Every finding on record at Vivo Healthcare Sebring

Based on observation, interviews and record review the facility failed to store food in accordance with professional standards for food safety, related to label and dating opened items, discarding items that were expired and not discarding items covered in bio-growth, in one of one walk-in cooler. Findings Included: During an observation of the walk-in cooler on 04/13/2026 at 10:53 a.m. the following was observed: A box of individually wrapped butter was found open, with butter smeared on the box and at least two of the individually wrapped blocks were open, exposing the butter. The box and the individual blocks were not dated/labeled. A produce box containing green bell peppers. Inside the box were approximately a dozen peppers with black circles on the surface that had a fuzzy black and white bio growth, and two of the peppers had a fuzzy white blue/green substance on the pepper. A produce box containing approximately 10 heads of cabbage. The cabbage heads had black spots all over the circumference of the head.A box of turkey franks that was open, exposing the franks. During an observation on 04/13/2026 at 10:55 a.m., a metal rack was observed to have small black winged pests flying around a box of bananas. The bananas observed were soft to the touch leaving indents where touched, and several had split skin exposing the flesh of the banana. During an interview on 04/13/2026 at 12:30 p.m., the Dietary Manager stated we check the date of the food in the walk-in cooler as we put away stock. We complete a weekly walk-through checking for outdated items. The items are added to the walk in, and a date is added for the date we received the item. We add another date when we open the item. We do not add an end date for the freezer or the fridge. Food is never in the walk in for long, so we do not need and end date. She reviewed the photographic evidence of the items in the walk-in fridge and stated the bell peppers do have some spots on them. I will discard them now. The box with the yellow/white cream should not be stored like that. We do thaw the hot dogs in the walk in, they are good for three days, the box has a received date and an open date. The bananas would have come in on Thursday. I checked them this morning because they were firm at that time. The cabbage has old leaves. We have a time with produce here. All open food items should be labeled and dated when opened, discarded three days after opening. No items should be stored without a cover, except the produce. During an interview on 04/14/2026 at 12:56 p.m., the Nursing Home Administrator stated I would expect the produce to be discarded if it shows signs of going bad. I would think that items in the fridge should have an open date and an expiration date so that everyone knows when the food needs to be discarded by. When checking temperatures of food, I would expect the food to be at the correct temperature where it is safe to serve at. All food should be tempted even if we're adding it to the steam table. Review of the facility policy titled food safety requirements dated 9/20/23 revealed policy it is the policy of this facility to procure food from sources of proved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, disturbed distributed and served in accordance with professional standards for future service safety.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. C. Preparation of food including fine, cooking, cooling, holding and reheating.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery receipt and ensure timely and proper storage. A. Follow contract vendor procedures when food arrives damaged or concerns are noted remove these foods from use. B. Dry food storage keeps foods beverages and a clean, dry area off the floor and clear of stealing sprinklers, sewer waste disposal pipes and vents.c. Refrigerated storage foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable practices to mean seems safe for refrigerated storage includes: monitoring food temperatures and functioning the refrigeration equipment daily. Labeling dating and monitoring refrigerated food include but not limited to leftovers so used by the use by date, or frozen when applicable discarded and keeping foods covered or in tight containers.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than five percent. A total of twelve medication administration opportunities were observed with four errors for two (#4 and #5) of four residents sampled for medication administration, which resulted in a medication administration error rate of 33.33%. Findings included: A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypertension and nontraumatic intracranial hemorrhage. A review of Resident #4's physician orders revealed the following orders: - An order dated 4/23/2024 for levetiracetam 1000 milligrams (mg) one tablet by mouth (PO) every 12 hours at 8:00 AM and 8:00 PM for seizures. - An order dated 5/10/2024 for metoprolol tartrate 50 mg one tablet PO two times a day at 8:00 AM and 9:00 PM for hypertension. An observation of medication administration was conducted on 9/3/2024 at 9:12 AM with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN prepared the following medications for administration to Resident #4: - levetiracetam 1000 mg, one tablet. - metoprolol tartrate 50 mg, one tablet. After preparing the medications Staff A, LPN entered Resident #4's room and administered the two medications. Staff A, LPN did not notify Resident #4 or Resident #4's physician prior to administering the two medications late. A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, atherosclerotic heart disease of coronary artery, and depression. A review of Resident #5's physician orders revealed the following orders: - An order dated 6/26/2024 for aspirin delayed release 81 mg 1 tablet PO one time a day at 8:30 AM for coronary artery disease. - An order dated 6/26/2024 for amlodipine besylate 10 mg one tablet PO one time a day at 8:30 AM for hypertension. - An order dated 6/26/2024 for clopidogrel 75 mg one tablet PO one time a day at 8:30 AM for atrial fibrillation. - An order dated 6/26/2024 for indapamide 1.25 mg one tablet PO one time a day at 8:30 AM for fluid retention. - An order dated 6/26/2024 for paroxetine hydrochloride (HCl) 30 mg one tablet PO one time a day at 8:30 AM for depression. - An order dated 6/26/2024 for levetiracetam 500 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for seizures. - An order dated 6/26/2024 for magnesium oxide 400 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for supplementation. - An order dated 8/31/2024 for depakote sprinkles 125 mg 3 capsules PO three times a day at 8:30 AM, 4:30 PM, and 9:00 PM for mood disorder. An observation of medication administration was conducted on 9/3/2024 at 9:18 AM with Staff A, LPN. Staff A, LPN prepared the following medications for administration to Resident #5: - Aspirin 81 mg chewable 1 tablet. - Amlodipine besylate 10 mg one tablet. - Clopidogrel 75 mg one tablet. - Indapamide 1.25 mg one tablet . - Levetiracetam 500 mg one tablet. - Depakote sprinkles 125 mg 3 capsules. After removing the medications from the medication cart Staff A, LPN crushed each medication individually and placed the medication in a small amount of pudding per Resident #5's preference. After preparing the medications Staff A administered the six medications to Resident #5 and returned to the medication cart. Staff A, LPN accessed Resident #5's electronic medication administration record (eMAR) and signed off the six medications as administered. Staff A, LPN also signed off paroxetine HCl 30 mg one tablet as administered but did not pull the medication from the medication cart to administer to Resident #5. After saving the data, the order for magnesium oxide 400 mg one tablet appeared as not being administered. Staff A, LPN removed magnesium oxide 400 mg one tablet, crushed the tablet, added the crushed tablet to a small amount of pudding, and administered the medication to Resident #5. After administering the medication Staff A, LPN accessed Resident #5's eMAR and marked the magnesium oxide 400 mg one tablet as administered. Staff A, LPN did not administer paroxetine HCl 30 mg one tablet to Resident #5. Following the observation of medication administration, an interview was conducted with Staff A, LPN at 9:38 AM. Staff A, LPN accessed Resident #5's eMAR and reviewed the physician order for aspirin delayed release 81 mg. Staff A, LPN removed the bottle of aspirin 81 mg chewable tablets and stated she administered the chewable form of the medication to Resident #5 because he's a crush, I had to give the chewable. Staff A, LPN addressed Resident #5's physician order for aspirin 81 mg delayed release did not match what she removed from the medication cart and stated I'm not sure what to do after the fact. Staff A, LPN reviewed Resident #5's eMAR and observed the physician order for paroxetine HCl 30 mg. Staff A, LPN was not aware she did not remove the medication to administer to Resident #5 before signing the medication off as administered in the eMAR. During the interview with Staff A, LPN, Staff B, Registered Nurse (RN) and Unit Manager (UM) approached the medication cart and was interviewed. Staff B, RN UM stated Resident #5's physician order for aspirin 81 mg should be for the chewable form of the medication and not the extended release form. Staff B, RN UM also stated if a different form of a medication was administered and did not match the physician order, it would be considered a medication error. Staff B, RN UM stated medications should be administered between an hour before and an hour after the scheduled time and if a medication is going to be administered late, the nurse should notify the resident's physician before administering the medication. Staff A, LPN stated she was aware the resident's physician needed to be notified when a medication is administered late, but was not sure if the physician needed to be notified prior to administering the medication or after administering the medication. Staff A, LPN also stated, maybe I wouldn't have made the error if you weren't watching me. An interview was conducted on 9/3/2024 at 1:57 PM with the facility's Director of Nursing (DON). The DON stated facility nursing staff were educated at orientation and at skills fairs on the rights of medication administration, which included the right medication, right dose, right resident, right time, and right route. The DON also stated nursing staff should notify the resident's physician if a medication was going to be administered late and the notification should occur prior to the late administration. The DON stated medications should be administered between an hour before and an hour after the scheduled time. A review of the facility policy titled Medication Administration, last revised on 9/1/2023, revealed under the section titled Policy, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy also revealed the following steps under the section titled Policy Explanation and Compliance Guidelines: - Review MAR to identify medication to be administered. - Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. - Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. - Administer medications as ordered in accordance with manufacturer specifications. - If any medication is not available, or the possibility of late administration, the Nurse will contact the Attending Physician. - Sign MAR after administered.

Based on record review, and staff interviews the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for three residents (#63, #56 and #30) of twenty four sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified. Findings included: 1. Review of Resident #63's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to include anxiety disorder as of 2/26/24 and depression as of 2/26/24. Review of Resident #63's medical record revealed a PASARR Level I, dated 11/23/23, and new one completed on 4/16/24. The PASARR Level 1 completed on 4/16/24 did not include the diagnoses of anxiety and depression in Section 1 A MI (mental illness) or suspected MI. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section I - Active Diagnoses revealed anxiety and depression as checked. Review of Resident #63's active orders as of 5/20/24 revealed an order for Mirtazapine oral tablet 7.5 mg (milligrams)- give 1 tablet by mouth at bedtime for depression with weight loss, start date 5/1/24. The orders were silent of medication ordered for anxiety. An interview was conducted on 5/20/24 at 6:33 p.m. with the Social Services Director (SSD) and the Director of Nursing (DON). The DON confirmed the facility's PASARR process when a resident comes from the hospital was they reviewed the PASARRs and clinicals the next morning. If the resident has a diagnosis not on the PASARR or they notice medications; they would initiate a new one (PASARR). Then they would request a Level II based on [vendor name] recommendations. The SSD and DON confirmed a whole house audit is completed by the SSD on Fridays to ensure all PASARRs are complete and accurate and given to the DON for review. They confirmed Resident #63's PASARR Level I was not accurate. 2. Review of Resident #56's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to include other stimulant abuse 8/16/22, generalized anxiety disorder as of 7/28/23, persistent mood (affective) disorder as of 3/11/24, and a binge eating disorder as of 3/11/24. Review of Resident #56's medical record revealed a PASARR Level I dated 7/30/23. The PASARR Level 1 did not include the diagnosis of substance abuse in Section 1 A MI (mental illness) or suspected MI. The medical record was silent of a revised PASARR Level I for the new diagnosis of persistent mood (affective) disorder. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section I - Active Diagnoses revealed anxiety, other stimulant abuse and binge eating disorder. Review of Resident #56's active orders as of 5/19/24 revealed: *Depakote Oral Tablet Delayed Release 250 MG - give 1 tablet by mouth three times a day related to persistent mood [affective] disorder, start date of 3/11/24, *Nortriptylie HCI Oral Capsule 25 MG - give 50 mg by mouth two times a day for depression, start date of 5/10/24, *Xanax Oral Tablet 1 MG - give 1 tablet by mouth at bedtime for anxiety, start date of 12/14/23. An interview was conducted on 05/20/24 at 6:44 p.m. with the Social Services Director (SSD) and Director of Nursing (DON). The SSD confirmed the PASARR dated 7/30/23 was the most recent PASARR for Resident #56. She confirmed the diagnosis of stimulant abuse should have been documented on the PASARR Level I and that Resident #56's PASARR Level I should have been redone. 37999 3. Review of Resident #30's Admission Record revealed the resident had been admitted on [DATE] and included diagnoses not limited to unspecified intractable epilepsy without status epilepticus (onset 1/23/24), personal history of traumatic brain injury (onset 1/23/24), unspecified anxiety disorder (onset 3/19/24, adjustment insomnia (onset 3/4/24), and mood disorder due to known physiological condition with mixed features (onset 5/14/24). Review of Resident #30's Preadmission Screening and Resident Review, dated 2/2/24 and completed by the facility's Director of Nursing (DON) showed the resident had a Mental Illness diagnosis of anxiety disorder and no Intellectual Disability related to condition, epilepsy or traumatic brain injury (TBI). The section for other indications did not reveal the resident had or may have had a disorder resulting in functional limitations in major life activities, serious difficulty interacting appropriately and communicating effectively, serious difficulty in sustaining focused attention for a long period to permit completion of tasks, or serious difficulty in adapting to typical changes in circumstances. The completion of the PASARR revealed the resident had no diagnosis or suspicion of a Serious Mental Illness or Intellectual Disability therefore a Level II was not required. Review of Resident #30's care plan included the following: - Activities of Daily Living (ADL) Care Plan: The resident has an ADL self-care performance deficit related to (r/t) decline in function and motility r/t TBI. - Resident at times makes complaints and upon investigating, complaints are found to be untrue. Resident has a tendency to fabricate stories (ex. missing items). The intervention instructed staff to Acknowledge resident's behaviors as an attempt to communicate needs. - Resident uses psychotropic medications r/t depression, anxiety, and insomnia. - Hypnotic Care Plan: The resident is on sedative/hypnotic therapy r/t Insomnia. - Anti-Anxiety Care Plan: Resident is at risk for adverse side effects related to use of anti-anxiety medication. - Antidepressant Care Plan: Resident is at risk for adverse side effects related to use of antidepressant medications. - Mood Care Plan: Potential for mood state issues related to anxiety. - Seizure Disorder Care Plan: Potential for injury or aspiration related to history of seizures. Review of the policy titled, Resident Assessment - Coordination with PASARR Program, implemented 9/1/23, revealed: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The compliance guidelines of the policy showed: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities, and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission. i. Negative Level 1 screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 screen - Necessitates a PASARR level 2 evaluation prior to admission. b. PASARR Level 2 - a comprehensive evaluation by the appropriate state designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/ or rehabilitative services through individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined as appropriate for admission. 6. The social services director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified in evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observation, interview and record review, the facility failed to ensure behavior monitoring for psychotropic medication was in place for five residents (#32, #56, #59, #63 and #65) and failed to appropriately monitor the side effects for psychotropic medication for one resident (#56) of seven sampled residents. Findings included: 1. Review of Resident #56's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to include other stimulant abuse, generalized anxiety disorder, persistent mood (affective) disorder, binge eating disorder, and chronic pain syndrome. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section E - Behaviors showed no behaviors were exhibited. Section N - Medications showed the resident was taking antianxiety antidepressant medications. Observation on 5/18/24 at 12:27 p.m. revealed Resident #56's room door was closed with a sign that showed Keep door closed. Resident did not answer to the knock on the door. Review of Resident #56's active physician orders as of 5/19/24 revealed: *Depakote Oral Tablet Delayed Release 250 MG (milligram) - give 1 tablet by mouth three times a day related to persistent mood [affective] disorder, start date of 3/11/24, * Xanax Oral Tablet 1 MG - give 1 tablet by mouth at bedtime for anxiety, start 12/14/23, *Nortriptyline HCI Oral Capsule 25 MG - give 50 mg by mouth two times a day for depression, start date of 5/10/24, *Monitor for antianxiety side effects every shift and report to MD if present: 0-None, 1-Drowsiness, 2-Slurred speech, 3-Dizziness, 4-Nausea, 5-Aggressive/impulse behavior, 6-Constipation, 7-Diarrhea, 8-Changes in appetite, hypertension, 9-other every shift for medication monitoring monitor for antianxiety medication side effects and place number corresponding with side effect. If other-document nurse's note., start 4/23/24. Review of the May 2024 Medication Administration Record (MAR) for Resident #56 showed medications were administered as ordered and there was no behavior monitoring for antidepressant medication until 5/19/24. In addition, the monitoring for the antidepressant side effects was documented as check marks for each administration and not a number which corresponded with the type of side effect. Review of Resident #56's active physician orders as of 5/19/24 revealed an order with a start date of 5/18/24 as: behavior monitoring - antidepressants behavior code: 0. None 1. Withdrawn 2. Anorexia 3. Crying 4. Social isolation 5. Apathy 6. Feeling of helplessness/worthlessness 7. Suicidal ideations 8. Insomnia 9. PN non pharmacological interventions code: 0, none 1. Activities 2. 1:1 3. Redirection 4. Repositioning 5. Food/fluids 6. Rest period 7. Quite [quiet] environment 8. Medication 9. PN Intervention outcome: I=improvement S= same W=Worsen N/A = not applicable every shift for antidepressant use codes applied to behavior; non pharmacological intervention, outcome. An interview with Staff K, Certified Nursing Assistant (CNA) on 5/20/24 at 10:21 a.m. revealed she has not had any issues with caring for Resident #56 but has heard others have. She stated he can tell you his needs and he watches the clock and puts his light on when he needs his pain pill. A review of the current care plan for Resident #56 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications, initiated 1/15/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift (every shift). Observe/document/report PRN (as needed) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living), continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt (weight) loss, n/v (nausea and vomiting), dry mouth, dry eyes. *Focus - The resident has a mood problem r/t (related to) Admission, being in a nursing facility, his age and pain, initiated 7/13/23 and revised 10/12/23. Interventions included administer medications as ordered. Administer medications as ordered. Monitor/document for side effects and effectiveness; behavioral health consults as needed ; monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. *Focus - Behavior Care Plan potential for impaired or inappropriate behaviors related to refusing to wear nonskid socks nor shoes. Plays music with explicit language loudly in hallways. Inappropriate behavior towards other residents (asking for a kiss). Resident is non-compliant with his smoking contract, as he was vaping in dining room, initiated 1/12/23 and revised 8/28/23. Interventions included: if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. *Focus - The resident is verbally aggressive (cursing at staff, cursing in front of the other resident, in a loud manner when he is frustrated, does not get his way, and/or wants his pain meds) r/t ineffective coping skills, initiated 3/2/23. Interventions included: analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document. In an interview on 5/20/24 starting at 11:17 a.m. Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed there was no behavior monitoring for the antidepressants and the physician order for behavior monitoring for the antidepressants was not entered until 5/18/24. Staff E, LPN/UM stated the doctor discharged the monitoring for behavior and she wasn't sure why. She confirmed this was on 4/23/24 and the doctor discharged the monitoring for antipsychotics on 5/6/24 and wasn't sure why. She confirmed behaviors were not monitored from 4/23/24 - 5/18/24. Staff E confirmed the side effect monitoring for the antianxiety medication on the MAR was documented as check marks and not the required numbers. Staff E stated the check mark just means the nurse signed off on it and not that he did or did not have side effects. An observation and attempted interview was conducted on 5/20/24 at 2:53 p.m. with Resident #56. Resident #56 was observed on his electric wheelchair dressed for the day, clean and no behaviors exhibited. When addressed with a greeting he did not respond and continued to drive away on his electric wheelchair. 2. Review of Resident #59's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to encephalopathy, and major depressive disorder. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section N - Medications showed the resident was taking an antidepressant medication. An observation from the hallway on 5/18/24 at 1:45 p.m. revealed Resident #59 in bed with bare chest and briefs exposed. At 2:10 p.m. Resident #59 was still in bed. An interview was attempted and the resident stated he didn't speak English. An observation was conducted on 5/19/24 at 10:05 a.m. and the privacy curtain was drawn for Resident #59 who was in bed. His roommate stated that Resident #59 never gets out of bed. Review of the May 2024 Medication Administration Record (MAR) for Resident #59 showed a physician order for Trazodone HCI Oral Tablet - give 100 mg by mouth at bedtime for depression, start 3/10/24. In review of the MAR this medication was administered as ordered. In review of the MAR and Treatment Administration Record (TAR) there was no behavior monitoring for the antidepressant medication. A review of the current care plan for Resident #59 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications, initiated 1/19/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt, n/v, dry mouth, dry eyes. *Focus - Mood Care Plan Potential for mood state issues related to depressive disorder. Interventions included: consultation with psychological/psychiatric per order; encourage and allow open expression of feelings; report to the physician/psychiatrist changes in mood status. An observation on 5/20/24 at 10:05 a.m. revealed Resident #59 was in bed sleeping. During an interview on 5/20/24 at 10:23 a.m. Staff K, Certified Nursing Assistant (CNA) stated Resident #59 speaks a little English and that he is always in bed until you get him up. He would stay in bed 24/7. He doesn't get out of bed unless we get him out so he will go to lunch and then want to go right back to bed. An interview was conducted on 5/20/24 at 11:08 a.m. with Staff E, LPN/UM who confirmed Resident #59 was alert an oriented and he can sit on the edge of the bed by himself without assistance. She stated they try to encourage him to get up. She stated they do monitor for behaviors for Trazodone. She reviewed the orders and MAR and TAR for Resident #59 and confirmed there was not an order and there had been no monitoring for behaviors for Resident #59. She said there is supposed to be and she confirmed that excessive sleeping could be a behavior. 3. Review of Resident #63's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to include anxiety disorder and depression. During an interview and observation on 5/18/24 at 11:37 a.m. Resident #63 was in bed with a family member visiting. Resident #63 stated she doesn't get out of bed and was recently readmitted from the hospital. She confirmed she had wounds and receives all her medications. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Review of Resident #63's active orders as of 5/19/24 revealed an order for Mirtazapine oral tablet 7.5 mg (milligrams)- give 1 tablet by mouth at bedtime for depression with weight loss, start date 5/1/24. The orders were silent of medication ordered for anxiety. The orders were silent of an order to monitor for behaviors. Review of the May 2024 MAR revealed the Mirtazapine was administered as ordered for Resident #63. A review of the current care plan for Resident #63 revealed: * Focus - Antidepressant Care Plan resident is at risk for adverse side effects related to use of antidepressant medications. Depression with weight loss, initiated 5/18/24. Interventions included: administer medications as ordered by physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, wt, n/v, dry mouth, dry eyes. During an interview on 5/20/24 at 11:14 a.m. Staff E, LPN/UM confirmed there wasn't an order to monitor behaviors for the antidepressant. She stated, There isn't and there should be. 36273 4. Review of Resident #65's Admission Record revealed he was admitted on [DATE]. The record included diagnoses not limited to personal history of traumatic brain injury, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, adjustment disorder with mixed anxiety and depressed mood. Review of Resident #65's care plan related to antidepressant, anti-psychotic and psychotropic medications revealed, Focus - Antidepressant Care Plan: Resident is at risk for adverse side effects related to the use of antidepressant medications. Interventions: Administer medications as ordered by the physician. Observe/document side effects and effectiveness Q-shift. Observe/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Focus - The resident uses psychotropic medications r/t depression Interventions: Administer medications as ordered by the physician. Observe for side effects Q-SHIFT. Observe/document/report PRN any adverse reactions of PSYCHOTROPIC medications Unsteady gait, tardive dyskinesia, EPS (shuffle gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Observe/record occurrence of for target behavior symptoms and document per facility protocol. Focus - Anti-psychotic Care Plan -The resident is at risk of adverse side effects related to use of antipsychotic medications. Interventions: Administer medications as ordered. Approach resident calmly. Attempt gradual dose reduction as indicated. Report results to physician as needed. Follow up with psych as indicated. Observe behavior. Observe for signs and symptoms, increase or decrease in behavior or adverse effects from the anti-psychotic medication. Redirect as needed. Report any adverse effects to MD. Review of Resident #65's MAR revealed the following medication orders, not limited to: Seroquel Oral Tablet 400 MG give 1 tablet by mouth at bedtime related to OTHER SPECIFIED PERSISTENT MOOD DISORDERS; Trazadone HCI Oral Tablet 100 MG give 2 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE; Zyprexa oral tablet 10 MG by mouth one time a day for depression; Seroquel Oral Tablet 200 MG give 1 tablet by mouth two times a day for mood disorder; and Lorazepam Oral tablet 0.5 MG give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days (start date, 5/18). Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: behavior monitoring - antidepressants behavior code: Use behavior codes as noted on the order. Monitor every shift for possible side effects and notify MD if noted. Monitor for antidepressant medication side effects and place number corresponding with side effect. If other-document nurse's note. Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: Behavior monitoring for-Anti-anxiety Behavior code: Use behavior codes as noted on the order. Review of Resident #65's active physician orders as of 5/17/24 revealed an order with a start date of 5/17/24 as: Behavior monitoring for-sedative/hypnotics Behavior code: Use behavior codes as noted on the order. Review of Resident #65's TAR for behavior monitoring for Anti-anxiety, Antidepressants and sedative/hypnotics revealed on 5/17, 5/18, 5/19 and 5/20 the box was checked and initialed but there was no place to document a behavior code for behavior monitoring as ordered. Review of Resident #65's TAR for monitoring of Antidepressant side effects: monitor every shift for possible side effects and notify MD if noted, revealed on 5/17, 5/18, 5/19 and 5/20 the box was checked and initialed, but there was no place to document a number corresponding with the side effect as ordered. During an interview on 5/20/2024 at 9:12 p.m. with Staff L, LPN, she stated she was not sure if they code for behaviors. She would look in document manager for behaviors, it would typically be in the progress notes or care plan. During an interview on 5/20/2024 at 9:16 p.m. with Staff M, LPN, he stated he would ask the previous nurse about behaviors, they would let him know to continue care. He was not sure on coding for behaviors. 37999 5. Review of Resident #32's Admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to metabolic encephalopathy and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #32's care plan revealed: At risk for adverse side effects related to use of antidepressant medications, depression. The interventions instructed nursing staff to: - Administer medications as order by physician and observe/document side effects and effectiveness every (Q) shift. - Observe/document/report as needed (PRN) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; Decline in ADL ability, continents, no avoiding; Constipation, fecal impaction, diarrhea; Gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; Dizziness/ vertical; Fatigue, insomnia; Appetite loss, weight loss, nausea/vomiting (n/v), dry mouth, dry eyes. Mood Care Plan: Potential for mood state issues related to depression. The interventions instructed nursing staff to: - Observe for effectiveness/ side effects of medications as ordered - see physicians orders. - Report to the physician/ psychiatrist changes in mood status. Review of the new evaluation for psychiatry services, dated 4/11/24, revealed the resident was currently taking 15 milligram (mg) of Mirtazapine at bedtime for depression, No behaviors reported by staff, and as symptoms can exacerbate on periodic basis in the facility setting we will follow up with this patient intermittently. Review of Resident #32's Order Summary Report, active as of 6:53 p.m. on 5/20/24 included: - Mirtazapine 15 milligram (mg) - Give 1 tablet orally at bedtime for depression. - Behavior Monitoring - Antidepressants. Behavior code: 0. None, 1. Withdrawn, 2. Anorexia, 3. Crying, 4. Social isolation, 5. Apathy, 6. Feeling of helplessness/worthlessness, 7. Suicidal ideations, 8. Insomnia, 9. PN. NON-PHARMALOGICAL INTERVENTIONS CODE: 0. None, 1. Activities, 2. 1:1, 3. Redirection, 4. Repositioning, 5. Food/fluids, 6. Rest period, 7. Quiet environment, 8. Medication, 9. PN. Intervention Outcome: I=Improvement, S=Same, W=Worsen, N/A=Not applicable, every day and night shift for Antidepressant use. Use codes applied to Behavior, non-pharmalogical intervention, (and) outcome. Review of Resident #32's May Medication Administration Record (MAR) showed the resident had received 15 mg of Mirtazapine at bedtime nightly as ordered. The MAR showed staff were ordered to monitor behavior signs, non-pharmalogical interventions (NPI), and outcome on 4/6/24 to the discontinuation of the order on 5/18/24 at 12:02 p.m. The behavior monitoring was not completed during the day shift on 5/1, 5/13, and 5/18/24. Review of Resident #32's May MAR showed the order for behavior monitoring was to be completed with the documentation in accordance with the above-mentioned physician order however the MAR did not have any spaces to document the behavior signs, NPI, or outcomes as ordered, the order was written at 7:00 p.m. on 5/18/24. The MAR revealed no behavioral monitoring was completed during the day shift on 5/18/24. Review of the policy titled, Use of Psychotropic Medication, implemented on 9/1/23, revealed Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy explanation and compliance guidelines revealed the following: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: and antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/more representatives, other professionals, and the interdisciplinary team. 4. The indications for use of any psychotropic drug will be documented in the medical record. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. 7. Residents who use psychotropic drugs shall receive non pharmaceutical interventions to facilitate reduction or discontinuation of the psychotropic drugs. 12. The effects of the psychotropic medications on a residence physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review. c. During Minimum Data Set (MDS) review (quarterly, annually, significant change), and d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturers specifications, and the residence comprehensive plan of care. 13. The residents response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the residence medical record.

Based on observation, record review, and interview the facility failed to provide an environment that was clean, safe, and sanitary for residents on one units (B Wing) of two units and two shower rooms (A Wing and B Wing) of two shower rooms. Findings included: On 5/20/24 starting at 3:00 p.m., observations were made of the resident rooms and shower rooms on the A Wing and B Wing. The following was observed: - A wheelchair in hallway across from the activity room with a ball of an unknown pink substance stuck to the seat of the chair and armrests that were ripped revealing foam interior. The was observed on 5/18/24, 5/19/24 and 5/20/24. - An observation of room [ROOM NUMBER] Bed A revealed a bottle of a name brand lotion, name brand dandruff shampoo, and another bottle of a name brand lotion sitting on the bedside dresser. The observation also revealed a bottle of an unknown green liquid in a basin sitting on top of a dresser. - An observation was made of a jar of name brand lotion on the bedside dresser of room [ROOM NUMBER] Bed B. - A bottle of body and hair cleanser was observed sitting on a dresser across from the beds in room [ROOM NUMBER]. - A can of name brand lubricant/degreaser sitting on the over-bed table in room [ROOM NUMBER]. The shower room on the 200 hall (B Wing) was observed at 3:42 p.m. and revealed an ant crawling in the shower, toilet was running with water and dark stain on inside of toilet bowl, and bowel movement swirling in the bowl, black bio growth was observed on the floor of the shower, the plastic ceiling light cover was cracked, and the shower chair had black bio growth on the blue chair back and leg rest, on the joints of the plastic frame, and under the seat. The continued environmental tour revealed the following observations: - at 3:49 p.m. from the hallway, an aerosol can of a brand disinfectant spray on the bedside table of room [ROOM NUMBER] bed B; - at 3:49 p.m. an aerosol can of a name brand deodorant/anti-perspirant was observed on the over-bed table of room [ROOM NUMBER] Bed B; - the wall next to the air conditioning unit of room [ROOM NUMBER] was bubbled and cracked; - room [ROOM NUMBER] had a bottle of a name brand diabetic lotion, a bottle of a name brand dry moisture lotion, a large bottle of non-alcohol mouthwash on the room's vanity, and a bottle of body mist without a diffuser on the window sill. In addition, at 4:01 p.m. the observation of the 100-hall shower room (A Wing) revealed a washcloth hanging from the handrail in the first shower stall, one washcloth hanging from the frame of the white plastic shower chair, a bottle of body wash, and a bottle of shampoo sitting on the hand rail of the shower. 36273 On 5/20/2024 at 3:38 p.m. an observation of room [ROOM NUMBER] B revealed a can of activICE (over the counter topical pain reliever) sitting on the table next to the bathroom door. The cap was missing. The resident in the room stated it was hers but she can't use it anymore because the spray top is missing due to falling on the floor. 38007 During an interview on 5/20/24 at 7:05 p.m. the Nursing Home Administrator (NHA) stated they do room rounds daily. The expectation is if staff see something they would report it. If it is something simple they would resolve it. During an interview on 5/20/24 at 7:16 p.m. the Housekeeping and Laundry Director stated they generally clean, mop and sweep each room everyday, once a day for each room. If there is a spill or something needs to be cleaned again they go back into rooms as needed. She confirmed there are a total of 11 staff members for housekeeping and laundry. She confirmed she hasn't been notified of items in resident rooms of concern or anything related to shower equipment or shower rooms. She stated CNAs (certified nursing assistants) are supposed to keep personal items bagged up in a plastic bag. Review of the policy titled, Safe and Homelike Environment, implemented 9/1/23, revealed the policy as: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Policy Explanation and Compliance guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on record review and interview the facility failed to revise the comprehensive care plan related to dialysis services for one resident (#45) of two residents sampled for dialysis. Findings included: Review of the Admission Record for Resident #45 revealed he was admitted to the facility on [DATE]. The Admission Record revealed diagnoses of end stage renal disease, and dependence on renal dialysis. Review of the active physician orders for May 2024 revealed and order for Dialysis - [Name of Dialysis Center, address and phone number] [name of transport company] transport chair time 0630 (a.m.)/PU (pick up) time 5:30-6a (a.m.) on Tuesday, Thursday and Saturday, 5/2/24 start. During an interview with Resident #45 on 5/18/24 at 12:54 p.m. he stated he goes to dialysis three times a week on Tuesday, Thursday and Saturdays. Review of the active care plan, initiated 2/22/23 and revised 11/20/23, revealed a Focus for renal failure with dialysis T/Th/S (Tuesday/Thursday/Saturday) at [name of dialysis center]. Interventions included: [name of dialysis center] on TU-TH-SA [name of transport company] pick up at 2:00 p.m., chair time is 2:30 p.m., revision 10/11/23. Review of the Dialysis List on the whiteboard in the nurses' station on the B Wing showed Resident #45's Chair time: 7:35 Leave: 12:10 .new time as of 4/24. (Photographic Evidence Obtained) An interview was conducted on 5/20/24 at 10:27 a.m. with Staff H, Certified Nursing Assistant (CNA). Staff H confirmed Resident #45 goes to dialysis. She reviewed the Dialysis List on the whiteboard in the B Wing nurses' station, at this time it was turned over, and stated his chair time is 7:35 (a.m.) so you would have him up at 6 (a.m.) for breakfast. She confirmed she would use this list as it tells staff who you should be expecting. During and interview on 5/20/24 at 11:00 a.m. the Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) and Director of Nursing (DON) confirmed the physician's order for dialysis for Resident #45 showed a chair time of 6:30 a.m. and a pick up of 5:30 a.m. - 6:00 a.m., as of 5/2/24. They confirmed the care plan showed a chair time of 2:30 p.m. and a pick up time of 2:00 p.m. They confirmed the Dialysis List showed 7:35 a.m. (chair time). They confirmed the 12:10 p.m. time was the time Resident #45 left the dialysis center. The DON stated the 4/24/24 date might have been when he missed dialysis and that it should have been taken down. A care plan was provided for review on 5/20/24 for Resident #45 with a focus for Renal failure with dialysis T/Th/S at [name of dialysis center]. Interventions included: [name of dialysis center] on TU-TH-SA [name of transportation company] pick up at 5:30 a.m. Chair time is 6:30 a.m. During an interview on 5/20/24 shortly after the interview with Staff E, LPN/UM and the DON at 11:00 a.m., Staff I, Transportation confirmed Resident #45's chair time had changed and now the chair time is 7:35 a.m. on Tuesday, Thursday and Saturdays and he is picked up at 7:00 a.m. She stated the sheet at the nurses' station is correct. She confirmed that she ensures any new information was to be communicated to MDS (minimum data set staff) to update the care plan to make sure he gets to dialysis. She stated she forgot to notify MDS of the changes. Review of the policy titled, Comprehensive Care Plans, implemented 9/1/23, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Policy Explanation and Compliance Guidelines revealed: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident' exercise of his or her right to refuse treatment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on record review, interview and observation, the facility failed to ensure reasonable accommodations were made to ensure one resident (#29) of twenty four sampled residents was provided the right sized incontinent supplies. Findings included: An interview was conducted with Resident #29 on 5/18/24 at 11:52 a.m. in her room while she was in bed. She stated for the last two weeks she hasn't been able to get medium size pull ups. She said, That is what I always wear. Right now I'm wearing small youth and they are tight. I have severe diarrhea and these are so tight. She confirmed she has told staff members but could not recall their names. Review of the Admission Record for Resident #29 revealed her most recent admission to the facility was 2/28/23 with diagnoses to include depression, anxiety, muscle wasting and atrophy, difficulty in walking, muscle weakness and need for assistance with personal care. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 3/27/24, revealed in Section C- Cognitive Patterns for the Brief Interview for Mental Status (BIMS) a score of 15, indicating the resident was cognitively intact. Section GG - Functional Abilities and Goals scored a 6 for independent for toileting hygiene. Section H - Bladder and Bowel shoed Resident #29 was always continent of bowel and bladder. A review of the active physician orders as of 5/20/24 revealed: Dicyclomine HCI Oral Capsule 10 MG (milligrams) - give 1 capsule by mouth two times a day for IBS (irritable bowel syndrome), start date of 5/10/24, Furosemide Oral Tablet 40 MG - give 1 tablet by mouth one time a day for edema, start date of 5/10/24, Loperamide HCI Capsule 2 MG - give 1 capsule by mouth as needed for loose stool after each loose stool, start date of 2/28/23. A review of the facility grievance log for May 2024 revealed no grievances for Resident #29. Review of Resident #29's current care plan revealed focus areas as: * The resident has bladder incontinence r/t (related to) dementia, impaired mobility, initiated 9/29/22. Interventions included: Brief use - the resident uses disposable briefs. Check and change prn (as needed), initiated 5/20/24. * The resident has bowel incontinence r/t immobility, initiated 9/29/22. Interventions included: check resident routinely and assist with toileting as needed, provide loose fitting, easy to remove clothing. * The resident has an ADL (activities of daily living) self-care performance deficit r/t activity intolerance, dementia, impaired balance, limited mobility. Interventions included: toilet use - the resident is independent for toileting. An interview was conducted on 5/20/24 at 10:32 a.m. with Staff H, Certified Nursing Assistant (CNA). Staff H stated the facility has a chart that tells them what size briefs a resident wears. For Resident #29, Staff H logged into the electronic medical record and looked at the Kardex. Staff H stated she uses the restroom by herself so we wouldn't supply her any. A review of the Kardex for Resident #29 revealed in the Bladder/Bowel section the following: * Brief use: The resident uses disposable briefs. Check and change prn (as needed). * Incontinent: Check and change as required for incontinence. Wash, rinse and dry perineum. Change clothing prn after incontinence episodes. The Kardex was silent of what size disposable briefs Resident #29 wore. Resident #29 was interviewed on 5/19/24 at 10:30 a.m. and stated she had a shower and that her roommate went to the A Wing and got her some briefs. She now has four to use. An interview was conducted on 5/20/24 at 2:19 p.m. with Staff J, Central Supply. Staff J explained when a resident first comes into the facility she will measure them and if they gain weight they will remeasure if needed. She stated there was no list of residents and the sizes they wore for briefs or pull ups. She stated, No, I'm the only one who does this. She stated she knows everyone. She confirmed Resident #29 wore a medium. She said, She wears a medium pull up. She stated she thinks Resident #29 could fit in a small, but she prefers medium. She stated on Fridays she stocks the clean linen closet with a case of each size for residents. She stated residents will tell her if they need more. She stated, she leaves enough for the weekend. Staff J stated she doesn't order [NAME] because there is no one here who wears small. During an interview and observation on 5/20/24 at 2:24 p.m. with Staff J, Central Supply a 22 pack of youth small pull ups were observed to the side of Resident #29's bed. Staff J stated that maybe Resident #29's family member sent them because she only uses medium. At this time, Resident #29 confirmed another staff member gave them to her and stated, They really don't fit. On 5/20/24 at 2:36 p.m. two packages of youth extra small pull ups were found on the shelf in the supply shed behind the facility. (Photographic Evidence Obtained) In addition, multiple packages of medium briefs and medium pull ups were observed. Staff J, Central Supply clarified a resident wears briefs if incontinent and pull ups are a resident's choice. If they are care planned for briefs they can choose to wear pull ups. She stated she normally goes to each resident two times a week to see what they need. She confirmed she was not aware of Resident #29's current need for medium pull ups. On 5/20/24 at 6:53 p.m. the Director of Nursing stated a resident could ask staff for the size needed and staff can ask other staff if they are not sure of what size. She confirmed the Kardex does not provide the size needed for a resident. She stated she hadn't heard anything about Resident #29's need for medium pull ups.

Based on observation, record review, and interview the facility failed to ensure a care plan had been developed and implemented for one resident (#70) out of one resident sampled for respiratory services. Findings included: On 5/18/24 at 12:31 p.m. Resident #70 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine on the bedside dresser next to the resident. The tubing and cannula attached to the machine were lying on top of it. The resident reported staff do not clean it, did not have anything to clean it with, and she would do it when she discharged to home. On 5/19/24 at 9:27 a.m. Resident #70 was observed lying in bed with the CPAP tubing and cannula sitting on top of the machine. Review of Resident #70's physician orders revealed an order for Bipap to be on every night at 129 setting, started on 3/19/24. The orders did not include an order to clean the equipment after resident use. Review of Resident #70's care plan, on 5/18/24 at 2:19 p.m., revealed no care plan related to the resident's respiratory status or use of respiratory equipment. (Photographic Evidence Obtained) Review of Resident #70's Admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to subsequent encounter (for) unspecified injury of head and subsequent encounter for fracture of nasal bones with routine healing. An interview was conducted with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) on 5/20/24 at 10:08 a.m. Staff E stated yes there should be orders for staff to assist with cleaning the CPAP and Resident #70 was an exception, the resident did not want staff to assist with cleaning it and was alert and oriented. Staff E stated there should be a care plan regarding the resident not wanting staff to clean the CPAP. The staff reviewed the resident's care plan and confirmed there was no focus related to the resident having a CPAP. Staff E left the interview to ask the person responsible for developing the care plans to attend the interview. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 5/20/24 at 10:18 a.m. The staff member stated yes there should have been a care plan for Resident #70's use of a CPAP and reported there is now. Review of Resident #70's Admission MDS assessment, dated 3/15/24, showed the resident did utilize non-specific oxygen therapy but did not reveal the resident used either CPAP or Bipap equipment. An additional review of Resident #70's Order Summary Report of active, as of 5/20/24 at 12:55 p.m., physician orders did not show staff were to clean or assist the resident with cleaning CPAP equipment. The review revealed active orders for: - BiPAP to be on every night at 129 settings at bedtime for BiPAP, start 3/19/24. - C-PAP to be on every night at 129 settings at bedtime for C-PAP, start on 5/20/24. An interview was conducted with the MDS Coordinator on 5/20/24 at 7:05 p.m. The MDS Coordinator reported reviewing Resident #70's care plan this morning with this writer and when later reviewing it, a care plan had been initiated for the resident's respiratory status on 3/10/24, but the MDS Coordinator had resolved it on 3/19/24 for an unknown reason. The MDS provided a revised care plan for Resident #70's respiratory status which showed the focus, goal, and interventions had been CANCELLED on 3/19/24. Review of the policy titled, Comprehensive Care Plans, implemented 9/1/23, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy definition of Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The review of the compliance guidelines revealed: 1. The care planning process will include an assessment of the resident's strength and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care assessment areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident' exercise of his or her right to refuse treatment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observations, record reviews, and interviews the facility failed to assess two residents (#73 and #178) out of twenty-eight sampled residents for the self-administration of medications and to ensure the self-administered medications were safely stored. Findings included: 1. On 5/18/24 at 12:14 p.m. Resident #73 was observed and interviewed in the resident's room. The observation revealed an allergy nasal spray bottle, 3 vials of an unknown type of eye drop and a medication bottle with a green top sitting on top of the bedside dresser underneath the resident's computer monitor. The resident reported having a lot of environmental allergies and the nasal spray was Fluticasone. Review of Resident #73's Admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses not limited to sequela unspecified fracture of right femur, unspecified rheumatoid arthritis, and history of falling. The Admission Record showed the resident suffered from almond, bread, tree, and shrub pollen allergies. Review of Resident #73's Order Summary Report, active as of 5/20/24 at 12:51 p.m., showed the resident did not have an order for Fluticasone nasal spray and an order had been received on 5/18/24 to start 5/19/24 for Artificial Tears Solution 1.4% (polyvinyl alcohol) - Instill 1 drop in both eyes one time a day for dry eyes, irritation. MAY KEEP AT BEDSIDE. The summary revealed an order received on 5/18/24 allowing the resident PER Advanced Registered Nurse Practitioner (ARNP) MAY KEEP EYE DROPS AT BEDSIDE. Review of Resident #73's May 2024 Medication Administration Record (MAR) showed an order for Artificial Tears solution, scheduled at 7 - 11 a.m., which started on 4/26/24 and discontinued at 4:54 p.m. on 5/14/24, an order which started on 5/15 and discontinued at 5/18/24 at 12:17 p.m. for Artificial Tears, and an order to start on 5/19/24 at 9:00 a.m. for Artificial Tears allowing for the resident to keep drops at bedside. The discontinued orders for Artificial Tears started on 4/26/24 and 5/14/24 did not reveal the resident was allowed to keep eye drops at bedside. Review of Resident #73's May MAR did not include an order for Fluticasone nasal spray. Review of Resident #73's Medication Self-Administration Safety Screen, dated 5/18/24 at 12:18 p.m., revealed the instructions were to complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. Use clinical judgment with Section B to determine if or what level of self-administration will be allowed. The review revealed the list of medications being considered for resident self-administration as Tears One drop in each eye Once daily and storage was Bedside with resident. The screen did not reveal any other medication being considered for self-administration. The screening revealed, The resident can demonstrate secure storage of medications kept in room. Completely capable. The screening was completed by Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). Review of Resident #73's care plan did not reveal the resident was able to self-administer medications. During an interview on 5/20/24 at 11:08 a.m. Staff E, LPN/UM reported the physician had screened (for self-administration of medications) Resident #73 on Friday (May 17th) and the Regional Nurse Consultant (RNC) had to find the appropriate screening. The staff member stated the screening should have included all medications if at bedside and at admission. Staff E stated the facility does ask or tells residents not to bring medications from home. The staff member reported the resident should have been care planned for self-administration. 2. On 5/18/24 at 11:08 a.m. Resident #178 was observed and interviewed lying in bed with an over-bed table in a reachable distance to the resident. The observation showed an unopened box of 20 pain relief topical patches and an opened roll-on pain reliever lying on the over-bed table and a tube of 100% Leptospermum Scoparium honey gel lying on the vanity across from the resident's bed. The resident stated her [family member] brought them (patches) in, did not think the facility even noticed (the resident) had them, and used the roll-on on arms 1-2 times a day. The resident reported not using the roll-on as often since starting therapy. The resident admitted to having a butt wound and did not know what (the facility) was putting on it. On 5/19/24 at 1:48 p.m. Resident #178 was observed lying in bed, the pain relief topical patches and roll-on pain reliever was no longer lying on the over-bed table. The resident stated the girl who took the patches told the resident they had to take them. Review of Resident #178's Admission Record showed the resident was admitted on [DATE] and diagnoses included but was not limited to sequela (of) unspecified injury to unspecified level of lumbar spinal cord, unspecified hemiplegia affecting right dominant side, and uncomplicated opioid dependence. Review of Resident #178's Admission/Readmission Nursing Evaluation, effective 5/18/24 at 9:18 p.m., showed the resident was to receive wound care, the resident's skin integrity was impaired with dry skin to nose and forehead, boggy bilateral heels, and redness to coccyx, the resident was medicated for pain and routine or as needed (PRN) pain medication had been ordered. The resident had reported sharp left lower leg pain that was alleviated with pain medication. The evaluation revealed the resident had not requested to self-administer any medications. Review of Resident #178's Order Summary Report, active as of 1:05 p.m. on 5/20/24, did not reveal an order allowing for the resident to self-administer any medication. The report did not reveal an order for either pain relief topical patches or a roll-on pain reliever. The Order Report did reveal the following: - Wound Care: Sacrum Pressure Injury (PI) stage 2. Clean with normal saline (N/S), apply Honey Fiber and cover with border foam one time a day for treatment. Ordered 5/17/24. Review of Resident #178's Medication Administration Record (MAR) revealed the resident was receiving Oxycodone 10 milligram (mg) frequently as needed (PRN) for pain. The MAR did not reveal an order for pain relief patches, or a roll-on pain reliever was active or discontinued. Review of Resident #178's care plan showed the resident had mildly impaired cognitive function with short-term memory loss. The care plan showed the resident had acute/chronic pain related to (r/t) (blank). The interventions did not reveal the resident was allowed to self-administer pain medication. During an interview on 5/20/24 at 11:42 a.m. Staff E, LPN/UM reported Resident #178 should have been screened for self-administration for pain relief patches and/or roll-on pain reliever at bedside. The staff member stated in her opinion the resident did not have the capability to self-administer since staff had to do everything for the resident. Review of the policy titled, Resident Self-Administration of Medication, implemented 9/1/23, showed It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely. A review of the policies compliance guidelines revealed: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facilities interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity to: swallow without difficulty, open medication bottles, (and/or) administered injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when the medications need to be taken; e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to the facility staff. f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medications. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families are the responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. 13. The care plan must reflect resident self-administration and storage arrangements for such medications.

Based on observations, record reviews, and interviews the facility failed to assess altered skin conditions and provide wound care according to facility protocol, physician orders, and professional standards for two residents (#15 and #71) out of two residents sampled for non-pressure related skin conditions. Findings included: 1. On 5/18/24 at 10:30 a.m. Resident #15 was observed sitting in the hallway between the two units of the facility. An undated white 2x2 bordered dressing stained with a red substance was observed on the resident's right ankle and a whitish/gray 2x2 bordered dressing dated 5/16/24 was observed on the resident's left ankle. The resident allowed photographic evidence to be obtained. On 5/18/24 at 3:04 p.m. Resident #15 was observed with the same dressings on each lower extremity. On 5/19/24 at 9:01 a.m. Resident #15 was observed with an undated 2x2 white bordered dressing stained with reddish-brown drainage on the right ankle. The observation revealed a dated 2x2 grayish-white dressing on the left ankle. On 5/19/24 at 1:35 p.m. Resident #15 was observed with the same dressings. Review of Resident #15's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed diagnoses not limited to unspecified chronic obstructive pulmonary disease, history of falling, other specified glaucoma, and need for assistance with personal care. Review of Resident #15's May 2024 Medication Administration Record (MAR) revealed no order regarding the treatment of the resident's bilateral lower extremity skin alterations. Review of the resident's May 2024 Treatment Administration Record (TAR) showed the following orders: - Clean Skin Tear to left lower extremity. Cleanse with normal saline, pat dry. Change dressing daily and as needed (prn). Every shift for skin impairment for 14 days, discontinue (DC) order after 14 days and leave of absence (LOA). Complete weekly non-pressure wound UDA. Start date: 5/3/24 and discontinued on 5/15/24 at 10:53 a.m. - Clean Skin Tear to left lower extremity. Cleanse with normal saline, pat dry. Change dressing daily and prn every day shift for skin impairment for 14 days. DC order after 14 days and LOA. Complete weekly non-pressure wound UDA. Start date 5/16/24 at 7:00 a.m. and discontinued on 5/20/24 at 9:20 a.m. - Weekly skin checks Saturday 7 a.m. - 3 p.m. every day shift every Saturday. Review of the TAR showed Staff D, Licensed Practical Nurse (LPN) had changed Resident #15's left lower extremity (LLE) skin tear dressing on 5/16/24, as the observed dressing had revealed. The TAR documentation showed Staff B, LPN, had documented changing the LLE dressing on 5/17 and Staff A, LPN, had documented changing the dressing on 5/18 and 5/19/24. Review of the TAR showed Staff A, LPN, had completed Resident #15's Weekly Skin Check on 5/18/24. Review of Resident #15's Weekly Skin Checks revealed the following: - 5/18/24 at 2:40 p.m., Resident #15 had no new injury or wound identified, the resident had no external devices such as casts, prosthetics, or braces. The evaluation revealed the resident had no previously noted or described skin injuries or wounds. - 5/11/24 at 11:11 a.m., Resident #15 had no new injury/wound identified and no external devices. The description of new skin injury/wound section showed the left lower leg (rear) had a skin tear under treatment. No previously skin injuries/wounds were noted. - 5/3/24 at 3:07 p.m., Resident #15 had a new injury/wound identified to two re-opened skin tears on left lower leg (rear). No other previously skin injuries or wounds were noted. Review of Resident #15's Certified Nursing Assistant (CNA) task history of Skin Observations, from 4/21/24 to 5/20/24 at 2:28 p.m. revealed the resident had no scratches, red areas, discolorations, skin tears or open areas. Review of Resident #15's progress notes revealed on 5/3/24 at 3:30 p.m., the resident was found on the floor in room and two LLE skin tears had reopened. Review of Resident #15's Progress notes revealed a Nurse's Note, dated 5/15/24 at 6:54 a.m. revealing the resident has two skin tears on left lower leg both are dry and healing, no open areas noted, redness or drainage noted. Review of Resident #15's progress notes did not show any further documentation between 5/15 and 5/19/24 related to the resident's bilateral lower extremity skin conditions. An interview and observation were conducted with the Regional Nurse Consultant (RNC), on 5/20/24 at 9:00 a.m. The RNC viewed Resident #15's bilateral lower extremity dressings. The resident raised her right leg revealing an undated 2x2 grayish-white bordered dressing stained with reddish-colored drainage and a dated gray left leg dressing stained with drainage. The RNC confirmed the left ankle dressing was dated 5/16/24 and the right ankle dressing was not dated. During an interview on 5/20/24 at 9:48 a.m., the RNC confirmed staff should have addressed the wounds. The Director of Clinical Operations (DCO) reviewed Resident #15's orders, confirming the orders were for the left leg and there was no wound care order for the right leg. The DCO confirmed the Weekly Skin Assessment done on 5/18/24 did not show any new or previous skin issues. The RNC stated there was a progress note on 5/15/24 revealing 2 skin tears. The mentioned note was reviewed with the RNC and DCO which they confirmed revealed 2 skin tears to the left leg and did not mention the right leg. Review of Resident #15's Treatment Administration Record (TAR) revealed an order, scheduled for 10:00 a.m. to start on 5/22/24 for Wound Care: Cleanse right outer lower leg skin tear with normal saline (NS), pat dry, apply Triple Antibiotic Ointment (TAO) every other day and as needed until healed in the morning, every other day for wound care. Review of a Change of Condition dated 5/20/24 at 9:45 a.m. revealed Resident #15's skin was assessed, resident treatment was changed to right lower leg skin tear, clean with normal saline (n/s) and apply Triple Antibiotic (AAA) ointment every other day (QOD) and PRN until resolved. Resident left lower leg have multiple old, scabbed areas. One scab is red on left inner calf area, treatment for skin prep daily to that area. Resident has no adverse effect. Resident missed treatments to lower legs, MD and Power of Attorney (POA) notified. Review of Skin Observation progress note dated 5/20/24 at 10:05 a.m., showed Resident #15 has skin tear on right lower leg and multiple scabbed areas on left lower leg, resident has one scabbed area with redness around it on left inner calf that area has new treatment for skin prep daily. The note showed the resident had an existing skin tear, scabbed areas resolved. Review of Resident #15's care plan revealed: - The resident had an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) Fatigue, Impaired balance, (and) Limited mobility. The interventions showed Skin Inspection: The resident requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. - The resident has potential/actual impairment to skin integrity r/t fragile skin, incontinence, and decline in function and mobility. The interventions instructed staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. 2. On 5/18/24 at 11:21 a.m. Resident #71 was observed sitting in wheelchair in between the bed of room. The observation revealed an undated 4x4 white bordered gauze dressing to the inner left elbow with drainage noted. During the observation, Staff C, Registered Nurse (RN) observed the dressing and confirmed it was undated. The staff member reported the family had allowed the resident to her drag arm across the bed yesterday and the dressing had been applied. Review of Resident #71's Admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to unspecified cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, unspecified macular degeneration, and need for assistance with personal care. Review of a progress note dated 5/18/24 at 11:36 a.m. revealed the nurse was called by family to Resident #71's room and informed the resident bumped arm on bed resulting in a skin tear. The area was cleansed with normal saline (NS), steri-strips were applied, and covered with a dry sterile dressing (DSD). The note revealed the Nurse Practitioner had been notified. The note did not reveal any further details regarding the wound such as size or approximation of skin. Review of the Change In Condition Evaluation, dated 5/17/24 at 2:00 p.m. and locked on 5/18/24 at 12:00 p.m., revealed the physician had been notified on 5/17/24 at 3:00 p.m. and the spouse of Resident #71 had been notified on 5/18/24 at 1:30 p.m. Review of the Situation, Background, Appearance (and) Review (SBAR) revealed the situation was Resident #71 had suffered a skin tear and the resident condition or symptoms had stayed the same, no changes to the resident's mental and functional status had been observed, and the behavioral, respiratory, cardiovascular, abdominal/GI, GU/Urine, Pain, Neurological, and Skin evaluations were Not clinically applicable to the change in condition being reported. The Appearance portion of the report was left blank and did not include a summary of the nurse's observations or evaluation. The Review and Notify section revealed the physician had been notified at 3:00 p.m. on 5/17/24 and the spouse was notified at 1:30 p.m. on 5/18/24 (the day after the incident and 1.5 hours after the SBAR was locked). Review of Resident #71's May Medication Administration Record (MAR) did not show an order had been received for wound care related to the resident's skin tear to inner left elbow. Review of Resident #71's May Treatment Administration Record (TAR) did not reveal an order had been obtained for wound care to the resident's inner left elbows skin tear at the time of or prior to the observation made with Staff C, RN on 5/18/24. The TAR did show an order with a start date of 5/20/24 at 7:00 a.m. instructing staff to Apply DSD to left elbow daily. Monitor skin tear one time a day for skin tear. Review of Resident #71's Active Order Summary, dated 5/20/24, revealed and order to Apply DSD to left elbow daily. Monitor skin tear one time a day for skin tear had been received on 5/19/24 and was to start on 5/20/24 (three days after the incident). Review of Resident #71's care plan revealed the following: - ADL Care Plan: The resident has an ADL self-care performance deficit r/t decline in function and mobility related Cerebrovascular Accident (CVA). The interventions included SKIN INSPECTION: The resident requires SKIN inspection PRN. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. - Resident has pressure ulcer or potential for pressure ulcer development r/t decline in function and mobility. The interventions included Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms (s/sx) of infection, wound size (length x width x depth), (and/or) stage. Review of the policy titled, Wound Treatment Management, implemented 9/1/23, revealed: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence- based treatments in accordance with current standards of practice and physician orders. The compliance guidelines showed: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or is wet. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the care rustics of the wound (see above). c. Changes in the residence goals and preferences, such as at end-of-life or in accordance with his/her rights. Review of the policy titled, Change in Condition, dated 2024, revealed: To ensure the facility promptly notifies the resident, his or her provider, and legal representative of changes in the resident's medical/ mental condition and/ or status (e.g. Changes in level of care, billing/ payments, resident rights, etc.). The process revealed the nurse supervisor/ charge nurse will notify the resident's provider or on call provider when there has been: a. An accident or incident involving the resident. b. An injury of an unknown source 2. When a resident has a change in condition that requires notification of the provider, the nurse supervisor/ charge nurse will call the DON/designee for guidance prior to notifying the provider to ensure all necessary information will be provided to the provider in order for the provider to make an informed decision regarding care and treatment that minimizes the need for a transfer to a higher level of care. (In the event of an emergency where 911 is necessary do not delay care notify 911 for immediate transport). 6. The nurse supervisor/ charge nurse will record in the resident's electronic health record (EHR) information relative to changes in the resident's medical/ mental condition or status.

Based on record review and interview the facility failed to ensure a pharmacy recommendation and physician order was implemented for one resident (#65) of two residents sampled for monthly drug regimen review. Findings included: Review of Resident #65's electronic medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, adjustment disorder with mixed anxiety and depressed mood. A review of the resident's physician orders revealed a current order, dated 4/7/2024, for Seroquel oral tablet 200 MG [milligram] (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for mood disorder. During a review of Resident #65's medical record, specifically the Consultant Pharmacist Medication Regimen Review, dated 4/25/20247, it revealed a recommendation suggesting adding an order to monitor for behaviors related to the use of Quetiapine (Seroquel). The Consultant Pharmacist Medication Regimen Review was signed by the Director of Nursing (DON), not dated, marked done, and agreed upon by checking AGREE: Please write order. No further action was taken. During an interview with the DON on 5/20/2024 at 9:07 p.m. she confirmed the Pharmacist Medication Regimen Review for Resident #65, dated 4/25/2024, was signed by the her (DON), not dated, and agreed with but no order was added as suggested. The DON stated, This one was missed but it will be added.

Based on observation, interview and record review, the facility failed to monitor side effects for one residents (#63) related to diuretic therapy and pain medication of seven sampled residents. Findings included: Review of Resident #63's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. The Admission Record showed diagnoses to neuromuscular dysfunction of bladder, pain in right hip, obstructive and reflux uropathy, acute kidney failure, and chronic kidney disease stage 3B and osseous and subluxation stenosis of intervertebral foramina of lumbar region. During an interview and observation on 5/18/24 at 11:37 a.m. Resident #63 was in bed with a family member visiting. Resident #63 stated she doesn't get out of bed and was recently readmitted from the hospital. She confirmed she had wounds and receives all her medications. Review of the Minimum Data Set, dated dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section N - Medications revealed Resident #63 received diuretic medication. Review of Resident #63's active physician orders as of 5/19/24 revealed: *Foley Catheter for DX (diagnosis) CKD (chronic kidney disease) Size 16f (ft)10 ml (milliliter), balloon, date 4/24/24. *Pain evaluation every shift for monitoring of patient's pain level, date 4/23/24. *Wound care: cleanse buttocks open area with wound cleaner or N/S then apply mycology cream mixed with hydrocortisone cream to peri-wound for pruritus and redness BID x 14 days every day and night shift for treatment, date 5/16/24; *Acetaminophen Oral Tablet 325 MG (milligrams) give 2 tablet by mouth every 6 hours as needed for pain 1-4, start 4/23/24; *Furosemide Oral Tablet 40 MG give 1 tablet by mouth one time a day for edema, date 5/10/24; *Oxycodone HCI Oral Tablet 5 MG give 1 tablet by mouth every 4 hours as needed for pain, start 4/27/24; *Tamsulosin HCI Oral Capsule 0.4 MG give 1 capsule by mouth at bedtime for overactive bladder, start 5/10/24. Review of the May 2024 Medication Administration Record (MAR) and Treatment Administration Record revealed the medications and treatments were administered as ordered for Resident #63. The MAR revealed Oxycodone HCI Oral Tablet was administered 35 times from 5/1/24 - 5/19/24. The MAR revealed the pain level was monitored. Review of the MAR and TAR revealed they were silent of monitoring for side effects of the pain medication and diuretic therapy. A review of the current care plan for Resident #63 revealed: * Focus - Pain Care Plan potential for alteration in comfort, initiated 3/4/24. Interventions included: notify MD (medical doctor) for new onset of pain, notify MD if pain medication is ineffective. *Focus - The resident is at risk for pain r/t (related to) declined function and mobility, initiated 11/30/23. The interventions included: Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function, monitor/document for side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls, monitor/record/report to nurse any s/sx (signs/symptoms) of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying , worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled up, thrashing). During an interview on 5/20/24 at 11:14 a.m. Staff E, Licensed Practical Nurse/Unit Manager confirmed there was no monitoring for side effects of the pain medication and diuretic therapy. She stated, No there isn't and there should be.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and four errors were identified for two residents (#78 and #3) of ten residents observed. These errors constituted a 16% medication error rate. Findings included: 1. On 5/19/24 at 2:09 p.m. an observation of medication administration with Staff C, Registered Nurse (RN) was conducted with Resident #78. Staff C dispensed the following medications: - Divalproex Delayed Release (DR) 250 milligram (mg) tablet - Magnesium Oxide 400 mg over the counter (otc) tablet On 5/19/24 at 2:09 p.m. the observation revealed the above medication profiles were colored red, showing the medications were late. Staff C, RN confirmed dispensing two tablets. Review of Resident #78 May Medication Administration Record (MAR) revealed the following medications and scheduled times to be administered: - Divalproex Sodium oral tablet Delayed Release 250 mg - Give 1 tablet by mouth three times a day for mood disorder. Scheduled for 1:00 p.m. with additional times of 9:00 a.m. and 9:00 p.m. - Magnesium Oxide oral tablet 400 mg - Give 1 tablet by mouth three times a day for low magnesium. Scheduled for 1:00 p.m. with additional times of 9:00 a.m. and 5:00 p.m. Review of the Medication Administration Audit Report for Resident #78 showed the above medications were dispensed at 2:10 p.m. and 2:11 p.m. 2. On 5/20/24 at 8:47 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse (LPN), was conducted with Resident #3. Staff D dispensed the following medications: - Multi Vitamin with mineral otc tablet - Famotidine 10 mg otc tablet - Ferrous sulfate 5 grams/325 mg otc tablet - Gabapentin 600 mg tablet - Losartan 50 mg tablet - Memantine 10 mg tablet - Metformin 850 mg tablet - Metoprolol 25 mg tablet - Potassium chloride 20 milliequivalent (meq) Extended Release (ER) Staff D, LPN confirmed dispensing 9 tablets prior to the administration. Staff D administered the medications for Resident #3. Review of Resident #3's May Medication Administration Record (MAR) revealed the following medications were to be administered per physician orders: - Daily Multiple Vitamins oral tablet (Multi Vitamin) - Give 1 tablet by mouth one time a day for supplement. - Famotidine oral tablet 20 mg - Give 1 tablet by mouth two times a day for Acid reflux. The review revealed Staff D had dispensed and administered a Multi Vitamin with mineral despite the physician order did not include minerals and 10 mg of Famotidine was administered instead of the ordered 20 mg. Review of the policy titled, Medication Administration, reviewed/revised 9/1/23, revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy's compliance guidelines included the following: - 10. Review MAR to identify medication to be administered. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to adhering to transmission-based precautions for one resident (#69) out of one resident observed with Contact Precautions and providing eye drops to one resident (#58) out of one resident observed during the administration of eye drops. Findings included: 1. On 5/18/24 at 12:36 p.m. an observation revealed Resident #69's had a sign posted on their door that showed, Special Contact Precautions in addition to standard precautions. The sign advised for All family and visitors: Please report to nurses station or see staff BEFORE entering room. The posting instructed Before entering, everyone MUST: - Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water. - Wear gown before entering and remove upon exiting. - Wear gloves before entering and remove upon exiting. - Before exiting, everyone MUST wash hands with soap and water. On 5/18/24 at 12:36 p.m., an observation was made of Staff C, Registered Nurse (RN) who knocked on the door to Resident #69's room and entered without donning a gown or gloving. Staff C exited the room and explained yes she should probably have put a gown on but was just seeing what the resident wanted (call light had been on). Staff C stated the resident was on contact precautions because of [chronic immune system disease] then reported Resident #69 had C-Diff. Review of Resident #69's physician orders revealed the resident was currently receiving Vancomycin 250 milligrams (mg) four times a day for C-Diff, dated 5/7 to 5/21/24. Review of the Centers of Disease Control and Prevention (CDC) Facts for Clinicians, located at https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html, revealed Clostridioides difficile (C.diff) was a common cause of antibiotic associated diarrhea (AAD). It accounts for 15 to 25% of all events of AAD. Prevent C. diff by appropriately using antibiotics and implementing infection control recommendations to prevent transmission. The CDC shows C. diff is a spore-forming, gram-positive anaerobic bacillus that produces 2 exotoxins: toxin A and toxin B. C. diff shades in faces. Any surface, device, or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores. C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. The treatment and recovery of C. diff included instructions for clinicians to wear gloves any gown when treating patients with potential infectious diarrhea, including C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, hand washing alone may not be sufficient to eliminate all C. diff spores. During an interview on 5/20/24 at 1:36 p.m. Staff F, Registered Nurse/Infection Preventionist (RN/IP) stated Contact Precautions were used for any infection that was communicable say C. diff. Staff F explained for Contact Precautions, before entering, staff should wash hands with soap and water, don a gown, gloves, (and) mask depending on if splash-back may occur. Staff F reported hand hygiene was to be done with soap and water as alcohol did not kill spores. Staff F reported walking into Resident #69's room without Personal Protective Equipment (PPE) and not washing hands was not appropriate. The Director of Nursing stated they received Special Contact precaution signs from a local state department. 2. On 5/19/24 at 1:52 p.m. Staff A, Licensed Practical Nurse (LPN) was observed during the administration of medications with Resident #58. Staff A dispensed one tablet and removed one bottle of eye drops from the medication cart, sanitizing hands then entered the resident's room. The staff member administered, with bare hands, one drop in right eye, missing, then dropped another in the right eye, then administered one drop into the left eye. An interview was conducted with Staff A on 5/19/24 at 2:05 p.m. and confirmed she should have worn gloves to administer the eye drops. During an interview on 5/19/24 at 1:52 p.m., Staff F, RN/IP stated Staff A, LPN should have gloved, administered eye drop in one eye, complete hand hygiene preferably ABHR then glove and place another drop in the other eye. Review of the policy titled, Administration of Eye Drops or Ointments, implemented 9/1/23, revealed Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions. The review of explanation and compliance guidelines instructed: 1. Verify orders and labeling prior to administration. 2. Gather supplies: medication, gloves, and tissues/ gauze/ cotton balls. Prepare a clean, dry surface for placing medication caps. 3. Wash hands or utilize alcohol-based hand rub and apply gloves. 4. Position resident with head tilted back. 5. Administration: a. remove medication cap in place on clean, dry surface (i.e. Tissue or paper towel) to prevent contamination. b. Steady hand holding the medication, as needed, on residence forehead. c. With other hand pull down lower lid to form a pouch of the conjunctival sac, avoiding placement of drops directly on the eyeball. d. For eye drops: squeeze the prescribed number of drops into the conjunctival sac, avoiding placement of the drops directly on the eyeball. I. Replace the medication cap. Avoid touching the inside of the cap. Remove gloves and perform hand hygiene. 7. If administering medication to both eyes, use a different gloved finger to apply pressure to the inner tier duct. If the eye medication is an antibiotic or antiviral, change gloves in between. If an eye infected, treat that infected eye last.

Based on observations, interviews and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document the occurrence of falls in the medical record for two (#3 and #4) of three residents sampled for documentation related to falls. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and dementia. A diagnosis of traumatic subdural hemorrhage without loss of consciousness was added on 12/23/2023. Resident #3 was discharged from the facility on 1/15/2024. A review of the facility's incident log for December 2023 revealed Resident #3 had an unwitnessed fall on 12/19/2023 at 4:34 PM. A review of Resident #3's progress notes dated 12/19/2023 at 9:00 PM revealed Resident #3 was transferred to the hospital and was diagnosed with a subdural hematoma. A review of Resident #3's progress notes did not reveal documentation related to Resident #3's fall on 12/19/2023 at 4:34 PM. Further review of Resident #3's medical record did not reveal documentation or assessments related to Resident #3's fall on 12/19/2023 at 4:34 PM. A review of a facility report dated 12/19/2023 at 4:34 PM revealed Resident #3 was observed sitting on the floor next to the toilet in his bathroom after a fall. The report also revealed Resident #3 had a small laceration to his nose and a small scraped area on his forehead with a yellow colored bruise on the left side of his nose. Resident #3 was assessed by the facility's Director of Nursing (DON) and sent to the hospital for evaluation. The facility report was not part of Resident #3's medical record. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and atrial fibrillation. A review of the facility's incident log for February 2024 revealed Resident #4 had an unwitnessed fall on 2/12/2024 at 2:13 PM. A review of Resident #4's progress notes did not reveal documentation related to Resident #4's fall on 2/12/2024 at 2:13 PM. Further review of Resident #4's medical record did not reveal documentation or assessments related to Resident #4's fall on 2/12/2024 at 2:13 PM. A review of a facility report dated 2/12/2024 at 2:13 PM revealed Resident #4 was observed sitting on the floor in his room with his head next to the wall beside the residents bed. Resident #4 was assessed by the DON and a lump was discovered on the back of Resident #4's head. Resident #4 was sent to the hospital for further evaluation. The facility report was not part of Resident #4's medical record. An interview was conducted on 2/13/2024 at 1:31 PM with the DON. The DON stated she was not able to find any documentation in Resident #3's medical record related to the resident's fall on 12/19/2023 at 4:34 PM. The DON also stated when a fall occurs in the facility, nursing staff should assess the resident for any injuries and document the call in a progress note and a change in condition assessment in the resident's medical record. The DON stated she was not able to find any documentation in Resident #4's medical record related to the resident's fall on 2/12/2024 at 2:13 PM. The DON stated the falls were documented in a facility record but she was unsure if the facility record was part of the resident's medical record. A review of the facility policy titled Documentation in Medical Record, last revised on 8/25/2022, revealed under the section titled Policy each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observations, record review, and interviews the facility failed to obtain wound care orders following the admission of one (#2) of one resident admitted with three (3) surgical wounds and one (1) unstageable pressure ulcer, and the facility failed to provide pressure ulcer care for one (#2) of one resident sampled for wound care. Findings included: Review of the Admission Record identified that Resident #2 was admitted from an acute facility on 2/25/23. The Admission Record included diagnoses not limited to fusion of spine - lumbar region, encounter for other orthopedic aftercare, site not specified urinary tract infection, occlusion and stenosis of right vertebral artery, and essential (primary) hypertension. Review of the hospital records did not identify the acute facility had ordered specific wound care procedures related to either the surgical wounds or the pressure ulcer for Resident #2. Resident #2's Admission/Readmission Nursing Evaluation, dated 2/25/23, Section C identified the resident had a pressure wound and surgical wound. The Weekly pressure wound note, dated 2/27/23, identified that Staff Member A, Wound Care Nurse (WCN), had assessed the pressure ulcer, which indicated the wound was located on the coccyx and was unstageable. The wound bed had slough tissue present, with moderate amount of serous drainage, and no odor. The wound presented with no signs of infection and that new orders were received. The progress note did not identify the specifics of the orders received. The wound measured 3.8 centimeter (cm) x 0.7 cm x 0.2 cm. Review of Resident #2's February Treatment Administration Record (TAR) did not include any orders for the care of the residents pressure ulcer or the surgical wounds to the lumbar region. A review of the resident's February Medication Administration Record (MAR) did not include wound care orders for the pressure ulcer or the surgical wounds. The facility failed to provide the March Treatment Administration Record (TAR) as requested that did identify that wound care orders were obtained on 3/2/23 for Resident #2's coccyx pressure ulcer but did indcate that the facility failed to provide care to the area on Saturday 3/4/23 and Sunday 3/5/23. On 3/6/23 the Wound Care Specialist, from an outside provider, indicated an assessment and evaluation was performed on Resident #2's unstageable coccyx. The depth of the wound was unable to be measured due to necrosis. The evaluation indicated that staff were to apply alginate calcium daily for 30 days, Santyl apply daily with border (dressing). The evaluation indicated that a surgical excisional debridement was completed per the resident permission. On 3/13/23 the wound care specialist noted that the resident was not seen due to a non-wound related hospitalization . The Director of Nursing (DON) stated, on 3/23/23 at 2:50 p.m., that Resident #2 had one wound. The DON reviewed physician orders and confirmed the resident did not have surgical wound care orders and stated that the facility would find out what the surgeon wanted by looking at the notes, and ask the Wound Care Nurse (WCN) to contact the surgeon. She stated that if the WCN was at the facility they would assess the wound then or the next day, and if (resident admitted ) on weekend they would see them on Monday, the Wound Care physician comes on Mondays. The DON confirmed that wound care orders would be obtained by the Attending physician until the wound could be evaluated. The DON reviewed progress notes, again, and stated she believed the resident came in with 3 pressure ulcers. Staff A was interviewed, at 3:11 p.m. on 3/23/23, with the DON and Nursing Home Administrator (NHA). The staff member reported doing all wound care in the facility on Monday through Friday and that Resident #2 came in with 3 surgical wounds and an unstageable coccyx (pressure wound). Staff A stated that the resident did not come into the faciltiy with any dressing change orders, that the surgical wounds were open to air, and the coccyx wound did have a dressing on it but did not have wound care orders. The staff member reported calling the Wound Care physician and receiving orders for the coccyx. The DON reported that expectation was that if Staff A was not available that staff nurses do the wound care. The DON stated that the expectation was that staff would obtain wound care orders for the care of the coccyx wound on 2/25/23, when the resdient was admitted . The DON and Staff A reviewed the physicain orders and confirmed orders were not received on 2/25 or on 2/26/23. They did identify that no wound care orders were documented in February following Resident #2's admission and that wound care was not completed on 3/4 or 3/5/23. The DON confirmed if it was not documented it was not done. The policy - Provision of Physician Ordered Services, implemented and reviewed/revised on 8/25/22, indicated The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The guidelines indicated that Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.

Based on interviews and record review, the facility failed to develop and implement a plan to ensure nutritional supplements were provided for 12 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) of 24 residents on one (B Wing) of two units during a period when the facility did not have an adequate supply of the ordered supplements. Findings included: An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 08/15/22 at 11:25 a.m. She confirmed she had residents assigned to her that had orders to receive nutritional supplements, including Resident #1. She stated, We haven't had any supplements at the facility since last Friday (08/12/22) because [Supplement B] is on recall so we were using [Supplement A] .now that's on backorder. She stated she had been told Supplement A was on backorder by Staff B, Central Supply. She stated, As of right now I can't give it [Supplement A] because we don't have any. An interview was conducted with Staff B, Central Supply on 08/15/22 at 12:14 p.m. She confirmed she was responsible for ordering nutritional supplements including Supplement A and Supplement B. She confirmed Supplement B had been recalled on 07/26/22 and at that time, the facility began using Supplement A instead. She reported an email was received the previous week from the corporation administration that Supplement A would be replaced with a different supplement (Supplement C). She stated she placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was conducted with Staff C, Registered Dietitian (RD) on 08/15/22 at 12:58 p.m. He reported the last time he was at the facility was on 08/12/22. Regarding nutritional supplements he said, I'm aware that the [Supplement B] got recalled and was switched out for [Supplement A]. He said, it came to my attention on Friday (08/12/22) that there was no [Supplement A] in the facility. He stated he spoke to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 08/12/22 about needing Supplement A and said, so then I was asking when the next shipment was going to be in .they told me they weren't sure. He said, I suggested [Supplement C] to the ADON, I don't know if she ordered it. He stated he did not know if there were other alternatives available in the facility that could have been substituted and that he had no further conversations about supplements, no involvement about supplements over the weekend, and had not received any contact from the facility about nutritional supplements and/or substitutions. A telephone interview was conducted with Staff D, LPN on 08/15/22 at 4:07 p.m. She confirmed she worked at the facility on the B wing on from 7:00 a.m. - 11: 00 p.m. on 08/13/22 and 08/14/22. She stated her assignment included residents who had orders for nutritional supplements. Regarding availability of nutritional supplements at the facility, she reported the facility did not have any stock of Supplement A during her shifts and said they were supplementing with a nutritional drink but could not recall the name of it. She stated the facility had been using Supplement B previously but said, I was told [Supplement B] was on backorder and that's when we switched over to [Supplement A] and I think with the sudden switch it was hard to get [Supplement A]. Staff D reported she found out the facility had run out of Supplement A in the report given by the night nurse when she began her shift on 08/13/22. She stated she had talked with other nurses working in the facility about whether there was any stock of Supplement A and all confirmed there was not. She confirmed she did not receive any instruction or guidance about nutritional supplements from the DON or anyone else and stated she had not had any conversations with the DON about nutritional supplements. A report of all residents in the facility with active orders for nutritional supplements was reviewed. 12 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) who resided on B Wing with orders in place for Supplement A and Supplement B were identified. Review of medical record for Resident #1 was conducted. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse to document amount consumes. No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes related to Supplement A revealed the following: 08/12/22 11:51 a.m. Supplement A waiting on order and 08/12/22 2:11 p.m. Supplement A waiting on order. The care plan revealed a focus area for impaired nutrition related to low body mass index (BMI) and history of significant weight loss with interventions that included Provide supplements per orders. Review of medical record for Resident #2 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 1:21 p.m. Supplement A awaiting delivery and 08/15/22 11:52 a.m. Supplement A MD notified, on order. The care plan revealed a focus area for impaired nutrition. Review of medical record for Resident #3 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 12:03 p.m. Supplement A waiting on order, 08/12/22 2:08 p.m. Supplement A waiting on order, 08/15/22 9:22 a.m. Supplement A awaiting delivery from pharmacy, MD notified and aware. The care plan revealed a focus area for impaired nutrition with interventions that included Provide supplements as needed. Review of medical record for Resident #4 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/15/22 11:21 a.m. Supplement A notified MD, [Supplement A] on order. The care plan revealed a focus area for impaired nutrition with interventions that included Provide supplements as needed. Review of medical record for Resident #5 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/15/22 9:15 a.m. Supplement A awaiting delivery from pharmacy, MD notified and aware. The care plan revealed a focus area for impaired nutrition with interventions that included Provide supplement as ordered. Review of medical record for Resident #6 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 12:00 p.m. Supplement A waiting on order, 08/15/22 9:19 a.m. Supplement A awaiting delivery form pharmacy, MD notified and aware. Review of medical record for Resident #7 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 12:03 p.m. Supplement A waiting on order, 08/15/22 9:23 a.m. Supplement A awaiting delivery from pharmacy, MD notified and aware, 08/15/11 12:36 p.m. Supplement A house stock supplement provided, MD aware, order to be changed. The care plan revealed a focus area for risk for malnutrition with interventions that included Provide and serve supplements as ordered. Review of medical record for Resident #8 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 12:03 p.m. Supplement A waiting on order. The care plan revealed a focus area for impaired nutrition with interventions that included Provide supplements as needed. Review of medical record for Resident #9 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/12/22 10:06 a.m. Supplement B unavailable, awaiting delivery, 08/12/22 12: 06 p.m. Supplement B awaiting delivery, 08/13/22 10:35 a.m. Supplement B used facility supplement. 08/14/22 2:47 p.m. Supplement B on backorder, 08/15/22 11:22 a.m. Supplement B notified MD, [Supplement B] on recall, 08/15/22 12:51 p.m. Supplement B MD notified, house supplement provided, order to be changed. The care plan revealed a focus area for impaired nutrition with interventions that included Provide Supplements as needed. Review of medical record for Resident #10 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revealed a focus area for malnutrition with interventions that included Provide and serve supplements as ordered. Review of medical record for Resident #11 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed an entry dated 08/15/22 8:28 a.m. Supplement A awaiting delivery. The care plan revealed a focus area for impaired nutrition. Review of medical record for Resident #12 was conducted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional active orders for nutritional supplements were present. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurses medication administration notes revealed the following: 08/15/22 11:52 a.m. Supplement A MD notified, on order and 08/15/22 2:14 p.m. Supplement A MD aware, house stock supplement provided, waiting on order. The care plan revealed a focus area for malnutrition with interventions that included Provide and serve supplements as ordered. An interview was conducted with the Nursing Home Administrator (NHA), the DON, the ADON, and the corporate Regional Nurse Consultant (RNC) on 08/15/22 at 1:25 p.m. Staff B, Central Supply also joined the interview. All parties confirmed Supplement B had been recalled and was not in use at the facility since that time. The RNC confirmed the date of the recall was 07/27/22. The DON confirmed that following the recall the facility began using Supplement A as the primary supplement for residents. The DON reported it was brought to her attention in the stand-down meeting on 08/12/22 that we were running low on [Supplement A]. She stated she had not confirmed how low the stock was. She stated discussion was held but no specific plan was put in place for the weekend related to nutritional supplements. Staff B said, I communicated in the stand down meeting on Friday (08/12/22) that there wasn't enough [Supplement A] for the weekend. The ADON said, my understanding is they were using [nutritional drink] over the weekend. The DON confirmed she had not directed facility nurses to replace Supplement A with a nutritional drink over the weekend. She confirmed that if a nutritional drink was used as a substitute there needed to have been physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said, we've contacted physicians and nurse practitioners today about getting new orders. Regarding why a plan had not been put into place once it was known on 08/12/22 that there was not enough supply of Supplement A to last the weekend, including no new physician orders, and no directives to nursing staff, the DON said, I don't know how to answer that. The DON stated that morning (08/15/22) she had investigated facility supply to see if there was any alternative to substitute for Supplement A and had found [Supplement D] and said, I tasted it and tastes okay. She revealed a container of the supplement and stated the nurses had since been instructed to use as substitution. The RNC interjected RD input would be needed to determine if appropriate substitution for Supplement A. At 3:15 p.m. on 08/15/22 the DON followed up and stated she had been at the facility on Saturday (08/13/22) and said, I was here Saturday for like 8 hours .I saw the supplements on the cart and was directing the nurses. Regarding why she had not shared this information in the previous interview about events of the weekend she responded, well you didn't directly ask me that. A follow up interview was conducted with the DON on 08/15/22 at 3:44 p.m. She stated she had worked in the facility on Saturday (08/13/22) for unrelated reason and said, while I was here I found out we were out of [Supplement A] on B wing . my understanding was we were out of [Supplement A] in the entire building. She reported she talked with the nurses about alternates and instructed them to use available supplements (nutritional drinks) as substitute. She confirmed she had not instructed the nurses to get physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, the plan was to come in and get it squared away today. Regarding Supplement D substitution initiated by her that day (08/15/22) she said, didn't know we had that until today. Review of an undated facility policy titled, Nutritional and Dietary Supplements revealed: It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Nutritional Supplements refers to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, total [MEDICATION(S)] products, enteral products and meal replacement products . The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs. Supplements may be provided by dietician recommendation as allowed by physician standing order. The care plan will be updated with the new or modified nutritional interventions.

Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment for five (Resident #3, #28, #45 #48, #49) of 17 facility residents receiving respiratory therapy during three (5/9/2022, 5/10/2022, and 5/11/2022) of four days observed. Findings included: 1. On 05/09/2022 at 10:07 a.m. and 12:13 p.m., Resident #49's nebulizer mask was observed on top of the nebulizer machine. Additionally, the oxygen nasal cannula and tubing were observed hanging over the oxygen concentrator. On 05/10/2022 at 08:50 a.m., observation revealed Resident #49's nebulizer facemask was not stored in the plastic storage bag, and the oxygen nasal cannula and tubing were hanging over the oxygen concentrator. On 05/11/2022 at 08:49 a.m., Resident #49's oxygen tubing was observed hanging over the oxygen concentrator, and the unbagged nebulizer facemask was on top of the bedside table. An observation was conducted with the Director of Nursing (DON) on 05/11/2022 at 10:15 a.m. During the observation, the DON confirmed Resident #49's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. Clinical Record review of Resident #49's Physician Order dated 12/13/2021 revealed the resident was to receive oxygen therapy via nasal cannula (NC) at 2 liters per minute continuous, and [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation every 4 hours (06:00, 10:00, 14:00, 1800, 2200, 0200). 2. On 05/09/2022 at 10:20 a.m., Resident #45's nebulizer facemask was observed in the top drawer of the bedside table, and the oxygen tubing was on the floor of the resident's room. The oxygen plastic storage bag dated 2/14/2022 was located on top of the oxygen concentrator. Interview with Resident #45 at the time of the observation revealed she did not know how her respiratory equipment should be stored. On 5/11/2022 at 08:38 a.m., an observation was made of Resident #45's unbagged oxygen cannula on the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:35 a.m. During the observation, the DON confirmed Resident #45's nebulizer facemask and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. A review of Resident #45's Physician Order dated 02/11/2021 revealed the resident was to receive Oxygen Therapy via Nasal cannula (NC) at 2 liters per minute as needed, and an order dated 12/09/2021 for [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation three times a day as needed. 3. On 05/09/2022 at 10:30 a.m., Resident #48 was observed to be lying in bed sleeping. The resident was not wearing respiratory/using respiratory equipment at the time of the observation. The resident's oxygen nasal cannula was observed unbagged on the bedside table. On 05/10/2022 at 08:30 a.m., Resident #48 was observed in his room. His unbagged oxygen nasal cannula was observed hanging over the left side bedrail. On 5/11/2022 at 08:09 a.m., Resident #48's nebulizer facemask was observed to be unbagged on the bedside table. Interview with Resident #48 at the time of observation revealed the facemask was always stored in this manner on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:00 a.m. of Resident #48's room. During the observation, the nebulizer facemask was on top of the bedside table, and the oxygen nasal cannula was hanging over the bedrail. The DON confirmed both respiratory devices were not stored appropriately. The DON immediately removed both respiratory devices and placed them in the garbage receptacle. Clinical Record review of Resident #48's Physician Order dated 12/13/2021 revealed the resident was to received oxygen therapy via nasal cannula (NC) at 2 liters per minute as needed, and Budesonide suspension for nebulization 0.5mg-2ml inhalation twice a day. 4. On 05/09/2022 at 11:00 a.m., Resident #28's room was observed with an unbagged nebulizer facemask on top of the bedside table. On 05/10/22 at 9:21 a.m. and 05/11/22 at 08:45 a.m., Resident #28's oxygen nasal cannula was observed on the floor of the room in front of the oxygen concentrator, and the unbagged nebulizer facemask was located on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:20 a.m. During the observation, the DON confirmed Resident #28's nebulizer facemask, and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table, and indicated the resident was not receiving nebulizer treatments. She then removed the oxygen cannula and placed both items into the garbage receptacle near the resident's bed. Clinical record review of Resident #28's Physician Order dated 04/22/2021 revealed Oxygen Therapy via Nasal cannula (NC) at 3 liters per minute as needed. 5. On 05/10/2022 at 08:45 a.m., an observation was made of Resident #3's room. During the observation, a nebulizer facemask was observed next to the plastic storage bag. On 05/11/2022 at 08:41 a.m., Resident #3's nebulizer facemask was stored on top of the bedside table near the plastic storage bag. An observation was conducted with the DON on 05/11/2022 at 10:24 a.m. During the observation, the DON confirmed Resident #3's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. On 5/11/2022 at 10:30 a.m., the DON confirmed all respiratory devices for Residents #3, #28, #45, #48, and #49 were not stored appropriately. The DON stated, This needs to be addressed promptly. There will be staff education and monitoring. A follow-up interview with the DON on 5/11/2022 at 11:40 a.m., revealed all respiratory equipment for residents observed was removed and replaced with new respiratory devices to include nebulizer facemasks and oxygen nasal cannulas. A review of the facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, with revision date of October 2010, revealed: Purpose: The purpose of this procedure is to administer aerosolized particles of medication safely and aseptically into the resident's airway. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Photographic evidence was obtained.

Based on observations, interviews and policy review, the facility did not ensure the kitchen was maintained in a sanitary manner during 3 of 4 days of survey. Findings included: An initial tour of the facility's kitchen was conducted on 05/09/22 at 09:48 AM. The tour was facilitated by the assistant certified dietary manager/CDM2 The kitchen tour revealed concerns with dirty vents located above food prep areas and clean dish storage areas. The vents were noted with dust, debris, and bio-growth. The CDM2 stated maintenance is supposed to clean the vents once a month. Concerns with Bio growth on the edge of the sink in dishwashing area were identified. The CDM2 stated they would clean it up. The CDM2 said, that is not sanitary. The CDM2 stated they have had that problem before. Photographic evidence was obtained. On 05/11/22 at 11:15 AM, a kitchen tour was conducted with the Registered Dietician (RD). An observation was made of ceiling vents in dish storage area and food service areas with dirt, debris, and bio growth. An interview was conducted on 05/11/22 at 11:35 AM with the RD. The RD stated she thought maintenance had cleaned all the vents. RD stated it will be done right after food service. An interview was conducted on 05/11/22 at 01:14 PM with the CDM2. The CDM2 stated they had scrubbed the sink area and removed the bio growth. The CDM2 stated they had scrapped off the old caulking in the sink area and applied new caulking. The CDM2 stated maintenance staff cleaned some vents, but they forgot the other two. A second interview was conducted with the RD on 05/11/22 at 1:11 PM. The RD stated the vents had now been cleaned and the CDM and maintenance will ensure surfaces are maintained in clean manner. When asked what the expectation was, the RD said, The vents will be cleaned weekly and then monthly after that. The RD stated dirty vents with debris over clean dishes and food service areas were of concern due to cross contamination. The RD said, We will make sure cleaning is done. On 05/11/22 at 1:39 PM, a telephonic interview was conducted with the CDM1. The CDM1 stated she had conducted an inspection a few weeks earlier and had identified the vents in the kitchen needed to be cleaned. The CDM1 stated the list was given to maintenance director. The CDM1 said, I forgot to follow-up. It was on my list 3 weeks ago. The CDM1 stated the expectation is to clean vents once a month. The CDM1 stated she would conduct inspections on an on-going basis. The CDM1 stated they did not have the vents on the checklist. The CDM1 said, I can understand the concern with dust flowing on food or food serving dishes. It is not sanitary. An interview was conducted with the Director of Maintenance (DOM) on 05/11/22 at 4:20 PM. The DOM stated he did not know the cleanliness and maintenance was on his list. The DOM said, I will make sure it is done going forward. It is on my list to make sure we dust them every week. The DOM stated the black stuff looked like bio growth. The DOM stated cleaning should be done more often. On 05/11/22 at 5:11 PM, the nursing home administrator (NHA) reviewed photographic evidence and stated the staff are always cleaning. It should not look like that. The NHA said, No, bio growth in the kitchen and near food surfaces is not good. I will follow-up and make sure they take care of it. Review of a facility policy titled sanitation revised October 2008, showed food service areas shall be maintained in a clean and sanitary manner. Review of a facility policy titled, cleaning and disinfection of environmental surfaces revised August 2019 showed environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards. Review of a facility policy titled, maintenance service revised December 2009, showed maintenance service will be provided to all areas of the building, grounds, and equipment. (2) Functions of maintenance personnel include maintaining the building in compliance with current federal. State, and local laws, regulations, and guidelines. Buildings will be maintained in good repair and free from hazards.

Based on observations, interviews, record review and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 and other infections on two (101-110 and 119-128) of six hallways and one of one laundry area. Findings included: 1. On 5/9/22 beginning at 11:30 AM, Staff I, Certified Nursing Assistant (CNA) was observed delivering and setting up lunch trays for residents in rooms 101 through 108. No hand hygiene by Staff I was observed between each tray delivered. 2. On 5/9/2022 at 11:23 a.m. a lunch meal tray service was observed in the hallway of the facility serving rooms 119 to 128. Staff A, CNA was observed getting a tray from an open metal dining cart and taking the tray into room [ROOM NUMBER]. Staff A was observed proceeding to get another tray from the cart without conducting hand hygiene and taking the tray into room [ROOM NUMBER]. Staff A could be seen setting up the food tray for the resident in room [ROOM NUMBER] without performing hand hygiene. Staff A proceeded to exit the room and was not observed to perform hand hygiene. Staff A then put on a gown and gloves, took another tray from the dining cart, and entered room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A came to the doorway and was handed another tray for room [ROOM NUMBER] by another staff member. Staff A could be seen setting up the tray for each resident in the room. Staff A exited the room, removed the gown and gloves in the hallway, and placed them in a small metal receptacle. Staff A was not observed conducting hand hygiene after removal of her gown and gloves. Staff A was observed putting on another gown and gloves and taking another tray from the dining cart and taking the tray into room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A set the tray on an overbed table and reached out into the hallway, while still wearing the same gown and gloves, to take another tray from the cart for room [ROOM NUMBER]. Staff A did not perform hand hygiene, and did not change her gown and gloves prior to serving the second resident in the room. Staff A proceeded to exit room [ROOM NUMBER], take off her gown and gloves in the hallway, and place them into a small metal receptacle. Staff A, CNA was not observed to perform hand hygiene after removal of her gown and gloves. Staff A then removed another tray from the dining cart and took the tray into room [ROOM NUMBER]. Staff A could be seen setting up the tray for the resident. Staff A returned to the hallway and without performing hand hygiene, she left the hallway and brought back a box of gowns to restock the supply in the hallway. Staff A , without performing any hand hygiene, proceeded to put on another gown and gloves and get another tray from the dining cart. Staff A was observed taking the tray into the room for Resident #21. Resident #21's room was not marked as being in isolation of any kind. Staff A was observed setting up the tray for the resident. Staff A exited Resident #21's room, took off her gown and gloves in the hallway and placed the items in a small metal receptacle. Staff A was not observed performing hand hygiene after removal of the gown and gloves. Staff A then assisted another employee to put on a gown, and she left the hallway pushing the dining cart as she left. On 5/09/22 at 11:45 a.m., a visitor was observed approaching Resident #21's room with a mask and shield on. The visitor was observed putting on gloves and a gown to enter the room. The visitor stated Resident #21 was on isolation due to being exposed to COVID. No signage was observed on the door indicating the resident was on isolation or providing any direction to visitors for Personal Protective Equipment (PPE) usage. Photographic evidence was obtained. A review of facility policy entitled Handwashing/Hand Hygiene with a revision date of August 2019 revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1 All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in prevention the transmission of healthcare-associated infections. 2 All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. .7 Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .b before and after direct contact with residents .f before donning sterile gloves .l after contact with objects in the immediate vicinity of the resident m after removing gloves n before and after entering isolation precaution settings o before and after eating or handling food p before and after assisting a resident with meals .8 Hand hygiene is the final step after removing and disposing of personal protective equipment 9 The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10 Single-use disposable gloves should be used .c when in contact with a resident or the equipment or environment of a resident, who is on contact precautions. A review of the facility policy entitled Isolation-Categories of Transmission-Based Precautions with a revision date of October 2018 indicated the following: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: 1 Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2 Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. .5 When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a The signage informs the staff of the type of CDC (Centers for Disease Control) precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions 1 Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. .4 Staff and visitors will wear gloves when entering the room .b Gloves will be removed and hand hygiene performed before leaving the room 5 Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions 1 Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets , larger than 5 microns in size, that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). .4 Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. 3. On 5/12/2022 at 9:29 a.m., an interview was conducted with the Director of Nursing (DON) and Assistant Nursing Director (ADON)/Infection Preventionist (IP), related to infection control procedures for hand hygiene. The DON revealed that her expectation for all staff is that they perform hand hygiene before between and after resident care. She further indicated that all staff must use Personal Protective Equipment (PPE) appropriately based on the signage posted on each resident isolation precaution room. The ADON indicated the facility does in-service training and stated The education is working; we are finding that the staff is telling other staff to wash their hands and don PPE. We are following the Centers for Disease Control (CDC) guidance (as a main source), pulling up the website continuously. On 5/12/2022 at 11:00 a.m., an observation was conducted with the DON of the Laundry area. Personal items of a large cup and two bags were on top of the folding table. These items were right next to many clean and folded resident gowns, that were placed on top of each other in a pile. Staff P, Laundry Aide, confirmed that her personal items were on the table, and stated, the facility does not provide a locker, there is no place to put items. Immediately after the interview a bottle of (Cleanser and Disinfectant) was seen on the other side of the folding table with no kill time on the label. Staff P confirmed she uses the product to clean the folding table and did not know the product kill or dwell time when she uses the product on the table. She stated, I do not know, I put it on and let it dry and do it once when I come into work. Further observations revealed that Staff P, Laundry Aide was wearing her own gown and surgical gloves while sorting dirty clothes on the dirty side of the laundry area. Staff P was observed wearing the same gown while transferring clean clothes into the dryers on the clean side of the laundry area. Staff was not using the facility provided PPE items of gown, goggles, and black gloves. Staff P was asked about her gown and stated, I refuse to use that [expletive]. She further indicated that she brings three gowns from home and changes them when necessary. On 05/12/2022 at 12:00 p.m. an interview with the DON and ADON (IP) was conducted. The ADON provided a copy of education and in-service training given to Staff P on 3/19/2022, held by the Housekeeping Director. Staff P signed and acknowledged she understood product kill and dwell time for the of (Cleanser and Disinfectant). The ADON also provided the product information, which showed that the product has a 10-minute kill time in order to be effective. She further revealed that all staff in the laundry room must wear the appropriate PPE which is hanging on hooks in the laundry room. The ADON stated Staff P cannot bring in her own personal gowns from home, and she cannot wear gloves that we use to take care of patients while sorting laundry. The DON reported that following the observation of the laundry area at 11:00 a.m. on 5/12/22 with the surveyor, all laundry on the folding table was being rewashed and the folding table was re-cleaned. The DON reported that maintenance was going to install a locker for staff to place all personal items in to avoid having personal items in the laundry area.

Based on review of the facility ' s policies and procedures regarding " CPR - Code Blue " and " Resuscitation -Cardio [MEDICAL CONDITION] " , both effective [DATE], with no Revised date; review of information provided in the facility ' s Florida Resident Handbook & Admissions Information provided upon admission page 8 - 10: Information for residents and their families about advance directives for medical care; review of Resident #1 ' s medical record including the Initial Social Service History completed on [DATE], and interview with facility staff, physicians, and family members, it was determined that the facility failed to follow the documented Advanced Directives to receive Cardio [MEDICAL CONDITION] Resuscitation , for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE]. Thirty-three residents, per the facility Advanced Planning audit conducted on [DATE], had communicated their wishes to the facility that they desired to be resuscitated and are at risk should they be found without pulse or respirations. Resident #1 had communicated that should she be found unresponsive she wanted to be resuscitated. Resident #1, on [DATE] at 4:30 a.m. was found unresponsive and without respirations or a pulse, but was not administered CPR and 911, Emergency Medical Services were not contacted. The facility failed to follow their policies related to advanced directives indicating that CPR (Cardio - [MEDICAL CONDITION] Resuscitation) would be administered to any and all residents unless there was a DNR (Do Not Resuscitate) order. Resident #1 had [DIAGNOSES REDACTED]. Nurses notes revealed a pleasant, alert and oriented [AGE] year old female who attended therapy on a daily basis. Nurses notes on the day the resident died did not reflect that staff followed the facility policy of checking the resident ' s medical record for advanced directives, and by not providing CPR. The actions of the nursing staff providing care during the early morning hours when the resident was found without respirations resulted in findings of Immediate Jeopardy on [DATE] at 4:30 p.m. which was determined to be ongoing. Findings include: 1. Review of the facility ' s " CPR-Code Blue " policy, effective ,[DATE] (with no policy number or Revised date), revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to: " Open the Airway 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] (with no policy number or Revised date) revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 2. Review of the Resident Handbook, provided upon admission to residents and responsible parties, included three pages of information about advanced directives to help residents and responsible parties through the process of defining and documenting their wishes concerning medical treatment and end of life decisions. Contained within the first two paragraphs of the document were the lines, " You alone have the right to make basic decisions about the medical and health care services you receive from your physician and health care providers. .... All of those who provide your health care are responsible for following your wishes. " 3. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician order [REDACTED]. [DIAGNOSES REDACTED]. The Interim Plan of Care, developed upon admission, included the questions, " Resident is a DNR " which was answered NO. The Goal was checked " Will follow Advanced Directives. " 4. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " . The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , resident ' s employment as a Caregiver, and that she had had three children. Daily preferences included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, enjoying snacks between meals, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and review of the plan revealed options to check identifying the resident ' s ' Problem/Need/Strength/Potential Concern. ' Checked on the care plan was the Problem/Need confirming that the discharge plan was to her home and the attending physician had determined that the resident ' s stay at the facility was short term. 5 Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 PT sessions. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed of the six short term goals, the resident progressed in five of them, with the resident meeting the goal for two of the five. 6. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 7. Review of care plans that were developed from the assessment included one for Discharge Planning and one for Advanced Directives. The Discharge Planning care plan, written on [DATE], indicated the resident had expressed the wish to be discharged home and the attending physician had determined that the resident needed a short term stay. The Advanced Directive care plan, written on [DATE] indicated that the resident had a Durable Power of Attorney for health care decisions and she was capable of making informed consent for her health care decisions. The goal indicated that the resident ' s advanced directives were in effect and " their wishes and directions will be carried out in accordance with their advanced directives. " Contained in the Problem column on the care plan form and in the Approach column on the form were areas detailing Do Not Resuscitate orders (DNRO). Neither of the columns had any of the options checked, indicating that the resident had a DNRO. Additional interventions had been written in, dated [DATE], indicating, " conversation with resident and daughter re: hospice and DNR " . 8. On [DATE] the resident accompanied by her daughter, saw the resident ' s oncologist. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 9. Review of nurses ' notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]), no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 10. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and the resident ' s wish not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger so she could go home, and had done well with both Occupational and Physical Therapy. 11. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview: In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE], it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. 12. An interview with the Medical Director on [DATE] beginning at 11:20 a.m. revealed that he recalled that a nurse had found a resident cold and unresponsive and had decided not to provide CPR. The doctor stated that he felt she had made the decision on her own. He was aware that other nurses were there as well but no one started CPR. He reported that he had provided his own inservice on this issue - essentially when to call a doctor, as only a doctor can pronounce a patient dead. The Medical Director stated, " Who knows what happened that night, what those nurses were thinking. " 13. A phone interview was conducted with Resident #1 ' s doctor on [DATE] at 1:00 p.m. The physician admitted remembering the resident but said she only remembers getting a phone call that the resident had died . She described the resident ' s diagnosis, but said that she didn ' t remember the code status and hadn ' t been told that the resident was found nonresponsive but hadn ' t been provided with CPR. The physician began to detail the process that should have occurred during the phone conversation - find a body, check for code status, if full code, call 911 and start CPR, and was surprised when again she was told that CPR had not been administered. She confirmed that she had not been made aware that that had occurred. 14.. Interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m. revealed that the resident had spoken with staff on [DATE] about end of life decisions. The RM reported that the resident had been talking with staff about how she was ready to die and wondering about the afterlife. The RM reported that ' Everyone knew her feelings. ' She stated that the facility was in the process of getting the resident to sign the DNR. But both the RM and the DON stated that the resident was essentially still a Full Code. The DON reported that nurses had been inserviced that they must do CPR unless they find a DNR in the record. She added that there had been three nurses working the floor that early morning and after checking the chart for the yellow DNR form, one should have started CPR and another should have called 911. She said that she didn ' t know what the nurses were thinking, by not starting CPR and she could only think that since the body was cold, it would not be worth starting CPR. Review of inservice sign in sheets from the training provided after the incident ([DATE], [DATE], and [DATE]) revealed 17 nurses and 2 aides signed as having attended. Review of the facility ' s list of personnel revealed 34 nurses and 65 aides were on staff. Review of the schedule of nurses and aides that worked the ,[DATE] shift on [DATE] revealed only one of the three nurses had signed and none of the five aides had signed as having attended. Review of an audit conducted by the Human Resources Director on [DATE] revealed of the 30 nurses currently on staff, only 15 nurses had current, active CPR certification cards. In the interview on [DATE] that began at 2:30 p.m .the DON reported that another approach to providing Advanced Directive status information to the nurses was to included it on a ' shift sheet ' report. The DON explained that the shift sheets were daily documents that included pertinent information about every resident and each shift updated the information as a way to keep current on the resident. These sheets were passed on to the next shift. The DON reported that the shift sheets were to include either " DNR " or " Full " for each resident, based on their documented Advanced Directive status. Review of the shift sheets for the 200 wing, on [DATE] at 3:50 p.m. confirmed that both shift sheets contained the Advanced Directive information, and both nurses on the 3 to 11 shift were aware of the inclusion of that information. Interview with two nurses on the 100 wing, on [DATE] at 3:40 p.m. revealed that neither nurse was aware that the information should be contained on the shift sheet. One nurse (employee B) reported at that time that Advanced Directive information was contained in the medical record, not the shift sheets. Interview with the Assistant Director of Nurses, at that time, revealed that the information had not been added to the shift sheets. Review of weeks of the saved shift sheets confirmed that the 100 wing had not implemented that approach to ensuring that resident ' s Advanced Directives were honored. 15. Interview with the Administrator on 06/ ,[DATE] at 4:30 p.m. revealed that he was aware of the planned approaches from [DATE] to ensure that residents with Full Code Advanced Directive status would be provided CPR. The Administrator was not aware that all staff had not been re-trained on the facility policy related to providing CPR. The Administrator also was not aware that the planned approach to include Advanced Directive information on the shift sheets had not been implemented on one of two resident ' s halls.

Based on review of the facility ' s policies and procedures regarding " CPR - Code Blue " and " Resuscitation -Cardio [MEDICAL CONDITION] " , both effective [DATE], with no Revised date; review of information provided in the facility ' s Florida Resident Handbook & Admissions Information provided upon admission page 8 - 10: Information for residents and their families about advance directives for medical care; review of Resident #1 ' s medical record including the Initial Social Service History completed on [DATE], and interview with facility staff, physicians, and family members, it was determined that the facility failed to follow the documented Advanced Directives to receive Cardio [MEDICAL CONDITION] Resuscitation , for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE]. Thirty-three residents, per the facility Advanced Planning audit conducted on [DATE], had communicated their wishes to the facility that they desired to be resuscitated and are at risk should they be found without pulse or respirations. Resident #1 had communicated that should she be found unresponsive she wanted to be resuscitated. Resident #1, on [DATE] at 4:30 a.m. was found unresponsive and without respirations or a pulse, but was not administered CPR and 911, Emergency Medical Services were not contacted. The facility failed to follow their policies related to advanced directives indicating that CPR (Cardio - [MEDICAL CONDITION] Resuscitation) would be administered to any and all residents unless there was a DNR (Do Not Resuscitate) order. Resident #1 had [DIAGNOSES REDACTED]. Nurses notes revealed a pleasant, alert and oriented [AGE] year old female who attended therapy on a daily basis. Nurses notes on the day the resident died did not reflect that staff followed the facility policy of checking the resident ' s medical record for advanced directives, and by not providing CPR. The actions of the nursing staff providing care during the early morning hours when the resident was found without respirations resulted in findings of Immediate Jeopardy on [DATE] at 4:30 p.m. which was determined to be ongoing. Findings include: 1. Review of the facility ' s " CPR-Code Blue " policy, effective ,[DATE] (with no policy number or Revised date), revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to: " Open the Airway 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] (with no policy number or Revised date) revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 2. Review of the Resident Handbook, provided upon admission to residents and responsible parties, included three pages of information about advanced directives to help residents and responsible parties through the process of defining and documenting their wishes concerning medical treatment and end of life decisions. Contained within the first two paragraphs of the document were the lines, " You alone have the right to make basic decisions about the medical and health care services you receive from your physician and health care providers. .... All of those who provide your health care are responsible for following your wishes. " 3. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician order [REDACTED]. [DIAGNOSES REDACTED]. The Interim Plan of Care, developed upon admission, included the questions, " Resident is a DNR " which was answered NO. The Goal was checked " Will follow Advanced Directives. " 4. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " . The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , resident ' s employment as a Caregiver, and that she had had three children. Daily preferences included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, enjoying snacks between meals, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and review of the plan revealed options to check identifying the resident ' s ' Problem/Need/Strength/Potential Concern. ' Checked on the care plan was the Problem/Need confirming that the discharge plan was to her home and the attending physician had determined that the resident ' s stay at the facility was short term. 5 Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 PT sessions. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed of the six short term goals, the resident progressed in five of them, with the resident meeting the goal for two of the five. 6. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 7. Review of care plans that were developed from the assessment included one for Discharge Planning and one for Advanced Directives. The Discharge Planning care plan, written on [DATE], indicated the resident had expressed the wish to be discharged home and the attending physician had determined that the resident needed a short term stay. The Advanced Directive care plan, written on [DATE] indicated that the resident had a Durable Power of Attorney for health care decisions and she was capable of making informed consent for her health care decisions. The goal indicated that the resident ' s advanced directives were in effect and " their wishes and directions will be carried out in accordance with their advanced directives. " Contained in the Problem column on the care plan form and in the Approach column on the form were areas detailing Do Not Resuscitate orders (DNRO). Neither of the columns had any of the options checked, indicating that the resident had a DNRO. Additional interventions had been written in, dated [DATE], indicating, " conversation with resident and daughter re: hospice and DNR " . 8. On [DATE] the resident accompanied by her daughter, saw the resident ' s oncologist. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 9. Review of nurses ' notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]), no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 10. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and the resident ' s wish not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger so she could go home, and had done well with both Occupational and Physical Therapy. 11. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview: In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE], it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. 12. An interview with the Medical Director on [DATE] beginning at 11:20 a.m. revealed that he recalled that a nurse had found a resident cold and unresponsive and had decided not to provide CPR. The doctor stated that he felt she had made the decision on her own. He was aware that other nurses were there as well but no one started CPR. He reported that he had provided his own inservice on this issue - essentially when to call a doctor, as only a doctor can pronounce a patient dead. The Medical Director stated, " Who knows what happened that night, what those nurses were thinking. " 13. A phone interview was conducted with Resident #1 ' s doctor on [DATE] at 1:00 p.m. The physician admitted remembering the resident but said she only remembers getting a phone call that the resident had died . She described the resident ' s diagnosis, but said that she didn ' t remember the code status and hadn ' t been told that the resident was found nonresponsive but hadn ' t been provided with CPR. The physician began to detail the process that should have occurred during the phone conversation - find a body, check for code status, if full code, call 911 and start CPR, and was surprised when again she was told that CPR had not been administered. She confirmed that she had not been made aware that that had occurred. 14.. Interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m. revealed that the resident had spoken with staff on [DATE] about end of life decisions. The RM reported that the resident had been talking with staff about how she was ready to die and wondering about the afterlife. The RM reported that ' Everyone knew her feelings. ' She stated that the facility was in the process of getting the resident to sign the DNR. But both the RM and the DON stated that the resident was essentially still a Full Code. The DON reported that nurses had been inserviced that they must do CPR unless they find a DNR in the record. She added that there had been three nurses working the floor that early morning and after checking the chart for the yellow DNR form, one should have started CPR and another should have called 911. She said that she didn ' t know what the nurses were thinking, by not starting CPR and she could only think that since the body was cold, it would not be worth starting CPR. Review of inservice sign in sheets from the training provided after the incident ([DATE], [DATE], and [DATE]) revealed 17 nurses and 2 aides signed as having attended. Review of the facility ' s list of personnel revealed 34 nurses and 65 aides were on staff. Review of the schedule of nurses and aides that worked the ,[DATE] shift on [DATE] revealed only one of the three nurses had signed and none of the five aides had signed as having attended. Review of an audit conducted by the Human Resources Director on [DATE] revealed of the 30 nurses currently on staff, only 15 nurses had current, active CPR certification cards. In the interview on [DATE] that began at 2:30 p.m .the DON reported that another approach to providing Advanced Directive status information to the nurses was to included it on a ' shift sheet ' report. The DON explained that the shift sheets were daily documents that included pertinent information about every resident and each shift updated the information as a way to keep current on the resident. These sheets were passed on to the next shift. The DON reported that the shift sheets were to include either " DNR " or " Full " for each resident, based on their documented Advanced Directive status. Review of the shift sheets for the 200 wing, on [DATE] at 3:50 p.m. confirmed that both shift sheets contained the Advanced Directive information, and both nurses on the 3 to 11 shift were aware of the inclusion of that information. Interview with two nurses on the 100 wing, on [DATE] at 3:40 p.m. revealed that neither nurse was aware that the information should be contained on the shift sheet. One nurse (employee B) reported at that time that Advanced Directive information was contained in the medical record, not the shift sheets. Interview with the Assistant Director of Nurses, at that time, revealed that the information had not been added to the shift sheets. Review of weeks of the saved shift sheets confirmed that the 100 wing had not implemented that approach to ensuring that resident ' s Advanced Directives were honored. 15. Interview with the Administrator on 06/ ,[DATE] at 4:30 p.m. revealed that he was aware of the planned approaches from [DATE] to ensure that residents with Full Code Advanced Directive status would be provided CPR. The Administrator was not aware that all staff had not been re-trained on the facility policy related to providing CPR. The Administrator also was not aware that the planned approach to include Advanced Directive information on the shift sheets had not been implemented on one of two resident ' s halls. 16. During the revisit on [DATE] using the facility's Allegation of Removal of Jeopardy document the following were reviewed and documented: 1. There was a review of all residents' medical records on [DATE], [DATE] and [DATE] by the consultant nurse pertaining to: if Resident had MD order for DNR, yellow DNR form and Care Plan for Advanced Directives. There was also documentation of reviews done by the facility's director of nursing (DON), assistant director of nursing (ADON), and social service director) SSD [DATE] and [DATE]. 2. Training had been conducted: a. The facility had current Policy Procedures related to the prevention of both Abuse and CPR code blue procedures. b. Documentation of employee training for abuse/neglect, advanced directives, CPR policy, code blue, medical records, location of DNR forms with the accompanying in-service sign in sheets ,[DATE]-[DATE] were completed. c. A revised New Employee Orientation Agenda including Advanced Directives was updated. d. Copies of all licensed nursing staff CPR certificates were provided which showed that the nursing staff are now all currently certified as trained in CPR. 3. Daily reviews were being conducted related to current code status of newly admitted residents and to expiration of residents. Daily DNR Worksheets and Expired Resident Review reviewed (form is now a 2 sided form ) - DNR status of admitted residents and expired resident review from [DATE] through [DATE] showed reviews were being conducted by the nursing administration. No residents have expired at the facility since the IJ complaint investigation . 4. Thirteen recently admitted or readmitted residents' charts were reviewed for current compliance with the corrective actions; All had accurate code status in the Physician order [REDACTED]. If the resident or his/her POA had indicated a DNR there was a yellow sheet with the necessary signatures on the form and the form was dated. It was noted that in the process of chart review that several long term residents changed their DNR status during that ,[DATE] review (usually from full code to DNR but atleast 2 -including long term residents changed their status from DNR to full code). Advance directive care plans were present in 9 residents' charts, four did not have the care plan form-two recently admitted residents within 14 day review window but two were readmitted residents who had been in the facility for longer periods of time. 5. The six facility staff who were interviewed related to the proper care and procedures for providing care to an unresponsive resident answered appropriately and reflected proper training.

Based on review of the Florida Resident Handbook & Admissions Information, Revised ,[DATE]; review of the facility policies (CPR-Code Blue and Resuscitation - Cardio [MEDICAL CONDITION]) and interviews with a family member, facility staff, and two physicians; it was determined that the facility failed to protect the right to be administered Cardio [MEDICAL CONDITION] Resuscitation for one (#1) of 19 sampled residents, who had died in the facility between [DATE] and [DATE]. Thirty three current residents had documented that they want to be resuscitated and are at risk should they be found without respirations or pulse, per an Advanced Care audit completed by the facility on [DATE]. Facility staff did not initiate Cardio-Pulmonary Resuscitation (CPR) when resident #1 was found without respirations and pulse, per her Advanced Directive. Facility staff did not begin the administration of CPR and contact 911 for medical aid in accordance with their policies and procedures. The facility did not honor the advanced directives expressed by the resident. Failure of the facility to correctly implement advanced directives resulted in the findings of ongoing immediate jeopardy identified on [DATE]. Findings include: 1. The Florida Resident Handbook & Admissions Information booklet, (Rev Fl ,[DATE]) provided to residents and responsible parties upon admission, was reviewed for Resident Rights. Per the Handbook, on page 20, Federal Resident/Patient Rights are described as: " The resident has a right to a dignified existence, self - determination and communication with, and access to, persons and services inside and outside the facility. In accordance with the Omnibus Budget Reconciliation Act ( " OBRA " or the " Act " ), a facility must protect and promote the rights of each resident, including each of the following rights: #36. To be informed as to his/her rights to accept or refuse medical care and to make advanced directives regarding care, and not to have his/her care conditioned upon, or to be discriminated against based upon, whether or not he/she has executed an advanced directive regarding care. " 2.Review of facility policy " CPR - Code Blue " (no policy number, Effective ,[DATE]) revealed the Guideline as " It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure of the policy directed: " 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4-CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. " 3. Review of the facility policy " Resuscitation - cardio-pulmonary " (no policy number, Effective ,[DATE]) revealed the Guideline as " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The relevant Procedures of the policy directed: " 1.Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2. The DNR form will then be placed on the chart and maintained throughout the entire stay. 3. The DNR order is not valid without the Physician ' s signature. " 4. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION], per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] upon the resident ' s admission, documented the resident ' s admitting [DIAGNOSES REDACTED]. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. Continent of bowel, Foley catheter patent draining clear yellow urine to bed side drainage bag. Denies pain. Left upper chest port dressing intact. IV antibiotic for UTI. Minimal assistance with bed mobility and transfers x one. " Nursing notes throughout the resident ' s stay ([DATE] through [DATE]) reflected a pleasant, oriented woman who could make her needs known and was trying to remain as independent as she could. 5. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " . The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , resident ' s employment as a Caregiver, and that she had had three children. Daily preferences included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, enjoying snacks between meals, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. 6. Orders for Therapy had been received and evaluations were made by both Occupational (OT) and Physical Therapy (PT) on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for three weeks in February, and 19 of the 20 PT sessions. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed the resident had progressed in five of the six goals, and met two of the five goals. 7. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 8 .On [DATE] the resident had an appointment with her oncologist, which her daughter attended also. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po (by mouth) every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 9. Review of nurses notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]) , no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body . " 10. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 12. Interview with the resident ' s physician, on [DATE] at 1:00 p.m. revealed that she could recall the resident and remembered that the resident had [MEDICAL CONDITION]. She recalled that she had been told that the resident died , but had not been made aware of the details of the death. She stated that she did not know that the resident had been a Full Code, had been found without respirations and pulse, and CPR had not been initiated, nor 911 called. 13. Interview with the facility ' s Medical Director (MD), on [DATE] at 11:40 a.m. revealed that he had been made aware of the details of the resident ' s death. The MD reported that he recalled that the resident had been found " cold to the touch, without respirations and pulse, and the resident ' s nurse had made the decision on her own not to provide CPR. " He confirmed that he had been told that other nurses had joined the resident ' s nurse at the bedside and reported that none of them chose to administer CPR or call 911. He added " Who knows what happened that night, what those nurses were thinking. " He stated that only physicians can pronounce a resident ' s death. 14. On [DATE] beginning at 2:30 p.m., the Director of Nurses (DON) and the Risk Manager (RM) were questioned about the nurse ' s note located in Resident #1 ' s medical record, written on [DATE] at 9:45 a.m. The RM reported a conversation that she had been told had taken place on [DATE] between the resident and her nurse where the resident was alleged to have said that she was ready to die. The RM reported that " everybody knew how she felt. " The DON confirmed that the resident (and physician) had not signed a DNR and essentially was a Full Code, even if the resident had made mention of being ready to die. The DON confirmed that Social Services had met with the resident and daughter on [DATE] and discussed end of life options such as DNR and Hospice, but that the resident and daughter wished to have the weekend to think about it and meet with Hospice. The DON reported that nursing staff were trained to check a resident ' s medical record for a DNR order and if the record does not contain a signed DNR form, they are to initiate CPR and call 911 for Emergency Medical Services (EMS). The DON also confirmed that all licensed nurses are to maintain current CPR certification. The DON confirmed that nursing staff that found resident #1 without respirations and pulse the morning of [DATE] did not initiate CPR and did not call 911. She reported she wasn ' t sure when the medical record was reviewed for the DNR. The DON and RM reported that nursing staff were inserviced after this incident. Review of the sign in sheets for those inservices dated [DATE], [DATE] and [DATE], revealed 17 nurses and 2 aides had attended. Review of the current employee roster revealed there were 34 nurses and 65 aides on staff. Review of an audit conducted by the Human Resources Director on [DATE] revealed of the 30 current nurses on staff, 15 nurses had current CPR certifications. The DON also reported in the interview that began at 2:30 p.m. on [DATE], that the daily shift sheets that the nurses used as forms of communication between the shifts were altered to include Advanced Directive information for each resident. Interview with the two nurses on duty, with review of the shift sheets in use on the 200 wing, on [DATE] at 3:50 p.m., revealed all residents had Advanced Directive information listed. Interview with two nurses on the 100 wing on [DATE], at 3:40 p.m., revealed no Advanced Directive information on the shift sheets. One of the two nurses, Employee B, revealed at that time that Advanced Directive information was not contained on the shift sheets, it could be found in the resident ' s medical record. Interview at that time with the Assistant Director of Nurses, revealed that Advanced Directive information had not been included on the shift sheets. Review of weeks of the shift sheets confirmed that no Advanced Directive information had been included on the shift sheets for the 100 wing. 15. Interview with the Administrator on [DATE] at 4:30 p.m. revealed he was not aware that all of the nursing staff had not been inserviced on providing CPR after the incident on [DATE]. He also reported that he was not aware that the change to the shift sheets, that they would include Advanced Directive status for each resident, had not been made on one of the two resident halls.

Based on review of the Florida Resident Handbook & Admissions Information, Revised ,[DATE]; review of the facility policies (CPR-Code Blue and Resuscitation - Cardio [MEDICAL CONDITION]) and interviews with a family member, facility staff, and two physicians; it was determined that the facility failed to protect the right to be administered Cardio [MEDICAL CONDITION] Resuscitation for one (#1) of 19 sampled residents, who had died in the facility between [DATE] and [DATE]. Thirty three current residents had documented that they want to be resuscitated and are at risk should they be found without respirations or pulse, per an Advanced Care audit completed by the facility on [DATE]. Facility staff did not initiate Cardio-Pulmonary Resuscitation (CPR) when resident #1 was found without respirations and pulse, per her Advanced Directive. Facility staff did not begin the administration of CPR and contact 911 for medical aid in accordance with their policies and procedures. The facility did not honor the advanced directives expressed by the resident. Failure of the facility to correctly implement advanced directives resulted in the findings of ongoing immediate jeopardy identified on [DATE]. Findings include: 1. The Florida Resident Handbook & Admissions Information booklet, (Rev Fl ,[DATE]) provided to residents and responsible parties upon admission, was reviewed for Resident Rights. Per the Handbook, on page 20, Federal Resident/Patient Rights are described as: " The resident has a right to a dignified existence, self - determination and communication with, and access to, persons and services inside and outside the facility. In accordance with the Omnibus Budget Reconciliation Act ( " OBRA " or the " Act " ), a facility must protect and promote the rights of each resident, including each of the following rights: #36. To be informed as to his/her rights to accept or refuse medical care and to make advanced directives regarding care, and not to have his/her care conditioned upon, or to be discriminated against based upon, whether or not he/she has executed an advanced directive regarding care. " 2.Review of facility policy " CPR - Code Blue " (no policy number, Effective ,[DATE]) revealed the Guideline as " It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure of the policy directed: " 1. Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4-CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. " 3. Review of the facility policy " Resuscitation - cardio-pulmonary " (no policy number, Effective ,[DATE]) revealed the Guideline as " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The relevant Procedures of the policy directed: " 1.Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2. The DNR form will then be placed on the chart and maintained throughout the entire stay. 3. The DNR order is not valid without the Physician ' s signature. " 4. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION], per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] upon the resident ' s admission, documented the resident ' s admitting [DIAGNOSES REDACTED]. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. Continent of bowel, Foley catheter patent draining clear yellow urine to bed side drainage bag. Denies pain. Left upper chest port dressing intact. IV antibiotic for UTI. Minimal assistance with bed mobility and transfers x one. " Nursing notes throughout the resident ' s stay ([DATE] through [DATE]) reflected a pleasant, oriented woman who could make her needs known and was trying to remain as independent as she could. 5. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " . The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , resident ' s employment as a Caregiver, and that she had had three children. Daily preferences included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, enjoying snacks between meals, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. 6. Orders for Therapy had been received and evaluations were made by both Occupational (OT) and Physical Therapy (PT) on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for three weeks in February, and 19 of the 20 PT sessions. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed the resident had progressed in five of the six goals, and met two of the five goals. 7. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 8 .On [DATE] the resident had an appointment with her oncologist, which her daughter attended also. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po (by mouth) every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 9. Review of nurses notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]) , no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body . " 10. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 12. Interview with the resident ' s physician, on [DATE] at 1:00 p.m. revealed that she could recall the resident and remembered that the resident had [MEDICAL CONDITION]. She recalled that she had been told that the resident died , but had not been made aware of the details of the death. She stated that she did not know that the resident had been a Full Code, had been found without respirations and pulse, and CPR had not been initiated, nor 911 called. 13. Interview with the facility ' s Medical Director (MD), on [DATE] at 11:40 a.m. revealed that he had been made aware of the details of the resident ' s death. The MD reported that he recalled that the resident had been found " cold to the touch, without respirations and pulse, and the resident ' s nurse had made the decision on her own not to provide CPR. " He confirmed that he had been told that other nurses had joined the resident ' s nurse at the bedside and reported that none of them chose to administer CPR or call 911. He added " Who knows what happened that night, what those nurses were thinking. " He stated that only physicians can pronounce a resident ' s death. 14. On [DATE] beginning at 2:30 p.m., the Director of Nurses (DON) and the Risk Manager (RM) were questioned about the nurse ' s note located in Resident #1 ' s medical record, written on [DATE] at 9:45 a.m. The RM reported a conversation that she had been told had taken place on [DATE] between the resident and her nurse where the resident was alleged to have said that she was ready to die. The RM reported that " everybody knew how she felt. " The DON confirmed that the resident (and physician) had not signed a DNR and essentially was a Full Code, even if the resident had made mention of being ready to die. The DON confirmed that Social Services had met with the resident and daughter on [DATE] and discussed end of life options such as DNR and Hospice, but that the resident and daughter wished to have the weekend to think about it and meet with Hospice. The DON reported that nursing staff were trained to check a resident ' s medical record for a DNR order and if the record does not contain a signed DNR form, they are to initiate CPR and call 911 for Emergency Medical Services (EMS). The DON also confirmed that all licensed nurses are to maintain current CPR certification. The DON confirmed that nursing staff that found resident #1 without respirations and pulse the morning of [DATE] did not initiate CPR and did not call 911. She reported she wasn ' t sure when the medical record was reviewed for the DNR. The DON and RM reported that nursing staff were inserviced after this incident. Review of the sign in sheets for those inservices dated [DATE], [DATE] and [DATE], revealed 17 nurses and 2 aides had attended. Review of the current employee roster revealed there were 34 nurses and 65 aides on staff. Review of an audit conducted by the Human Resources Director on [DATE] revealed of the 30 current nurses on staff, 15 nurses had current CPR certifications. The DON also reported in the interview that began at 2:30 p.m. on [DATE], that the daily shift sheets that the nurses used as forms of communication between the shifts were altered to include Advanced Directive information for each resident. Interview with the two nurses on duty, with review of the shift sheets in use on the 200 wing, on [DATE] at 3:50 p.m., revealed all residents had Advanced Directive information listed. Interview with two nurses on the 100 wing on [DATE], at 3:40 p.m., revealed no Advanced Directive information on the shift sheets. One of the two nurses, Employee B, revealed at that time that Advanced Directive information was not contained on the shift sheets, it could be found in the resident ' s medical record. Interview at that time with the Assistant Director of Nurses, revealed that Advanced Directive information had not been included on the shift sheets. Review of weeks of the shift sheets confirmed that no Advanced Directive information had been included on the shift sheets for the 100 wing. 15. Interview with the Administrator on [DATE] at 4:30 p.m. revealed he was not aware that all of the nursing staff had not been inserviced on providing CPR after the incident on [DATE]. He also reported that he was not aware that the change to the shift sheets, that they would include Advanced Directive status for each resident, had not been made on one of the two resident halls. 16. During the revisit on [DATE] using the facility's Allegation of Removal of Jeopardy document the following were reviewed and documented: 1. There was a review of all residents' medical records on [DATE], [DATE] and [DATE] by the consultant nurse pertaining to: if Resident had MD order for DNR, yellow DNR form and Care Plan for Advanced Directives. There was also documentation of reviews done by the facility's director of nursing (DON), assistant director of nursing (ADON), and social service director) SSD [DATE] and [DATE]. 2. Training had been conducted: a. The facility had current Policy Procedures related to the prevention of both Abuse and CPR code blue procedures. b. Documentation of employee training for abuse/neglect, advanced directives, CPR policy, code blue, medical records, location of DNR forms with the accompanying in-service sign in sheets ,[DATE]-[DATE] were completed. c. A revised New Employee Orientation Agenda including Advanced Directives was updated. d. Copies of all licensed nursing staff CPR certificates were provided which showed that the nursing staff are now all currently certified as trained in CPR. 3. Daily reviews were being conducted related to current code status of newly admitted residents and to expiration of residents. Daily DNR Worksheets and Expired Resident Review reviewed (form is now a 2 sided form ) - DNR status of admitted residents and expired resident review from [DATE] through [DATE] showed reviews were being conducted by the nursing administration. No residents have expired at the facility since the IJ complaint investigation . 4. Thirteen recently admitted or readmitted residents' charts were reviewed for current compliance with the corrective actions; All had accurate code status in the Physician order sheets-either full code or DNR. If the resident or his/her POA had indicated a DNR there was a yellow sheet with the necessary signatures on the form and the form was dated. It was noted that in the process of chart review that several long term residents changed their DNR status during that ,[DATE] review (usually from full code to DNR but atleast 2 -including long term residents changed their status from DNR to full code). Advance directive care plans were present in 9 residents' charts, four did not have the care plan form-two recently admitted residents within 14 day review window but two were readmitted residents who had been in the facility for longer periods of time. 5. The six facility staff who were interviewed related to the proper care and procedures for providing care to an unresponsive resident answered appropriately and reflected proper training

Based on an interview with a resident ' s family, and review of the resident ' s medical record, it was determined that the facility failed to ensure that the necessary services to honor a resident ' s Advanced Directives and provide cardio [MEDICAL CONDITION] resuscitation, were initiated for one resident (#1) of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents identified by the facility through an Advance Care Planning audit conducted on [DATE], indicated they want to be resuscitated and are at risk should they be found nonresponsive and without a pulse. Through interview with facility staff and with the Medical Director and the resident ' s doctor, and review of the facility ' s policies related to Abuse, Neglect, and Exploitation; and policies related to the provision of CPR (Cardio- [MEDICAL CONDITION] Resuscitation) - Code Blue, Resuscitation - Cardio-pulmonary and staff CPR Certification, it was determined that the facility staff did not implement their policies to honor a resident ' s right to choose cardiopulmonary resuscitation, and did not ensure that all licensed nursing staff would maintain their current CPR certification. Failure of facility staff to honor the expressed wishes of the resident when CPR was not initiated after Resident #1 was found without respirations or pulse, to not ensure that all staff were trained on the facility policy related to CPR and to not ensure that all licensed nursing staff maintained their current CPR certification, led to the findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the medical record for Resident #1 revealed a nurses note written on [DATE], at 0945 indicating, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " There was no indication in the nurse ' s notes, or anywhere in the resident ' s medical record, to indicate an attempt was made to resuscitate the resident, even though the medical record documented the resident ' s desire to be resuscitated. There was no call to 911 or Emergency Medical Services documented in the record. 2. In an interview, conducted on [DATE] beginning at 1:30 p.m., the daughter of Resident #1 reported that her mother had planned on being discharged from the facility after receiving IV (intravenous) antibiotics for a urinary tract infection, and getting stronger from physical and occupational therapy. The daughter confirmed that her mother had seen the Oncologist on [DATE], and had received a referral to Hospice, but she didn ' t think her mother ' s death was imminent. A meeting with Hospice to learn of the options - Hospice House or home with Hospice care - had been set up for 9:00 a.m. on [DATE]. The daughter accepted condolences when she spoke of her mother ' s death occurring at approximately 4:30 a.m. on [DATE]. It was confirmed in the interview that the resident had wanted to be resuscitated should anything happen, and she hadn ' t yet decided on DNR status. 3. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview. A phone call on [DATE], at 5:30 p.m., to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE], it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. 4. Interview with the Medical Director, on [DATE] beginning at 11:20a.m., revealed when asked if he was familiar with an incident concerning resident #1, replied that he recalled that a nurse had found the resident cold and unresponsive and had decided not to provide CPR. The doctor stated that he felt she had made the decision on her own. He was aware that even though other nurses were there as well, no one started CPR. The Medical Director stated, " Who knows what happened that night, what those nurses were thinking. " 5. Interview with the Resident ' s doctor, on [DATE] at 1:00 p.m., via the telephone, revealed she could recall the resident and the resident ' s diagnosis, but didn ' t recall that she had been told the details of the resident ' s death. The physician reported that she knew she had been told that the resident died , but did not know that the resident was a Full Code, that she had been found nonresponsive and for whom CPR was not administered. 6. Further review of the resident ' s medical record revealed that she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION], per the Physician Orders upon admission. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff. " Review of nurses notes during the entire stay in the facility ([DATE] - [DATE]) revealed the resident was alert, able to make her needs known, and had attempted to remain independent with her activities of daily living. 7. Review of the Initial Social Services History, documented on [DATE], indicated the resident wished to be a Full code - to receive cardio-pulmonary resuscitation if she was found without respirations or pulse. The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , the resident ' s employment as a Caregiver, and that she had had three children. Daily preferences reflected her desire to be independent and included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and was marked to indicate the attending physician had determined that the resident ' s stay at the facility was short term. 8. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for both Occupational Therapy (OT) and Physical Therapy (PT) a calendar documenting attendance by the resident at therapy sessions revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 sessions with the PT. Review of the OT discharge summary revealed the comment, " patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed the resident had progressed with five of the six short term goals and two of the five had documentation that the resident met the goal. 9. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already having been developed for the resident to return to the community. 10. In an interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] that began at 2:30 p.m., it was revealed that an investigation had been made into the events that occurred in the morning on [DATE] that resulted in the death of resident #1. During the interview, it was confirmed that the nurses should have checked the medical record for the resident ' s code status and finding it Full Code (due to the absence of a signed DNR form), should have begun CPR and phoned 911 for Emergency Medical Services. The DON reported that all nurses had been trained as to the facility policy and should have known what to do upon finding a resident without respirations or pulse. A review of the investigation did not reveal interviews or analysis that would have explained why resuscitation had not been administered or why 911 had not been contacted. The RM, during the interview, referred to the Oncologist ' s appointment that the resident had on [DATE] and that it hadn ' t been good news for the resident. The RM reported that the Social Services Director (SSD) had met with the resident and her daughter on [DATE] and had discussed DNR status and hospice, but per the SSD note, they wanted the weekend to think about the issues. The RM referred to a conversation that the resident ' s nurse reported had occurred on [DATE], but had not documented, where the nurse said the resident had stated that she was " ready to die " . The RM reported that " Everybody knew her feelings " , when she was asked about staff failing to honor the resident ' s wishes about being resuscitated. 11. Review of facility policy for " Abuse, Neglect, and Misappropriation " (with no policy number, Effective ,[DATE]) revealed " Verbal, sexual, physical, and mental abuse, corporal punishment, neglect, and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited. All allegations of abuse, involving abuse along with injuries of unknown origin, are reported immediately to the charge nurse and / or administrator of the facility along with other officials in accordance with State law through established guidelines. " Under part II Training/Identification/Prevention, the procedure includes: " Staff receives orientation and on-going training on: What constitutes abuse, neglect, and misappropriation of resident property. " Under part V Protection of the Resident, the procedure includes: " The Administrator and / or DON will notify state agencies according to their reporting guidelines. " Under part VII Investigation, the procedure includes: " The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " 12. Review of facility policy for CPR-Code Blue (no policy number, effective 12/ 2010), revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to: " Open the Airway 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " 13. Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] (with no policy number or Revised date) revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 14. Review of the facility policy entitled " CPR - Certification " (with no policy number, Effective ,[DATE]) revealed the Guideline: It is the policy of the facility to maintain CPR certified personnel on a 24 hour basis. Procedure was listed as: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 15. Review of the action plan, verbally reported by Director of Nurses and Risk Manager on [DATE] beginning in an interview at 2:30 p.m., developed in response to the death of resident #1 when CPR was not administered when she was found unresponsive, revealed all nursing staff were to be inserviced on facility policy related to Code Blue, CPR and Resuscitation. She reported that the three nurses who were on duty on the 11 to 7 shift on [DATE] were to be ' coached ' , defined as a one on one training as to the CPR policies and a formal write up to be filed in their personnel records. Review of the inservice sign in sheets documenting the nursing staff inservices revealed three days of inservices, [DATE], [DATE], and [DATE], had been conducted at which 19 nursing staff (nurses and aides) attended out of 101 total nursing staff. Review of the personnel files of the three nurses who were on duty on the 11 - 7 shift on [DATE] revealed two of the three nurses received their coaching and the write up was in their files. The third nurse, the nurse who had found the unresponsive resident, had not returned to the facility to receive the coaching. The second area of correction, verbally reported by the Director of Nurses, related to the addition of advanced directive information on the ' shift sheet ' . The shift sheet is a document used on a daily basis that lists all residents ' pertinent information. The nurse on each shift updates the information, adding anything new that occurred during the shift for each resident. The DON reported that adding either Full or DNR to the information provided about each resident would be a quick reference for the nurses. Interview on [DATE] at 3:40 p.m. with two nurses on the 100 wing revealed neither were aware of the shift sheets containing resident advanced directive information. One nurse (employee B) reported when asked about advance directive information that they would check the chart for that information. The Assistant Director of Nurses, during that interview, revealed that the shift sheets had not contained that information, which was evident as she riffled through weeks of old shift sheets. An interview with two nurses on the 200 wing, on [DATE] at 3:50 p.m. revealed their shift sheets contained the resident ' s advanced directive information, and a visual confirmation was made as well. 16. In an interview with the Human Resources Director (HRD) on [DATE] beginning at 3:00 p.m. it was confirmed that she maintained a list of all nurses and their active CPR certification. The list was provided and revealed that of the 30 nurses on staff (full time, part time, and prn - as needed); she was only able to confirm that 15 nurses had active CPR certification as confirmed by current CPR cards. The HRD reported that the facility had been providing the CPR training but recently they had to cancel the training as there wasn ' t enough staff to warrant the training. 17. In an interview with the Administrator on [DATE] beginning at 4:15 p.m., it was revealed that he was unaware that all of the nursing staff had not attended inservice training on Advanced Directives and administering CPR, after the incident on [DATE]. He also confirmed that he was not aware that the shift sheets used to communicate resident information between the three shifts did not include the Advanced Directive information as planned. On [DATE], after reviewing the CPR certification audit provided at 3:00 p.m., the Administrator confirmed that he was not aware that half of the nurses did not have the current CPR certification.

Based on an interview with a resident ' s family, and review of the resident ' s medical record, it was determined that the facility failed to ensure that the necessary services to honor a resident ' s Advanced Directives and provide cardio [MEDICAL CONDITION] resuscitation, were initiated for one resident (#1) of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents identified by the facility through an Advance Care Planning audit conducted on [DATE], indicated they want to be resuscitated and are at risk should they be found nonresponsive and without a pulse. Through interview with facility staff and with the Medical Director and the resident ' s doctor, and review of the facility ' s policies related to Abuse, Neglect, and Exploitation; and policies related to the provision of CPR (Cardio- [MEDICAL CONDITION] Resuscitation) - Code Blue, Resuscitation - Cardio-pulmonary and staff CPR Certification, it was determined that the facility staff did not implement their policies to honor a resident ' s right to choose cardiopulmonary resuscitation, and did not ensure that all licensed nursing staff would maintain their current CPR certification. Failure of facility staff to honor the expressed wishes of the resident when CPR was not initiated after Resident #1 was found without respirations or pulse, to not ensure that all staff were trained on the facility policy related to CPR and to not ensure that all licensed nursing staff maintained their current CPR certification, led to the findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the medical record for Resident #1 revealed a nurses note written on [DATE], at 0945 indicating, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " There was no indication in the nurse ' s notes, or anywhere in the resident ' s medical record, to indicate an attempt was made to resuscitate the resident, even though the medical record documented the resident ' s desire to be resuscitated. There was no call to 911 or Emergency Medical Services documented in the record. 2. In an interview, conducted on [DATE] beginning at 1:30 p.m., the daughter of Resident #1 reported that her mother had planned on being discharged from the facility after receiving IV (intravenous) antibiotics for a urinary tract infection, and getting stronger from physical and occupational therapy. The daughter confirmed that her mother had seen the Oncologist on [DATE], and had received a referral to Hospice, but she didn ' t think her mother ' s death was imminent. A meeting with Hospice to learn of the options - Hospice House or home with Hospice care - had been set up for 9:00 a.m. on [DATE]. The daughter accepted condolences when she spoke of her mother ' s death occurring at approximately 4:30 a.m. on [DATE]. It was confirmed in the interview that the resident had wanted to be resuscitated should anything happen, and she hadn ' t yet decided on DNR status. 3. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. One of the three nurses agreed to an interview. A phone call on [DATE], at 5:30 p.m., to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE], it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. 4. Interview with the Medical Director, on [DATE] beginning at 11:20a.m., revealed when asked if he was familiar with an incident concerning resident #1, replied that he recalled that a nurse had found the resident cold and unresponsive and had decided not to provide CPR. The doctor stated that he felt she had made the decision on her own. He was aware that even though other nurses were there as well, no one started CPR. The Medical Director stated, " Who knows what happened that night, what those nurses were thinking. " 5. Interview with the Resident ' s doctor, on [DATE] at 1:00 p.m., via the telephone, revealed she could recall the resident and the resident ' s diagnosis, but didn ' t recall that she had been told the details of the resident ' s death. The physician reported that she knew she had been told that the resident died , but did not know that the resident was a Full Code, that she had been found nonresponsive and for whom CPR was not administered. 6. Further review of the resident ' s medical record revealed that she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION], per the Physician Orders upon admission. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff. " Review of nurses notes during the entire stay in the facility ([DATE] - [DATE]) revealed the resident was alert, able to make her needs known, and had attempted to remain independent with her activities of daily living. 7. Review of the Initial Social Services History, documented on [DATE], indicated the resident wished to be a Full code - to receive cardio-pulmonary resuscitation if she was found without respirations or pulse. The Social Services History included questions that would help the facility build a relationship with the resident and included answers that described childhood memories of " traveled a lot due to father being in the army " , the resident ' s employment as a Caregiver, and that she had had three children. Daily preferences reflected her desire to be independent and included being able to choose what clothing she preferred to wear, being able to care for her personal belongings and having a place to lock them up, staying up past 8 p.m., being able to use a phone in private, and allowing family to be involved in care discussions. Social activities that the resident enjoyed included crochet, plants, bowling, watching television and reading. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and was marked to indicate the attending physician had determined that the resident ' s stay at the facility was short term. 8. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for both Occupational Therapy (OT) and Physical Therapy (PT) a calendar documenting attendance by the resident at therapy sessions revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 sessions with the PT. Review of the OT discharge summary revealed the comment, " patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed the resident had progressed with five of the six short term goals and two of the five had documentation that the resident met the goal. 9. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already having been developed for the resident to return to the community. 10. In an interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] that began at 2:30 p.m., it was revealed that an investigation had been made into the events that occurred in the morning on [DATE] that resulted in the death of resident #1. During the interview, it was confirmed that the nurses should have checked the medical record for the resident ' s code status and finding it Full Code (due to the absence of a signed DNR form), should have begun CPR and phoned 911 for Emergency Medical Services. The DON reported that all nurses had been trained as to the facility policy and should have known what to do upon finding a resident without respirations or pulse. A review of the investigation did not reveal interviews or analysis that would have explained why resuscitation had not been administered or why 911 had not been contacted. The RM, during the interview, referred to the Oncologist ' s appointment that the resident had on [DATE] and that it hadn ' t been good news for the resident. The RM reported that the Social Services Director (SSD) had met with the resident and her daughter on [DATE] and had discussed DNR status and hospice, but per the SSD note, they wanted the weekend to think about the issues. The RM referred to a conversation that the resident ' s nurse reported had occurred on [DATE], but had not documented, where the nurse said the resident had stated that she was " ready to die " . The RM reported that " Everybody knew her feelings " , when she was asked about staff failing to honor the resident ' s wishes about being resuscitated. 11. Review of facility policy for " Abuse, Neglect, and Misappropriation " (with no policy number, Effective ,[DATE]) revealed " Verbal, sexual, physical, and mental abuse, corporal punishment, neglect, and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited. All allegations of abuse, involving abuse along with injuries of unknown origin, are reported immediately to the charge nurse and / or administrator of the facility along with other officials in accordance with State law through established guidelines. " Under part II Training/Identification/Prevention, the procedure includes: " Staff receives orientation and on-going training on: What constitutes abuse, neglect, and misappropriation of resident property. " Under part V Protection of the Resident, the procedure includes: " The Administrator and / or DON will notify state agencies according to their reporting guidelines. " Under part VII Investigation, the procedure includes: " The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " 12. Review of facility policy for CPR-Code Blue (no policy number, effective 12/ 2010), revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to: " Open the Airway 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " 13. Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] (with no policy number or Revised date) revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 14. Review of the facility policy entitled " CPR - Certification " (with no policy number, Effective ,[DATE]) revealed the Guideline: It is the policy of the facility to maintain CPR certified personnel on a 24 hour basis. Procedure was listed as: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 15. Review of the action plan, verbally reported by Director of Nurses and Risk Manager on [DATE] beginning in an interview at 2:30 p.m., developed in response to the death of resident #1 when CPR was not administered when she was found unresponsive, revealed all nursing staff were to be inserviced on facility policy related to Code Blue, CPR and Resuscitation. She reported that the three nurses who were on duty on the 11 to 7 shift on [DATE] were to be ' coached ' , defined as a one on one training as to the CPR policies and a formal write up to be filed in their personnel records. Review of the inservice sign in sheets documenting the nursing staff inservices revealed three days of inservices, [DATE], [DATE], and [DATE], had been conducted at which 19 nursing staff (nurses and aides) attended out of 101 total nursing staff. Review of the personnel files of the three nurses who were on duty on the 11 - 7 shift on [DATE] revealed two of the three nurses received their coaching and the write up was in their files. The third nurse, the nurse who had found the unresponsive resident, had not returned to the facility to receive the coaching. The second area of correction, verbally reported by the Director of Nurses, related to the addition of advanced directive information on the ' shift sheet ' . The shift sheet is a document used on a daily basis that lists all residents ' pertinent information. The nurse on each shift updates the information, adding anything new that occurred during the shift for each resident. The DON reported that adding either Full or DNR to the information provided about each resident would be a quick reference for the nurses. Interview on [DATE] at 3:40 p.m. with two nurses on the 100 wing revealed neither were aware of the shift sheets containing resident advanced directive information. One nurse (employee B) reported when asked about advance directive information that they would check the chart for that information. The Assistant Director of Nurses, during that interview, revealed that the shift sheets had not contained that information, which was evident as she riffled through weeks of old shift sheets. An interview with two nurses on the 200 wing, on [DATE] at 3:50 p.m. revealed their shift sheets contained the resident ' s advanced directive information, and a visual confirmation was made as well. 16. In an interview with the Human Resources Director (HRD) on [DATE] beginning at 3:00 p.m. it was confirmed that she maintained a list of all nurses and their active CPR certification. The list was provided and revealed that of the 30 nurses on staff (full time, part time, and prn - as needed); she was only able to confirm that 15 nurses had active CPR certification as confirmed by current CPR cards. The HRD reported that the facility had been providing the CPR training but recently they had to cancel the training as there wasn ' t enough staff to warrant the training. 17. In an interview with the Administrator on [DATE] beginning at 4:15 p.m., it was revealed that he was unaware that all of the nursing staff had not attended inservice training on Advanced Directives and administering CPR, after the incident on [DATE]. He also confirmed that he was not aware that the shift sheets used to communicate resident information between the three shifts did not include the Advanced Directive information as planned. On [DATE], after reviewing the CPR certification audit provided at 3:00 p.m., the Administrator confirmed that he was not aware that half of the nurses did not have the current CPR certification. 18. During the revisit on [DATE] using the facility's Allegation of Removal of Jeopardy document the following were reviewed and documented: 1. There was a review of all residents' medical records on [DATE], [DATE] and [DATE] by the consultant nurse pertaining to: if Resident had MD order for DNR, yellow DNR form and Care Plan for Advanced Directives. There was also documentation of reviews done by the facility's director of nursing (DON), assistant director of nursing (ADON), and social service director) SSD [DATE] and [DATE]. 2. Training had been conducted: a. The facility had current Policy Procedures related to the prevention of both Abuse and CPR code blue procedures. b. Documentation of employee training for abuse/neglect, advanced directives, CPR policy, code blue, medical records, location of DNR forms with the accompanying in-service sign in sheets ,[DATE]-[DATE] were completed. c. A revised New Employee Orientation Agenda including Advanced Directives was updated. d. Copies of all licensed nursing staff CPR certificates were provided which showed that the nursing staff are now all currently certified as trained in CPR. 3. Daily reviews were being conducted related to current code status of newly admitted residents and to expiration of residents. Daily DNR Worksheets and Expired Resident Review reviewed (form is now a 2 sided form ) - DNR status of admitted residents and expired resident review from [DATE] through [DATE] showed reviews were being conducted by the nursing administration. No residents have expired at the facility since the IJ complaint investigation . 4. Thirteen recently admitted or readmitted residents' charts were reviewed for current compliance with the corrective actions; All had accurate code status in the Physician order sheets-either full code or DNR. If the resident or his/her POA had indicated a DNR there was a yellow sheet with the necessary signatures on the form and the form was dated. It was noted that in the process of chart review that several long term residents changed their DNR status during that ,[DATE] review (usually from full code to DNR but atleast 2 -including long term residents changed their status from DNR to full code). Advance directive care plans were present in 9 residents' charts, four did not have the care plan form-two recently admitted residents within 14 day review window but two were readmitted residents who had been in the facility for longer periods of time. 5. The six facility staff who were interviewed related to the proper care and procedures for providing care to an unresponsive resident answered appropriately and reflected proper training

Based on review of the medical record for Resident #1, and interview with facility staff concerning the incident which occurred on [DATE], as well as further interviews with a family member, the Medical Director, and review of the facility ' s policy on Abuse, Neglect and Misappropriation; review of the facility ' s Florida Resident Handbook & Admissions Information booklet; review of facility audits which monitored CPR (Cardio [MEDICAL CONDITION] resuscitation) certification and nurse training, and a review of the nurse ' s job description, it was determined that the facility failed to ensure that the necessary services to honor a resident ' s Advanced Directives and provide cardio [MEDICAL CONDITION] resuscitation, were initiated for one resident (#1) of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents had been identified, through a facility audit conducted on [DATE], as having documented their wishes for Full Code status, indicating they wanted to be provided with CPR, and are at risk should they be found without respirations or pulse. Resident #1, a [AGE] year old female, had been admitted for a short term stay to receive IV antibiotics. Upon admission it was clearly documented by the Social Services Director that the resident was a Full Code and wished to go home after her therapy was completed. Interview with the resident ' s daughter confirmed that her mother did not want to remain in the nursing home and was to meet with Hospice to learn of her options the morning of her death. The facility failed to conduct a full investigation into why the resident ' s wishes were not honored related to receiving CPR, failed to report the resident ' s death to the state agency, failed to provide training to all nursing staff and failed to ensure that all licensed nursing staff maintained their CPR certification, per their policies. These findings led to the determination of Immediate Jeopardy which was ongoing on [DATE]. Findings include: 1. An interview was conducted with the Director of Nurses (DON) and the Risk Manager (RM) [DATE] beginning at 2:30 p.m. concerning a nurse ' s note written on [DATE] at 9:35 a.m. ( " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " ) The DON confirmed that the resident did not have a signed DNR (Do Not Resuscitate) document and she was essentially a Full Code. The DON confirmed that nurses are trained on the facility policy that requires staff to check the resident ' s medical record for Advanced Directives if a resident is found unresponsive. " If there is no signed DNR in the chart, the nurses are to call a Code Blue, initiate CPR and phone 911 for emergency medical services. " Also the DON confirmed that all licensed nursing staff are to maintain their CPR certification. The RM reported that she had been made aware of the death of resident #1 the morning of [DATE] and had conducted an investigation. Review of the investigation revealed a time line of the actions of the three nurses and one aide. But there was no conclusion to explain what had happened, no causative analysis, only reported information. The investigation did not include a plan of correction, but the RM reported that all of the nursing staff had been inserviced . Review of the inservice sign in sheets for the trainings held on [DATE], [DATE], and [DATE], after the incident on [DATE], revealed 17 of the 34 nurses and two of the 65 aides that were on staff had signed as having attended. The DON reported that the three nurses that were on duty on the 11 - 7 shift on [DATE] received one on one counseling (coaching) which was filed in their personnel records. Review of the personnel files for the three nurses revealed the coaching had been conducted for two of nurses, but the third nurse - the one who had found the unresponsive nurse and had not initiated CPR - had not returned to the facility to receive the coaching. The DON described one other intervention implemented in response to the failure to provide CPR to a Full Code resident. She reported that an addition had been made to the nursing endorsement sheets used to track resident status every shift. These ' shift sheets ' were updated with any pertinent information about each resident and shared with the next shift. The DON reported that after the [DATE] incident, each resident ' s code status was listed on the sheets - whether they were Full Code or DNR - for easy reference. Interview with the two nurses on the 100 wing on [DATE] at 3:40 p.m. revealed that neither nurse were aware that the code status was listed on the shift sheet. One of the nurses reported that information about code status was found in the medical record. Interview at that time with the unit manager revealed that they hadn ' t been including the code status on the shift sheets and as she riffled through weeks of the shift sheets, it was clear that code status was not on the sheets. Interview at 3:45 p.m. with the two nurses on the 200 wing revealed both of their shift sheets included the code status, and both nurses confirmed that they were aware the code status was on the sheets, but the medical record was really where they needed to check a resident ' s code status. 2. Interview with the Human Resources Director (HRD), on [DATE] beginning at 3:00 p.m. revealed nurses are to maintain current CPR certification and to provide the facility with a copy of their CPR certification card. Review of the Licensed Nurse job description, (updated [DATE]), revealed the second bullet point under the Job Requirements listed " Must have a current / active CPR certification. " The HRD reported that she was in the process of auditing all of the nurses ' personnel files to ensure that they all had their current CPR certifications. She provided a list of the facility ' s 30 floor nurses and 15 of the nurses had CPR Renewal Dates listed indicating active status. She explained that if there wasn ' t a date listed, then she wasn ' t aware of the nurses ' current CPR status. 3. During the interview with the Director of Nurses, on [DATE] which began at 2:30 p.m., the DON was questioned about whether a report had been filed with the State Agency about resident #1 ' s death. She responded that there had not been a report filed. Review of filed Federal and State Reports (13 reports) from March, April, May and June through [DATE], revealed no report related to the death of resident #1. The DON reported that the Administrative staff had discussed the incident and decided that the incident was not reportable. 4. An interview was conducted with the Medical Director of the facility on [DATE] beginning at 11:20 a.m. The Medical Director reported that he recalled, " a nurse had found a resident cold, unresponsive, and decided not to provide CPR. She made the decision on her own. Other nurses came in but no one started CPR. Who knows what happened that night, what those nurses were thinking. " The Medical Director reported that the issue was discussed in the Quality Assurance meeting, including their intervention to inservice staff, but he did not remember any causative analysis being discussed. He stated that the issue had not been brought up at the following meeting. 5. Review of the facility ' s policy Abuse, Neglect and Misappropriation, effective ,[DATE], revealed the Policy indicated, " Verbal, sexual, physical, and mental abuse , corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited; All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. " Relevant Procedures listed in the Policy included under Training/Identification/Prevention, included " Staff receives orientation and on-going training on ' What constitutes abuse, neglect and misappropriation of resident property. ' " Listed under Protection of the Resident, " The Administrator and or DON will notify state agencies according to their reporting guidelines. " Listed under Investigation, " The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " 6. Review of the Florida Resident Handbook & Admissions Information booklet, provided to residents and responsible parties upon admission, included information under Rules & Regulations about Abuse . The booklet includes: " The facility has policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. It is the intent of this facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident ' s property, or any injury of unknown origin. All staff are trained upon hire and provided education about abuse and neglect at least annually. " 7. Review of the medical record for Resident #1 revealed she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician order [REDACTED]. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. " Nurses notes throughout the resident ' s stay ([DATE] until [DATE]) documented similar descriptions of the resident - that she was alert and oriented, pleasant, needed assistance with activities of daily living, and was trying to be as independent as she could be. 8. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " , indicating the resident wanted to be resuscitated should she be found without respirations or pulse. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and revealed a form on which staff checked relevant options. Options checked for Resident #1 included the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. A Social Services note had been written on [DATE] documented, " Dr (oncologist) made referral for hospice for patient. Spoke with patient and daughter about hospice and DNRO and they will take the weekend to think over both and get back with SSD (Social Services Director) on both. " 9. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for Occupational Therapy (OT) and for Physical Therapy (PT) ( a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed of the six short term goals, the resident was documented as having made progress with five of them and two of the five were documented as the resident had met the goal. 10. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist, in an appointment on [DATE], had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and her desire not to die in the facility. She confirmed, at that time, that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. , on [DATE], to learn about the options - Hospice house or Hospice care at her home . She confirmed that her mother had been attending therapy to get stronger so she could return home, and had done well with both Occupational and Physical Therapy. 12. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. Only one of the three nurses had agreed to an interview. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview. 13. Interview with the Administrator on [DATE], at 4:15 p.m., revealed he was not aware that all nursing staff had not attended the inservices on providing CPR after the incident on [DATE]. He reported that he was not aware that both nursing stations were not including the Advanced Directive information on their shift sheets as had been developed as an intervention after the incident on [DATE]. He also revealed that he was not aware that 15 of the 30 current licensed nursing staff did not have current CPR certifications.

Based on review of the medical record for Resident #1, and interview with facility staff concerning the incident which occurred on [DATE], as well as further interviews with a family member, the Medical Director, and review of the facility ' s policy on Abuse, Neglect and Misappropriation; review of the facility ' s Florida Resident Handbook & Admissions Information booklet; review of facility audits which monitored CPR (Cardio [MEDICAL CONDITION] resuscitation) certification and nurse training, and a review of the nurse ' s job description, it was determined that the facility failed to ensure that the necessary services to honor a resident ' s Advanced Directives and provide cardio [MEDICAL CONDITION] resuscitation, were initiated for one resident (#1) of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents had been identified, through a facility audit conducted on [DATE], as having documented their wishes for Full Code status, indicating they wanted to be provided with CPR, and are at risk should they be found without respirations or pulse. Resident #1, a [AGE] year old female, had been admitted for a short term stay to receive IV antibiotics. Upon admission it was clearly documented by the Social Services Director that the resident was a Full Code and wished to go home after her therapy was completed. Interview with the resident ' s daughter confirmed that her mother did not want to remain in the nursing home and was to meet with Hospice to learn of her options the morning of her death. The facility failed to conduct a full investigation into why the resident ' s wishes were not honored related to receiving CPR, failed to report the resident ' s death to the state agency, failed to provide training to all nursing staff and failed to ensure that all licensed nursing staff maintained their CPR certification, per their policies. These findings led to the determination of Immediate Jeopardy which was ongoing on [DATE]. Findings include: 1. An interview was conducted with the Director of Nurses (DON) and the Risk Manager (RM) [DATE] beginning at 2:30 p.m. concerning a nurse ' s note written on [DATE] at 9:35 a.m. ( " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " ) The DON confirmed that the resident did not have a signed DNR (Do Not Resuscitate) document and she was essentially a Full Code. The DON confirmed that nurses are trained on the facility policy that requires staff to check the resident ' s medical record for Advanced Directives if a resident is found unresponsive. " If there is no signed DNR in the chart, the nurses are to call a Code Blue, initiate CPR and phone 911 for emergency medical services. " Also the DON confirmed that all licensed nursing staff are to maintain their CPR certification. The RM reported that she had been made aware of the death of resident #1 the morning of [DATE] and had conducted an investigation. Review of the investigation revealed a time line of the actions of the three nurses and one aide. But there was no conclusion to explain what had happened, no causative analysis, only reported information. The investigation did not include a plan of correction, but the RM reported that all of the nursing staff had been inserviced . Review of the inservice sign in sheets for the trainings held on [DATE], [DATE], and [DATE], after the incident on [DATE], revealed 17 of the 34 nurses and two of the 65 aides that were on staff had signed as having attended. The DON reported that the three nurses that were on duty on the 11 - 7 shift on [DATE] received one on one counseling (coaching) which was filed in their personnel records. Review of the personnel files for the three nurses revealed the coaching had been conducted for two of nurses, but the third nurse - the one who had found the unresponsive nurse and had not initiated CPR - had not returned to the facility to receive the coaching. The DON described one other intervention implemented in response to the failure to provide CPR to a Full Code resident. She reported that an addition had been made to the nursing endorsement sheets used to track resident status every shift. These ' shift sheets ' were updated with any pertinent information about each resident and shared with the next shift. The DON reported that after the [DATE] incident, each resident ' s code status was listed on the sheets - whether they were Full Code or DNR - for easy reference. Interview with the two nurses on the 100 wing on [DATE] at 3:40 p.m. revealed that neither nurse were aware that the code status was listed on the shift sheet. One of the nurses reported that information about code status was found in the medical record. Interview at that time with the unit manager revealed that they hadn ' t been including the code status on the shift sheets and as she riffled through weeks of the shift sheets, it was clear that code status was not on the sheets. Interview at 3:45 p.m. with the two nurses on the 200 wing revealed both of their shift sheets included the code status, and both nurses confirmed that they were aware the code status was on the sheets, but the medical record was really where they needed to check a resident ' s code status. 2. Interview with the Human Resources Director (HRD), on [DATE] beginning at 3:00 p.m. revealed nurses are to maintain current CPR certification and to provide the facility with a copy of their CPR certification card. Review of the Licensed Nurse job description, (updated [DATE]), revealed the second bullet point under the Job Requirements listed " Must have a current / active CPR certification. " The HRD reported that she was in the process of auditing all of the nurses ' personnel files to ensure that they all had their current CPR certifications. She provided a list of the facility ' s 30 floor nurses and 15 of the nurses had CPR Renewal Dates listed indicating active status. She explained that if there wasn ' t a date listed, then she wasn ' t aware of the nurses ' current CPR status. 3. During the interview with the Director of Nurses, on [DATE] which began at 2:30 p.m., the DON was questioned about whether a report had been filed with the State Agency about resident #1 ' s death. She responded that there had not been a report filed. Review of filed Federal and State Reports (13 reports) from March, April, May and June through [DATE], revealed no report related to the death of resident #1. The DON reported that the Administrative staff had discussed the incident and decided that the incident was not reportable. 4. An interview was conducted with the Medical Director of the facility on [DATE] beginning at 11:20 a.m. The Medical Director reported that he recalled, " a nurse had found a resident cold, unresponsive, and decided not to provide CPR. She made the decision on her own. Other nurses came in but no one started CPR. Who knows what happened that night, what those nurses were thinking. " The Medical Director reported that the issue was discussed in the Quality Assurance meeting, including their intervention to inservice staff, but he did not remember any causative analysis being discussed. He stated that the issue had not been brought up at the following meeting. 5. Review of the facility ' s policy Abuse, Neglect and Misappropriation, effective ,[DATE], revealed the Policy indicated, " Verbal, sexual, physical, and mental abuse , corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited; All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. " Relevant Procedures listed in the Policy included under Training/Identification/Prevention, included " Staff receives orientation and on-going training on ' What constitutes abuse, neglect and misappropriation of resident property. ' " Listed under Protection of the Resident, " The Administrator and or DON will notify state agencies according to their reporting guidelines. " Listed under Investigation, " The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " 6. Review of the Florida Resident Handbook & Admissions Information booklet, provided to residents and responsible parties upon admission, included information under Rules & Regulations about Abuse . The booklet includes: " The facility has policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. It is the intent of this facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident ' s property, or any injury of unknown origin. All staff are trained upon hire and provided education about abuse and neglect at least annually. " 7. Review of the medical record for Resident #1 revealed she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician order [REDACTED]. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. " Nurses notes throughout the resident ' s stay ([DATE] until [DATE]) documented similar descriptions of the resident - that she was alert and oriented, pleasant, needed assistance with activities of daily living, and was trying to be as independent as she could be. 8. Review of the Initial Social Services History, documented on [DATE], indicated the code status as " Full Code " , indicating the resident wanted to be resuscitated should she be found without respirations or pulse. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and revealed a form on which staff checked relevant options. Options checked for Resident #1 included the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. A Social Services note had been written on [DATE] documented, " Dr (oncologist) made referral for hospice for patient. Spoke with patient and daughter about hospice and DNRO and they will take the weekend to think over both and get back with SSD (Social Services Director) on both. " 9. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for Occupational Therapy (OT) and for Physical Therapy (PT) ( a calendar for attendance by the resident at therapy) revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed of the six short term goals, the resident was documented as having made progress with five of them and two of the five were documented as the resident had met the goal. 10. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist, in an appointment on [DATE], had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and her desire not to die in the facility. She confirmed, at that time, that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. , on [DATE], to learn about the options - Hospice house or Hospice care at her home . She confirmed that her mother had been attending therapy to get stronger so she could return home, and had done well with both Occupational and Physical Therapy. 12. 16. During the revisit on [DATE] using the facility's Allegation of Removal of Jeopardy document the following were reviewed and documented: 1. There was a review of all residents' medical records on [DATE], [DATE] and [DATE] by the consultant nurse pertaining to: if Resident had MD order for DNR, yellow DNR form and Care Plan for Advanced Directives. There was also documentation of reviews done by the facility's director of nursing (DON), assistant director of nursing (ADON), and social service director) SSD [DATE] and [DATE]. 2. Training had been conducted: a. The facility had current Policy Procedures related to the prevention of both Abuse and CPR code blue procedures. b. Documentation of employee training for abuse/neglect, advanced directives, CPR policy, code blue, medical records, location of DNR forms with the accompanying in-service sign in sheets ,[DATE]-[DATE] were completed. c. A revised New Employee Orientation Agenda including Advanced Directives was updated. d. Copies of all licensed nursing staff CPR certificates were provided which showed that the nursing staff are now all currently certified as trained in CPR. 3. Daily reviews were being conducted related to current code status of newly admitted residents and to expiration of residents. Daily DNR Worksheets and Expired Resident Review reviewed (form is now a 2 sided form ) - DNR status of admitted residents and expired resident review from [DATE] through [DATE] showed reviews were being conducted by the nursing administration. No residents have expired at the facility since the IJ complaint investigation . 4. Thirteen recently admitted or readmitted residents' charts were reviewed for current compliance with the corrective actions; All had accurate code status in the Physician order [REDACTED]. If the resident or his/her POA had indicated a DNR there was a yellow sheet with the necessary signatures on the form and the form was dated. It was noted that in the process of chart review that several long term residents changed their DNR status during that ,[DATE] review (usually from full code to DNR but atleast 2 -including long term residents changed their status from DNR to full code). Advance directive care plans were present in 9 residents' charts, four did not have the care plan form-two recently admitted residents within 14 day review window but two were readmitted residents who had been in the facility for longer periods of time. 5. The six facility staff who were interviewed related to the proper care and procedures for providing care to an unresponsive resident answered appropriately and reflected proper training. 6. During the revisit to remove the immediate jeopardy on [DATE] a record review was conducted of the facility's most recent QA meeting agenda and sign in sheet when the committee reviewed the Allegation of Removal of Jeopardy and current progress with ongoing compliance.

Based on review of the facility ' s abuse prohibition policy, and policies related to administering Cardio [MEDICAL CONDITION] Resuscitation (CPR) and maintaining CPR certification, review of a resident ' s medical record and interview with a family member, and interview with facility staff , it was determined that the facility failed to implement their policies related to abuse prohibition and honoring Advanced Directives, when they did not honor the Advanced Directive to receive cardio [MEDICAL CONDITION] resuscitation, for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE], of 33 residents who had documented , per a facility Advanced Care audit conducted on [DATE], that they wanted to be resuscitated and were at risk should they be found without respirations and a pulse. Resident #1 was found nonresponsive on [DATE] and was not resuscitated per her documented wishes. Failure of the facility to correctly implement the policies for prohibiting abuse and neglect, which included training staff, investigating the incident, and reporting the incident to the appropriate state agencies, by not ensuring that all staff would perform CPR to any and all residents unless there was a valid Do Not Resuscitate (DNR) order, and for ensuring that all nursing staff would maintain active , current CPR certification, resulted in the findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the facility Abuse Prohibition policy, " Abuse, Neglect and Misappropriation " (no policy number, effective ,[DATE]), revealed relevant policy statements included: " Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. " Under Procedure, section II. Training/Identification/Prevention included the guideline: " Staff receives orientation and on-going training on: What constitutes abuse, neglect and misappropriation of resident property. " Under section V. Protection of the Resident: " The Administrator and/or DON (Director of Nurses) will notify state agencies according to their reporting guidelines. " Under section VII. Investigation: " The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " Under section VIII. Follow up: " A. All allegations are to be reported within the timeframe allotted by the state agency. E. All allegations of abuse are reviewed at QA meetings for any further resolution related to educational opportunities. " 2. Review of the policy related to Resuscitation-Cardio [MEDICAL CONDITION] (no policy number, effective ,[DATE]), revealed the Guideline: " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is consent or authorization Do Not Resuscitate (DNR) for the issuance of an order not to resuscitate. Included under the Procedure were five steps - four of which were relevant: " 1.Upon admission, Social Services Director, Nursing Department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2. The DNR form will then be placed on the chart and maintained throughout the entire stay. 3. The DNR order is not valid without the Physician ' s signature. 5. Social Service Director or designee will review DNR orders at least quarterly and more often if necessary. 3. Review of the facility policy related to CPR - Code Blue (no policy number, effective ,[DATE]), revealed the same Guideline as the policy listed in #2 above: " It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. Included under the Procedure were five steps: " 1.Should a resident is identified without a pulse or respirations the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the emergency code documentation form to document the event. " 4. Review of the facility policy related to CPR - Certification (no policy number, effective ,[DATE]), revealed the Guideline: " It is the policy of this facility to maintain CPR certified personnel on a 24 hour basis. " Five steps were listed under the Procedure: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 5. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] upon the resident ' s admission, documented multiple [DIAGNOSES REDACTED]. x 4, verbalized needs to staff. " Nurses notes throughout the resident ' s stay in the facility ([DATE] through [DATE]) documented the resident as alert, usually oriented, sometimes confused, but able to make needs known, with continued efforts to maintain her independence. 6. Review of the Initial Social Services (SS) History, documented on [DATE], indicated the resident ' s advanced directives wishes for " Full Code " - resuscitation should she be found nonresponsive without respirations or pulse. The SS History documented the anticipated length of stay as eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. 7. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for Occupational Therapy (OT) and the Physical Therapy (PT) , ( a calendar for attendance by the resident at therapy) revealed the resident attended 17 of the 20 sessions with the OT, and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed the resident had made progress with five of the six short term goals and had met two of the five goals. 8. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 9. Review of nurses notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]), no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 10.In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the two nurses agreed to an interview. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview.. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist (in an appointment that both had attended on [DATE]), had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. On [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 12. Interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m. revealed they had been called into the facility by nursing staff the morning of [DATE] due to a Full Code resident, having been found nonresponsive, was not administered CPR, and ultimately died . The DON reported that facility nurses are required to maintain their CPR certification as a condition of employment. (CPR certification not only trains how to perform cardio [MEDICAL CONDITION] resuscitation, but trains the nurse on identifying life-threatening emergencies.) The DON explained that once the nurse found the unresponsive resident, she should have checked the medical record for the advanced directive. Once it was clear that the resident was a Full Code, the nurse should have called a ' code blue ' and started CPR. (A code blue would require all staff present to assist in the resuscitation efforts - administer CPR, call 911, and call the doctor and family.) The DON confirmed that per the nurses note and per the interviews that were conducted on the morning on [DATE] that did not happen. 13. Review of the investigation conducted by the RM revealed she had drawn up a timeline based on interviews with the nurses and aides that were working the 11 to 7 shift on [DATE]. Notes made during the interviews revealed that the resident ' s nurse had checked the resident ' s medical record and noted that the resident was full code, but per the investigation, had " no immediate interventions. " The resident ' s nurse left the resident to find one of the other two nurses on duty and per the RM ' s notes revealed that she knew the resident was a Full Code. Review of the investigation into the incident did not reveal analysis or continued interviews with the nurses or aides as to why there was no intervention - why no one administered CPR. When the lack of causal analysis was questioned, on [DATE], in the interview that began at 2:30 p.m. , the RM reported that " everybody knew how she felt " , referring to a conversation that the 7 to 3 nurse reported had occurred on [DATE], but hadn ' t documented. Review of Social Service notes revealed on [DATE] the Social Services Director documented what the nurse reported was said in the conversation with the resident on [DATE]. The nurse said that the resident told her ' she was ready to die ' . 14. The Director of Nurses reported, on [DATE] in the interview that began at 2:30 p.m. that the facility ' s plan of action in response to the incident was to inservice all nursing staff and coach (provide one on one training with a written warning filed in their personnel record), the three nurses who were on duty the morning on [DATE]. Review of the inservice sign in sheets for the inservices provided in response to the incident ([DATE], [DATE], [DATE]), revealed 19 nursing staff (17 nurses and 2 aides) signed as having attended. Review of the facility ' s list of current nursing staff revealed there were 34 nurses and 65 aides employed. Review of the three nurses ' personnel files revealed two of the three had received the coaching and the written warning. The third nurse, the resident ' s nurse who had not initiated CPR, had not returned to the facility to receive the coaching. 15. Review of nurses with current CPR certifications, per an audit performed by the Human Resources Director and provided on [DATE] at 3:00 p.m., revealed 15 of the 30 nurses on staff had current/active CPR certification cards. 16. The DON also reported the facility had changed the shift sheets to include resident ' s advanced directive information. Per the DON, the shift sheet is a document used on a daily basis that lists all residents ' pertinent information. The nurse on each shift updates the information, adding anything new that occurred during the shift for each resident. The DON reported that adding either Full or DNR to the information provided about each resident would be a quick reference for the nurses. Interview on [DATE] at 3:40 p.m. with two nurses on the 100 wing revealed neither was aware of the shift sheets containing resident advanced directive information. One nurse reported when asked about advance directive information that they would check the chart for that information. The unit manager on the 100 wing, during that interview, revealed that the shift sheets had not contained that information, which was evident as she rifled through weeks of old shift sheets. Interview with two nurses on the 200 wing, on [DATE] at 3:50 p.m. confirmed that they were aware of the change to the shift sheets and the information was visible on the shift sheet for each resident. 17 .In the interview with the DON on [DATE] beginning at 2:30 p.m. , it was confirmed that the facility had not filed a report related to this incident with the State agency. 18. In an interview with the Administrator on [DATE] beginning at 4:30 p.m. , it was confirmed that this incident had been discussed at the Quality Assurance (QA) meeting on [DATE]. He reported that the resident ' s medical record was reviewed by the physician at the meeting and the action plan of inservicing all staff was discussed. He reported that it had not been discussed at subsequent meetings as staff felt that it had been resolved. The review of the attendance at the inservices, held in response to the incident that occurred on [DATE], revealed 17 of 34 nurses and 2 of 65 aides attended. This information was presented to the Administrator on [DATE] at approximately 4:15 p.m. He reported that he was not aware that all of the nursing staff had not been inserviced. Also, at that time, he was made aware of the results of the CPR audit - that half of the nurses on staff, 15 of 30, were CPR certified.

Based on review of the facility ' s abuse prohibition policy, and policies related to administering Cardio [MEDICAL CONDITION] Resuscitation (CPR) and maintaining CPR certification, review of a resident ' s medical record and interview with a family member, and interview with facility staff , it was determined that the facility failed to implement their policies related to abuse prohibition and honoring Advanced Directives, when they did not honor the Advanced Directive to receive cardio [MEDICAL CONDITION] resuscitation, for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE], of 33 residents who had documented , per a facility Advanced Care audit conducted on [DATE], that they wanted to be resuscitated and were at risk should they be found without respirations and a pulse. Resident #1 was found nonresponsive on [DATE] and was not resuscitated per her documented wishes. Failure of the facility to correctly implement the policies for prohibiting abuse and neglect, which included training staff, investigating the incident, and reporting the incident to the appropriate state agencies, by not ensuring that all staff would perform CPR to any and all residents unless there was a valid Do Not Resuscitate (DNR) order, and for ensuring that all nursing staff would maintain active , current CPR certification, resulted in the findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the facility Abuse Prohibition policy, " Abuse, Neglect and Misappropriation " (no policy number, effective ,[DATE]), revealed relevant policy statements included: " Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. " Under Procedure, section II. Training/Identification/Prevention included the guideline: " Staff receives orientation and on-going training on: What constitutes abuse, neglect and misappropriation of resident property. " Under section V. Protection of the Resident: " The Administrator and/or DON (Director of Nurses) will notify state agencies according to their reporting guidelines. " Under section VII. Investigation: " The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. " Under section VIII. Follow up: " A. All allegations are to be reported within the timeframe allotted by the state agency. E. All allegations of abuse are reviewed at QA meetings for any further resolution related to educational opportunities. " 2. Review of the policy related to Resuscitation-Cardio [MEDICAL CONDITION] (no policy number, effective ,[DATE]), revealed the Guideline: " It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is consent or authorization Do Not Resuscitate (DNR) for the issuance of an order not to resuscitate. Included under the Procedure were five steps - four of which were relevant: " 1.Upon admission, Social Services Director, Nursing Department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2. The DNR form will then be placed on the chart and maintained throughout the entire stay. 3. The DNR order is not valid without the Physician ' s signature. 5. Social Service Director or designee will review DNR orders at least quarterly and more often if necessary. 3. Review of the facility policy related to CPR - Code Blue (no policy number, effective ,[DATE]), revealed the same Guideline as the policy listed in #2 above: " It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) (sic) for the issuance of an order not to resuscitate. Included under the Procedure were five steps: " 1.Should a resident is identified without a pulse or respirations the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2. CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3. A call will be placed for Emergency Medical Assistance and Transport. 4. CPR will continue until Emergency Medical Assistance arrives to assume responsibility for providing CPR. 5. Utilize the emergency code documentation form to document the event. " 4. Review of the facility policy related to CPR - Certification (no policy number, effective ,[DATE]), revealed the Guideline: " It is the policy of this facility to maintain CPR certified personnel on a 24 hour basis. " Five steps were listed under the Procedure: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 5. Resident #1 was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] upon the resident ' s admission, documented multiple [DIAGNOSES REDACTED]. Review of a nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff. " Nurses notes throughout the resident ' s stay in the facility ([DATE] through [DATE]) documented the resident as alert, usually oriented, sometimes confused, but able to make needs known, with continued efforts to maintain her independence. 6. Review of the Initial Social Services (SS) History, documented on [DATE], indicated the resident ' s advanced directives wishes for " Full Code " - resuscitation should she be found nonresponsive without respirations or pulse. The SS History documented the anticipated length of stay as eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] confirming that the discharge plan was to her home, and the attending physician had determined that the resident ' s stay at the facility was short term. 7. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix for Occupational Therapy (OT) and the Physical Therapy (PT) , ( a calendar for attendance by the resident at therapy) revealed the resident attended 17 of the 20 sessions with the OT, and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. Review of the PT discharge summary revealed the resident had made progress with five of the six short term goals and had met two of the five goals. 8. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and was able to complete the brief interview for mental status appropriately. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 9. Review of nurses notes revealed on [DATE] at 0200, the nurse wrote, " v/s (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics). VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]), no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 10.In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the two nurses agreed to an interview. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview.. 11. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist (in an appointment that both had attended on [DATE]), had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. On [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 12. Interview with the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m. revealed they had been called into the facility by nursing staff the morning of [DATE] due to a Full Code resident, having been found nonresponsive, was not administered CPR, and ultimately died . The DON reported that facility nurses are required to maintain their CPR certification as a condition of employment. (CPR certification not only trains how to perform cardio [MEDICAL CONDITION] resuscitation, but trains the nurse on identifying life-threatening emergencies.) The DON explained that once the nurse found the unresponsive resident, she should have checked the medical record for the advanced directive. Once it was clear that the resident was a Full Code, the nurse should have called a ' code blue ' and started CPR. (A code blue would require all staff present to assist in the resuscitation efforts - administer CPR, call 911, and call the doctor and family.) The DON confirmed that per the nurses note and per the interviews that were conducted on the morning on [DATE] that did not happen. 13. Review of the investigation conducted by the RM revealed she had drawn up a timeline based on interviews with the nurses and aides that were working the 11 to 7 shift on [DATE]. Notes made during the interviews revealed that the resident ' s nurse had checked the resident ' s medical record and noted that the resident was full code, but per the investigation, had " no immediate interventions. " The resident ' s nurse left the resident to find one of the other two nurses on duty and per the RM ' s notes revealed that she knew the resident was a Full Code. Review of the investigation into the incident did not reveal analysis or continued interviews with the nurses or aides as to why there was no intervention - why no one administered CPR. When the lack of causal analysis was questioned, on [DATE], in the interview that began at 2:30 p.m. , the RM reported that " everybody knew how she felt " , referring to a conversation that the 7 to 3 nurse reported had occurred on [DATE], but hadn ' t documented. Review of Social Service notes revealed on [DATE] the Social Services Director documented what the nurse reported was said in the conversation with the resident on [DATE]. The nurse said that the resident told her ' she was ready to die ' . 14. The Director of Nurses reported, on [DATE] in the interview that began at 2:30 p.m. that the facility ' s plan of action in response to the incident was to inservice all nursing staff and coach (provide one on one training with a written warning filed in their personnel record), the three nurses who were on duty the morning on [DATE]. Review of the inservice sign in sheets for the inservices provided in response to the incident ([DATE], [DATE], [DATE]), revealed 19 nursing staff (17 nurses and 2 aides) signed as having attended. Review of the facility ' s list of current nursing staff revealed there were 34 nurses and 65 aides employed. Review of the three nurses ' personnel files revealed two of the three had received the coaching and the written warning. The third nurse, the resident ' s nurse who had not initiated CPR, had not returned to the facility to receive the coaching. 15. Review of nurses with current CPR certifications, per an audit performed by the Human Resources Director and provided on [DATE] at 3:00 p.m., revealed 15 of the 30 nurses on staff had current/active CPR certification cards. 16. The DON also reported the facility had changed the shift sheets to include resident ' s advanced directive information. Per the DON, the shift sheet is a document used on a daily basis that lists all residents ' pertinent information. The nurse on each shift updates the information, adding anything new that occurred during the shift for each resident. The DON reported that adding either Full or DNR to the information provided about each resident would be a quick reference for the nurses. Interview on [DATE] at 3:40 p.m. with two nurses on the 100 wing revealed neither was aware of the shift sheets containing resident advanced directive information. One nurse reported when asked about advance directive information that they would check the chart for that information. The unit manager on the 100 wing, during that interview, revealed that the shift sheets had not contained that information, which was evident as she rifled through weeks of old shift sheets. Interview with two nurses on the 200 wing, on [DATE] at 3:50 p.m. confirmed that they were aware of the change to the shift sheets and the information was visible on the shift sheet for each resident. 17 .In the interview with the DON on [DATE] beginning at 2:30 p.m. , it was confirmed that the facility had not filed a report related to this incident with the State agency. 18. In an interview with the Administrator on [DATE] beginning at 4:30 p.m. , it was confirmed that this incident had been discussed at the Quality Assurance (QA) meeting on [DATE]. He reported that the resident ' s medical record was reviewed by the physician at the meeting and the action plan of inservicing all staff was discussed. He reported that it had not been discussed at subsequent meetings as staff felt that it had been resolved. The review of the attendance at the inservices, held in response to the incident that occurred on [DATE], revealed 17 of 34 nurses and 2 of 65 aides attended. This information was presented to the Administrator on [DATE] at approximately 4:15 p.m. He reported that he was not aware that all of the nursing staff had not been inserviced. Also, at that time, he was made aware of the results of the CPR audit - that half of the nurses on staff, 15 of 30, were CPR certified.

Based on a review of the Job Description for the Administrator, review of the medical record for Resident #1, and policy and procedure review, review of the Resident Handbook, Florida Resident Handbook & Admissions Information, and interviews with facility staff and a family member, it was determined that administration failed to provide resource management to follow the documented Advanced Directives to receive cardio [MEDICAL CONDITION] resuscitation, for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE], and the 33 residents who had documented that they wished to be resuscitated, and are at risk should they be found unresponsive, without respirations or pulse. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and facility policies for advanced directives, the identification of residents who are full code and administration of cardio [MEDICAL CONDITION] resuscitation (CPR). The failure of facility administrative staff to identify the severity of this incident, to fully investigate for cause and plan interventions to prevent a recurrence, and to monitor the action plan for effectiveness, and to ensure that certified staff would properly implement policies on providing CPR and implement training received , resulted in the omission of three staff to perform CPR and call for Emergency Medical Services (911) when Resident #1 was found without respirations. These actions resulted in findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the job description for the administrator, (Updated [DATE]) , revealed the following relevant information: Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility ' s business objectives. Essential Duties & Responsibilities: Management duties including, but not limited to , hiring, training, and developing, coaching and counseling, and terminating department staff , as deemed necessary. Monitor each department ' s activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Responsible for Quality Assurance program. Monitor Human Resources practices to verify compliance with employment laws and company policies, and to confirm practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, proactive supervisory practices and maintaining a proactive work environment. 2. Review of Resident #1 ' s medical record revealed a note written by the nurse, on [DATE] at 0200, documenting, " v/t (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics) . VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]) , no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated , " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 3. Review of the resident ' s medical record revealed she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] revealed multiple [DIAGNOSES REDACTED]. Review of the Interim Care Plan, developed upon admission, revealed the question: " Resident is a DNR " to which the answer was checked " No " . The Goal which was checked indicated, " Will follow Advanced Directives. " 4. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. " Review of nurses notes during the resident ' s admission, from [DATE] through [DATE], revealed the resident was pleasant, alert and oriented, able to make her needs known, and interested in maintaining independence with her activities of daily living. 5. Review of the Initial Social Services History, documented on [DATE], indicated the Advanced Directive code status as " Full Code " , meaning that the resident wanted to be resuscitated should she be found unresponsive, without respirations and pulse. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and contained options that staff could check which pertained to the resident. The care plan was checked for " discharged to her home " , and " the attending physician had determined that the resident ' s stay at the facility was short term. " 6. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix ( a calendar for attendance by the resident at therapy) for Occupational Therapy (OT) and Physical Therapy (PT), revealed the resident attended 17 of the 20 sessions with the OT and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed out of the six short term goals, the resident had met two of the five goals and PT had documented progress on five of the six goals. 7. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 8. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m., on [DATE], to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 9. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the three nurses agreed to an interview. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview.. 10 .Interview with the Director of Nurses (DON) and the Risk Manager (RM), on [DATE] beginning at 2:30 p.m. revealed that they had been called into the facility the morning of [DATE] to be told that that resident #1 had been found without respirations or pulse, and CPR had not been initiated. The RM reported she had drawn a time line of events based on interviews she had conducted with the nurses and aides working that 11 - 7 shift on [DATE]. The notes in the time line reflected that the resident ' s nurse checked the chart for the advanced directive, and even though there was no DNR form in the chart, the nurses did not initiate CPR and call 911. The RM reported that on [DATE] the resident had seen her Oncologist and had gotten bad news. On [DATE] the Social Services Director spoke with the resident and her daughter about a Hospice referral and Do Not Resuscitate. They both wanted to think about it over the weekend. Social Services (SS) wrote a note on [DATE] referring to a conversation that a day nurse had with the resident on [DATE], but had not documented. The SS note contained the nurses ' report of the resident ' s statement that she was ready to die. The RM reported when asked about the failure to honor the resident ' s wishes to be provided with CPR, that " everyone knew her feelings. " The DON and RM confirmed that the resident was " essentially still a full code however. " They confirmed that nurses had been trained, through the required CPR certification training, that residents are to be provided with CPR unless there is a valid DNR in the resident ' s chart. They also confirmed that facility policy required that all residents receive CPR unless a valid DNR was in the chart, as well as requiring that all nurses maintain active CPR certification. The DON, during the interview, reported that part of the action plan in response to the resident not being provided with CPR per her wishes, was to inservice all staff. She reported that inservices were conducted in the following days after the resident ' s death. Review of the sign in sheets for the inservices, dated [DATE], [DATE], and [DATE], revealed two of the 65 aides employed by the facility and 17 of the 34 nurses employed by the facility had attended the inservices. The DON reported that the three licensed nurses who were on duty the morning of the resident ' s death were ' coached ' , meaning they were provided one on one counseling with a written warning filed in their personnel record. Review of the coaching revealed two of the three nurses received the coaching. The resident ' s nurse had not returned to the facility and had not received the coaching. 11. Review of the Nurses job description revealed a Job Requirement was to have a current/active CPR certification. Interview with the Human Resources Director (HRD), on [DATE] at 3:00 p.m. revealed that she had conducted an audit of the nurses ' CPR cards. Review of the audit revealed that of the 30 nurses employed by the facility, the HRD only had active CPR cards for 15 of the nurses. Review of the facility policy, " CPR Certification " (Effective ,[DATE]), included the Guideline: " It is the policy of this facility to maintain CPR certified personnel on a 24 hour basis. " Facility Procedure included: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 12.Review of the facility ' s policy " CPR-Code Blue " , effective ,[DATE] revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to : " 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " 13. Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] , revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 14. Review of the Resident Handbook, Florida Resident Handbook & Admissions Information, provided upon admission to residents and responsible parties, included three pages of information about advanced directives to help residents and responsible parties through the process of defining and documenting their wishes concerning medical treatment and end of life decisions. Contained within the first two paragraphs of the document were the lines, " You alone have the right to make basic decisions about the medical and health care services you receive from your physician and health care providers. .... All of those who provide your health care are responsible for following your wishes. " 15. Interview with the Administrator on [DATE] beginning at 4:30 p.m. revealed that the incident that had occurred on [DATE] had been discussed at the April Quality Assurance meeting. He reported that the Medical Director had reviewed the resident ' s chart at the meeting and there was a discussion about the inservicing of all nursing staff that had occurred. He reported that the issue was not reviewed again at the May meeting as the staff had agreed the issue had been resolved. During an interview with the Administrator on [DATE] which began at 4:00 p.m., he was made aware that not all of the nursing staff had been inserviced after the incident occurred. He also reviewed the CPR audit conducted by the HRD in which it was revealed that 15 of the 30 nurses on staff had active CPR certification. The change to the shift sheets was also discussed and how the 100 wing had not been including advanced directive information on the shift sheets. The Administrator confirmed that he had not been made aware that interventions to prevent a resident from not receiving CPR had not been monitored and ensured that they had been completed.

Based on a review of the Job Description for the Administrator, review of the medical record for Resident #1, and policy and procedure review, review of the Resident Handbook, Florida Resident Handbook & Admissions Information, and interviews with facility staff and a family member, it was determined that administration failed to provide resource management to follow the documented Advanced Directives to receive cardio [MEDICAL CONDITION] resuscitation, for one (#1) of 19 sampled residents who died in the facility between [DATE] and [DATE], and the 33 residents who had documented that they wished to be resuscitated, and are at risk should they be found unresponsive, without respirations or pulse. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and facility policies for advanced directives, the identification of residents who are full code and administration of cardio [MEDICAL CONDITION] resuscitation (CPR). The failure of facility administrative staff to identify the severity of this incident, to fully investigate for cause and plan interventions to prevent a recurrence, and to monitor the action plan for effectiveness, and to ensure that certified staff would properly implement policies on providing CPR and implement training received , resulted in the omission of three staff to perform CPR and call for Emergency Medical Services (911) when Resident #1 was found without respirations. These actions resulted in findings of ongoing immediate jeopardy on [DATE]. Findings include: 1. Review of the job description for the administrator, (Updated [DATE]) , revealed the following relevant information: Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility ' s business objectives. Essential Duties & Responsibilities: Management duties including, but not limited to , hiring, training, and developing, coaching and counseling, and terminating department staff , as deemed necessary. Monitor each department ' s activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Responsible for Quality Assurance program. Monitor Human Resources practices to verify compliance with employment laws and company policies, and to confirm practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, proactive supervisory practices and maintaining a proactive work environment. 2. Review of Resident #1 ' s medical record revealed a note written by the nurse, on [DATE] at 0200, documenting, " v/t (vital signs) ,[DATE], 74, 20, 98. Resident continues po abt (by mouth antibiotics) . VRE urine ([MEDICATION NAME] resistant [MEDICATION NAME]) , no adverse reactions observed. " The next note written by the nurse, on [DATE] at 0945 indicated , " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body. " 3. Review of the resident ' s medical record revealed she was a [AGE] year old female who had been admitted to the facility on [DATE] to receive IV antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION] , per the Physician Orders upon admission. The Nursing Admission Information form, completed on [DATE] revealed multiple [DIAGNOSES REDACTED]. The Goal which was checked indicated, " Will follow Advanced Directives. " 4. A nurse ' s note written on [DATE] at 1330 described the resident as " alert and oriented x 4, verbalized needs to staff, respirations even unlabored. " Review of nurses notes during the resident ' s admission, from [DATE] through [DATE], revealed the resident was pleasant, alert and oriented, able to make her needs known, and interested in maintaining independence with her activities of daily living. 5. Review of the Initial Social Services History, documented on [DATE], indicated the Advanced Directive code status as " Full Code " , meaning that the resident wanted to be resuscitated should she be found unresponsive, without respirations and pulse. The anticipated length of stay was eight weeks and the current discharge goal was " discharge home with home health. " A Discharge Care Plan was initiated on [DATE] and contained options that staff could check which pertained to the resident. The care plan was checked for " discharged to her home " , and " the attending physician had determined that the resident ' s stay at the facility was short term. " 6. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix ( a calendar for attendance by the resident at therapy) for Occupational Therapy (OT) and Physical Therapy (PT), revealed the resident attended 17 of the 20 sessions with the OT and 19 of the 20 sessions with the PT. Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed out of the six short term goals, the resident had met two of the five goals and PT had documented progress on five of the six goals. 7. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 8. An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m., on [DATE], to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger, and had done well with both Occupational and Physical Therapy. 9. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the three nurses agreed to an interview. Two of the three nurses and the five aides that worked the 11 to 7 shift on [DATE] were not available for interview.. 10 .Interview with the Director of Nurses (DON) and the Risk Manager (RM), on [DATE] beginning at 2:30 p.m. revealed that they had been called into the facility the morning of [DATE] to be told that that resident #1 had been found without respirations or pulse, and CPR had not been initiated. The RM reported she had drawn a time line of events based on interviews she had conducted with the nurses and aides working that 11 - 7 shift on [DATE]. The notes in the time line reflected that the resident ' s nurse checked the chart for the advanced directive, and even though there was no DNR form in the chart, the nurses did not initiate CPR and call 911. The RM reported that on [DATE] the resident had seen her Oncologist and had gotten bad news. On [DATE] the Social Services Director spoke with the resident and her daughter about a Hospice referral and Do Not Resuscitate. They both wanted to think about it over the weekend. Social Services (SS) wrote a note on [DATE] referring to a conversation that a day nurse had with the resident on [DATE], but had not documented. The SS note contained the nurses ' report of the resident ' s statement that she was ready to die. The RM reported when asked about the failure to honor the resident ' s wishes to be provided with CPR, that " everyone knew her feelings. " The DON and RM confirmed that the resident was " essentially still a full code however. " They confirmed that nurses had been trained, through the required CPR certification training, that residents are to be provided with CPR unless there is a valid DNR in the resident ' s chart. They also confirmed that facility policy required that all residents receive CPR unless a valid DNR was in the chart, as well as requiring that all nurses maintain active CPR certification. The DON, during the interview, reported that part of the action plan in response to the resident not being provided with CPR per her wishes, was to inservice all staff. She reported that inservices were conducted in the following days after the resident ' s death. Review of the sign in sheets for the inservices, dated [DATE], [DATE], and [DATE], revealed two of the 65 aides employed by the facility and 17 of the 34 nurses employed by the facility had attended the inservices. The DON reported that the three licensed nurses who were on duty the morning of the resident ' s death were ' coached ' , meaning they were provided one on one counseling with a written warning filed in their personnel record. Review of the coaching revealed two of the three nurses received the coaching. The resident ' s nurse had not returned to the facility and had not received the coaching. 11. Review of the Nurses job description revealed a Job Requirement was to have a current/active CPR certification. Interview with the Human Resources Director (HRD), on [DATE] at 3:00 p.m. revealed that she had conducted an audit of the nurses ' CPR cards. Review of the audit revealed that of the 30 nurses employed by the facility, the HRD only had active CPR cards for 15 of the nurses. Review of the facility policy, " CPR Certification " (Effective ,[DATE]), included the Guideline: " It is the policy of this facility to maintain CPR certified personnel on a 24 hour basis. " Facility Procedure included: " 1.Licensed nursing personnel will have CPR certification validated upon employment. 2. The CPR card will be copied upon employment. The copy will be placed in the employee ' s personnel file. 3. The Staff Development Coordinator or designee will maintain an updated list of personnel for re-certification purposes. 4. The Staff Development Coordinator or designee will notify the licensed staff when re-certification is warranted. 5. The Staff Development Coordinator or designee will coordinate with a certified CPR instructor to conduct CPR classes as needed. " 12.Review of the facility ' s policy " CPR-Code Blue " , effective ,[DATE] revealed the " Guideline: It shall be the policy of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate " (sic). A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. " The Procedure outlined in the policy directed staff to : " 1- Should a resident be identified without a pulse or respiration the status of the resident will be determined. CPR will be initiated unless there is a DNR order and consent in place. 2-CPR will be initiated utilizing the American Heart Association/Red Cross guidelines. 3-A call will be placed for Emergency Medical Assistance and Transport. 4- CPR will continue until Emergency Medical Assistance arrives to assure responsibility for providing CPR. 5- Utilize the emergency code documentation form to document the event. " 13. Review of a second policy, " Resuscitation - Cardio [MEDICAL CONDITION] " , effective ,[DATE] , revealed the Guideline: It is the intent of this facility to administer cardiopulmonary resuscitation on any/all residents unless there is a consent or authorization Do Not Resuscitation (DNR) for the issuance of an order not to resuscitate. A competent resident, legal guardian, healthcare proxy, and the attending physician may make a DNR decision. The Procedure outlined in the policy included: 1-Upon admission, Social Services Director, Nursing department or designee will explain this policy and, in the event that a DNR order is requested, Social Services will obtain the appropriate representative and MD signatures. 2- The DNR form will then be placed on the chart and maintained throughout the entire stay. 3- The DNR order is not valid without the Physician ' s signature. 14. Review of the Resident Handbook, Florida Resident Handbook & Admissions Information, provided upon admission to residents and responsible parties, included three pages of information about advanced directives to help residents and responsible parties through the process of defining and documenting their wishes concerning medical treatment and end of life decisions. Contained within the first two paragraphs of the document were the lines, " You alone have the right to make basic decisions about the medical and health care services you receive from your physician and health care providers. .... All of those who provide your health care are responsible for following your wishes. " 15. Interview with the Administrator on [DATE] beginning at 4:30 p.m. revealed that the incident that had occurred on [DATE] had been discussed at the April Quality Assurance meeting. He reported that the Medical Director had reviewed the resident ' s chart at the meeting and there was a discussion about the inservicing of all nursing staff that had occurred. He reported that the issue was not reviewed again at the May meeting as the staff had agreed the issue had been resolved. During an interview with the Administrator on [DATE] which began at 4:00 p.m., he was made aware that not all of the nursing staff had been inserviced after the incident occurred. He also reviewed the CPR audit conducted by the HRD in which it was revealed that 15 of the 30 nurses on staff had active CPR certification. The change to the shift sheets was also discussed and how the 100 wing had not been including advanced directive information on the shift sheets. The Administrator confirmed that he had not been made aware that interventions to prevent a resident from not receiving CPR had not been monitored and ensured that they had been completed. 16. During the revisit on [DATE] using the facility's Allegation of Removal of Jeopardy document the following were reviewed and documented: 1. There was a review of all residents' medical records on [DATE], [DATE] and [DATE] by the consultant nurse pertaining to: if Resident had MD order for DNR, yellow DNR form and Care Plan for Advanced Directives. There was also documentation of reviews done by the facility's director of nursing (DON), assistant director of nursing (ADON), and social service director) SSD [DATE] and [DATE]. 2. Training had been conducted: a. The facility had current Policy Procedures related to the prevention of both Abuse and CPR code blue procedures. b. Documentation of employee training for abuse/neglect, advanced directives, CPR policy, code blue, medical records, location of DNR forms with the accompanying in-service sign in sheets ,[DATE]-[DATE] were completed. c. A revised New Employee Orientation Agenda including Advanced Directives was updated. d. Copies of all licensed nursing staff CPR certificates were provided which showed that the nursing staff are now all currently certified as trained in CPR. 3. Daily reviews were being conducted related to current code status of newly admitted residents and to expiration of residents. Daily DNR Worksheets and Expired Resident Review reviewed (form is now a 2 sided form ) - DNR status of admitted residents and expired resident review from [DATE] through [DATE] showed reviews were being conducted by the nursing administration. No residents have expired at the facility since the IJ complaint investigation . 4. Thirteen recently admitted or readmitted residents' charts were reviewed for current compliance with the corrective actions; All had accurate code status in the Physician order sheets-either full code or DNR. If the resident or his/her POA had indicated a DNR there was a yellow sheet with the necessary signatures on the form and the form was dated. It was noted that in the process of chart review that several long term residents changed their DNR status during that ,[DATE] review (usually from full code to DNR but atleast 2 -including long term residents changed their status from DNR to full code). Advance directive care plans were present in 9 residents' charts, four did not have the care plan form-two recently admitted residents within 14 day review window but two were readmitted residents who had been in the facility for longer periods of time. 5. The six facility staff who were interviewed related to the proper care and procedures for providing care to an unresponsive resident answered appropriately and reflected proper training. 6. During the revisit to remove the immediate jeopardy on [DATE] a record review was conducted of the facility's most recent QA meeting agenda and sign in sheet when the committee reviewed the Allegation of Removal of Jeopardy and current progress with ongoing compliance.

Based on review of the medical record for resident #1 , interview with a family member and facility staff, and review of planned interventions related to an investigation of a Full Code resident ' s death who had not been resuscitated, the facility failed to ensure that the Advanced Directives were followed for one resident (#1) who had requested to receive cardio [MEDICAL CONDITION] resuscitation of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents had documented that they wanted to be resuscitated, per a facility Advance Care Planning audit conducted on [DATE], and were at risk should they be found without pulse or resuscitation. It was revealed in facility interviews that the death of resident #1 was discussed in the Quality Assurance Meeting held on [DATE], however there was no analysis of the incident that led to an appropriate plan of action to prevent a repeat occurrence, and no planned monitoring of the interventions. The failure of the facility administrative staff to identify the severity of this incident, fully investigate for cause and plan interventions to prevent an occurrence , and then monitor the action plan for effectiveness, led to the determination of ongoing immediate jeopardy identified on [DATE] . Findings include: 1. Review of the medical record for resident #1, revealed a nurses note written on [DATE] at 0945 which documented, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body " Further review of the medical record did not locate a signed DNR (Do Not Resuscitate) form, which indicated that the resident would be considered a Full Code and cardio [MEDICAL CONDITION] resuscitation (CPR) should have been initiated and 911 (Emergency Medical Services) called. 2 .Review of the admission nurses notes dated [DATE], located in the medical record for resident #1, revealed an alert and oriented [AGE] year old female, who had been admitted for a short term stay to receive IV antibiotics for a Urinary Tract Infection. Review of the Nursing Admission Form, completed for resident #1 upon admission, on [DATE] revealed that the resident had multiple diagnosis, among which was [MEDICAL CONDITION]. 3. Review of the Social Services History form, completed on [DATE] documented the resident as wishing to be resuscitated, should she be found without respirations or pulse. Per the Social Services History, the resident ' s stay in the facility was short term and the discharge plan was to return to her home 4. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) for both Occupational (OT) and Physical (PT) therapy revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 PT sessions Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed of the six short term goals, the resident made progressed with five of them, two of which were met 5. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 6.On [DATE] accompanied by her daughter, the resident saw her oncologist. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 7.An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger so she could be discharged home and had done well with both Occupational and Physical Therapy. 8. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the three nurses that worked the 11 to 7 shift on [DATE] agreed to an interview. The other two nurses and the five aides were not available for interview.. 9. An interview was conducted with both the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m . The DON confirmed that the resident was a " DNR " and the nurses should have initiated CPR and phoned 911. The RM talked about the investigation that she had conducted into what had happened on the morning of [DATE]. She had drawn up a time line for the investigation based on the interviews she had conducted with the nurses and aides on duty on the 11 to 7 shift on [DATE] . She did not arrive at a conclusion as to why the nurses did not follow facility policy and CPR training that all nurses are to receive and maintain as a condition of employment. The DON discussed the plan of action based on the incident and reported that it included inservicing all nursing staff and ' coaching ' the nurses that were involved in not calling a code blue (administering CPR and calling 911). Review of the sign in sheets of the three inservices that were reportedly given to staff based on the incident ([DATE], [DATE], and [DATE]) did not reveal that the three aides that were working the unit on which resident #1 resided had signed as having attended any of the three of the inservices. A total of 17 nurses signed as having attended the inservices , out of a total of 34 nurses employed at that time and 2 of the 65 aides signed as having attended the inservices. Two of the three nurses who had worked the shift during which resident #1 expired had been ' coached ' - one on one training with a written warning filed in their personnel record. The third nurse, the resident ' s nurse, had not returned to work, and had not received the ' coaching ' . 10.The Corporate Nurse, on [DATE] at 3:15 p.m. when asked about facility requirements related to nurses being CPR certified , reported that the licensed nurse ' s job description required maintaining active certification. . Review of the Licensed Nurse job description, (updated [DATE]), revealed the second bullet point under the Job Requirements listed " Must have a current / active CPR certification. " The Human Resources Director (HRD) , on [DATE] at 3:00 p.m. provided her audit of nurses ' CPR certification. Of the 30 current nurses on staff, the HRD had the current CPR cards for 15 of the nurses. 11. The DON also reported that another step in their action plan was to list advanced directives on a ' shift sheet ' for easy referral for the nurses. She described the ' shift sheet ' as a document that captured information about the residents that occurred during the three shifts. This information could easily be provided to the next shift, and who could continue to document any changes or information about the residents. Review of the shift sheets for the 200 wing revealed a sheet of paper with four columns - the first column documented the resident ' s name , room number, and in the corner either " full " or " dnr " , indicating the advanced directive. Both nurses on the 200 wing, on [DATE] at 3:50 p.m.were able to identify this new intervention and both of their shift sheets contained the information about the residents. The two nurses questioned on the 100 hall (on [DATE] at 3:45 p.m.) about the inclusion of the advanced directive information on the shift sheet denied having seen that information on the shift sheets. One nurse (employee B) reported, at that time, that advanced directive information was contained in the resident ' s medical record, not the shift sheet. The unit manager , at that time, was questioned about including the advanced directive information on the shift sheets and she reported that they hadn ' t been including it on their wing ' s shift sheets. 12. Interview with the Administrator on [DATE] beginning at 4:30 p.m. confirmed that on [DATE] at the Quality Assurance meeting there had been a discussion about the incident that had occurred on [DATE] in which resident #1 was not provided CPR per her wishes. The Administrator reported that the Medical Director reviewed the resident ' s chart at the meeting and the action plan to inservice staff had been discussed as well. The Administrator reported that in the May meeting, held on [DATE], there was no discussion of the incident and monitoring of the action plan, as the staff felt it had been resolved. The Administrator reported that the staff at the meeting in April had discussed the incident and determined it was an isolated event, isolated to only that one nurse . When it was pointed out to him that actually it was not isolated, as there were three nurses on duty and six aides, none of which attempted to honor the resident ' s wishes of wanting to be resuscitated, he agreed and said that was why they had inserviced all staff that had worked that night. The Administrator also reported that the incident had not been reported to the State agency. The Administrator was not aware that not all of the nursing staff had been inserviced and was not aware that one of the two nurses wings, actually the wing where the incident had taken place, was not implementing the action plan of including advanced directives on the shift sheets. There was no documentation indicating that the action plan had been monitored. He was also not aware that only half of the nurses had active CPR certification, per the facility audit. 13..In an interview with the Medical Director, on [DATE] beginning at 11:30 a.m., it was revealed that he had been made aware of the incident that occurred in the morning of [DATE]. He reported that he was also aware of the inservicing related to the incident because that been discussed at the QA meeting. He confirmed that the medical record had been reviewed at the QA meeting, but added that " who knows what those nurses were thinking. " He did not say that any cause analysis had been conducted as to the reason for not administering CPR and phoning 911. The Medical Director reported that the issue had not been discussed at the next QA meeting.

Based on review of the medical record for resident #1 , interview with a family member and facility staff, and review of planned interventions related to an investigation of a Full Code resident ' s death who had not been resuscitated, the facility failed to ensure that the Advanced Directives were followed for one resident (#1) who had requested to receive cardio [MEDICAL CONDITION] resuscitation of 19 sampled residents who had died in the facility between [DATE] and [DATE]. Thirty three current residents had documented that they wanted to be resuscitated, per a facility Advance Care Planning audit conducted on [DATE], and were at risk should they be found without pulse or resuscitation. It was revealed in facility interviews that the death of resident #1 was discussed in the Quality Assurance Meeting held on [DATE], however there was no analysis of the incident that led to an appropriate plan of action to prevent a repeat occurrence, and no planned monitoring of the interventions. The failure of the facility administrative staff to identify the severity of this incident, fully investigate for cause and plan interventions to prevent an occurrence , and then monitor the action plan for effectiveness, led to the determination of ongoing immediate jeopardy identified on [DATE] . Findings include: 1. Review of the medical record for resident #1, revealed a nurses note written on [DATE] at 0945 which documented, " this nurse entered resident ' s room at 0430 am and found resident pale, cold to touch, with no pulse and no respirations. Doctor called at 0440 am and left message. Doctor returned call at 0450 am and informed doctor no respirations and no pulse. Doctor advised staff to release body " Further review of the medical record did not locate a signed DNR (Do Not Resuscitate) form, which indicated that the resident would be considered a Full Code and cardio [MEDICAL CONDITION] resuscitation (CPR) should have been initiated and 911 (Emergency Medical Services) called. 2 .Review of the admission nurses notes dated [DATE], located in the medical record for resident #1, revealed an alert and oriented [AGE] year old female, who had been admitted for a short term stay to receive IV antibiotics for a Urinary Tract Infection. Review of the Nursing Admission Form, completed for resident #1 upon admission, on [DATE] revealed that the resident had multiple diagnosis, among which was [MEDICAL CONDITION]. 3. Review of the Social Services History form, completed on [DATE] documented the resident as wishing to be resuscitated, should she be found without respirations or pulse. Per the Social Services History, the resident ' s stay in the facility was short term and the discharge plan was to return to her home 4. Orders for Therapy had been received and evaluations were made by both Occupational and Physical Therapy on [DATE]. Review of the Service Log Matrix (a calendar for attendance by the resident at therapy) for both Occupational (OT) and Physical (PT) therapy revealed the resident attended 17 sessions with the OT five days a week for four weeks in February, and 19 of the 20 PT sessions Review of the OT Discharge Summary revealed the comment, " Patient has made consistent progress with skilled interventions. " Review of the PT discharge summary revealed of the six short term goals, the resident made progressed with five of them, two of which were met 5. A 14 day Minimum Data Set Assessment was completed for this resident on [DATE]. The assessment identified the resident as having no visual or hearing deficits and being able to complete the brief interview for mental status appropriately. She self-identified as feeling down or depressed, having trouble sleeping, having a poor appetite and feeling tired or having little energy. Functional status was identified as needing extensive assistance from one person for bed mobility, transferring, moving about on the unit, dressing, using the toilet, and with personal hygiene. The resident denied having pain. The question " Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months " was answered NO. The resident was documented as having attended 150 minutes in the prior seven days of Occupational Therapy and 135 minutes in the prior seven days of Physical Therapy. The resident was documented as having participated in the assessment and that there was an active discharge plan already occurring for the resident to return to the community. 6.On [DATE] accompanied by her daughter, the resident saw her oncologist. Review of the oncologist ' s note revealed the [DIAGNOSES REDACTED]. " Findings were listed as " poor performance status - ambulatory with walker, short distances only, needs help with ADLs (activities of daily living). " Recommendations were listed as " refer to hospice, prescribe [MEDICATION NAME] 5 mg po every six hours as needed for pain, stool softener daily, and return to clinic in one month. " 7.An interview was conducted with the resident ' s daughter on [DATE] beginning at 1:30 p.m. The daughter reported that of course she was aware that her mother was very sick and the oncologist had said there was nothing more to be done, but he hadn ' t alluded to imminent death. The daughter reported that when her mother was admitted to the facility it was for IV antibiotics and therapy with the discharge plan to go home. She said the facility was aware of the plan to go home, and not to die in the facility. She confirmed that there had been talk about Do Not Resuscitate orders, but no decision had been made. She reported that she and her mother were going to meet with a Hospice representative at 9:00 a.m. on [DATE] to learn about the options - Hospice house or Hospice care at her home. She confirmed that her mother had been attending therapy to get stronger so she could be discharged home and had done well with both Occupational and Physical Therapy. 8. In a phone call (on [DATE] at 5:30 p.m.) to one of the three nurses (employee D) on duty on the 11 to 7 shift on [DATE] , it was revealed that the nurse who had found the resident (employee A) had come over to the 200 wing looking for the third nurse. Employee D reported she didn ' t know the third nurse ' s location, and asked why employee A needed her. Employee A reported that one of her residents was dead and she wanted a second nurse to check her out. Employee D reported that she asked if the resident was a DNR and employee A responded no, that she hadn ' t found a DNR. Employee D said that she went into the resident ' s room and found that the patient was cold. Employee D reported " I ' m not excusing that I didn ' t give CPR, I don ' t know why - I take my job seriously and I can ' t believe that ' s what I did, I don ' t know why. " Employee D reported that she went back to her wing and the third nurse joined her later and told her that she had called the Director of Nurses and they weren ' t allowed to leave the building until they spoke with the Administrator, the DON, and the corporate lawyer. She confirmed that Employee A never returned to work, and that she and the third nurse were suspended without pay for three days and had to attend an inservice about the CPR policy. She said she had gotten a call from Human Resources (on [DATE]) and was told to bring in her CPR certification card and she had to attend another inservice prior to working that night. One of the three nurses that worked the 11 to 7 shift on [DATE] agreed to an interview. The other two nurses and the five aides were not available for interview.. 9. An interview was conducted with both the Director of Nurses (DON) and the Risk Manager (RM) on [DATE] beginning at 2:30 p.m . The DON confirmed that the resident was a " DNR " and the nurses should have initiated CPR and phoned 911. The RM talked about the investigation that she had conducted into what had happened on the morning of [DATE]. She had drawn up a time line for the investigation based on the interviews she had conducted with the nurses and aides on duty on the 11 to 7 shift on [DATE] . She did not arrive at a conclusion as to why the nurses did not follow facility policy and CPR training that all nurses are to receive and maintain as a condition of employment. The DON discussed the plan of action based on the incident and reported that it included inservicing all nursing staff and ' coaching ' the nurses that were involved in not calling a code blue (administering CPR and calling 911). Review of the sign in sheets of the three inservices that were reportedly given to staff based on the incident ([DATE], [DATE], and [DATE]) did not reveal that the three aides that were working the unit on which resident #1 resided had signed as having attended any of the three of the inservices. A total of 17 nurses signed as having attended the inservices , out of a total of 34 nurses employed at that time and 2 of the 65 aides signed as having attended the inservices. Two of the three nurses who had worked the shift during which resident #1 expired had been ' coached ' - one on one training with a written warning filed in their personnel record. The third nurse, the resident ' s nurse, had not returned to work, and had not received the ' coaching ' . 10.The Corporate Nurse, on [DATE] at 3:15 p.m. when asked about facility requirements related to nurses being CPR certified , reported that the licensed nurse ' s job description required maintaining active certification. . Review of the Licensed Nurse job description, (updated [DATE]), revealed the second bullet point under the Job Requirements listed " Must have a current / active CPR certification. " The Human Resources Director (HRD) , on [DATE] at 3:00 p.m. provided her audit of nurses ' CPR certification. Of the 30 current nurses on staff, the HRD had the current CPR cards for 15 of the nurses. 11. The DON also reported that another step in their action plan was to list advanced directives on a ' shift sheet ' for easy referral for the nurses. She described the ' shift sheet ' as a document that captured information about the residents that occurred during the three shifts. This information could easily be provided to the next shift, and who could continue to document any changes or information about the residents. Review of the shift sheets for the 200 wing revealed a sheet of paper with four columns - the first column documented the resident ' s name , room number, and in the corner either " full " or " dnr " , indicating the advanced directive. Both nurses on the 200 wing, on [DATE] at 3:50 p.m.were able to identify this new intervention and both of their shift sheets contained the information about the residents. The two nurses questioned on the 100 hall (on [DATE] at 3:45 p.m.) about the inclusion of the advanced directive information on the shift sheet denied having seen that information on the shift sheets. One nurse (employee B) reported, at that time, that advanced directive information was contained in the resident ' s medical record, not the shift sheet. The unit manager , at that time, was questioned about including the advanced directive information on the shift sheets and she reported that they hadn ' t been including it on their wing ' s shift sheets. 12. Interview with the Administrator on [DATE] beginning at 4:30 p.m. confirmed that on [DATE] at the Quality Assurance meeting there had been a discussion about the incident that had occurred on [DATE] in which resident #1 was not provided CPR per her wishes. The Administrator reported that the Medical Director reviewed the resident ' s chart at the meeting and the action plan to inservice staff had been discussed as well. The Administrator reported that in the May meeting, held on [DATE], there was no discussion of the incident and monitoring of the action plan, as the staff felt it had been resolved. The Administrator reported that the staff at the meeting in April had discussed the incident and determined it was an isolated event, isolated to only that one nurse . When it was pointed out to him that actually it was not isolated, as there were three nurses on duty and six aides, none of which attempted to honor the resident ' s wishes of wanting to be resuscitated, he agreed and said that was why they had inserviced all staff that had worked that night. The Administrator also reported that the incident had not been reported to the State agency. The Administrator was not aware that not all of the nursing staff had been inserviced and was not aware that one of the two nurses wings, actually the wing where the incident had taken place, was not implementing the action plan of including advanced directives on the shift sheets. There was no documentation indicating that the action plan had been monitored. He was also not aware that only half of the nurses had active CPR certification, per the facility audit. 13..In an interview with the Medical Director, on [DATE] beginning at 11:30 a.m., it was revealed that he had been made aware of the incident that occurred in the morning of [DATE]. He reported that he was also aware of the inservicing related to the incident because that been discussed at the QA meeting. He confirmed that the medical record had been reviewed at the QA meeting, but added that " who knows what those nurses were thinking. " He did not say that any cause analysis had been conducted as to the reason for not administering CPR and phoning 911. The Medical Director reported that the issue had not been discussed at the next QA meeting. 14. During the revisit to remove the immediate jeopardy on [DATE] a record review was conducted of the facility's most recent QA meeting agenda and sign in sheet when the committee reviewed the Allegation of Removal of Jeopardy and current progress with ongoing compliance.