Every finding on record at Vivo Healthcare Winter Haven

Based on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) staffing data for the first quarter in the Fiscal Year 2025. Findings Included: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed there was no facility staffing data submitted for the period of October 1 to December 31 (FY Quarter 1 2025). During an interview on 04/10/2025 at 10:05 a.m., the Nursing Home Administrator (NHA) stated he had nothing to do with PBJ and was not aware they had triggered for not reporting PBJ data for Quarter 1. He stated they used a third party company who submitted their PBJ staffing hours. He stated he could pull the [NAME] report to view the hours but rarely looks at it. The facility did not have a policy or procedure on the expectaions of reporting PBJ staffing hours.

Based on interviews and records reviewed, the facility failed to developed and implemented action plans to correct identified quality deficiencies; measure the success of actions implemented and track performance to ensure improvements are realized and sustained, track medical errors and adverse events, analyze their causes, and implement preventive actions and mechanisms, conduct at least one Performance Improvement Plan (PIP) annually that focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis, and did not ensure the QAA Committee regularly reviews and analyzes data collected under the QAPI program and resulting from drug regimen reviews, and act on the data to make improvements. The Findings Included; Record review of the facility's policies and procedures titled Quality Assurance and Performance Improvement dated 9/2023 revealed: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. 2. The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member or other individual in a leadership role; and iv. The Infection Preventionist. b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. c. Develop and implement appropriate plans of action to correct identified quality deficiencies. d. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. e. The QAA committee must sign to verify approval of all plans of correction written. 3. The QAPI plan will address the following elements: a. Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions. b. Policies and procedures for feedback, data collection systems, and monitoring. c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i. Tracking and measuring performance. ii. Establishing goals and thresholds for performance improvements. iii. Identifying and prioritizing quality deficiencies. iv. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. d. A prioritization of program activities that focus on resident safety, health outcomes, autonomy, choice and quality of care, as well as, high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves. The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified. e. A commitment to quality assessment and performance improvement by the governing body and/or executive leaders. f. Process to ensure care and services delivered meet accepted standards of quality. 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: a. The written QAPI plan. b. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. c. Data collection and analysis at regular intervals. d. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 5. The plan and supporting documentation will be presented to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request. 6. The plan and supporting documentation will be presented to Centers for Medicare & Medicaid Services (CMS) upon request. Program Development Guidelines: 1. Program Design and Scope - a. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. b. At a minimum, the QAPI program will: i. Address all systems of care and management practices. ii. Include clinical care, quality of life, and resident choice. iii. Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility (SNF) or Nursing Facility (NF). iv. Reflect the complexities, unique care, and services the facility provides. 2. Governance and Leadership - a. The governing body and/or executive leadership is responsible and accountable for the QAPI program. b. Governing oversight responsibilities include, but are not limited to the following: i. Approving the QAPI plan annually, and as needed. ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities. iii. Ensuring the program is sustained during transitions in leadership and staffing. iv. Ensuring the program is adequately resourced, including ensuring staff time, equipment, and technical training as needed. v. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. vi. Ensuring that corrective actions address gaps in systems, and are evaluated for effectiveness. vii. Setting clear expectations around safety, quality, rights, choice, and respect. c. The QAA Committee shall communicate its activities and the progress of its subcommittee activities to the governing body (if leadership role is greater than the administrator) at least quarterly, with a formal meeting no less than annually. d. The QAA Committee shall submit supporting documentation of ongoing QAPI activities to the Governing Body upon request. e. QAPI training that outlines and informs staff of the elements ofQAPI and goals of the facility will be mandatory for all staff. 3. Program Feedback, Data Systems, and Monitoring - a. The facility maintains procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. b. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. Data sources may include, but are not limited to: The facility assessment. ii. Paper and electronic medical records. iii. Grievance logs. vi. Medical record audits and drug regimen reviews. v. Skilled care claims. vi. Clinical logs such as for falls, pressure injuries, and weights. vii. Staffing trends. viii. Incident and accident reports. including reports of adverse events or abuse, neglect, or exploitation. ix. Minimum Data Set (MDS). x. Quality measures. xi. Survey outcomes. xii. Staff. resident and family satisfaction surveys. xiii. Suggestions. c. Data is collected from all departments and is used to develop and monitor performance indicators. i. Facility staff are responsible for following departmental procedures for data collection. ii. Department heads are responsible for ensuring data is collected appropriately and performance metrics are monitored in accordance with facility policy. iii. Sample data collection forms are maintained with the written QAPI plan. 4. Program Activities - a. All identified problems will be addressed and prioritized, whether by frequency of data collection/ monitoring or by the establishment of sub-committees. Considerations include, but are not limited to: i. High-risk, high-volume, or problem-prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice, health equity, and quality of care. iv. Certain classes of medications, such as antipsychotics, which could identify trends. b. Medical errors and adverse events are routinely tracked. i. Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event. ii. An investigation will be conducted on each identified medical error or adverse event to analyze causes. iii. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education. iv. Monitoring will be conducted to ensure desired outcomes are achieved and sustained. c. The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Additional projects may be conducted as needed, and may be clinical or non-clinical in nature. i. The number and frequency of improvement activities conducted shall reflect the scope and complexity of the facility's services as reflected in the facility assessment. ii.PIPS shall be designed to achieve and sustain performance improvement over time and to have an expected favorable outcome. iii. The QAA Committee shall select additional members to participate in various subcommittees based upon the PIP topic and participant expertise. iv. Each sub-committee shall be guided by a QAA Committee member who will facilitate coordination of the PIP and ensure each sub-committee is adequately resourced. v. Upon conclusion of the PIP, the sub-committee shall provide the QAA Committee with a report, which contains a summary and analysis of activities and recommendations for improvement. 5. Program Systematic Analysis and Systemic Action - a. The facility takes actions aimed at performance improvement as documented in QAA Committee meeting minutes and action plans. Performance/success of the actions will be monitored and documented in subsequent QAA Committee or sub-committee meetings. b. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with the QAPI plan, but no less than annually. During an interview on 04/10/25 at 03:24 PM the Nursing Home Administrator stated the facility had a QAPI/QAA program that met at least once a month; on the last Tuesday of every month. The participants included the Director of Nursing (DON), The Medical Director, and other Interdisciplinary Team members. Participants included all department heads including the Maintenance Director and the Housekeeping Director. The NHA stated he was not able to show signature pages or any other documentation related to the meetings as the QAPI/QAA book is missing, and does not know where the book is currently.

Based on observations, record review, and interviews, the facility failed to implement an effective infection control program related to 1.) initiating contact precautions for one resident (#154) of one resident suspected and treated for a highly contagious condition, 2.) failed to clean shared equipment appropriately and store it in a sanitary manner, and 3.) failed to promote good hand hygiene by limiting the length of fingernails of direct care staff. Findings included: 1. Review of Resident #154's Admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses of diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #154's Medication Administration Record on 4/7/25 at 3:30 p.m. revealed the following: - Saccharomyces boulardii - 2 capsules by mouth two times a day for gastrointestinal (GI) support for 14 days, started on 4/2/25. - Flagyl 500 milligram (mg) - Give 500 mg by mouth three times a day for possible C-diff (Clostridioides difficile) for 10 days, started on 3/31/25. On 4/7/25 at 3:56 p.m., the door and immediate area to Resident #154's room did not reveal signage indicating the resident was under transmission-based precautions. Personal Protective Equipment (PPE) was not observed outside of the resident's room. Review of the Resident Matrix, printed by the facility on 4/7/25, did not show any resident in the facility was on transmission-based precautions. Review of Resident #154's Order Summary Report dated 4/10/25 did not reveal physician orders for any type of precautions. The review revealed staff were to check stool for C-diff one time only for multiple loose stools until 3/31/25 23:59 [11:59 p.m.]), which was documented as completed on 3/31/25. Review of a provider note, dated 4/2/25 at 1:00 a.m. showed the resident was to receive Flagyl 500 mg three times a day for possible C-diff for 10 days from 3/31/25 to 4/10/25. The note revealed on 3/28/25, the resident reported some loose stools this morning and noted it was going on for 3-4 days. On 3/31/25, the provider noted the resident reported continuing loose stools and thought she had 2-3 loose stools the previous night. On 4/2/25, the resident reported having 5 episodes of diarrhea that day and 4 the previous day and the C-diff stool study was pending. Review of Resident #154's progress notes showed a stool sample was collected on 4/1/25. Review of Resident #154's laboratory results did not reveal any results or pending results for the resident's completed stool collection. During an interview on 4/10/25 at 9:38 a.m., the Director of Nursing (DON) stated until they get the culture back, they treat prophylactically and do not use precautions until it's determined by the culture, stating it's the facility policy. Review of Resident #154's Certified Nursing Assistant (CNA) Task documentation for bowel elimination revealed three available questions - bowel continence, size of bowel movement (BM), and consistency of BM. Staff documented the resident was incontinent of bowel when appropriate from 3/26/25 to 4/10/25 with one incident of continence on 4/10/25. Review of Resident #154's care plan showed the resident was on antibiotic therapy related to (r/t) infection C-diff, initiated on 3/28/25 and instructed staff to report pertinent lab results to the physician. During an interview on 4/10/25 at 10:09 a.m., Staff S, CNA stated Resident #154 was having semi-formed stools, not runny today, but in the past stools have been runny. Staff S, CNA reported the resident has not been on any type of precautions and asked about it when the resident was having loose stools but did not get any further information. The staff member stated staff are notified of precautions usually by signage, the PPE caddy hanging from the door, and the nurse. During an interview with the DON on 4/10/25 at 3:01 p.m. regarding infection control, the DON stated the determination of needed isolations was based on the strand of the organism and determined the strand usually by culturing. If a culture isn't obtained, sometimes the doctor will order an antibiotic prophylactically depending on symptoms, McGeer's criteria, and how the doctor orders them. The DON stated staff are to handwash when hands were visually soiled and every other time between alcohol-based hand rub, if C-diff staff have to wash hands. She stated if Resident #154 was not on isolation, the negative outcome would be staff could contract and spread it. She reported some of the resident's lab results came back but the stool results were pending. In morning meeting lab results are reviewed. Floor nurses, the DON, and Unit Managers can obtain lab results. Review of the policy titled Transmission-Based (Isolation) Precautions, implemented 9/2023, revealed under Policy, it is the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. The policy defined contact precautions as: Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. The policy revealed the following under Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Centers of Disease Control and Prevention (CDC), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. 4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. 6. High touch objects and environmental surfaces (e.g., bed rails, over bed table, bedside commode, lavatory surfaces in resident bathrooms) should be cleaned and disinfected with an EPA (Environmental Protection Agency) registered disinfectant for healthcare use at least daily invisibly soiled. 7. Visitors coming in to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident. 9. Initiation of transmission-based precautions (isolation precautions) - a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. b. An order for transmission-based precautions/ isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. c. The order for transmission-based precautions/ isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. 10. Contact precautions - a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the residence environment. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the residence environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., . C difficile, noroviruses and other intestinal tract pathogens, .). e. Residents experiencing with wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions even before a specific organism has been identified. 12. Discontinuation of transmission-based precautions (Isolation Precautions)- a. Transmission-based precautions remain in effect for limited periods (i.e., while the risk of transmission of the infectious agent persists or the duration of the illness). b. Empirically initiated transmission-based precautions may be adjusted are discontinued when an additional clinical information becomes available (e.g., confirmatory laboratory results). 2. On 4/8/25 at 4:06 p.m., Staff Q, Licensed Practical Nurse (LPN) was observed during medication administration for Resident #98. The staff member removed the resident's individual glucometer from the medication cart. After obtaining a blood glucose level reading, the staff member opened a container of disinfectant wipes, which she brought into the room, and placed on the resident's over-bed table (obt), wiped the glucometer, and placed the meter directly on the resident's obt without a barrier. Staff Q, LPN placed a blood pressure cuff on the resident's right arm, obtained blood pressure of 143/78, wiped the cuff and monitor with a disinfectant wipe, and placed both on the resident's obt without a barrier. Staff Q, LPN removed the container of wipes and placed it in the bottom drawer of the cart. The staff member removed a clear bag containing a temporal thermometer and pulse oximeter, placing the thermometer against the resident's temple before placing it back into the bag and placing it in the bottom drawer. Immediately following the medication observation, Staff Q, LPN stated disinfection was done to get rid of stuff, she confirmed the cuff was contaminated and not cleaning the thermometer. Review of the policy titled Routine Cleaning and Disinfection, implemented 9/2023, revealed under Policy, it was the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment, and to prevent the development and transmission of infections to the extent possible. 3. On 4/8/25 at 4:06 p.m. Staff Q, LPN was observed with square-cut fingernails painted a light purple color on 8 of 10 fingers extending one half to three quarters of an inch past the end of the fingertips. The staff member confirmed the fingernails were acrylic and the nails on bilateral pointer fingers had broken off. The staff member was observed having difficulty removing the green tags on the emergency drug kit and opening a container of disinfectant wipes. On 4/8/25 at 5:18 p.m., Staff R, LPN was observed during medication administration. The staff member had square-cut fingernails, painted pink with black stripes, on eight of the ten fingers extending approximately one quarter of an inch past the end of each finger. On 4/9/25 at 4:48 p.m., the Director of Nursing was observed with almond-shaped fingernails painted with white tips extending approximately one quarter of an inch past the fingertips. An interview was conducted with the DON on 4/10/25 at 10:20 a.m. The DON stated anyone providing care should have clean, short fingernails, including the DON. A request was made to the facility on [DATE] for the Dress Code policy. The policy was not provided. Review of the Centers of Disease Control and Prevention (CDC) guidance - Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, directed the guidance to Protect yourself and your patients from deadly germs by cleaning your hands. The recommendations for treating a patient with confirmed or suspected C. difficile infection showed C. diff is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are an inactive form of the germ and have a protective coating allowing them to live on surfaces for months. When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. Current evidence demonstrates that C. difficile spores may not be fully removed from hands, regardless of the method used to clean hands. This further emphasizes the need for appropriate use of gloves for the care of patients with CDI. The CDC recommendations for maintaining fingernail and jewelry safety revealed the following: - Natural nails should not extend past the fingertip. - Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive-care units or operating rooms. - Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing.

Based on observations, record reviews, and interviews the facility failed to establish an effective antibiotic stewardship program related to the antibiotic use protocols and monitoring the use of antibiotics. Findings included: Review of February 2025's Infection Control Log, 2/1 to 2/28/25, showed the facility had a total of 7 infections effecting 7 residents for the month. The log revealed the facility had 3 Urinary Tract Infections (UTIs), one mouth, one eye, one acute kidney injury, and one leg cellulitis infections. Five of the infections listed did not include an onset date, two of the UTIs were cultured with no information related to culturing for three of the infections (yes or no), two of the three UTIs had organisms listed, five of the list did not show whether the infection required isolation or not or if they were Healthcare-Associated Infections (HAI). Six of the seven infections did not show a resolution date. The section of the log used to document the total number of infections (skin, eye, UTI with catheter, Urinary Tract, Upper Respiratory, Lower Respiratory, Gastrointestinal, other) was not completed and did not reveal a date the information was reported to the Infection Control/Performance Improvement Committee. Review of February 2025 Monthly Resident Infection Analysis showed one of the two facility units had 2 nosocomial (originated in hospital) and the other unit had four nosocomial infections for a total of six infections. The analysis did not show any infections were community-acquired or if there were any residents with repeat infections in the last 30 days. The number of infections by type listed one E.coli, one Cellulitis, and one other. The analysis did not show infections by site or if any sites required isolation precautions. The Infection Preventionist signed the form on 3/2/25 however there was no Director of Nursing signature. Review of March 2025 Infection Control Log, 3/1 to 3/31/25, revealed the facility had 10 UTIs, one skin rash, one case of shingles, one upper respiratory infection (URI), 2 cases of bronchitis, one case of pneumonia, a total of sixteen infections. The incomplete log did not include admitted s for thirteen of the residents listed, only four infections had onset dates listed. The log showed four of the ten UTIs had been cultured, and no x-rays had been completed to diagnosis the four respiratory infections. The URI infection was listed with the organism of Respiratory Syncytial virus (RSV), which showed the effected had been isolated but did not reveal if the infection was HAI or community acquired. The log showed information for four of the sixteen infections had required isolation or not, no information related to HAI, if any infection had been recultured or the date any of the sixteen infections had resolved. Nine of the sixteen infections had the name of the ordered antibiotic listed. The log did not break down any infections per site or the date the information had been reported to the Infection Control/Performance Improvement Committee. An interview was conducted on 4/10/25 at 10:20 a.m. with the Director of Nursing (DON) as the Infection Preventionist, (IP) was unavailable. The DON reported for a newly ordered antibiotic the facility would request a culture to support the antibiotic, contact the physician to ensure it was the correct antibiotic also, use the culture to ensure the antibiotic was appropriate, if appropriate to continue or change. The facility used McGeer criteria which is documented in a book not in the electronic record. The facility does an infection line listing and maps infections monthly. The IP presents info to the Quality Assurance committee, there were no trends for March. A continued interview was conducted on 4/10/25 at 3:01 p.m. with the DON. The DON stated the IP had the position for 6 months and both her and the IP had completed Centers for Disease Control and Prevention (CDC) training. The DON stated isolation was determined by the strand of organism, the facility does not get a culture for all of infections, sometimes the doctor will order an antibiotic prophylactically. The facility determined appropriateness by symptoms, McGeer's criteria and how the doctor orders them. The DON confirmed ordering doesn't follow the antibiotic stewardship. The DON stated the Medical Director doesn't usually order antibiotics unnecessarily and neither of the two in-house physicians order antibiotics prophylactically. The DON was asked for the facility's antibiotic utilization rate and she reviewed the Monthly Resident Infection log and stated both units had a total of 9 infections, after pausing a few minutes the DON reported each (two) units had 9 infections. The DON reviewed March Infection Control Log that showed multiple UTIs had not been cultured, she stated at that point without cultures the doctors were treating prophylactically. When a resident is admitted or readmitted the culture should be requested from the hospital to determine if the antibiotic is appropriate. She stated the incident of shingles was to be reported but did not know if it was and it would be reported to the Centers for Disease Control (CDC). The DON reported when a resident comes from the hospital, the facility would request culture results, would reconcile it with the physician and the doctor confirms if the antibiotic is appropriate. The charts are reviewed during morning meetings which included the IP. The IP reaches out to the physician to ask if the antibiotic is appropriate. The DON confirmed the IP had not been doing McGeer criteria during her tenure, the last McGeer criteria completed was in September 2024. The DON stated there was no evidence that the IP followed up on antibiotics, as there was no documentation with the physicians or QA to review. Review of the policy - Antibiotic Stewardship Program, implemented 9/1/23, revealed the following: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 1. The infection preventionist, with oversight from the director of nursing, serves as the leader of the antibiotic stewardship program and receives support from the administrator and other governing officials of the facility. a. Infection Preventionist - coordinates all antibiotic stewardship activities comma maintains documentation comma and serves as a resource for all clinical staff. b. Director of Nursing - serves as backup coordinator for antibiotic stewardship activities, provides support and oversight, and ensures accurate advice adequate resources for carrying out the program. c. Administrator - provides adequate resources for carrying out the program and ensures review of the antibiotic use and resistance data at QAPI meetings. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Laboratory testing shall be in accordance with current standards of practice. ii. The facility uses the (CDC NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. iii. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. b. Monitoring antibiotic use: i. Monitor response to antibiotics common in laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review as requested by the QAA committee. v. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). vi. Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotics timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/ or work plans associated with the program. b. Assessment forms. c. Antibiotic use protocols/ algorithms. d. Data collection forms for antibiotic use, process, and outcome measures. e. Antibiotic stewardship meeting minutes. f. Feedback reports. g. Records related to education of physician ,staff, residents, and families. h. Annual report. 12. Data obtained from antibiotic stewardship monitoring activities as discussed in the facilities QAPI meetings.

Based on interview, observation, and record review, the facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three Wings/Common areas (100, 400 and 600) of six Wings toured. Findings included: On 4/8/2025 at 12:40 p.m., 4/9/2025 at 09:50 a.m., and on 4/10/2025 at 10:10 a.m. the following was observed: Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with unfinished walls near the TV and bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed without a call light pulling string in the bathroom. Resident room [ROOM NUMBER] was observed with broken drawers. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with no call light system in the bathroom. Resident room [ROOM NUMBER] was observed with a broken toilet. Resident room [ROOM NUMBER] was observed with pest feces in the shower. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat, unpainted walls near the TV and baseboards missing near the air conditioner. Resident room [ROOM NUMBER] was observed with brown, rough surfaces in the bathroom walls and over the toilet seat. Resident room [ROOM NUMBER] was observed with no paint on the walls near the TV and no light in the bathroom. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat, and no call light in the bathroom. Resident common areas in the 100 Wing were observed with bio growth on the ceiling near the nurses station in the sitting area. The common area in the 400 Wing was observed with bio growth on the ceiling near the nurses station and the ceiling tiles hanging loose in the sitting area. The 600 Wing hallway was observed with bio growth in the light at the end of the hallway and also near the sprinkler head in the same area. On 4/10/25 at 11:08 a.m. an interview was conducted with the Director of Maintenance (DOM). The DOM stated he walked the facility daily and if he saw an issue, he resolves it immediately or enters it into the electronic maintenance work order system. He stated the staff also enters issues into the electronic maintenance work order system, and he reviews the system for additions on a daily basis if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Nursing Home Administrator (NHA). The DOM stated he tries to get issues fixed immediately and if he can't get it accomplished, he has his assistant who fixes it and keeps a log with emails correspondence. The DOM stated he does not have a written policy regarding daily, weekly, monthly or annual maintenance. He stated it is directed through the electronic maintenance work order system. The DOM stated he did not have a bio growth policy. He stated if he suspected bio growth, he would clean the area and watch it. Review of an undated facility document titled, Patch and paint revealed twenty-two resident room walls were patched without paint. Review of an undated facility document titled, electronic maintenance work order system task manager, did not show a task manager for maintenance of walls, floorboards or resident equipment was in place. Review of an undated facility document titled, Work Orders showed no orders addressing the walls or floorboards or bio growth or the falling ceiling. Review of a facility policy titled, Routine Cleaning and Disinfection policy, dated 9/2023 Reviewed by Clinical Services, showed it is the policy of this facility to ensure the provision of routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Cleaning refers to the removal of visible soil from objects and surfaces, transmission-based precautions refers to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Photographic evidence obtained.

Based on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for 3 of 5 months reviewed and two (#19 and #69) of 52 total residents sampled. Findings included: 1. Review of the Resident Council Minutes dated November 18, 2024 showed: New Business: Current Situation Weekend Call lights long response time 11-7 and Customer Service. Review of Resident Council Minutes dated 2/12/205 showed: New Business: Current Situation To long to answer call lights 11-7. Review of Resident Council Minutes dated 3/13/2025 showed: New Business: Current Situation call lights. During the Resident Council Meeting on 4/8/25 at 2:30 p.m., Resident Council stated call lights and staff assistance continue to be a problem, especially on evenings and weekends. A review of the Grievance Logs from November 2024 to March 2025, revealed an absence of grievance issue concern on behalf of the Resident Council. An interview was conducted on 4/8/25 at 3:49 p.m. with the Activity Director (AD). The AD stated the residents request for her to assist with the council minutes. Part of these duties was reviewing the residents concerns with the Social Service Director (SSD) who was also the Grievance Coordinator. The AD stated Resident Council has had multiple call light recurrences of residents not receiving assistance, the SSD writes the grievance and I let Resident Council know the issue is resolved. During an interview on 4/8/25 at 4:46 p.m. and follow up interview on 4/9/25 at 11:55 a.m. with the SSD the grievance process was reviewed. The SSD stated once the grievance was received, it was logged in by social services. The SSD said I take the grievance to our morning meeting for discussion, at which all managers, including the Administrator, were in attendance. We decide who would be responsible for investigating the grievance and that manager takes the grievance to complete the investigation, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form was returned to social services. The SSD stated we like this process to occur within three to five days. The SSD reported noticing an issue with call lights and customer service, especially for nights and weekends stating, we should definitely do better with this. The SSD confirmed not seeing any grievances from Resident Council recorded on the log. 2. Review of a grievance dated 3/10/25 for Resident #69, revealed the grievance was filed by the resident related to not receiving staff assistance. The investigative section of the report showed Nurse Aide in dining room for lunch. The notification of the representative section was blank. During an interview on 4/8/25 at 2:29 p.m. during the Resident council meeting Resident #69 stated she continued to have difficulty in receiving staff assistance. Review of Resident #69's Cognitive Pattern assessment dated [DATE] showed the resident was cognitively intact with a score on the Brief Interview for Mental Status (BIMS) of 15 out of 15. 3. Review of a grievance dated 2/6/25 for Resident #19, revealed the grievance was filed by the Resident, related to not receiving staff assistance and maintenance of an air mattress. The investigative section of the report showed Maintenance changed mattress, nothing was noted regarding staff assistance. The date resolved section was blank. During an interview on 4/7/25 at 10:14 a.m., Resident #19 stated continued difficulty in receiving staff assistance. Review of the Admission Record for Resident #19 showed an original admitted in April of 2024 and a readmitted on 2/27/25. The Admission Record included diagnoses of multiple sclerosis, depression, diabetes mellitus, and quadriplegia. Review of Resident #19's Cognitive Pattern assessment dated [DATE] showed the resident was cognitively intact with a score on the Brief Interview for Mental Status (BIMS) of 15 out of 15. An interview on 4/9/25 at 12:20 p.m. was conducted with the Nursing Home Administrator (NHA). The NHA stated grievances were brought to morning meeting for discussion and the appropriate department manager followed through with the grievance and the SSD ensured completion. The NHA stated the facility noted a call light response issue about four months ago. The facility decided to add a Certified Nursing Assistant (CNA) to the 3 p.m. to 11 p.m. shift to assist with new admissions, labeling clothing, and assisting with call lights. The NHA was not aware of further issues. Review of the facility's policies and procedures titled Resident and Family Grievances, with a revision date of 4/29/2024 revealed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: . 2. The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; coordinating any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 7. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Officer. b. Written complaint to a staff member or Grievance Officer. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Compliance Line (if applicable). 10. Procedure: a. The staff member receiving the grievance Will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. ii. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. b. Forward the grievance form to the Grievance Officer as soon as practicable. c. Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Officer. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. iii. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. d. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. e. The facility will take appropriate action in accordance with State law if an alleged violation of resident's rights is confirmed by the facility or an outside entity, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency. f. If resident observes his/her rights and requests a written response it will contain the following: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. g. For investigations regarding allegations of neglect, abuse, Injuries of unknown source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State law, within five working days of the incident. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances. 13. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 14. The facility will make prompt efforts to resolve grievances. 16. If the Resident/Responsible Party or concerned parties' express dissatisfaction with resolution the following may be indicated: a. Setting up a Special Care Meeting b. Appointing an On Going Partner c. Notify the Attending Physician and Medical Director when appropriate. 17. All Grievances should be documented on the Grievance Log and maintained per retention policy. 18. Trended issues should be addressed in center Quality Assurance/Risk Management meeting by the Grievance Officer and discussed with the Center Clinical Risk Manager. 19. The center's appointed Grievance Officer shall receive formal and documented in-servicing on how to conduct an appropriate center investigation for timely grievance resolution.

Based on record review and interviews, the facility failed to maintain accurate Pre-admisson Screening and Resident Review (PASRR) screenings for eight residents (#2, # 67, #64, #83, #57, #26, #20, and #81) out of 52 residents sampled. Findings included: 1. Review of Resident #2's admission record revealed an admitted [DATE], with diagnoses to include Other Bipolar Disorder, Major Depressive Disorder, Single Episode, Unspecified. Review of Resident #2's Level I PASRR, dated 03/15/2025, showed the Level I PASRR was missing diagnoses including Bipolar Disorder and Major Depressive Disorder. A rescreen was not perfomred by the facility to include these diagnosis and assess if a Level II screen wuld be needed. 37999 2. Review of Resident #81's Admission Record showed the resident was admitted on [DATE], 9/3/24, and 2/10/25. The record revealed the resident's primary diagnosis with an onset date of 8/15/24 was unspecified Alzheimer's disease, other diagnoses included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 2/10/25), unspecified anxiety disorder (onset 11/22/24), mood disorder due to known physiological condition with mixed features (onset 11/19/24), and unspecified depression (onset 9/18/24). Review of Resident #81's care plan revealed the resident had a behavior problem related to (r/t) combative toward staff both physical and verbally, exit seeking, wander in resident's room(s), bit a couple of staff members (and) resident slapped another resident. The focus was initiated on 9/26/24 with a goal of fewer episodes of behaviors (target date 6/16/25). Review of Resident #81's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 8/13/24, did not show the resident had any Mental Illness (MI) or suspected Mental Illness (SMI) and had no history of receiving services for MI. The decision-making section did not show the resident had exhibited actions or behaviors that may make them a danger to themselves or others and did not have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The PASRR did show the resident did have a secondary diagnosis of dementia, related neurocognitive disorder, and the primary diagnosis of a SMI or Intellectual disability. The screening showed the resident did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR was not required. Review of Resident #81's PASRR was not updated to include mental illness diagnoses documented after the screening was completed and did not show the resident's primary diagnosis was unspecified Alzheimer's disease. 3. Review of Resident #57's Admission Record revealed the resident was admitted on [DATE] and 3/29/24. The record revealed the resident had a secondary diagnoses of unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 3/29/24), and unspecified cerebral palsy (11/2/23). Review of Resident #57's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 12/6/23 and completed by the facility's Director of Nursing (DON), showed the resident had diagnoses of anxiety, depression, and schizoaffective disorders. The screening did not reveal the resident had the Intellectual Disability (ID) related condition of Cerebral Palsy. Review of Resident #57's PASRR revealed the facility did not update accurately related to not including the diagnosis of Cerebral Palsy in the resident's screening. 4. Review of Resident #64's Admission Record revealed the resident was admitted on [DATE] and 4/2/25. The record revealed diagnoses not limited to unspecified depression (onset 2/25/25), and unspecified anxiety disorder (onset 2/25/25). Review of Resident #64's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 2/21/25 completed at an acute care facility prior to the resident's admission. 34768 5. Resident #67 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Alzheimer's disease, unspecified; mood disorder due to known physiological condition with mixed features. major depression, disorder single episode, unspecified, sever protein-calorie malnutrition, dysphagia, and adult failure to thrive. Review of the 01/04/2025 in Section I PASRR Screen Decision-Making A. Depressive Disorder. Mood disorder was not addressed on the PASRR. 6. Resident #26 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to polyneuropathy, acute kidney failure, nontraumatic subdural hemorrhage, chronic kidney disease, anxiety disorder, unspecified, muscle weakness, other seizures, Hypertension, anemia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview of Mental Statu (BIMS) score of 05 or severe cognitive impairment. Section O, Special Treatments, Procedures, and Programs showed on oxygen therapy. Review of the PASRR, dated 11/05/2016, showed Screen Decision Making A. SMI or suspected SMI was blank. 48223 7. Review of the Admission Record showed Resident #83 was admitted on [DATE] with diagnoses of, encephalopathy, hypertension, depression, dementia and other comorbidities. Review of Resident #83's PASRR Level I Assessment, dated 1/22/2024, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of Dementia. No Level II PASRR was completed due to the qualifying diagnoses. 8. Review of the Admission Record showed Resident #20 was admitted on [DATE] with diagnoses of osteomyelitis of vertebra, low back pain, cocaine abuse, hypo-osmolality and hyponatremia anxiety disorder, depression, and other comorbidities. Review of Resident #20's PASRR Level I Assessment, dated 06/05/2021 did not reveal a qualifying mental health diagnosis marked in section I A. nor was the characteristics of behaviors completed. No Level II PASRR was completed due to the qualifying diagnoses. During an interview on 04/10/25 at 11:48 AM, with the Nursing Home Administrator and the Director of Nursing (DON), the DON stated the hospital is to complete the PASRR prior to admission to the facility. Once admitted the Interdisciplinary Team (IDT) reviews the documentation from the hospital to include the PASRR, and determine if the information is correct. If the information is not correct then a new PASRR will be completed by the facility. The DON confirmed if a resident has a diagnosis of a mental illness or serious mental illness the diagnosis should be indicated in section IA of the PASRR, as well as if the resident has dementia. The DON stated the form should be completed accurately to reflect the resident's conditions. The expectation would be that a new PASRR would be completed to reflect the diagnosis and characteristics of the resident. Review of the facility's policies and procedures titled Resident Assessment - Coordination with PASRR Program dated 9/1/2023 revealed: Policy: 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. Policy Explanation and Compliance Guidelines: 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 I Screen -- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level Il evaluation prior to admission. b. PASARR Level Il -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 the 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. 3. A record of the pre-screening shall be maintained In the resident's medical record. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level Il determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 8. Any level Il resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. 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 Il 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 and 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 follow the comprehensive person-centered care plans for three (#26, #38, and #7) of 52 sampled residents. Findings included: 1. An observation on 04/07/2025 at 10:25 a.m revealed Resident #38 sitting in his room in his bed. The head of the bed was elevated. His un-bagged nebulizer mask was laying on the overbed table. The nebulizer machine was off. He stated the nurse brought in medicine for his machine and left. Resident #38 stated he took it off after it was finished. He stated the nurse did not stay with him. An observation on 04/07/2025 at 11:26 a.m revealed Resident #38's un-bagged nebulizer was still laying on the overbed table. An observation on 04/08/25 at 8:58 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. The nebulizer mask was in a plastic bag on the overbed table. The oxygen concentrator was set at 3.5 liters per minute. An observation on 04/09/2025 at 10:30 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. His nebulizer mask was sitting on top of a plastic bag. The nebulizer machine was off. His oxygen concentrator was set at 1.5 liters per minute. During an interview on 04/09/2025 at 10:46 a.m. with Staff P, Licensed Practical Nurse (LPN) she verified Resident #38's oxygen was set at 1.5 liters instead of 2 liters per minute as per the physician orders. Staff P, stated the oxygen setting was supposed to match the physician orders. She stated she entered the room and put the nebulizer mask in the plastic bag. Staff P stated, No, I did not stay with [Resident #38] the whole time he was on his nebulizer. Staff P stated she brought his (oral) medications in including his nebulizer medication. She stated she brought in his roommate's medications and gave another resident (in another room) their medication. Staff P stated she just came in and put the nebulizer mask back in the bag as it was laying on the plastic bag. She stated she was not in the room the whole time he was on the nebulizer; she just came back. Resident #38 stated he did his own nebulizer treatments and turned the machine off. During an interview on 04/09/2025 at 11:38 a.m., the Director of Nursing (DON) stated they did not have anyone that was self-medicating. She stated the process for nebulizer treatments was for the nurse to check the lung sounds, put the medications in the nebulizer cup, put the mask on the resident's face, stay with the resident, when the resident was finished, take the mask off, check the lung sounds, rinse the mask and put it back in the plastic bag. If the resident was giving his own nebulizer treatments, he should have an order to self-medicate, assessment for self-medications and care planned for such. The DON stated they did not have an order for self-medication for Resident #38 nor had anyone assessed him. The DON stated they should be following the physician order for the number of liters of oxygen Resident #38 was to receive. If the order was for 2 liters the oxygen concentrator should be on 2 liters not 1.5 liters. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Section GG Functional Abilities showed dependence on eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the active physician orders as of 04/10/2025 showed, Oxygen at 2 liters per minute continuous via nasal cannula (O2@2 lpm (liters per minute) continuous via N/C) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 8 hours as needed for Shortness of Breath (SOB) Review of the physician orders showed none regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML every 8 hours as needed for SOB was administered 2 to 3 times a day. Review of the assessments showed no documentation regarding assessing Resident #38 for self-medicating of nebulizer treatments. Review of the care plans for Resident #38 showed, At risk for impaired respiratory status related to COPD, bronchitis as of 03/20/2025. Interventions included but not limited to administer medications as per order, administer oxygen as per order, and administer respiratory treatment as directed. Monitor lung sounds as ordered. Check lung status including lung sounds as indicated, all initiated as of 03/20/2025. . 2. Observation on 04/07/2025 at 10:06 a.m. showed Resident #26 was lying in bed sleeping. Her gastrostomy tube feeding was infusing at 70 cc per hour. Her oxygen concentrator was set at 1.5 liters per minute. She had her nasal cannula in place. An observation on 04/07/25 at 4:52 p.m. showed Resident #26 was lying in bed asleep. Her oxygen concentrator was set at 1.5 liters per minute. An observation on 04/08/2025 at 8:55 a.m. showed Resident #26 was lying in bed sleeping. Her oxygen concentrator was set at 1.5 liters per minute. An observation on 04/09/2025 at 10:26 a.m. showed Resident #26's oxygen concentrator was set at 2 liters per minute. Staff P, Licensed Practical Nurse (LPN) verified her oxygen was not at 2 Liters per minutes as per her orders. Staff P LPN stated the oxygen should match the physician orders. Resident #26 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to polyneuropathy, acute kidney failure, nontraumatic subdural hemorrhage, chronic kidney disease, anxiety disorder, unspecified, muscle weakness, other seizures, Hypertension, anemia, and unspecified dementia. Review of the MDS dated [DATE] showed a BIMS score of 05 or severe impairment. Section O, Special Treatments, Procedures, and Programs showed on oxygen therapy. The resident had an oxygen therapy care plan initiated on 01/14/2025. Interventions included but not limited to oxygen: O2 as ordered as of 01/14/2025. Review of the physician orders showed O2@2 lpm via N/C or (oxygen at 2 liters per minute via nasal cannula) as of 11/14/2024. Review of the Treatment Administration Record (TAR) for April 2025 showed O2@2 lpm via N/C to be monitored every shift. The following lacked documentation it was monitored: 04/02/25 on day shift; 04/03/2025 on day shift; 04/04/2025 on evening shift; and 04/08/2025 on evening shift. During an interview on 04/10/2025 at 3:57 p.m. the DON stated the care plans and physician orders for Resident's #26 and #38 should have been followed related to oxygen therapy. She verified both had not been followed. 20536 3. On 4/7/2025 at 10:30 a.m. through to at least 10:50 a.m., and 11:50 a.m. though to at least 12:30 p.m., Resident #7 was observed in her room and lying in bed with the head of the bed raised at approximately forty degrees. Resident #7 appeared with both of her upper extremities contracted. Both of her hands and fingers were in a closed position. Resident #7 was not observed wearing either splints or orthotics. There were no splints or orthotics visible in the room during the multiple visits. On 4/7/2025 at 1:00 p.m., an interview with Staff C, Certified Nursing Assistant (CNA) confirmed she had Resident #7 on her assignment for the day and that she did not know the resident well. Staff C confirmed the resident had contracted upper extremities on both sides. Staff C was not sure if the resident had splints or orthotics. On 4/8/2025 at 7:50 a.m. through to 8:10 a.m., 12:15 p.m., 1:55 p.m., and 2:58 p.m., Resident #7 was again observed in her room and lying in bed under the bed linen, with a sheet pulled up to her waistline. She was observed with her eyes closed and with both of her arms and hands folded and positioned on top of her stomach area. Resident #7 was observed during specified times without any splints/orthotics on either of her upper extremities. Both of her hands and fingers were noted in a half closed position. There were no splints/orthotics visible within the resident's room. On 4/9/2025 at 8:00 a.m., 8:55 a.m., 9:24 a.m., 9:56 a.m., 11:54 a.m., 1:00 p.m., and 3:00 p.m. Resident #7 was observed in her room and lying in bed with the HOB raised approximately forty-five degrees. The call light was observed on the bed placed within her reach, with both extremities exposed and with one positioned on her stomach, and the other to her side on the bed. Both hands and fingers appeared in a closed position. Both hands and upper extremities were without any splints or orthotics. There were no splints/orthotics visible in the room. On 4/9/2025 at 10:00 a.m., an interview with Staff F, Occupational Therapist (OT) revealed the Rehabilitation Director was not available today for interview, but she (Staff F) would try to answer any questions. Staff F revealed she knew of Resident #7 very little, but did confirm she had contractures. Staff F revealed the resident was discharged from Occupational Therapy on 1/10/2025. Staff F continued to say Resident #7 was referred to Restorative Nursing for contracture management to include utilization of splints/orthotics on her right elbow, right hand and left palm. Since Staff F was not able to say what the outcome was related to Restorative Nursing and her current contracture management. On 4/9/2025 at 12:10 p.m., an interview with Staff G, Certified Nursing Assistant (CNA), who was assigned to Resident #7 during the 7- 3 shift, revealed she had only been working the unit for about one week and did not know all the residents on the hallway to include Resident #7. She said Resident #7 was basically totally dependent on staff with most of her Activities of Daily Living (ADL). She explained as far as she knew, Resident #7 did not wear splints/orthotics. She confirmed there were no orthotics or splints in the room. On 4/9/2025 at 12:20 p.m., an interview with Staff E, Licensed Practical Nurse (LPN) , revealed she normally had the same floor hall on her routine 7-3 assignment. Staff E said Resident #7 had limited Range of Motion with upper extremity contractures. She did not know if the resident was ordered and care planned for the use of splints/orthotics for the contractures. Staff E reviewed the care plan [brand name for a summary of patient care information] on her computer and confirmed there was no documentation to support the resident was to wear splints or orthotics on either of her extremities. She reviewed the electronic medical record and found documentation indicating the resident was supposed to wear a right elbow extension splint, a right resting hand splint, and a left palm guard for 6 hours per day, 5 days a week and supplied and removed by nursing staff. She also confirmed the original order date was 2/20/2025. On 4/10/2025 at 10:15 a.m., an interview was conducted with Staff D, the 100, 200, 300 Unit Manager. She revealed she was not aware Resident #7 was not offered or donned with splints/orthotics on her upper extremities the past few days. Staff D revealed it was brought to her attention by [Staff E] yesterday afternoon on 4/9/2025. Staff D revealed she, as the Unit Manager, should have been monitoring her nursing staff to ensure care plan interventions and orders were followed; especially for those who were on contracture management, and who required use of splints/orthotics. Staff D was not sure who was responsible for donning and doffing splints/orthotics on a daily basis, but thought it was Restorative Nursing. Staff D said she had seen Resident #7 in the past wearing splints/orthotics on her left palm and right hand/arm. She could not say if Resident #7 ever had any behaviors of refusing to wear the splints/orthotics, and if she had, the nursing staff would have to report that to her so she could document the behaviors and have the Interdisciplinary Care Plan team develop a care plan problem area to identify that. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; Cognition/Brief Interview for Mental Status or BIMS score - 00 of 15, which indicated severe cognitive impairment. Behaviors - Physical bx.(behaviors) symptoms directed towards others 1 - 3 days during the 7 day assessment period; ADL - Impairment both sides upper and lower extremities, Substantial assistance to dependent on staff for most ADLs. Review of the current Physician's Order Sheet (POS) for the month 4/2025, revealed the following but not limited to orders: c. Patient will wear R elbow extension splint, R resting hand splint, and L palm guard for 6 hours per day 5 days a week a supplied and removed by nursing staff. Order date 2/20/2025). Review of the nurse progress notes dated from 12/1/2024 through to 4/9/2025 did not include any documented evidence of the resident receiving any assistance with upper extremity splint/orthotics. Nor was there documentation to support Resident #7 ever refused wearing said splint/orthotics. Review of the current care plans with next review date 5/5/2025 revealed the following but not limited to: 1. ADL Resident has a self care deficit with need for staff assistance with ADL completion on daily basis: Dx. contractures, weakness, impaired mobility, impaired cognition, Right elbow extension splint, Right resting hand splint and left palm guard. Followed by MD order, with interventions in place to include but not limited to: Patient will wear R elbow extension splint, Right resting hand splint, and Left palm guard for 6 hours per day 5 days a week as applied and removed by nursing staff. 2. Resident has limited physical mobility r/t weakness bilateral upper extremity and bilateral lower extremities with interventions in place to include but not limited to: Resident is totally dependent on 1 staff for locomotion using wheelchair, Monitoring/documenting/report PRN any signs/symptoms of immobility forming or worsening, thrombosis formation, Provide gentle range of motion as tolerated with daily care. 3. Alteration in musculoskeletal status r/t contracture to L ankle, Right ankle, R wrist, and R elbow, with interventions in place to include but not limited to: Anticipate needs, Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders and or PT treatment plan, Monitor/document/report PRN signs and symptoms or complications related to arthritis; Joint stiffness, usually worse on waking; Swelling; Decline in mobility, Decline in self care ability, Contracture formation/joint shape changes, clicking with joint movement, pain after exercise or weight bearing. 48223

Based on observation, interview, and record review, the facility failed to provide grooming assistance of shaving facial hair for four (#5, #14, #33, #46) of six residents sampled for activities of daily living (ADL). Findings included: 1. On 04/08/25 at 02:35 PM, Resident #5 was observed in Resident Council meeting with several white hairs about 1/4 inch in length on her chin. During an interview on 04/08/25 at 05:07 PM, Resident #5 stated she did not like the facial hair and hoped the facility would assist in removal. The resident stated they don't ask me. Review of the Certified Nursing Assistant (CNA) ADL task report for Resident #5 for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #5's care plan dated 1/25/25 revealed Resident #5 required supervision or touching assistance with personal and oral hygiene and partial moderate assistance on bathing/showering. 2. On 04/07/25 at 10:20 AM, Resident #14 was sleeping in bed with two patches of approximately 1/2 inch gray hair patches on each side of her chin. During an interview on 04/07/25 at 02:00 PM, the Resident Representative (RR) for Resident #14 stated the resident would not want to have whiskers; what lady wants to have whiskers? The RR said she wished the facility would take care of this. On 04/08/25 at 12:25 PM, Resident #14 was sitting up in the wheelchair with her lunch meal and still had the two patches of approximately 1/2 inch gray hair on each side of her chin. Review of the CNA ADL task report for Resident #14 for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #14's care plan dated 2/12/25 revealed Resident #14 required maximum assistance with oral hygiene and was dependent on bathing/showering. The resident had no care plan for any behaviors/rejection of care. 3. During an observation on 04/07/2025 at 10:16 a.m., Resident #33 was observed to have small patches of white hair protruding from her chin. During an observation on 04/08/2025 at 12:19 p.m., Resident #33 was observed having the same small patches of white hair protruding from her chin. Review of Resident #33's active care plans revealed no care plans for rejection of ADL care. Review of Resident #33's ADL care plan dated 3/21/2025 revealed the resident required partial/moderate assistance with bathing/showering; provide sponge bath when a full bath/shower cannot be tolerated. Review of Resident #33's CNA ADL task report for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. 4. During an observation on 04/07/2025 at 12:19 p.m., Resident #46 was observed to have a white patch of hair protruding from her chin. During an observation on 04/08/2025 at 9:23 a.m., Resident #46 was observed with a patch of white hair protruding from her chin. Review of Resident #46's CNA ADL task report for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #46's care plan initiated 8/19/22 revealed Resident #46's facial hair will be removed as desired, requires assistance of 1 with oral and personal hygiene and was dependent on staff for bathing/showering. The care plan did show behaviors of refusing showers, but did not document refusal of personal grooming. During an interview on 04/08/25 at 3:03 PM Staff W, CNA stated if a female resident has facial hair, we (staff) should shave them. During an interview on 04/08/25 at 4:10 PM Staff Y, CNA stated facial grooming was completed daily during morning care, and during bath/shower days. This included, male and female residents. Staff Y, CNA stated females should not have facial hair. We should shave them. During an interview on 04/08/25 at 4:53 PM Staff R, Licensed Practical Nurse (LPN) stated that ADL care was completed at least in the morning. ADL care included facial grooming. Female residents should not have whiskers. Staff R, LPN was not aware of any female residents who refused facial grooming. During an interview on 04/08/25 at 4:55 PM Staff AA, LPN Unit Manager stated ladies facial grooming should be included with ADL care. Staff AA, LPN did not know of any female residents who wanted facial hair and was unaware of any residents refusing to have facial hair removed. During an interview on 04/08/25 at 5:00 PM the Director of Nursing (DON) stated ADL care was all encompassing of general hygiene to include facial grooming (for both males and females). The DON reported if the resident does not want to have facial hair, it should be shaved. The DON said the resident's preference should be care planned and if the resident has behavior of refusing care, this should be care planned. The DON stated the expectation would be for resident's preferences to be followed. Review of the facility's policies and procedures titled Grooming a Resident's Facial Hair with a revision date of 7/1/2024 revealed: Policy: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Policy Explanation and Compliance Guidelines: 5. When the facial hair is covered with shaving cream and softened, begin shaving. Shave in the direction that the hair grows. Hold the skin taut and smooth by pulling the skin upward with one hand and shaving with a downward stroke with your other hand. Use short, even strokes. Be particularly careful with the neck, chin, and upper lip. Use upward strokes for the neck, downward and slightly diagonal strokes for the chin, and very short downward strokes above the lip. 8. Allow the resident to look in a mirror to make sure they are satisfied with their appearance.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty-one medication administration opportunities were observed, and fourteen errors were identified for four residents (#40, #98, #93, and #53) of six residents observed. These errors constituted a 34.15% medication error rate. Findings included: 1. On [DATE] at 8:24 a.m. an observation of medication administration with Staff P, Licensed Practical Nurse (LPN) was conducted with Resident #40. The staff member searched medication cart for a bottle of Calcium 500 milligram(mg) tablets. Staff P went to the central supply office cupboard and retrieved an over-the counter bottle before revealing the bottle was Calcium with Vitamin D and not the medication the resident was ordered. The staff member proceeded to dispense the following: - Carvedilol 3.125 mg tablet - Furosemide 40 mg tablet - Jardiance 10 mg tablet - Lisinopril 40 mg tablet Staff P confirmed dispensing four (4) tablets prior to administering the medications to Resident #40. The staff member informed the resident of owing him one calcium (tablet). Review of Resident #40's April Medication Administration Record (MAR) showed an order dated [DATE] for Calcium Oral Tablet - Give 500 mg by mouth one time a day for supplement. The MAR revealed the resident had received 500 mgs of Calcium per the physician order daily from ,d+[DATE] - [DATE]. The Director of Nursing (DON) had documented 5 on [DATE], which according to the legend Hold/See progress note. The MAR revealed the order for 500 mgs of Calcium had been discontinued on [DATE] at 9:33 a.m. and a different order was written for one tablet of Calcium 600/Vitamin D 10 microgram (mcg) to be administered one time a day for vitamin (vit) deficiency (def). The order for Calcium with Vitamin D was to start on [DATE] at 10 a.m. Review of a progress note written on [DATE] at 9:35 a.m. (1 hour 11 minutes after observation) showed the order for 500 mg of Calcium had been updated per the physician had changed the order to Calcium 600/Vit D 10 mcg. 2. On [DATE] at 4:06 p.m. an observation of medication administration with Staff Q, Licensed Practical Nurse (LPN) was conducted with Resident #98. The staff member removed the resident's glucometer and a blood pressure machine from the medication cart. The glucometer was used to obtain the resident's blood glucose level of 414 and a blood pressure of ,d+[DATE] was obtained. Staff Q removed from the top drawer of the medication cart a clear plastic bag containing a box, which the staff member removed a vial of Insulin Lispro. The plastic bag revealed the vial had been opened on ,d+[DATE] and a handwritten date revealing the insulin had expired on [DATE]. The staff member stated the insulin was good for one month and should still be good then looked at the date and confirmed it had expired on [DATE]. Staff Q searched medication cart and was unable to locate another Insulin Lispro vial or pen for Resident #98. The staff member observed the unit's medication refrigerator and reported the resident did not have any extra Humalog. The staff member returned to the medication cart and dispensed one 2.5 milligram (mg) tablet of Midodrine into a medication cup and handed it to the resident. The Midodrine blister card label had parameters to hold for systolic >140. The staff member was asked to stop, take cup back from resident, and review the physician order. Staff Q read the order aloud and stated she should not give the Midodrine but was going to contact the physician and verify the order as she felt it was wrong due to the medication was for low blood pressure. As the pharmacy delivery was standing at the nursing station during the observation with Staff Q, she stated she was going to check and see if Resident #98's Humalog was included in the delivery (which it was not). The staff member returned to the unit's medication refrigerator and removed an Insulin Lispro Kwikpen from the Emergency Drug Kit (EDK), labeling it with the resident's name and the date it was opened. The staff member returned to the resident's room, placed needle on pen, dialing the dosage selector to 16 units, saying one unit was used to prime the pen because it was new. Staff Q stood in front of the resident's trash can, pointed the needle end of the pen downwards and pushed the dosage selector, dialed the pen to 15 units and injected the resident in the right lower abdominal quadrant. The staff member called physician who confirmed the Midodrine order was correct, and it was to be held for a blood pressure greater than 140. An interview was conducted with Staff Q on [DATE] at 5:08 p.m. The staff member stated she was not going to administer the Midodrine because she was thinking about it. Then after discussing the observation, the staff member admitted that she was going to administer the Midodrine prior to being asked to stop. The staff member reported she had been educated to prime the insulin pens with one unit to get rid of the air bubble. She confirmed by holding the pen with the needle downwards the air bubble would have been toward the top of insulin cartridge and the air bubble would not have been removed. Review of Resident #98's April Medication Administration Record (MAR) revealed an order for Midodrine 2.5 mg - Give 1 tablet by mouth three times a day for dizziness/low blood pressure (BP), hold for systolic BP greater than (>) 140. Review of policy/procedure - Insulin Pens, implemented ,d+[DATE] revealed it was the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self administration of insulin therapy upon discharge. The compliance guidelines described Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The procedure revealed staff to prime the insulin pen by - Dial 2 units by turning the dose selector clockwise. - With the needle pointing up, push the plunger, and watch to see at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. 3. On [DATE] at 5:37 p.m. an observation of medication administration with Staff R, Licensed Practical Nurse (LPN) was conducted with Resident #93. The staff member dispensed the following: - Magnesium Oxide 400 milligram (mg) over the counter (OTC) tablet Staff R confirmed the resident was to receive a tablet of Citalopram but it hadn't arrived so she had documented a progress note. The staff member confirmed one tablet had been dispensed. Review of Resident #93's April Medication Administration Record (MAR) revealed the resident was to receive Celexa (Citalopram Hydrobromide) 10 milligram (mg) tablet - give 1 tablet by mouth in the evening for depression (start date [DATE]). The record showed Staff R had documented 9 (per legend = other/see progress notes). 4. On [DATE] at 9:11 a.m. an observation of medication administration with Staff E, Licensed Practical Nurse (LPN) was conducted with Resident #53. The staff member dispensed the following medications: - Baclofen 10 milligram (mg) tablet - Gabapentin 600 mg tablet - Venlafaxine Extended Release (ER) 75 mg - 3 capsules - Cetirizine 10 mg over the counter (OTC) tablet - Sucralfate 1 gram(gm)/10 milliliter (mL) oral suspension - 10 mL's - Ferrous sulfate 325 mg OTC tablet - Spiriva Respimat 2.5 mg actuation inhalation The staff member searched the bottom drawer of medication cart for additional medications before writing Lamotrigine, Lisinopril, potassium, Prednisone, Spirolactone, Aldactone, and Jardiance on report sheet. Staff E asked resident about taking Miralax or Lactulose, which the resident refused both and the staff member stated the resident had also refused the inhaler Anoro. The resident complained of pain and the staff member stated the resident's hydrocodone ,d+[DATE] mg tablets were not available. Staff E confirmed dispensing 8 oral medications, one liquid, and one inhaler. The resident asked the staff member for Zofran, which after looking in locked narcotic box in drawer of medication cart, Staff E reported it was not available and reordered it. Staff E reported to Staff D, Registered Nurse/Unit Manager (RN/UM) the resident did not have all these showing her the medications written on the report. Staff D stated the resident had just returned from the hospital, providing a blister card of hydrocodone/acetaminophen ,d+[DATE] mg tablets, reporting the hospital had changed it but physician had okayed for the resident to receive prior ordered narcotic. Review of Resident #53's MAR revealed Staff E had documented 9 - other/see progress notes on [DATE] during the time of the observation for the following medications: - Aldactone (Spironolactone) 25mg - one time a day - Azithromycin 250 mg - one time a day for infection for 3 days - Empagliflozin 10 mg - one time a day for Type 1 Diabetes Mellitus - Lamotrigine 200 mg tablet - one time a day - Lisinopril 10 mg - one time a day - Potassium Chloride ER 20 meq - Prednisone 20 mg - give 2 tablets for pain for 2 days - Spironolactone 50 mg The MAR showed Staff E had administered one 100 mg capsule of Colace, which was not observed or accounted for during the confirmation of the number of oral medications. Review of a list of medications available in the electronic dispenser, as of [DATE] at 9:49 a.m., the following medications were available: - Azithromycin 250 mg - 13 tablets were on hand - Lisinopril 5 mg - 12 tablets were on hand - Potassium Chloride ER 10 meq - 14 tablets were on hand - Prednisone 5mg - 20 tablets were on hand Review of Resident #53's progress notes showed the resident had been transferred to hospital on [DATE] at 8:00 a.m. during shift change. The progress notes revealed on [DATE] the resident continued to be hospitalized . The notes did not reveal staff had documented when the resident had returned from the hospital or had assessed the resident upon return. The MAR revealed empty spaces and hospitalization codes from [DATE] until the scheduled dose of Insulin Aspart at 4:00 p.m. on [DATE] when the resident had received 6 units for a blood sugar of 202. During an interview on [DATE] at 10:02 a.m. Staff E stated she did not know how long Resident #53 had been in hospital, but she was coming in when the staff member was leaving ([DATE] at approximately 4:30 p.m.). The staff member stated the policy for missing (unavailable) medications were to call the pharmacy and the physician. She stated some of the medications said they were on order. Review of the pharmacy Delivery & Cut-off Times showed Monday - Friday new order cut off times were 11:00 a.m. with a departure time of 2:00 p.m. and 8:00 p.m. with a departure time of 2:00 a.m., for new admissions the cutoff time was 10:00 p.m. with a departure time of 2:00 a.m. The information revealed if a refill was needed immediately, please contact pharmacy and if something was faxed after cutoff and needed to be received staff with to call the pharmacy immediately. During an interview on [DATE] at 10:25 a.m. the Director of Nursing (DON) stated the procedure for unavailable medications was to either get an order to hold the medication, to call pharmacy to see how quickly it could arrive, or an order to administer it when it arrived, regarding over-the-counter medications, the facility can get them from local drug store. The DON reported staff should retrieve medications from central supply or the electronic dispenser if the medication was not available on the cart. She reported an order can be changed per the physician discretion, if the doctor felt it more beneficial to the resident the order can be changed. In regards to Resident #40, the DON stated the medical director was here, assessed the resident, and felt changing the medication to Calcium with Vitamin D was appropriate, however Calcium 500 mg tablets should have been available. She stated typically medications should be re-ordered within a week, for a re-admission (Resident #53) the hospital will give orders, staff reconcile them, and if the medications were held in the medication room, staff were to return them to the cart, if they had been sent back they would arrive on the next delivery. The DON stated medications for Resident #53 probably missed the cutoff time but would have arrived on this morning's run. Reviewed list of medications available in electronic dispenser with the DON, who was surprised Citalopram (Resident #93) was not available but felt it was strange it wasn't available one day, administered for 4 days, then not available on the 5th day. An interview was conducted with the DON on [DATE] at 3:57 p.m. The DON reported physicians would need to be notified when the medication was not available. Review of the policy - Medication Administration, reviewed/revised [DATE], 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. - 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. - 12. Identify expiration date. If expired, notify nurse manager. - 14. Administer medication as ordered in accordance with manufacturer specifications. - 15. If any medication is not available, or the possibility of late administration, the nurse will contact the attending physician. - 18. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. Review of the policy - Medication Reconciliation, reviewed/revised ,d+[DATE], revealed this facility reconciles medication frequently throughout a resident state to ensure that the resident is free of any significant medication errors, and that the facilities medication error rate is less than 5%.

Based on observations, interviews, and record review, the facility failed to maintain an effective resident call system in four resident rooms (#204, #207, #403, and #609) of sixty four resident rooms in the facility Findings included: On [DATE] at 12:40 p.m. and [DATE] at 9:50 a.m., the following observations were made. a. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. b. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. c. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. d. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. During an interview with the Nursing Home Administrator (NHA) on [DATE] at 2:53 p.m., the NHA stated he was notified of the broken call light pull strings in room [ROOM NUMBER], #207, #403, and #609. On [DATE] at 11:08 a.m., an interview was conducted with the Director of Maintenance (DOM). The DOM said he walks the facility daily and if he sees an issue he resolves it immediately or enters it into the electronic maintenance work order system. The staff also enters issues into the electronic maintenance work order system and he reviews the system for additions on a daily basis, if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Administrator. The DOM stated he tries to get issues fixed immediately and if he can't get it accomplished he has his assistant, who fixes it and keeps a log with emails. The DOM stated he does not have a written policy regarding daily, weekly, monthly, or annual maintenance and it's directed through the electronic maintenance work order system. Review of an undated facility document titled electronic maintenance work order system weekly tasks schedule showed to conduct a test of the nurse call system. A review of the electronic maintenance work order system report revealed Conduct a test of the nurse call system was listed under the section titled Tasks due this week. Review of a facility document titled Work Orders, dated [DATE] to [DATE] showed there were no work orders placed for call light parts to address call light concerns in rooms #204, #207, #403, or #609. Review of a facility policy titled Call Lights: Accessibility and Timely Response dated ,d+[DATE] showed under Policy, the purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. The policy also revealed the following under Policy Explanation and Compliance Guidelines: . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 7. The call system must be accessible to the residents at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

Based on interview, observation, and record review, the facility failed to maintain an effective pest control management system in nine rooms (100, 103, 108, 106, 207, 210, 303, 410, and 604) out of 52 rooms toured, and for one resident (#78) of one resident sampled. Findings included: On 4/9/2025 at 12:45 p.m. and on 04/10/2025 at 10:10 a.m., observations were made of live crawling bugs and what appeared to be insect feces in resident rooms and common areas. The rooms included rooms 100, 103, 108, 106, 207, 210, 303, 410, and 604, and common areas of the 400 Wing. On 4/7/2025 at 11:00 a.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated she had seen pests throughout the entire facility. On 4/10/2025 at 11:08 a.m., an interview was conducted with the Director of Maintenance (DOM). The DOM said, he walked the facility daily and if he saw an issue he resolved it immediately or entered it into the electronic maintenance work order system. The staff also entered issues into an electronic maintenance work order system, and he reviewed the system for additions on a daily basis if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Nursing Home Administrator (NHA). The DOM stated he tried to get issues fixed immediately and if he could not get it accomplished, he had his assistant who fixes it and keeps a log with emails. The DOM stated that he does not have a written policy regarding daily, weekly, monthly or annual maintenance, and it's directed through the electronic maintenance work order system. The DOM stated that the pest control schedule is for two times a month and if he sees a repetitive cycle, he will defer to the contractor. The DOM also stated that he has a background in Pest Control. On 4/7/2025 at 10:12 a.m. an interview was conducted with Resident #78. The resident stated that she has had multiple sightings of roaches and ants throughout her room and pointed out what appeared to be pest droppings under her nightstand. Review of a facility document titled the Pest Control Service Agreement dated, 2/12/2024 showed the Service Agreement states, during the term of this Agreement, (names pest control company), will provide the pest management services, described in a Service Specifications attached hereto and incorporated herein as Exhibit A-Client Proposal & Specifications (the Service Specifications). Covered pests: Mice, Rats, Ants and Roaches. Common areas, kitchen and exterior perimeters are included in the program. Initial service includes installation of equipment, logbook, map creation, inspection and spot treatments as needed. Schedule of one time and biweekly maintenance noted in agreement. Review of a facility document titled, pest log, for wings 100, 200 and 300 showed roaches were noted on: 12/3/2024, 12/30/2024, 12/31/2024, 1/3/2025, 1/11/2025, 2/22/2025, 3/20/025, 3/20/2025, 3/11/2025, 3/11/2025, and 4/2/2025. Ants were noted on: 2/8/2025, 2/8/2025, 2/8/2025, 3/14/2025. Flies were noted on 2/4/2025 and spiders were noted on 4/2/2025. Review of a facility document titled pest log for wings 400, 500 and 600 showed roaches were noted on 9/24/2024, 10/27/2024, 12/23/2024, 12/30/2024, 1/14/2025, 2/5/2025, 2/24/2025, 4/2/2025, and 4/9/2025. Ants were noted on: 11/23/2024, 12/13/2024. Fleas were noted on: 2/5/2024. Pests were identified by a resident on: 3/7/2025. Review of a facility document titled, Pest Control Program Policy, dated 9/2023, reviewed by the administration stated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition of Effective pest control program is defined as measure to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). Policy explanation and compliance guidelines: 1. Facility will maintain written agreement with a qualified outside pest service. 2. Facility will ensure appropriate chemicals are used. 3. Facility will maintain a report system of issues that may arise 4. Facility will utilize a variety of methods in controlling pests. 5. Facility will ensure that the outside pest service also treats the exterior perimeter. Photographic Evidence Obtained.

Based on observation interview and record review, the facility failed to honor the resident's right to a dignified existence and self-determination by failing to serve identifiable foods for two (#67 and #38) of two residents sampled for pureed diets. Finding included: 1. Resident #67 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Alzheimer's disease, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive. An observation on 04/07/2025 at 12:48 p.m. revealed Resident #67 being assisted by an unidentified staff to eat her pureed diet. Resident #67's meal ticket was lying on her tray. The meal ticket did not show the food items she was eating. During the observation and interview the staff member assisting her to eat stated they did not know what the pureed items were. They stated it may have been spaghetti or pasta and peas. Review of the menu for the day showed on 04/07/2025 for lunch the residents received spaghetti sauce with meatballs, spaghetti noodles, tossed salad with dressing, bread sticks, mandarin oranges, 2% milk and coffee/tea. An observation and interview on 04/10/2025 at 8:19 a.m. showed Resident #67 being assisted with her puree breakfast at bedside by Staff I, Certified Nursing Assistant (CNA). Staff M, CNA was assisting her roommate. An observation of Resident #67's tray on her overbed table revealed a pureed meal on the plate. The meal ticket did not show the food items she was eating. The plate showed a mound of uniform texture yellow portion, and the other two portions were eaten. Staff I, CNA and Staff M, CNA stated sometimes they do not know what they are feeding the residents. Staff M, CNA stated, Better for us, better for them. Staff I stated, If it looks like bread, we can tell if it is pancakes or waffles only if there is syrup on the tray, otherwise it is bread. They both stated they would want to know what they were feeding the residents. Staff I, CNA stated, What if a family member asked us what they were eating, we don't know. They stated they should put it on the meal ticket. When asked about food allergies, the staff member said, Good question. During a follow -up interview on 04/10/2025 at 8:45 a.m. with the Certified Dietary Manager (CDM) and Staff I, CNA, they both verified the unidentified food items Resident #67 had been served were pureed eggs, muffin and sausage. They confirmed the meal ticket did not include this information. Review of the menu for the day showed on 04/10/2025 for breakfast the residents received orange juice, cheese omelet, cereal of choice, muffin, 2% milk, coffee/tea. During an interview on 04/09/2025 at 2:27 p.m. The CDM stated the CNA should be telling the resident what the meal consists of. The CDM stated, The puree diet is also what is on the menu, the menu reflects what we pureed. The CDM stated the CNA should be referencing the meal ticket to ensure the resident was getting the proper diet. 2. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, dysphagia, and anemia. Review of the Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, meaning cognitively intact. Review of the physician orders showed NAS (No Added Salt) diet, Pureed texture, Thin consistency. During an interview on 04/07/2025 at 11:18 a.m. Resident #38 stated he eats mashed potatoes and oatmeal every day. He stated he wanted something else, but they don't offer him other foods. During an interview and observation on 04/10/2025 at 8:16 a.m. Resident #38 was observed eating his oatmeal. An observation was made of a pureed meal on his tray placed on his overbed table. The plate showed three mounds, one was uniform texture yellow portion, one was light brown uniform texture portion, and one lumpy darker brown portion, a bowl of oatmeal, and fluids. Resident #38 stated he was eating his oatmeal only. Resident #38 stated, I don't know what it is. Not eating it. It doesn't look good. Eating my oatmeal only. During an interview and observation on 04/10/2025 at 8:30 a.m. The CDM stated the residents with pureed diet were served eggs, muffin and hot cereal. It was confirmed an observation was made of oatmeal in a bowl on the side of Resident #38's tray. The CDM was observed looking into the pureed containers in the kitchen and she stated she did not know what the residents had been served. The CDM went to Resident #38's room and observed his tray. The CDM stated it was eggs, a muffin and sausage. Review of the menu for the day revealed sausage was not on the menu. 3. Review of the facility policy, Nutritional Management, dated 9/1/2023 showed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance guidelines: 2. Identification / assessment: B. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. 4. Care plan implementation: B. Interventions will be individualized to address the specific needs of the resident. Examples include but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet 5. Monitoring / revision: i. Interviewing the resident and / or resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary. Review of an undated facility policy titled, Pureed Food Preparation, showed facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. Review of the facility policy, Resident Rights, dated 9/1/2023 showed the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 2. Planning and Implementing care. The resident has the right to be informed of, and participate in, his or her treatment. 4. Respect and dignity. c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. 5. Self-determination. The resident has the right, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. (Photographic Evidence Obtained)

Based on observation, interview, and record review, the facility failed to obtain physician orders, assess the residents or develop care plans for two (#38 and #89) of two residents related to self-medicating for nebulizer treatments. Findings included: 1. An observation on 04/07/2025 at 10:25 a.m revealed Resident #38 sitting in his room in his bed. The head of the bed was elevated. His un-bagged nebulizer mask was laying on the overbed table. The nebulizer machine was off. He stated the nurse brought in medicine for his machine and left. Resident #38 stated he took it off after it was finished. He stated the nurse did not stay with him. An observation on 04/07/2025 at 11:26 a.m revealed Resident #38's un-bagged nebulizer was still laying on the overbed table. An observation on 04/08/25 at 8:58 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. The nebulizer mask was in a plastic bag on the overbed table. An observation on 04/09/2025 at 10:30 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. His nebulizer mask was sitting on top of a plastic bag. The nebulizer machine was off. Photographic evidence obtained. During an interview on 04/09/2025 at 10:46 a.m. with Staff P, Licensed Practical Nurse (LPN), she stated she entered the room and put the nebulizer mask in the plastic bag. Staff P stated, No, I did not stay with [Resident #38] the whole time he was on his nebulizer. Staff P stated she brought his (oral) medications in including his nebulizer medication. She stated she brought in his roommate's medications and gave another resident (in another room) their medication. Staff P stated she just came in and put the nebulizer mask back in the bag as it was laying on the plastic bag. She stated she was not in the room the whole time he was on the nebulizer; she just came back. Resident #38 stated he did his own nebulizer treatments and turned the machine off. During an interview on 04/09/2025 at 11:38 a.m., the Director of Nursing (DON) stated they did not have anyone that was self-medicating. She stated the process for nebulizer treatments was for the nurse to check the lung sounds, put the medications in the nebulizer cup, put the mask on the resident's face, stay with the resident, when the resident was finished, take the mask off, check the lung sounds, rinse the mask and put it back in the plastic bag. If the resident was giving his own nebulizer treatments, he should have an order to self-medicate, assessment for self-medications and care planned for such. The DON stated they did not have an order for self-medication for Resident #38 nor had anyone assessed him. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, dysphagia, and anemia. Review of the Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Section GG Functional Abilities showed dependence on eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the active physician orders as of 04/10/2025 showed: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 8 hours as needed for Shortness of Breath (SOB) Review of the physician orders showed none regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML every 8 hours as needed for SOB was administered 2 to 3 times a day. Review of the assessments showed no documentation regarding assessing Resident #38 for self-medicating of nebulizer treatments. Review of the care plans for Resident #38 showed At risk for impaired respiratory status related to COPD, bronchitis as of 03/20/2025. Interventions included but not limited to administer medications as per order, administer oxygen as per order, and administer respiratory treatment as directed. Monitor lung sounds as ordered. Check lung status including lung sounds as indicated, all initiated as of 03/20/2025. 48223 2. An observation and interview on 04/07/2025 at 10:35 a.m., revealed Resident #89 lying in bed, with the head elevated. His un-bagged nebulizer pipe was laying on the nightstand. The nebulizer machine was off. Resident #89 stated the nurse brought in the medicine, set up the pipe, turned on the machine, and left the room. Resident #89 stated when the medicine was finished, he placed the pipe on the nightstand and turned off the machine. Resident #89 stated the nurse did not stay in the room. Observation on 04/07/2025 at 12:26 p.m. revealed Resident #89's un-bagged nebulizer was still laying on the nightstand. Review of Resident #89's Admission Record showed an admitted [DATE], with diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD) and Respiratory conditions due to other specified external agents. Review of the Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Section GG Functional Abilities showed set up assistance with eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the physician orders summary report dated as of 04/09/2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 6 hours for Cough. Review of the physician orders showed no order regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for March and April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML inhale orally four times a day for COPD related to Sleep Apnea, with a start date of 1/19/25 and discharge date of [DATE]. Documentation showed medication given. Review of the progress notes showed no documentation regarding self-medication of nebulizer treatment. Review of the assessments showed no documentation regarding assessing Resident #89 for self-medicating of nebulizer treatments Review of the care plans for Resident #89 showed the focus: The resident has altered respiratory status related to Sleep Apnea. CPAP (Continuous Positive Airway Pressure), date initiated 1/21/2025. Interventions included but not limited to administer medications as per order, Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger; Monitor for signs and symptoms of respiratory distress and report to MD (Medical Doctor) as needed: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey; all dated as initiated 1/21/25. Review of the facility's policies and procedures titled Nebulizer Therapy with a revised date of 3/1/2025 revealed: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. If the nebulizer will supply oxygen to the patient, refer to policy Oxygen Concentrator. Policy Explanation and Compliance Guidelines: Care of the Resident 1. Verify practitioner's order. 2. Gather appropriate equipment and ordered medication. 3. Knock to gain permission to enter room and explain the procedure to the resident. 4. Perform hand hygiene. 5. [NAME] gloves and other personal protective equipment (PPE) as needed to comply with standard or transmission-based precautions. 6. Obtain resident's vital signs, and perform respiratory assessment to establish a baseline. 7. Correctly assemble the tubing, nebulizer cup, and mouthpiece (or mask) per manufacturer's specifications and ensure connections are secured tightly. 8. Place ordered medication into nebulizer cup. Premixed solutions may be used if available in the correct dosage. 9. Assist resident into a comfortable position. If possible, place resident an upright position to encourage full lung expansion and promote aerosol dispersion. 10. Connect the nebulizer to a power source. 11. Instruct resident on how to use the nebulizer appropriately. 12. Turn the machine on. 13. Keep nebulizer vertical during treatment. 14. Observe resident during the procedure for any change in condition. 15. When medication delivery is complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Review of the facility's policies and procedures titled Resident Self-Administration of Medication dated 9/1/2023 revealed: Policy: 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 facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's 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. resident's physical capacity to: swallow without difficulty, open medication bottles, administer 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 medications need to be taken; e. 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 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. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR. 13. The care plan must reflect resident self-administration and storage arrangements for such medications. Photographic Evidence Obtained.

Based on record review and interview the facility failed to provide notification to the resident representative for one of six residents (Resident #106) sampled for accidents out of a total sample of 52 residents. Findings Included: Review of Resident #106's Admission Record showed an admitted [DATE], discharge date of [DATE] to an acute care hospital, and diagnoses to include urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, difficulty walking, and repeated falls. Resident #106 had three family members listed as emergency contacts on the Admission Record. Review of the Change in Condition Evaluation dated 07/15/2024 at 2:43 a.m. showed Resident #106 fell on [DATE] at 2:20 a.m. Section 3. Resident/Representative Notification was blank. Review of the progress notes showed no documentation the family was called post fall on 07/15/2024. Review of the Situation, Background, Assessment, Recommendations (SBAR) dated 07/16/2024 showed Resident #106 was sent to the ER for treatment on 07/16/2024 at 12:20 a.m. The family was notified on 07/16/2024 at 7:00 a.m. about the 07/15/2024 at 2:20 a.m. fall and being sent to the ER. During an interview on 04/09/2025 at 2:26 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) it was confirmed Resident #106 fell on [DATE] at 2:20 a.m. The resident was assessed for the pain and neuro-checks were conducted. The resident stated she was getting ready for the day, and was reminded what time it was. The resident had no pain at the time of the fall and no injuries at that time were noted. The DON confirmed there was no documentation that the family was informed of the fall on 7/15/2024 at 2 a.m. She stated there was documentation the family was informed she was going to the hospital on 07/16/2024 after the resident expressed an increase in pain and x-rays revealed a left hip fracture. The DON stated the family should have been informed about the fall on 7/15/2024.

Based on observations, record reviews, and interviews, the facility failed to revise the care plans and related interventions accurately for one residents (#93) of fifty-two sampled residents related to indwelling urinary catheter. Findings included: Review of Resident #93's care plan revealed the following focuses and relevant interventions: - Enhanced Barrier Precautions related to (r/t) indwelling urinary catheter (and) wound. The focus was initiated on 1/27/25 and revised on 4/7/25. - Has a[n] [indwelling] Catheter. Diagnosis (DX) wounds. The focus was initiated on 1/15/25 and revised on 4/9/25. The goal was for the resident to remain free from catheter-related trauma through review date. On 4/7/25 at 11:28 a.m., Resident #93 was observed lying in bed. No urinary catheter was observed. During an interview on 4/8/25 at 5:43 p.m., Resident #93 reported not having a urinary catheter and stated it came out on its own about 3 weeks ago. The nurse at the time was going to put it back but needed a 16 French (fr) sized catheter, but only had a 14 fr available and did not have an order for the catheter, so they left it out. An observation was made at the time of interview and confirmed the resident did not have a urinary catheter. During an interview on 4/9/25 at 1:40 p.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON stated Resident #93 did have an indwelling catheter when admitted , but had it removed. The DON reviewed documentation for Resident #93, reporting there was a progress note from 3/18/25 related to the removal of the resident's catheter. The note reported the catheter was found on the bed, balloon was deflated, and 30 cubic centimeters (cc) of water out. The resident's physician was notified and ordered to leave the catheter out and see how well the resident did without the catheter. During an interview on 4/9/25 at 2:45 p.m. with the Minimum Data Set (MDS) Lead and Regional MDS Coordinator (Reg MDS), the Reg MDS stated the resident had a care plan for the catheter but no order for it. The MDS Lead reported the resident had a catheter and confirmed, when she saw the resident on 4/7/25, the resident had a urinary catheter. The Reg MDS left the interview to determine whether the resident had a urinary catheter, returned, and confirmed the resident did not have a catheter. A continued interview was conducted on 4/9/25 at 3:09 p.m. with the MDS Lead, who stated the resident's catheter was discontinued yesterday and she did not have the physician order at that time. Review of the facility policy titled Comprehensive Care Plans implemented on 9/1/23 revealed under Policy, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, and 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 revealed the following under Policy Explanation and Compliance Guidelines: . 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 resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, and interview, the facility failed to assess, document and/or treat a surgical wound for one (#96) of one resident sampled for skin conditions. Findings included: On 4/7/25 at 5:10 p.m., Resident #96 was observed with a blue cast on his right arm and a mesh pad covering a black area approximately 2 centimeters (cm) x 3 cm on his interior left ankle. The mesh was lifted off the skin in one corner. The resident stated the doctor did not want it to come off and it had been there for about a month. Review of Resident #96's Admission Record revealed the resident had been admitted on [DATE] and included diagnoses not limited to unspecified fracture of right femur subsequent encounter for closed fracture with routine healing, stress fracture right ankle subsequent encounter for fracture with routine healing, and multiple sites muscle wasting and atrophy not elsewhere classified. Review of Resident #96's Admission/Readmission Nursing Evaluation, effective 2/7/25, showed the resident was admitted for a right ankle/femur fracture, chronic obstructive pulmonary disease (COPD), hypertension (HTN), and left ankle Open Reduction and Internal Fixation (ORIF). The skin integrity revealed abrasions on top of his scalp, [Brand Name] drain removal site to abdomen, right inner ankle surgical site, and left inner ankle surgical site. Review of Resident #96's Order Summary Report did not show orders had been received from the surgeon or facility physician regarding the care of the resident's left ankle mesh covered surgical site. Review of Weekly Skin Checks revealed the following: - 2/14/25 showed the resident had surgical incisions to abdomen and right leg. There was no mention of the left ankle surgical site. - On 2/19/25 the facility documented the resident had no new and/or existing area of skin impairment, did have a [Brand Name] drain surgical site AB([NAME]), and no resolved skin impairment. No mention of left ankle surgical site. - On 2/26/25 the facility documented the resident's skin was clear with no impairment, no existing skin impairment, and no resolved skin impairment. - On 3/5/25 staff revealed the resident had an existing skin impairment, a surgical incision to the abdomen and right leg. The assessment showed the resident did not have any resolved skin impairments. - On 3/14/25 staff documented the resident had an abdomen surgical incision with no resolved skin impairments. - On 3/28/25 the assessment revealed the resident's skin was clear with no impairment. - On 4/2/25 the Director of Nursing (DON) documented the resident's skin was clear with no impairment. On 4/9/25 at 4:30 p.m., Staff H, Licensed Practical Nurse (LPN) stated it was her first time working Resident #96's hall. Staff H observed the mesh pad on the resident's left ankle and spoke with the resident and visitor. During an interview and observation of Resident #96 on 4/9/25 at 4:42 p.m., the DON reported the resident had several fractures prior to admission, confirmed knowledge of the left ankle mesh pad and the wound specialist had not recommended anything further for the ankle. She stated she had not seen the area recently (did weekly skin check week prior). She reported the last wound specialist evaluation was on 3/6/25 (month prior). The DON stated the expectation would be for nurses to address the issue. She observed the mesh pad attached to the left ankle and confirmed something should have been done about it, nurses at least should be monitoring the area. The resident informed DON the mesh pad was a surgical site where screws had been placed. Review of Resident #96's March and April Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show staff were monitoring the surgical site on the left ankle. Review of Resident #96's care plan revealed the following focuses and interventions: - Has potential/actual impairment to skin integrity related to (r/t) decreased mobility, fragile skin, (and) incontinence. Right leg - closed surgical = resolved, Abdomen - closed surgical = resolved. The interventions include instructions for staff to Monitor/ document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/ symptoms (s/sx) of infection, maceration etcetera (etc) to MD. Review of Resident #96's physician orders, MAR, TAR, and care plan did not include follow up instructions on how staff were to care for the surgical site to left ankle. Review of the policy - Documentation in Medical Record, implemented 3/2024, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and including enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the residence medical record in accordance with state law and facility policy. 3. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/ or responses to care.

Based on observation staff interview and record review, the facility failed to ensure a contracture management program to include wearing of splints/orthotics was implemented for one (#7) of fifty - two sampled residents during three of three days observed (4/7/2025, 4/8/2025, and 4/9/2025). Findings included: On 4/7/2025 from10:30 a.m. to 12:30 p.m. Resident #7 was observed in her room lying in bed with both of her upper extremities noted to be contracted. Both of her hands and fingers were in a closed position. Resident #7 was not observed wearing either splints or orthotics. There were no splints or orthotics visible in the room during the multiple visits. Resident #7 was not able to answer any questions related to her medical care and services as she was observed with cognitive deficits. On 4/7/25 at 1:00 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed she had Resident #7 on her assignment for the day and that she did not know the resident well. Staff C was able to observe Resident #7 while positioned in bed and confirmed she had contracted upper extremities on both sides. Staff C was not sure if the resident had splints or orthotics to wear, and she was also not sure if Resident #7 was being seen by Restorative Nursing for contracture management. Staff C confirmed she did not see any orthotics or splints in the room for the resident to use. During multiple observation conducted on 4/8/2025 from 7:50 a.m. through 2:58 p.m., Resident #7 was again observed in her room and lying in bed. Resident #7 was observed without any splints/orthotics on either of her upper extremities. During multiple observation conducted on 4/9/2025 from 8:00 a.m. through 3:00 p.m. Resident #7 was observed in her room and lying in bed with both hands and upper extremities without any splints or orthotics. On 4/9/2025 at 10:00 a.m. an interview was conducted with Staff F, Occupational Therapist (OT). Staff F revealed the Rehabilitation Director was not available today for interview, but she (Staff F) would try to answer any questions. Staff F revealed she knew of Resident #7 very little, but did confirm she had contractures. Staff F needed to refer to the electronic medical record to see if OT had her on case load. Staff F revealed Resident was discharged from OT on 1/10/2025, following plateauing with goals. Staff F continued to say Resident #7 was referred to Restorative Nursing for contracture management to include utilization of splints/orthotics on her Right elbow, Right hand and Left palm. Staff F was not able to say what the outcome was with regards to Restorative Nursing and her current contracture management. On 4/9/2025 at 12:10 p.m. an interview with Staff G, Certified Nursing Assistant (CNA) assigned to Resident #7 during the 7a.m. - 3 p.m. shift, revealed she had only been working the unit for about one week now and did not know all the residents on the hallway to include Resident #7. Staff G stated Resident #7 was totally dependent on staff with most of her ADLs. (activities of Daily Living). Staff G confirmed Resident #7 does have limited range of motion with all her extremities and knew Resident #7 had any contractures on her upper extremities. Staff G explained as far as she knew, Resident #7 did not wear any splints/orthotics. She confirmed there were no orthotics or splints in the room, as she would have seen them. Staff G confirmed there was no documentation in the CNA's task sheet from the care plan indicating if Resident #7 utilizes splints/orthotics. On 4/9/2025 at 12:20 p.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN) who normally had Resident #7 in her assignment. Staff E revealed she knew Resident #7 had limited Range of Motion (ROM) with upper extremity contractures. She did not know if the resident was ordered, and care planned for the use of splints/orthotics for the contractures. Staff E reviewed the care plan's document used by staff with instructions specific to a resident's care needs and confirmed there was no documentation to support the resident was to wear splints or orthotics on either of her extremities. Staff E then reviewed the electronic medical record to include the current order sheet and current care plans and found documentation indicating the resident was supposed to wear a Right elbow extension splint, a Right resting hand splint, and a Left palm guard for 6 hours per day, 5 days a week and supplied and removed by nursing staff. She confirmed the original order date was 2/20/2025. On 4/10/2025 at 10:15 a.m. an interview was obtained Staff D, Registered Nurse (RN)/Unit Manager (UM). Staff D revealed she was not aware Resident #7 was not offered or donned with splints/orthotics on her upper extremities the past few days. Staff D revealed it was brought to her attention by Staff E, LPN, the previous afternoon on 4/9/2025. Staff D revealed she was the Unit Manager and should be monitoring her nursing staff to ensure care plan interventions and orders were being followed, especially for those who are on contracture management requiring use of splints/orthotics. Staff D, RN was not sure who's initial responsibility was to don and doff the splints/orthotics on a daily basis. Review of Resident #7's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 2/2/2025 with diagnoses to include but not limited to: Dysphagia, Contracture Right wrist, Contracture L (left) wrist, Contractures unspecified joint, Chronic pain, Anxiety, Dementia. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score of 00 of 15. Under ADL, it showed, Impairment both sides upper and lower extremities, with substantial assistance to dependent on staff for most ADLs. Review of the current Physician's Order Sheet (POS) for the month 4/2025, revealed the following but not limited to orders: a. Patient will wear R (Right) elbow extension splint, R resting hand splint, and L palm guard for 6 hours per day 5 days a week a supplied and removed by nursing staff. Order date 2/20/2025). b. Skilled Occupational therapy three to four times per week for sixty days which may include therapeutic exercise and activities, neuromuscular reeducation, orthotics management, manual therapy, and w/c management. (order date 1/30/2025). Review of the Occupational Therapy Evaluation and Pan of Treatment with a certification period 1/29/2025 - 3/27/2025 revealed primary diagnoses to included: Muscle wasting and atrophy, Contractures unspecified joints, Lack of coordination. The Plan of Treatment revealed approaches to include but not limited to: Initial encounter, Orthotic management and training, each 15 minutes with a frequency of 3 to 4 times a week for 60 days, on a daily basis. The New Goal section revealed the Patient will safely wear least restrictive splinting/orthotic devices 4 hours on / 4 hours off without swelling/edema and complaints of discomfort in order to maintain joint mobility and improve PROM (Passive Range of Motion) for adequate hygiene. The recommendation section of the assessment summary revealed; Orthotics - Splint/Orthotic Recommendations: It is recommended the patient wear appropriate orthotics. Further assessment will follow in order to obtain or fabricate orthotics for both wrists and Right elbow. The Clinical Impression section of the summary revealed; Patient presents with severe limitations in joint mobility and muscle strength in all extremities as well as pain, deficits in cognition, and poor balance and sitting tolerance. She has pressure wounds and increasing contractures and is in need of proper positioning. Review of the Occupational Therapy Discharge Summary dated 1/10/2025 revealed patient discharged to reside in the Long-Term Care facility. Review of the Restorative Nursing Program for ROM dated 2/19/2025 revealed; Program type - Passive Range of Motion; Program goals - Increase joint motion to max. range, Improve circulation. Joint exercises to include: Shoulders - In front of body, out to side of body, palm neutral; Arm circles in front of body and out in front of body. Precautions included R upper extremity shoulder, elbow, wrist, and digit contractures. Left upper extremity digits 3, 4, 5, contractures. Patient is aphasic, confuses easily. Review of the nurse progress notes dated from 12/1/2024 through to 4/9/2025 did not include any documented evidence of the resident receiving any assistance with upper extremity splint/orthotics. Nor was there any documentation to support Resident #7 ever refused wearing said splint/orthotics. Review of the current care plans with next review date 5/5/2025 revealed the following but not limited to: 1. ADL Resident has a self-care deficit with need for staff assistance with ADL completion on daily basis: Dx. contractures, weakness, impaired mobility, impaired cognition, Right elbow extension splint, Right resting hand splint and left palm guard. Followed by MD order, with interventions in place to include but not limited to: Patient will wear R elbow extension splint, Right resting hand splint, and Left palm guard for 6 hours per day 5 days a week as applied and removed by nursing staff. 2. Resident has limited physical mobility r/t weakness bilateral upper extremity and bilateral lower extremities with interventions in place to include but not limited to: Resident is totally dependent on 1 staff for locomotion using wheelchair, Monitoring/documenting/report PRN any signs/symptoms of immobility forming or worsening, thrombosis formation, Provide gentle range of motion as tolerated with daily care. 3. Alteration in musculoskeletal status r/t contracture to L ankle, Right ankle, R wrist, and R elbow, with interventions in place to include but not limited to: Anticipate needs, Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders and or PT treatment plan, Monitor/document/report PRN signs and symptoms or complications related to arthritis; Joint stiffness, usually worse on waking; Swelling; Decline in mobility, Delcine in self-care ability, Contracture formation/joint shape changes, clicking with joint movement, pain after exercise or weight bearing. Review of a facility's Restorative Nursing Program policy and procedure with an implementation date of 9/2023 for review showed it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The definition section of the policy revealed; Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The policy Explanation and Compliance Guidelines revealed but were not limited to: 3 . Nursing personnel are trained on basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: d. Promoting independence in ADLs, performing tasks for residents only as needed to ensure completion of tasks. e. Assisting residents in adjustment to their disabilities and use of any assistive devices. f. Assisting residents with range of motion exercise, performing passive range of motion for residents who lack active range of motion ability. 4. All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants. 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include, but not limited to: a. Passive or active range of motion. b. Splint or brace assistance. 13 . The Restorative nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly and document accordingly.

Based on observations, record review, and interviews, the facility failed to ensure physician orders were in place for one (Resident #19) of two residents sampled for a Foley catheter. Findings included: A review of admission record revealed Resident #19 was readmitted on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of bladder, quadriplegia, resistance to multiple antibiotics, carrier of other enterobacterales and other co-morbidities. A review of Resident #19's care plan revealed the following: Focus: Resident #19 Urinary catheter r/t (related to) Neuromuscular Dysfunction of Bladder Date Initiated: 04/04/2024 Revision on: 02/22/2025. Interventions included: Change catheter as needed Date Initiated: 04/13/2024; Foley Catheter as ordered Date Initiated: 04/13/2024 Revision on: 04/07/2025; Observe/document for pain/discomfort due to catheter Date Initiated: 04/04/2024; Observe/record/report to MD for s/sx (signs/symptoms) (Urinary Track Infection) UTI - pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Date Initiated: 04/04/2024; Provide catheter care Date Initiated: 04/04/2024 Revision on: 04/07/2025; Provide privacy bag to drainage bag per facility protocol Date Initiated: 04/04/2024 Revision on: 04/07/2025 . A review of physician orders revealed the following: 1-Catheter care every shift and as needed. order date 4/11/2024 2- Monitor catheter for patency and drainage every shift. Order date 4/11/2024 3- Catheter-Bag change as Needed. Order date 4/11/2024 4- Foley Catheter 30 F 30 cc balloon No directions specified for order. Order date 9/1/2024. No diagnosis was found in the physician orders or notes for the Foley catheter. Review of the Medication and Treatment Records for March and April of 2025 revealed no order to change the catheter, or size of balloon and Foley catheter. During an interview on 4/9/2025 at 1:40 p.m. the Director of Nursing (DON) stated the expectation for Foley catheter orders would include: balloon and Foley size, catheter care, and to change the catheter for blockage or leakage, as needed. The DON confirmed not seeing an order for Resident #19's catheter. The DON stated knowing the catheter was changed about two weeks ago, but was unable to provide documentation. The DON stated the resident has a diagnosis of neuromuscular bladder, although not everyone with this diagnosis needs a catheter. The DON stated Resident #19 had multiple wounds and the catheter could be for the benefit of wound healing. The DON confirmed the physician order did not have a diagnosis, Foley or balloon size. Review of the facility's policies and procedures titled Catheter Care, dated 9/1/2023, revealed: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Based on observation, record review, and interviews, the facility failed to identify, implement, monitor, and modify interventions for one (Resident #33) out of 52 related to coughing during meals. Findings Included: During an observation on 04/07/2025 at 12:18 p.m., Resident #33 was observed sitting in the dining room with a plate of spaghetti, meatballs and garlic toast. Resident #33's eyes became watery and was observed coughing after taking a bite of food. Resident #33 continued to cough for a few seconds when staff approached Resident #33 raised her hands and removed the plate of spaghetti and toast. During an interview on 04/07/2025 at 1:19 p.m., Resident #33's Family Member (FM) stated that she had had an issue with the facility not assisting the resident with eating. She stated the resident had had issues with chewing her food and was supposed to be on a pureed diet. She stated the last time the resident went to the hospital and came back to the facility, she brought up that the resident needed assistance with eating and was told by the facility they did not have any documentation from the hospital for assisting her with food and never addressed her concern. Review of Resident #33's admission record revealed an admitted [DATE] with an initial admitted [DATE]. Resident #33 was admitted to the facility with diagnosis to include Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Acute Respiratory Failure with Hypoxia, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. Review of Resident #33's Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) score of 05 out of 15 which indicated severe cognitive impairment. Review of Section. K. Swallowing/Nutritional Status revealed Nutritional Approaches Mechanically altered diet-require change in texture of food or liquids and Therapeutic diet. Review of Resident #36's Physician Orders revealed: 01/09/2025-Regular diet, Regular texture, Thin consistency two handle cup with concave lid for Speech Therapy (ST) Swallowing precautions in place 02/03/2025-Regular diet, Pureed texture, Nectar Thin consistency 02/07/2025-Regular diet, Mechanical Soft texture, Thin consistency, Two Handled Cup with lid 03/24/2025- CCHO diet, Mechanical Soft texture, Thin consistency no dry foods for moist 04/07/2025- Regular diet, Pureed texture, Thin consistency, Two Handled Cup 4/8/2025-Regular diet, Mechanical Soft texture, Thin consistency for Two Handled Cup Diet Review of the facility's Menu Titled: Agora/Fall Winter 2024-25, Week 4, Monday, Mechanical, Lunch revealed: 3 oz Spaghetti Sauce w/ Meatballs 4 oz of spaghetti noodles 4 oz tossed salad w/ dressing, 2 oz Bread sticks. Review of Resident #36's Care Plan dated 03/20/2025 revealed: Focus: The resident has a nutritional problem or potential nutritional problem r/t fluid restriction, impaired skin, abnormal labs, mechanically altered diet, dx (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) of protein calorie malnutrition, COPD,, heart failure, HD, dementia, depression, atrial fibrillation, HTN. Interventions/Task: Mechanically altered diet and/or thickened liquids, Provide and serve supplements as ordered, Provide, serve diet as ordered, monitor intake and record every meal. Review of Resident #36's Progress Notes showed showed 04/08/2025: Resident observed in dining room with saltine crackers on her plate. The item was not provided by Dietary and had not yet been consumed, Resident #33 asked another resident at the table for crackers and the resident obliged. Item was removed from plate prior to consumption. Resident is non-compliant with her diet. The responsible party informed via telephone and educated on residents diet. 4/7/2025 12:16 p.m. Nurses Notes Note Text: coughing noted with meals, diet downgraded per MD orders. Speech to consult. 3/31/2025 17:19 (5:19 p.m.) Nurses Note Note Text: Attempted to leave voicemail for the resident's [family member] to update her on the resident's follow-up modified barium swallow scheduled for tomorrow. Unfortunately, her voicemail box is full. 3/31/2025 17:32 (5:32 p.m.) Nurses Note Note Text: The [family member] called back and was updated on [the resident's] appointment. She also requested that per the hospital, the resident be an assisted [with meals]. I did explain that no notes were seen stating that from the hospital 3/20/2025 19:02 (7:02 p.m.) Admit/Readmit Note Text: Resident readmit at 17:00 (5:00 p.m.). Resident arrived via stretcher, admitting dx (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) Hypoxia. Discharge reports show Diet change to level 5 mince, moist, and bite size foods. POA stated, resident needs assistance during meals. Concentrator set up, bed in low position, and call light within reach. Medication and MD orders reviewed. 3/18/2025 00:18 (12:18 a.m.) Alert Note Note Text: resident is alert to person, place, and situation; is noted to be non-compliant with diet. 2/6/2025 16:49 (4:49 p.m.) Nurses Note Note Text: Resident sitting on her bed eating pork skins and coughing in between each bite. Educated resident that her diet has downgraded to puree. 2/3/2025 18:01 (6:01 p.m.) Nurses Note Note Text: Resident coughing during meal. Speech therapist was present and downgraded resident to puree. Resident was unable to eat on her own. CNA present had to assist resident during meal. Review of Speech Therapy Notes Revealed: 01/18/2025: Safe Swallowing Strategies 01/20/2025: Oral Intake: Swallowing Abilities = Min/Close Supervision; Current Diet: Regular Textures; Current Liquids= Thin Liquids 02/03/2025: Oral Intake: Swallowing Abilities=Mod; Current Diet=Puree Consistencies; Current Liquids=Thin Liquids 02/07/2025: Oral Intake; Wallowing Abilities=Mild; Current Diet: Mechanical Soft Textures, Mechanical Soft/Ground textures; Current Liquids=Thin Liquids 02/11/2025: Oral Intake: Swallowing Abilities=Min/Close Supervision; Current Diet=Mechanical Soft Textures, Mechanical Soft/Ground Textures; Current Liquids=Thin Liquids 04/08/2025: Initial Assessment/Current Level of Function & Underlying Impairments: Prior Level of Function: Intake/Diet Level=mechanical soft, thin, liquids, successive swallows; swallowing abilities=mild; Medical Factors: Precautions/ Contraindications: Aspiration-Mech Soft Solids; Intake/Diet Level: Puree Consistencies, thin liquids, successive swallows; intake method= All oral Clinical Bed side Assessment: Swallowing abilities mild; Assessment Summary: Clinical Impressions: Pt presents w/mild-moderate oral phase dysphagia, exhibiting prolonged mastication w/ reduced mastication efficiency, reduced lingual coordination for bolus manipulation/propulsion, and intermittent oral residue w/solids. Pt able to safely consume thin liquids (via cup) w/o overt, s/s of aspiration. SLP recommending diet texture modification back to baseline diet of mech . soft solids w/ thin liquids, but at this time pt appears to remain at baseline level of function. Evaluation Only. Further testing: Further exam/consult not indicated d/t = other (Pt at baseline level of function). During an interview on 04/09/2025 12:44 p.m., Regional Director of Therapy stated the facility currently did not have a full-time speech therapist. They did not get the results of the swallow study because the resident was out of the facility and went to the appointment while she was discharged from the facility. He stated Resident #33 was only seen by speech in February on the 6th for an evaluation and had not seen the resident after that so the speech therapist would not have anything else to add about the resident. He stated the Speech Therapist who saw Resident #33 on 04/08/2025 was new and would not know much about Resident #33. During an interview on 04/09/2025 at 1:06 p.m., Certified Dietary Manager (CDM) stated Resident #33 had been a resident for a long time and was on a mechanically soft diet with gravy to keep her food moist. She stated Resident #33 had had a choking incident before and she thought that was why she had a hard time eating now. She stated when the resident ate her food, she had noticed Resident #33 chewed and stopped and then swallowed. She thought she might have a swallowing issue. Residents on mechanically altered diets were supposed to get a bread stick instead of garlic bread, but they did not receive garlic sticks so she served all residents the garlic bread. During an interview on 04/09/2025 at 2:12 p.m., the Registered Dietician (RD) stated Mechanical soft diet was where the food was chopped up. Residents on a mechanically soft diet should not be given anything that could cause them to choke. You want to be sure there is no crust or something too hard. During an interview on 04/09/2025 at 2:28 p.m., Staff N, Speech Therapist, stated she started seeing Resident #33 in February because she was having a hard time with her diet. She stated she first saw Resident#33 when she had a choking incident in the dining room she was unsure of the date but knew it was in February. She stated she was there for this incident so she downgraded her diet at that time to a puree diet, Resident #33 did not like the pureed food so she would go and get snacks from the vending machine. She stated she evaluated and observed Resident #33 eating chips, and she was okay with those, so she upgraded her diet back to Mechanical soft diet because she did well with eating the chips. Resident #33 should be supervised while she is eating. Typically, she would review the swallow study she was not aware Resident #33 had an order for a swallow study or that it had been completed because the last she knew, Resident #33 was in the hospital. The provider was the one who would have ordered the swallow study. She stated she could recommend one, but she had not recommended one for Resident #33. She stated breads were not typically recommended for residents with a mechanically soft diet. During an interview on 04/09/2025 at 2:36 p.m., Staff O, Speech Therapist, stated she did not typically work at this facility and covered a different area, but the facility called and asked for her to come in and see Resident #33 on 04/08/2025 because she had a choking event on Monday (04/07/2025). They wanted to make sure she was on an appropriate diet. She did a bedside swallow evaluation. She checked to see if Resident #33 was aspirating while eating. She gave her different textures and water to drink and made sure she was chewing well enough. After evaluating Resident #33 she felt she was okay to be upgraded back to a Mechanically soft diet. She felt like pureed was way too restrictive. She stated residents on a Mechanically soft diet really should not have anything with a crust. During an interview on 04/10/2025 at 12:10 p.m., the Director of Nursing (DON) stated the resident had had issues with eating on and off. She started coughing while eating so they put her on a puree diet. Resident #33 did not like the pureed food, so they had speech come see her. She had another episode and speech evaluated her again. She stated medical records was responsible for requesting the records after appointments. She confirmed their swallow study results were not in Resident #33's chart. Once results were received, the unit manager, Assistant Director of Nursing (ADON), or the DON made sure it was reviewed by the physician. During an interview on 04/10/2025 at 3:45 p.m., Staff D, Registered Nurse, Unit Manager stated Resident #33 coughed during eating. Resident #33 was non-compliant and when they switched to puree she would not eat it. She did go to the vending machine to get food and she had a friend who gave her food. The hospital changed her to a minced grade 5 diet which was the same as the mechanical soft diet. She spoke with someone at the hospital and confirmed what a minced diet was and they told her that Resident #33's food had to be moist. When they found Resident #33 eating foods she was not supposed to, they provided education to the resident on why she should not be eating those foods. They had told her friend to not share foods with Resident #33 as well. They moved the vending machine from the dining room to a more closed area to make sure Resident #33 did not have full access it. She had not seen her with any other foods she was not supposed to have. The CNA's were aware that she had food limits. She was always in the dining room for meals for supervision. During an interview on 04/10/2025 at 2:03 p.m., the Medical Physician stated she was not aware Resident #33 had any incidents while eating this week. Resident #33 had been evaluated by speech therapy in the past. When Resident #33 went to the hospital they had speech therapy evaluate her and there were no new diet recommendations. Usually if Resident #33 had an issue with eating it was short lived. Resident #33 was on a Mechanically soft diet, meaning her food should be chopped up very finely especially any meats. She did not believe garlic toast was on a Mechanical soft diet. Resident #33 has been known to not be compliant with her diet. She would expect staff to take the unapproved food items from Resident #33 and to be sure items were removed from her room. She expected staff to supervise Resident #33 a little closer. She reviewed Resident #33's hospital discharge record and stated they recommended speech and language/ cognitive therapy on 03/20/2025. The nurse and the unit manager review the hospital orders. There is a nurse practitioner who also sees the residents and she would have addressed these orders as well. Review of the facilities policy titled serving a meal dated 9/20/23 revealed, Policy It is the policy of this facility to serve meals that meet the nutritional needs of residents. Policy Explanation and Compliance Guidelines Diet should be served in accordance with the physician's order. Resident should be encouraged to eat in the dining room, however, requests to remain in the room should be honored. Review of the facilities undated policy titled Therapeutic Diets revealed, Policy Therapeutic diets are prepared and served as ordered by the attending physicians.

Based on staff and family interviews, record review and policy review it was determined the facility failed to correctly identify and protect the end of life rights of one (Resident #2) of eight sampled residents related to the resident's right to have his end of life wishes honored to not receive Cardiopulmonary Resuscitation (CPR) if found unresponsive. Resident #2 was an [AGE] year-old male with hospice enrollment and a designated family member as his power of attorney (POA), who had the legal authority to make medical decisions on his behalf. The facility failed to verify Resident #2's Do Not Resuscitate (DNR) code status selection with his Power of Attorney/Daughter within a timely manner after admission into their facility, so, when Resident #2 was found unresponsive, not breathing, and, without a pulse, resuscitation was attempted. Resident #2 was transferred to the facility from a sister facility for care due to a [DIAGNOSES REDACTED]. The admitting facility failed to honor the end of life wishes for Resident #2, and his Power of Attorney representative when facility staff failed to verify his DNR code status selection upon or after admission. When the resident became lethargic, cyanotic, and slow to respond the facility called EMS (Emergency Medical Services) who administered manual CPR when the resident then became unresponsive. From the time of CPR initiation to Resident #2's pronounced death 32 minutes of lifesaving procedures were provided including multiple rounds of CPR, endotracheal intubation, and bone marrow medication injections. Failure of nursing staff to verify and obtain required documentation of Resident #2's advance directive selection to be allowed to die naturally when found unresponsive, represented a failure in the facility's admission process related to code status determination. The failure of the facility to correctly implement advance directive selection and verification resulted in findings of Immediate Jeopardy on [DATE]. On the day the immediate jeopardy was identified, [DATE], the facility census was 78, of which 11 had DNR code status selections. The Immediate Jeopardy was determined to be removed on [DATE]. Findings included: 1. Resident #2's Progress Notes, dated [DATE] at 3:32 a.m. signed by Staff A, Licensed Practical Nurse (LPN) revealed, This nurse noted that the patient was lethargic, respirations elevated, temperature elevated, hypotensive, skin dusty, nail beds cyanotic contacted to further evaluate patient, patient in bed with the head of bed elevated, patient flaccid and slow to respond. Attempted to make contact with RP (representative), unable to make contact. Will attempt to make contact again. A progress note, dated [DATE] at 3:42 a.m., signed by Staff A, LPN revealed . Patient condition worsening, EMS (Emergency Medical Services) called. A review of progress notes, dated [DATE] at 4:18 a.m., signed by Staff A, LPN revealed EMS started CPR upon arrival to facility, and RP/POA (power of attorney) contacted, stated that patient is a DNR, notified that of patient has a change in condition. EMS called, CPR in progress at this time A progress note, dated [DATE] at 4:19 a.m., signed by Staff A, LPN revealed Patients family educated that we do not have a DNR (State of Florida Do Not Resuscitate Order Form (Golden Rod)) and that the patient would be a full code . According to a Florida Department of Health web page, dated [DATE], a(NAME)Rod is a form developed by the state of Florida to be a portable communication of a patient's wishes to not be resuscitated. The original intent was use by EMS personnel. It is called the(NAME)Rod because in order to be legally valid this form MUST be printed on yellow paper prior to being completed. http://www.floridahealth.gov/about/patient-rights-and-safety/do-not-resuscitate/index.html A review of Resident #2's Admission Record, revealed an admission date of [DATE] with a designated POA for care and financial decisions. During an interview on [DATE] at 10:22 a.m. Resident #2's POA stated her father was on hospice care prior to arriving to the facility. The POA stated no one from the facility discussed Resident #2's advance directive information or DNR code status selection/paperwork requirements prior to Resident #2's change in condition on [DATE]. The POA stated when she was notified of Resident #2's change in condition related to difficulty in breathing, she instructed the facility nurse (Staff A, LPN) that should her father code to not initiate CPR as he had a DNR code status selection. Staff A, LPN notified her that Resident #2 was already under the care of EMS and CPR would have to be initiated if he coded due to the facility lacking a golden rod form. According to the Centers for Medicare and Medicaid Services Cardiopulmonary Resuscitation (CPR) in Nursing Homes memorandum page 9, revised [DATE], revealed The facility must ensure compliance with Federal and State requirements regarding advance directives. At the time the resident is admitted to a nursing home, staff must determine whether the resident has executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. Such a directive or instructions could be . a pre-existing medical order for do not resuscitate (DNR) . A review of Prehospital Care Report Summary, dated [DATE], page 3 revealed manual CPR was initiated by EMS at 4:12 a.m. At 4:18 a.m., a cardiopulmonary assist system-compression device was used. At 4:18 a.m. a Treatment- IO (intraosseous) Insertion Tibia Proximal was administered along with injections of [MEDICATION NAME] and sodium [MEDICATION NAME]. At 4:22 a.m. a supraglottic airway device was inserted into Resident #2's pharynx to assist with ventilation. At 4:34 a.m., Resident #2's care was transferred to hospital staff. A review of Resident #2's Emergency Department Documents, dated [DATE] at 4:36 a.m., page 4 revealed The patient presents in [MEDICAL CONDITION]. The onset was 15 minutes ago. Witnessed arrest EMS . Pre-arrival Treatment cardiopulmonary resuscitation, [MEDICATION NAME] ([MEDICATION NAME]). Preceding symptoms unknown . Per EMS, was called due to pt (patient) w/ (with) agonal breathing. Upon EMS arrival, agonal breathing continued and upon hooking pt up to cardiac monitor pt proceeded into PEA (pulseless electrical activity) . EMS . performed multiple rounds of CPR Per EMS, pt is DNR, but unable to show paperwork . Page 6 revealed Endotracheal intubation . Oral intubation: A 7.5 ET (endotracheal) tube was inserted, using a curved blade, Secured: measures 25 cm (centimeters) at the teeth . Total time: 15 minutes . Resident #2 was pronounced expired on [DATE] at 5:17 a.m. According to the Journal of Intensive Care, published [DATE], revealed, Effective chest compression remains the cornerstone of successful CPR, and manual chest compression is still a standard procedure. However, a variety of internal injuries to intra-[MEDICATION NAME] organs as well as abdominal viscera has been recognized Generally, pericardial injury develops together with rib or sternal fracture. During repetitive compressions of the chest wall, displaced fragments of rib or sternal fracture directly injure the pericardium and the heart . The study can be found at https://jintensivecare.biomedcentral.com/articles/10.1186/s[DATE]-5#:~:text=Although%20chest%20compression%20is%20a%20standard%20technique%20in,dissection%2C%20many%20patients%20die%20before%20reaching%20the%20hospital. 2. Resident #2's Admission Record revealed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. His Barden Scale for Predicting Pressure Sore Risk, dated [DATE], revealed he had very limited sensory perception and mobility, with a nutritional intake of nothing by mouth. A review of Resident #2's primary care physician consultation note from the Transferring Facility, obtained from the closed record at the facility, dated [DATE], revealed . Originally admitted with history of not eating for about 4 days prior Showed problem with swallowing. Peg tube placed Given his terminal status of Dementia at hospital discussed with family who agree to return to (Transferring Facility) under the care of hospice . PSYCH: oriented to name only, confused, poor eye contact, speech diminished output . review of the resident's medical record revealed [REDACTED].#2 signed and dated by the POA and a Physician on [DATE]. The fax was dated [DATE] and timed 04:27 a.m. There was no information regarding the sender. A review of Order Summary Report, revealed an active advance directive order, created on [DATE] by Staff A, LPN, for full code. An interview was conducted with Staff M, LPN on [DATE] at 4:17 p.m. She confirmed she was assigned to Resident #2 when he arrived in the facility for admission from (Transferring Facility). She confirmed determining a resident's code status was part of the nursing assessment process with new admissions and that a nurse was supposed to confirm with resident, family, doctor within first few hours. She stated she was not involved in that part of Resident #2's admitting process because Resident #2 fell and was transferred to the hospital for evaluation within the first two hours of being in the facility. Resident #2's Progress Notes, signed and dated [DATE] at 7:50 p.m. by Staff M, LPN revealed resident arrived at approximately 3:45pm via ems on a stretcher . alert with confusion peg tube intact . I immediately called the DON (Director of Nursing) and she agreed that I should call EMS .ems arrived around 4:30 (p.m.) and transported the resident back to the ER (emergency room ) will continue to monitor. A review of Change in Condition form, dated [DATE], revealed Resident #2 fell . Page 5, Section 11: Advance Care Planning Information (the resident/patient has orders for the following advance care planning) revealed full code selected. Page 6 reflected the POA was notified of the event on [DATE] at 7:50 p.m. During an interview on [DATE] at 10:22 a.m., the POA stated the facility did not contact her about Resident #2's fall. The POA stated she was notified that Resident #2 was in the ER due to the ER nurse contacting her to verify what facility he should be discharged back to. The POA stated when she spoke to the DON regarding not being contacted about her father's fall prior to his discharge to the ER, it seemed like she was trying to sweep it under the rug saying that it could have been that they didn't have my contact information, which is just not true. Resident #2's Progress Notes, signed and dated [DATE] at 11:39 p.m. by Staff A, LPN revealed Patient return from ER with no new orders . Patient care provided by nursing staff. Resident #2's Progress Notes, signed and dated [DATE] at 8:56 a.m. by the DON revealed IDT (interdisciplinary team) meeting held to review resident's observation on floor on [DATE] MD (Medical Director) notified . Resident returned same shift . MD, resident and family are aware of plan of care and are in agreement. Review of Resident #2's record revealed a Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated [DATE] and showed information related to when Resident #2 was admitted from a hospital to the Transferring Facility, in Section H: Advance Care Planning, no box was selected. Interviews were conducted with Staff A, Licensed Practical Nurse (LPN) on [DATE] at 12:10 p.m. and on [DATE] at 6:27 p.m. It was revealed during these interviews she was the assigned COVID-19 positive designated unit nurse on [DATE] when Resident #2 returned from the hospital due to his fall, and on [DATE] when Resident #2 had the change in condition. She confirmed it was a nurse's responsibility to determine the code status for a new admission during their admitting assessment process. Regarding documents used in this determination, Staff A said, We have the 3008 and normally we verify through medical records or the family or both but normally we can verify through the medical records . normally want to go ahead and do it as soon as they get in (determining a resident's code status), if I don't see any advance directives or DNR documented then (I) verify with the family, if we don't have a documented DNR then couldn't make them one, if nothings on the paperwork then I'd normally call the facility that they came from and the family. Regarding the paperwork for Resident #2, Staff A reported that she did not recall finding a 3008 form for the resident and said, nothing was in paperwork for the resident revealing DNR. Staff A, LPN confirmed that she had entered an order for [REDACTED].#2 sometime during her shift when he was first admitted but was unable to reach her and could not recall if she left her a message. She confirmed she did not document the contact attempt and could not provide a reason why she did not document it. She confirmed she should have documented the attempt according to facility and documentation expectations. Staff A confirmed Resident #2 was not someone who could make his own decisions. Staff A confirmed she did not attempt to contact the POA for Resident #2 again until he had a change of condition on [DATE] when she attempted contact for the purpose of informing the POA of the change of condition. Staff A said, the event occurred around 4 a.m. in the morning .I went into his room and it was kind of difficult to arouse him and um so I took some lung sounds and there were some crackles and stuff, he was different than when he had first come from the hospital, (I) went through (his) chart and didn't see a DNR, tried to get vital signs and couldn't get any on him, called the doctor, then called EMS, called the daughter to let her know what was going on with her dad, told her he wasn't doing good and I was calling EMS to get him transferred out, she told me he was supposed to have a DNR, explained to her that he didn't have one on his chart. Staff A stated she looked through Resident #2's medical chart to find additional medical history information that might assist in her assessment of his change in condition and found something scribbled across a piece of paper that said hospice and a company that was (Hospice Company). Staff A confirmed the following timeline of calls made after assessing Resident #2 had a change in condition: 1) called the resident's physician who ordered to call EMS and have resident transferred to the hospital; 2) called EMS; 3) called POA and left message for her; 4) called facility where resident had transferred from; 5) called hospice company. Staff A confirmed that she placed the call to the Transferring Facility in order to get hospice information stating, . I wasn't familiar with him and happened to just see that on the top of a sheet of paper. Staff A, LPN reported that the nursing staff she spoke with at the Transferring Facility were agency staff and nobody was able to provide her with any information about Resident #2. Staff A reported that after she spoke with the other facility she researched the contact information for the hospice company using the internet, contacted them, they confirmed Resident #2 had been under their care at the other facility, and they stated they would send a hospice nurse to the facility. Staff A confirmed that there were no orders for hospice or evidence that resident was receiving hospice services at the facility. Staff A reported that right after that the daughter called me back, I was telling her about the change in condition, that EMS was there .she said he was hospice and supposed to have a DNR, I told her I didn't see one on the chart and that legally had to have one, I told her at that time EMS was in the room with her dad. Staff A said, When they (EMS) were putting him (Resident #2) in the ambulance I called her (Resident #2's POA) to let her know they were leaving with him and that's when she said that hospice nurse was bringing the DNR .I told her that when EMS had been pushing him out of the room he coded and they had started CPR. Staff A stated she told the POA that there was no point for the DNR to be sent to the facility because Resident #2 was on his way to the hospital and she recommended it be sent there. Regarding the faxed copy of the golden rod found in the closed file for Resident #2 with date/time stamp of [DATE], 4:27 a.m., Staff A stated to her knowledge the fax came from the hospice provider. She said, the daughter never informed me that a DNR (golden rod) was coming over the fax, and said, I am on the COVID unit and the COVID unit does not have a fax machine. Staff A said, an hour before end of shift another nurse (Staff B) brought it to me, I think what she said was that the hospice nurse brought it to the facility, I never talked to the hospice nurse, I don't know for sure positively if she (Staff B) said the lady brought it to her or faxed it to her. An interview was conducted on [DATE] at 2:59 p.m. with the DON. She reported that Staff A had confirmed with her that she had tried to contact Resident #2's POA about the code status during his admission but did not document the attempt and could not provide a reason for not documenting the attempt. The DON said, and if it's not documented, it didn't happen. An interview was conducted [DATE] at 1:45 p.m. with the DON & the Social Services Manager (SSM). The SSM confirmed she had some responsibilities related to confirming and establishing advance directives and code status for facility residents. She explained she was a double checker to ensure that code status for residents was accurate and that if a resident had a DNR the golden rod paperwork was on file in all the necessary places. She stated there was no specific expectation on a timeframe for completing this process for new admissions and said, Usually within 72 hours depending on what day of the week they're admitted , not a set standard, I'm not here on weekends, and I try to verify it (code status) a couple days after admission. The SSM and DON reported that the SSM was responsible for completing a weekly audit to confirm accuracy of advance directives and code status documents for all residents in the facility. The DON confirmed that nursing staff had primary responsibility for initiating the process of determining code status when admitting a new resident and said, we look on the 3008, if they come with a DNR we make sure it's (golden rod) on the chart, that it's all uploaded, that the order's there. The DON stated that if a resident arrived without a 3008 form that the facility would call the referring provider and get one saying, . not supposed to admit a resident without a 3008, if not in the packet we get it right away. The DON stated that if nothing was entered on the 3008 form or any other document regarding advance directives or code status then the process was to ask the resident or their decision maker. The DON stated that every new admission record was audited the morning after their admitted by a clinical team who met every morning Monday-Friday. She stated that if a resident was admitted on a weekend then that audit would occur on the following Monday. She stated that the audit process was to go through the whole admission and verify everything including the code status. The DON confirmed that when a resident was admitted they were entered as a full code if status could not be confirmed immediately and remained full code until status of DNR could be established and documents fully formed and established. An interview was conducted on [DATE] at 4:54 p.m. with the Business Development Coordinator (BDC) regarding her process and responsibilities for new admissions. She confirmed there was an assessment packet that contained documents that she gathered and provided to the nursing staff to aid in their process. She said, as far as the advance directives that usually is not done until admissions (until nursing admits the resident), the 3008 will say they are a DNR or full code, if they are a DNR we would call the hospital to see if they have the DNR (golden rod), if not then we contact the family. She said, if the DNR paperwork is not in hand, and that documentation is not in place then they are a full code. She stated that there was a facility generated admission packet of admitting forms that was completed by facility staff after the resident was admitted and stated that admission paperwork needed to be completed within ,[DATE] hours, and that paperwork for Resident #2 was not completed here because he came from a sister facility. The BDC confirmed that the admission packet contained a notification and consent form regarding advanced directives and that education is provided to new residents before they are admitted about advanced directives, that the facility can help them with establishing, and that until a resident has documents in place for DNR then they are considered a full code in the facility until that documentation is in place. Regarding Resident #2, the BDC stated that she had not personally handled his admission. She said, he was a transfer from a sister facility, he tested positive for COVID-19, (the) liaison (Community Care Liaison) took care of this information, got this documentation faxed to us, and they were (already) in-route (to the facility), he came with a discharge packet. The BDC said, the other facility should have sent us his DNR form (golden rod) in his package (discharge packet), but was unsure of what the Community Care Liaison requested. Regarding the 3008 form, the BDC stated that it was required for a transfer admission but was unsure if that was the facility policy. Regarding 3008 forms, the BDC stated they had to be current within 30 days prior to their admission or transfer and that a resident could not be admitted without an updated 3008 form. An interview was conducted on [DATE] at 8:01 a.m. with the Community Care Liaison (CCL), the Administrator (NHA), and the DON. The CCL confirmed that she was familiar with Resident #2 but had not performed the admission process or participated in gathering the admission packet for the resident; she stated that her only involvement was receiving the call from the Transferring Facility when they called to inquire about whether the facility could accept Resident #2. The CCL stated that she happened to answer the phone, took the call, consulted with the facility business office and at that time it was determined the facility was not going to accept the Resident. The CCL stated that she was not involved in the case after that. The NHA confirmed that at first Resident #2 was denied admission to the facility because of his financials, however, the corporate Regional Vice President (RVP) contacted her and advised to accept Resident #2 and informed her that the resident was being transported to the facility for admission. The NHA stated Resident #2 was admitted with whatever documentation he had with him and said, we never saw the package (admission packet) at this point. The NHA said, this was not a normal admission, stated that she did not verify what information was coming with the resident and that she was not involved in the admitting process after the phone call from the RVP. The NHA said, the normal processes in place did not occur with this resident because of the haste of the transfer. The DON stated the day after Resident #2 was admitted to the facility she began requesting additional missing documentation from the Transferring Facility. An interview was conducted on [DATE] at 5:02 p.m. with the DON. She stated that for a DNR code status selection to be honored for a resident, the golden rod must be signed by the resident, if able, or the representative if the resident is not able, and the physician. She said, if that form is not in place then they are a full code, if we attempted to contact someone and they did not answer, and they do not have the DNR form (golden rod) in place then they would be made a full code. The DON stated the facility does not have a defined set amount of times for attempting contact with the family stating, we contact until we reach them. She said, the policy at (name of facility corporation) is that the DNR form (golden rod) must be completed to be considered a DNR .the resident is educated on the fact that if they want to be a DNR but there is no completed golden rod then they would be considered a full code Do not have a set amount of times to contact the family, we contact until we reach them. The DON confirmed the standard process when handing off care to EMS was to provide advance directive information about the resident including providing the golden rod if on record. She said, EMS would determine if that was sufficient for them. Regarding Resident #2, the DON said, with this particular Resident, he came, left to the hospital, then came back late, so the nurse did try and call the family and they did not answer. The DON stated she would anticipate another attempt would have been made the next day to contact the family. She confirmed that the clinical team did have a meeting the following morning to review Resident #2's admission and did not catch the need to confirm code status/advance directives. She stated that during this audit she looks for the completed DNR form and if one is not found the resident would be a full code and that is where social services gets involved within 72 hours. The DON stated she would expect a nurse to document any attempts they were making to contact a family member or responsible party for determining code status or DNR status. An interview was conducted on [DATE] at 10:08 a.m. with the corporate RVP and the corporate RDON. The RVP confirmed that Resident #2 was transferred to the facility due to positive COVID status and said that the transfer was rushed. She said, I cannot tell you much, do remember directing (Resident #2) to come to the facility due to the facility having a COVID-19 unit and it being an emergency situation. She stated that on the date that Resident #2 was transferred, the transferring facility had been notified that several of their staff members including their DON were positive for COVID as well as Resident #2. The RVP stated that the RDON was at the Transferring Facility and helped to put the document packet together of what needed to be sent with Resident #2. The RVP said, sounds like the DNR paperwork was left off .that is not the norm at all, the (RDON) is very sure that she included the DNR documents that evening during the transfer. The RDON confirmed she did compile Resident #2's documents to send to the facility. She stated she recalled that the medical records staff person at the Transferring Facility assisted with compiling the documents and faxed them over to the facility. The RDON stated she could not recall exactly what was included, but that she did print out the order summary and a history and physical document (H&P). She stated that the order summary report would have been printed on [DATE] in the morning, that she did not check the package that was sent over by medical records but that she was certain that the package included the order summary report. The RDON stated that the normal process for the admission package would be to include the DNR status information including the State of Florida Do Not Resuscitate form. She stated that she did instruct the medical records staff person at the Transferring Facility to include the DNR and the order summary report and stated the medical records staff confirmed that she understood and knew to include that information. Regarding the 3008 form, the RDON stated it was used to assist with determining code status within 30 days. She stated she did not discuss the 3008 form or complete an updated 3008 form. She stated that normally she would have completed an updated 3008 form but due to the circumstances at the Transferring Facility she did not think about it. The RDON stated she never had any discussions with the accepting facility regarding additional documentation but that she did recall a conversation with the Administrator of the Transferring Facility who reported that the facility contacted her about documentation and to her knowledge the Administrator had instructed the medical records staff to fax the DNR form for Resident #2 to the receiving facility. Review of Resident #2's medical record revealed an Order Summary Report, dated [DATE], User; (Regional DON), titled with (Transferring Facility Name) at top of the report. Review of the document revealed under order summary Do NOT Resuscitate . Communication method verbal . order status active . order date [DATE]. An interview was conducted on [DATE] at 6:20 p.m. with the DON regarding the order summary report from the transferring facility, found in the medical record, showing an order for [REDACTED].#2's medical record. During the interview conducted with Staff A, LPN on [DATE] at 6:27 p.m. she said that she never saw the order summary report from the Transferring Facility at any point in her review of Resident #2's medical record. Interviews were conducted with Staff A LPN, Staff B LPN, and the DON regarding where the faxed State of Florida Do Note Resuscitate Order form was received from and none could provide that information. An interview was conducted on [DATE] at 10:27 a.m. with the Administrator of the Transferring Facility. She confirmed she remembered Resident #2. She stated she received a call from a nurse at her facility at about 4:00 a.m., was unsure about the date of the call. She stated the nurse told her that the receiving facility was requesting the DNR status of Resident #2 because they did not receive it when he transferred there. The Administrator stated she told the nurse to find the documents in the electronic health record (EHR) system but the nurse was unable to access them and so the Administrator called the medical records staff person and instructed her to access the DNR information. The Administrator stated the medical records staff person went to the transferring facility and faxed the DNR document for Resident #2 to the receiving facility. The Administrator stated that Resident #2's daughter had also called the transferring facility that night and spoke with the facility nurse regarding the DNR form. An interview was conducted on [DATE] with the Transferring Facility Medical Records Staff Person. She confirmed she had faxed the DNR form for Resident #2 to the facility on [DATE] to a nurse (Staff B). She stated she did not know why the document was being requested, but that it was being requested by Resident #2's daughter. She confirmed and stated she was certain that she put a copy of Resident #2's State of Florida DNR form in the packet that was sent with Resident #2 when he transferred to the receivin (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling face first onto a driveway, sustaining facial injury and requiring a trip to the emergency room for evaluation for one (Resident #88) of three residents sampled. Resident #88 sustained an unwitnessed fall around 3:45 a.m. on 9/17/19 and was started on neurological checks and every 15 minute safety checks. Resident #88 was observed by his nurse at approximately 3:30 p.m. and not again until he was found unsupervised outside the front entrance of the facility at approximately 5:30 p.m. The resident fell off of the curb in his wheelchair while wearing an alarmed seat belt, landed on his face, sustained a hematoma to the right side of his head, laceration on the right elbow, right shoulder, and right temporal area and required transport to the hospital for evaluation. Findings Included: Resident #88 was admitted to the facility originally on 7/19/15 and readmitted on [DATE]. Review of his record revealed he was a [AGE] years old with [DIAGNOSES REDACTED]. Review of the resident's 9/2/19 Minimum Data Set Annual assessment showed a Brief Interview for Mental Status score of 7 (severe cognitive impairment) with Inattention and Disorganized Thinking continuously present. He required extensive assistance of one person to move in his room, in the nearby corridor and off the unit. Review of a hospital emergency room record dated 9/17/19 at 9:11 p.m. showed Resident #88 had a laceration to Right forehead from an unwitnessed fall, poor historian. The resident reported pain and underwent Cat Scans of the head and cervical spine, chest X rays, pelvic x rays, EKG(Electrocardiogram) and blood testing. Impression and plan reflected [DIAGNOSES REDACTED]. A telephone interview was conducted on 9/27/19 at 11:28 a.m. with Staff Member Q, RN, the nurse assigned to Resident #88 on 9/17/19. She stated her started shift at 3:00 p.m. on 9/17/19. Staff member Q, RN stated she saw Resident #88 on 9/17/19 about 3:30 p.m. sitting in his wheel chair in the hallway and he must have gone outside as the receptionist would let him out on the porch. After 5 p.m. sometime, Staff member Q, RN stated she received a call about someone outside on the ground. Staff member Q, RN stated Resident #88 fell out of his wheelchair on his face and broke his wheel chair. He had a huge hematoma to his right side of head. The ARNP (Advanced Registered Nurse Practitioner) came to assess him and we cleaned him up and took him to his room while the ambulance was called and he went to the hospital around 7:30 p.m. and came back that night. Staff member Q, RN restated she saw Resident #88 around 3:30 p.m. and then again after the fall around 5:30 p.m., although he was on 15 minute checks and neuro checks for a fall at 3:30 a.m. that morning. Staff member Q, RN stated she got busy with giving medication and did not see him again until after the fall although she confirmed she documented that she checked on him every 15 minutes. Review of the nursing progress notes dated 9/17/19 at 3:35 a.m. the nurse documented while at the nurses station, heard a male voice calling softly from the direction of the 300 hall. Immediately stood and went in the direction of call. Note resident in a sitting position legs bent in doorway of room facing room across the hall. Resident is alert and oriented to self, able to move all extremities without difficulty. Resident denies any pain, skin intact no bruising, no skin tear noted. Resident's destination unknown denies the need for restroom. Resident reason for leaving bed was to get dress and fix belt. neuro checks initiated, began 15 minute checks. MD notified. Review of the nursing progress notes dated 9/17/19 at 5:35 p.m. Staff member Q, RN documented, Resident in the front of the porch and he fell off the side walk. Patient was in the wheelchair and was found on the pavement face down. Call ARNP immediately and we assess the patient, the patient had hematoma in the right side of the forehead. Laceration on the right elbow, right shoulder, and right temporal area. The ARNP put in an order for [REDACTED]. Review of the nursing progress notes dated 9/18/19 at 2:18 a.m. reflected the resident returned from the hospital with no new orders and continue monitoring for fall precaution. Review of the nursing progress notes dated 9/18/19 at 9:50 a.m. reflected fall meeting held this morning, safety and neuro checks initiated. Physical therapy screening completed. Apply wanderguard to resident for safety issues. Encourage attendance in activities. Review of the nursing progress notes dated 9/18/19 at 2:23 p.m. reflected has no memory of falls on 9/17/19, bruising areas to arms and hands, small area to forehead checks at baseline. Monitored every 15 minutes today. Review of the nursing progress notes for skin dated 9/18/19 at 3:30 p.m. reflected head to toe skin observation completed follow up return from hospital stay post incident 9/17/19. 2x2 cm hematoma noted to right temple, to leave open to air. 1.0 cm scratch noted to bedside right eye, to leave open to air. Right arm 0.3 cm scratch to leave open to air. Right hand little finger skin tear noted to leave to air. 1.2 cm skin tear noted right elbow treatment in place. discoloration noted to right shoulder front/rear 10x10 cm. physician notified. Review of the nursing progress notes dated 9/20/19 at 3:06 a.m. reflected resident is sleeping, no distress noted post fall, able to make needs known but confused sometimes. During an interview on 9/26/19 at 4:36 p.m. with Staff member G, RN, Assistant Director of Nursing (ADON) and the Director of Nursing (DON), Staff member G, RN stated the resident's last fall was on 9/17/19, he fell on front of the porch in the sitting area at 5:35 p.m. Resident #88 fell in his wheel chair on the pavement. He was not allowed out unless someone was with him. He was trying to turn to come back in and was closer to the curb. Resident #88 likes to sit in the sun. He turned and was found on his face but was on his right side because he wearing his seatbelt. The receptionist was at the desk. He did not have a wanderguard at the time. When he goes out we should be watching him. The receptionist is there till 8 p.m. at night. she will let someone know if she has to do something and that he needs to be watched if he is outside. Staff member G, RN stated no one saw him fall. The receptionist did not see him fall but heard it. His ARNP was here in the building and assessed him. He had injuries to his forehead and elbow with a laceration. The ARNP wanted to have a cat scan and x-ray but chose to send him out to the hospital instead. He came back the next day. Staff member G, RN stated, We found that he was trying to come back in and because he was sitting in the sun close to the curb, he turned around and his wheel was too close to the curb. He could push the button to open the door to come back in. We did put the wander guard on him for safety so he has to be escorted out and we initiated an 11 p.m. to 7 a.m. aide to come in and sit with those residents who like to keep busy. That person just started so we have not dedicated anyone to taking him outside. Staff member G, RN stated the resident went outside by himself and is alert and oriented. We encourage him to go out, he loves the sun. During the conversation on 9/26/19 at 5:03 p.m. The DON (Director of Nurses) and Staff member G, RN, ADON stated that the resident was being watched by the receptionist while he was on the front porch. The DON stated the receptionist has not been trained to care for residents and was unsure how long the resident was out on porch when he fell . The administrator walked in the room during the Interview on 9/26/19 at 4:40 p.m. and stated they are looking into getting a fence to put on the porch after the incident so residents can go outside safely without the worry of falling off the curb. We decided to hire a fencing company that will be out on 9/30/19 to mark and measure where the fence will go. The Administrator stated the resident was not a wanderer and was allowed outside alone. During an interview on 9/27/19 at 11:05 a.m. with the ARNP, she stated she heard the call and went out front on the drive way to assess the resident. He was in a sitting position with his legs stretched out on the ground in the driveway area. He was assessed and could move all his extremities and he was put back in his wheel chair. He had right sided head hematoma with bruises on the right pinky with a laceration on the right elbow and below the right eye. He was not on blood thinners and it was a non emergent situation so the ambulance service may take an hour to an hour and half to come get the resident. The ARNP stated she was told someone was keeping an eye on him but not sure from where. The ARNP walked to the front doors and pointed to the leftside of the drive way area from inside the building where she observed the resident and assessed him. She walked outside the front doors to the left of the building and walked down the sloping side walk and pointed to the side walk and curb where Resident #88 fell down to the driveway in his wheel chair with alarmed seatbelt. The area was approximately nine feet away from the far right column at the main entrance of the facility. The Receptionist area could not be viewed from this area. Photographic evidence obtained. During an interview with the Regional Nurse Consultant on 9/27/19 at 11:25 a.m. regarding the investigation on the resident's fall on 9/17/19. She confirmed the fall investigation on the 9/17/19 fall at 5:30 p.m. included one witness statement from the nurse on duty that evening which was the resident was found by the receptionist on the drive way face down. The resident fell off the wheelchair into the pavement. Resident was assess by ARNP. During an interview on 9/27/19 at 12:49 p.m. with the Director of Rehab, she confirmed Resident #88 was currently on occupational therapy since 8/21/19 and that speech therapy completed on 8/28/19. Resident #88 was discharged from physical therapy on 7/22/19 after getting picked up on 3/13/19 for falls. His cognition has changed and that has impacted his therapy. We used a global deterioration scale (GDS) to test his dementia. We tested Resident #88, he is now a 5 on the GDS scale with 7 being the worst on a scale of 7. Someone scoring a 1 would be normal and a score of 4 would start seeing dementia. Resident #88 was a 4 in (MONTH) and transitioned to a 5. In that period there is a big milestone change. A score of 4 you can still learn, a 5 it is a major milestone he can not learn new information. He has disorganized thoughts and he told me the other day his mother was another resident. He was fine later that day but that's what happens with dementia. A few months ago they had to change his room and we had so many issues trying to orient him to a picture he picked out so he could find his room. He has a self alarming seat belt which would help him stop and think twice due to the loud noise it makes when you release it. Last week he had a recert for occupational therapy. He received another wheel chair after the fall on 9/17/19 since the arm rest was broken. Resident #88 self propels, he goes all over the place. Occupational therapy has been working on wheel chair mobility outside in response to the first fall off the curb in August. Therapy would never let him outside alone due to his cognition. The therapist will work with him outside since his wheels came off the side walk in both falls out front. Therapy picked him up after the first fall off the curb out front on 8/20/19 to get him safer outside. When he started he was contact guard and now he is modified independent for wheel chair mobility but would still need to be observed due to his dementia. He has been on therapy 12 different times since he has been in the facility. He is now in the sunshine group and occupational therapy takes him out. Anyone can take him outside. During an interview on 9/27/19 at 8:42 a.m. with Staff member G, RN, ADON to discuss Resident #88's falls, she stated Resident #88 fell on [DATE] around 3:35 a.m. Staff member G, RN stated, Resident #88 had two falls on 9/17/19. Staff member G, RN, ADON stated, the nurses at the nurses station heard voices and saw the resident sitting in the doorway of his room. He was oriented to self with no injury. He was trying to go to the bathroom and get himself dressed. He does not normally do that on his own. He was wearing non skid socks, a gown and brief. Since he does not usually do that so we offered to get him up early. We started safety checks every 15 minutes for 72 hours, neuro checks and therapy screening. The intervention was to get him up early if need be. Staff member G, RN stated Resident #88 fell on [DATE], it happened between 7:00 p.m. and 7:15 p.m., the staff took Resident #88 in the room and toileted him. While the aide was getting his bed ready, Resident #88 attempted to get up off the toilet and slid off to the floor. It was an unwitnessed fall with the aide in room. He was wearing a shirt, non skid socks, while sitting on the toilet. The interventions were not leaving the resident in the bathroom unattended and another therapy screen. Staff member G, RN stated Resident #88 fell on [DATE] but did not have the time documented on the root cause analysis. Staff member G, RN stated her notes show the fall occurred at 5:15 p.m. with the resident sitting out front on the front porch, the receptionist went out and asked the resident to come back in. Resident #88 turned his chair around and he tilted off the curb. He landed on his side off the curb. He came out of the wheel chair and was sitting on his butt. No injuries observed. He rolled off the curb on the right side. He was in sight if you walked to the door and looked to the right. When asked what happened, Resident #88 stated he was coming in when the chair got too close to the curb. Resident #88 was assessed, no pain, he was assisted up to the chair. We started safety checks and neuro checks and physical therapy assessed. At the IDT (Interdisciplinary Team Meeting) we came up with the need to make sure he was with someone while outside and ongoing education before going outside. We put him in the Sunshine group, activities takes the residents outside. During an interview with staff member U, RN, Unit Manager on 9/27/19 at 1:49 p.m. she confirmed when a resident is started on safety checks they should be observed every 15 minutes for safety and that continues and is documented for 72 hours. During an interview on 9/27/19 at 1:28 p.m. with the DON she confirmed that the nurse should visualize the resident every 15 minutes and document. If the nurse did not visualize the resident they should not be signing off on the document as that could be grounds for termination. Review of the resident's record revealed a document titled Resident Safety Check dated 9/17/19 with the resident's name on the bottom. Initials beside the blanks provided for each 15 minute check began at 3:45 am and continued until 7:30 pm. From 7;30 pm on 9/17/19 until 2:30 am on 9/18/19 the document was marked Hospital. Review of Resident #88's progress notes revealed the following in regards to the resident's falls in (MONTH) 2019: 8/30/19 IDT Meeting held this morning on fall, interventions put in place. Not to leave the resident in the bathroom unattended, continue neuro and safety checks. PT screen also in place. signed Staff G 8/29/19 At 7:10 pm I was notified by the CNA that (Resident #88) was placed in the toilet and the patient attempted to get up and slide of the toilet. Patient is on the safety check and neuro check. signed Staff Q 8/21/19 IDT New interventions put in place pertaining to fall on 8/20/19. Resident will make sure that someone is with him when he's outside. Activities made aware to add resident to sunshine group. 8/20/19 Resident stated he was wheeling chair too close to curb and fell , resident was educated on the importance of asking for assistance and being inside if feeling tired. 8/20/19 receptionist found resident on the floor on buttocks in front by the receptionist. Resident has no new injuries. .resident started on q 15 minute checks and neuro checks, will continue to monitor for changes, call light in reached. Review of the resident's record revealed a Care Plan for actual fall with no injury initiated 9/13/19 with the focus of: trying to get up to get dress, no injuries 9/17/19 and the wheelchair rolled off the curb, abrasions, hematoma and skin tears 9/17/19. Interventions included: 9/17/19 Bed in low position 9/17/19 at 5:35 p.m. physical therapy screen, neuro checks, safety checks, placed on 1:1 (one to one) until sent to the ER for CT scan and x-ray right shoulder, secure care monitor placed so he doesn't go outside unattended (not an elopement risk), already has self releasing alarm seat belt on wheel chair (can release on request) 9/17/19 at 3:35 a.m. physical therapy evaluation, neuro checks, staff to apply non-skid socks at bedtime, safety checks, do not place clothing within eye sight when sleeping, change out of clothes at bedtime, 8/20/19 PT screen, neuro checks, safety checks, therapy to address wheelchair mobility when outside of facility, can add to sunshine activity group. 8/29/19 PT screen, neuro checks, safety checks, when assisting with toileting do not leave resident unattended Review of the resident's record revealed a Care Plan for the focus of: at risk for future falls due to CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), dementia, confusion, gait/balance problems, incontinence, psychoactive drug use, history of falls, initiated 9/13/19. The interventions, all initiated on 9/13/19 were: the resident uses alarming seat belt, evaluate for adaptive equipment as needed, the resident needs activities, PT evaluate PRN (as needed), appropriate footwear, educate resident/representative and care givers about safety reminders and what to do if fall occurs, call light in reach, anticipate and meet needs. During an interview and observation on 9/24/19 at 10:22 a.m. with Resident #88, he was seated near the nurses station in his wheel chair with the seat belt alarm attached and stated just a lost boy looking for his mommy while looking around the area. During an interview and observation on 9/26/19 at 8:45 a.m. Resident #88 was observed selfpropelling in his wheelchair with an alarmed seatbelt and wanderguard to the left leg. Resident #88 stated he was going to eat while heading toward the 100 hallway side door when a staff member went to redirect him and turn him around to head towards the dining room. During an observation of Resident #88 on 9/26/19 at 3:45 p.m. with staff member V, CNA, Resident #88 displayed disorganized thought process and was difficult to understand mumbling and gesturing to staff member V, CNA to find his hat that was on his bed at his other house. Staff member V, CNA showed Resident #88 his bed and stated he did not have a hat on his bed. The resident spoke loudly and stated, Not this bed, the one where I live. Staff member V, CNA attempted to orient the resident and asked if she could change the resident who was noticeably wet and odorous. Review of the policy and procedure for Resident safety checks, document N-1275 with revised date of 8/24/17 one page reflected: Initiate Resident safety check with intervals designated by physician or clinical nurse noting reason for form. Check resident at required intervals. Initial form indicating check was completed. Form is filed in medical record. Review of the policy and procedure Fall Management , document N-1259, revised on 7/29/19 revealed a Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall and minimize the potential for a resulting injury. The Process included: Post Fall Strategies: 1. Resident will be evaluated and post fall car provided. 2. Initiate Neurological checks as per policy or directed by physician order 3. Notify physician and resident representative 4. Re-evaluate fall risk utilizing the Post Fall Evaluation 5. Update Care Plan and Nurse Aide Kardex with interventions 6. Initiate post fall documentation every shift for 72 hours 7. Interdisciplinary Team to review fall documentation and complete root cause analysis 8. Update plan of care with new interventions as appropriate 9. Review resident weekly x 4

Based on observation, medical record review and interviews with staff, the Advanced Registered Nurse Practitioner (ARNP) and the facility Administrator, the facility failed to notify the medical care provider of an abnormal radiology report resulting in a delay in treatment for one (Resident #3) of five sampled residents. The resident complained of pain in the shoulder after a fall and had an x ray ordered on [DATE] at 5:11 pm. The X-ray found an acute impacted fracture to the humerus bone, results were sent to the facility on [DATE] at 9:43 pm. Facility staff were unaware of the X-ray results showing a fracture. The resident complained of severe pain the next day, 7/6/19, another x ray was ordered with the results being Impacted fracture right humeral head neck. No change. The resident was sent to the emergency roiagnom on [DATE] at 3:53 pm. Findings included: On 8/11/19 at 8:10 a.m. Resident #3 was observed lying in bed in an upright position with the table tray across the bed eating breakfast. The resident had a sling in place to the right arm with a strap around the neck. When asked what happened the resident stated I was looking at the birds outside the window and I fell and hurt my shoulder. The resident was unable to state when this occurred. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had been transferred to the hospital on [DATE] for abnormal x-ray results. Review of all completed and discontinued orders for Resident #3 revealed a completed order on 7/5/19 for X-ray 2 view of Right Shoulder for complaints of pain and chest x-ray PA and IA to rule out pneumonia one time only and a discontinued order on 7/6/19 for Right shoulder x-ray one time only for pain. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. One dose of [MEDICATION NAME] 650 mg was administered to Resident #3 and signed off by staff on 7/6/19 at 10:00 am. Review of the ARNP notes dated 7/5/19 revealed the following: 82 y/o WM pt seen today at the request of nursing staff, they report that pt didn't eat breakfast and during lunch he had an episode of emesis. After having the emesis pt became more weakened and almost fell when he was being transferred back to bed with the sit to stand. Staff also report that pt had a small amount of vomit discharge from his nose. Pt became less responsive at that time but when questioned by me at the bedside pt became fully awake and responsive. A reported R(right) shoulder pain but denied any falls or injury that he could recall. When evaluated the R shoulder was found to be swollen anteriorly, labs and x-rays ordered at this time. Pt also started on an antiemetic. I will also order a swallow eval. Review of the progress notes for Resident #3 revealed the following: 7/5/19 17:11 (5:11 pm) Resident in wheelchair sign and symptoms of vomiting and lethargic new order for chest x-ray PA and lateral view to rule out pneumonia, and x-ray of right shoulder for c/o (complaints of) pain. 7/5/19 22:39 (10:39 pm) Resident was vomiting and was weak. Notified ARNP and order CBC (complete blood count), CMP (complete metabolic panel), chest X-ray, shoulder X-ray, [MEDICATION NAME], speech consult. 7/6/19 07:33 am, x-ray results in, lab results pending at this time. No vomiting observed during this shift. 7/6/19 08:30 am, This writer inquired with night shift nurse during report as to if MD or ARNP was notified off X-ray results that were received- x-ray results were received at the following date and time to facility: 6/5/19 at 2143 (11:43 pm) This writer was given in report that night shift nurse spoke with ARNP and she would be in today to evaluation. signed Staff C, LPN 7/6/19 08:34 am, This writer observed during walking rounds with off going night shift nurse that this patient has bruising to right shoulder. Night shift nurse stated ARNP is aware of results of x-ray two chest and right shoulder. Night shift nurse advised that the ARNP would be in to evaluate patient today this afternoon. Patient complains of right shoulder pain patient was administered PRN Tylenol. Will follow up. signed Staff F, LPN 7/6/19 11:01 am, MD notified resident in severe pain of the right shoulder, x-ray ordered 2 view signed Staff D, LPN 7/6/19 15:07 (3:07 pm) x-ray tech arrived now at 1507 to do right shoulder x-ray signed Staff D, LPN 7/6/19 15:53 (3:53 pm) x-ray results received via fax at 1543 patient has fracture to right humeral head. MD was notified of x-ray results of positive x-ray result. MD aware, advised to send to ER signed Staff F, LPN Review of radiology reports for Resident #3 revealed the following: 1-Date of service: 7/5/19 Examination: Shoulder complete min 2V, right Conclusion: Acute nondisplaced common, impacted proximal right humeral fracture neck Electronically signed by radiologist: 7/5/19 9:39:58 PM ALERT printed across page 2-Date of service: 7/6/19 Comparison: 7/5/19 Examination: Shoulder complete min 2V, right Conclusion: Impacted fracture right humeral head neck. No change. Electronically signed by radiologist: 7/6/19 3:42:56 PM An interview was conducted on 8/11/19 at 1:50 p.m. with Staff A, Licensed Practical Nurse (LPN) and Unit Manager. Staff A, LPN stated she was told that a second x-ray was done on Resident #3 because the first x-ray report did not have an alert across the paperwork. She stated the staff nurse told her that the ARNP was going to follow up the following afternoon after the incident. An interview was conducted with the Administrator on 8/11/19 at 3:00 p.m. The Administrator stated that during his investigation into the fall for Resident #3 the nurse on the afternoon shift told him the only report that she saw was the chest x-ray report. He stated the nurse reported she had not received the report for the shoulder x-ray. He stated the facility received the report from the first x-ray after they ordered a new x-ray on 7/6/19 because the radiology facility informed them a shoulder x-ray had already been completed on 7/5/19. The Administrator stated that during the investigation he discovered that neither the afternoon nor night shift nurse knew of the results from the shoulder x-ray completed on 7/5/19. The Administrator stated he discovered during his investigation the night shift nurse had received a call from the radiology facility asking them if they had received the x-ray reports and the nurse told them yes. An interview was conducted with Staff B, Registered Nurse (RN) on 8/11/19 at 3:26 p.m. Staff B, RN stated she was caring for Resident #3 on 7/5/19 on the afternoon shift. She stated she was not aware that the resident had suffered a fall. She stated the nurse aide came to tell her the resident was sick and vomiting and wanted me to assess the resident. She stated she assessed the resident and informed the ARNP so the resident would be seen. She stated the day shift nurse gave her report and she did a change of condition report in the computer for the vomiting. She stated she did not do a report about the fall because she was unaware there was a fall. She stated she was called the next day and told of the fall. She confirmed she was told that labs and x-rays were ordered on Resident #3 and that she knew that a chest x-ray and shoulder x-ray were ordered. She stated she was told by the day shift nurse that the ARNP had ordered an x-ray of the shoulder because the resident complained of pain. She stated she did receive the chest x-ray results around 9 p.m. She stated the chest x-ray was negative and she confirmed she did not call the ARNP with the results. She stated she gave report to the night shift nurse, gave her the chest x-ray results and told her they were still waiting for other results. She stated she asked the night shift nurse to call the doctor or wait until the ARNP came in to see the resident the next morning and show her the results. She stated normally she would call and give the results to the doctor but she was trying to finish charting and give report. An interview was conducted with the Administrator on 8/11/19 at 3:45 p.m. The Administrator stated that the expectation would be the nurse file a report about a fall, do an assessment of the resident, and notify the provider and make sure all of the circumstances are documented in the medical record. The Administrator confirmed that a fall report was not done at the time of the incident because the nurse aide had not reported it to the nurse and had only told the ARNP. The Administrator stated the ARNP assumed the nurse was aware of the fall. He confirmed the nurse should have been looking for the results. He stated the nurse aide involved in the incident was terminated and the day shift nurse who sent the resident out for treatment was no longer with the facility so neither staff member was available for interview. An interview was conducted with the ARNP on 8/12/19 at 10:45 a.m. The ARNP confirmed she was responsible for the care of Resident #3 and had been present in the facility on 7/5/19 the day of the incident. The ARNP stated she was told by nursing that the resident was nauseated, weak and vomited at lunch. She stated she did not recall ever being told of lab or x-ray results by nursing. She stated the expectation would be that nursing notify her of results within a 24 hour period if it is not a stat order or within a few hours if a resident's condition is abnormal. The ARNP stated she was made aware the Resident #3 was sent out to the hospital later on. She stated she did not know why she was not notified of the abnormal x-ray results. An interview was conducted with Staff C, LPN on 8/12/19 at 11:40 p.m. via telephone. Staff C, LPN stated she had provided care for Resident #3 on the night shift on 7/5/19 into the day shift of 7/6/19. Staff C stated she received report from the afternoon shift nurse and was given a chest x-ray report. She stated she was told the ARNP was in to see the resident and suspected the resident might have aspirated. She stated she took the chest x-ray report and put it at the bottom of her medication cart so she would remember to pass it on to the next shift. She stated she reviewed the report and she noticed it was negative. She stated the afternoon nurse did not tell her if the provider was notified of the results. She stated she was fairly new to the facility and only works as needed. She stated the afternoon nurse did not tell her about an x-ray of the shoulder being done. She stated that now she does a chart check at night to make sure no orders are missed and checks the fax machine to look for any new results. She stated she was not aware of the x-ray of the shoulder for Resident #3 until the next day. She stated she did not review the orders or look for any other results during the night shift. She stated she gave report to the day shift nurse and told her exactly what she had been told. She stated she did walk around rounds with the day shift nurse and told her the ARNP would be in to check on the resident and would need the results. She confirmed she was not told anything about a fall for Resident #3. She stated the following day she received a phone call from the Director of Nursing (DON) asking about the x-ray of the shoulder and if she had received a report. She stated she told the DON she had never received an x-ray report on the shoulder and she was not aware of a fall. She stated that another nurse she was working with asked her if she had received an x-ray report when the radiology facility called during the night and she told then she had gotten an x-ray report. She stated she assumed the nurse was referring to the chest x-ray. She stated she did not have access to a computer system to look up results of tests. A review of the facility policy entitled Laboratory, Diagnostic and X-Ray effective 11/30/14 and revised on 9/21/17 revealed the following: Policy: To provide guidance on ordering, obtaining, documenting and reporting laboratory, diagnostic and x-ray results. Procedure: Results of laboratory work, diagnostic test, and x-ray to be sent to the Center ----Stat testing results or critical values to be called to the Center The Center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order Document notification of the practitioner and resident/resident representative of results

Based on interviews with the facility ' s nursing and administrative staff, a family member, social worker, physicians, review of clinical records, and facility policies, it was determined that the facility failed to protect the rights of residents to refuse Cardiopulmonary Resuscitation (CPR) for 11 (#1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12) out of 12 residents reviewed. The facility initiated CPR on resident #1, a [AGE] year old, alert and oriented resident who had stated on admission that he did not want to be resuscitated and CPR was done against the resident ' s expressed wishes. The facility failed to honor resident #2 ' s right to formulate an advanced directive and denied the resident/family and opportunity to refuse treatment and sign a DNR. The facility performed CPR on resident #2 without clarifying her wishes on admission and during the three months of her stay. The facility called 911 on both residents who were both at the mercy of the staff and both were intubated and provided unwanted treatments to prolong life. The facility violated these resident ' s rights by failing to honor their wishes to have a peaceful and dignified death and failed to protect these residents from unwanted potentially violent interventions at their last moments of life. The facility also failed to obtain physician signatures for DNR orders in a timely fashion and failed to place the signed DNR ' s in the resident ' s records for nine residents (# 3, 4, 5, 6, 7, 8, 9, 11 & 12). These residents were at risk for their Do Not Resuscitate wishes not being followed due to the facility system failure. Failure of the facility staff to correctly implement advanced directives resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to the scope and severity of an " E " . Findings Include: 1.Review of the Consulate Health Care Policies and Procedures with Subject: Do Not Resuscitate - (Orders to Withhold Cardiopulmonary Resuscitation) with an effective date of ,[DATE] and no revision date, determined that the policy states: There may be a variety of situations in which it is justifiable to withhold or withdraw medical treatment. Dilemmas may be created by the availability of modern medical technology. The question of whether or not to initiate CPR if the resident experiences an acute cardiac or respiratory collapse will be addressed upon admission and the responsible party for making the decision will be identified. DO NOT RESUSCITATE (DNR) orders denote that in the event of an acute cardiac or respiratory collapse, NO CPR measures will be initiated. Procedure: Social Service 1. Make a determination as to who will be making the DNR decision for the resident. Defines what competent resident means and states if the resident is competent they can make the decision, otherwise the conservator, health care proxy, or family member. Under d.) family member it states in the event that the resident is deemed mentally incompetent by his/her attending physician, the person is not conserved or has not named a health care agent, the family will then be consulted regarding the CPR/DNR decision. 2. Explain DNR status and what it means to the resident and responsible party and discussion document in the: a. Admission assessment and B. Social services progress notes. 3. Notify the appropriate personnel and complete, sign, and date. Medical Staff will assist in the process with the resident. B. if the competent resident wishes to have a DNR status, the physician will assure completion of the documentation, sign the Do Not Resuscitate Order and complete the informed consent obtaining the signature of the resident with facility staff witness. Work with facility and family for the incompetent resident.. On the last page entitled: Identification of resident who wish to be a Do Not Resuscitate status it states: Residents identified as not wanting Cardiopulmonary Resuscitation will have a yellow dot affixed to the spine of their individual chart. There is also a list maintained at the nurse ' s station that signifies those residents who are a DNR status. The facility did not follow this policy for 11 of 12 residents. #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, & 12. Review of the Consulate Health Care Policies and Procedures Subject: Advanced Directives- Admission/Social Service effective ,[DATE] and revised on ,[DATE]. Under Policy it is stated: The facility Social Service Staff will abide by resident advanced directives, if known. Procedure: under #2. Upon admission, Social Services must communicate residents, family members or responsible parties of: A) Their right to make choices concerning health care and treatments, including life sustaining treatments. b) Determine whether the resident has an advanced directive and, if not, determine whether the resident wishes to establish an advanced directive. c) Define and clarify medical issues and present the information regarding relevant health care issues to the resident or his/her legal representative. d) Identify and assess medical issues where life-sustaining treatments are potential options and implement choices related to health care decisions. The policy goes on to say that Social Services and/or Admissions staff must complete the Advanced Directives Discussion Document (Attachment A), which must be a part of the resident ' s file confirming the parties were appropriately informed and an advanced directive, if one exists, was obtained or was identified as to its location. Under a) Indicate the resident ' s wishes to provide, with hold or not decide on the areas including CPR, artificial respiration, and artificial means of providing nutrition and hydration. Upon completion of the Advanced Directives Discussion Document, fill out Attachment B, Notification of Physician, to alert physician that discussion has taken place and place in the medical record. 2.The face sheet, dated [DATE], for resident #1 revealed that he was a [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A history and physical from the hospital, dated [DATE], stated the resident was mentally sharp and was able to relate his own symptoms to the physician. It also listed [DIAGNOSES REDACTED]. Review of the Admission Data Collection Form dated [DATE] at 8:00 a.m., revealed that the resident was assessed as having no long or short term memory problems and was independent in decision making skills. The resident signed the admission agreement himself on [DATE]. The resident was informed of his rights and given written information: Under the admission agreement Notification and Consent form dated [DATE] signed by resident #1 number 7. is entitled Advanced Directives and states that " You have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Please indicate if you possess any of the following documents or have a substitute decision-maker and indicate the identity and/or location of each " . Listed are: advanced directives, health care agent, conservator of person, living will, durable power of attorney and other. The form is blank. This form was witnessed by the admissions staff. On the next page under #12 the resident signed, " I hereby acknowledge that I have received copies of the following information and that it has been clearly explained to me by the facility staff " . Listed and initialed are: Advanced Directives and Patient ' s Rights. In an interview with the Customer Care Liaison on [DATE] at 12:01 p.m., she stated that if nothing is checked or written it on the Notification and Consent form, it indicates the resident had no Advanced Directives on admission. She said if they have Advanced Directives but they do not have them with them, she would make a note on that form. This form was signed by the primary admissions person. It was confirmed at 2:30 p.m. on [DATE] by the admissions marketing person that the resident had no advanced directives on admission. A booklet entitled Resident Bill of Rights (A guide to your rights as a resident) was the information provided in the packet. Resident ' s rights were described and explained in this packet and under #K it says: You have the right to refuse medication or treatment and to be informed of the consequences of such decisions, unless it has been determined under state law that you are unable to provide informed consent. This right was not honored by the facility. Review of the Initial Social Service History, dated [DATE], revealed that resident #1 had been living at home alone before becoming ill. The Consulate Health Care Advanced Directives Discussion Document dated [DATE] states: The purpose of the this document is to obtain information regarding your wishes on specific life support decisions you may have made, Advanced Directives and/or substitute decision makers you may have appointed to speak for you. In addition, this facility wishes to inform you that you have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Listed below are three particular types of life support systems. Please indicate your feeling regarding the following: Cardiopulmonary resuscitation (CPR) and artificial respiration were listed and both had been checked by the resident under " Withhold " . This form was signed by the resident and the social worker on [DATE]. Review of the State of Florida form Do Not Resuscitate Order, the resident signed on [DATE] stated based upon informed consent, I, the undersigned hereby direct that CPR be withheld or withdrawn. The form was signed by the physician on [DATE]. It stated I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient ' s cardiac or respiratory arrest. Review of a nurse ' s note dated [DATE] stated that at approximately 12:25 a.m., the resident was found by Nurse E not breathing, no heart rate or pulse, skin color ashen, and cool to touch. Code blue called. CPR started. Dr. was paged after 911 called and emergency contact person was notified. EMS arrived at approximately 1:05 a.m. Emergency contact person arrived at 1:07 a.m. The Dr. called back at approximately 1:15 a.m. stating the resident signed a DNR on [DATE]. DNR paper not in chart.-found in social services office -shown to EMS - CPR stopped at approximately 1:20 p.m. In a telephone interview with Nurse E on [DATE] at 1:53 p.m., she confirmed that she wrote the nurse ' s note above and stated she is the one who found resident #1 not breathing and with no pulse. She said it was hard to tell how long it had been because his skin felt neither warm nor cold, but just as it usually did. He was not cold. She said his aid was in there at midnight and he was OK. She was in there about 12:20 p.m. and found him unresponsive. She went in and thought " Oh my God, I think he is dead " . She thought at first he was a DNR because of his age, but when she checked the chart, she was surprised no yellow DNR form was in there. She said she grabbed the crash cart and went to the room and initiated CPR. By that time someone had called the code and other nurses showed up to help. She said Angel was doing compressions and she was performing artificial respirations using the ambu bag. The other nurse was holding the seal on resident #1 ' s mouth. The doctor called back after the medics arrived and took over the CPR. Nurse D talked to the doctor and asked them to stop the CPR. They found the DNR paper in the social workers office and stopped CPR. He did not respond at all to the resuscitation. In an interview with Nurse G (LPN) on [DATE] at 6:25 a.m., she stated she recalled that 3 weeks ago resident #1 had coded. The nurses were called about midnight or so to the skilled unit (SSU) by an overhead page. She checked the chart and did not see a yellow DNR form on chart. She thinks Nurse E checked the Medication Administration Record (MAR) to see if the yellow DNR form was in there. They did not see a DNR so CPR was initiated by Nurse C, Nurse E, and Nurse G. Nurse D called 911. The Certified Nursing Assistants (CNAs) were around to assist. They administered oxygen thru the ambu bag. When Emergency Medical Services (EMS) arrived, she remembered being tired from participating in the resuscitation. Nurse D called the physician and Nurse G thought the doctor stated he said he signed a DNR. She said Nurse D found the DNR on the social services desk. This was told to her after the fact. No one in management had approached her and asked her what happened or investigated with her. She stated she did tell the unit managers what happened. Nurse G was asked how they identify whether or not a resident is a DNR, she stated they keep a copy of the yellow Do Not Resuscitate (DNR) form in the Medication Administration Record (MAR) and in the chart under the tab called advanced directives. There should be a yellow dot on bulletin board in room and on the outside of the resident ' s chart too. She tried to show us a yellow dot in a resident ' s room, but it was not there. She stated sometimes it gets knocked off by the curtain. She said they don ' t rely on the dots but always check the chart or the MAR. In an interview on [DATE] at 7:55 a.m. with Nurse D, when asked how she identifies who is a DNR. She said to identify someone who is a DNR, they use a yellow dot on chart and yellow dot sticker in room on bulletin board. A yellow DNR form would be in the chart and in the MAR. If there was no form, they would announce code blue three times on loudspeaker and take the crash car to the resident ' s room. All of the nurses are required to respond to a code. There is a crash cart for each unit supplied with an ambu bag, oxygen, a back board, airways, different types of masks for oxygen and she is pretty sure there is suction equipment. She stated that about 3 weeks ago on the skilled (SSU) a gentlemen who was [AGE] years old was found not breathing and without a pulse. She stated she made the phone calls to 911. A new nurse, Nurse E was on the phone and having difficulty remembering the address of the facility, so she took over the phone call to 911 and then Nurse E helped with the resident. She completed the hospital transfer papers and had someone go to the front door to let EMS in. Nurse E came back and called the family. Then Nurse D stated she called the doctor and he said the resident had signed a DNR. EMS came and continued CPR and intubated the resident. The doctor said to tell them to stop CPR and EMS said they could not stop until a yellow DNR order was presented to them. The nurse looked everywhere for it. She knew social services handled the DNRs, so she looked in the social services office for it and she brought it back to unit and gave it to EMS. She stated from the time she arrived on the unit, it may have been 20 minutes by the time the CPR was stopped. He did not recover. The family came in and knew there was a DNR. The nurse said she told the family the truth about the DNR and he did not seem upset. He wanted to know where it was and she told him. The nurse stated they were upset because the DNR was not where it was supposed to be. She did not know who discussed it or talked about it afterward. She stated no one in management approached her to ask her what happened or investigate this incident with her. She said this is not a usual occurrence, this does not happen and has never happened before. In an interview on [DATE] at 6:45 a.m. with Nurse C, he stated there are yellow stickers on the chart if a resident has a DNR order and he would check the yellow DNR order sheet in the chart and/or in the MAR and call for help if a resident was found not breathing and without pulse. He stated he was involved with when resident #1 coded. Nurse E was working the hall and was fairly new to the facility. She called him and said, " I think the guy is dead " . They checked the chart and MAR and saw that he was not a DNR so they initiated CPR. Nurse G came over from the GNR unit and told Nurse E to call 911. They did CPR until the paramedics came. It was around 12:20 or 1:20 a.m., not sure. He thinks they did CPR for 30 minutes. He remembers sweating. The paramedics took over, then Nurse E called doctor and he said he had signed a DNR. He said he did not see the order but heard about this later, because when the paramedics arrived, he left the room and went back to his assignment. In an interview with the Administrator (Executive Director) on [DATE] at 7:10 a.m., she stated resident #1 was [AGE] years old and was there only about 3 weeks. She confirmed that the resident was given CPR because the signed DNR order was not in his chart. She thinks it was a weekend and thinks she was called about it. In an interview at 10:07 a.m., when asked if she had reported the incident to the state as required, she said no. She stated she was the assigned Risk Manager for the facility and she had called her corporate office and consulted with them and they stated it was not reportable because it did not result in a resident injury. When asked for her investigation, she produced 2 short statements. One was from the Social Service Director and one was from the Business Development/Admissions person. She stated that she determined that the problem was a communication error between the two employees. She said the Social Service Director (Director of Resident and Family Services) told the assistant social worker that 3 DNRs in her office needed to be signed by the physician. The assistant gave them to the Business Development/Admissions person and she took them to the doctors and had them signed on [DATE]. When the Business Development/Admissions person returned, she handed the folder containing the signed DNRs to the Social Service Director, not telling her what was in them. The Social Service Director was engaged in a meeting with the Business Office Manager at the time. The Social Service Director put the folders with the signed DNRs in it on her desk and did not file them. She did not look in the folder and did not realize what they were. The Administrator concluded it was an honest error on the part of two employees- one not saying what was in the folder and the other not looking in the folder and realizing the importance and gravity of the situation. She stated " I don ' t feel the system is as strong as it is supposed to be. " The Administrator went on to say that she did not investigate any further and had not looked at the actual yellow DNR forms and had not interviewed any other staff. She did not know there was a delay in the physician signing the DNR. The resident had signed it on [DATE] and the physician signed it on [DATE]. She stated she only found out about the delay on [DATE] when the surveyors started looking into it. When asked what the process was for a DNR, she stated that if the physician has not signed the DNR, they will take it to the physician to be signed and that it was the responsibility of the Social Service Director to get it signed. Further interview with the Administrator at 10:26 a.m. confirmed that this is a delay in getting the DNR ' s signed and is a result of a system that needs to be adjusted. At 11:45 a.m., the Administrator stated the corporation has no time frame or expectation of how long it should take for the DNR to be signed by the physician after the resident has indicated that he does not want CPR and has signed the Do Not Resuscitate form. She stated she did not question the time frame for getting the Do Not Resuscitate Order form signed. In an interview with the Social Services Director on [DATE] at 8:27 a.m., she stated she thought resident #1 signed a DNR. She looked in the chart and found copy of the DNR signed by resident #1 on [DATE]. She confirmed at this time that the physician had not signed the DNR until [DATE]. She looked in the closed record at this time and was unable to locate the social services assessment in the record. The Social Service Director stated she did not know why CPR was done on this resident and stated a DNR was signed on [DATE] by the physician. She stated she had 3 DNR forms in her office that had not been signed and the assistant social worker gave them to the Business Development/Admissions person in admissions to take to the physician for signature. One of the DNR ' s was for resident # 1. The Business Development/Admissions staff took them to the physician, had them signed and brought them back to her and handed the Social Service Director the folder while she was with the business office in a meeting. She handed her a folder but did not say what was in it. She took the folder and put it in her office and does not recall looking to see what was in it. When she came in the next day, she found 2 DNRs on her desk and the Director of Nurses (DON) told her that they found resident #1 ' s DNR on the floor in her office. She was made aware that they did CPR him. She stated " If I had opened the folder, I would have taken care of them - made five copies and put them in the charts. But I did not open the folder and left it on my desk. " After that she checked her log in the computer of DNRs outstanding and waiting for signatures and the Administrator asked her to write a statement about what happened. Interview with the Business Development/Admissions person, on [DATE] at 2:35 pm. revealed that she took 3 DNR papers to the physicians to be signed. She waited while they were signed and brought them back to facility between 3 and 3:30 p.m. on [DATE]. As she walked in the front door, she saw the Social Service Director and the Business Office Manager in a meeting with the Administrator and she handed the one manila file folder to the Social Service director. This folder contained resident # 1 ' s signed DNR. In a telephone interview with the resident ' s attending physician on [DATE] at 3:10 pm., he stated once the patient says he wants a DNR then he should be a DNR. The physician stated that resident #1 was a DNR and he had signed it. He stated he expected that when he signed the order it should be implemented immediately. 3.In an interview with the Director of Nurses on [DATE] at 4:00 p.m., she stated that resident #2 coded at change of shift on [DATE] at about 3:00 p.m. She said the medical director was in the building and participated in the resuscitation attempt. She stated she called the Administrator at the ALF where resident #2 had previously lived to try and get another phone number for the resident ' s family because she could not locate the family. When she talked to the responsible party, the DON told her about the facility having performed CPR on her mother. The daughter said her mother would not have wanted CPR and she had a living will. The DON stated she does know why this was not addressed in advance. The DON said she had never met the family before yesterday and that resident #2 had died . On [DATE] at 3:30 p.m., a physician ' s progress note stated that resident # 2 had been seen in the facility, then complained of shortness of breath, became unresponsive, coughed up blood and became pulseless. CPR was initiated, the resident coded, EMS arrived, Epi given x 3 and the patient was intubated, cool and mottled, at bedside 45 minutes. Review of the record for resident #2 revealed no advanced directives or any documentation in the chart showing that the Social Service staff or the Admission staff had reviewed or discussed advanced directives with resident #2. This resident was not given the opportunity to refuse treatment. In an interview with a family member of resident #2 on [DATE] from 9:40 a.m. to 10:10 a.m., she stated emphatically that her mother would not have wanted CPR and that she had a living will. She was extremely upset that her mother had been resuscitated. She stated she was called by the facility on [DATE] about 4:00 p.m. and when she arrived at the facility, she was told her mother she was still there. She went up to her mother as they were putting her on the stretcher and patted her and said she would follow her to the hospital. She said her mother was intubated and unconscious. She stated her mother had a DNR before she came to the facility and she thought it would follow her. She never dreamed her mother would die this way and was very upset that she was given CPR. She said her mother was a Registered Nurse and knew about these things and would never have wanted it. She was crying and said she could rejoice about her mother ' s death if only this had not happened and her heart was broken. She stated that if anyone had approached her at the nursing home about signing a DNR, she absolutely would have signed it immediately. When asked if anyone at the facility had asked her in advance what her mother ' s wishes were she said, " I don ' t think so. " She was not concerned because she said her mother had always had a DNR. She said she had one for 7 years at the Assisted Living Facility where she lived before becoming ill and she was under the impression that it would follow her so she did not think there was anything to worry about. In an interview with the Social Services director on [DATE] at 2:00 p.m., she stated there were no Advanced Directives or documentation of having approached the resident or family and discussing advanced directives or DNR. She said she did not approach the resident on admission because the resident was confused and would not have been able to make any decisions. She could not locate any documentation that the family was approached about Advanced Directives. She confirmed she did not talk to the resident about Advanced Directives and confirmed that there was no evidence that family was contacted. She stated she did not know why she did not talk to the family about Advanced Directives. She also documented in resident #2 ' s social service notes on [DATE] that the resident had improved and was alert and oriented. She reviewed this note and could not say why the resident was not approached at this time to review her wishes for Advanced Directives or why the family was not approached to reassess the resident ' s capacity to make health care decisions when her mental status had improved. Review of the face sheet for resident #2 revealed she was age [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incapacity statement entitled, " Physician ' s Evaluation of Resident ' s Capacity to make Health Care Decisions or Provide Informed Consent " was signed by the physician on [DATE]. Review of the resident admission data collection completed on [DATE] at 4:00 p.m. revealed that the resident had a short and long term memory problem and had moderately impaired decision making skills. Review of the Minimum Data Set assessment (MDS) with an observation end date of [DATE] revealed no information about advanced directives and the resident ' s brief interview for mental status (BIMS) score was ,[DATE] possible points. The MDS with observation end date of [DATE] revealed no information about advanced directives, but the MDS did reveal that the resident ' s cognitive status with a BIMS score of ,[DATE] showed significant improvement from [DATE]. In an interview with on [DATE] at 3:40 p.m., the Unit Manager on the SSU unit, she stated that the resident was confused on admission, but had improved in her thinking over time. The record revealed that even though the resident had a statement signed by the physician that she was incapacitated to make health care decisions, she was able to sign a form entitled " Consent for Midline or PICC insertion " on [DATE] when she needed intravenous antibiotics. Review of the nurse ' s notes for the month of [DATE] revealed that the nurses charted that the resident was alert and oriented to time, place, and person every shift. Even though the resident showed marked improvement in mental status, she was not approached by anyone regarding Advanced Directives regarding her wishes if she should be found not breathing or without pulse. Review of the Notification and Consent form (page 3) of the admission paperwork revealed that the resident had signed the admission consents herself on [DATE] though declared incompetent 2 days later. This form indicates that the resident was given information about advanced directives on [DATE]. Review of the Notification and Consent Form (page2) revealed under the title Advanced Directives. Under #7, the form states to please indicate if you have any of the following documents or if you have a substitute decision maker: 1. Advanced Directives, 2. Health Care Agent 4. Living Will. This was blank. The admissions coordinator stated in an interview that if they are blank, it means they did not have any advanced directives or did not bring them. Review of the Pre hospital Care Report Summary completed by the paramedics that came to the facility revealed that the paramedics were called at 3:03 p.m. and arrived at the facility at 3:16 p.m. The chief complaint recorded was [MEDICAL CONDITION], paramedic assessment revealed that the patient was apneic and pulseless; pupils were fixed and dilated with blood pressure of ,[DATE]. The following treatments were provided: Automatic Electronic Defibrillator applied and no shock advised, chest compressions, ventilated with bag valve mask (Ambu bag), electrocardiogram, intravenous line inserted into left hand and fluids and medication given, oxygen, intubation with a combitube (endotracheal tube), and several doses of [MEDICATION NAME]. Review of the hospital emergency room record revealed that the resident was transported via ambulance and arrived in the ER at 3:47 p.m. with CPR in progress on arrival. The resident was placed on a monitor. At 3:51 p.m. it is documented that the resident was initially coding on arrival and regained pulse after [MEDICATION NAME]/[MEDICATION NAME]/calcium given. Pt. remains unresponsive, noted to have dark blood in the endotracheal tube and severely coarse rales/rhonchi. Per EMS, the resident had been unresponsive and pulseless since 3:00 p.m., regained pulse en route for a short time, then pulseless/apneic again. At 3:52 p.m., the resident was intubated again and placed on a ventilator. At 3:56 p.m., they recorded a blood pressure of ,[DATE], pulse 76, and respirations 18 and it is documented that the code was terminated. At 4:05 p.m., the doctor inserted a second intravenous line into the external jugular (neck) area and lab work was drawn. At 4:25 p.m. a urinary catheter was inserted was inserted to monitor output. A [MEDICAL CONDITION] tube was inserted through the resident ' s mouth at 4:30 p.m. on the first attempt due to possible GI bleed and connected to intermittent suction. At 4:50 pm., the report states that the family was at the bedside and stated the resident had a DNR and the family was the power of attorney. They were requesting the care be withdrawn. The physician informed the family that the DNR was being sent from the nursing home and that once it arrived care will be withdrawn. A later note, at 5:25 p.m., stated that the resident ' s family stated the resident had a DNR on file with the attending physician and wished care be withdrawn. The medication keeping her blood pressure up was turned off and the resident promptly arrested. The resident was pronounced dead at 5:27 p.m. In an interview with the Medical Director on [DATE] at 3:00 p.m., he stated his expectations were, the DNR and advanced directives should be part of the admission packet. It should be signed the first week here and made part of admission process and it should go immediately into the chart after it is signed. The resident and family were never given an opportunity to sign a DNR. The facility did not follow their Advanced Directives policy which would have led to the DNR being signed and saving the resident from the ,[DATE] hour prolonged death involving chest compressions, tubes in her mouth and stom

Based on interviews with the facility ' s nursing and administrative staff, a family member, social services, physicians, review of clinical records, and facility policies, it was determined that the facility failed to protect the rights of 2 (#1, 2) of 12 sampled residents to formulate an advanced directive related to end of life decisions. The facility failed to follow its own policies for Advanced Directives and " Do Not Resuscitate " related to determining whether the resident wished to establish an advance directive, obtaining and placing the advance directives in the resident ' s record and failed to ensure that nursing staff had advance directive information, including State of Florida Do Not Resuscitate Orders (DNR ' s) available for review in case of an emergency. The facility initiated CPR on resident #1, a [AGE] year old, alert and oriented resident who had stated on admission that he did not want to be resuscitated and CPR was done against the resident ' s expressed wishes. The facility failed to honor resident #2 ' s right to formulate an advanced directive and refuse treatment. The facility performed CPR on resident #2 without clarifying her wishes on admission. The facility failed to protect the residents from unwanted potentially violent interventions at their last moments of life. They initiated cardiopulmonary resuscitation (CPR) and called 911 on both residents who were both intubated and provided life support interventions. The facility ' s failure to follow the advance directives policy and the Do Not Resuscitate policy represents a failure that could also lead to failure to provide CPR when wanted by the resident. The facility failed to obtain physician signatures for DNR orders in a timely fashion and failed to place the DNR in the resident ' s records when signed for nine of twelve residents (# 3, 4, 5, 6, 7, 8, 9, 11 & 12). Failure of the facility staff to correctly implement advanced directives resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to the scope and severity of an " E " . Findings Include: 1. Resident #1 signed a State of Florida Do Not Resuscitate Order (DNR) on [DATE]. The form was signed by the physician on [DATE] and an order was written. The resident was found without pulse or respirations on [DATE] at 12:25 a.m. per nurse ' s notes, and CPR was initiated and emergency personnel tried to provide life support measures in spite of the resident ' s express written wishes, via a signed DNR order, not to be resuscitated. Review of the face sheet dated [DATE] for resident #1 revealed that he was a [AGE] year old gentleman who was admitted on [DATE] to the facility from the hospital. Under the box Advanced Directive on the face sheet " No " is checked. Under primary [DIAGNOSES REDACTED]. Under secondary [DIAGNOSES REDACTED]. The admission agreement was signed by the resident on [DATE]. The readmission agreement dated [DATE] was also signed by the resident on [DATE] and stated that I, the above named resident, do consent to waive the resigning of the complete agreement and all applicable consents. I further acknowledge that there are no amendments to the original admission agreement and consent forms and that the original agreement and all consent forms are still valid. Under the admission agreement Notification and Consent form, dated [DATE], signed by the resident number 7 is entitled Advanced Directives and states that: " You have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Please indicate if you possess any of the following documents or have a substitute decision-maker and indicate the identity and/or location of each " : lists advanced directives, health care agent, conservator of person, living will, durable power of attorney and other and is not filled in. This form was witnessed by the admissions staff. On the next page under #12 the resident signed, " I hereby acknowledge that I have received copies of the following information and that it has been clearly explained to me by the facility staff " . Listed and initialed are: Advanced Directives and Patient ' s Rights. In an interview with the Customer Care Liaison on [DATE] 12:01 p.m., she stated if nothing is checked or written it on this form, it indicates the resident had no advanced directives on admission. She said if they have advanced directives but they do not have them with them, she would make a note on that form. This form was signed by the primary admissions person. This was confirmed at 2:30 p.m. by the admissions marketing person that the resident had no advanced directives on admission. A booklet entitled Resident Bill of Rights (A guide to your rights as a resident) was in the packet and is " the following information " as outlined in the admissions packet. Resident ' s rights are described and explained in this packet and under #K it says: You have the right to refuse medication or treatment and to be informed of the consequences of such decisions, unless it has been determined under state law that you are unable to provide informed consent. A history and physical from the hospital, dated [DATE], stated that resident #1 was mentally sharp. According to the history, the resident was able to relate his own symptoms to the physician. It also listed [DIAGNOSES REDACTED]. Review of the Admission Data Collection Form, dated [DATE] at 8:00 a.m., revealed that the resident was assessed as having no long or short term memory problems and was independent in decision making skills. Review of the Initial Social Service History, dated [DATE], revealed that the resident had been living at home alone. A " Consulate Health Care Advanced Directives Discussion Document " was signed by the resident and the Social Service Director on [DATE]. This form stated: The purpose of the this document is to obtain information regarding your wishes on specific life support decisions you may have made, advanced directives and/or substitute decision makers you may have appointed to speak for you. In addition, this facility wishes to inform you that you have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Listed below are three particular types of life support systems. Please indicate your feeling regarding the following: Cardiopulmonary resuscitation (CPR) and artificial respiration were listed and both had been checked by the resident under " withhold " . A State of Florida Do Not Resuscitate Order form was found in the resident ' s record. The first section of the form stated: " Based upon informed consent, I, the undersigned hereby direct that CPR be withheld or withdrawn. " This section was signed by resident # 1 on [DATE]. The form was not signed by the physician until [DATE]. It stated " I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient ' s cardiac or respiratory arrest. " Review of a nurse ' s note dated [DATE] stated that at approximately 12:25 a.m., the resident was found by the nurse not breathing, no heart rate or pulse, skin color ashen, and cool to touch. Code blue called. CPR started. Dr. was paged after 911 called and emergency contact person was notified. EMS arrived at approximately 1:05 a.m. Emergency contact person arrived at 1:07 a.m. The Dr. called back at approximately 1:15 a.m. stating the resident signed a DNR on [DATE]. DNR paper not in chart.-found in social services office -shown to EMS - CPR stopped at approximately 1:20 p.m. Resident # 1 ' s wishes not to be treated were not honored for approximately one hour. In a telephone interview with Nurse E, on [DATE] at 1:53 p.m. she confirmed she wrote the above nurse ' s note. She stated she is the one who found resident #1 not breathing and with no pulse. She said it was hard to tell how long it had been because his skin felt neither warm nor cold, but just as it usually did. He was not cold. She said his aide was in there at midnight and he was OK. She was in there about 12:20 a.m. and found him unresponsive. She went in and thought " Oh my God, I think he is dead " . She thought at first he was a DNR because of his age, but when she checked the chart, she was surprised no yellow DNR form was in there. She said she grabbed the crash cart and went to the room and initiated CPR. By that time someone had called the code and other nurses showed up to help. She said Nurse C was doing compressions and she was performing artificial respirations using the ambu bag. The other nurse was holding the seal on resident #1 ' s mouth. She stated that the doctor called back the facility after the medics arrived and took over the CPR. She stated Nurse D talked to the doctor and the doctor asked them to stop the CPR. They found the DNR form in the social workers office and stopped CPR. He did not respond at all to the resuscitation. In an interview with Nurse G (LPN) on [DATE] at 6:25 a.m. she stated that about 3 weeks ago resident #1 coded. The nurses were called about midnight or so to the skilled unit (SSU) by an overhead page. There were 2 nurses on each unit that night. She checked the chart and did not see a yellow DNR form on the chart. She thinks Nurse E checked the Medication Administration Record (MAR). They did not see a DNR so CPR was initiated by Nurse C, Nurse B and Nurse G. The medics were called by Nurse D and the Certified Nursing Assistants (CNAs) were around to assist. Oxygen was applied thru the Ambu bag. When the medics arrived she said was tired from participating in the resuscitation. Nurse G stated Nurse D called the physician and Nurse G thinks that he said he signed a DNR. She stated Nurse D found the DNR on the social services desk. This was told to her after the fact. She stated no one in management had approached her about this incident to investigate. She stated she offered information to the two Unit Mangers about what happened. In an interview on [DATE] at 7:55 a.m. with Nurse D, she stated that about 3 weeks ago on the skilled (SSU) a gentleman who was about [AGE] years old coded ( resident # 1). The code was announced and she was in the bathroom and did not hear it. The CNAS told her about it when she came out, so she went over to the skilled unit. She stated she made the phone calls to 911. A new nurse, Nurse E, was on the phone and having difficulty remembering the address of the facility, so she took over the phone call to 911 and Nurse E went and helped in the room with the resident. She filled out transfer paper work and had someone go to the front door to let the medics in. Nurse E came back and called the family. Nurse D stated " then I called the doctor and he said he had signed a DNR " . The EMTs came and took over CPR. The doctor said to tell them to stop CPR and they said they could not stop until a yellow DNR order was presented to them. They looked everywhere for it. She stated she knew social services handled the DNRs, so she looked in the social services office for it and she found it and gave it to the EMTs. She stated from the time she arrived on the unit, it may have been 20 minutes by the time the CPR was stopped. When the DNR paper was found it was yellow, she knows the doctor ' s signature was on it and there were 2 signatures but she was not sure who signed it. She stated resident # 1 did not recover. She stated the family came in and knew there was a DNR. Nurse D said she told him the truth about the DNR and he did not seem upset. He wanted to know where it was and she told him. Nurse D stated they, the nurses, were upset because the DNR was not where it was supposed to be. She did not know who discussed it or talked about it afterward. She stated no one in management approached her to ask her what happened or investigate this incident with her. In an interview on [DATE] at 6:45 a.m. with Nurse C, an LPN, he stated he was involved when resident #1 coded. He stated the nurse working the hall was Nurse E, an LPN who was fairly new to the facility. She called him and said " I think the guy is dead " . They checked the chart and MAR and saw that he was not a DNR so they initiated CPR. Nurse G came over from the GNR unit and told Nurse E to call 911. They did CPR until the paramedics came. It was around 12:20 or 1:20 a.m., not sure. He thinks they did CPR for 30 minutes. He remembers sweating. The paramedics took over the CPR and Nurse D called the doctor. The doctor said he had signed a DNR for resident # 1. Nurse C stated he did not see the order but heard about this later, because when the paramedics arrived, he left the room and went back to his assignment. In an interview with the Administrator (Executive Director) on [DATE] at 7:10 a.m. she stated resident #1 was [AGE] years old and was there only about 3 weeks. She confirmed that the resident was given CPR because the signed DNR order was not in his chart. She thinks it was a weekend and thinks she was called about it. In an interview at 10:07 a.m., when asked if she had reported the incident to the state as required, she said no. She stated she was the assigned Risk Manager for the facility and she had called her corporate office and consulted with them and they stated it was not reportable because it did not result in a resident injury. When asked for her investigation, she produced 2 short statements. One was from the Social Service Director and one was from the Business Development/Admissions person. She stated that she determined that the problem was a communication error between the two employees. She said the Social Service Director (Director of Resident and Family Services) told the assistant social worker that 3 DNRs in her office needed to be signed by the physician. The assistant gave them to the Business Development/Admissions person and she took them to the doctors and had them signed on [DATE]. When the Business Development/Admissions person returned, she handed the folder containing the signed DNRs to the Social Service Director, not telling her what was in them. The Social Service Director was engaged in a meeting with the Business Office Manager at the time. The Social Service Director put the folders with the signed DNRs in it on her desk and did not file them. She did not look in the folder and did not realize what they were. The Administrator concluded it was an honest error on the part of two employees- one not saying what was in the folder and the other not looking in the folder and realizing the importance and gravity of the situation. She stated " I don ' t feel the system is as strong as it is supposed to be. " She stated Resident #1 was alert and you could communicate with him. The Administrator went on to say that she did not investigate any further and had not looked at the actual yellow DNR forms and had not interviewed any other staff. She did not know there was a delay in the physician signing the DNR. The resident had signed it on [DATE] and the physician signed it on [DATE]. She stated she only found out about the delay on [DATE] when the surveyors started looking into it. When asked what the process was for a DNR, she stated that if the physician has not signed the DNR, they will take it to the physician to be signed and that it was the responsibility of the Social Service Director to get it signed. Further interview with the Administrator at 10:26 a.m. confirmed that this is a delay in getting the DNR ' s signed and is a result of a system that needs to be adjusted. At 11:45 a.m., the Administrator stated the corporation has no time frame or expectation of how long it should take for the DNR to be signed by the physician after the resident has indicated that he does not want CPR and has signed the Do Not Resuscitate form. She stated she did not question the time frame for getting the Do Not Resuscitate Order form signed. The Administrator stated at noon that she did a rapid root cause of incident. She stated she thought it was just a mistake and that nursing had functioned appropriately and she closed her investigation. In an interview with the Social Services Director on [DATE] at 8:27 a.m., she stated she thought resident #1 signed a DNR. She looked in the chart and found copy of the DNR signed by resident #1 on [DATE]. She confirmed at this time that the physician had not signed it until [DATE]. She looked in the closed record at this time and was unable to locate social services assessment in record. The Social Service Director stated she did not know why CPR was done on this resident and stated a DNR was signed on [DATE] by the physician. She stated she had 3 DNR forms in her office that had not been signed and the assistant social worker gave them to the Business Development/Admissions person in admissions to take to the physician for signature. One of the DNR ' s was for resident # 1. The Business Development/Admissions staff took them to the physician, had them signed and brought them back to her and handed the Social Service Director the folder while she was with the business office in a meeting. She handed her a folder but did not say what was in it. She was engaged in a conversation. She took the folder and put it in her office. She does not recall looking to see what was in it. When she came in the next day, she found 2 DNRs on her desk and the Director of Nurses (DON) told her that they found resident #1 ' s DNR on the floor in her office. She was made aware that they did CPR him. She stated " If I had opened the folder, I would have taken care of them - made five copies and put them in the charts. But I did not open the folder and left it on my desk. " She stated that she didn ' t realize that the Business Development/Admissions person had handed her the signed DNR ' s. After that she checked her log in the computer of DNRs outstanding and waiting for signatures and the Administrator asked her to write a statement about what happened. Interview with the Business Development/Admissions person, on [DATE] at 2:35 pm. revealed that she took 3 DNR papers to the physicians to be signed. She waited while they were signed and brought them back to facility between 3 and 3:30 p.m. on [DATE]. As she walked in the front door, she saw the Social Service Director and the Business Office Manager in a meeting with the Administrator and she handed the one manila file folder to the Social Service director. This folder contained resident # 1 ' s signed DNR. In an interview with the resident ' s attending physician on [DATE] at 3:10 pm. he stated that his expectations were that once the patient says he wants a DNR then he should be a DNR. The physician stated that resident #1 was a DNR. He stated, it was when he came to the facility to see other patients he signed resident #1 ' s DNR. It should be respected even if it is not signed yet. It could be a verbal order and I could sign when I come in. He stated he expected that when he signed the order it should be implemented immediately. 2. On [DATE] at 3:30 p.m., a physician ' s progress note stated that resident # 2 had been seen in the facility, then complained of shortness of breath, became unresponsive, coughed up blood and became pulseless. CPR was initiated, the resident coded, EMS arrived, Epi given x 3 and the patient was intubated, cool and mottled, at bedside 45 minutes. Review of the record for resident #2 revealed no advanced directives or any documentation in the chart showing that the Social Service staff or the Admission staff had reviewed or discussed advanced directives with resident #2. In an interview with a family member of resident #2 on [DATE] from 9:40 a.m. to 10:10 a.m., she stated emphatically that her mother would not have wanted CPR and that she had a living will. She was extremely upset that her mother had been resuscitated. She stated she was called by the facility on [DATE] about 4:00 p.m. and when she arrived at the facility, she was told her mother she was still there. She went up to her mother as they were putting on the stretcher and patted her and said she would follow her to the hospital. She said her mother was intubated and unconscious. She stated her mother had a DNR before she came to the facility and she thought it would follow her. She never dreamed her mother would die this way and was very upset that she was given CPR. She said her mother was a Registered Nurse and knew about these things and would never have wanted it. She was crying and said she could rejoice about her mother ' s death if only this had not happened and her heart was broken. She stated that if anyone had approached her at the nursing home about signing a DNR, she absolutely would have signed it immediately. When asked if anyone at the facility had asked her in advance what her mother ' s wishes were she said " I don ' t think so. " She was not concerned because she said her mother had always had a DNR. She said she had one for 7 years at the Assisted Living Facility where she lived before becoming ill and she was under the impression that it would follow her so she did not think there was anything to worry about. In an interview with the Social Services director on [DATE] at 2:00 p.m., she stated there were no advanced directives or documentation of having approached the resident or family and discussing advanced directives or DNR. She said she did not approach the resident on admission because the resident was confused and would not have been able to make any decisions. She could not locate any documentation that the family was approached about advanced directives. She confirmed she did not talk to the resident about advanced directives and confirmed that there was no evidence that family was contacted. She stated she did not know why she did not talk to the family about advanced directives. She also documented in resident #2 ' s social service notes on [DATE] that the resident had improved and was alert and oriented. She reviewed this note and could not say why the resident was not approached at this time to review her wishes for advanced directives or why the family was not approached to reassess the resident ' s capacity to make health care decisions when her mental status improved. Review of the face sheet for resident #2 revealed she was age [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incapacity statement entitled Physician ' s Evaluation of Resident ' s Capacity to make Health Care Decisions or provide Informed Consent was signed by the physician on [DATE]. Review of the resident admission data collection completed on [DATE] at 4:00 p.m. revealed that the resident had a short and long term memory problem and had moderately impaired decision making skills. Review of the Minimum Data Set assessment (MDS) with an observation end date of [DATE] revealed no information about advanced directives and the resident ' s brief interview for mental status (BIMS) score was ,[DATE] possible points. The MDS with observation end date of [DATE] revealed no information about advanced directives, but the MDS did reveal that the resident ' s cognitive status with a BIMS score of ,[DATE] showed significant improvement from [DATE]. In an interview with on [DATE] at 3:40 p.m., the Unit Manager on the SSU unit, she stated that the resident was confused on admission, but had improved in her thinking over time. The record revealed that even though the resident had a statement signed by the physician that she was incapacitated to make health care decisions, she was able to sign a form entitled " Consent for Midline or PICC insertion " on [DATE] when she needed intravenous antibiotics. Review of the nurse ' s notes for the month of [DATE] revealed that the nurses charted that the resident was alert and oriented to time, place, and person every shift. Even though the resident showed marked improvement in mental status, she was not approached by anyone regarding advanced directives regarding her wishes if she should be found not breathing or without pulse. Review of the Notification and Consent form (page 3) of the admission paperwork revealed that the resident had signed the admission consents herself on [DATE] though declared incompetent 2 days later. This form indicates that the resident was given information about advanced directives on [DATE]. Review of the Notification and Consent Form (page2) revealed under the title Advanced Directives. Under #7, the form states to please indicate if you have any of the following documents or if you have a substitute decision maker: 1. Advanced Directives, 2. Health Care Agent 4. Living Will. This was blank. The admissions coordinator stated in an interview that if they are blank, it means they did not have any advanced directives or did not bring them. In an interview with the Director of Nurses on [DATE] at 4:00 p.m., she stated that resident #2 coded at change of shift on [DATE] at about 3:00 p.m. She said the medical director was in the building and participated in the resuscitation attempt. She stated she called the Administrator at the ALF where resident #2 had previously lived to try and get another phone number for the resident ' s family because she could not locate them. She obtained the phone number and called a family member and who had the responsible party call the DON. When the responsible party called her back, the DON told her about the facility having performed CPR on her mother. The daughter said her mother would not have wanted CPR and she had a living will. The DON stated she does know why this was not addressed in advance. The DON said she had never met the family before yesterday and that resident #2 had died . Review of the Pre hospital Care Report Summary completed by the paramedics that came to the facility revealed that the paramedics were called at 3:03 p.m. and arrived at the facility at 3:16 p.m. The chief complaint recorded was [MEDICAL CONDITION], paramedic assessment revealed that the patient was apneic and pulseless; pupils were fixed and dilated with blood pressure of ,[DATE]. The following treatments were provided: Automatic Electronic Defibrillator applied and no shock advised, chest compressions, ventilated with bag valve mask (Ambu bag), electrocardiogram, intravenous line inserted into left hand and fluids and medication given, oxygen, intubation with a combitube (endotracheal tube), and several doses of [MEDICATION NAME]. Review of the hospital emergency room record revealed that the resident was transported via ambulance and arrived in the ER at 3:47 p.m. with CPR in progress on arrival. The resident was placed on a monitor. At 3:51 p.m. it is documented that the resident was initially coding on arrival and regained pulse after [MEDICATION NAME]/[MEDICATION NAME]/calcium given. Pt. remains unresponsive, noted to have dark blood in the endotracheal tube and severely coarse rales/rhonchi. Per EMS, the resident had been unresponsive and pulseless since 3:00 p.m., regained pulse en route for a short time, then pulseless/apneic again. At 3:52, the resident was intubated again and placed on a ventilator. At 3:56 p.m., they recorded a blood pressure of ,[DATE], pulse 76, and respirations 18 and it is documented that the code was terminated. At 4:05 p.m., the doctor inserted a second intravenous line into the external jugular (neck) area and lab work was drawn. At 4:25 p.m. a urinary catheter was inserted was inserted to monitor output. A [MEDICAL CONDITION] tube was inserted through the resident ' s mouth at 4:30 p.m. on the first attempt due to possible GI bleed and connected to intermittent suction. At 4:50 pm., the report states that the family was at the bedside and stated the resident had a DNR and the family was the power of attorney. They were requesting the care be withdrawn. Dr. Shaw informed family that the DNR was being sent from the nursing home and that once it arrived care will be withdrawn. A later note at 5:25 p.m., stated that the resident ' s family stated the resident had a DNR on file with the attending physician and wished care be withdrawn. The medication keeping her blood pressure up was turned off and the resident promptly arrested. The resident was pronounced dead at 5:27 p.m. In an interview with the Medical Director on [DATE] at 3:00 p.m., he stated his expectations were that the DNR and advanced directives should be part of the admission packet. It should be signed the first week here and made part of admission process and it should go immediately into the chart after it is signed. Resident #2 and/or her family were never given an opportunity to sign a DNR. The facility did not follow their advanced directives policy which would have led to the DNR being signed and saving the resident from the ,[DATE] hour prolonged death involving chest compressions, tubes in her mouth and stomach and into her lungs, needles in her arms and neck and a tube being inserted into the bladder, the time when she just wanted to die with dignity and without interventions. 3. An interview was conducted with a Customer Care Liaison who assists with the admissions process, on [DATE] at 12: 01 p.m. She stated that the primary admission person is on vacation this week. She stated she helps out with the admissions process when the other person is busy or is out. She also stated she is a nurse and she does the pre admission assessments at the hospital. She stated as part of the admission process she asks them if they have any advance directives. If they say yes, she asks whether they have the advanced directives with them. If not, she asks them to bring in copes as soon as they can. She stated if they do not have advance directives, she lets them know that the facility can provide that service for them and she will get the information to social services so social services can follow up with them. She stated that the resident ' s or responsible party ' s signature on the admission paperwork is documentation that she gave them the advance directives booklet. She stated that if there is nothing checked or indicated in section 7 of the notifications and consents section of the admission paperwork for advance directives, the resident had no advance directives at admission. She stated that if the resident has advance directives but does not have them with them at admission she makes a note so that social services can follow up and get the paperwork. In an interview with the Social Services Director on [DATE] at 8:27 a.m., she said they do what is called a Meet and Greet with the resident and/or family, usually within 72 hours of admission to greet them and get to know them. This may be the first time she sees the resident. Also present are the unit manager, therapy, dietary and sometimes activities. This is the first contact with the resident by the care plan team. The first time I go over the social service assessment is not at this Meet and Greet. She does it later when she does the full assessment. She stated when she does the Initial Social Service History assessment, she starts the Advanced Directives. She tries to do it within 5 days of the resident ' s admission. She asks the resident and/or families if they have any advanced directives. She may already have copies of advanced directives from the admission staff. If so, she will review those with the resident /or families and then ask about CPR and explain it to them. She also discusses artificial respirations and artificial nutrition and hydration. She has handouts for them and if they have no advanced directives, she may give them blank living wills health care surrogate papers to look at and review. She stated if the resident signs a DNR when she does the advanced directives decision document, she tells them that the physician has to sign it and write a DNR order before it is valid. She stated " we are supposed to give them to nursing/ unit managers to get them signed if I am not here but I like to get them signed by

Based on interviews with the facility ' s Social Services Director, Administrator, Social Services Assistant, Admissions staff, nursing, a family member, physicians, review of clinical records, and facility policies, it was determined that the facility failed to provide medically related social services that promoted actions that maintained the dignity, choices, and individual needs of 11 (#1, 2, 3, 4, 5, 6, 7, 8, 9, 11, & 12) of 12 residents reviewed. The facility failed to aggressively identify resident ' s Advanced Directives and, even when they were identified failed to assure that the choices were followed though and made clearly known to the nursing staff for implementation. The rights of 2 (#1, 2) of 12 sampled residents to formulate and implement Advanced Directives related to end of life decisions were not honored. The facility failed to follow its own policies for Advanced Directives and " Do Not Resuscitate " related to determining whether the resident wished to establish an advance directive, obtaining and placing the Advance Directives in the resident ' s record and failed to ensure that nursing staff had advance directive information. The facility initiated Cardiopulmonary Resuscitation (CPR) on resident #1, a [AGE] year old, alert and oriented resident who had stated on admission that he did not want to be resuscitated. The facility failed to honor resident #2 ' s right to formulate an advanced directive and refuse treatment. The facility performed CPR on both residents and failed to protect the residents from unwanted potentially violent interventions at their last moments of life. The facility ' s failure to follow the Advance Directives policy and the Do Not Resuscitate policy represents a failure to provide medically related social services that has the potential to fail to provide CPR when wanted by the resident. The facility failed to obtain physician signatures for DNR orders in a timely fashion and failed to place the DNR in the resident ' s records when signed for nine of twelve residents (# 3, 4, 5, 6, 7, 8, 9, 11, & 12). Failure of the facility staff to provide medically related social services for end of life decisions resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to the scope and severity of an " E " . Findings include: 1. An interview was conducted with the Social Services Director (Director of Resident and Family Services) on [DATE] at 8:27 a.m. She stated she was responsible for discussing and obtaining the Advanced Directives with the residents. She said they do what is called a " Meet and Greet " with the resident and/or family, usually within 72 hours of admission to greet them and get to know them. This may be the first time she sees the resident. Also present are the unit manager, therapy, dietary and sometimes activities. This is the first contact with the resident by the care plan team. The first time she goes over the social service assessment is not at this " Meet and Greet " . She does it later when she does the full assessment. She stated when she does the Initial Social Service History assessment, she starts the Advanced Directives. She tries to do it within 5 days of the resident ' s admission. She asks the resident and/or families if they have any advanced directives. She may already have copies of advanced directives from the admission staff. If so, she will review those with the resident /or families and then ask about CPR and explain it to them. She gives them written information about advanced directives if needed. She stated if the resident signs a DNR when she does the Advanced Directives Decision Document, she tells them that the physician has to sign it and write a DNR order before it is valid. She stated " we are supposed to give them to nursing/ unit managers to get them signed if I am not here but I like to get them signed by the physicians myself but I am not always here when the physicians ' are here " . She stated for those residents who are already here, advanced directives are reviewed quarterly with the MDS assessment. They ask if their wishes are the same and discuss with everyone to see if still appropriate. Review of the job description provided by the Social Services Director (who also brought her own personnel file in and gave it to the surveyors herself) entitled Director of Resident and Family Services I and II, unsigned and undated, revealed under duties and responsibilities: As part of the Admission process meet with the resident and family to review policies on Advance Directives, Resident ' s Right s and Discrimination. Conduct and document a social service evaluation including identification of resident ' s problems and needs. Ensure all documentation complies with all applicable regulations. Under the section: resident ' s right it stated to ensure that all social services personnel are knowledgeable of the resident ' s rights and responsibilities including the right of refusal. The duties outlined above were not effectively performed by the Social Services Director. The individual resident ' s needs were not successfully and aggressively addressed concerning end of life choices. 2. Review of the face sheet dated [DATE] for resident #1 revealed that he was a [AGE] year old man who was admitted on [DATE]. The primary [DIAGNOSES REDACTED]. The resident signed his own admission agreement on [DATE]. The readmission agreement dated [DATE] was also signed by the resident on [DATE] and stated that I, the above named resident, do consent to waive the resigning of the complete agreement and all applicable consents. I further acknowledge that there are no amendments to the original admission agreement and consent forms and that the original agreement and all consent forms are still valid. Under the admission agreement Notification and Consent form, dated [DATE], and signed by the resident, number 7. is entitled, Advanced Directives, and states that " You have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Please indicate if you possess any of the following documents or have a substitute decision-maker and indicate the identity and/or location of each " : lists advanced directives, health care agent, conservator of person, living will, durable power of attorney and other and is not filled in. This form was witnessed by the admissions staff. On the next page under #12 the resident initialed that he had received information regarding Advanced Directives and Patient ' s Rights. In an interview with the Customer Care Liaison on [DATE] at 12:01 p.m., she stated if nothing is checked or written it on this form, it indicates the resident had no Advanced Directives on admission. She said if they have Advanced Directives but they do not have them with them, she would make a note on that form. This form was witnessed by the primary admissions person. This was confirmed at 2:30 p.m. by the admissions marketing person that the resident had no advanced directives on admission. A booklet entitled Resident Bill of Rights (A guide to your rights as a resident) was in the packet and is a copy of what resident #1 would have received on admission. Resident ' s rights are described and explained in this packet and under #K it says: You have the right to refuse medication or treatment and to be informed of the consequences of such decisions, unless it has been determined under state law that you are unable to provide informed consent. A history and physical from the hospital dated [DATE] stated that resident #1 was mentally sharp and was able to relate his symptoms to the physician. It also listed [DIAGNOSES REDACTED]. Review of the Admission Data Collection Form dated [DATE] at 8:00 a.m. revealed that the resident was assessed as having no long or short term memory problems and was independent in decision making skills. Review of the Initial Social Service History dated [DATE] revealed that the resident had been living at home alone. A " Consulate Health Care Advanced Directives Discussion Document " was signed by the resident and the Social Service Director on [DATE]. This form states: The purpose of the this document is to obtain information regarding your wishes on specific life support decisions you may have made, advanced directives and/or substitute decision makers you may have appointed to speak for you. In addition, this facility wishes to inform you that you have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Listed below are three particular types of life support systems. Please indicate your feeling regarding the following: Cardiopulmonary resuscitation (CPR) and artificial respiration were listed and both had been checked by the resident under " Withhold " . A State of Florida Do Not Resuscitate Order form was found in the resident ' s record. The first section of the form stated: " Based upon informed consent, I, the undersigned hereby direct that CPR be withheld or withdrawn. " This section was signed by resident # 1 on [DATE]. The form was not signed by the physician until [DATE]. It stated, " I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient ' s cardiac or respiratory arrest. " Interviews with nurses confirmed that this resident received cardiopulmonary resuscitation against his will. The resident was at the mercy of the staff and relying on them to carry out his instructions at the time of his death. Review of a nurse ' s note dated [DATE] stated that at approximately 12:25 a.m., the resident was found by the nurse not breathing, no heart rate or pulse, skin color ashen, and cool to touch. Code blue called. CPR started. Dr. was paged after 911 called and emergency contact person was notified. EMS arrived at approximately 1:05 a.m. Emergency contact person arrived at 1:07 a.m. Dr. called back at approximately 1:15 a.m. stating the resident signed a DNR on [DATE]. DNR paper not in chart.-found in social services office -shown to EMS - CPR stopped at approximately 1:20 p.m. Resident # 1 ' s wishes not to be treated were not honored for approximately one hour. In a telephone interview with Nurse E, on [DATE] at 1:53 p.m. she confirmed she wrote the above nurse ' s note. She stated she is the one who found resident #1 not breathing and with no pulse. She said it was hard to tell how long it had been because his skin felt neither warm nor cold, but just as it usually did. He was not cold. She said his aide was in there at midnight and he was OK. She was in there about 12:20 a.m. and found him unresponsive. She went in and thought " Oh my God, I think he is dead " . She thought at first he was a DNR because of his age, but when she checked the chart, she was surprised no yellow DNR form was in there. She said she grabbed the crash cart and went to the room and initiated CPR. By that time someone had called the code and other nurses showed up to help. She said Nurse C was doing compressions and she was performing artificial respirations using the ambu bag. The other nurse was holding the seal on resident #1 ' s mouth. She stated that the doctor called back the facility after the medics arrived and took over the CPR. She stated Nurse D talked to the doctor and the doctor asked them to stop the CPR. They found the DNR form in the social workers office and stopped CPR. He did not respond at all to the resuscitation. In an interview with Nurse G (LPN) on [DATE] at 6:25 a.m. she stated that about 3 weeks ago resident #1 coded. The nurses were called about midnight or so to the skilled unit (SSU) by an overhead page. There were 2 nurses on each unit that night. She checked the chart and did not see a yellow DNR form on the chart. She thinks Nurse E checked the Medication Administration Record (MAR). They did not see a DNR so CPR was initiated by Nurse C, Nurse B and Nurse G. The medics were called by Nurse D and the Certified Nursing Assistants (CNAs) were around to assist. Oxygen was applied thru the Ambu bag. When the medics arrived she said was tired from participating in the resuscitation. Nurse G stated Nurse D called the physician and Nurse G thinks that he said he signed a DNR. She stated Nurse D found the DNR on the social services desk. This was told to her after the fact. She stated no one in management had approached her about this incident to investigate. She stated she offered information to the two Unit Mangers about what happened. In an interview on [DATE] at 7:55 a.m. with Nurse D, she stated that about 3 weeks ago on the skilled (SSU) a gentleman who was about [AGE] years old coded ( resident # 1). The code was announced and she was in the bathroom and did not hear it. The CNAS told her about it when she came out, so she went over to the skilled unit. She stated she made the phone calls to 911. A new nurse, Nurse E, was on the phone and having difficulty remembering the address of the facility, so she took over the phone call to 911 and Nurse E went and helped in the room with the resident. She filled out transfer paper work and had someone go to the front door to let the medics in. Nurse E came back and called the family. Nurse D stated " then I called the doctor and he said he had signed a DNR " . The EMTs came and took over CPR. The doctor said to tell them to stop CPR and they said they could not stop until a yellow DNR order was presented to them. They looked everywhere for it. She stated she knew social services handled the DNRs, so she looked in the social services office for it and she found it and gave it to the EMTs. She stated from the time she arrived on the unit, it may have been 20 minutes by the time the CPR was stopped. When the DNR paper was found it was yellow, she knows the doctor ' s signature was on it and there were 2 signatures but she was not sure who signed it. She stated resident # 1 did not recover. She stated the family came in and knew there was a DNR. Nurse D said she told him the truth about the DNR and he did not seem upset. He wanted to know where it was and she told him. Nurse D stated they, the nurses, were upset because the DNR was not where it was supposed to be. She did not know who discussed it or talked about it afterward. She stated no one in management approached her to ask her what happened or investigate this incident with her. In an interview on [DATE] at 6:45 a.m. with Nurse C, an LPN, he stated he was involved when resident #1 coded. He stated the nurse working the hall was Nurse E, an LPN who was fairly new to the facility. She called him and said " I think the guy is dead " . They checked the chart and MAR and saw that he was not a DNR so they initiated CPR. Nurse G came over from the GNR unit and told Nurse E to call 911. They did CPR until the paramedics came. It was around 12:20 or 1:20 a.m., not sure. He thinks they did CPR for 30 minutes. He remembers sweating. The paramedics took over the CPR, then Nurse D called the doctor. The doctor said he had signed a DNR for resident # 1. Nurse C stated he did not see the order but heard about this later, because when the paramedics arrived, he left the room and went back to his assignment. In an interview with the Administrator on [DATE] at 7:10 a.m. she stated resident #1 was [AGE] years old and was there only about 3 weeks. She confirmed that the resident was given CPR because the signed DNR order was not in his chart. She thinks it was a weekend and thinks she was called about it. In an interview at 10:07 a.m., when asked if she had reported the incident to the state as required, she said no. She stated she was the assigned Risk Manager for the facility and she had called her corporate office and consulted with them and they stated it was not reportable because it did not result in a resident injury. When asked for her investigation, she produced 2 short statements from the Social Service Director and the Business Development/Admissions person. She stated that she determined that the problem was a communication error between the two employees. She said the Social Service Director told the assistant social worker that 3 DNRs in her office needed to be signed by the physician. The assistant gave them to the Business Development/Admissions person and she took them to the doctors and had them signed on [DATE]. When the Business Development/Admissions person returned, she handed the folder containing the signed DNRs to the Social Service Director, not telling her what was in them. The Social Service Director was engaged in a meeting with the Business Office Manager at the time. The Social Service Director put the folders with the signed DNRs in it on her desk and did not file them. She did not look in the folder and did not realize what they were. The Administrator concluded it was an honest error on the part of two employees- one not saying what was in the folder and the other not looking in the folder and realizing the importance and gravity of the situation. She stated " I don ' t feel the system is as strong as it is supposed to be. " She stated Resident #1 was alert and you could communicate with him. The Administrator went on to say that she did not investigate any further and had not looked at the actual yellow DNR forms and had not interviewed any other staff. She did not know there was a delay in the physician signing the DNR. The resident had signed it on [DATE] and the physician signed it on [DATE]. She stated she only found out about the delay on [DATE] when the surveyors started looking into it. When asked what the process was for a DNR, she stated that if the physician has not signed the DNR, they will take it to the physician to be signed and that it was the responsibility of the Social Service Director to get it signed. Further interview with the Administrator at 10:26 a.m. confirmed that this is a delay in getting the DNR ' s signed and is a result of a system that needs to be adjusted. At 11:45 a.m., the Administrator stated the corporation has no time frame or expectation of how long it should take for the DNR to be signed by the physician after the resident has indicated that he does not want CPR and has signed the Do Not Resuscitate. She stated she did not question the time frame for getting the Do Not Resuscitate Order form signed. She admitted to not doing a thorough investigation. In an interview with the Social Services Director on [DATE] at 8:27 a.m., she stated she thought resident #1 signed a DNR. She looked in the chart and found copy of the DNR signed by resident #1 on [DATE]. She confirmed at this time that the physician had not signed it until [DATE]. She looked in the closed record at this time and was unable to locate the social services assessment in record. The Social Service Director stated she did not know why CPR was done on this resident and stated a DNR was signed on [DATE] by the physician. She stated she had 3 DNR forms in her office that had not been signed and the assistant social worker gave them to the Business Development/Admissions person in admissions to take to the physician for signature. One of the DNR ' s was for resident # 1. The Business Development/Admissions staff took them to the physician, had them signed, brought them back and handed the Social Service Director the folder while she was with the business office in a meeting. She was engaged in a conversation and took the folder and put it in her office. She does not recall looking to see what was in it. When she came in the next day, she found 2 DNRs on her desk and the Director of Nurses (DON) told her that they found resident #1 ' s DNR on the floor in her office. She was made aware that they did perform CPR on resident #1 against his wishes. She stated " If I had opened the folder, I would have taken care of them - made five copies and put them in the charts. But I did not open the folder and left it on my desk. " She stated that she didn ' t realize that the Business Development/Admissions person had handed her the signed DNR ' s. After that she checked her log in the computer of DNRs outstanding and waiting for signatures and the Administrator asked her to write a statement about what happened. Interview with the Business Development/Admissions person, on [DATE] at 2:35 pm. revealed that she took 3 DNR papers to the physicians to be signed. She waited while they were signed and brought them back to facility between 3 and 3:30 p.m. on [DATE]. As she walked in the front door, she saw the Social Service Director and the Business Office Manager in a meeting with the Administrator and she handed the one manila file folder to the Social Service director. This folder contained resident # 1 ' s signed DNR. 3. Review of a physician ' s progress note for resident #2 dated [DATE] at 3:30 p.m., revealed documentation that resident # 2 had been examined in the facility, and then complained of shortness of breath, became unresponsive, coughed up blood and became pulseless. CPR was initiated, the resident coded, EMS arrived, Epi given x 3 and the patient was intubated, cool and mottled, at bedside 45 minutes. Review of the record for resident #2 revealed no Advanced Directives or any documentation in the chart showing that the Social Service staff or the Admission staff had reviewed or discussed advanced directives with resident #2. The admission Notification and Consent form signed by the resident [DATE] indicated nothing listed on the Advanced Directives list. Under #7, the resident initialed that she had received the patient ' s rights and advanced directive information. The Social Services Director stated she did not talk to this resident because she was confused, but she signed her own admission papers, then 2 days later was declared incompetent. In an interview with a family member of resident #2 on [DATE] from 9:40 a.m. to 10:10 a.m., she stated emphatically that her mother would not have wanted CPR and that she had a living will. She was extremely upset that her mother had been resuscitated. She stated she was called by the facility on [DATE] about 4:00 p.m. and when she arrived at the facility, she was told her mother she was still there. She went up to her mother as they were putting on the stretcher and patted her and said she would follow her to the hospital. She said her mother was intubated and unconscious. She stated her mother had a DNR before she came to the facility and she thought it would follow her. She never dreamed her mother would die this way and was very upset that she was given CPR. She said her mother was a Registered Nurse and knew about these things and would never have wanted it. She was crying and said she could rejoice about her mother ' s death if only this had not happened and her heart was broken. She stated that if anyone had approached her at the nursing home about signing a DNR, she absolutely would have signed it immediately. When asked if anyone at the facility had asked her in advance what her mother ' s wishes were she said, " I don ' t think so. " She stated she was not concerned at the time because she said her mother had always had a DNR and she thought it would follow her. She said she had one for 7 years at the Assisted Living Facility where she lived before becoming ill and she was under the impression that it would follow her so she did not think there was anything to worry about. In an interview with the Social Services director on [DATE] at 2:00 p.m., she confirmed there were no Advanced Directives or documentation of having approached the resident or family and discussing Advanced Directives or DNR. She said she did not approach the resident on admission because the resident was confused and would not have been able to make any decisions. She could not locate any documentation that the family was approached about advanced directives. She confirmed she did not talk to the resident about advanced directives and confirmed that there was no evidence that family was contacted. She stated she did not know why she did not talk to the family about advanced directives. She also documented in resident #2 ' s social service notes on [DATE] that the resident had improved and was alert and oriented. She reviewed this note and could not say why the resident was not approached at this time to review her wishes for advanced directives or why the family was not approached to reassess the resident ' s capacity to make health care decisions when her mental status improved. Review of the face sheet for resident #2 revealed she was age [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incapacity statement entitled Physician ' s Evaluation of Resident ' s Capacity to make Health Care Decisions or provide Informed Consent was signed by the physician on [DATE]. Review of the resident Admission Data Collection completed on [DATE] at 4:00 p.m. revealed that the resident had a short and long term memory problem and had moderately impaired decision making skills. Review of the Minimum Data Set assessment (MDS) with an observation end date of [DATE] revealed no information about advanced directives and the resident ' s brief interview for mental status (BIMS) score was ,[DATE] possible points. The MDS with observation end date of [DATE] revealed no information about advanced directives, but the MDS did reveal that the resident ' s cognitive status with a BIMS score of ,[DATE] showed significant improvement from [DATE]. In an interview with on [DATE] at 3:40 p.m., the Unit Manager on the SSU unit, she stated that the resident was confused on admission, but had improved in her thinking over time. The record revealed that even though the resident had a statement signed by the physician that she was incapacitated to make health care decisions, she was able to sign a form entitled " Consent for Midline or PICC insertion " on [DATE] when she needed intravenous antibiotics. Review of the nurse ' s notes for the month of [DATE] revealed that the nurses charted that the resident was alert and oriented to time, place, and person every shift. Even though the resident showed marked improvement in mental status, she was not approached by anyone regarding advanced directives regarding her wishes if she should be found not breathing or without pulse. Review of the Notification and Consent form (page 3) of the admission paperwork revealed that the resident had signed the admission consents herself on [DATE] though declared incompetent 2 days later. This form indicates that the resident was given information about advanced directives on [DATE]. Review of the Notification and Consent Form (page2) revealed under the title Advanced Directives. Under #7, the form states to please indicate if you have any of the following documents or if you have a substitute decision maker: 1. Advanced Directives, 2. Health Care Agent 4. Living Will. This was blank. The admissions coordinator stated in an interview that if they are blank, it means they did not have any advanced directives or did not bring them. In an interview with the Director of Nurses on [DATE] at 4:00 p.m., she stated that resident #2 coded at change of shift on [DATE] at about 3:00 p.m. She said the medical director was in the building and participated in the resuscitation attempt. She stated she called the Administrator at the ALF where resident #2 had previously lived to try and get another phone number for the resident ' s family because she could not locate them. She obtained the phone number and called a family member and who had the responsible party call the DON. When the responsible party called her back, the DON told her about the facility having performed CPR on her mother. The daughter said her mother would not have wanted CPR and she had a living will. The DON stated she does know why this was not addressed in advance. The DON said she had never met the family before yesterday and that resident #2 had died . Review of the Pre hospital Care Report Summary completed by the paramedics that came to the facility revealed that the paramedics were called at 3:03 p.m. and arrived at the facility at 3:16 p.m. The chief complaint recorded was cardiac arrest, paramedic assessment revealed that the patient was apneic and pulseless; pupils were fixed and dilated with blood pressure of ,[DATE]. The following treatments were provided: Automatic Electronic Defibrillator applied and no shock advised, chest compressions, ventilated with bag valve mask (Ambu bag), electrocardiogram, intravenous line inserted into left hand and fluids and medication given, oxygen, intubation with a combitube (endotracheal tube), and several doses of epinephrine. Review of the hospital emergency room record revealed that the resident was transported via ambulance and arrived in the ER at 3:47 p.m. with CPR in progress on arrival. The resident was placed on a monitor. At 3:51 p.m. it is documented that the resident was initially coding on arrival and regained pulse after epinephrine/bicarb/calcium given. Pt. remains unresponsive, noted to have dark blood in the endotracheal tube and severely coarse rales/rhonchi. Per EMS, the resident had been unresponsive and pulseless since 3:00 p.m., regained pulse en route for a short time, then pulseless/apneic again. At 3:52, the resident was intubated again and placed on a ventilator. At 3:56 p.m., they recorded a blood pressure of ,[DATE], pulse 76, and respirations 18 and it is documented that the code was terminated. At 4:05 p.m., the doctor inserted a second intravenous line into the external jugular (neck) area and lab work was drawn. At 4:25 p.m. a urinary catheter was inserted was inserted to monitor output. A gastric tube was inserted through the resident ' s mouth at 4:30 p.m. on the first attempt due to possible GI bleed and connected to intermittent suction. At 4:50 pm., the report states that the family was at the bedside and stated the resident had a DNR and the family was the power of attorney. They were requesting the care be withdrawn. Dr. Shaw informed family that the DNR was being sent from the nursing home and that once it arrived care will be withdrawn. A later note at 5:25 p.m., stated that the resident ' s family stated the resident had a DNR on file with the attending physician and wished care be withdrawn. The medication keeping her blood pressure up was turned off and the resident promptly arrested. The resident was pronounced dead at 5:27 p.m. In an interview with the Medical Director on [DATE] at 3:00 p.m., he stated his expectations were that the DNR and advanced directives should be part of the admission packet. It should be signed the first week here and made part of admission process and it should go immediately into the chart after it is signed. The resident and family were never given an opportunity to sign a DNR. The facility did not follow their Advanced Directives policy which would have led to the DNR being signed and saving the resident from the ,[DATE] hour prolonged death involving chest compressions, tubes in her mouth and stomach and into her lungs, needles in her arms and neck and a tube being inserted into the bladder, the time when she just wanted to die with dignity and without interventions. 4. An interview was conducted with a Customer Care Liaison who assists with the admissions process, on [DATE] at 12: 01 p.m., She stated that the primary admission person is on vacation this week. She stated she helps out with the admissions process when the other person is busy or is out. She also stated she is a nurse and she does the pre admission assessments at the hospital. She stated as part of the admission process she asks them if they have any advance directives. If they say yes, she asks whether they have the advanced directives with them. If not, she asks them to bring in copes as soon as th

Based on interviews with the facility ' s nursing and administrative staff, a family member, social services, physician, review of clinical records and facility policies, it was determined that administration failed to provide resource management to ensure the rights of two (# 1, #2) of twelve sampled residents to refuse treatment and formulate advanced directives related to end of life decisions were protected. Administration did not ensure the direct functions and operations of the facility, including the provision for medically related social services, were in accordance with current regulations governing long term care facilities related to implementing policies and procedures for advance directives and do not resuscitate orders . The facility ' s failure to follow the Advance Directives policy and the Do Not Resuscitate policy represented a failure that could also lead to failure to provide CPR when wanted by the resident. The facility failed to obtain physician signatures for DNR orders in a timely fashion and failed to place the DNR in the resident ' s records when signed for nine of twelve residents (# 3, 4, 5, 6, 7, 8, 9, 11 & 12). The Administration ' s failure to ensure that the resident ' s expressed wishes related to advance directives and the right to refuse treatment were honored and protected led to findings of Immediate Jeopardy which was removed on [DATE] and reduced to the scope and severity of an " E " . Findings include: 1.Review of the job description for the Administrator (Executive Director ), which was provided by the Administrator on [DATE], but did not contain a signature or date, revealed the following relevant information: Purpose of Your Job Position: The Executive Director I, is responsible for management of the facility in a manner which exemplifies Consulate Health Care ' s standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate [MEDICATION NAME], Honesty, Integrity, and Respect for one another and everyone they come into contact with, and business practices are conducted with [MEDICATION NAME]. The primary purpose of the Executive Director is to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Job Functions: As Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day to day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Supervises Director of Clinical Services, Business Office Manager, Business Office Coordinator, Director of Admission, Director of Rehabilitation Services, Director of Resident and Family Services, Director of Therapeutic Recreational Services, Director of Hospitality Services, Director of Dining Services, Director of Environmental Services, Customer Care Associated. You will also provide leadership to all facility staff in meeting the goal of providing quality resident care. Duties and Responsibilities: Maintain and guide to implementation, facility policies and procedures in compliance with corporate, state, federal and other regulatory guidelines. Support and guide the facility ' s quality improvement process. Ensure a safe, clean and comfortable environment for residents, visitors and staff. Maintain a file for and monitor incident reports. Create and maintain an atmosphere in which employees demonstrate respect, warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility. Ensure that residents, visitors and employees are treated with respect and [MEDICATION NAME] as evidence by satisfaction surveys. Adhere to facility policies and procedures and participated in facility quality improvement and safety programs. Attend to overall operation of the facility. Embrace Consulate Health Care ' s five core values of [MEDICATION NAME], honesty, integrity, respect and [MEDICATION NAME] and incorporate them into the daily job function. Demonstrate respect and [MEDICATION NAME] in every interaction. Demonstrate a [MEDICATION NAME] for caring as evidenced by interactions with co- workers, residents, families and visitors. Resident Rights: Ensure that the resident ' s right to fair and equitable treatment, self- determination, individuality, privacy, property and civil rights, included the right to wage complaints, are well established and maintained at all times. 2. Resident #1 signed a State of Florida Do Not Resuscitate Order (DNR) on [DATE]. The form was signed by the physician on [DATE] and an order was written. The resident was found without pulse or respirations on [DATE] at approximately 12:25 a.m. per nurse ' s notes and CPR was initiated and emergency personnel tried to provide life support measures in spite of the resident ' s express written wishes, via a signed DNR order, not to be resuscitated. Review of the face sheet dated [DATE] for resident #1 revealed that he was a [AGE] year old gentleman, who was admitted on [DATE] to the facility from the hospital. Under the box Advanced Directive on the face sheet " No " is checked. Under primary [DIAGNOSES REDACTED]. Under secondary [DIAGNOSES REDACTED]. The admission agreement was signed by the resident on [DATE]. The readmission agreement dated [DATE] was also signed by the resident on [DATE] and stated that I, the above named resident, do consent to waive the resigning of the complete agreement and all applicable consents. I further acknowledge that there are no amendments to the original admission agreement and consent forms and that the original agreement and all consent forms are still valid. Under the admission agreement notification and consent form dated [DATE] signed by the resident number 7 is entitled Advanced Directives and states that " You have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Please indicate if you possess any of the following documents or have a substitute decision-maker and indicate the identity and/or location of each " : lists advanced directives, health care agent, conservator of person, living will, durable power of attorney and other and is not filled in. This form was witnessed by the admissions staff. On the next page under #12 the resident signed, " I hereby acknowledge that I have received copies of the following information and that it has been clearly explained to me by the facility staff " . Listed and initialed are: Advanced Directives and Patient ' s Rights. In an interview with the Customer Care Liaison on [DATE] 12:01 p.m., she stated if nothing is checked or written on this form, it indicates the resident had no advanced directives on admission. She said if they have advanced directives but they do not have them with them, she would make a note on that form. This form was signed by the primary admissions person. This was confirmed at 2:30 p.m. by the admissions marketing person that the resident had no advanced directives on admission. A booklet entitled Resident Bill of Rights (A guide to your rights as a resident) was in the packet and is " the following information " as outlined in the admissions packet. Resident ' s rights are described and explained in this packet and under #K it says: You have the right to refuse medication or treatment and to be informed of the consequences of such decisions, unless it has been determined under state law that you are unable to provide informed consent. A history and physical from the hospital dated [DATE] stated that resident #1 was mentally sharp. According to the history, the resident was able to relate his own symptoms to the physician. It also listed [DIAGNOSES REDACTED]. Review of the Admission Data Collection Form dated [DATE] at 8:00 a.m. revealed that the resident was assessed as having no long or short term memory problems and was independent in decision making skills. Review of the Initial Social Service History dated [DATE] revealed that the resident had been living at home alone. A " Consulate Health Care Advanced Directives Discussion Document " was signed by the resident and the Social Service Director on [DATE]. This form states: The purpose of the this document is to obtain information regarding your wishes on specific life support decisions you may have made, advanced directives and/or substitute decision makers you may have appointed to speak for you. In addition, this facility wishes to inform you that you have the right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Listed below are three particular types of life support systems. Please indicate your feeling regarding the following: Cardiopulmonary resuscitation (CPR) and artificial respiration were listed and both had been checked by the resident under " Withhold " . A State of Florida Do Not Resuscitate Order form was found in the resident ' s record. The first section of the form stated: " Based upon informed consent, I, the undersigned hereby direct that CPR be withheld or withdrawn. " This section was signed by resident # 1 on [DATE]. The form was not signed by the physician until [DATE]. It stated " I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient ' s cardiac or respiratory arrest. " Review of a nurse ' s note dated [DATE] at approximately 12:25 a.m., the resident was found by the nurse not breathing, no heart rate or pulse, skin color ashen, and cool to touch. Code blue called. CPR started. Dr. was paged after 911 called and emergency contact person was notified. EMS arrived at approximately 1:05 a.m. Emergency contact person arrived at 1:07 a.m. The Dr. called back at approximately 1:15 a.m. stating the resident signed a DNR on [DATE]. DNR paper not in chart.-found in social services office -shown to EMS - CPR stopped at approximately 1:20 p.m. Resident # 1 ' s wishes not to be treated were not honored for approximately one hour. In a telephone interview with Nurse E, on [DATE] at 1:53 p.m. she confirmed she wrote the above nurse ' s note. She stated she is the one who found resident #1 not breathing and with no pulse. She said it was hard to tell how long it had been because his skin felt neither warm nor cold, but just as it usually did. He was not cold. She said his aide was in there at midnight and he was OK. She was in there about 12:20 a.m. and found him unresponsive. She went in and thought " Oh my God, I think he is dead " . She thought at first he was a DNR because of his age, but when she checked the chart, she was surprised no yellow DNR form was in there. She said she grabbed the crash cart and went to the room and initiated CPR. By that time someone had called the code and other nurses showed up to help. She said Nurse C was doing compressions and she was performing artificial respirations using the Ambu bag. The other nurse was holding the seal on resident #1 ' s mouth. She stated that the doctor called back the facility after the medics arrived and took over the CPR. She stated Nurse D talked to the doctor and the doctor asked them to stop the CPR. They found the DNR form in the social workers office and stopped CPR. He did not respond at all to the resuscitation. In an interview with Nurse G (LPN) on [DATE] at 6:25 a.m. she stated that about 3 weeks ago resident #1 coded. The nurses were called about midnight or so to the skilled unit (SSU) by an overhead page. There were 2 nurses on each unit that night. She checked the chart and did not see a yellow DNR form on the chart. She thinks Nurse E checked the Medication Administration Record (MAR) to see if the yellow DNR form was in there. They did not see a DNR so CPR was initiated by Nurse C, Nurse B and Nurse G. The medics were called by Nurse D and the Certified Nursing Assistants (CNAs) were around to assist. Oxygen was applied thru the Ambu bag. When the medics arrived she said was tired from participating in the resuscitation. Nurse G stated Nurse D called the physician and Nurse G thinks that he said he signed a DNR. She stated Nurse D found the DNR on the social services desk. This was told to her after the fact. She stated no one in management had approached her about this incident to investigate. She stated she offered information to the two Unit Mangers about what happened. In an interview on [DATE] at 7:55 a.m. with Nurse D, she stated that about 3 weeks ago on the skilled (SSU) a gentleman who was about [AGE] years old coded ( resident # 1). The code was announced and she was in the bathroom and did not hear it. The CNAS told her about it when she came out, so she went over to the skilled unit. She stated she made the phone calls to 911. A new nurse, Nurse E, was on the phone and having difficulty remembering the address of the facility, so she took over the phone call to 911 and Nurse E went and helped in the room with the resident. She filled out transfer paper work and had someone go to the front door to let the medics in. Nurse E came back and called the family. Nurse D stated " then I called the doctor and he said he had signed a DNR " . The EMTs came and took over CPR. The doctor said to tell them to stop CPR and they said they could not stop until a yellow DNR order was presented to them. They looked everywhere for it. She stated she knew social services handled the DNRs, so she looked in the social services office for it and she found it and gave it to the EMTs. She stated from the time she arrived on the unit, it may have been 20 minutes by the time the CPR was stopped. When the DNR paper was found it was yellow, she knows the doctor ' s signature was on it and there were 2 signatures but she was not sure who signed it. She stated resident # 1 did not recover. She stated the family came in and knew there was a DNR. Nurse D said she told him the truth about the DNR and he did not seem upset. He wanted to know where it was and she told him. Nurse D stated they, the nurses, were upset because the DNR was not where it was supposed to be. She did not know who discussed it or talked about it afterward. She stated no one in management approached her to ask her what happened or investigate this incident with her. In an interview on [DATE] at 6:45 a.m. with Nurse C, an LPN, he stated he was involved when resident #1 coded. He stated the nurse working the hall was Nurse E, an LPN who was fairly new to the facility. She called him and said " I think the guy is dead " . They checked the chart and MAR and saw that he was not a DNR so they initiated CPR. Nurse G came over from the GNR unit and told Nurse E to call 911. They did CPR until the paramedics came. It was around 12:20 or 1:20 a.m., not sure. He thinks they did CPR for 30 minutes. He remembers sweating. The paramedics took over the CPR, and then Nurse D called the doctor. The doctor said he had signed a DNR for resident # 1. Nurse C stated he did not see the order but heard about this later, because when the paramedics arrived, he left the room and went back to his assignment. In an interview with the Administrator (Executive Director) on [DATE] at 7:10 a.m. she stated resident #1 was [AGE] years old and was there only about 3 weeks. She confirmed that the resident was given CPR because the signed DNR order was not in his chart. She thinks it was a weekend and thinks she was called about it. In an interview at 10:07 a.m., when asked if she had reported the incident to the state as required, she said no. She stated she was the assigned Risk Manager for the facility and she had called her corporate office and consulted with them and they stated it was not reportable because it did not result in a resident injury. When asked for her investigation, she produced two short statements. One was from the Social Service Director and one was from the Business Development/Admissions person. She stated that she determined that the problem was a communication error between the two employees. She said the Social Service Director (Director of Resident and Family Services) told the assistant social worker that 3 DNRs in her office needed to be signed by the physician. The assistant gave them to the Business Development/Admissions person and she took them to the doctors and had them signed on [DATE]. When the Business Development/Admissions person returned, she handed the folder containing the signed DNRs to the Social Service Director, not telling her what was in them. The Social Service Director was engaged in a meeting with the Business Office Manager at the time. The Social Service Director put the folders with the signed DNRs in it on her desk and did not file them. She did not look in the folder and did not realize what they were. The Administrator concluded it was an honest error on the part of two employees- one not saying what was in the folder and the other not looking in the folder and realizing the importance and gravity of the situation. She stated " I don ' t feel the system is as strong as it is supposed to be. " She stated Resident #1 was alert and you could communicate with him. The Administrator went on to say that she did not investigate any further and had not looked at the actual yellow DNR forms and had not interviewed any other staff. She did not know there was a delay in the physician signing the DNR. The resident had signed it on [DATE] and the physician signed it on [DATE]. She stated she only found out about the delay on [DATE] when the surveyors started looking into it. When asked what the process was for a DNR, she stated that if the physician has not signed the DNR, they will take it to the physician to be signed and that it was the responsibility of the Social Service Director to get it signed. Further interview with the Administrator at 10:26 a.m. confirmed that this is a delay in getting the DNR ' s signed and is a result of a system that needs to be adjusted. At 11:45 a.m., the Administrator stated the corporation has no time frame or expectation of how long it should take for the DNR to be signed by the physician after the resident has indicated that he does not want CPR and has signed the Do Not Resuscitate She stated she did not question the time frame for getting the Do Not Resuscitate Order form signed. The Administrator stated at noon that she did a rapid root cause of incident. She stated she thought it was just a mistake and that nursing had functioned appropriately and she closed her investigation. In an interview with the Social Services Director on [DATE] at 8:27 a.m., she stated she thought resident #1 signed a DNR. She looked in the chart and found copy of the DNR signed by resident #1 on [DATE]. She confirmed at this time that the physician had not signed it until [DATE]. She looked in the closed record at this time and was unable to locate social services assessment in record. The Social Service Director stated she did not know why CPR was done on this resident and stated a DNR was signed on [DATE] by the physician. She stated she had 3 DNR forms in her office that had not been signed and the assistant social worker gave them to the Business Development/Admissions person in admissions to take to the physician for signature. One of the DNR ' s was for resident # 1. The Business Development/Admissions staff took them to the physician, had them signed and brought them back to her and handed the Social Service Director the folder while she was with the business office in a meeting. She handed her a folder but did not say what was in it. She was engaged in a conversation. She took the folder and put it in her office. She does not recall looking to see what was in it. When she came in the next day, she found 2 DNRs on her desk and the Director of Nurses (DON) told her that they found resident #1 ' s DNR on the floor in her office. She was made aware that they did CPR him. She stated " If I had opened the folder, I would have taken care of them - made five copies and put them in the charts. But I did not open the folder and left it on my desk. " She stated that she didn ' t realize that the Business Development/Admissions person had handed her the signed DNR ' s. After that she checked her log in the computer of DNRs outstanding and waiting for signatures and the Administrator asked her to write a statement about what happened. Interview with the Business Development/Admissions person, on [DATE] at 2:35 pm. revealed that she took 3 DNR papers to the physicians to be signed. She waited while they were signed and brought them back to facility between 3 and 3:30 p.m. on [DATE]. As she walked in the front door, she saw the Social Service Director and the Business Office Manager in a meeting with the Administrator and she handed the one manila file folder to the Social Service director. This folder contained resident # 1 ' s signed DNR. In an interview with the resident ' s attending physician on [DATE] at 3:10 pm. he stated that his expectations were that once the patient says he wants a DNR then he should be a DNR. The physician stated that resident #1 was a DNR. He stated, it was when I came to see other patients, is when I signed his DNR. It should be respected even if it is not signed yet. It could be a verbal order and I could sign when I come in. He stated he expected that when he signed the order it should be implemented immediately. 3. On [DATE] at 3:30 p.m., a physician ' s progress note stated that resident # 2 had been seen in the facility, then complained of shortness of breath, became unresponsive, coughed up blood and became pulseless. CPR was initiated, the resident coded, EMS arrived, Epi given x 3 and the patient was intubated, cool and mottled, at bedside 45 minutes. In an interview with the Director of Nurses on [DATE] at 4:00 p.m., she stated that resident #2 coded at change of shift on [DATE] at about 3:00 p.m. She said the medical director was in the building and participated in the resuscitation attempt. She stated she called the Administrator at the ALF where resident #2 had previously lived to try and get another phone number for the resident ' s family because she could not locate them. She obtained the phone number and called a family member and who had the responsible party call the DON. When the responsible party called her back, the DON told her about the facility having performed CPR on her mother. The daughter said her mother would not have wanted CPR and she had a living will. The DON stated she does know why this was not addressed in advance. The DON said she had never met the family before yesterday and that resident #2 had died . Review of the record for resident #2 revealed no advanced directives or any documentation in the chart showing that the Social Service staff or the Admission staff had reviewed or discussed advanced directives with resident #2. Review of the face sheet for resident #2 revealed she was age [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incapacity statement entitled Physician ' s Evaluation of Resident ' s Capacity to make Health Care Decisions or provide Informed Consent was signed by the physician on [DATE]. Review of the resident admission data collection completed on [DATE] at 4:00 p.m. revealed that the resident had a short and long term memory problem and had moderately impaired decision making skills. Review of the Minimum Data Set assessment (MDS) with an observation end date of [DATE] revealed no information about advanced directives and the resident ' s brief interview for mental status (BIMS) score was ,[DATE] possible points. The MDS with observation end date of [DATE] revealed no information about advanced directives, but the MDS did reveal that the resident ' s cognitive status with a BIMS score of ,[DATE] showed significant improvement from [DATE]. In an interview with on [DATE] at 3:40 p.m., the Unit Manager on the SSU unit, she stated that the resident was confused on admission, but had improved in her thinking over time. The record revealed that, even though the resident had a statement signed by the physician that she was incapacitated to make health care decisions, she was able to sign a form entitled " Consent for Midline or PICC insertion " on [DATE] when she needed intravenous antibiotics. Review of the nurse ' s notes for the month of [DATE] revealed that the nurses charted that the resident was alert and oriented to time, place, and person every shift. Even though the resident showed marked improvement in mental status, she was not approached by anyone regarding advanced directives regarding her wishes if she should be found not breathing or without pulse. Review of the Notification and Consent form (page 3) of the admission paperwork revealed that the resident had signed the admission consents herself on [DATE] though declared incompetent 2 days later. This form indicates that the resident was given information about advanced directives on [DATE]. Review of the Notification and Consent Form (page2) revealed under the title Advanced Directives. Under #7, the form states to please indicate if you have any of the following documents or if you have a substitute decision maker: 1. Advanced Directives, 2. Health Care Agent, 4. Living Will. This was blank. The admissions coordinator stated in an interview that if they are blank, it means they did not have any advanced directives or did not bring them. In an interview with a family member of resident #2 on [DATE] from 9:40 a.m. to 10:10 a.m., she stated emphatically that her mother would not have wanted CPR and that she had a living will. She was extremely upset that her mother had been resuscitated. She stated she was called by the facility on [DATE] about 4:00 p.m. and when she arrived at the facility, she was told her mother she was still there. She went up to her mother as they were putting on the stretcher and patted her and said she would follow her to the hospital. She said her mother was intubated and unconscious. She stated her mother had a DNR before she came to the facility and she thought it would follow her. She never dreamed her mother would die this way and was very upset that she was given CPR. She said her mother was a Registered Nurse and knew about these things and would never have wanted it. She was crying and said she could rejoice about her mother ' s death if only this had not happened and her heart was broken. She stated that if anyone had approached her at the nursing home about signing a DNR, she absolutely would have signed it immediately. When asked if anyone at the facility had asked her in advance what her mother ' s wishes were she said " I don ' t think so " . She was not concerned because she said her mother had always had a DNR. She said she had one for 7 years at the Assisted Living Facility where she lived before becoming ill and she was under the impression that it would follow her so she did not think there was anything to worry about. In an interview with the Social Services director on [DATE] at 2:00 p.m., she stated there were no advanced directives or documentation of having approached resident #2 or her family and discussing advanced directives or DNR. She said she did not approach the resident on admission because the resident was confused and would not have been able to make any decisions. She could not locate any documentation that the family was approached about advanced directives. She confirmed she did not talk to the resident about advanced directives and confirmed that there was no evidence that family was contacted. She stated she did not know why she did not talk to the family about advanced directives. She also documented in resident #2 ' s social service notes on [DATE] that the resident had improved and was alert and oriented. She reviewed this note and could not say why the resident was not approached at this time to review her wishes for advanced directives or why the family was not approached to reassess the resident ' s capacity to make health care decisions when her mental status improved. Review of the Notification and Consent form (page 3) of the admission paperwork revealed that the resident had signed the admission consents herself on [DATE] though declared incompetent 2 days later. This form indicates that the resident was given information about advanced directives on [DATE]. Review of the Notification and Consent Form (page2) revealed under the title Advanced Directives. Under #7, the form states to please indicate if you have any of the following documents or if you have a substitute decision maker: 1. Advanced Directives, 2. Health Care Agent 4. Living Will. This was blank. The admissions coordinator stated in an interview that if they are blank, it means they did not have any advanced directives or did not bring them. Review of the Pre hospital Care Report Summary completed by the paramedics that came to the facility revealed that the paramedics were called at 3:03 p.m. and arrived at the facility at 3:16 p.m. The chief complaint recorded was [MEDICAL CONDITION], paramedic assessment revealed that the patient was apneic and pulseless; pupils were fixed and dilated with blood pressure of ,[DATE]. The following treatments were provided: Automatic Electronic Defibrillator applied and no shock advised, chest compressions, ventilated with bag valve mask (Ambu bag), electrocardiogram, intravenous line inserted into left hand and fluids and medication given, oxygen, intubation with a combitube (endotracheal tube), and several doses of [MEDICATION NAME]. Review of the hospital emergency room record revealed that the resident was transported via ambulance and arrived in the ER at 3:47 p.m. with CPR in progress on arrival. The resident was placed on a monitor. At 3:51 p.m. it is documented that the resident was initially coding on arrival and regained pulse after [MEDICATION NAME]/[MEDICATION NAME]/calcium given. Pt. remains unresponsive, noted to have dark blood in the endotracheal tube and severely coarse rales/rhonchi. Per EMS, the resident had been unresponsive and pulseless since 3:00 p.m., regained pulse en route for a short time, then pulseless/apneic again. At 3:52, the resident was intubated again and placed on a ventilator. At 3:56 p.m., they recorded a blood pressure of ,[DATE], pulse 76, and respirations 18 and it is documented that the code was terminated. At 4:05 p.m., the doctor inserted a second intravenous line into the external jugular (neck) area and lab work was drawn. At 4:25 p.m. a urinary catheter was inserted was inserted to monitor output. A [MEDICAL CONDITION] tube was inserted through the resident ' s mouth at 4:30 p.m. on the first attempt due to possible GI bleed and connected to intermittent suction. At 4:50 pm., the report states that the family was at the bedside and stated the resident had a DNR and the family was the power of attorney. They were requesting the care be withdrawn. Dr. Shaw informed family that the DNR was being sent from the nursing home and that once it arrived care will be withdrawn. A later note at 5:25 p.m., stated that the resident ' s family stated the resident had a DNR on file with the attending physician and wished care be withdrawn. The medication keeping her blood pressure up was turned off and the resident promptly arrested. The resident was pronounced dead at 5:27 p.m. In an interview with the Medical Director on [DATE] at 3:00 p.m., he stated his expectations were, the DNR and advanced directives should be part of the admission packet. It should be signed the first week here and made part of admission process and it should go immediately into the chart after it is signed. The resident and family were never given an opportunity to sign a DNR. The fac