Every finding on record at Williston Care Center and Rehab

Based on interview and record review, the facility failed to ensure the staff member designated as Food Services Supervisor met the required qualifications.Findings include:During an interview on 8/24/2026 beginning at 9:12 AM, Staff A introduced herself as the Dietary Manager. Staff A reported she was not a Certified Dietary Manager (CDM) but had completed a food safety and management course.During an interview on 8/26/2026 at 10:52 AM, the Administrator stated Staff A had been in the position of Food Services Supervisor for 30 days; and Staff A was still in training and the Registered Dietician was contracted and not a full-time employee of the facility. The Administrator stated Staff A's previous food service experience involved working at fast food restaurants.Review of Staff A's job description titled Food Services Supervisor signed by Staff A on 8/3/2026, read, Education: CDM Certification required . Experience: Must have, as a minimum three (3) years experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility.Review of Staff A's undated resume showed Staff A had previous experience as a Dietary Assistant Manager with a contracted dietary services provider. Further review did not show 2 or more years of experience in the position of director of food and nutrition services in a related medical facility setting.Review of the Registered Dietician's contract, signed on 8/24/2023, read, 9. Scope of Work: A Consultant Dietician will be assigned to provide clinical nutrition and food service management consulting services on a part-time basis appropriate to fulfill the responsibilities thereunder.

Based on record review and interview, the facility failed to ensure blood sugar re-checks and provider communication were accurately documented for 1 of 5 residents, Resident #4, reviewed for medication management.Findings include:Review of Resident #4's physician order dated 5/15/2026 read, Instant Glucose, Give 1 unit by mouth every 15 minutes as needed for hypoglycemia- May repeat 2x [times] for 3 total administrations for responsive patients with blood sugars less than 70 or 70-100 with signs and symptoms of hypoglycemia. Give one tube followed by snack or drink per prescribed diet. Repeat accuchecks every 15-30 minutes until blood sugar is greater than 100.Review of Resident #4's physician order dated 6/10/2026 read, Novolin R FlexPen 100 unit/ml Solution pen-injector, Inject subcutaneously before meals and at bedtime for DM [Diabetes Mellitus]. Notify MD [Medical Doctor] for BS [Blood Sugar] under 70 or above 400 and follow protocol as directed.Review of Resident #4's Weights and Vitals Summary for June 2026 showed blood glucose level of 69 mg/dL [milligram/deciliter] on 6/8/2026 at 6:45 AM. There was no re-check of blood glucose documented after 15-30 minutes of the initial blood sugar level.Review of Resident #4's MAR for June 2026 did not show administration of instant glucose on 6/8/2026.Review of Resident #4's progress notes dated 6/8/2026 showed no documentation related to hypoglycemia management.Review of Resident #4's Weights and Vitals Summary for July 2026 showed blood glucose level of 69 mg/dL on 7/1/2026 at 6:29 AM, 66 mg/dL on 7/29/2026 at 5:44 AM, and 69 mg/dL on 7/31/2026 at 5:38 AM. There was no re-check of blood glucose documented after 15-30 minutes of the initial blood sugar level.Review of Resident #4's Medication Administration Record (MAR) for July 2026 did not show administration of instant glucose on 7/1/2026, 7/29/2026 and 7/30/2026.Review of Resident #4's progress note dated 7/1/2926 read, Blood sugar 69, snack offered and taken. No S/S [signs or symptoms] of hypoglycemia.Review of Resident #4's progress note dated 7/29/2026 showed no documentation related to hypoglycemia management.Review of Resident #4's progress note dated 7/31/2026 read, MD notified. Snack given.During an interview on 8/27/2026 at 9:14 AM, Staff F, Licensed Practical Nurse (LPN), stated, I don't recall. Normally I give him a snack and let the provider know. I will recheck the blood sugar. I am not sure why it is not showing in the record.During an interview on 8/27/2026 at 9:18 AM, Staff G, LPN, stated, I am surprised I did not leave a note. I offered instant glucose and a sugary snack. I will recheck after 30 minutes of the initial one.During an interview on 8/27/2026 at 9:24 AM, the Advance Practice Registered Nurse #1 stated, The staff keep me informed of [Resident #4's name] low blood sugar reading. If he is alert, a snack is enough. They have to re-check his blood sugar. I do expect the staff to have a note regarding the communication with me and the re-check of the blood sugar.During an interview on 8/27/2026 at 10:45 AM, the Director of Nursing stated, Nurses are to document accurately the communication with the provider and document the re-checks of the blood sugars.Review of the facility policy and procedure titled Charting and Documentation with the last review date of 1/29/2026 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 3 of 7 residents, Residents #3, #4, and #41, reviewed for MDS assessments. Findings include: 1) Review of Resident #3's quarterly MDS assessment dated [DATE] under Section N- Medications showed the resident was being administered anticoagulants for the lookback period. Review of Resident #3's physician orders showed no order for medications with anticoagulant classification. Review of Resident #3's Medication Administration Record for June 2026 did not show anticoagulants being administered during the lookback period. During an interview on 8/26/2026 at 11:23 AM, Staff C, MDS Coordinator stated, I do not see anticoagulants administered. It [Section N-Medication of the MDS assessment] will need to me corrected. 2) Review of Resident #4's MDS assessment dated [DATE] under Section N- Medications showed the resident was not receiving hypoglycemic (including insulin) medications. Review of Resident #4's physician order dated 5/14/2026 read, Lantus SoloStar 100 unit/ml [milliliter] Solution pen-injector, Inject 20 units subcutaneously at bedtime for DM [Diabetes Mellitus]. Review of Resident #4's physician order dated 6/10/2026 read, Novolin R FlexPen 100 unit/ml Solution pen-injector, Inject subcutaneously before meals and at bedtime for DM. Notify MD [Medical Doctor] for BS [Blood Sugar] under 70 or above 400 and follow protocol as directed. During an interview on 8/26/2026 at 12:18 PM, the MDS Coordinator stated, [Resident #4's name] was administered insulin. The section should have said yes. It needs to be corrected. 3) Review of Resident #41's MDS assessment dated [DATE] showed the resident was not receiving no dialysis under Section O- Special Treatments, Procedures, and Programs. Review of Resident #41's physician order dated 8/3/2026 read. May change dialysis days due to holiday and/or unexpected situations. Review of Resident #41's physician order dated 8/6/2026 read, Dialysis Tues/Thurs/Sat [Tuesday, Thursday, Saturday] chair time @ [at] 11:30 AM. During an interview on 8/26/2026 at 11:15 AM, Staff B, MDS Coordinator stated, There was a modification made to the MDS on 8/6/2026 for the dialysis and was accepted by me on 8/25/2026. Review of the facility policy and procedure titled MDS Assessments with the last review date of 1/29/2026 read, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI [Resident Assessment Instrument] manual guidelines.

Based on observation, interview, and record review, the facility failed to ensure orders were in place for flushing an intravenous (IV) catheter before and after medication administration for 1 of 2 residents, Resident #110, reviewed for intravenous medication administration.Findings include:During an observation on 8/26/2026 at 5:59 AM, Staff D, Licensed Practical Nurse (LPN), entered Resident #110's room. Staff D assessed Resident #110's IV catheter. Staff D primed the IV line and cleaned the needleless connector. Staff D proceeded to flush the IV catheter with 10 milliliters of normal saline. Staff D connected the IV tubing to the needleless connector, and the medication began to be administered.During an interview on 8/26/2026 at 5:59 AM, Staff D, LPN, stated, I always flush the line before and after with normal saline.Review of Resident #110's medical record did not show a physician order for normal saline flushes.During an interview on 8/26/2026 at approximately 9:10 AM, Staff E, Registered Nurse, stated, I will flush her [Resident #110] IV before and after the medication administration with normal saline.During an interview on 8/26/2026 at 10:34 AM, the Director of Nursing stated, I do not see an order in there. I would have to put one in.During an interview on 8/26/2026 at 11:42 AM, the Director of Nursing stated, When she [Resident #110] went to the hospital and came back, the order fell off and was not put back.Review of the facility policy and procedure titled IV Infusion with the last review date of 1/29/2026 read, Policy: It is the policy of this facility to provide administration of intravenous fluids, medications and electrolytes for the purpose of hydration and management of infections or other medical conditions. Procedure: 1. Obtain a physician's order for the IV medication or hydration. 6. Administer IV medications or fluids per physician orders.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent nutritional risk as ordered by the physician for 3 of 7 residents, Residents #18, #55, and #111, reviewed for nutrition. Findings include: 1) Review of Resident #55's physician order dated 7/18/2026 read, Check weights daily x [times] 3 days then weekly. Review of Resident #55's Weights and Vitals Summary showed the resident weighed 122 lbs (pounds) on 7/18/2026, and 108.4 lbs on 8/9/2026, indicating 11.5 lbs (9.4%) loss, and 110.5 lbs on 8/26/2026. There was no other weight documented. Review of Resident #55's Nutrition Risk Evaluation dated 7/23/2026 read, Receives a Regular, Mechanical Soft diet with thin liquids and is consuming 50-100% of most meals with 4 recordings < [less than] 50% since admission. Resident is totally dependent on staff at meals, she has no teeth per nsg [nursing] assessment also noted to have swallowing difficulties. Current Body weight is 122# [pounds] with a BMI [Body Mass Index] of 19.7 on Low end of normal range. Abnormal labs: Alb(l), Hgb(l) all other Nutrition related labs are within normal ranges. There are no Pressure areas nor edema noted, however, resident has Soft Boggy Heels on Both Right & Left Sides, Redness to the Sacrum. Resident is Malnourished with a score of 7. PO [oral] intakes may stabilize once ABT [antibiotic therapy] is completed. Recommend 1) Add Fortified foods at meals. Continue to monitor and follow up as needed. During an interview on 8/26/2026 at approximately 1:20 PM, the Director of Nursing (DON) stated she was unable to locate additional weights for Resident #55; and she has meeting with the Registered Dietitian weekly to go overweight loss but for some reason the resident did not trigger. During an interview on 8/26/2026 at 2:26 PM, the Registered Dietitian (RD) stated, Normally if they let me know that she is having issues eating. There was nothing to go by that she was having issues. They were not doing the weekly weights didn't have anything to go by. Normally, they do a reweight to verify and then let me know. Nurses should have reweighted and then if it was accurate weight loss, let me know. 2) Review of Resident #111's physician order dated 7/14/2026 read, Weekly weights on day shift every day shift every Wed [Wednesday] for weight tracking. Review of Resident #111's Weights and Vitals Summary showed the resident weighed 123.9 lbs on 7/10/2026, 122.4 lbs on 8/2/2026, and 120.4 lbs on 8/5/2026. There was no other weight documented. Review of Resident #111's Nutrition Risk Evaluation dated 7/14/2026 read, Due to underweight status, recommending 1) fortified foods with meals, 2) MVM [Multivitamin/Mineral Supplement] po daily. Will continue to monitor and follow up as needed. During an interview on 8/26/2026 at 2:15 PM, the RD stated, [Resident #111's name] has had no significant weight loss at this time. Patient remains stable. There were no weekly weights I could find. During an interview on 8/27/2026 at 8:16 AM, the DON stated, I was not able to locate weekly weights for [Resident #111's name]. Usually, it will show up in the medication treatment record and the certified nursing assistant will get the weights and the nurse will put it in the system. The supplementation documentation was not triggered on the record. 3) Review of Resident #18's physician order dated 4/30/2026 read, Frozen Nutritional Treat two times a day 1 carton with lunch and dinner. Review of Resident #18's care plan, initiated on 5/28/2024, revealed Resident #18 was malnourished and had the potential for further complications with nutrition/hydration and weight changes. Resident #18's care plan documented Resident #18's need for use of a mechanically altered/therapeutic diet with use of frozen nutritional treats. Review of Resident #18's lunch ticket dated 8/26/2026, read, Instructions: Frozen Nutritional Threat [Sic]. Review of Resident #18's supper ticket dated 8/26/2026, read, Instructions: Frozen Nutritional Threat [Sic]. During an observation on 8/25/2026 at 12:55 PM, Resident #18 received lunch in his room. There was no frozen nutritional treat provided with Resident #18's lunch. During an observation on 8/26/2026 at 12:42 PM, Resident #18 received lunch in his room. There was no frozen nutritional treat provided with Resident #18's lunch. During an interview on 8/26/2026 at 1:33 PM, the Regional Dietary Manager stated a frozen nutritional treat would be the only supplement provided by the kitchen. During an interview on 8/26/2026 at 1:53 PM, the Regional Dietary Manager stated the kitchen staff had missed sending Resident #18's frozen nutritional treat to the floor with his lunch. He stated the floor nursing staff served as fail safe to check and ensure the residents had been provided meals and supplements as prescribed. During an interview on 8/26/2026 at 2:14 PM, the Registered Dietician confirmed Resident #18 should be served the frozen nutritional treat two times a day to provide additional calories and protein. Review of the facility policy and procedure titled Weights and Weight Loss with the last review date of 1/29/2026 read, Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedures: 1. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded. 4. Consistent weight loss noted during the admission weight process will be brought to attention of the physician and/or RD and responsible party. 5. Significant weight loss shall be addressed by the physician and/or RD through discussion with the resident and/or resident representative for known preferences and desires and development and implementation of interventions to attempt to address the weight loss.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a safe manner in 1 of 2 nourishment rooms, [NAME] Nutrition Room.Findings include:During an observation on 8/24/2026 at 9:30 AM, the thermometer in the freezer of the [NAME] Nourishment Room was registering a temperature of approximately 60 degrees Fahrenheit. The thermometer line was slanted inside the casing. The interior of the freezer was warm and two cardboard boxes of food items were wet to the touch.During an interview on 8/24/2026 beginning at 9:30 AM, the Dietary Manager acknowledged the thermometer in the [NAME] Nourishment Room freezer was not operational. She confirmed the food items stored in the freezer were thawing.Review of the facility policy and procedure titled Foods Brought in From the Outside with the last review date of 1/29/2026 read, 8) The nursing staff shall ensure the temperatures of the refrigerator and freezer, if applicable, meets the minimum temperature requirements.

Based on interview and record review, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for 2 of 7 residents, Residents #1 and #3 reviewed for Minimum Data Set (MD) assessments. 1)Review of Resident #1 Minimum Data Set (MDS) titled Quarterly dated 9/18/2025 in Section J Bladder and Bowel documented no indwelling catheter.Review of Resident #1 physician order dated 1/24/2025 read, Cath [Catheter] Change urinary catheter bag and tubing once monthly and as needed.Review of Resident #1 physician order dated 9/9/2025 read, Suprapubic Catheter Dx [Diagnosis]: Neurogenic bladder.Review of Resident #1 physician order dated 9/9/2025 read, Cath: Catheter care with soap and water every shift pat dry, apply T-drain per resident request and as needed.During an interview on 12/05/2025 at 12:40 with the MDS Coordinator stated, [Residnet #1's name] does have a catheter, not sure why it was coded no. We will have do submit a modification and correct it.Review of the facility policy and procedure titled MDS Assessment with an issue date of 4/1/2022 read, Policy: It will be the policy of this facility to complete MDS assessment in accordance with the RAI [Resident Assessment Manual] manual guidelines. Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts time and appropriate resident assessments.2) During an interview on 12/05/25 at 12:05 PM, Staff A, Certified Nursing Assistant [CNA], identified Resident #3 as a resident who requires assistance with eating who resides on her assigned hallway.During an interview on 12/05/25 at 12:15 PM, Staff B, CNA, identified Resident #3 as a resident who requires assistance with eating who resides on her assigned hallway.Review of Resident #3's Minimum Data Set [MDS], under Section GG, dated 11/02/25 read: A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident - independent.Review of Resident #3's progress notes documented a Dietary Note dated 10/03/25 that read, Intake 75-100% - dependent with meals.Review of Resident #3's progress notes documented a Dietary Note dated 11/04/25 that read, Intake 75-100% - dependent with meals.During an interview on 12/15/25 at 3:34 PM, the MDS Coordinator stated, We looked into the MDS [for Resident #3], it was a coding error.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles for 2 of 4 medication carts and 1 of 4 hallways reviewed for unattended medication and labeling. Findings include: 1) During an observation on 3/31/25 at 11:20 AM of Resident #318 it showed the resident had a PICC (peripherally inserted central catheter) line to the upper left arm. There was IV (intravenous) tubing that was not dated and an IV-cefriaxone (used to treat bacterial infections) solution medication bag that was not labeled with the date and time. During an interview on 3/31/2025 at 12:52 PM Staff F, Registered Nurse (RN) stated, The IV tubing hanging from the I/V pole for [Resident #318's name] should have a label with a date and time it was hung. During an interview on 4/03/25 at 09:16 AM the Director of Nursing (DON) stated, Staff should have labeled the medication bag and the IV tubing. Review of the policy and procedure titled IV Infusions with a last review date 1/31/2025 read, 6. Administer IV medications, fluids and flushes per physician orders. Applicable labeling of resident identifier and date(s) of administration should be present on the IV medication and tubing, as is appropriate. 46523 2) During an observation on 3/31/2025 at 10:23 AM with Staff F Registered Nurse (RN) of [NAME] -1 Medication Cart there was one open bottle of glucose strips that did not have an open date and one insulin aspart pen with an expiration date of 3/29. During an interview on 3/31/2025 at 10:27 AM with Staff F stated, Glucose strips should be labeled when opened with an open date and any expired medications should be removed from medication cart and disposed of. 3) During an observation on 3/31/2025 at 10:38 AM with Staff L, License Practical Nurse (LPN) of the Medication Cart North-2 there were three loose medications in the medication drawer and an expired Fluticasone inhalation powder with an expiration date of 3/30. During an interview on 3/31/2025 at 10:39 AM Staff L, LPN stated, There should not be any loose medication in the medication cart if they fall when pouring medication they should be disposed. Any expired medication should not be kept in the mediation cart. 4) During an observation on 3/31/2025 at 2:00 PM of Resident #51's room it showed the resident was sitting at bedside. On top of the resident's bedside table there was a medication cup containing white powder. During an interview on 3/31/2025 at 2:00 PM Resident #51's spouse stated, The nurses apply that [white powder in the medication cup] to her groin area for redness. 5) During an observation on 4/2/2025 at 4:24 PM with Staff M, RN and Staff N, LPN the medication room on the North wing could be observed. There was a small backpack, a large tumbler, and a large bag containing a coca cola bottle that was visible. During an interview on 4/2/2025 at 4:24 PM Staff N, LPN stated, Medication rooms should not be used to store personal ideas or food. The staff have a staff lounge where they can keep those items. During an interview on 4/3/2025 on 9:17 AM the Director of Nursing stated, When opening glucose strip bottles they should be labeled with an open date. Any expired medication should be disposed and not be in the medication cart. I normally like to remove the medication from the cart a day before expiring because staff might forget and give it. Medication rooms should not store any personal items, no drinks or food and medication should not be left unattended in the room. Review of the policy and procedure titled Medication/Biological Storage with a last review date of 1/31/2025 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure, and orderly manner. Procedure: 2. The nursing staff shall be responsible for maintaining mediation storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 6 residents, Resident #66 reviewed for medication review and 1 of 3 residents, Resident #31 reviewed for weights. Findings include: 1) Review of Resident #66's physician order dated 3/1/2025 read, Insulin Apart FlexPen 100 unit/ml [100 unit per milliliter] solution pen-injector inject as per sliding scale. Review of Resident #66 Medication Administration Record for the month of March 2025 documented Insulin Apart at 0630 [6:30 AM] on 3/27/2025 was blank, at 1630 [4:30PM] on 3/15/2025 and 3/28/2025 the entry was blank, on 3/12/2025 at 2100 [9:00 PM] the entry was blank, and no blood sugar levels or insulin coverage was documented. Review of Resident #66's progress note dated 3/28/2025 read, Resident went out today. Returned drunk slurred speech, unsteady gait. Meds held per md's [Medical Doctor's] orders. Review of Resident #66 Release of Responsibility for leave of absence form documented on 3/15/2025 at 2:04 PM Resident #66 signed himself out of the facility and returned on 3/15/2025 at 6:51 PM. During an interview on 4/1/2025 at 4:30 PM Staff P, Licensed Practical Nurse (LPN) stated, [Resident #66's name] came back to the facility and he had been drinking. I contacted the provider, and he said to hold Resident #66's medications. On 3/12/2025 I think I was not able to wake him up and I called the provider. I should have documented something in the progress notes I don't know if I did. I should have also coded the medication record accordingly instead of leaving it blank. During an interview on 4/1/2025 at 4:47 PM Staff Q, LPN stated, When I work with [Resident #66's name] he always gets his insulin. I do not know why the entry for 3/7/2025 is blank, it might not have saved, but I always give him his insulin. During an interview on 4/1/2025 at 4:42 PM Medical Doctor #1 stated, Nursing staff have contacted me when [Resident #66's name] has come back to the facility and they suspect he is intoxicated. I expect nurses to do blood sugars if they are able to. I do not think it is critical if they are not able to check his blood sugars. During an interview on 4/2/2025 at 7:45 AM the Director of Nursing stated, [Resident #66's name] had signed out on 3/15/2025 during the time of administration. The nursing staff are expected to accurately document on the medication record and use the appropriate code. The nurse should not leave blank entries on the medication record. Review of the policy and procedure titled Charting and Documentation with a last review date of 1/31/2025 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedures: 1. Observations, medication administration, services performed, ect., should be documented in the resident's clinical records. 51447 2) Review of the medical diagnosis for Resident #31 documented a diagnosis of diastolic (congestive) heart failure. Review of Resident #31's physician order dated 10/21/2024 read, Check weight every other day related to diastolic heat failure. Review of documented weights for March 2025 for Resident #31, did not contain documentation for weights on the following days, March 10, 12, 16, 18, 20 and 24. During an interview on 4/2/2025 at 3:24 PM Staff K, Certified Nursing Assistant (CNA) stated, I recall having (Resident #31's name) and weighing her but I must of forgot to document it. During an interview on 4/2/2025 at 12:47 PM the DON stated, My expectations are that the CNA's would weigh the residents as order.

Based on observation, interview and record review the facility failed to ensure it is free of medication errors of five percent or greater for 2 of 33 observations of medication administration, the error rate was 6.06%. Findings include: During an observation on 4/2/2025 at 8:18 AM of Staff B License Practical Nurse (LPN) for Resident #416's medication administration, Staff B removed one tablet of Amiodarone 100 mg (milligrams), one tablet empagliflozin 10 mg, one tablet Ferex 150 plus, half a tablet of spironolactone 12.5 mg, two tablets of Bumex 2mg, one tablet of Eliquis 5 mg, on tablet of Entresto 49-51mg, and one tablet of metoprolol 25 mg placing the medications into a clear medication cup. Staff B entered Resident #416's room and administered all the medications in the medication cup. Staff B returned to the medication cart and signed off the administration of the medications as listed. Review of Resident #416's physician order dated 3/25/2025 read, Amiodarone HCI Tablet 100 mg (Amiodarone HCI) give 200 mg by mouth one time a day for htn [hypertension]. During an interview on 4/3/2025 at 8:24 AM with Staff B LPN stated, I should have given two tablets instead of just one because each tablet is 100 mg and the order reads to give 200 mg. During an interview on 4/3/2025 at 9:00 AM the Director of Nursing (DON) stated, Not giving the correct dosage amount is a medication error and staff would need to contact the doctor because she should have given two tablets instead of one. The admitting nurse copies the orders; calls the doctor who approves or makes changes. Staff are to compare the medication to the medication administration record and do the three checks and compare multiple times and compare it is the right dose and medication. The staff are expected to follow physician orders. During an interview on 4/3/2025 at 10:42 AM Medical Doctor #1 stated, Medication is for rate control. We try to tamper down due to the toxicity of the medication half a dose or even missing one dose will not cause his heart rate to spike. Anytime they do not give a medication, it is a medication error. Nurses should follow the physician orders. During an observation on 4/3/2025 at 8:40 AM Staff E, LPN was administering medication to Resident #67. Staff E, LPN placed one tablet of Vitamin D 1000 unit into a medication cup. Review of Resident #67's physician orders dated 9/4/2024 read, Vitamin D3 Tablet 5000 Units, give 1 tablet by mouth one time a day for supplement. Give w/ [with]1000 iu [international unit] to equal 6000 iu. During an interview on 4/3/2025 at 8:49 AM with Staff E LPN stated, It should be 1000 unit of Vitamin D3 not Vitamin D. We don't use a lot of Vitamin D3 so I was not sure. During an interview on 4/3/2025 at 9:13 AM the DON stated, The nurse should have pulled a Vitamin D3 1000 unit not a vitamin D 1000 unit it is not equivalent. Review of the policy and procedure titled Medication Errors with a last review date 1/31/2025 read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall stive to identify and manage them appropriately when they occur. Review of the policy and procedures titled Medication Administration with a last review date of 1/31/2025 read, Policy: It will be the policy of the facility to administer medications in a timely manner and as prescribed by the physician, unless other wised clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by resident.

Based on observation, interview and record review the facility failed to prevent the possible spread of infection for failing to perform hand hygiene for 2 of 7 residents, Residents #15 and #29, reviewed activities of daily living and for 1 of 7 residents, Resident #416, reviewed during medication administration. Findings include: 1) During an observation on 4/2/2025 at 8:03 AM Staff B License Practical Nurse (LPN) did not perform hand hygiene and began to retrieve Resident #416's ceftazidime (used to treat bacterial infections) intravenous solution, normal saline flush, alcohol wipes and IV (intravenous) tubing. Staff B, LPN did not perform hand hygiene, donned a gown, gloves, and entered Resident #416's room. Staff B, LPN placed the supplies on the resident's bedside tablet without sanitizing or placing a barrier on the table, opened the IV tubing bag, untangled the tubing, removed a blue cover top from the connector site of the IV tube placing the cap on top of Resident #416's bedside table. Staff B, LPN connected the tubing to the IV medication bag and primed the tubing (to fill the tubing with fluid to remove the air bubbles). Staff B, LPN reconnected the cap to the end of the tubing. Staff B, LPN removed the Curos cap (a single-use device containing a foam pad impregnated with 70% isopropyl alcohol) from Resident # 416 needleless connector and proceeded to connect the IV tubing to the needless connector. During an interview on 4/2/22025 at 8:18 AM Staff B, LPN stated, I should have done hand hygiene before starting to remove the medication from the medication cart. I also should have placed a barrier on top of [Resident #416's name] bedside table and sanitized the tubing before connecting it to the Residents PICC [peripherally inserted central catheter) line. During an interview on 4/02/2025 at 9:24 AM the Director of Nursing stated, Typically when you pull the medication you will document immediately when you come out of the room and not prior to because they might refuse. The medication should be given an hour before and hour after. She should have done hand hygiene and she should have had a barrier down and sanitize and cleaned with alcohol. Review of the policy and procedure titled Hand Hygiene with a last review date of 1/31/2025 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; e. Before and after handling an invasive device (e.g. urinary catheters, IV access sites). 50695 2) During an observation on 3/31/25 at 9:55 AM, Resident #29 was lying in a bariatric bed; dressed in a hospital gown and wearing a brief. Both of the resident's feet were propped up on pillows, and there was a Podus Boot (designed to support and position the ankle and foot) on his right foot. During an interview on 3/31/25 at 9:55 AM, Resident #29 stated that he wore briefs and that he required assistance from the staff for his Activities of Daily Living (ADL) needs. During an observation on 4/2/25 at 9:25 AM, Staff A, Certified Nursing Assistant (CNA) performed peri-care for Resident #29. Staff A did not remove her gloves and perform hand hygiene. Staff A opened a drawer in Resident #29's dresser, pulled out a tube of ointment, and applied some to Resident #29's sacrum and buttocks. After applying the ointment for Resident #29, while still wearing her soiled gloves, Staff A picked up the wash basin, emptied the water out of the basin and placed the basin, soap and ointment in the drawers of the resident's dresser. During an interview on 4/2/25 at 9:38 AM, Staff A, CNA stated, I should have changed my gloves and washed my hands after I dumped the basin, before putting away the ointment and soap. During an interview on 4/2/25 at 9:42 AM, the Director of Nursing (DON) stated that she would expect the staff member to remove their gloves after completing the catheter and/or peri-care, wash their hands, and don new gloves before cleaning the area or touching and/or putting away supplies. Review of the policy and procedure titled Perineal/Incontinence Care, issued 4/1/22, and last reviewed/revised 1/31/25, read, Policy: It will be the policy of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition and provide appropriate care and services required to maintain functional levels while providing perineal/incontinence care. 3) During an observation on 3/31/25 at 2:55 PM, Resident #15 was sitting up in a wheelchair next to her bed. A urinary drainage bag was observed hanging off of the side of her wheelchair. During an observation on 4/2/25 at 8:18 AM, Staff A, CNA performed catheter care for Resident #15. After completing catheter care, the CNA did not remove her gloves, did not perform hand hygiene, and while still wearing her soiled gloves, she picked up the wash basin, wiped Resident #15's overbed table, emptied the water out of the basin and placed the basin in a drawer of the resident's dresser. During an interview on 4/2/25 at 9:38 AM, Staff A, CNA stated, I should have changed my gloves and washed my hands after I dumped the basin, and before putting away the soap. During an interview on 4/2/25 at 9:42 AM, the DON stated that for residents with a catheter they would be on Enhanced Barrier Precautions, and for catheter care the expectation would be for the staff member to wash their hands, don a gown and gloves, and have all necessary supplies available. She stated that she would expect the staff member to remove their gloves after completing the catheter and peri-care, wash their hands, and don new gloves before cleaning the area, touching and/or putting away supplies. Review of Resident #15's physician order documented Enhanced Barrier Precautions when providing Direct Care to resident (Gown and Gloves) - every shift for infection prevention (indwelling catheter); Catheter care with soap and water daily and as needed every evening shift for prophylaxis. Review of Resident #15's Care Plan documented Focus - [Resident #15's name] is at risk for infection and enhanced barrier precautions (EBP) are indicated due to: indwelling medical devices (specify - urinary catheter). Goals - Risk of infection will be reduced through use of enhanced barrier precautions daily through next review date. Interventions - Educate resident/family on the need for enhanced barrier precautions to reduce risk of infections. Employ enhanced barrier precautions when performing high contact resident care (dressing, bathing, transferring in room/shower/therapy, personal hygiene assist, changing linens, changing briefs, toileting, device care, wound care, therapy services) Review of the policy and procedure titled Indwelling Catheters, issued 4/1/22, last reviewed on 1/31/25, read, Policy It will be the policy of this facility to provide appropriate documentation for the use and care for indwelling catheters of the residents that have the indication for use beyond 14 days. Procedure: 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site.

Based on observations, interviews and record reviews, the facility failed to provide nail care services for dependent residents for 1 of 5 residents, Resident #54, reviewed for activities of daily living (ADL). Findings include: During an observation on 3/31/2025 at 10:05 AM Resident #54 was observed to have a large amount of a brown substance under the fingernails of both of her hands. During an observation on 4/1/2025 at 10:51 AM Resident #54 was observed to have a large amount of a brown substance under the fingernails of both of her hands. During an observation on 4/2/2025 at 9:20 AM Resident #54 was observed to have a large amount of a brown substance under the fingernails of both of her hands. During an interview on 4/2/2025 at 11:12 AM Staff O, Certified Nursing Aide (CNA) stated, Her (Resident #54) nails are dirty and do not look like they have been cleaned recently. During an interview on 4/2/2025 at 12:37 PM the DON (Director of Nursing) stated, My expectations are a dependent resident should have their nails cleaned with their ADL care. Review of medical diagnosis on 4/2/2025 at 2:04 PM for Resident #54 included but not limited to diagnoses of muscle weakness, dementia and osteoarthritis. Review of the annual Minimum Data Set (MDS) section C dated 2/15/2025 for Resident #54 read, Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of the annual MDS section E dated 2/15/2025 for Resident #54 read, Rejection of care - Behavior not exhibited. Review of the annual MDS section GG dated 2/15/2025 for Resident #54 read, that the Resident is dependent for showers/bathing and personal hygiene. Review of Resident #54's Care Plan dated 2/26/2025 read, Focus: [Resident #54's first name] has self-care deficits with dressing, grooming, bathing related to cognitive deficit as a result of dementia. Review of policy and procedure P&P Nail Care dated 4/1/2022 read, Policy: It will be the policy of this facility to provide nail care to residents per resident preference and to maintain dignity. Procedure: 3. Nail care includes regular cleaning and trimming.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan that addressed the residents' medical, physical, mental and psychosocial needs for 4 of 9 residents, Resident numbers #31, #33, #66, and #367, reviewed for comprehensive care plans. Findings include: 1) Review of medical diagnosis for Resident #31 revealed a diagnosis of major depressive disorder, generalized anxiety disorder and persistent mood disorder. Review of the [Name of the organization that provides behavioral health/psychiatric and psychotherapy services] progress note dated 3/19/2025 for Resident #31 read, Chief Complaint: depression, anxiety, insomnia and mood disorder. During an interview on 4/2/2025 at 11:22 AM, APRN (Advanced Practice Registered Nurse) #2 stated, The Resident does have diagnosis and receives treatment for major depressive disorder, generalized anxiety disorder and persistent mood disorder. During an interview on 4/2/2025 at 12:20 PM Resident #31 stated, I have been diagnosed with anxiety and depression for about 12-[AGE] years. Review of Resident #31's care plan did not contain a focused plan of care with goals and interventions related to the resident's diagnosis and treatment of major depressive disorder, generalized anxiety disorder and persistent mood disorder. During an interview on 4/2/2025 at 12:47 PM the DON stated, I am aware of [Resident #31 name] has a diagnosis of major depressive disorder, generalized anxiety disorder and persistent mood disorder and would expect that the resident would be care planned for those diagnosis. 50695 2) Review of Resident #367's Census Data documented the resident was admitted to the facility on [DATE]. Review of Resident #367's medical diagnoses included Type 2 Diabetes Mellitus. Review of Resident #367's physician orders documented an order dated 3/21/25 at 11:17 PM that read, Insulin Aspart FlexPen 100 unit/ml Solution pen-injector Inject subcutaneously two times a day for DM Notify MD [Medical Doctor] for BS [blood sugar] under 70 or above 450 - Inject as per sliding scale: if 0 - 59 give sugar containing beverage if able or glucagon; 60 - 199 = 0 units; 200 - 224 = 3 units; 225 - 249 = 4 units; 250 - 274 = 5 units; 275 - 299 = 6 units; 300 - 324 = 7 units; 325 - 349 = 8 units; 350 - 374 = 9 units; 375 - 399 = 10 units; 400 - 424 = 11 units; 425 - 449 = 12 units; 450 - 700 = 14 units. Call MD for 450 and above, subcutaneously two times a day for diabetes. Review of Resident #367's care plan did not contain a focused plan of care with goals and interventions related to the resident's diagnosis and treatment of Diabetes Mellitus. During an interview on 4/3/25 at 10:27 AM, the Director of Nursing (DON) stated that she expected to see Diabetes Mellitus as an active diagnosis, and be reflected on the resident's care plan. During an interview on 4/3/25 at 1:10 PM, Staff H, Minimum Data Set (MDS) Coordinator stated It's not there [the diagnosis of Diabetes Mellitus]. Somehow, we missed it for [Resident #367's name's] care plan. During an interview on 4/3/25 at 1:12 PM, Staff H, MDS Coordinator stated that a focus, goal, or intervention related to Diabetes Mellitus was not on Resident #367's Care Plan. 46523 3) During an observation on 3/31/2025 at 10:02 AM Staff F Registered Nurse (RN) was speaking to Resident #33 in Spanish. During an interview on 4/1/2025 at 3:56 PM with Staff G, Minimum Data Set (MDS) Coordinator stated, [Resident #33's name] speaks some English but he is not fluent in English. The best language to communicate with him would be Spanish. During an interview on 4/1/2025 at 2:30 PM with Staff C, License Practical Nurse (LPN) Unit Manager stated, In the afternoon [Resident #33's name] is a bit more confused and will reply in Spanish. During an interview on 4/2/2025 at 9:57 AM with Staff D Certified Nursing Assistant (CNA) stated, [Resident #33's name] can speak some English but if we cannot understand him. I will go get a therapist that speaks Spanish or even use a phone that will translate. Review of Resident #33's care plan did not document for focus, goals, or interventions for communication in Spanish. Review of Resident #33's Nursing Admission assessment dated [DATE] read, F. Communication: 1. Communication: g. interpreter needed-foreign language .2. Primary Language: b. Spanish. 4) During an observation on 3/31/25 at 10:02 AM Resident #33 was wandering the hall of the unit and was cleaning the floors with a paper napkin. Resident #33 was repeatedly observed walking the hallway. During an observation on 4/1/2025 at 8:44 AM Resident #33 was cleaning the floor with a white paper napkin. Review of Resident #33's care plan did not document for focus, goals, and interventions related to the resident's behavior of cleaning the unit and collecting trash. During an interview on 4/2/2025 at 11:23 AM with APRN #2 stated, [Resident #33's name] likes to clean and keep active. The behaviors he is having are his preferences and not causing distress to himself or any resident. During an interview on 4/3/2025 at 9:26 AM the Director of Nursing (DON) stated, [Resident #33's name] overall is helpful and likes to keep busy by picking up trash and cleaning, no negative behaviors. The staff will redirect the residents due to safety. I do not see Resident #33 care plan for these behaviors, and it should be. During an interview on 4/3/2025 at 1:17 PM with Staff G MDS Coordinator stated, I do not see a focus for [Resident #33's name] for interpreter services due to language preferences at times and for his behaviors of cleaning due to safety. 5) Review of Resident #66 progress note dated 3/3/2025 read, Resident signed out of facility and was found at gas station near facility intoxicated. Slurred speech and alcohol smell noted. Review of Resident #66's progress note dated 3/6/2025 read, Resident was out returned to facility drunk. Resident admitted drinking. Review of Resident #66's progress note dated 3/15/2025 read, Resident was out, returned he had been drinking MD [Medical Doctor] called. To hold Pregabalin this evening, as per MD's orders. Review of Resident #66's progress note dated 3/20/2025 read, Resident returned to facility very drunk, slurred speech, walking unsteady, [Medical Doctor #1's name] called, wants meds held. Resident lying in bed at this time. During an interview on 4/2/2025 at 7:41 AM the Director of Nursing stated, [Resident #66's name] for the last month or two has started getting drunk. He is coming back with that haze with that drunk look, and you can kind of smell it but does not bring the alcohol into the facility. We reached out to the doctor, and he addressed it with him. [Resident #66's name] is denying he is drinking. I would expect this behavior to have been care planned. During an interview on 4/2/2025 at 11:21 AM the Advance Practice Registered Nurse #2 stated, The facility notified me that [Resident #66's name] was drinking and has had increased depression. He denied he was drinking, and he did not want to make changes. Resident #66 was not suicidal or raised any concern. I offered psychotherapy and every time he denied issues with drinking. During an interview on 4/3/2025 at 1:18 PM Staff G, MDS Coordinator stated, [Resident #66's name] should be care planned with a focus for his behaviors regarding drinking. I do not see that as part of his focus. Review of the policy and procedure titled Comprehensive Assessments and Care Plans with a last review date of 1/31/2025 read, Standards: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid]. Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate standardized reproducible assessment of each resident's functional capacity.

Based on record reviews and interviews, the facility failed to accurately assess the resident status for 3 of 9 residents, Residents #31, #54, and #367) reviewed for accuracy of assessments. Findings include: 1) Review of the annual Minimum Data Set (MDS) dated [DATE] section C for Resident #54 read, BIMS (Brief Interview for Mental Status as a score of 00, indicating severe cognitive impairment. Review of annual Minimum Data Set (MDS) dated [DATE] section J for Resident #54 read, Current tobacco - Yes. During an interview on 4/1/2025 at 4:06 PM Staff H, MDS Nurse stated, The resident [Resident #54] is not a smoker and the documentation in the MDS in section J, was documented in error. 2) Review of the medical diagnosis for Resident #31documented a diagnosis of acute respiratory failure with hypercapnia (a condition where there's an abnormally high level of carbon dioxide in the blood). Review of a physician order for Resident #31 read, Continuous O2 (oxygen) at 3 Liters per Minute (L/min) via NC (nasal canula) q (every) shift. Review of the annual (MDS) dated [DATE] section O for Resident #31 read, oxygen therapy-no. Review of the most recent Care Plan for Resident #31 read, (Resident #31's first name) has a potential for complications of respiratory distress. Interventions: Administer O2 as order. During an interview on 4/3/2025 at 1:20PM Staff G, MDS Nurse, stated, The resident [Resident #31] is on continuous oxygen therapy and the documentation in the MDS in section O, was documented in error. 50695 3) Review of Resident #367's Census Data revealed the Resident was admitted to the facility on [DATE]. Review of Resident #367's medical diagnoses included the following relevant information: Type 2 Diabetes Mellitus without complications; immunodeficiency due to drugs, other fracture of the first lumbar vertebra, subsequent encounter for fracture with routine healing; pyoderma gangrenosum; unspecified protein-calorie malnutrition; rheumatoid arthritis, unspecified; generalized anxiety disorder; brief psychotic disorder; major depressive disorder, single episode, spinal stenosis, lumbar region without neurogenic claudication; fusion of spine, lumbar region; Review of Resident #367's MDS Evaluation, dated 3/18/25 documented the following relevant information: Section C: BIMS Score 15, Section I: The resident's primary medical condition category: Metabolic - Diabetes Mellitus (DM) - No, Section N: N0300. Injections - Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. - 6; N0350. Insulin - A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. - 6 Review of Resident #367's physician orders documented an order dated 3/21/25 at 11:17 PM that read, Insulin Aspart FlexPen 100 unit/ml Solution pen-injector Inject subcutaneously two times a day for DM Notify MD [Medical Doctor] for BS [blood sugar] under 70 or above 450 - Inject as per sliding scale: if 0 - 59 give sugar containing beverage if able or glucagon; 60 - 199 = 0 units; 200 - 224 = 3 units; 225 - 249 = 4 units; 250 - 274 = 5 units; 275 - 299 = 6 units; 300 - 324 = 7 units; 325 - 349 = 8 units; 350 - 374 = 9 units; 375 - 399 = 10 units; 400 - 424 = 11 units; 425 - 449 = 12 units; 450 - 700 = 14 units. Call MD for 450 and above, subcutaneously two times a day for diabetes. During an interview on 4/3/2025 at 10:27 AM, the Director of Nursing (DON) stated she expects to see that residents' Minimum Data Set (MDS), specifically Section I, would document Diabetes Mellitus as an active diagnosis. During an interview on 4/3/2025 at 1:10 PM, Staff G, MDS Coordinator, stated that she would expect to see diabetes documented in Section I and under Section I the resident's primary medical condition category: Metabolic - Diabetes Mellitus (DM) It says 'no,' and it should say, 'yes.' During an interview on 4/3/2025 at approximately 3:30 PM, Staff G, MDS Coordinator stated that they do not have a specific policy related to the completion of MDS Evaluations, that they use the Resident Assessment Instrument (RAI) Manual, and that it has everything they need.

Based on observation and interview, the facility failed to maintain dignity for a resident who needed assistance with feeding for 1 of 6 residents, Resident #5, reviewed for dining. Findings include: During an observation on 3/31/2025 at 2:58 PM Staff D, Certified Nursing Assistant (CNA) was observed standing while feeding Resident #5 at bedside. During an observation on 4/02/2025 at 12:51 PM Staff D, CNA, was standing by Resident #5's bedside feeding Resident #5. During an interview on 4/02/2025 at 12:51 PM Staff D, CNA stated, I have a bad back. The CNA then quickly sat down in the chair that was beside her. During an interview on 4/02/2025 at 12:56 PM Staff C, Unit Manager stated, Staff are supposed to sit while assistive feeding. During an interview on 4/03/2025 at 9:16AM the Director of Nursing (DON) stated, There should be good lighting, set the resident up, and sit down to feed the resident. The policy and procedure were requested for assistive dining. The DON stated she did not have a policy on feeding residents, but the standard of care is for staff to sit at eye level to feed residents.

Based on observation, interview, and review of facility policy and procedure the facility failed to label and store all medications in accordance with professional standards of practice in 3 of 4 medication carts reviewed for medication storage. Findings include: During an observation of medication cart #1 on 1/8/2023 at 8:55 AM with Staff A, Licensed Practical Nurse (LPN) there was one unopened Levemir insulin pen with pharmacy instructions to refrigerate until opened and one unopened Ozempic pen with pharmacy instructions to refrigerate until opened. During an interview on 1/8/2024 at 9:03 AM Staff A, LPN stated, They must have just been put on the cart. I did not put them on the cart. They should be in the refrigerator until we need them, and they are opened. During an observation of medication cart #2 on 1/8/2024 at 9:05 AM with Staff B, LPN there was one unopened bottle of latanoprost ophthalmic solution (eye drops) with pharmacy instructions to refrigerate until opened, and one Loperamide (a medication to treat diarrhea) tablet with no resident identifier and not in the original pharmacy packaging. During an interview on 1/8/2024 at 9:10 AM Staff B, LPN stated, I think the eye drops are labeled to refrigerate until opened, these are not opened. During an observation of medication cart #3 on 1/8/2024 at 9:12 AM with Staff C, LPN there was one opened 10 ml (milliliter) bottle of Lidocaine 1% with no resident identifier, no date opened and not within the original pharmacy packaging, one opened bottle of Lidocaine 1% 10 ml bottle with no date opened, one opened bottle of Dorzol/timolol ophthalmic solution with no date opened, one opened bottle of prednisolone acetate ophthalmic solution with an opened date of 11/2/2023 and one opened bottle of Latanoprost 0.005% ophthalmic solution with an open date of 11/2/23. During an interview on 1/8/2023 at 9:15 AM Staff C, LPN stated, The lidocaine should have the dates opened, what the resident's name is, and it should be in the pharmacy bag with the resident's name. I think all eye drops are good for six months after they are opened, but I don't really know. Review of GoodRx - www.goodrx.com reads, Many manufacturers recommend that you throw away eye drops 28 days after opening the bottle. This is because the preservatives inside can start to break down and allow bacteria to grow. During an interview on 1/11/2024 at 11:10 AM the Director of Nursing (DON) stated, I expect all staff to label medications, remove expired medications from the cart daily, and keep all medications in the refrigerator until they are ready to be used. Review of the policy and procedure titled, Medication/Biological Storage with an issued date of 4/1/2022, and last approval date of 8/12/2023, read, Policy: It will be the policy of this facility to store medications, drugs, and biologicals in a safe, secure, and orderly manner. Procedure: 1. Medications, drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received, unless otherwise necessary. 4. The facility shall not use discontinued, outdated up to including (7-days) or deteriorated medications, drugs, or biologicals. 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses station or other secure location. Medications must be stored separately from food and must be labeled accordingly .

Based on record review, interview, and review of policies and procedures the facility failed to consult with the physician and/or resident representative when there was a change of condition for 2 of 4 residents, Residents #47 and #361, reviewed for changes in condition in a total sample of 37 residents. Findings include: Review of the admission record for Resident #47 documented diagnosis that include type II diabetes mellitus, chronic pancreatitis, gastroparesis, gastroesophageal reflux disease, essential tremor, and major depressive disorder. Review of the physician orders for Resident #47 dated 10/22/2023 read, Humalog injection solution inject as per sliding scale. Inject subcutaneously before meals and at bedtime. If less than 70, notify MD [Medical Doctor], follow hypoglycemia [a low blood sugar result] protocol. Inject as per sliding scale, 201-250 = 2 units, 251-300 = 4 units, 301-360 = 8 units, greater than 400, administer 10 units and notify MD. Review of the January 2024 medication administration record (MAR) for Resident #47 documented a blood sugar of 48 at 6:30 AM on 1/5/2024, a blood sugar of 54 documented on 1/6/2024 at 6:30 AM, and a blood sugar of 64 documented on 1/10/2024 at 6:30 AM. Review of the nursing progress notes for Resident #47 did not provide for documentation of the physician or the resident's representative being notified of Resident #47's blood sugar results of less than 70 per the MD orders for the month of January 2024, and the record did not contain Interact Change of Condition forms documenting notification to the resident's representative or the resident's physician of the low blood sugar results. Review of the December 2023 MAR for Resident #47 documented a blood sugar of 60 on 12/16/2023 at 6:30 AM, a blood of 44 documented on 12/21/2023 at 6:30 AM, and a blood sugar of 53 documented on 12/27/2023 at 6:30 AM. Review of the nursing progress notes for Resident #47 did not provide documentation of the physician or the resident's representative being notified of the blood sugar results of less than 70 per the MD orders for the month of December 2023, and the record did not contain Interact Change of Condition forms documenting notification to the resident's representative or the resident's physician of the low blood sugar results. During an interview on 1/11/2024 at 10:55 AM the Director of Nursing (DON) stated, All the low blood sugars should have been called to the doctor. I can't find any notification to the doctor in the chart. There are no nurses' notes about this. They should have followed the doctors' orders, and they didn't. During an interview on 1/11/2023 at 2:00 PM Staff G, Registered Nurse, (RN) stated, I remember that her [Resident #47] blood sugar was 48, she was on her cell phone, and I didn't see any concerns. I should have notified the doctor. I can't tell you why I didn't. I was not following the doctors' orders. Review of the policy and procedure titled, Diabetes/hypo/hyperglycemia [low/high blood sugar] with an issue date of 4/1/2022, last approval date of 8/12/2023 read, It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. 5. Staff will provide glucose [sugar] monitoring, medication administration, laboratory testing and diet per physician orders.7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receiving insulin or oral hypoglycemics have parameters as to when the physician should be notified. 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in the clinical record. 2. Review of the admission record for Resident #361 documented diagnoses that include chronic obstructive pulmonary disease, asthma, type II diabetes mellitus, and essential primary hypertension. Review of the admission MDS (Minimum Data Set) for Resident #361 dated 1/5/2024 documented a BIMS (Brief Interview of Mental Status) as a 03, (suggests severe cognitive impairment). Review of the nursing progress note for Resident #361 dated 1/6/2024 at 8:21 AM read, Patient had a fall attempting to get up from his chair. Patient was checked and assessed, he denies any pain. No injuries observed. Vital signs within normal limits, b/p [blood pressure] 116/64, pulse 80, resp [respirations] 18 temp [temperature] 97.5. Review of the medical record for Resident #361 did not provide for documentation of the resident's representative being notified of the resident having suffered a fall. Review of the nursing progress note for Resident #361 dated 1/9/2024 at 1541 (3:41 PM) documented the physician was notified of the resident's fall, but the record did not contain documentation of the resident's representative being notified of the resident's fall.

Based on observation, interview, and record review the facility failed to provide the necessary care and services for maintaining urine flow and ensuring proper infection control techniques for urinary catheter care for 1 of 3 residents, Resident #361, reviewed for urinary catheters in a total sample of 37 residents. Findings include: Review of the admission record for Resident #361 documented diagnoses to include chronic obstructive pulmonary disease, asthma, type II diabetes mellitus, and essential primary hypertension. Review the physician orders for Resident #361 dated 12/29/2023 read, Catheter Care: Monitor urinary catheter for impairment of drainage flow (kinks). Ensure bag has privacy cover and is below bladder. During an observation on 1/8/2024 at 11:51 AM, Resident #361 was sitting in a wheelchair in the hallway with a urinary catheter drainage bag attached to the wheelchair with the catheter tubing resting on the floor and dragging across the floor when Resident #361 began wheeling himself in the hallway. The tubing had amber colored urine and was not able to drain into the urinary catheter drainage bag. During an observation on 1/9/2024 at 7:51 AM, Resident #361 was sleeping in bed with his urinary catheter drainage bag on the floor with amber colored urine from the top of the tubing, filling the tubing and unable to drain into the urinary catheter drainage bag. During an observation on 1/10/24 at 8:15 AM, Resident#361 was sitting in a wheelchair with a urinary catheter bag attached to the wheelchair. The catheter tubing was looped and was dragging on the floor as the resident wheeled himself in the wheelchair. The tubing was filled with amber colored urine and was unable to drain into the urinary catheter drainage bag. During an interview on 1/9/2023 at 7:55 AM Staff F, Certified Nursing Assistant (CNA) stated, Oh, it [the catheter tubing/drainage bag] should not be that way. The tubing should not be all looped and kinked and it should not be on the floor. The urine needs to drain into the bag, and it can't. During an interview on 1/9/2024 at 8:03 AM, Staff C, Licensed Practical Nurse (LPN) stated, The catheter [drainage bag] should not be on the floor and tubing should not be dragged on the ground. Catheters should be kept so urine is able to flow out and it can't that way. During an interview on 1/11/2023 at 10:40 AM the Director of Nursing (DON) stated, All catheter tubing should be free of loops or kinks that would prevent the urine from freely draining. This could cause a UTI [urinary tract infection]. We should evaluate the resident when we place them in a wheelchair to make sure the tubing is not looping, kinking, or dragging on the ground. Review of the policy and procedure titled, Indwelling Catheters with an issue date of 4/1/2022, and last approval date of 8/12/2023 read, It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Procedure: 10. Staff should ensure proper placement of the catheter tubing as to ensure that it is not kinked, pulling and allows for gravity drainage .

Based on record review, interview, and review of the facility policies and procedures the facility failed to ensure residents who required blood glucose monitoring received treatment in accordance with professional standards of practice by failing to document, assess and treat hypoglycemia (low blood sugar) for 1 of 3 residents, Resident #47, reviewed for insulin administration. Findings include: Review of the admission record for Resident #47 documented diagnosis to include type II diabetes mellitus, chronic pancreatitis, gastroparesis, gastroesophageal reflux disease, essential tremor, and major depressive disorder. Review of the physician orders for Resident #47 dated 7/7/2023 read, For blood sugar less than 60 and resident is able to swallow, administer food or glucose gel per manufacturers instruction and notify MD [Medical Doctor] as needed for hypoglycemia. Review of the physician orders for Resident #47 dated 10/22/2023 read, Humalog injection solution inject as per sliding scale. Inject subcutaneously before meals and at bedtime. If less than 70, notify MD [Medical Doctor], follow hypoglycemia [a low blood sugar result] protocol. Inject as per sliding scale, 201-250 = 2 units, 251-300 = 4 units, 301-360 = 8 units, greater than 400, administer 10 units and notify MD. Review of the January 2024 medication administration record (MAR) for Resident #47 documented a blood sugar of 48 at 6:30 AM on 1/5/2024, a blood sugar of 54 documented on 1/6/2024 at 6:30 AM, and a blood sugar of 64 documented on 1/10/2024 at 6:30 AM. There was no documentation of treatment for the low blood sugar results as ordered by the physician. Review of the December 2023 MAR for Resident #47 documented a blood sugar of 60 on 12/16/2023 at 6:30 AM, a blood sugar of 44 on 12/21/2023 at 6:30 AM, and a blood sugar of 53 documented on 12/27/2023 at 6:30 AM. There was no documentation of treatment for the low blood sugar results as ordered by the physician. Review of the nursing progress notes for Resident #47 for the period of 12/01/2023 through 01/10/2024 did not provide for documentation of the physician being notified of Resident #47's blood sugar results of less than 70 per the MD orders related to the sliding scale and/or notification when the resident's blood sugar results were less than 60. There was no documented notification to the resident's representative of the resident's change in condition. The nursing progress notes did not provide documentation of an assessment of the resident with findings of a low blood sugar, treatment of the blood sugars less than 60, or of a reassessment of the resident's blood sugars. During an interview conducted on 1/11/2024 at 10:55 AM the Director of Nursing stated, All the low blood sugars should have been called to the doctor. I can't find any notification to the doctor in the chart, no nurses' notes about this. They should have followed the doctors' orders, and they didn't. The nurses should have treated the low blood sugars per the orders and rechecked the blood sugars. That is a standard of practice. During an interview conducted on 1/11/2023 at 2:00 PM Staff G Registered Nurse (RN) stated, I remember that her [Resident #47] blood sugar was 48, she was on her cell phone, and I didn't see any concerns. I did not use the hypoglycemia protocol. I did not recheck her blood sugar. She seemed just fine, her usual self. I don't remember if I had told the oncoming nurse about her blood sugar. I should have rechecked her blood sugar and offered her the hypoglycemia protocol. I should have notified the doctor. I can't tell you why I didn't. I was not following the doctor's orders. Review of the policy and procedure titled, Diabetes/hypo/hyperglycemia [low/high blood sugar] issued date of 4/1/2022, with a last approval date of 8/12/2023 reads It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders.7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receiving insulin or oral hypoglycemics have parameters as to when the physician should be notified. 10. Nursing interventions, per physician orders, may vary for residents experiencing hypoglycemia depending on the severity and symptoms of the resident as residents' behavior is different depending on their sensitivity to hypoglycemia. Responsive residents that are able to swallow may receive juice or other rapidly absorbed glucose as an intervention. Responsive residents that are unable to swallow or unresponsive residents may receive oral glucose paste to the buccal mucosa, intramuscular glucagon, or IV 50% dextrose and notify physician for further orders. 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in the clinical record.

Based on observation, interview, and record review the facility failed to implement a person-centered comprehensive care plan for respiratory care for 2 of 3 residents, Resident #96 and #7, reviewed for respiratory care services out of a total sample of 37 residents. Findings include: Review of the admission record for Resident #96 documented diagnosis to include chronic obstructive pulmonary disease (COPD), chronic systolic congestive heart failure (CHF), acute respiratory distress, and essential primary hypertension. Review of the physician orders for Resident #96 dated 10/21/2023 read, Continuous O2 [oxygen] at 3 LPM [liters per minute] via nasal cannula as needed for respiratory distress. Review of the written plan of care for Resident #96 read, [Resident #96's name] has a potential for complications of respiratory distress r/t [related to] dx [diagnosis] of COPD and CHF. Interventions: Administer O2 as ordered (3 liters) During an observation on 1/8/2024 at 11:09 AM Resident #96 was observed in bed with oxygen being administered by a concentrator at 4 liters via nasal cannula. During an observation on 1/10/2024 at 12:16 PM Resident #96 was observed in bed with oxygen being administered by a concentrator at 3.5 liters via nasal cannula. During an interview on 1/10/2024 at 12:30 PM Staff H, Licensed Practical Nurse (LPN) stated, The oxygen is running at, I think, 3-3.5 liters. We should follow the orders and the care planned interventions when running oxygen. He is care planned for oxygen at 3 liters. During an interview on 1/11/2023 at 10:52 AM the Director of Nursing (DON) stated, We should administer oxygen at the ordered rates, and we should follow the care plans and the care planned interventions. 2. Review of the admission record for Resident #7 documented diagnosis to include chronic COPD, chronic respiratory failure with hypoxia, hypertensive heart failure, and heart failure. Review of the physician orders for Resident #7 dated 8/9/2023 read, Ipratropium-Albuterol inhalation solution 0.5-2.5 3 mg/3 ml [3 milligrams per 3 milliliters] inhale orally three times a day for COPD. Review of the written plan of care for Resident #7 read, [Resident #7's name] has a potential for complications of respiratory distress r/t dx of COPD, CHF. Interventions: Administer O2 as ordered. (3 Liters, store respiratory equipment in infection control bag when not in use; change q [every] week and prn [as needed]. During an observation on 1/8/2024 at 10:36 AM Resident #7 was observed at bedside with oxygen being administered via nasal cannula. A passive nebulizer (respiratory equipment), was sitting on the nightstand with unlabeled tubing and no infection control bag to store the nebulizer when not in use. During an interview on 1/8/2023 at 11:00 AM Staff C, LPN stated, I don't know why the passive nebulizer isn't in a bag, it should be. During an interview on 1/11/2023 at 10:52 AM the Director of Nursing (DON) stated, We should have all respiratory care equipment in a bag, and we should be following our care planned interventions. There is no policy that I know of for this.

Based on interviews and record review, the facility failed to honor a resident's expressed advanced directive for end of life by failing to ensure life saving measures, such as cardiopulmonary resuscitation [CPR], were initiated when Resident #1 was found unresponsive and absent of life. Staff A, Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. The hospice report of death record states the facility staff pronounced the resident deceased and did not document hospice's assessment of the resident's status. Resident #1 was pronounced deceased by Staff A, LPN who is not qualified to pronounce. CPR was not initiated per the resident's wishes due to the determination of being deceased by Staff A. The Administrator was informed of the existence of and provided with the template for Immediate Jeopardy on [DATE] at 1:50 PM. The Immediate Jeopardy began on [DATE] and was removed on site on [DATE]. The scope and severity of the deficiencies were lowered to E, pattern, with no actual harm, with potential for more than minimal harm when the facility provided evidence of the actions taken to remove the immediacy. Findings include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of, acute and chronic respiratory failure, morbid obesity due to excess calories, cirrhosis of the liver, hemiplegia and hemiparesis following cerebral infarction, left non dominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, essential (primary) hypertension, major depressive disorder, generalized anxiety, and cognitive communication deficit. Review of the Minimum Date Set (MDS) Comprehensive Quarterly Resident assessment dated [DATE] for Resident #1 documented a BIMS (Brief Interview for Mental Status) Score of ,d+[DATE] indicating moderate cognitive impairment. Review of Resident #1's resident centered care plan initiated on [DATE] read, [Resident #1's name] expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code. [Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR]. Review of Resident #1 physicians' progress note dated [DATE] read, Code status discussed/request {sic} to remain full code. Review of Resident #1's Hospice Admission Orders/Hospice Certification dated [DATE] under the section titled, Resuscitation, the Do Not Resuscitate box was left blank/not checked. Review of the nursing progress note dated [DATE] at 8:06 AM, written by Staff A, LPN reads, At approximately 6:30 AM, this nurse went into room [Resident #1's room] to give medication and observed patient lying in bed on back absent of pulse and respiration. Called [Hospice company name], [Resident #1's primary care physician name], and [Resident #1's daughters name]. Review of the hospice form titled Record of Death for Resident #1 completed on [DATE] read, Relative/Guardian: [Resident #1's Daughter's Name]. Time Notified: 0640 [6:40 AM]. Nurse Notifying: [Staff A's Name]. Date & Time Of Death: [DATE] 0630 [6:30 AM]. Service of Doctor: [Resident #1's physician's Name]. Time MD Notified: 0730 [7:30 AM]. Nursing Notifying: [Staff A's Name]. Pronounced By: [Staff A's Name]. Review of Staff A, LPN's, statement of incident dated [DATE] documented, At approximately 0630 [6:30 AM], I came out of room [Facility Resident's Room Number] after passing out medication when CNA [Staff B's Name] came to me and said she thinks [Resident #1's Room Number] has passed. I went immediately and checked the resident for signs of resp. pulse [respirations and pulse]. I did not find any. I went and got my stethoscope and checked to verify my findings. I immediately went to my desk called [Name of Hospice Company] at 0640 [6:40 AM] concerning the expiration on {sic} [Resident #1's Room Number]. I called family at 0645 [6:45 AM] concerning their family member and I contacted the patients' doctor at 7A [7:00 AM]. Hospice nurse arrived to facility at approximately 0730 [7:30 AM]. Review of Resident #1's physicians orders, date created [DATE] at 7:54 AM, by Staff A, LPN, with an order date of [DATE] at 3:15 PM, read, DNR [Do Not Resuscitate]. During an interview on [DATE] at 10:00 AM, the Administrator stated, The Nurse [Staff A, LPN] assigned to Resident #1 had put a DNR order in Resident #1's chart after Resident #1 was found deceased , without an order from the Primary Physician. During a telephone interview on [DATE] at 10:16 AM, Staff B, CNA stated, Around 5:30 AM, I went into the residents' room [Resident #1's room] and noticed he was cold to touch, his lips were a little blue and his chest was not moving up and down. I notified the nurse [Staff A]. I saw her feel for a pulse, she did not start CPR, and [she] said he had passed. During a telephone interview on [DATE] at 12:17 PM, Staff A, LPN stated, At around 6:30 AM I was passing medications, when CNA [Staff B's Name] came and said she thinks [Resident #1 Name] has passed. I went immediately and checked [Resident #1's Name] for signs of respirations, pulse, I did not find any. I went and got my Stethoscope to verify my findings. The resident had no pulse, no eye movements, he was blue and stiff to the touch, he just had that look. I have been a hospice nurse on and off for over [AGE] years and knew he had been deceased for a while. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated, The LPN [Staff A] did not start CPR. Irreversible death is someone that is cold, has blueness of lips, mottling, lividity, and stiffness. An RN (Registered Nurse) can assess these symptoms and an LPN can observe and report. An LPN can describe symptoms but cannot pronounce death. A physician can pronounce death. When asked why the LPN created a DNR order she stated, the nurse made a mistake, when she thought the resident [Resident #1] was a DNR. A request was made for documentation of Resident #1 exhibiting mottling, lividity, and stiffness. None was provided. Review of www.crossroadshospice.com/hospice-resouces/end-of-lifesigns/mottled-skin-before-death read, Mottling is blotchy, red-purplish marbling of the skin. Mottling most frequently occurs first on the feet, then travels up the legs. Mottling of skin before death is common and usually occurs during the final week of life, although in some cases it can occur earlier. Mottling is caused by the heart no longer being able to pump blood effectively. Because of this, blood pressure drops, causing extremities to feel cool to the touch. The skin then starts to become discolored. During an interview on [DATE] at 11:30 AM, the Regional Nurse Consultant/ [NAME] President (VP) of Clinical Services stated, The CNA [Staff B] informed the LPN [Staff A] the patient [Resident #1] did not seem to be breathing. The LPN [Staff A] looked at patient [Resident #1], there was no heartbeat, no breathing, cyanotic around the mouth, no signs of life. The LPN [Staff A] knew he was on hospice and later realized he was a full code. During a telephone interview on [DATE] at 11:55 AM, Staff C, CNA stated, I was doing my rounds at approximately 6:30 AM, when I was told by [Staff A's name ] that the resident [Resident #1] had passed. When I went in to see [Resident #1's name], I saw that he [Resident #1] had chocolate around his mouth, and a Three Musketeer's candy wrapper on his chest. I helped with the postmortem care of the resident [Resident #1]. During an interview on [DATE] at 2:44 PM, the Medical Director stated, I expect that when an LPN comes across a resident that is a full code and no signs of life that CPR should be started, and EMS [Emergency Medical Services] should be activated. During an interview on [DATE] at 3:15 PM, with Staff A, LPN, when asked if she could clarify why CPR was not started on [Resident #1's name], Staff A stated, When I went into the residents' room, I could see that he was dead, rigor mortis had set in. When asked why she did not chart these observations she stated, That is how I always chart it, just without pulse and respirations. Review of the policy and procedure titled Code Blue & CPR, last reviewed on [DATE], reads, Policy: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). Review of the policy and procedures titled Advance Directives, last reviewed on [DATE], reads, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive and participate in advanced care planning. Advanced directives/advanced care planning designations will be respected in accordance with state law and facility policy. Review of the policy and procedure titled Determination of Code Status, last reviewed on [DATE], reads, Policy: The residents code status will be determined by a physician's order and/or validly executed State of Florida DNR Order Form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and/or documented evidence of resident wishes being in place. 12. Any resident without a signed State of Florida DNR Order form, or without a Physician's DNR order, or without documented verbal wishes of desire for withholding of resuscitation measures, will be a Full Code. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following: On [DATE] identified staff member A, LPN and Staff B, CNA have been removed from the schedule. 1. On [DATE] the facility director of nursing/designee initiated a house wide full chart review of residence records and systems reviews to include: cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR [electronic health record] reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO [Do Not Resuscitate Order] form scanned into residents records and appropriately signed by the resident or resident representative, DNR book and advanced directive list is accurate and validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residents' choice. 2. On [DATE] the director of nursing conducted an audit of residents currently residing in the facility to ensure accuracy of code status within the facility's electronic health record. 3. Residents on Hospice were interviewed by a licensed nurse to validate code status. 4. On [DATE] the facilities executive director and risk manager was {sic} educated by the regional nurse consultant on components of F678 cardiopulmonary resuscitation (CPR) with an emphasis on the provision of CPR in accordance with physician orders to include monitoring of facility systems during administrative/clinical stand up and stand down to ensure residents receive the necessary care and services. Areas of focus to include: Residents Rights, Advance Directives, Following Physicians Orders, Process of code status determination, performing a Code Blue, Paging overhead during a code, Crash Cart process, Identification and response to a resident found to be unresponsive-assessment/evaluation, eInteract SBAR [Situation, Background, Assessment, Recommendation] and Stop-and-Watch to identify and document change and condition, staff to notify the facility Director of Nursing in person and or phone call as soon as possible in the event of an expired resident to review code status - if the DNS [Director of Nursing Services] is unable to be reached, the Executive Director is to be notified. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. 5. As of [DATE], 20 out of 23 licensed nurses, that includes (Registered Nurses, Licensed practical Nurses) were educated. ***(the 3 licensed nurses that were not educated are PRN [as needed] only, were unable to be contacted and will not work until receiving this education in person) ***(Staff will not work without receiving this education) Numbers [20 out of 23] of employees obtained from current active employee roster. Residents' Rights education to include but not limited to the following: 1. The residents Code Status will be determined by a physician's order and or validly {sic} executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced Directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 2. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. Following Physicians Orders. Facility policy regarding code status determination. Completing verbal order if required. Location of DNR order within the EHR. Location of DNR binders (to be used when EHR is inaccessible). Paging overhead during a code. Crash Cart process. Identification and response to a resident found to be unresponsive assessment/evaluation. Timely response to a resident needing assistance. Performing a code blue mock drill documented on code checklist. P&P [policy and procedure] Determination of Code Status. P&P Mock Code. P&P Advanced Directives. P&P Residents Rights. Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. P&P Death of resident with emphasis of a resident may be declared dead by a licensed physician, emergency medical services, or the registered nurse with the physician authorization in accordance with state law. ***(Newly hired employees will receive education on the above in orientation). 2. As of [DATE], 146 out of 160 staff have been educated. ***(the 14 staff members that were not educated due to PRN and/or out of {sic} LOA (Leave of Absence)). ***(Staff will not work without receiving this education) Number of employees [146 out of 160] obtained from current active employee roster. Resident rights education to include but not limited to the following: 1. The residents code status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced 2. {sic} directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 3. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. 4. Where to locate physician order for code status in the EHR. 5. eInteract Stop and Watch to identify and document change in condition. ***(Newly hired employees will receive education in orientation). 1. On [DATE] Systemic Change: the licensed nurse and one other staff member to verify codes status prior to initiating CPR or withholding CPR. 2. On [DATE] Systemic Change: the facility initiated an advanced directives compliance tracking tool to be used daily during morning clinical meetings to validate advanced directives for new admissions or readmissions and to validate or confirm code status log is being carried out and remains effective. This tool will be utilized to validate any changes in code status as well as tracking new admissions. 3. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meeting to validate that if there is a code that the licensed nurse and one other staff member are to verify code status prior to initiating CPR or withholding CPR. 4. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meetings to validate that licensed physician, a registered nurse, or emergency medical services with physician authorization in accordance with the state law has pronounced death. 5. On [DATE], [DATE], [DATE] Ad-Hoc Quality Assurance Performance Improvement meetings were carried out as it relates to resident rights to formulate advanced directives, provision of CPR, competent staffing, and neglect to include a root cause analysis using 5 why's QAPI CMS [Centers for Medicare and Medicaid Services] tool and audits to be carried out with progress presented to monthly QAA [Quality Assurance and Accreditation] to ensure compliance/recommendations. Review of the Notice of Disciplinary Action for Staff A, LPN, and Staff B, CNA related to employment suspension was documented as completed on [DATE]. Review of the house wide full chart review of resident records including cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO form scanned into residents records and appropriately signed by the resident or resident representative, DNR book and advanced directive list is accurate and validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residence choice were documented as completed on [DATE]. Review of the audit to ensure code status within the electronic health record was documented as completed on [DATE] by the Director of Nursing. Review of education conducted by the Regional Nurse Consultant on the components of F678 Cardiopulmonary Resuscitation with an emphasis on the provisions of CPR in accordance with physician orders including monitoring of facility systems for the facility's Executive Director and the Risk Manager were documented as completed on [DATE] and for the Director of Nursing was documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, paging overhead during a code, crash cart process, identifications and responses to a resident found to be unresponsive, assessment/evaluation, timely response to a resident needing assistance, performing a code blue (mock codes) documented on code check list, Policy and Procedure on Determination of Code Status, Policy and Procedure on Mock Code, Policy and Procedure on Advanced Directives, Policy and Procedure on Code Blue and CPR, Policy and Procedure on Resident Rights, Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record, Policy and Procedure on Death of a Resident with emphasis of a resident may be declared dead by a Licensed Physician, Emergency Medical Services, or the Registered Nurse with physician authorization for 20 out of 23 licensed nurses were documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, where to locate physician order for code status in the EHR, einteract Stop and Watch to identify change in condition for 146 out of 160 staff was documented as completed on [DATE]. Review of the Advanced Directives Compliance Tracking Tool initiated on [DATE] was documented and up to date as of [DATE]. Review of the Supervisor Tool initiated on [DATE] was documented and up to date as of [DATE]. A review of the Ad-Hoc QAPI meetings held on [DATE], and [DATE] were carried out as it relates to Resident Rights to formulate Advanced Directives, Provisions of CPR, Competent Staffing, and Neglect. Those in attendance included The facility administrator, Director of Nursing, Clinical Educator/Risk Manager, Unit Manager, MDS, Admissions, Rehab, Staffing, Dietary, Social Services Director, Activities, Medical Records, Environmental Services, Maintenance, and the Medical Director. During staff interviews completed on [DATE], 5 RN's, 12 LPN's, and 14 CNA's verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status in the EHR residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR.

The facility failed to ensure nursing staff followed policy/procedure and the nurse practice act related to initiating emergency care for a resident found to be without a pulse or respiration such as initiating cardiopulmonary resuscitation (CPR) or calling emergency medical services. Staff A, a Licensed Practical Nurse, observed Resident #1 on [DATE] at 6:30 AM, unresponsive and absent of life, pronounced Resident #1 as deceased and withheld cardiopulmonary resuscitation despite the resident's full code status. The Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. The hospice report of death record states that facility staff pronounced the resident deceased and did not document hospice's assessment of the resident's status. Resident #1 was pronounced deceased by Staff A, LPN who is not qualified to pronounce. CPR was not initiated per the resident's wishes due to the determination of being deceased by Staff A. The Administrator was informed of the existence of and provided with the template for Immediate Jeopardy on [DATE] at 1:50 PM. The Immediate Jeopardy began on [DATE] and was removed on site on [DATE]. The scope and severity of the deficiencies were lowered to E, pattern, with no actual harm, with potential for more than minimal harm when the facility provided evidence of the actions taken to remove the immediacy. Findings include: Review of the Licensed Practical Nurse/Registered job description reads, Purpose of your job position: The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by CNA's and other nursing personnel. Such supervision must be in accordance with current federal state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Charting and Documentation: Complete and file required record keeping forms or charts upon the resident's admission, transfer and or discharge. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. Receive telephone orders from physicians and record on the physician's order form. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents' response to the care. Maintain established nursing objectives and standards. Ensure that the direct nursing care is provided by a licensed nurse, qualified to perform the procedure. Use an automated external defibrillator as required. Perform Cardiopulmonary Resuscitation (CPR) as necessary. Ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes. Specific Requirements: Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. Review of the Nurse Practice Act reads, (15) Licensed practical nurse means any person licensed in this state or holding an active multistate license under s. 464.0095 to practice practical nursing. (18) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist; and the teaching of general principles of health and wellness to the public and to students other than nursing students. Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure, morbid obesity due to excess calories, cirrhosis of the liver, hemiplegia and hemiparesis following cerebral infarction, left nondominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, essential (primary) hypertension, major depressive disorder, generalized anxiety, and cognitive communication deficit. Review of Resident #1's resident centered care plan initiated on [DATE] read, [Resident #1's name] expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code. [Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR]. Review of the nursing progress note dated [DATE] at 8:06 AM, written by Staff A, LPN reads, At approximately 6:30 AM, this nurse went into room [Resident #1's room] to give medication and observed patient lying in bed on back absent of pulse and respiration. Called [Hospice company name], [Resident #1's primary care physician name], and [Resident #1's daughters name]. Review of the hospice form titled Record of Death for Resident #1 completed on [DATE] read, Relative/Guardian: [Resident #1's Daughter's Name]. Time Notified: 0640 [6:40 AM]. Nurse Notifying: [Staff A's Name]. Date & Time Of Death: [DATE] 0630 [6:30 AM]. Service of Doctor: [Resident #1's physician's Name]. Time MD Notified: 0730 [7:30 AM]. Nursing Notifying: [Staff A's Name]. Pronounced By: [Staff A's Name]. Review of Resident #1's physicians orders, date created [DATE] at 7:54 AM, by Staff A, LPN, with an order date of [DATE] at 3:15 PM, read, DNR [Do Not Resuscitate]. During an interview on [DATE] at 10:00 AM, the Administrator stated, The Nurse [Staff A, LPN] assigned to Resident #1 had put a DNR order in Resident #1's chart after Resident #1 was found deceased , without an order from the Primary Physician. During a telephone interview on [DATE] at 10:16 AM, Staff B, CNA stated, Around 5:30 AM, I went into the residents' room [Resident #1's room] and noticed he was cold to touch, his lips were a little blue and his chest was not moving up and down. I notified the nurse [Staff A]. I saw her feel for a pulse, she did not start CPR, and [she] said he had passed. During a telephone interview on [DATE] at 12:17 PM, Staff A, LPN stated, At around 6:30 AM I was passing medications, when CNA [Staff B's Name] came and said she thinks [Resident #1 Name] has passed. I went immediately and checked [Resident #1's Name] for signs of respirations, pulse, I did not find any. I went and got my Stethoscope to verify my findings. The resident had no pulse, no eye movements, he was blue and stiff to the touch, he just had that look. I have been a hospice nurse on and off for over [AGE] years and knew he had been deceased for a while. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated, The LPN [Staff A] did not start CPR. Irreversible death is someone that is cold, has blueness of lips, mottling, lividity, and stiffness. An RN (Registered Nurse) can assess these symptoms and an LPN can observe and report. An LPN can describe symptoms but cannot pronounce death. A physician can pronounce death. When asked why the LPN created a DNR order she stated, the nurse made a mistake, when she thought the resident [Resident #1] was a DNR. A request was made for documentation of Resident #1 exhibiting mottling, lividity, and stiffness. None was provided. During an interview on [DATE] at 11:09 AM, the Administrator stated, The nurse [Staff A] pronounced the death. When asked if an LPN can pronounce death, the Administrator stated, Two nurses can pronounce death, a single LPN cannot pronounce death. During an interview on [DATE] at 11:30 AM, the Regional Nurse Consultant/ [NAME] President (VP) of Clinical Services stated, The CNA [Staff B] informed the LPN [Staff A] the patient [Resident #1] did not seem to be breathing. The LPN [Staff A] looked at patient [Resident #1], there was no heartbeat, no breathing, cyanotic around the mouth, no signs of life. The LPN [Staff A] knew he was on hospice and later realized he was a full code. During a telephone interview on [DATE] at 11:55 AM Staff C, CNA stated, I was doing my rounds at approximately 6:30 am, when I was told by [Staff A's name] that [Resident #1] had passed. During an interview on [DATE] at 2:24 PM, the Risk Manager stated, An LPN cannot pronounce death. During an interview on [DATE] at 2:44 PM, the Medical Director stated, I expect that when an LPN comes across a resident that is a full code and no signs of life that CPR should be started, and EMS [Emergency Medical Services] should be activated. An LPN cannot pronounce death. During an interview on [DATE] at 3:15 PM, with Staff A, LPN, when asked if she could clarify why CPR was not started on [Resident #1's Name], Staff A stated, When I went into the residents' room, I could see that he was dead, rigor mortis had set in. When asked why she did not chart these observations she stated, that is how I always chart it, just without pulse and respirations. During an interview on [DATE] at 3:40 PM the Regional Nurse Consultant and VP of Clinical Services stated, An LPN cannot pronounce death, it is out of the scope of practice for an LPN. Review of the Facility Assessment Tool, updated [DATE], documented every staff member has knowledge competency in: abuse, neglect, exploitation and misappropriation, resident rights; identification of condition change; and resident preferences. Additional knowledge competencies for all staff include dementia management, infection transmission and prevention, immunization, QAPI [Quality Assurance Performance Improvement], and OSHA hazard communication. Competencies are based on current standards of practice. Competencies are verified upon orientation, at least annually and as needed. The facility provides education and training. The staff training and education program is designed to ensure knowledge competency for all staff. Review of the policy and procedure titled Code Blue & CPR, last reviewed on [DATE], reads, Policy: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). Review of the policy and procedures titled Advance Directives, last reviewed on [DATE], reads, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive and participate in advanced care planning. Advanced directives/advanced care planning designations will be respected in accordance with state law and facility policy. Review of the policy and procedure titled Determination of Code Status, last reviewed on [DATE], reads, Policy: The residents code status will be determined by a physician's order and/or validly executed State of Florida DNR Order Form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and/or documented evidence of resident wishes being in place. 12. Any resident without a signed State of Florida DNR Order form, or without a Physician's DNR order, or without documented verbal wishes of desire for withholding of resuscitation measures, will be a Full Code. Policy for pronouncement of death was requested on [DATE] at 11:30 AM and at 3:44 PM. No policy was received. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following: On [DATE] identified staff member A, LPN and staff member B, CNA have been removed from the schedule. 1. On [DATE] the facility Director of Nursing/designee initiated a house - wide full chart review of resident records and systems reviews to include: Cross checking DNR/advanced directives with Social Service List. Ensure DNR orders with the EHR [electronic health record] reflect resident status. DNR books updated appropriately and reflect physician orders. Accuracy of physician orders as it pertains to code status/advanced directives. Yellow DNRO [Do Not Resuscitate Order] form scanned into resident records and appropriately signed by the resident or resident representative. DNR book and Advanced Directive list is accurate and validated. Care Plan and advanced directive care plan tracking form accurate. Validated residents on hospice to validate code orders. Residents on hospice services to validate code status was resident's choice. 2. On [DATE] the Director of Nursing conducted an audit of residents currently residing in the facility to ensure accuracy of code status within the facility's electronic health record. 3. Residents on hospice were interviewed by a licensed nurse to validate code status. 4. On [DATE] the facilities Executive Director and Risk Manager and [DATE] Director of Nursing Services was re-educated by the Regional Nurse Consultant on components of F726 Competent Nursing Staff with an emphasis on the provision of CPR in accordance with physician orders to include monitoring of facility systems during administrative/clinical stand up and stand down to ensure residents receive the necessary care and services and ensuring only qualified individual pronouncement death of a resident in the facility. Areas of focus to include: Residents Rights, Advance Directives, Following Physicians Orders, Process of code status determination, performing a Code Blue, Paging overhead during a code, Crash Cart process, Identification and response to a resident found to be unresponsive-assessment/evaluation, eInteract SBAR [Situation, Background, Assessment, Recommendation] and Stop-and-Watch to identify and document change and condition, staff to notify the facility Director of Nursing in person and or phone call as soon as possible in the event of an expired resident to review code status - if the DNS [Director of Nursing Services] is unable to be reached, the Executive Director is to be notified. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. The facility has initiated a supervisory tool to be used daily during clinical meetings to validate that Licensed Physician, a Registered Nurse, or Emergency Medical Services with physician authorization in accordance with the state law has pronounced death. As of [DATE], 20 out of 23 licensed nurses, that includes (Registered Nurses, Licensed practical Nurses) were educated. ***(the 3 licensed nurses that were not educated are PRN [as needed] only, were unable to be contacted and will not work until receiving this education in person) ***(Staff will not work without receiving this education) Numbers [20 out of 23] of employees obtained from current active employee roster. Residents' Rights education to include but not limited to the following: 1. The residents Code Status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced Directives education to include but not limited to the following: In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced directives the resident will be considered a 'full code' until validation of the resident/representative wishes otherwise. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. Procedure: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and or respirations. In the absence of pulse and or respirations do the following: ,d+[DATE] Revised: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility Protocol (i.e., Code Blue & room [ROOM NUMBER] times) and director staff to bring Emergency Equipment Cart to the scene. 5. Two staff members other than the one who is evaluating the resident and preparing to provide emergency care, must promptly check current code status by checking the code status sections of the EHR [Electronic Health Record], eMAR [Electronic Medication Administration Record] or point of care kiosk. At that point provisions or withholding of resuscitation efforts may begin. If a patient is determined to be a full code, CPR will be initiated immediately. 6. (* In the event the EHR is unavailable, code status may be validated using a secondary check of the code binder via presence of physician order and or a signed State of Florida Do Not Resuscitate Order (DH form #1896), and or documented verbal wishes of resident/representative or physician order) CPR will be initiated and will continue until the arrival of EMS or until discovery of a valid DNR. 7. If, after the initiation of resuscitative efforts, a physician order, a valid State of Florida Do Not Resuscitate Order (DH form #1896), and or documented verbal wishes of resident/representative is found, resuscitative efforts may be ceased or withdrawn as long as such efforts have been unsuccessful to that point. 8. If resuscitation efforts have been initiated, and are successful, such efforts should continue until arrival of EMS, even if a valid DNR/Advanced Directive has later been discovered. 9. Once resuscitative efforts are concluded, or resident is transported to the emergency center: a. Call attending/covering provider. b. Call emergency center and give report to the Admitting/Triage nurse as appropriate. c. Call resident family representative. d. Document details of resuscitative efforts in the EHR in a timely manner to include all observation/assessment and care provided. CPR sequence: 1. Check patient for responsiveness. 2. If unresponsive, call for help and activate EMS, or direct others to do so. 3. Obtain emergency equipment or direct others to do so. 4. Check for breathing and pulse. 5. If no pulse, and not breathing, begin CPR cycle (30 compressions/2 breaths) ***Compressions depths for ADULT are as follows: at least 2 inches (5cm) but avoid compressions deeper than 2.4 inches (6cm) (See AHA (American Heart Association) flowchart on next page). Clinical signs of irreversible death per AHA include: Decapitation, Transection, Decomposition, Dependent Lividity, Rigor Mortis. Following Physicians Orders. Facility policy regarding code status determination. Completing verbal order if required. Location of DNR order within the EHR. Location of DNR binders (to be used when EHR is inaccessible). Paging overhead during a code. Crash Cart process. Identification and response to a resident found to be unresponsive assessment/evaluation. Timely response to a resident needing assistance. Performing a code blue mock drill documented on code checklist. P&P [policy and procedure] Determination of Code Status. P&P Mock Code. P&P Advanced Directives. P&P Residents Rights. Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. P&P Death of resident with emphasis of a resident may be declared dead by a licensed physician, emergency medical services, or the registered nurse with the physician authorization in accordance with state law. ***(Newly hired employees will receive education on the above in orientation). 2. As of [DATE], 146 out of 160 staff have been educated. ***(the 14 staff members that were not educated due to PRN and/or out of {sic} LOA (Leave of Absence)). ***(Staff will not work without receiving this education) Number of employees [146 out of 160] obtained from current active employee roster. Resident rights education to include but not limited to the following: 1. The residents code status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced 2. {sic} directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 3. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. 4. Where to locate physician order for code status in the EHR. 5. eInteract Stop and Watch to identify and document change in condition. ***(Newly hired employees will receive education in orientation). 1. On [DATE] Systemic Change: the licensed nurse and one other staff member to verify codes status prior to initiating CPR or withholding CPR. 2. On [DATE] Systemic Change: the facility initiated an advanced directives compliance tracking tool to be used daily during morning clinical meetings to validate advanced directives for new admissions or readmissions and to validate or confirm code status log is being carried out and remains effective. This tool will be utilized to validate any changes in code status as well as tracking new admissions. 3. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meeting to validate that if there is a code that the licensed nurse and one other staff member are to verify code status prior to initiating CPR or withholding CPR. 4. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meetings to validate that licensed physician, a registered nurse, or emergency medical services with physician authorization in accordance with the state law has pronounced death. 5. On [DATE], [DATE], [DATE] Ad-Hoc [when necessary or needed] Quality Assurance Performance Improvement meetings were carried out as it relates to resident rights to formulate advanced directives, provision of CPR, competent staffing and neglect to include a root cause analysis using 5 why's QAPI CMS [Centers for Medicare and Medicaid Services] tool and audits to be carried out with progress presented to monthly QAA [Quality Assurance and Accreditation] to ensure compliance/recommendations. Review of Suspension for Staff A, LPN, and staff B, CNA was documented on [DATE]. Review of the house wide full chart review of resident records including cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR [electronic health record] reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO [Do Not Resuscitate Order] form scanned into residents records and appropriately signed by the resident or resident representative, DNR book and advanced directive list is accurate and validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residence choice. was documented as completed on [DATE]. Review of the Director of Nursing audit to ensure code status within the electronic health record was documented as completed on [DATE]. Review of Education given by the Regional Nurse Consultant on the components of F678 Cardiopulmonary Resuscitation with an emphasis on the provisions of CPR in accordance with physician orders including monitoring of facility systems for the facility's Executive Director and the Risk Manager was documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, paging overhead during a code, crash cart process, identifications and responses to a resident found to be unresponsive, assessment/evaluation, timely response to a resident needing assistance, performing a code blue (mock codes) documented on code check list, Policy and Procedure on Determination of Code Status, Policy and Procedure on Mock Code, Policy and Procedure on Advanced Directives, Policy and Procedure on Code Blue and CPR, Policy and Procedure on Resident Rights, Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record, Policy and Procedure on Death of a Resident t with emphasis of a resident may be declared dead by a Licensed Physician, Emergency Medical Services, or the Registered Nurse with physician authorization for 20 out of 23 licensed nurses was documented as completed on [DATE]. Review of mock code drills were documented as conducted and completed for each shift from [DATE] through [DATE]. Review of the Advanced Directives Compliance Tracking Tool initiated on [DATE], was documented and up to date as of [DATE]. Review of the Supervisor Tool initiated on [DATE] was documented and up to date as of [DATE]. A review of the Ad-Hoc QAPI meetings held on [DATE], [DATE], and [DATE], were carried out as it relates to Resident Rights to formulate Advanced Directives, Provisions of CPR, Competent Staffing, and Neglect. Those in attendance included The facility administrator, Director of Nursing, Clinical Educator/Risk Manager, Unit Manager, MDS, Admissions, Rehab, Staffing, Dietary, Social Services Director, Activities, Medical Records, Environmental Services, Maintenance, and the Medical Director. During staff interviews completed on [DATE], 5 RN's, and 12 LPN's verified having received education and verbalized understanding of resident rights, advanced directives, following physicians' orders, process of code status determination, performing a code blue, crash cart process, documentation in point click care, confirmation of code order by 2 licensed nurses, policy and procedure death of a resident with emphasis of who may declare a death in the facility. During staff interviews completed on [DATE], 5 RN's, 12 LPN's, and 14 CNA's verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status in the EHR residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR.

Based on resident record review and staff interview, the facility Administration failed to utilize resources effectively to ensure one of three residents (#1) reviewed for a full code status received emergency care for basic life support, including CPR (Cardiopulmonary Resuscitation) according to facility policies and procedures, and to prevent neglect. Resident #1 became unresponsive and the facility nursing staff failed to follow policies and procedures for CPR. The resident died . This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on (MONTH) 29, 2019. The Administrator was informed of the Immediate Jeopardy on (MONTH) 3, 2019. The Immediate Jeopardy was on-going. : This has the potential to affect 55 of 101 residents with a Full Code Status. Cross reference to F600, and F678. The findings included The facility policy and procedure titled, Emergency Procedure Cardiopulmonary Resuscitation stated: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation, for victims of sudden [MEDICAL CONDITION]. General Guideline: 1. Sudden [MEDICAL CONDITION] is a loss of heart function due to abnormal heart rhythms (arrhythmia's). [MEDICAL CONDITION] occurs soon after symptoms appear. It is the leading cause of death among adults. 2. A [MEDICAL CONDITION] refers to impaired blood flow to the heart which leads to damage of the heart muscle. A [MEDICAL CONDITION] can cause sudden [MEDICAL CONDITION]. 4. The chance of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. 7. If the resident's DNR (Do Not Resuscitate) is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. Procedure: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR. The facility policy and procedure titled, Abuse Protection and Response Policy, included, Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. During an interview on [DATE] at 11:50 AM the Director of Nursing (DON stated, I am the DON and the Risk Manager (RM). When asked regarding the incident involving Resident #1 she stated, On [DATE] in the main dining room, the staff members in the main dining room during lunch time was a person from housekeeping, an agency CNA, Staff E, CNA, and Staff F, CN[NAME] I was called by my on-call supervisor who informed me that they had done a code on Resident #1 in the main dining room. The aide, Staff E, CNA found the resident slumped over, pushed the emergency alarm in the main dining room. The receptionist paged for nurses to come. The CNA pushed the resident back toward her room and nurses met her in the hallway. The staff brought her in the room, transferred the resident to bed and initiated CPR. They took her to her room because there is no suction machine in the dining room, it is on the crash cart. As a prudent nurse, once the code status was verified, I would have started CPR regardless of where the resident was. The surveyor asked what plan of correction was put into place after the incident, the DON replied, No action was taken at that point. The nurses followed the CPR protocol. The surveyor requested documentation of training provided to the nursing staff related to emergency procedures and CPR. On [DATE] at 5:18 PM, the DON said, Emergency Procedure Cardiopulmonary Resuscitation is an area that she knew training was needed and that she had conducted one mock drill prior to this incident. The training documentation titled, Mock Code Checklist dated [DATE] at 12:58 PM to 1:06 PM revealed a mock drill was conducted with seven LPNs (Licensed Practical Nurses) in attendance. The surveyor requested the DON (Director of Nursing) on [DATE] at 5:18 PM for documentation of other staff having received training related to Emergency Procedure Cardiopulmonary Resuscitation. The facility did not provide any additional documentation. The Mock Code Checklist sign in sheet dated [DATE] documented the nurses who responded to the code blue for Resident #1 had not attended the mock code. Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. enough blood to meet the body's needs). physician's orders [REDACTED]. The resident's Care Plan dated [DATE] documented the resident wishes a full code. The nurses' progress notes dated [DATE] at 12:29 PM revealed, Staff G, CNA (Certified Nursing Assistant) called overhead for all nurses to come to main dining room stat (immediately). Another CNA wheeled Resident #1 out of dining room while nurses proceeded with the resident to the unit in her room to assess her. Assessed resident and she had food coming out of her mouth and she was cyanotic and clammy. Mouth sweep was done, no palpable pulse and unresponsive. Chart and code status and observed resident being a full code. Code blue called. Resident transferred from wheelchair to bed. Staff came with crash cart. Back board placed. CPR initiated at 12 PM. 911 called by this nurse. Review of the Code Blue documentation record revealed, Code Blue time was 11:59 AM. Time of first vital sign No pulse. Time CPR started 12:02. Periodic notes: Vital signs unable to obtain pulse, resident was not breathing. Chunks of food, peas, carrots, noodles were pulled out of her mouth and suction was used to pull food out of her mouth. CPR was then started. Eight to ten minutes later, EMT (Emergency Medical Technician) arrive and took over CPR. Resident transported: 12:20. During an interview with Staff D, LPN (Licensed Practical Nurse) on [DATE] at 12:54 PM, she stated, I have worked here for two weeks. Between 11:50 AM and 12 noon, I heard the alarm and did not know what the alarm was for. I asked another nurse and she said it is the dining room alarm. I heard the alarm and then I heard an overhead page for Code Blue and we came running to the dining room. The resident was in the dining room and the staff members were trying to get her out of the dining room. The resident was slumped over in her chair, unresponsive with her chin to her chest, arms at her side, her lips were cyanotic. I felt for the pulse and there was no pulse. They called a code and took her back to her room. I lowered her bed down, me and three other staff members lifted her in the bed. I swept the food out of her mouth. I got out noodles, peas, pieces of carrots that were chewed in her mouth. CPR was started. Rescue came in and took over. The surveyor asked what she would have done differently when she found the resident unresponsive and pulseless, she replied, I would have done CPR in the hallway. The surveyor conducted a follow up interview with Staff D, LPN, at 9:17 PM via telephone. The surveyor asked why CPR was not started in the dining room, and she replied, I was new in the facility, the other nurse was the lead nurse who handled the code. We took the resident back to her room. The surveyor asked why the crash cart with the suction machine was not taken to the main dining room to conduct the code blue, and she replied, When the code blue was called she was being taken back to her room. During an interview on [DATE] at 2:32 PM, Staff F CNA stated, Staff [NAME] CNA came to me and said to look at the resident. I looked at the Resident and I told Staff [NAME] CNA to call the nurse. Staff [NAME] CNA rang the emergency alarm. Staff E, CNA's actions caused a delay in starting CPR. Staff G, Receptionist stated during an interview on [DATE] at 3:30 PM, Staff E, CNA came out of the dining room after she activated the alarm and asked if nurses are coming. I said, No. So, I made an overhead page for nurses to come stat to the dining room. Within a minute or two nurses arrived to the dining room. I saw the nurse Staff, C LPN in the dining room bringing her out of the dining room, the resident was blue looking. Staff E, CNA stated in an interview on [DATE] at 5:30 PM, I noticed Resident #1 was coughing. I told her to keep coughing and eat slowly. At 11:58 AM I found her slumped over and I called for Staff F, CN[NAME] The resident looked pale. I ran and pressed the emergency call light. I ran out of the hall to see if nurses were coming. I asked the receptionist to page. The Receptionist called the nurses, overhead paged, then the nurses were coming down the hall. When the nurses came in, the resident was still in the main dining room, in the middle of the dining room where the juice is located. Then the nurses took the resident out from the dining room. I don't know where they took her. The surveyor asked why she did not start CPR, she did not respond. Staff C, LPN stated during an interview on [DATE] at 5:41 PM, Around close to 12:00 PM, I heard the dining room alarm go off. We took off running. The resident had been rolled out by the receptionist's desk. The resident had food in her mouth, was slumped over in her wheelchair, her lips were every blue, she had no pulse, and was not breathing. We brought her in her room, did some finger sweeps from her mouth and got whole pieces of peas, noodles, and dices of carrot, not chewed. Four of us lifted her from the chair to the bed. I started compressions and Staff D, LPN did the Ambu bag (artificial manual breathing unit). She was suctioned, but it wasn't effective because the food was whole. Someone called 911, the crash cart was brought in. There was no in service training after the incident. The surveyor asked Staff C, LPN what she would have done differently, and she replied, We needed access to a suction machine, we took her to her room. Resident #1's hospital History and Physical, dated [DATE] at 1:38 PM revealed: [MEDICAL CONDITION]. Onset Occurred today (45 50 minutes prior to arrival). Presents via EMS (Emergency Medical Services) in [MEDICAL CONDITION]. Per EMS, patient collapsed suddenly approximately 45 50 minutes prior to arrival. Patient possibly had choking episode prior to this. Initial rhythm was asystole. After several rounds of [MEDICATION NAME] in route, they were able to obtain PEA (Pulseless Electrical Activity). Patient received a total of 6 rounds of [MEDICATION NAME]. The hospital's Death Note dated [DATE] at 7:03 PM revealed: Date Patient Expired: [DATE]. Time of Death 2:17 PM.

Based on record review and interview, the facility failed to prevent neglect through not providing emergency care to one (Resident #1) of three residents reviewed for a full code status. The facility failed to honor Resident #1's Full Code Status order. The facility failed to honor Resident #1's expressed and written wishes to have cardiopulmonary resuscitation (CPR) implemented in the event of [MEDICAL CONDITION] (Full Code). The facility nursing staff failed provide basic life support, including CPR immediately, to a resident who became unresponsive, and the resident died . This failure resulted of Immediate Jeopardy. The Immediate Jeopardy began (MONTH) 29, 2019. The Administrator was informed the Immediate Jeopardy on (MONTH) 3, 2019. The Immediate Jeopardy was on-going. This has the potential to affect 55 of 101 residents with a Full Code Status. Cross reference to F678 and F835. The findings included: Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. enough blood to meet the body's needs). physician's orders [REDACTED]. The resident's Care Plan dated [DATE] documented the resident wishes a full code. The nurses' progress notes dated [DATE] at 12:29 PM revealed, Staff G, CNA (Certified Nursing Assistant) called overhead for all nurses to come to main dining room stat (immediately). Another CNA wheeled Resident #1 out of dining room while nurses proceeded with the resident to the unit in her room to assess her. Assessed resident and she had food coming out of her mouth and she was cyanotic and clammy. Mouth sweep was done, no palpable pulse and unresponsive. Chart and code status and observed resident being a full code. Code blue called. Resident transferred from wheelchair to bed. Staff came with crash cart. Back board placed. CPR initiated at 12 PM. 911 called by this nurse. Review of the Code Blue documentation record revealed, Code Blue time was 11:59 AM. Time of first vital sign - No pulse. Time CPR started - 12:02. Periodic notes: Vital signs unable to obtain pulse, resident was not breathing. Chunks of food, peas, carrots, noodles were pulled out of her mouth and suction was used to pull food out of her mouth. CPR was then started. Eight to ten minutes later, EMT (Emergency Medical Technician) arrive and took over CPR. Resident transported: 12:20. During an interview on [DATE] at 11:50 AM, the DON (Director of Nursing) stated, I am the DON and the Risk Manager (RM). When asked regarding the incident involving Resident #1 she stated, On [DATE] in the main dining room, the staff members in the main dining room during lunch time was a person from housekeeping, an agency CNA, Staff E, CNA, and Staff F, CN[NAME] I was called by my on-call supervisor who informed me that they had done a code on Resident #1 in the main dining room. The aide, Staff E, CNA found the resident slumped over, pushed the emergency alarm in the main dining room. The receptionist paged for nurses to come. The CNA pushed the resident back toward her room and nurses met her in the hallway. The staff brought her in the room, transferred the resident to bed and initiated CPR. They took her to her room because there is no suction machine in the dining room, it is on the crash cart. As a prudent nurse, once the code status was verified, I would have started CPR regardless of where the resident was. The surveyor asked what plan of correction the facility put into place after the incident the DON replied, No action was taken at that point. During an interview with Staff D, LPN (Licensed Practical Nurse) on [DATE] at 12:54 PM, she stated, I have worked here for two weeks. Between 11:50 AM and 12 noon, I heard the alarm and did not know what the alarm was for. I asked another nurse and she said it is the dining room alarm. I heard the alarm and then I heard an overhead page for Code Blue and we came running to the dining room. The resident was in the dining room and the staff members were trying to get her out of the dining room. The resident was slumped over in her chair, unresponsive with her chin to her chest, arms at her side, her lips were cyanotic. I felt for the pulse and there was no pulse. They called a code and took her back to her room. I lowered her bed down, me and three other staff members lifted her in the bed. I swept the food out of her mouth. I got out noodles, peas, pieces of carrots that were chewed in her mouth. CPR was started. Rescue came in and took over. The surveyor asked what she would have done differently when she found the resident unresponsive and pulseless, she replied, I would have done CPR in the hallway. The surveyor conducted a follow up interview with Staff D, LPN, at 9:17 PM via telephone. The surveyor asked why CPR was not started in the dining room, and she replied, I was new in the facility, the other nurse was the lead nurse who handled the code. We took the resident back to her room. The surveyor asked why the crash cart with the suction machine was not taken to the main dining room to conduct the code blue, and she replied, When the code blue was called she was being taken back to her room. During an interview on [DATE] at 2:32 PM, Staff F, CNA stated, Staff E, CNA came to me and said to look at the resident. I looked at the Resident and I told Staff E, CNA to call the nurse. Staff E, CNA rang the emergency alarm. Staff E, CNA's actions caused a delay in starting CPR. Staff G, Receptionist stated during an interview on [DATE] at 3:30 PM, Staff E, CNA came out of the dining room after she activated the alarm and asked if nurses are coming. I said, No. So, I made an overhead page for nurses to come stat to the dining room. Within a minute or two nurses arrived to the dining room. I saw the nurse Staff, C LPN in the dining room bringing her out of the dining room, the resident was blue looking. Staff E, CNA stated in an interview on [DATE] at 5:30 PM, I noticed Resident #1 was coughing. I told her to keep coughing and eat slowly. At 11:58 AM I found her slumped over and I called for Staff F, CN[NAME] The resident looked pale. I ran and pressed the emergency call light. I ran out of the hall to see if nurses were coming. I asked the receptionist to page. The Receptionist called the nurses, overhead paged, then the nurses were coming down the hall. When the nurses came in, the resident was still in the main dining room, in the middle of the dining room where the juice is located. Then the nurses took the resident out from the dining room. I don't know where they took her. The surveyor asked the why she did not start CPR, she did not respond. Staff C, LPN stated during an interview on [DATE] at 5:41 PM, Around close to 12:00 PM, I heard the dining room alarm go off. We took off running. The resident had been rolled out by the receptionist's desk. The resident had food in her mouth, was slumped over in her wheelchair, her lips were every blue, she had no pulse, and was not breathing. We brought her in her room, did some finger sweeps from her mouth and got whole pieces of peas, noodles, and dices of carrot, not chewed. Four of us lifted her from the chair to the bed. I started compressions and Staff D, LPN did the Ambu bag (artificial manual breathing unit). She was suctioned, but it wasn't effective because the food was whole. Someone called 911, the crash cart was brought in. There was no in service training after the incident. The surveyor asked Staff C, LPN what she would have done differently, and she replied, We needed access to a suction machine, we took her to her room. Resident #1's hospital History and Physical, dated [DATE] at 1:38 PM revealed: [MEDICAL CONDITION]. Onset Occurred today (45 50 minutes prior to arrival). Presents via EMS (Emergency Medical Services) in [MEDICAL CONDITION]. Per EMS, patient collapsed suddenly approximately 45 50 minutes prior to arrival. Patient possibly had choking episode prior to this. Initial rhythm was asystole. After several rounds of [MEDICATION NAME] in route, they were able to obtain PEA (Pulseless Electrical Activity). Patient received a total of 6 rounds of [MEDICATION NAME]. Review of the hospital's Death Note dated [DATE] at 7:03 PM revealed: Date Patient Expired: [DATE]. Time of Death 2:17 PM. The facility's policy and procedure, revised ,[DATE], titled, Emergency Procedure Cardiopulmonary Resuscitation stated: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation, for victims of sudden [MEDICAL CONDITION]. General Guideline: 1. Sudden [MEDICAL CONDITION] is a loss of heart function due to abnormal heart rhythms (arrhythmia's). [MEDICAL CONDITION] occurs soon after symptoms appear. It is the leading cause of death among adults. 2. A [MEDICAL CONDITION] refers to impaired blood flow to the heart which leads to damage of the heart muscle. A [MEDICAL CONDITION] can cause sudden [MEDICAL CONDITION]. 4. The chance of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. 7. If the resident's DNR (Do Not Resuscitate) is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. Procedure: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR. The facility policy and procedure, revised ,[DATE], titled, Abuse Protection and Response Policy, included, Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. The facility failed to prevent neglect for failure to provide immediate emergency cardiac care for resident #1. The contributing factors for causing the delay in starting CPR were the nurses' failure to bring the crash cart with the suction machine to the dining room; the nurses' failure to respond to the emergency alarm system; and Staff [NAME] CNA's failure to immediately start resuscitation.

Based on resident record review and staff interview, the facility failed to honor a resident's right to receive adequate and appropriate health care consistent with the resident's care plan and established and recognized practice standards. The facility failed to implement written policies and procedures to provide emergency care for basic life support, including CPR (Cardiopulmonary resuscitation) for one (Resident #1) of three residents reviewed for a full code status. The facility failed to honor Resident #1's expressed and written wishes to have cardiopulmonary resuscitation implemented timely in the event of [MEDICAL CONDITION]. The facility nursing staff failed to follow policies and procedures for CPR in a timely manner, and the resident died . This failure resulted in a Class I deficiency. The Class I began on (MONTH) 29, 2019. The Administrator was informed the Class I on (MONTH) 3, 2019. This has the potential to affect 55 of 101 residents with a Full Code Status. The findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. enough blood to meet the body's needs). physician's orders [REDACTED]. The resident's Care Plan dated [DATE] documented the resident wishes a full code. The nurses' progress notes dated [DATE] at 12:29 PM revealed, Staff G, CNA (Certified Nursing Assistant) called overhead for all nurses to come to main dining room stat (immediately). Another CNA wheeled Resident out of dining room while nurses proceeded with resident to the unit in her room to assess her. Assessed resident and she had food coming out of her mouth and she was cyanotic and clammy. Mouth sweep was done, no palpable pulse and unresponsive. Chart and code status and observed resident being a full code. Code blue called. Resident transferred from wheelchair to bed. Staff came with crash cart. Back board placed. CPR initiated at 12 PM. 911 called by this nurse. Review of the Code Blue documentation record revealed, Code Blue time was 11:59 AM. Time of first vital sign No pulse. Time CPR started 12:02. Periodic notes: Vital signs unable to obtain pulse, resident was not breathing. Chunks of food, peas, carrots, noodles were pulled out of her mouth and suction was used to pull food out of her mouth. CPR was then started. Eight to ten minutes later, EMT (Emergency Medical Technician) arrive and took over CPR. Resident transported: 12:20. During an interview on [DATE] at 11:50 AM the DON (Director of Nursing) stated, I am the DON and the Risk Manager (RM). When asked regarding the incident involving Resident #1 she stated, On [DATE] in the main dining room, the staff members in the main dining room during lunch time was a person from housekeeping, an agency CNA, Staff E, CNA, and Staff F, CN[NAME] I was called by my on call supervisor who informed me that they had done a code on Resident #1 in the main dining room. The aide, Staff E, CNA found the resident slumped over, pushed the emergency alarm in the main dining room. The receptionist paged for nurses to come. The CNA pushed the resident back toward her room and nurses met her in the hallway. The staff brought her in the room, transferred the resident to bed and initiated CPR. They took her to her room because there is no suction machine in the dining room, it is on the crash cart. As a prudent nurse, once the code status was verified, I would have started CPR regardless of where the resident was. The surveyor asked what plan of correction was put into place after the incident the DON replied, No action was taken at that point. The nurses followed the CPR protocol. An interview was conducted on [DATE] at 12:54 PM with Staff D, LPN (Licensed Practical Nurse. She stated, I have worked here for two weeks. Between 11:50 AM and 12 noon, I heard the alarm and did not know what the alarm was for. I asked another nurse and she said it is the dining room alarm. I heard the alarm and then I heard an overhead page for Code Blue and we came running to the dining room. The resident was in the dining room and the staff members were trying to get her out of the dining room. The resident was slumped over in her chair, unresponsive with her chin to her chest, arms at her side, her lips were cyanotic. I felt for the pulse and there was no pulse. They called a code and took her back to her room. I lowered her bed down, me and three other staff members lifted her in the bed. I swept the food out of her mouth. I got out noodles, peas, pieces of carrots that were chewed in her mouth. CPR was started. Rescue came in and took over. When asked what she would have done differently when she found the resident unresponsive and pulseless she replied, I would have done CPR in the hallway. The surveyor conducted a follow up interview with Staff D, LPN at 9:17 PM via telephone. The surveyor asked why CPR was not started in the dining room she replied, I was new in the facility, the other nurse was the lead nurse who handled the code. We took the resident back to her room. The surveyor asked why the crash cart with the suction machine was not taken to the main dining room to conduct the code blue, and she replied, When the code blue was called she was being taken back to her room. During an interview on [DATE] at 2:32 PM Staff F, CNA stated, Staff E, CNA came to me and said to look at the resident. I looked at the Resident and I told Staff E, CNA to call the nurse. Staff E, CNA rang the emergency alarm. Staff E, CNA's inactions caused a delay in starting CPR. Staff G, Receptionist stated during an interview on [DATE] at 3:30 PM, Staff E, CNA came out of the dining room after she activated the alarm and asked if nurses are coming. I said, No. So, I made an overhead page for nurses to come stat to the dining room. Within a minute or two nurses arrived to the dining room. I saw the nurse Staff, C LPN in the dining room bringing her out of the dining room, the resident was blue looking. Staff E, CNA stated during an interview on [DATE] at 5:30 PM, I noticed Resident #1 was coughing. I told her to keep coughing and eat slowly. At 11:58 AM I found her slumped over and I called for Staff F, CN[NAME] The resident looked pale. I ran and pressed the emergency call light. I ran out of the hall to see if nurses were coming. I asked the receptionist to page. The Receptionist called the nurses, overhead paged, then the nurses were coming down the hall. When the nurses came in, the resident was still in the main dining room, in the middle of the dining room where the juice is located. Then the nurses took the resident out from the dining room. I don't know where they took her. The surveyor asked the CNA why she did not start CPR she did not respond. Staff C, LPN stated during an interview on [DATE] at 5:41 PM, Around close to 12:00 PM, I heard the dining room alarm go off. We took off running. The resident had been rolled out by the receptionist's desk. The resident had food in her mouth, was slumped over in her wheelchair, her lips were every blue, she had no pulse, and was not breathing. We brought her in her room, did some finger sweeps from her mouth and got whole pieces of peas, noodles, and dices of carrot, not chewed. Four of us lifted her from the chair to the bed. I started compressions and Staff D, LPN did the Ambu bag (artificial manual breathing unit). She was suctioned, but it wasn't effective because the food was whole. Someone called 911, the crash cart was brought in. There was no in service training after the incident. The surveyor asked Staff C, LPN what she would have done differently, and she replied, We needed access to a suction machine, we took her to her room. Resident #1's hospital History and Physical dated [DATE] at 1:38 PM revealed: [MEDICAL CONDITION]. Onset Occurred today (45 50 minutes prior to arrival). Presents via EMS (Emergency Medical Services) in [MEDICAL CONDITION]. Per EMS, patient collapsed suddenly approximately 45 50 minutes prior to arrival. Patient possibly had choking episode prior to this. Initial rhythm was asystole. After several rounds of [MEDICATION NAME] in route, they were able to obtain PEA (Pulseless Electrical Activity). Patient received a total of 6 rounds of [MEDICATION NAME]. The hospital's Death Note dated [DATE] at 7:03 PM revealed: Date Patient Expired: [DATE]. Time of Death 2:17 PM. The facility's policy and procedure, revised ,[DATE], titled, Emergency Procedure Cardiopulmonary Resuscitation stated: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation, for victims of sudden [MEDICAL CONDITION]. General Guideline: 1. Sudden [MEDICAL CONDITION] is a loss of heart function due to abnormal heart rhythms (arrhythmia's). [MEDICAL CONDITION] occurs soon after symptoms appear. It is the leading cause of death among adults. 2. A [MEDICAL CONDITION] refers to impaired blood flow to the heart which leads to damage of the heart muscle. A [MEDICAL CONDITION] can cause sudden [MEDICAL CONDITION]. 4. The chance of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. 7. If the resident's DNR (Do Not Resuscitate) is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. Procedure: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR. The facility policy and procedure, revised ,[DATE], titled, Abuse Protection and Response Policy, included, Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. The American Heart Association website titled About CPR and ECC (Emergency Cardiovascular Care) revealed, CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after [MEDICAL CONDITION]. The facility failed to prevent neglect for failure to provide immediate emergency cardiac care for resident #1. The contributing factors for causing the delay in starting CPR were the nurses' failure to bring the crash cart with the suction machine to the dining room; and the nurses' failure to respond to the emergency alarm system.