow indicator dot placed inside the name band to indicate the presence of the DNR and 3. Yellow indicator dot on the spine of the resident's medical record/binder. An interview with RN A on [DATE] revealed that she was not aware of the resident's code status. She did not see a yellow armband on the resident's wrist indicating DNR. She also did not see the yellow dot on the nameplate of his door. An interview with LPN B on [DATE] at 11:35 AM revealed that she did not recall a yellow armband or the yellow dot on the door. She stated that she did not trust the armband or the yellow dot on the door, as they were not always updated. She said that she was instructed by RN A to look for the resident's code status. She said that the resident had just been admitted the previous evening and not all of his orders were in the electronic medical record. She could not remember exactly where she found the resident's DNR form but thought it was in an envelope with his hospital records. An interview with the DON on [DATE] at 1:40 PM contradicted this finding as she stated that she thought the yellow dot was on the door and the resident had a yellow armband indicating DNR. When it was revealed to the DON that the resident's DNR order had not been entered electronically into the medical record until after he deceased on [DATE] at 1:11 PM, she stated that she was not aware of this and would have to contact the IT department.

Based on interview and record review, the facility failed to ensure nursing staff had adequate competency and skill to determine residents' resuscitation status and intervene appropriately according to advance directives for 1 of 6 sampled residents (#1). Resident #1 was found in bed, unresponsive, on [DATE] at approximately 5:15 AM. Registered Nurse (RN) A initiated CPR without determining resident #1's code status, and provided intermittent, ineffectual resuscitation efforts before and after receiving verification of his Do Not Resuscitate (DNR) status. The facility's actions to perform cardiopulmonary resuscitation (CPR) against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. This resulted in substandard quality of care and Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. Cross-reference F155, F223, F281, F520. Findings: Resident #1, a [AGE] year-old male, was admitted to the facility for short-term rehabilitation on [DATE] at 4:17 PM. On admission, resident #1 had a State of Florida Do Not Resuscitate Order. On [DATE] at approximately 5:15 AM, resident #1 was found unresponsive by the lab technician. Registered Nurse (RN) A documented that she checked resident #1 for a radial pulse, but was not certain if she was feeling her own pulse. She started doing chest compressions by herself without using a backboard and without ascertaining resident #1's code status. She then stopped compressions to step out of the room and call out for assistance from LPN B. She resumed chest compressions by herself and then stopped again to assist LPN B locate resident #1's advance directives. The electronic record and yellow advance directive binder did not contain a DNR order for resident #1. The form was eventually located in an envelope with resident #1's hospital records. RN A called 911, informed them resident #1 had a DNR and instructed them to come to the facility. RN A then called the advanced registered nurse practitioner (ARNP) who instructed her to continue cardiopulmonary resuscitation (CPR) until paramedics arrived. Resident #1 was pronounced dead by the paramedics on [DATE] at 5:28 AM. In an interview conducted on [DATE] at 10:00 AM, RN A stated when the laboratory technologist reported resident #1 was not arousable, she rushed into the room and observed resident #1 resting with his eyes closed, mouth slightly open and looked like he was sleeping. She stated she then checked for resident #1's pulse on his left wrist and felt a faint pulse, but was not sure. She said, Maybe it was my pulse. RN A confirmed she initiated CPR by starting chest compressions, realized she needed assistance, rushed to the nurses' station and shouted for help then returned to the room and resumed CPR on resident #1. She explained her efforts to resuscitate resident #1 were ineffective as the bed was too soft and he was sinking into the mattress. RN A explained she did not have a backboard to provide a firm surface. She stated licensed practical nurse (LPN) B arrived within a few minutes, and she asked her to verify resident #1's code status. RN A stated she got tired of waiting for LPN B to return with verification of resident #1's code status, and CPR was not having a positive effect anyway, so she ceased resuscitation efforts again and returned to the nurses' station where LPN B was still searching for a DNR form or order. RN A stated she told the 911 operator to send a team to the facility as there was nothing to lose; might as well save a life if he can be resuscitated even though LPN B found the DNR order. RN A revealed that she was a new nursing school graduate and had been working at the facility for approximately 5 months. The 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), instructed Rescuers should attempt to minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute. The Summary of High Quality CPR Components included Limit interruptions of chest compressions to less than 10 seconds. The AHA recommended healthcare providers call for nearby help upon finding the unresponsive victim, and activate the emergency response system before starting CPR. The pulse should be checked on the side of the neck over the carotid artery in preference to the radial artery in the wrist. The updated Basic Life Support (BLS) Retraining Intervals 2015 read, Given the rapidity with which BLS skills decay after training, coupled with the observed improvement in skill and confidence among students who train more frequently, it may be reasonable for BLS retraining to be completed more frequently by individuals who are likely to encounter [MEDICAL CONDITION]. The document indicated growing evidence continued to show that recertification in basic and advanced life support every 2 years is inadequate for most people, and it was reasonable that individuals who were likely to encounter a [MEDICAL CONDITION] victim perform more frequent mannequin-based retraining. Although data was limited, the AHA recognized an improvement in skills and confidence among students who train more frequently. (http://eccguidelines.heart.org/wp-content/uploads/[DATE]-AHA-Guidelines-Highlights-English.pdf) On [DATE] at 12:09 PM, LPN B confirmed she was called to assist RN A but did not announce a Code Blue over the intercom. She explained she had no experience with residents dying, and the facility provided a paper in-service. LPN B said, It would have been helpful to get hands-on practice so we would know what to do. Paper in-service does not help us learn what to do in an emergency situation. LPN B stated that she was, not familiar with people dying as I am a new nurse. On [DATE] at 4:50 PM, the ARNP stated RN A was confused at the time of the incident, and based on questions she asked the previous day, [DATE], regarding DNR status and CPR, and what to do if the resident had a weak pulse, she thought RN A was still not clear on how to determine a resident has no pulse and/or is not breathing and when to initiate CPR. In an interview on [DATE] at 11:00 AM, RN A confirmed she was confused regarding DNR code status and the circumstances that required initiation of CPR. She explained the facility provided training a few months prior, possibly in April or [DATE], but it only lasted for a few minutes and she signed for receipt of a policy. RN A recalled being taught to err on the side of caution and start compressions even if DNR. On the 11 PM -7 AM shift on ,[DATE] -[DATE], the facility census was 109 and the facility has a capacity of 114 residents. On the daily attendance report for the transitional care unit (TCU) dated [DATE], 3 nurses and 6 CNAs were listed for the 3 PM to 11 PM and 3 nurses and 3 CNAs were listed for the 11 PM to 7 AM shift. Resident #1 was admitted to the TCU on [DATE]. During interviews conducted between [DATE] and [DATE], 17 nursing staff, including RNs, LPNs and certified nursing assistants (CNAs), stated although certified to perform CPR, they had concerns regarding identification of residents who had DNR orders, and questioned their own readiness and ability to perform CPR appropriately: On [DATE] at 5:54 PM, LPN U stated she was on staff for about 3 weeks, and was not aware of the color bracelet used to identify residents with DNR status. On [DATE] at 12:00 PM CNA C stated she knew nothing about the facility's yellow wristband and yellow dot system that identified residents who had DNR advance directives. CNA C, on staff for 7 months, stated she never received training on CPR or DNR. On [DATE] at 2:13 PM, LPN K could not recall any education on CPR or advance directives in the last year. On [DATE] at 2:25 PM, LPN L, on staff for 7 months, stated she had not received education on advance directives and CPR since general orientation. On [DATE] at 2:35 PM, RN M stated she was a new nurse and on staff for about a month. She explained she received a brief computer-based training on advance directives in orientation, and no education on CPR. RN M stated if she found an unresponsive resident she would shout for the other nurse as she would not feel comfortable doing CPR. On [DATE] at 2:41 PM, CNA N stated residents with DNR orders got yellow wristbands, but this was not reliable because sometimes residents removed them. She could not recall an in-service on CPR or advance directives in the past 3 years. On [DATE] at 2:48 PM, CNA O stated she recalled computer training in orientation about 8 months ago, and verbal training on CPR. CNA O, She told us how many times to press, meaning chest compressions. On [DATE] at 2:50 PM, RN J stated she had been on staff for 2 months and had not received any CPR training. She said, It would be helpful to do mock codes. I had it at another facility and it was helpful. RN J said the facility did not conduct any mock codes. On [DATE] at 3:11 PM, CNA P stated she could not recall any recent training on advance directives or CPR. On [DATE] at 4:00 PM, CNA G stated she received computer training on CPR and DNR in orientation. CNA G explained she worked on the unit on the day of the incident with resident #1, and said, It was very confusing as to what to do. She stated she received a handout after the incident, but no training. On [DATE] at 9:08 AM, CNA R stated the last training she received on advance directives and CPR was about a year ago. CNA R stated in-services were no longer hands-on since the educator was no longer employed there. On [DATE] at 9:14 AM, CNA S confirmed the last time she received education on code status was over a year ago. She explained, There was not much training since the educator left. On [DATE] at 9:34 AM, LPN Q stated she received training on CPR and advance directives in orientation for a few minutes, maybe it was a policy but could not recall any details. On [DATE] at 10:57 AM, LPN T stated the facility's orientation consisted mostly of computer modules. She said, It was really boring. I didn't feel like I learned anything in the training. LPN T could not recall any education on advance directives or CPR either during or after her orientation. She stated she felt like training was done after the fact rather than in advance. On [DATE] at 11:23 AM, LPN H could not recall if advance directives and CPR were addressed in her orientation, but was sure she had not received any education on those topics for since the educator left. She confirmed since the facility's educator left They go over things with us, we have to sign and get a flyer. LPN H stated she did not always keep the flyers. Review of the policy and procedure for Code Guidelines issued ,[DATE] revealed, CPR will be provided for all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by physician on their medical records. The procedure included guidelines for individuals who were trained and those who were not trained in CPR, and specified the individual who responded to a call for help should call Code Blue over the intercom 3 times. The policy read, The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code . The Code Guidelines policy and procedure did not specify whether CPR should be performed by nurses and/or CNAs. It did not address which staff members were required to have CPR certification or the recommended level of training and method of instruction. Review of the job descriptions for RNs and LPNs revealed an expectation of Delivery and administration of nursing care as directed by physician orders, regulations and standards of practice to meet the needs of the residents. The qualifications for RN and LPN positions included hold and maintain current license .in good standing. The job descriptions did not include a requirement for nurses to maintain current CPR certification. Review of the general orientation and annual nurse and CNA education competency checklists revealed staff were required to complete emergency training and a mock code on orientation and annually. The facility's 2017 Monthly Education Plan revealed the topics of Advance Directives and CPR/Code Blue were scheduled for [DATE] in an instructor led training format. During an interview on [DATE] at 11:47 AM, the director of nursing (DON) stated any education she had provided on advance directives or CPR was done verbally. She said, I personally have not done hands-on. The DON said she has been responsible for education since the staff educator left, but she could not provide a definitive time frame for how long the facility did not have a staff educator. On [DATE] at 1:41 PM the DON confirmed the facility provided a brief computer-based training on advance directives for all employees during orientation and annually. She validated the facility did not conduct hands-on trainings such as drills or mock codes. The DON stated she was not aware of any competency testing with real life scenarios regarding following DNR directives and performing CPR. She explained staff were responsible for maintaining CPR certification, and admitted the facility did not have a system to monitor that certification was current. The DON confirmed there was no evaluation process in existence to monitor the effectiveness of training provided by the facility before and after the incident involving resident #1. On [DATE] at 11:47 AM, on [DATE] at 8:42 AM, 9:41 AM, 1:15 PM and 1:41 PM, requests were made for staff CPR certification records, nurse and CNA competency checklists and proof of completion of all education and in-services. On [DATE] at 2:58 PM, the Regional Director of Clinical Operations explained the facility had just begun, and was still in process of validating and uploading CPR certification for all licensed employees. The facility was not able to provide complete records of staff education and training.

Based on interview and record review, the facility failed to administer its resources effectively to ensure that advance directives were honored and that cardiopulmonary resuscitation was not initiated for 1 of 6 residents with Do Not Resuscitate directives, (resident #1). Resident #1 was found in bed, unresponsive at approximately 5:15 AM on [DATE]. Registered nurse (RN) A initiated chest compressions without first determining the resident's code status and continued ineffective resuscitative efforts even after receiving verification that the resident had a do not resuscitate (DNR) order. The facility's actions to perform cardiopulmonary resuscitation (CPR) against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. The administration's failure to protect the resident from futile intermittent chest compressions which violated his Do Not Resuscitate wishes, the failure to follow process for determining code status, the failure to perform CPR efficiently, the failure to react effectively in an emergency situation, and the failure to adequately train and monitor staff in DNR/CPR competency led to Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. Cross Reference: F155, F223, F281, F353, F520 Findings: Resident #1 was a [AGE] year old male who had a Florida Do Not Resuscitate order at admission on [DATE] at 4:17 PM. On [DATE], the resident was found in bed, unresponsive by the lab technician. A telephone interview conducted with RN A on [DATE] at 10:00 AM revealed that she was alerted by the lab technician on [DATE] at approximately 5:15 AM that she was not able to rouse resident #1. RN A said she rushed into the room and observed the resident in bed and he appeared to be sleeping. She stated that he was unresponsive and when she checked for his radial pulse, she thought she felt a faint pulse, but was not sure if she was detecting her own pulse. She stated that she panicked and started chest compressions but realized that she needed help. She stopped compressions, left the resident, stepped out of the room and shouted for help. She then returned to the room and resumed compressions. She explained that her efforts to resuscitate resident #1 were ineffective as, I did not have a backboard and he was sinking into the mattress. She stated that licensed practical nurse, (LPN) B arrived within a few minutes and I asked her to verify the resident's code status. The RN A said it was taking LPN B a long time to return and, I knew the compressions were not working, so she stopped compressions, left the resident and went to the nursing station where LPN B was checking for the resident's status. RN A then phoned emergency services, (911) and during her phone call, was informed by LPN B that resident #1 had a DNR order. Despite verification of the DNR order, RN A directed emergency services to come to the facility. RN A stated she then called the nurse practitioner to inform her that resident #1 did not have a pulse and 911 had been called. The nurse practitioner told her to verify code status and continue compressions until paramedics arrived. The RN A returned to the resident, resumed compressions until the paramedics arrived at the facility and pronounced the resident's death at 5:28 AM on [DATE]. An interview with the administrator, director of nursing (DON), clinical regional director, and the regional director of operations on [DATE] at 1:40 PM revealed that although the resident's advance directives were not followed, they did not view this incident as a violation of the resident's rights and wishes. They did not acknowledge potential for serious negative outcome for the failure to provide competent basic life support if another resident was found unresponsive in the future. The administrator stated, we felt that there was no negative outcome. The DON stated, the outcome did not change, he passed away. The end outcome was the same anyway. The Administration failed to evaluate the care that resident #1 received and had not identified the many failures with their processes. A review of the DNR status policy revised ,[DATE] read, when a resident is admitted with a completed DNR form, the attending physician will be notified so that the facility required DNR order will be obtained and entered into the electronic health record under CODE STATUS. The yellow DNR form will be placed under the medical record. The social service director will ensure that the three yellow indicator dots are in the following locations: the resident's nameplate, yellow name band or yellow dot inside the name band to indicate DNR and on the resident's medical record/binder. An interview with RN A on [DATE] at 11:00 AM revealed that she was not aware of the resident's code status. She did not see a yellow armband or dot on armband or on the door nameplate. An interview with LPN B on [DATE] at 11:35 AM revealed that she did not recall a yellow armband or the yellow dot on the door. She stated that since the resident was newly admitted , all his orders were not in the electronic medical record. She could not remember exactly where she found the DNR form but thought it was in an envelope with his hospital records and not in the DNR binder where it should have been. It was also noted that the resident's DNR order had not been entered electronically until about 8 hours after he deceased on [DATE] at 1:11 PM. The administrator and DON on [DATE] at 1:40 PM could not explain why the resident's DNR form was not in the DNR binder, or why the resident did not have the yellow armband or the yellow dot on his nameplate. The DON contradicted RN A and LPN B stating she thought the yellow dot was on the door and the resident had a yellow armband. She was not able to explain why the DNR order was not entered into the medical record at admission but entered 8 hours after the resident deceased . She stated that she was not aware of this and would have to contact the information technology (IT) department. The DON on [DATE] at 1:40 PM stated that this incident was not a competency/training issue but an, emotional, knee jerk reaction by the nurse. She stated that she gave an in service to RN A via telephone and then again in person, but could not provide documentation of the in service. She said she started in services on [DATE] one day after the incident. She reviewed the DNR policy with the staff and made copies of the policy available for staff. An interview with RN A on [DATE] at 11:00 AM noted that she had an in service on DNR but it was only a few minutes long and there was no time to clarify or ask questions. A review of the the in service attendance record dated [DATE] noted that only 19 of the 175 current staff received the in service. Interviews conducted with 33 facility staff (CNA, LPN, RN) from ,[DATE]-[DATE] revealed that the only training received at the facility about advance directives was a brief computer based in service during orientation and then annually. An interview with LPN B on [DATE] at 11:35 AM revealed that she received a paper in service. She stated that it would have been helpful to get hands on practice as reviewing a policy did not help in knowing what to do in an emergency situation. An interview with the DON on [DATE] at 1:40 PM confirmed that there was no hands on training such as drills or mock codes done at the facility. She was not able to provide an answer when asked how many of the staff were CPR certified. She stated that staff obtained Basic Life Support training every 2 years on their own and the facility had not tracked the staff's current certification. She was unable to provide a list of how many of the licensed staff were CPR certified. When the DON was questioned regarding staff competency on CPR and following DNR directives and what to do in real life scenarios, she stated that she was not aware of any competency assessments being done at the facility. The DON was questioned on [DATE] at 1:40 PM whether the medical director was aware that resident #1 received resuscitation against his wishes. She stated that the medical director was informed of the incident via telephone on [DATE] and he suggested that all staff be re-educated on the DNR policy, not just RN A. An interview with the medical director on [DATE] at 1:30 PM confirmed that he had been informed of the incident involving RN A and resident #1 and had given the directive to re-educate all staff. He was not aware if all staff had been re-educated of the DNR policy as he was not involved in the training and a meeting had not been held to discuss this incident. He said that he had not been utilized as a resource for training/education. An interview with RN A on [DATE] at 10:00 AM revealed that she was a new nursing school graduate and had been working at the facility for approximately 5 months. She stated that she had never experienced a resident dying and she did not know what to do when she found resident #1 unresponsive. She stated that even LPN B was fairly new and was also, rattled, as this was her first time with a dying resident. On [DATE] at 11:35 AM, LPN B stated that she was, not familiar with people dying as I am a new nurse. An interview with LPN Q on [DATE] at 9:34 AM noted that, the problem was that there were two new graduate nurses working on the same side and they were fairly new to the facility. She stated, on top of that they did not have a process in place for identifying status, no armband and no dot and they could not find his (resident #1) DNR status. On [DATE] at 1:40 PM the DON stated that there was no concern with having RN A and LPN B working together on the same side as she did not consider LPN B to be inexperienced as she had been at the facility for one and half years. A review of the administrator's job description read that the administrator was responsible to, manage, lead and direct overall operations of the facility in accordance with customer needs, regulations and company policies. With focus on maintaining excellent care for the residents Demonstrates strong ethical practices regarding resident rights. Understand, comply with and promote all rules and regulations regarding residents' rights. Although it was the job of administration to ensure the highest well-being of residents, there was no indication that administration had reviewed their process of allocating resources to maintain efficient and effective resident care.

Based on interview and record review, the facility failed to protect the resident from neglect by failing to provide services ensure that his advance directives for Do Not Resuscitate (DNR) were not violated and that cardiopulmonary resuscitation was not initiated for 1 of 6 sampled residents, (resident #1). Resident #1 was found unresponsive in bed at approximately 5:15 AM on [DATE]. Registered nurse (RN) A chose to initiate chest compressions without first determining the resident's code status and continued intermittent, ineffective resuscitative measures even after receiving verification that the resident had a Do Not Resuscitate order (DNR). The failure to prevent neglect by not providing the care and services to honor the DNR order and initiate cardiopulmonary resuscitation (CPR). The facility's actions to perform cardiopulmonary resuscitation (CPR) against the resident's established DNR, could result in Resident #1 experiencing severe pain; broken ribs; broken sternum; mediastinal bleeding; aspiration pneumonia; organ damage; neurological complications, such as severe cognitive impairment and permanent brain damage; coma; possible undesired intubation (a tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth); mechanical ventilation; sophisticated medical life support; a prolonged dying process; and denying a natural, dignified death. This resulted in substandard quality of care and Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was determined to be ongoing as of the exit date of [DATE]. The failure to follow the facility policy and process for Basic Life Support put all of the facility's residents at risk. Cross Reference: F155, F281, F353, F490, F520 Findings: Resident #1 was a [AGE] year old who had been living at home with his wife. He was admitted to the hospital on [DATE] for shortness of breath. While in hospital, resident #1 had a discussion with his physician about his advance directives and made his wishes clear as per the Do Not Resuscitate (DNR) order. A review of the Florida Do Not Resuscitate Order read, Based upon informed consent, I .direct that CPR be withheld or withdrawn. The physician's statement on the form read, I, am the physician of the patient. I direct the withholding or withdrawing of CPR, cardiac compression .from the patient in the event of the patient's cardiac or respiratory arrest. This form was signed by the resident and his physician prior to admission to the facility on [DATE]. A physical therapy note dated [DATE] read that resident would benefit from continued skilled physical therapy in a rehabilitation setting upon discharge. The resident was discharged from hospital and admitted to the facility on [DATE] for short-term rehabilitation. His [DIAGNOSES REDACTED]. He was alert, oriented, and able to verbalize his needs. He was able to use a bedside urinal and utilize the call light for assistance. A review of the facility's Resident Rights form read that the resident has a right to be participate in his treatment including right to formulate advance directives and the right to exercise his rights at the facility. The facility must protect and promote the rights of the resident. A review of the DNR status policy revised ,[DATE] noted that when a resident is admitted with a completed DNR form, the attending physician will be notified so that the facility required DNR order will be obtained and entered into the electronic health record under CODE STATUS. The yellow DNR form will be placed under the medical record. The social service director will ensure that the three yellow indicator dots are in the following locations: the resident's nameplate, yellow name band or yellow dot inside the name band to indicate DNR and on the resident's medical record/binder. A telephone interview with registered nurse (RN) A on [DATE] at 10 AM revealed, on [DATE] at approximately 5:15 AM, 13 hours after admission, the resident was found unresponsive in bed by the lab technician. The registered nurse, (RN) A assessed the resident's radial pulse and thought it questionable as was not certain if she was feeling her own pulse. She stated that she panicked and she started chest compressions by herself without the use of a backboard, or a resuscitator bag to assist ventilation for artificial respirations, and without ascertaining the resident's code status. She then stopped compressions, left the resident's room, and called out for help from LPN B, the other nurse on the unit. She then went back to the resident and resumed chest compressions by herself. She again stopped compressions, left the resident and went to the nurse's station as LPN B was still at the nurse's station because she was not able to quickly confirm the code status. The electronic record did not contain the DNR order and the Florida DNR form was not in the required yellow DNR binder. The DNR form was then located within an envelope containing the resident's hospital records. The RN A then called emergency services (911), and instructed them to come to the facility despite verification of the DNR order. She stated that she thought, nothing to lose, might as well save a life if he can be resuscitated. While still at the nursing station, she called the Nurse Practitioner who instructed her to verify the resident's code status and continue CPR until paramedics arrived. A telephone interview with RN A on [DATE] at 11:00 AM revealed that she was not aware of the resident's code status. She could not explain why she stopped compressions and then continued compressions again and again despite knowing that the resident had a DNR order. She stated that she knew that DNR meant not to resuscitate but was confused about the circumstances in which not to resuscitate. An event note dated [DATE] at 5:28 AM revealed that RN A performed CPR until the ambulance personnel came in to the room and checked the resident. The resident was pronounced deceased by the paramedics at 5:28 AM on [DATE]. An interview with the certified nursing assistant (CNA) G on [DATE] at 4:00 PM revealed that she had cared for the resident in the early morning of [DATE]. She stated that the resident was scared and lonely as he was away from his family and was in a new, unfamiliar setting. He rang his call light several times during the night, as he wanted a drink and assistance with repositioning. She stated, I think he was lonely and wanted some support and reassurance. She stated that she was aware that the lab technician came at approximately 5:15 AM and said he was not breathing. It was very confusing after that, as nursing staff did not know what to do. They should not have done chest compressions if he was a DNR. An interview with LPN B on [DATE] at 11:35 AM revealed that she was called to the room of resident #1. She stated that she, checked for the resident's pulse and got nothing; his color was grayish. I left the room and am not sure what RN A was doing. She said if the resident had a DNR order, we don't do anything. An interview with LPN Y on [DATE] at 2:13 PM noted that if the resident is without vital signs and has a DNR order, I would not initiate any CPR. An interview with the administrator, director of nursing, (DON), clinical regional director, and the regional director of operations on [DATE] at 1:40 PM revealed that they identified that neglecting to honor the resident's directive not to be resuscitated as a violation of his wishes, but they did not consider the incident as neglect due to the failure to provide the services to ensure they withheld CPR for residents who make that designation.