Every finding on record at Winter Haven Health and Rehabilitation Center

Based on record review, and interviews, the facility failed to ensure the facility wide assessment included information related to staff education and competencies needed for the care of residents with different acuities, and the number of staff needed for each shift.Findings included: A review of the facility's staffing data report, reported to the Centers for Medicare and Medicaid services (CMS), revealed excessively low weekend staffing was triggered for the quarter of October 1, 2026 to December 31, 2026. On 6/18/26 at 11:45 a.m., an interview with the Staffing Coordinator was conducted. She said she staffed the facility by what the opening census was. The Staffing Coordinator stated, I used to use the facility assessment to staff the building but now I just use the census.A review of the facility assessment revealed a count of various personnel, however there was no documentation related to staff education and competencies or staffing needs for each shift based on residents' acuity. On 6/18/26 at 12:02 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She said the interdisciplinary team (IDT), managers, and leadership completed the facility assessment. She said it was updated annually, every July. She said they have a template of the facility assessment that was used. The NHA said she obtained staffing numbers/information from human resources. She said acuity can change based on discharge, admissions, or if a resident had a change in condition. She said if the facility assessment included staffing numbers for each shift, based on acuity, that would mean nursing leadership and the IDT would need to update the assessment every day. The NHA said she was not aware the facility assessment included staff education, competencies and staffing needed each shift based on the residents' acuity. She said the current facility's assessment showed the count of how many staff the facility had, but it did not show the number of staff needed on each shift. A review of the facility's policy titled Facility Assessment, dated 8/2024, revealed the following, Policy The facility will conduct and document a facility wide assessment to determine what resources are necessary to care for its residents 24 hours a day. The Facility Assessment will use data driven indicators that focus on the outcomes of care and contingency planning for events that do not require activation of the facility's emergency plan but may impact resident care. The Quality Assurance, Assessment, and Compliance (QAA&C) Committee will implement the Facility Assessment through individual and community assignments. Further review of the policy, under procedure, revealed the following, Assessment will address: The facility's resident population needs, The facility's resources, and Facility and community-based risk assessment.

Based on observations, interviews, and record review, the facility failed to implement an effective infection control program related to: 1) ensuring precautions were initiated for two residents (#22 and #28) out of two residents diagnosed with a multi-drug resistant organism (MDRO), 2) ensuring one resident (#29) out of 18 residents with enhanced barrier precautions (EBP) had signage posted outside of the room; 3) ensuring hand hygiene was performed by staff members on one unit (300) out of three units while passing meal trays, 4) assisting residents on one unit (300) with hand hygiene prior to meal service, 5) cleaning and disinfecting multi-use medical devices before or after used during medication administration, 6) to ensure hand hygiene was performed during medication administration, 7) ensuring fingernails of direct care staff were maintained in a sanitary length to promote adequate hand hygiene. Findings included: 1. An observation was made on 06/15/26 at 10:12 a.m. of Resident #22 lying atop bed in room. The resident was able to reposition to a sitting position without assistance. The resident was able to answer questions appropriately. Review of Resident #22's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to unspecified Alzheimer's Disease and unspecified Bipolar Disorder. Review of Resident #22's June Treatment Administration Record (TAR) revealed an order obtain a urinalysis and culture/sensitivity to rule out (r/o) urinary tract infection one time only for 1 day, scheduled for and obtained 06/15 at 1:19 a.m. A review of Resident #22's laboratory results was conducted on 06/17/26 at 12:35 p.m. with Staff J, Licensed Practical Nurse (LPN). Staff J opened laboratory results for the resident and found urine culture and sensitivity results for the resident. The results showed the collection of a clean catch urine was completed on 06/14 at 3:00 p.m. and the vendor reported results on 06/16/26 at 7:48 p.m. (approximately 17 hours prior to the staff members review). The results showed the urine was positive for the antibiotic resistance organisms, Extended-Spectrum Beta-Lactamases (ESBLs). The staff member reported not being told by off-going nurse of the results and the resident required contact isolation. Review of Resident #22's progress notes revealed the physician was notified of urinalysis results on 06/17 at 1:44 p.m.,18 hours after the vendor reported the results. The provider did order for the broad-spectrum antibiotic, Ertapenem to be administered intramuscularly for 10 days. Review of the Centers of Disease Control and Prevention (CDC) education, About ESBL-producing Enterobacterales, dated June 12, 2025, disclosed ESBL-E were resistant to common antibiotics and might need complex treatments. The education educated Good hand hygiene and infection prevention practices can help reduce infection risk and can spread from person to person through dirty hands and surfaces. The CDC recommended washing hands after using the bathroom and before eating or preparing food. During an interview on 6/18/26 at 12:06 p.m. the Infection Preventionist/Assistant Director of Nursing (IP/ADON) stated expectations for determining isolation status for residents and ensuring transmission-based precautions are followed were the facility looks at paperwork from the hospital and form 3008, if any discrepancies the facility contacts hospital and they put out the necessary equipment. The IP stated if a resident was at the facility the facility reached out to physician when the culture comes back and lets them know what was going on (with the resident). 2. On 6/15/26 at 10:42 a.m. Resident #29 was observed sitting upright in reclining chair bent over at waist. The resident was not receiving liquid nutrition at the time. Staff J, Licensed Practical Nurse (LPN), had reported earlier on 6/15/26 the resident's liquid nutrition went up at 6:00 p.m. and came down at 6:00 a.m. On 6/15/26 at 12:45 p.m. an observation showed Resident #29's room was not posted with Enhanced Barrier Precaution (EBP) signage. On 6/16/26 at 3:17 p.m. an observation revealed the resident's room continued to be without EBP signage. Review of Resident #29s admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to Traumatic subarachnoid or hemorrhage without loss of consciousness subsequent encounter, gastrostomy status (04/03/24), Unspecified severe protein calorie malnutrition, and oropharyngeal phase dysphagia. Review of the facility matrix revealed Resident #29 received enteral tube feedings. Review of the CDC education located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, dated June 28, 2024, revealed EBPs were An infection control intervention designed to reduce transmission of multi drug-resistant organisms (MDROs) in nursing homes. EBPs involve the use of gloves and gowns during high-contact care for residents known to be colonized or infected with a MDRO and those with an increased risk of acquiring an MDRO (example: residents with wounds or indwelling medical device). During an interview on 06/18/26 at 12:05 p.m. the IP stated Enhanced Barrier Precautions should be initiated as soon as there is a foley (urinary) catheter, or gastrostomy tube (g-tube). The sign (for EBP) should be next to the door, gowns and gloves should be used for enhanced barrier and staff were last educated on 06/11 on infection control. Review of the policy – Barrier Precautions, effective August 2025, revealed Enhanced Barrier Precautions (EBP) referred to an infection control Intervention designed to reduce transmission or multidrug resistant organisms that employ targeted gown and gloves used during high contact resident activities. EBP is indicated for residents with any of the following: - Infection or colonization with a CDC targeted multi drug resistant Organism when contact precautions do not otherwise apply or, - Wounds and/ forward indwelling medical devices even if the resident is not known to be infected or colonized with a multi drug resistant Organism. The policies Appendix A reveal a table for implementing Contact versus Enhanced Barrier Precautions. The table showed infected or colonized resident with a CDC-targeted MDRO without a wound, indwelling medical device, or secretions or excretions that are unable to be covered or contained required EBP as well as a resident who had a wound or indwelling medical device, without secretions or excretions that are unable to be infected of colonized with any MDRO. 3. On 6/15/26 at 12:48 p.m. an observation showed Staff K, Activity Certified Nursing Assistant (CNA) and Staff L, CNA passing meal trays to residents on the 300 hall, a secured unit. Staff K was observed sanitizing hands after passing tray to a resident in room [ROOM NUMBER], came out of room and moved the meal cart down hall before removing another tray and delivered it to room [ROOM NUMBER]. Staff K was observed moving cart to outside room [ROOM NUMBER], wiped forehead, shut door to 307, reopened then shut door again, sanitized hands, moved cart to beside nursing station, removed meal tray, and delivered it to room [ROOM NUMBER]. The observation showed Staff K moved the meal cart, removed meal trays and served the resident without performing hand hygiene between moving the cart and the removal of trays. An interview was conducted on 6/15/26 at 1:02 p.m. with Resident #69. The resident stated staff does not offer hand washing before meals. The resident had a Brief Interview of Mental Status (BIMS) of 8, showing moderate cognitive impairment. On 6/15/26 at 1:07 p.m. revealed Staff L, CNA, delivered a meal trays to the two residents in room [ROOM NUMBER] without offering hand hygiene to either resident. On 6/15/26 at 1:11 p.m. Staff L was observed delivering meal tray to room [ROOM NUMBER] who was asleep on top of bed. The staff member woke the resident up, encouraging to sit up. The staff member held hand to assist the resident in sitting up. The resident was observed licking finger and the staff member handed the resident a sandwich. Staff L did not offer the resident hand hygiene prior to eating. During an interview on 06/18/26 at 12:05 p.m. the IP stated residents should be offered hand hygiene prior to eating. The hand hygiene should be offered in the dining room before giving residents (meal) trays. The IP stated staff should be performing hand hygiene before touching meal trays and staff could spread germs between (residents). 4. On 6/15/26 at 9:39 a.m., an observation of Staff Q, Licensed Practical Nurse (LPN) revealed she was providing medications to residents and she had dark-colored painted fingernails, longer than half an inch. On 6/15/2026 at 10:28 a.m., an observation of Staff R, LPN revealed she was at the medication cart and she had naturally-colored, artificial fingernails that were extended more than one inch. On 6/17/26 at 10:30 a.m., an observation of Staff B, Registered Nurse (RN) revealed she had artificial nails, that were extended more than one inch. 5. On 6/15/26 at 12:41pm, an observation was made of the dining room in the 300 hall, secured unit. Eight residents were observed sitting in the dining room waiting for their meal trays. Staff K, Activity Certified Nursing Assistant (CNA) was in the dining room supervising the residents. Staff K, Activity CNA did not offer hand hygiene to the residents while they awaited for their meal trays. On 6/15/26 at 12:57 p.m., Staff M, CNA began distributing trays to residents. Hand hygiene was still not offered prior to residents consuming their meals. On 6/15/26 at 1:01 p.m., two additional residents entered the dining room and joined the group. Hand hygiene was not offered to these residents upon their arrival. 6. Observed Staff P, Licensed Practical Nurse (LPN) on 06/16/2026 at 8:44 a.m. administer morning medications for Resident #67. He used a blood pressure wrist cuff without sanitizing before and after and performed no hand hygiene prior to preparing medication administration or after medication administration. An interview was conducted on 6/16/2026 at 8:50 a.m. with Staff P, LPN. He stated, Usually would wipe the blood pressure wrist device prior to using it on a resident and would wipe the wrist device again after using it with the resident. He described that he would use hand sanitizer prior to preparing medication and would wash his hands in the resident room after medication administration. He confirmed he did not perform either action during medication administration with Resident #67. An interview was conducted on 6/18/26 at 12:05 p.m. with Assistant Director of Nursing (ADON). ADON confirmed expectation of personal hygiene during medication administration to include before preparing medication, between residents, and to wash hands with soap and water when visibly soiled. ADON verified medical devices, including the wrist blood pressure cuffs, be cleaned between each resident. 6. Observed Resident #28's isolation status as enhanced barrier on 6/15/26 at 9:45 a.m., 6/16/26 at 3:19 p.m., and 6/17/26 8:15 a.m. A review of Resident #28's transfer form dated 6/11/26 revealed a primary diagnosis of infected surgical wound. Section F showed methicillin resistant staphylococcus aureus (MRSA) in wound and an isolation precaution of contact. A review of Resident #28's medical record revealed an initial admission date of 6/12/26 with methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere listed in diagnoses. An interview was conducted on 6/18/26 at 09:06 a.m. with Staff B, Registered Nurse (RN). She confirmed the assigned nurse and unit manager are responsible for reviewing the transfer form for new admissions to determine isolation status. An interview was conducted on 6/18/26 at 09:10 a.m., an interview was conducted with Staff H, RN. She reported that it is the responsibility of the assigned nurse for an admission to review the transfer form to determine diagnoses and isolation status. A phone interview was conducted with Medical Director on 6/18/26 at 9:29 a.m. He verified expectations of isolation status and personal protective equipment to be posted at the door. He confirmed MRSA cultured from a wound would require contact isolation. An interview was conducted on 6/18/26 at 12:05 p.m. with Assistant Director of Nursing (ADON). ADON stated isolation is determined from the transfer form on admission and the necessary isolation signage and personal protective equipment would be made available outside resident room. An interview was conducted on 6/18/26 from 1:56 - 2:16 p.m. with ADON. ADON responded regarding why Resident #28 was not placed on contact isolation on admission. She stated, In my defense, the status was not clear. A review of Facility policy titled, Hand Hygiene, effective October 2021 included: Policy: The facility considers hand hygiene the primary means to prevent the spread of infections Procedure: Personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Personnel shall follow the handwashing/hand hygiene guidelines to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Residents, family members, visitors, volunteers and those who provide services under a contractual agreement will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and other written materials provided at the time of admission and posted throughout the facility. Employees must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: When coming on duty; When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after performing any invasive procedure (e.g., finger stick blood sampling); Before and after entering isolation precaution settings; Before and after eating or handling food (hand washing with soap and water); Before and after assisting a resident with meals (hand washing with soap and water); Before and after assisting a resident with personal care (e.g., oral care, bathing); Before and after handling peripheral vascular catheters and other invasive devices; Before and after inserting indwelling catheters; Before and after changing a dressing; Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); After personal use of the toilet (hand washing with soap and water); Before and after assisting with toileting (hand washing with soap and water); After contact with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, C. difficile (hand washing with soap and water); After blowing or wiping nose; After contact with mucous membranes, body fluids, or excretions; After handling soiled linens, dressings, bedpans, catheters, or urinals; After handling soiled equipment or utensils; After performing personal hygiene (soap and water); After removing gloves or aprons; and After completing duty. The alternate method of hand hygiene is with an alcohol-based hand rub (ABHR) Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. The wearing of artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents. The Infection Prevention Coordinator maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an usual infection control risk. A review of Facility policy titled Barrier Precautions, effective August 2025, included: Contact Precautions are used when the employee expects to be in direct or indirectcontact with a resident and / or his or her environment including a person's room or objectsin contact with the person, that has an infection with an organism transmitted fecal-orally,such as Clostridium difficile, or wound and skin infections, or multi-drug resistant bacteriasuch as methicillin-resistant Staphylococcus aureus (MRSA). [1]PPE required before entering a contact precaution designated room is always gloves and agown. Mask and eye protection are additionally required if contact with bodily secretionsis possible. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designedto reduce transmission or multi-drug-resistant organisms that employ targeted gown andglove use during high contact resident activities. EBP are used in conjunction withstandard precautions and expand the use of PPE to donning of gown and gloves duringhigh-contact resident care activities that provide opportunities for transfer of MDROs tostaff hands and clothing. EBP is indicated for residents with any of the following: Infection or colonization with a CDC-targeted multi-drug-resistant organism when Contact Precautions do not otherwise apply or, Wounds and / or indwelling medical devices even if the resident is not known to beinfected or colonized with a multi-drug-resistant organism. A review of Facility policy titled Isolation Precautions, effective October 2021, included: PolicyTransmission-Based Precautions will be initiated when there is reason to believe that aresident has a communicable infectious disease. Transmission-Based Precautions mayinclude Contact Precautions, Droplet Precautions, or Airborne Precautions. The facility shall make every effort to use the least restrictive approach to managingindividuals with potentially communicable infections. Transmission-Based Precautionsshall only be used when the spread of infection cannot be reasonably prevented by lessrestrictive measures. Procedure If a resident is suspected of, or identified as, having a communicable infectious disease,the Charge Nurse or Nursing Supervisor shall notify the Infection Preventionist and theresident's Attending Physician for appropriate Transmission-Based Precautions. If the Attending Physician or his/her alternate fails to respond appropriately tonotification of a suspected or confirmed communicable infectious disease, the staff willinform the Medical Director and Administrator. In the event the Attending Physician fails to take appropriate action, the InfectionPreventionist or Medical Director shall have the authority to implement appropriateTransmission-Based Precautions. Transmission-Based Precautions shall remain in effect until the Attending Physician orInfection Preventionist discontinues them, which should occur after pertinent criteria fordiscontinuation are met. When Transmission-Based Precautions are implemented, the Infection Preventionist (ordesignee) shall:a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintainedin or near the resident's room so that everyone entering the room can access whatthey need;b. Post the appropriate notice on the room entrance door, to alert visitors & staffthat they must first see a nurse to obtain additional information about the situationbefore entering the room;c. Ensure that an appropriate linen barrel/hamper and waste container, withappropriate liner, are placed in or near the resident's roomd. Place necessary equipment and supplies in the room that will be needed duringthe period of Transmission-Based Precautions;e. Be sure that an adequate supply of antiseptic soap and paper towels aremaintained in the room during the isolation period; andf. Explain to the resident (or representative) the reason(s) for the precautions. In an emergency, the Director of Nursing, Infection Preventionist, Administrator and/or Medical.Director shall have the administrative authority, accountability, and responsibility to:a. Institute actions necessary to control or prevent infections within the facility;b. Notify the health department of reportable diseases, as appropriate;c. Initiate isolation precautions;d. Obtain laboratory specimens;e. Restrict or ban admissions;f. Restrict or ban visitation; andg. Implement other measures as necessary to prevent and control infections within thefacility. Attending physicians will be involved in decisions related to the residents under theircare that involve infection control issues. The Medical Director, with the help of the QAPI Committee, will help resolve differences of opinion. Notifiable disease reporting begins at the State and local level. It is mandatory that a reportable diseasebe reported to State jurisdictions when identified by a healthcare provider, hospital, or laboratory. Thistype of reporting uses uses personal identifiers and enables the State to identify cases where diseasecontrol and prevention is needed. Each State has its own laws and regulations defining what diseasesare reportable. The list of reportable diseases varies among States and over time. Although disease reporting is mandated at the State, territory, and local levels by legislations orregulation, State notification to CDC is voluntary. All State health departments voluntarily report toCDC reportable disease and conditions that are reportable in their jurisdictions. The list of nationalnotifiable diseases, conditions, and outbreaks is revised periodically. Conditions are added to the list asemerging pathogens, environmental hazards, or conditions emerge as public health concerns.Conditions are deleted from the list when surveillance is found not to be useful. Public health officialsat State health departments collaborate with CDC in determining which disease, conditions andoutbreaks should be considered nationally notifiable.

Based on interviews and record review, the facility failed to ensure the Level 1 Pre-admission Screening and Resident Reviews (PASRR) were accurate for four residents (#2, 22, 26, and 29) out of 11 residents sampled. Findings included: 1. A review of Resident #26's admission record revealed an admission date of 4/12/24, with a readmission admission date of 12/16/25. The admission record revealed diagnoses to include; generalized anxiety disorder (onset 8/15/24), dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 8/1/25), bipolar disorder, unspecified (onset 4/12/24). A review of Resident #26's Pre-admission Screening and Resident Review (PASRR), dated 4/12/24, revealed the following diagnoses documented under Section A. MI (Mental Illness) or suspected MI: Bipolar disorder and depressive disorder. Anxiety was not documented. During an interview on 6/18/26 at 10:52 a.m., the Social Services Director (SSD) stated Resident #26's Level 1 PASRR should have included an anxiety diagnosis. 2. On 06/15/26 at 10:12 a.m. Resident #22 was observed lying on bed and was able to sit up unassisted. The resident was seen in assigned bed within a secured unit. Review of Resident #22's admission Record showed the resident was admitted on [DATE]. The record showed the resident's primary diagnoses included; unspecified Alzheimer's disease with co-morbidities of dementia in other diseases classified elsewhere moderate with agitation, unspecified bipolar disorder, unspecified recurrent major depressive disorder, and generalized anxiety disorder. Review of Resident #22's Preadmission Screening and Resident Review (PASRR), dated 10/30/25, showed in Section 1 the resident did have diagnoses of anxiety, bipolar and depressive disorders. Review of Section II showed the resident did not have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The instructions in section II: Other indications for PASRR Screen Decision-Making revealed A Level II PASRR evaluation must be completed prior to admission if any box in Section 1A or 1B is checked and there is a yes checked in Section II1, II2, or II3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. The screening was completed prior to the resident's admission at this facility by a Registered Nurse (RN) at an acute care facility and showed there was no diagnosis or suspicion of a serious mental illness or intellectual disability therefore a Level II PASRR evaluation was not required. 3. On 6/15/26 at 10:42 a.m. Resident #29 was observed sitting upright in a reclining chair in room. The resident was bent over at waist but able to straighten up without assistance. The resident resided on the facility's secure unit. Review of Resident #29's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to; unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified recurrent major depressive disorder, generalized anxiety disorder, and unspecified anxiety disorder. Review of Resident #29's facility provided PASRR, dated 02/14/24 included the resident's diagnosis of anxiety disorder and showed the resident had serious difficulty with concentration, persistence and pace (section II2B). The resident had a primary diagnosis of dementia (section II5). The instructions instructed users that a Level II PASRR evaluation must be completed prior to admission if any box in Section 1A or 1B was checked (anxiety diagnosis) and a yes was answered in sections II1, II2, or II3 unless the individual met the definition of a provisional admission or a hospital discharge exemption. The PASRR was completed on 02/14/24 at an acute care facility and revealed a Level II PASRR evaluation was not required. Review of Resident #29's PASRR uploaded into the resident's electronic medical record, dated 03/08/24 and completed by another facility revealed the resident did not have any mental illness and/or intellectual disabilities. Review of Section II of the screening showed the resident did not have a serious difficulty with concentration, persistence, and pace. The resident did have a primary diagnosis of dementia with a secondary diagnosis of Dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an serious mental illness or intellectual disability. The decision-making showed a Level II evaluation was not necessary. During an interview on 06/18/26 at 10:52 a.m. with the Assistant Director of Nursing and Social Service Director (SSD), the SSD stated both Resident #22 and #29 should have had a Level II PASSR completed. 4. A review of Resident #2's admission record revealed an initial admission on [DATE] and re-admission on [DATE], with diagnoses to include anxiety disorder, unspecified, depression, unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #2's physician orders revealed the following:- memantine hcl [hydrochloride] oral tablet 5 mg (memantine hcl) give 1 tablet via peg-tube one time a day related to dysphagia following cerebral infarction. A review of Resident #2's Level 1 Preadmission Screening and Resident Review (PASSAR), dated 6/24/24, had no diagnoses documented under section A - mental illness (MI) or suspected MI. On 6/18/26 at 10:52 a.m., an interview was conducted with the Social Services Director (SSD). She said PASSRs are reviewed in morning meetings, gradual dose reductions (GDRs), standard of care (SOC), and if there was medication change or a resident declined. She said the Assistant Director of Nursing (ADON) will review what the SSD did and correct anything, if needed. The SSD stated the ADON was her, back up. The SSD said a newly admitted resident's PASSR is reviewed in the daily morning meetings. She said the team looked at medications and diagnoses to make sure the PASSR was accurate or if it needed to be updated. The SSD said if it was a current resident and they had a change in medications or diagnoses; the psychiatry nurse practitioner would communicate to her and the PASSR would be updated. She said for a submission for a level II PASSR screening, the resident would need to have dementia and two other diagnoses. She said the state affiliated vendor that managed the PASSRs does not trigger a Level II screen for anxiety and dementia, however she would submit for a screening although the system did not identify it. The SSD confirmed Resident #2 has diagnoses of dementia, anxiety, and depression. She said the Level I PASSR should have updated, as well as submit for a Level II screening. A review of the facility's policy titled Pre-admission Screening and Resident Review Requirements Level I and Level II, dated 8/2025, revealed the following: Policy Pre-admission Screening and Resident Review (PASRR) Nursing Homes are required to complete preadmission resident screening for mental illness and intellectual disability prior to admission. The screening is reviewed by Admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payer source. Level I screening is typically done by discharge planners and hospital staff as a step in the discharge process. A resident review must be completed when there has a been a significant change in a resident's mental or physical condition. Resident review is also required if a resident is transferred to a hospital for care and the stay lasts longer than 30 consecutive days prior to readmission to the nursing . Procedure PASRR Level I . 2. Upon admission the Social Services Director / Nursing Administration will review the PASRR for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident record. 3. Social Services or a Registered Nurse will review the PASRR Level I form to determine if a Serious Mental Illness (SMI) and / or Intellectual Disability (ID) exists. The existence of either, or both, condition(s) triggers the requirement for a Level Il review by the appropriate state agency. 7. Each psychiatric diagnosis shall be listed on the PASRR.

Based on observations, interviews, and record review, the facility failed to follow professional standards of practice for wound care for two residents (#28, #150) out of three sampled. Findings included:1. A review of Resident #28's medical record revealed an initial admission date of 6/12/26 with diagnoses to include: disruption of wound, unspecified, subsequent encounter; infection following a procedure, other surgical site, subsequent encounter; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere.A review of Resident #28's transfer form, dated 6/11/26, revealed a primary diagnosis of infected surgical wound.A review of Resident #28's hospital Discharge summary, dated [DATE], revealed an admission of 6/5/26 and discharge of 6/12/26. Hospital course included; Resident was seen for consultation, evaluation, and management of infected surgical wound to the lumbar region after having lumbar surgery on 5/8/26. Note stated, Surgical incisions are currently being treated with dry dressing change 2-3 times weekly.A review of Resident #28's Admission/readmit: Data Collection and Baseline Care Plan, dated 6/12/26 at 7:31 p.m., revealed: Actual wound not markedAn observation and interview was conducted with Resident #28 on 06/15/2026 at 9:45 a.m. She reported being admitted on [DATE] and had concerns with staff providing wound care. She expressed she was worried about infection and her wound getting worse. An observation was conducted of Resident #28's wound dressing on 6/15/26 at 10:02 a.m. with Staff I, Certified Nursing Assistant (CNA), present revealed an old surgical scar partially covered by one dressing. There were three overlapping, 4 x 4 inch adhesive, gauze dressings with a darkened area underneath that was visible from the dressing surface consistent with old wound drainage approximately the size of a golf ball. The dressing was not dated, timed, or initialed. [photographic evidence obtained]An observation was conducted on 6/16/26 from 1:38-1:47 p.m. with the Medical Director and Staff A, LPN, at Resident #28's bedside for wound assessment and dressing change. Staff A, Licensed Practical Nurse (LPN), removed old dressing with gloves. Medical Director assessed the wound and acknowledged the wound remained open with drainage. The Medical Director asked Staff A, LPN, and Resident #28 if the wound is being packed. Resident #28 informed Medical Director she should be getting wound care. Resident #28's back revealed three open surgical sites. The primary surgical site at the middle of the lower back had observable depth and a thick, yellow-white substance at wound opening. Two smaller surgical sites observed to be open and have thick, yellow-white substance, and unclear presence of depth. Staff A, LPN, proceeded with wound care without performing hand hygiene and applying new gloves. LPN cleansed wound with saline-soaked gauze and applied zinc around open wounds. Staff A, LPN, removed two sterile dressings from the packaging and placed them on Resident 28's bedside table. Staff A, LPN wrote on dressings with pen found on the bedside table. She applied the two dressings to the wound sites.An interview was conducted on 6/16/26 at 1:55 p.m. with Staff A, LPN. She stated after removing an old dressing, she would remove her gloves and perform hand hygiene. She stated she did not perform this action during Resident #28's wound care. She stated she was confusing herself between clean and sterile processes. She was unable to comment on a policy and procedure for wound care. She walked behind the nursing station and looked in a cabinet area with binders; she was unable to locate a binder for wound care. She stated they have a handbook with policies and procedures but stated she did not have it with her. An observation was conducted of wound assessment and dressing change for Resident #28 on 6/16/26 from 4:02 to 4:59 p.m. Staff members involved included Assistant Director of Nursing (ADON); Regional Nurse Consultant (RNC); and Staff G, Registered Nurse (RN), Unit Manager. At 4:15 p.m., ADON; Staff G, RN, Unit Manager; and RNC huddled around a computer screen at the 200-hall nursing station reviewing wound care orders. At 4:17 p.m. ADON left the 200-hall and returned with a tablet for wound measurements. At 4:19 p.m., ADON and RNC left 200-hall for aluminum foil to create a barrier at the bedside table. From 4:20 - 4:59 p.m., ADON performed Resident #28's wound care. RNC presented intermittently and provided additional wound supplies when requested. ADON removed old dressing from Resident #28. With the same gloves, ADON grabbed saline-soaked gauze and cleansed the wound bed with three different gauze and sites. ADON assisted Staff G, RN, Unit Manager, with tablet for wound measurements. ADON removed gloves and was going to apply new gloves when RNC stated, Are you done washing your hands? ADON observed to enter bathroom perform hand hygiene and applied new gloves. Staff G, RN, Unit Manager, entered the room with wound dressings and medical scissors that were not packaged and used to cut a strip of foam that was used to pack the wound. ADON informed Resident #28 wound care orders were being changed and stated, You don't need zinc in an open wound. Unit Manager returned to the room with wound ointment in a medication cup held with non-gloved hand. ADON grabbed the medication cup with gloves and proceeded to cleanse Resident #28's wound with saline-soaked gauze. ADON packed wound and Staff G, RN, Unit Manager, grabbed scissors that had been placed on the bedside table off the foil barrier and cut the excess foam from Resident #28's wound bed. ADON resumed remainder of wound care to include applying ointment and sterile dressings to wound sites.Review of Resident #28's care plan included: Problem of actual wound; surgical wound on her back with infection. Date Initiated: 06/15/2026. Intervention included; observe that dressing is covering & adhering. Report loose dressing to nurse. No specific wound dressing interventions listed, no goals listed.A review of Resident #28's orders revealed:Zinc Oxide external paste 20%, apply to Coccyx [tailbone] topically two times a day for redness, started 6/13/26Skin checks every shift 3 days, started 6/13/26Cleanse lower back with NS, pat dry. cover with dry dressing, no directions specified, started 6/15/26Santyl External Ointment 250units/Gram (Collagenase) with instructions apply to lower back topically one time a day for wound care. Cleanse lower back wounds with normal saline, pat dry apply Santyl to wound bed, pack wound with calcium alginate and cover with foam dressing, started 6/16/26A review of Resident #28's medication administration record and treatment administration record showed: No wound dressing documentation from 6/12/26 to 6/16/26A phone interview was conducted with Medical Director on 6/18/26 at 9:29 a.m. The Medical Director stated Resident #28's wound was post-surgical and confirmed during his assessment he observed open area with purulent [pus] drainage. 2. A review of Resident #150's medical record revealed an initial admission date of 3/23/26 with diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified severe protein-calorie malnutrition; and bacteriuria. A telephone interview was conducted on 6/15/26 from 11:39 - 11:51 a.m. with Resident #150's legal representative. She confirmed Resident #150 was found to have skin issues at the end of May, but she was not clear on the plan for treatment or how the wounds were being addressed.An observation and interview were conducted on 6/16/26 at 1:10 p.m. with Staff N, CNA. Observed Resident #150's right and left hip to have white adhesive dressings dated 6/19/26. An interview was conducted with Staff E, RN, on 6/16/26 at 1:12 p.m. She confirmed that wound care for Resident #150 is performed on the 11 p.m. - 7 a.m. shift. Regarding the wound dressing being dated 6/19/26, she stated, Maybe they did not date it correctly. She denied that she had seen the wound and stated, I don't do wound care.Review of Resident #150's orders revealed:Clean left hip with normal saline pat dry apply zinc oxide paste skin protectant daily; every night shift for wound care, ordered 6/2/26, initial start date on 5/28/26Clean right hip with normal saline pat dry apply zinc oxide paste skin protectant daily, ordered 6/2/26, initial start date on 5/28/26Review of Resident #150's MDS, completed 4/2/26, revealed a Brief Interview for Mental Status score of 0 [indicates severe problems with thinking and memory], no skin issues, and no significant change assessment was identified.Review of Resident #150's care plan revealed: Wound risk, date initiated 3/24/26; no care plan for acquired woundsReview of Resident #150's skin issues notes from 5/27/26 to 6/16/26, completed by ADON, revealed the following (wound measurements are length x width x depth in centimeters):5/27/26:Left hip, abrasion, new, acquired in-house, 1.49 x 1.38 x 0, no dressingRight hip, moisture associated skin damage, new, acquired in-house, 0 x 0 x 0, no dressing6/2/26Left hip, 5.63 x 3.35 x 0, calcium alginate and foam dressingRight hip, 4.73 x 6.48, 0, no dressing6/9/26Left hip, 5.25 x 5.25 x 0, moderate odor after cleansing, calcium alginate and foam dressingRight hip, 1.09 x 1.45 x 0, calcium alginate and foam dressing6/16/26:Left hip, 1.47 x 4.74 x 0, foam and dry dressingRight hip, 1.47 x 1.38 x 0, calcium alginate and foam dressingAn interview was conducted on 06/17/2026 at 4:01 PM with Minimum Data Set (MDS) Nurse. She stated Resident #150 met criteria for a significant change assessment. She verified that one had not been completed and stated she was going to start one. She reviewed Resident #150's care plan and confirmed the care plan was not updated for Resident #150's wounds. She stated the importance of keeping care plans updated as It is the care provided to the residents.An interview was conducted on 6/18/26 from 1:56 - 2:16 p.m. with ADON regarding Resident #150 wound treatments. She stated she put a dressing on the Resident without an order. She confirmed a physician order must be obtained.An interview was conducted on 6/18/26 at 09:06 a.m. with Staff B, RN. She described aseptic technique [to prevent spread of infection] during wound care as keeping everything clean. She reported after removing an old dressing, she would remove gloves and perform personal hygiene. She stated this is to prevent infection.An interview was conducted on 6/18/26 at 9:10 a.m. with Staff H, RN. She stated aseptic technique is to remain clean, prevent cross-contamination, and perform hand hygiene. She confirmed after removing an old dressing she would remove gloves, perform hand hygiene, apply new gloves, and continue with wound care. She reported following expectations for wound care prevents risk of infection for the residents.An interview was conducted on 6/18 at 8:20 a.m. with Staff G, RN, Unit Manager. She confirmed expectations for staff to follow aseptic technique with wound care. She verified staff should remove gloves and perform hand hygiene after removing an old dressing and use a barrier to keep wound supplies clean. She confirmed expectation that wound orders are updated with physician orders and wound treatments are reflected in the care plan. She confirmed importance of wound care to prevent infection.A phone interview was conducted with the Medical Director on 6/18/26 at 9:29 a.m. He reported residents admitted from the hospital setting with a wound have been evaluated by a wound care physician and would be admitted with wound care orders. He confirmed expectations to have wound care orders in place with specific instructions on admission. He confirmed expectations for aseptic technique during wound care. He confirmed staff should remove gloves and perform hand hygiene after removing the old dressing and prior to proceeding with wound care. He confirmed expectations for wound care treatment to be provided per physician order. An interview was conducted on 6/18/26 from 1:56 - 2:16 p.m. with ADON. She confirmed expectation for aseptic technique and once an old dressing is removed, gloves are removed, hand hygiene is performed, and new set of gloves are applied. ADON verified wound care treatment to be physician ordered. A review of Facility policy titled Hand Hygiene, effective October 2021, revealed:Policy: The facility considers hand hygiene the primary means to prevent the spread of infectionsProcedure included: Before and after changing a dressing

Based on review of infection surveillance data and interviews the facility failed to implement an effective antibiotic stewardship program related to unknown antibiotic utilization rates, antibiotic use without gathering infection criteria information, and improperly documenting unobtained culture results.Findings included: Review of the facility surveillance data showed the following documentation:March 2026 showed a one resident was ordered the antibiotic Levaquin without symptoms, no onset date, did not reveal a culture was obtained, no listed results and or sensitivity was confirmed. Seven residents with cough/chest congestion was documented as not having a culture completed however showed positive results.May 2026 showed five confirmed or suspected infections for foul smelling urine, two wounds with inflammation/purulent, and one wound of inflammation/redness was prescribed antibiotics. The listing showed a culture had been obtained with positive results for all 8. The listing did not reveal any pathogens or sensitivities. Resident #25 was listed as having inflammation/redness to two wounds, a culture was obtained and had negative results. The resident was ordered an antibiotic. June 2026 showed Resident #18 had cultures obtained for cough/congestion and foul smelling urine. The documentation showed the cultures were negative with orders for antibiotics. Review of Resident #25's Report of Possible or Known Infection or Communicable Disease, dated 05/14/26 showed the resident's wound had inflammation- redness. The form revealed a history of exposure to an Infectious Disease was unknown, no culture was obtained and an antibiotic was prescribed. The data did not reveal if the resident had any other symptom such as temperature and/or unusual pain the area, or the symptoms met the criteria of an infection. Review of the policy - Antibiotic Stewardship, effective March 2017, showed the purpose was Improving the use of antibiotics in healthcare to protect the patients and reduce the potential threat of antibiotic resistance is a national priority for the national strategy for combating antibiotic resistance bacteria, the [NAME] House. The Centers for Disease Control and Prevention (CDC) recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Per Centers for Disease Control and Prevention, 40-75% have antibiotics prescribed in nursing homes may be unnecessary or inappropriate. The procedure included:3. The director of nursing and infection preventionist will monitor for compliance with the antibiotic stewardship policies;4. Antibiotic use and resistance data will be reviewed at the quality assurance and performance improvement (QAPI) meeting as needed;5. Administration and the infection preventionist will communicate with nursing staff in the prescribing clinicians the facilities expectations regarding use of antibiotics and the monitoring and enforcement of stewardship policies.The individuals accountable for the antibiotic stewardship program included the IP. The Infection Preventionist has information to provide strategies to improve antibiotic use. This includes tracking of antibiotic starts, evaluation, and management of treated infections and reviewing antibiotic resistance patterns. Provide education relating to antibiotic stewardship questions and acts as a resource.Review of the policy - Actions to Improve Antibiotic Prescribing and Use, effective April 2017, revealed should an antibiotic be ordered prior to receiving culture results the antibiotic would be reassessed to determine if the antibiotic was still warranted and if the antibiotic was effective against the organism. The facility would utilize the Report of Possible or Known Infection or Communicable Disease for a standard assessment and communication tool. During an interview on 06/18/26 at 12:06 p.m. the Infection Preventionist (IP) reported following a specific criterion for all infections, at time of admission and during any change in condition. The IP did not provide a criterion for Resident #25, instead provided the communication tool. The IP was unable to report the facility's latest antibiotic utilization rate as the information was with the Quality Assurance (QA) and reported listing positive culture results for cultures not obtained because the resident exhibited the reported symptoms.

Based on interviews and record review, the facility failed to ensure the ophthalmology provider's orders were discussed with the primary physician and implemented for one resident (#111) of one resident reviewed for vision services. Findings included:On 6/15/26 at 10:14 a.m., an interview was conducted with Resident #111. He said he saw the eye doctor last week and was prescribed eye drops to be administered in the morning and at night. He said he has not had eye drops provided to him. A review of Resident #111's admission record revealed an admission date of 7/20/23. A review of Resident #111's physician orders revealed the following:- Ophthalmic, Auditory, Psychological, Psychiatric, Dental, Physiatry, and Podiatry services as needed. - Refresh Plus Ophthalmic Solution (Carboxymethylcellulose Sodium (Opth [medication pertaining to the eye]) Instill 1 drop in both eyes every 8 hours as needed for dry eyes, with an order date of 9/27/24. A review of Resident #111's medication administration record (MAR) and treatment administration record (TAR) revealed no documentation of eye drops being administered in May 2026 and June 2026. A review of Resident #111's care plan revealed the following: - COGNITION: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Moderately Impaired: Bims Score 8-12, Neurological symptoms Date Initiated: 07/24/2023. - VISION: [Resident #111] has impaired visual function r/t Unable to read small print Date Initiated: 01/26/2026 Revision on: 01/26/2026, with interventions to include, Vision consult as needed. A review of Resident #111's paper-based/physical records revealed a prescription from the eye care provider, dated 6/4/26, with the following orders, Artificial tear 1gt [one drop] BID [twice a day] OU [both eyes] x [for] 90 d [days]. A review of Resident #111's eye care provider notes, dated 6/4/26, revealed the following, .Chief Complaint: The patient/staff reports they have blurred vision Chief Complaint: The patient/staff reports ocular fatigue or eye strain. Impression(s) Bilateral: Dry eye syndrome . Treatment dry eye: Bilateral: Order Ats [artificial tears] BID ou x 90 days. Monitor 1 mo. [month] ck [check] .A review of Resident #111's progress notes, from 6/1/26 to 6/17/26, revealed no documentation related to the eye provider's orders from 6/4/26, to include consulting with the primary physician. On 6/17/26 at 11:29 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She said when an outside provider has an order, they write it on an order slip, then it was provided to her directly. Staff A, LPN said she made sure she understood the order, then documents the order in the electronic health record and puts the slip in the paper-based chart. She said she also lets the doctor know the order has been completed, as well as notifying the residents' family. She confirmed Resident #111 was last seen by the eye provider on 6/4/26. She said the eye provider's order would have been provided to his assigned nurse. Staff A, LPN said she was not working that day. She reviewed the current orders for Resident #111 and said the eye drops order he had was an as needed order, and confirmed the new orders were not in the active physician orders. She confirmed she had not administered eye drops to Resident #111 and based on the MAR; he has not been receiving the drops. On 6/17/26 at 12:23 p.m., an interview was conducted with the Director of Nursing (DON). He said orders or recommendations from an outside provider would have to go through nursing, as they put in the physician orders. The DON said the nursing staff should call the resident's physician first to get their permission. He said the expectation would be to call the physician first, then put the orders in. Regarding Resident #111, the DON said he needed to look into the eye providers orders as it may be a discontinued order. On 6/17/26 at 1:19 p.m., a follow-up interview was conducted with the DON. He said he did not find eye drop orders in discontinued orders for Resident #111. He confirmed the orders from 6/4/26 were not transcribed. A policy regarding vision services was requested but not provided. A review of the facility's policy titled Physician Orders, dated 2/2026, revealed the following, Procedure . 15. Review orders from a physician other than the attending (specialist, consulting physician, etc.) with the attending physician prior to implementation unless the attending physician has given previous written direction to accept the specialist/consultant order(s).

Based on observations, record reviews, and interviews the facility failed to ensure one (#11) of two residents sampled for accidents related to falls received neurological assessments after an unwitnessed fall.Findings included: On 06/15/26 at 1:35 a.m. an observation showed Resident #11 sitting upright in bed with eyes closed. On 6/18/26 at 9:54 a.m. Resident #11 was observed transferring self into wheelchair in the hallway outside of room. Review of Resident #11s progress notes revealed on 2/5/26 at 6:09 a.m. the resident had informed staff of falling on the floor with complaint of pain to right shoulder. Staff documented there was no swelling, bruising, or redness noted. The note did not reveal if the resident's Power of Attorney was notified. There were no further notes at this time as to how the resident was found, who found the resident, or where the resident was found. Review of Resident #11's progress notes showed a post-event note dated 2/5/26 at 11:23 p.m. (17 hours and 14 minutes after the event) revealing the note was an Initial Event note. The note showed the resident had an unwitnessed fall on 02/05/26 at 4:50 p.m. in the resident's room. The resident was found to be oriented to person and the most recent blood pressure was obtained on 02/05/26 at 3:00 p.m. (8 hours prior to the initial event note and 9 hours after the first note showing the resident had fallen) and a temperature, pulse, and respiration rate were obtained on 02/05/26 at 5:00 p.m. The initial/post event note showed pupil response, hand grasps, extremity movement, skin, and pain had been evaluated. The description of the event showed the resident was found sitting on floor and didn't see objects nearby for the resident to hit head on. The resident was last toileted on 02/05/26 at 4:00 a.m. and low bed, bedside mat, and nonskid material to seat of wheelchair were initiated. The note did show Hospice and the representative were notified. The note did not show where in the room the event occurred, who found the resident, how the resident was sitting, or vital signs at the time of fall. Review of Resident #11's progress notes revealed the following:-02/06/26 at 1:13 a.m. Vital signs within normal limit (WNL), resident able to make needs known to staff. Will continue to monitor. Call light within reach, head of bed (HOB) elevated, bed at lowest position.-02/06/26 at 2:56 a.m. earlier approximal 4:45 p.m. resident found on the floor in their room, showed no visible injuries, neurological assessment no evidence of head or neck trauma. Upon reassessment, just now noted swelling to right upper arm Distal pulses are strong and capillary refill is normal. An x-ray was ordered by Hospice Trauma nurse.-02/06/26 at 3:21 a.m. Resident resting comfortably in bed, when asked if Tylenol for pain resident stated no comma no voiced complaints at this time period will continue to monitor.-02/06/26 at 7:32 am. Earlier approximal 4:45 p.m. Resident was found on the floor in their room showed no visible injuries neurological assessment no evidence of heterogeneity neck trauma. Distal pulses are strong in capillary refill was normal. An X-ray was ordered by a Hospice trauma nurse. Neuro assessment vitals WNL.-02/06/26 at 10:49 a.m. Therapy referral. Recent fall. Referral made to Occupational and Physical Therapy.-02/06/26 at 11:21 a.m. the note showed the family member and the primary physician were notified. The physician had no new orders.-02/06/26 at 11:42 a.m. a note showed the resident's pain level had elevated. The note did not reveal a neurological assessment was completed.-02/06/26 at 5:31 p.m. showed a neuro check note (first) with vital signs was completed. The vital signs were taken at time the note was written, an assessment of mental status, pupil reactivity, hand grasps, range of motion in extremities, and pain was completed. -02/07/26 at 12:48 p.m. showed a second neuro check note was completed (19 hours after the first). Review of Resident #11s electronic neuro checks showed staff did not complete neurological assessments every 15 minutes x 4, every 1 hour x 4, or every 4 hours x2 after the resident had an unwitnessed fall. Review of Resident #11s Medication and Treatment Administration Records did not include neurological assessment documentation. During an interview with the Risk Manager (RM)/Administrator (NHA) on 06/18/26 at 9:03 a.m. the NHA stated staff walked into room and found resident seated on floor near bed. An assessment was done then resident was assisted back to bed. She stated a neuro assessment was done, no bruising or swelling, and resident reported pain to right shoulder informing staff of falling and hurt arm. The Director of Nursing (DON) was also present during the interview with the NHA. The DON stated neuro checks are done if unwitnessed (fall). The DON stated neuro checks are to be done every 15 minutes x 4, every 1 hour x4, every 4 hours x 2 and every 8 hours x 9. The DON reviewed Resident #11s record and stated he did not see neuro checks were completed. The DON stated the expectation was for them (neuro checks) to be completed. The Director reported the residents Brief Interview of Mental Status was 3 in March 2026 (indicating a severe cognition impairment). Review of the policy - Fall and Injury Reduction Policy, effective March 2023, showed the following: The facility has designated an implemented processes, which strive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions, and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such occurrence. The policy did instruct staff to evaluate the resident status post witnessed/unwitnessed fall or observed on floor event. The resident was not to be moved from floor until a nurse evaluated and if no signs/symptoms of injury staff were to assist resident from floor using a mechanical lift unless resident can actively assist in getting off the floor. The facility failed to provide page 2 of this 2 page policy.

Based on observations, interviews. and record review, the facility failed to follow professional standards of practice for parenteral therapy [delivery of nutrients or medication into the bloodstream through a catheter that is placed into a vein] for one resident (#27) out of one sampled. Findings included: Review of Resident #27's medical record showed an admission date of 5/21/26 with diagnoses to include: Type II Diabetes Mellitus without complications, acute pulmonary edema, pleural effusion in other conditions classified elsewhere.An observation was conducted of Resident #27 on 6/15/26 at 10:15 a.m. with a right-hand peripheral intravenous (IV) catheter [device inserted into a vein to delivery medication or nutrients into the bloodstream] covered with gauze-like tape, site was not visible, and no date, time, or initials present. [photographic evidence obtained]Review of Resident #27's orders on 6/15/26 at 2:01 p.m. revealed the following:6/5/26 12:15 p.m., start IV (intravenous), order completed 6/6/266/6/26 at 2:00 p.m., Zosyn (antibiotic) IV, use 3.375 milligram (mg) IV every 8 hours for pneumonia for 10 days6/15/26 10:30 a.m., document IV site appearance every shift; U=remarkable, R=redness, S=swollen, W=warm to touch, D=drainage every shift, report any changes to medical doctor6/15/26 10:30 a.m., IV normal saline flush, 10 milliliters (ml), every 8 hours to maintain patency (to ensure the line remains open and clear)6/15/26 10:33 a.m., change IV site every 72 hours and as needed, change IV dressing with each site change and as needed Review of Resident #27's medication administration record revealed:6/5/26 IV insertion documented at 1:28 p.m. and 6.39 p.m.6/6/26 - 6/16/26 Zosyn 3.375 mg administered every eight hours for 10 daysIV site assessment and normal saline flushes not documented from 6/4/26 to 6/14/26No IV site change every 72 hours documented; No IV dressing change documentedReview of Resident #27's nursing progress note, dated 6/5/26 at 4:31 p.m., by Staff G, Registered Nurse (RN), Unit Manager, charted insertion of IV in the right hand with dressing applied and secured.On 6/18 at 8:20 a.m., an interview was conducted with Staff G, RN, Unit Manager. She stated IV sites are to be covered with clear occlusive dressings and are contained in IV start kits. She reviewed photographic evidence of Resident #27's dressing and verbalized dressing did not meet expectations and stated date, time, and initials were not present. She confirmed IV sites are to be changed every 72 hours. She confirmed importance of IV management to prevent infection.On 6/18/26 at 09:06 a.m., an interview was conducted with Staff B, RN. She stated the expectations for IVs to include covered with a clear occlusive dressing to ensure the site is visible to assess for infection; dated, timed, and initialed; IV site changed every 72 hours. She stated staff perform these measures to prevent infection.On 6/18/26 at 09:10 a.m., an interview was conducted with Staff H, RN. She stated IV insertion sites are covered with a clear occlusive dressing. She stated expectations for IV dressing to be dated, timed, and initialed. She reported IV sites are changed every 72 hours. She stated IV standards are followed to prevent infection.An interview was conducted on 6/18/26 from 1:56 - 2:16 p.m. with Assistant Director of Nursing (ADON). She stated IV bundle included orders to change IV site every 72 hours, assessment of IV site every shift, and IV normal saline flushes every 8 hours. ADON confirmed expectations for IV orders to be entered and followed when IVs are started. ADON stated IV kits include clear occlusive dressings and IV site must remain visible for assessment. ADON stated IV dressing must be dated, timed, and initialed. ADON stated, Can't argue with that when informed of IV dressing that was not dated, timed, or initialed; site was covered with gauze tape; and no occlusive dressing was utilized. ADON was unable to comment regarding Resident #27's IV orders being entered on 6/15/26.A Facility policy for IV care and maintenance was requested. Facility referenced an Infusion Therapy Policy and Procedure Manual from an external pharmacy company. No internal policy provided by Facility.A review of the Infusion Therapy Policy and Procedure Manual from the external pharmacy company, dated 10/2024, included:Section 3.2IV Catheter DressingTransparent, semi-permeable membrane (TSM) dressings are changed a minimum of every 7 days and PRN whenever the dressing integrity becomes disrupted, becomes wet, loose, or soiled or if skin integrity is compromised under the dressing.If a gauze dressing is necessary, change every 48 hours or sooner if the dressing becomes compromised.Catheter RemovalShort and long peripheral IV catheters will be removed immediately upon suspected contamination or if sign and symptoms of complications occur.Section 4.17Flush Chart showed short and long peripheral IV catheters are flushed pre and post use with 10 mL of saline and every eight hours and as needed when the lumen is locked with no infusion running.Section 4.18 Dressing Change for Vascular Access Devices2. Short peripheral catheter dressings are changed every 7 days or when the integrity of the dressing is compromised. Change the dressing if moisture, drainage or blood is present or for further assessment if infection is suspected.Section 6.1 Assessment of the Resident Receiving IV Therapy6. Recommended minimum assessment of short peripheral catheters is every 4 hours. Assess every 1-2 hours for residents who have cognitive deficits or residents receiving vesicant medications.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan to document and address known triggers which could retraumatize a resident with previous trauma for one resident (#7) out of one resident sampled.Findings Included:During an observation and interview on 6/15/26 at 10:00 a.m., Resident #7 was sitting on the side of her bed. During the introduction, the resident provided a spiral notebook and pen and gestured to use these items to communicate with her. Resident #7 was hearing impaired and said due to scarring in the ears, the doctor told her she was not a candidate for regular or bone conduction hearing aids. The resident said she has a lot of anxiety.Review of admission record showed Resident #7's initial admission was on 9/8/23 and readmission 4/5/24 with diagnoses including rheumatoid arthritis, anxiety, depression and adjustment disorder, nightmare disorder and post-traumatic stress disorder (PTSD.)Review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], Section B, Hearing revealed the ability to hear is highly impaired; Section C, Cognition revealed Brief Interview for Mental Status (BIMS) summary score 15/15 indicating cognition was intact.Review of Resident #7 psychosocial history and assessment dated [DATE] show the resident has a history of trauma, .with triggers like sleep causing nightmares.Review of Resident #7's care plan focused on trauma informed care, initiated on 12/5/24 showed the following:The care plan goals: Staff will make effort to avoid flashback or trigger; staff will assist in managing the resident's response to trigger and the frequency or severity of my trauma-related signs and symptoms will not increase.The care plan interventions: coordinate psychology or psychiatric services on admission and as needed, coordinate support group as requested, encourage to express feeling, concerns and thoughts, know what triggers are and minimize exposure if possible, observed for reported symptoms of a trigger and provide meaningful activities. Review of Psychiatry Progress Note dated 5/16/26 showed Resident #7 is a long-term resident, . on psych services for management of anxiety, depression, and PTSD. Mood: Anxious .During an interview on 6/17/26 at 11:01 a.m., Staff R, Registered Nurse (RN) said sometimes [Resident #7] gets anxious and takes medication for it.During an interview and record review on 6/17/26 at 4:12 p.m. the Clinical Reimbursement Director (CRD) said discussions during care plan meetings, clinical meetings and orders are used to update residents' care plan. She said she does not know if Resident #7 has triggers or even would like to talk about it. The CRD reviewed Resident #7's current trauma informed care plan of care interventions and said no triggers are listed.Review of facility policy titled Care Plan -Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024, revealed the following:POLICY: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions.The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.The overall care plan should be oriented towards:1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situation, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions 2. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities 5. Comprehensive Plan of Carea. The care plan is developed by members of the IDT and the resident, resident's family, or representative, as appropriate, in conjunction with completion of the Admission, Annual, Significant Change in Assessment or other comprehensive assessment, and the associated care Area Assessments.b. The comprehensive care plan describes or includes:i. The services that are to be and goals that reflect the Resident's wishes, choices, and exercise of rights.ii. Any services that would normally be provided but not provided due to the residents' rights of rights, including the right to refuse treatment, and any alternative means or options to address the problem.iv. The needs, strengths, and preferences identified in the comprehensive resident assessment.v. Prevention of avoidable declines in functioning or functional levelsvi. Standards of current professional practicevii. Adequate information provided to make informed choices

Based on observations, record reviews, and interviews the facility failed to obtain laboratory testing for two residents (#22 and #44) out of two residents sampled for diagnostic testing; and failed to notify the physician for one resident (#22) out of one samples for a positive multidrug-resistant organism urine sample. Findings included: 1. An observation was made on 06/15/26 at 10:12 a.m. of Resident #22 lying atop bed in room. The resident was able to reposition to a sitting position without assistance. The observation of the back of toilet shared with this resident, resident roommate, and the room next door revealed two (2) empty laboratory specimen containers sitting on back of toilet. The containers were labeled for Resident #22; one was dated 6/9. Review of Resident #22's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to unspecified Alzheimer's disease, history of falling, and Type II Diabetes Mellitus without complications. Review of Resident #22's June 2026 Treatment Administration Record (TAR) revealed an order to obtain a urinalysis and culture/sensitivity to rule out (r/o) urinary tract infection one time only for 1 day, scheduled for and obtained 06/15 at 1:19 a.m. Review of Resident #22's stool culture results was conducted on 06/17/26 at 12:35 p.m. with Staff J, Licensed Practical Nurse (LPN). The staff member stated the results of laboratory results were not integrated with the facility's electronic record, having to access the vendors website for results. Staff J opened laboratory results for the resident and found urine culture and sensitivity results for the resident. The results showed the collection of a clean catch urine was completed on 06/14 at 3:00 p.m. and the vendor reported results on 06/16/26 at 7:48 p.m. (approximately 17 hours prior to the staff members review). The results showed antibiotic resistance organisms, Extended-Spectrum Beta-Lactamases (ESBLs), were detected. The urine contained 10,000 - 50,000 colony-forming unit (cfu)/milliliter (mL) of actinotignum schaalii and escherichia coli (e-coli). The staff member reported not being told by off-going nurse of the results and the resident required contact isolation. Review of Resident #22's progress notes revealed the physician was notified of urinalysis results on 06/17 at 1:44 p.m., one hour and nine minutes after Staff J and this writer reviewed the orders, and 18 hours after the vendor reported the results. The provider did order for the broad-spectrum antibiotic, Ertapenem to be administered intramuscularly for 10 days. An interview was conducted on 06/18/26 at 9:28 a.m. with the Director of Nursing (DON). The DON stated they follow a timely manner because you don't want to delay in service. The DON stated staff are to ask for physician orders if required to keep from going back to the hospital because they are a lot of things we can do in house. The DON described the laboratory process as the vendor comes in, draws the labs, and the facility gets the labs (results) back, we follow up with physician and get orders if needed. Residents have the right to refuse, we educate them, notify the physician (of refusal) and most of the time the physician says to try the next lab day. The DON reported the facility hasn't been doing (noting) refusals in the electronic record, we just put it for the next day. The DON stated a person with hypernatremia can become delirious, can dehydrate and can have cardiac issues. The DON reported lab results received should be followed up in a timely manner, within two (2) hours even if it's after hours. The DON reported hearing them talking about Resident #22, the lab was not reported, and (person with) ESBL should be on Contact precautions if its not contained, explaining containment meant if they had a closed system similar to a catheter, should be in a room by self if incontinent and walking around because there is no way to contain it. The DON stated the physician should have been notified (regarding Resident #22) and reported to the oncoming nurses. 2. An observation was made on 06/15/26 at 11:26 a.m. of Resident #44 with a visitor eating a meal brought by the visitor. The visitor reported the resident had a bout of hypernatremia recently. Review of Resident #44's April 2026 Medication Administration Record (MAR) showed the resident did receive Dextrose 5% intravenously (IV) from 4/9 to 4/12/26 due to hypernatremia. The resident's Treatment Administration Record (TAR) showed staff were to obtain daily basic metabolic panel (BMP) while on IV fluids every night shift, dated 04/10 - 04/14/26. The TAR showed the daily BMP was obtained one time on 04/13/26. Review of a physician note, dated 04/29/26 showed Resident #44 was slowly getting back to baseline. The Assessment/Plan (A/P) revealed hypernatremia - status post (s/p) intravenous fluids (IVF) and instructed staff to recheck labs. Review of Resident #44s MAR and TAR did not show an order had been obtained to recheck labs on 04/29 or 04/30/26. Review of the laboratory vendor's website showed staff had obtained daily BMP results on 04/11, 04/13, and 04/14/26. The order for a BMP on 04/12 showed no sample collection date and collection pending, no results. The review of laboratory results showed on 04/30/26 at 12:14 a.m. an order for a BMP, Complete Blood Count (CBC) and magnesium (MG). The review showed there was no collection date for 4/30/26 and the status was collection pending, no results. The facility did not provide laboratory results for 04/12 and/or 04/30/26 for the resident. Review of Resident #44's sodium results showed a reference level of 136-145, on 04/07 resident level was 145, 04/09: 148, 04/11: 147, 04/13: 146, and on 04/14: 144. Review of Resident #44's progress notes did not reveal the resident refused laboratory testing on 04/12 or 04/30/26. A lab/diagnostic note dated 04/12/26 at 11:07 a.m. showed the nurse had reported results to the physician and obtained orders to continue the dextrose 5% and recheck in the morning of 04/13. The progress notes showed notes were written by the Staff O, LPN on 04/29 at 5:58 a.m. and 04/30/26 at 5:55 a.m., Resident observed resting in bed throughout the night, with no behavioral concerns or care refusals noted. Remained calm, cooperative, and in no apparent distress. Upon morning assessment, resident was alert, oriented, and easily redirected. Morning medications were administered as scheduled and tolerated well, with no adverse reactions observed. The note showed on 04/30/26 the resident had not refused care and did not reveal the resident refused laboratory testing. Review of Resident #44's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified Alzheimer's disease, presence of automatic (implantable) cardiac defibrillator, essential hypertension, unspecified atrial fibrillation, and other cardiomyopathies. An interview was conducted on 6/17/26 at 12:19 p.m. with Staff O, Licensed Practical Nurse (LPN). The staff member reported being unable to find a note regarding why lab was not drawn, there had to be an order for it (reviewing vendors site). Staff O stated lab requests are placed on a log within the lab binder with the resident's face sheet and order. During an interview on 06/18/26 at 9:41 a.m. the Director of Nursing (DON) stated Resident #44's physician would normally tell the nurse if recommending something. The DON confirmed the resident had been treated for hypernatremia and had gotten normal saline IV fluids. The DON stated the labs on 04/29 should have been drawn, reported to the physician and if the resident refused both the spouse and physician would be notified. The DON stated the physician and spouse had not been notified labs were not drawn. The facility failed to provide a policy regarding laboratory testing.

Based on interviews and record reviews, the facility failed to ensure care for gastrostomy tubes was provided in accordance with professional standards for one (#2) of three residents sampled for gastrostomy tubes. Findings included: A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of intestinal obstruction. Resident #2 was discharged from the facility on 8/24/2024. A review of Resident #2's physician orders revealed the following orders: - An order dated 8/11/2024 indicating Resident #2's gastrostomy tube (GT) site may be left open to air if clean and no drainage and to monitor for skin integrity and changes every shift. - An order dated 8/14/2024 to evaluate for displacement of the GT every shift by observing for abdominal distension, nausea, vomiting, and pain. If displacement is suspected, clamp GT and call the physician. A review of Resident #2's Treatment Administration Record (TAR) for August 2024 revealed the following: - Monitoring of Resident #2's GT site for drainage, cleanliness, and skin integrity changes was not completed for the Day (7 AM to 3 PM) shift on 8/15, 8/16, 8/17, 8/19, 8/22, 8/23, or 8/24/2024 and was not completed on the Evening (3 PM to 11 PM) shift on 8/18/2024. - Evaluation of Resident #2's GT for displacement and observation of signs of abdominal distension, nausea, vomiting, and pain was not completed for the Day (7 AM to 3 PM) shift on 8/15, 8/16, 8/17, 8/19, 8/22, 8/23, or 8/24/2024 and was not completed on the Evening (3 PM to 11 PM) shift on 8/18/2024. An interview was conducted on 10/28/2024 at 3:37 PM with Staff A, Registered Nurse (RN) and Unit Manager (UM) and the facility's Director of Nursing (DON). The DON stated when a resident with a GT was admitted to the facility a set of batch orders were put into the resident's order set by the admitting nurse. Staff A, RN UM stated GT's were normally left open to air unless there was drainage present around the GT site. The DON stated if a resident with a GT had an order in place to assess the GT site every shift for drainage, the order should be signed off as directed in the physician order to signify the assessment was completed. If drainage was identified during the assessment, the nurse should notify the resident's physician and follow the physician orders. A follow up interview was conducted on 10/28/2024 at 4:35 PM with the DON. The DON reviewed the missing documentation in Resident #2's TAR related to monitoring the GT site for drainage and evaluation of the resident's GT every shift. The DON was not able to state why the orders were not signed off as completed in Resident #2's TAR but stated the resident's nurse might have interpreted the order differently and might have thought the order did not need to be signed off if the resident's GT site had no drainage that day. The DON stated it would not be acceptable for nursing staff to not sign off orders related to wound care or medication administration. A request for a policy related to the maintenance of gastrostomy tubes was made to the DON following the interview. The DON stated the facility did not have a policy related to the maintenance of gastrostomy tubes and staff were to follow the physician orders.

Based on observations, interviews, and record review the facility failed to provide a clean, sanitary, and homelike environment for residents on one unit (#300) out of three units in the facility. Findings included: An observation was conducted on 1/21/24 at 10:19 a.m. of room [ROOM NUMBER]. The observation revealed a three-drawer dresser inside the bathroom with a missing drawer and on the floor next to the dresser was 2 gray water basins sitting on the floor. The over-bed table of the room was rusty and uncleanable. The vinyl baseboard near the closet was missing and the wallboard was broken. The wall near the entrance door was broken behind the baseboard. An observation on 1/21/24 at 10:45 a.m., was made of room [ROOM NUMBER]. An open area of approximately 3/4 inch was noted on the side of the wall air conditioning unit. The area was open to the outside and could be seen while standing in the resident room. The closet door track was rusty and unclean. An over-the-bed table located in the room was rusty and uncleanable. The toilet in the bathroom shared by room [ROOM NUMBER] and 304 did not have a tank cover and a plastic cup was sitting on the handrail in the bathroom containing 3 disposable razors and water. During the observation of room [ROOM NUMBER] on 1/21/24 at 10:48 a.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM), stated the razors should not be left in the bathroom and the toilet without a cover should not have been left like that way. Staff A stopped the Maintenance Director in the hallway and the Maintenance Director reported not knowing about the toilet tank cover and the expectation was for staff to notify him of any concerns. Staff A provided a copy of the Concierge Program Rounds form. The form revealed the concierge was to note any environmental issues such as: room odor, closet doors, bedside table, nightstand, chair, cubical curtains, and call lights. The form revealed, If another issue is identified that is not on this list, please write it on the back of this page. Include the room number. An interview was conducted on 1/21/24 at 10:55 a.m. with Staff J, Certified Nursing Assistant (CNA). Staff J stated she had shaved the resident and was coming back for the razors observed in the bathroom shared by room [ROOM NUMBER] and 304. The staff member stated the toilet tank cover had been reported awhile ago. An observation was made on 1/21/24 at 11:07 a.m., of room [ROOM NUMBER]. The bed mattress was noted to have a disintegrated vinyl backing. The mattress was uncleanable. An interview was conducted with Staff K, Certified Nursing Assistant (CNA), on 1/21/24 at 11:12 a.m. The staff member stated the resident who had personal items in room [ROOM NUMBER] had been sent to the emergency room and had not been in the building since Saturday. On 1/22/24 at 12:00 p.m., the Maintenance Director and Staff D, Staffing Coordinator, were observed moving the bed, including the uncleanable mattress, from room [ROOM NUMBER] to room [ROOM NUMBER]. The Maintenance Director stated room [ROOM NUMBER] was going to be closed for the safety of the resident. Staff D stated the mattress should have been taken out of service before today or prior to when the resident who was in room [ROOM NUMBER] had been taken to the hospital. An observation on 1/21/24 at 12:39 p.m., revealed a three-drawer dresser in room [ROOM NUMBER] next to bed A with a drawer sitting on the floor and missing the top and bottom drawer. An observation of room [ROOM NUMBER] on 01/21/24 at 12:42 p.m., revealed a rusty over-the bed table and an uneven transition between the resident's room and bathroom. The room smelled of very strong urine. An observation on 1/21/24 at 1:15 p.m. of the bathroom shared by room [ROOM NUMBER] and 313 was missing the toilet paper bracket, one bracket was attached to the wall under the handrail. The toilet paper roll was sitting on the handrail. An observation of room [ROOM NUMBER] on 1/22/24 at 9:00 a.m. revealed a portion of vinyl baseboard missing revealing crumbling wallboard. The observation showed a portion of wall behind the baseboard was cracked. An interview was conducted on 1/24/24 at 12:00 p.m. with the Account Manager for Housekeeping/Laundry. She stated the facility had identified rusty overbed tables and staff were steaming them to clean. The Manager stated the 300 hall had been completed. A tour of the 300 hall was conducted on 1/24/24 at 11:59 a.m., with the Maintenance Director. The Maintenance Director reported being at the facility for 4 months and was the only person in the maintenance department. The tour included room [ROOM NUMBER]. The Director stated the gap between the wall and air conditioning unit should not be that way, the broken plaster in room [ROOM NUMBER] should be fixed, and the toilet paper holder in the bathroom of 312 and 313 had been fixed once before. The Director observed one of the rusty over bed tables and agreed it was not only rusty but dirty with an unknown substance. The Director confirmed the uneven transition between the floor in room [ROOM NUMBER] and the bathroom should be fixed. He reported removing the dresser in room [ROOM NUMBER] and confirmed it should have been removed prior to the observation on 1/21/24. Immediately following the tour of the 300 unit on 1/24/24, a request was made for a policy regarding the maintenance of the facility. The facility did not provide the policy by the completion of the survey. (Photographic evidence was obtained).

Based on interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four residents (#51, #236, #72, #115) out of six sampled residents, were revised for accuracy related to diagnoses. Findings included: 1) A review of Resident #51's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record showed diagnoses of unspecified Alzheimer's disease with an onset date of 8/3/21, unspecified dementia unspecified severity with other behavioral disturbance, mild single episode major depressive disorder, delusional disorders, and other insomnia. Review on 1/22/24 at 9:51 a.m., of Resident #51's Admission Record showed Alzheimer's disease was the primary diagnosis. Review of Resident #51's PASRR, dated 3/16/23, showed the resident had a mental illness (MI) of depressive disorder and did not reveal the resident's delusional disorder. The PASRR did not reveal the resident had a primary diagnosis of dementia or related neurocognitive disorder (Alzheimer's disease). Section II question 7 of the PASRR showed the resident had validating documentation to support the dementia or related neurocognitive disorder. The PASRR revealed the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual disability and a Level II was not required. On 1/22/24 at 4:20 p.m., the Social Service Director (SSD) reviewed Resident #51's diagnoses and PASRR. She confirmed it did not include all the resident's diagnoses and should be revised. 2) Review of Resident #236's Admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified Bipolar disorder, unspecified depression, and unspecified recurrent major depressive disorder. Review of Resident #236's PASRR, dated 1/17/24, did not show the resident had any mental illness (MI) or intellectual disability (ID) diagnoses and a Level II was not required. A request was made to the Nursing Home Administrator (NHA) on 1/22/24 at 2:30 p.m. for a copy of Resident #236's PASRR. During an interview on 1/22/24 at 4:11 p.m., the SSD stated a revision of Resident #236's PASRR was done on 1/22/24. She reported working on PASRR's for the last hour and a half. She stated she goes through new admissions on Mondays and fixes them (PASRR's) then if needed. The SSD reported usually PASRR's come into the facility a couple hours before the admission or come in with the new admission, and are reviewed during the morning meetings. On 1/22/24 at 5:45 p.m., the SSD provided a PASRR Level I submission, dated 1/22/24 at 3:48 p.m., and a document showing Resident #236's PASRR Level I was resubmitted at 4:43 p.m. on 1/22/24. 39438 3) Resident #72 was admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, unspecified psychosis not due to a substance or known physiological condition, other specified depressive episodes, and Bipolar disorder. Review of Resident #72's PASRR Level I Assessment, dated 02/21/23, revealed a qualifying diagnosis of Bipolar disorder and no PASRR Level II was required. Review of Resident #72's medical record revealed a new diagnosis of generalized anxiety disorders documented on 05/25/23 and the resident was not assessed for PASRR Level II. Section I Active Diagnosis of the significant change in status Minimum Data Set (MDS), dated [DATE], showed Resident #72 had the following psychiatric/mood disorders: anxiety disorder, depression, Bipolar disorder, and psychotic disorder. On 01/22/24 at 4:26 p.m., the Social Services Director (SSD) confirmed Resident #72's current diagnoses were not reflected on the PASRR Level I. She stated a PASRR Level II should have been submitted. 48823 4) A review of admission record, dated 08/11/2023, revealed Resident #115 was admitted on [DATE] with diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, adult failure to thrive, other symptoms and signs involving cognitive functioning and awareness, adjustment disorder with mixed disturbance of emotions and conduct, and dementia in other disease classified elsewhere severe with other behavioral disturbance. A review of Pre-Admission Screening and Resident Review (PASRR) dated 08/10/2023, revealed a documented history of secondary diagnosis related to neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a serious mental illness or intellectual disability. In section II: Other indications for PASRR screen decision-making, continued: Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? The response was yes - medical/functional history prior to onset. A review of Minimum Data Set (MDS) Quarterly None PPS Section C Cognition, dated 11/17/2023 revealed a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive deficit. A review of the medical record did not include a Level II PASRR determination. The facility did not provide a Level II PASRR determination. During an interview on 01/22/24 04:29 pm with the Director of Social Services (DSS) she stated the PASRR Level I for Resident #115, which indicated a Level II PASRR should have been completed was not uploaded into the medical record, and she did not have any additional records.

Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment for a qualifying mental health diagnosis for two residents (#6 and #97) of six residents sampled. Findings included: Review of the Admission Record showed Resident #6 was admitted on [DATE], and readmitted on [DATE], with diagnoses of dementia without behavioral disturbance, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, mood disorder, and other comorbidities. Review of Resident #6's PASRR Level I Assessment, dated 02/24/2023, showed a qualifying mental health diagnosis marked in section I A. for anxiety. Section II, (7) is marked yes for having validating documentation to support the dementia . and documentation should accompany the Level I PASRR screen . There is no evidence a Level II evaluation was submitted. During an interview on 01/22/2024 at 04:11 PM, the Social Service Director (SSD) confirmed responsibility for the completion and oversite of the PASRR process. The SSD stated the PASRR Level I for Resident #6 was inaccurate, and a new PASRR should be completed for an evaluation of a Level II PASRR. Review of the Admission Record showed Resident #97 was admitted on [DATE] with diagnoses of psychotic disorder with delusions, adjustment disorder, dementia, major depressive disorder, and other comorbidities. Review of Resident #97's PASRR Level I Assessment, dated 03/16/2023, showed a qualifying mental health diagnosis marked in section I A. for depressive disorder and other: psychotic disorder with delusions, adjustment disorder with mixed disturbance, unspecified behavioral and emotional disorders, currently receiving services for MI and receiving Lexapro, Seroquel. Section (7) is marked yes for having validating documentation to support the dementia . and documentation should accompany the Level I PASRR screen. There is no evidence a Level II PASRR evaluation was submitted. During an interview on 01/22/2024 at 04:11 PM, the Social Service Director (SSD) confirmed responsibility for the completion and oversite of the PASRR process. The SSD stated the PASRR Level I for Resident #97 was inaccurate, and a new PASRR should be completed for an evaluation of a Level II PASRR. Review of the facilities policy and procedures titled topic PASRR requirements Level I and Level II - Florida, with effective date February 2021 revealed the following: Policy: Pre-Admission Screening and Resident Review (PASRR) pre-admission screening for mental illness and intellectual disability is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payer source . Procedure: . 2. Social Services or Registered Nurse (RN) will review to determine if a Serious Mental Illness (SMI) and Intellectual Disability (ID) or both exist while reviewing the PASRR form. The existence of either, or both, conditions trigger the requirement for Level II review and will be provided to the appropriate state agencies by the Social Service Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident's record . PASRR Level II . 3. Level II PASRR must be completed if the below are listed but not limited to: .the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion, or diagnosis of, SMI, ID, or both .

Based on observations, interviews, and record review the facility failed to provide treatments and care in accordance with professional standards of practice as evidence by 1) failure to assess and treat a wound for one resident (#51) out of two sampled for skin conditions, 2) failure to document and treat a change in condition according to facility policy for one resident (#82) out of two residents sampled for change in condition, and 3) failure to maintain a midline intravenous catheter as ordered for one resident (#41) out of one sampled for intravenous access. Findings included: 1) On 1/21/24 at approximately 10:18 a.m., Resident #51 was observed sitting across from the nursing station of the secured unit with other residents. The observation showed a brown adhesive dressing on the left toe. The dressing appeared to be undated. On 1/21/24 at 10:22 a.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) placed blue non-slip socks on Resident #51. The staff member reported not knowing why the resident had a dressing on the left middle toe and would have to check but podiatry was in the building last week. Staff A removed the dressing and stated she was going to check (the area) later and confirmed the dressing was not dated. The observation revealed an area on the tip of the left middle toe with a scant amount of bright red drainage near the top of the toe nail. The staff member called the Director of Nursing (DON) informing her that the dressing was not one used by the facility and reported the DON confirmed podiatry had been in the facility last week. The staff member reviewed the resident's clinical record located on the unit and stated the last documentation from the podiatry provider was from November 2023. Review of Resident #51's Admission Record showed the resident was originally admitted on [DATE] with a diagnosis of unspecified Diabetes Mellitus due to underlying condition with Diabetic neuropathy. The record included additional diagnoses of Type 2 Diabetes Mellitus without complications (onset 8/9/22), unspecified Alzheimer's disease, Essential (primary) hypertension, and adult failure to thrive. A review of Resident #51's Podiatry notes, dated 1/17/24, revealed mycotic nails of right foot, have approximately 2 millimeter (mm) thickness of sublingual debris, and the mycotic nails are thickened, yellowed, causing pain. The note showed there was hyperkaratotic tyloma at the medial plantar left hallux with pain. The provider documented the removal of the hyperkaratotic lesion and all affected nails were debrided to reduce length and thickness, which included nails 1-5 on bilateral feet by the use of manual nippers and an electric grinder. The note showed there were no complications and the patient tolerated well. A review of Resident #51's Medication and Treatment Records for January 2024 did not reveal an order for a dressing to be applied to the resident's left toe. The Medication Administration Record showed the resident received oral and injectable medications for Diabetes Mellitus. A review of Resident #51's progress notes, dated 1/17/24 at 6:34 a.m. to 1/21/24 at 10:52 a.m. (30 minutes after observation with Staff A), did not show staff had noted the area or a dressing had been applied on the resident's left middle toe. The Skin/Wound note, dated 1/21/24 at 10:52 a.m., showed Staff A had noted a dressing to the resident's 3rd digit on left foot and when the dressing had been removed The toe nail had blood tinge at the top. A review of Resident #51's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's Brief Interview of Mental Status score was 3/15, indicative of severe cognition impairment. The MDS did showed the resident had a diagnosis of Diabetes Mellitus. A review of the Certified Nursing Assistant (CNA) plan of care (Kardex) for Resident #51 showed staff were to Observe extremities for changes in extremities, to monitor for major and minor bleeding, and Report changes in discoloration area, pain location/type frequency/intensity, and Skin Observation. A review of the CNA documentation of Skin Observation from 12/26/23 to 1/22/24, showed the aides identified twice (1/8/24 and 1/20/24) discoloration. The resident's progress notes did not show the discoloration on 1/20/24 had been documented or if the nurse had assessed the area of discoloration. A review of Resident #51's Skin Check Weekly and as needed (PRN) evaluation, showed on 1/17/24 at 2:27 p.m., the resident had No New Areas of Skin Impairment. The Skin Check Weekly and PRN evaluation, dated 1/22/24 at 11:07 a.m., did not identify any new areas of skin impairment. A review of Resident #51's care plan revealed the following focuses and interventions: - Has an Activities of Daily Living (ADL) self care performance deficit and requires one-person assist for personal hygiene and dressing. - At risk of developing a wound. The interventions showed staff were to review with the resident/family/caregivers causes of skin breakdown. - Has Diabetes Mellitus as evidence by Type 2 Diabetes. The interventions showed staff were to observe/document/report to physician as needed the signs/symptoms of hypoglycemia and hyperglycemia. - Is on Aspirin. The interventions revealed staff were to provide a safe environment, assist with transfers/mobility as needed, and to protect extremities from trauma to lessen the possibility of bleeding/injury. The staff were to observe extremities for changes in extremities. A review of the policy entitled Weekly and PRN Skin Check, effective October 2021, revealed the following: Weekly and prn Skin Check was used to document skin condition throughout the Resident/Patient's stay in the facility and the nurse would conduct a weekly skin check and/or a prn check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. If a new area of impairment is identified during or between scheduled checks, it soul be documented on the weekly and prn skin check and the appropriate skin grid initiated depending on the cause. The procedure showed If a new area is identified the appropriate skin grid should be initiated within 8 hours. A review of the document titled The Centers of Disease Control and Prevention (CDC) guidance Diabetes and Your Feet, last reviewed April 11, 2023, showed the following: If you have diabetes, here's a way to keep standing on your own feet: check them every day - even if they feel fine - and see your doctor if you have a cut or blister that won't heal. The guidance revealed there was a lot to manage with diabetes: checking blood sugar, eating healthy, being active, taking medications, doctor appointments and With all that, your feet might be the last thing on your mind. But daily care is one of the best ways to prevent foot complications. The CDC showed tips on how to prevent feet complications which included: check your feet every day for cuts, redness, swelling, sores, blisters, corns, calluses, or any other change to the skin or nails, wash your feet every day, dry completely, and apply lotion to the top and bottom, and never go barefoot - always wear shoes and socks or slippers to avoid injury. Most people with diabetes can prevent serious foot complications. Regular care at home and going to all doctor's appointments are your best bet for preventing foot problems (and stopping small problems from becoming serious ones). 2) A review of Resident #82's Admission Record showed the resident was admitted on [DATE]. The record revealed the resident's diagnoses included anoxic brain damage not elsewhere classified, unspecified intractable epilepsy with status epilepticus, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, cachexia, unspecified protein-calorie malnutrition, and adult failure to thrive. A review of Resident #82's progress notes, dated 1/19/24, revealed the first note was a Hospital Transfer Evaluation Summary, documented at 5:57 a.m., which showed the resident was being transferred to an acute care facility To get G-Tube replaced. The note included the following vital signs and the date they were obtained: Blood pressure (BP): 105/64, obtained 11/4/23 at 7:15 a.m. Pulse: 86, obtained 11/4/23 at 7:14 a.m. Respiration Rate: 17, obtained 11/4/23 at 7:13 a.m. Temperature: 97.1, obtained 11/4/23 at 7:14 a.m. Oxygen (O2) saturation: 98.0%, obtained 2/23/23 at 2:30 p.m. Pain: 0, obtained 1/19/24 at 1:47 a.m. The document showed the resident's blood pressure, pulse, respiration rate, and temperature were obtained 10 weeks and 6 days prior the transfer on 1/19/24, the oxygen saturation was obtained 11 months prior to the transfer, and the pain level was obtained 4 hours prior to the unplanned transfer. The note revealed the resident's guardian was notified of the transfer but was not aware of the clinical situation and did not show the primary care physician was notified of the transfer. A review of the Hospital Transfer Evaluation Summary did not reveal why the gastrostomy tube (G-tube) required replacement, and the record did not include any other progress note completed at the time of the evaluation revealing the reason for the replacement (clogged, dislodged, broken), the condition of the resident or the status of the G-Tube insertion site. A review of the progress note, dated 1/19/24 at 6:20 a.m., revealed Transfer was told to be canceled due to new policy on G-tube insertion. Resident remained in the facility for care. The note did not show the physician or guardian was notified the transfer was canceled due to a new policy. A review of Resident #82's progress notes on 1/19/24 revealed the following in their entirety: - 1/19/24 at 8:47 a.m., Resident sent to emergency room to replace G-tube. Doctor and patient manager (name) notified. - 1/19/24 at 10:14 a.m., Resident send hospital. - 1/19/24 at 2:08 p.m., Resident just returned from (acute care facility) emergency room (ER) via stretcher by transport services. GTube placement was verified via contrast and contrast appeared in the correct space in stomach and she was sent back here. An interview and observation of Resident #82 was conducted on 1/23/24 at 1:49 p.m. with Staff C, Registered Nurse (RN). The staff member cleaned the GTube site during the observation. Resident #82 remained non-verbal throughout the treatment and followed staff and writer with eyes. The site was clean, no redness, and without drainage. Staff C stated the resident often pulls at the tube and during the 3-11 shift the tube had came out. The staff member reported the resident had a Foley (urine catheter) in the area to keep it open and it wasn't bleeding. Staff C stated she had replaced the G-tube but wasn't able to hear the swish of air and there was no residual so Resident #82 was sent out to the hospital at approximately 7:30 a.m. The staff member retracted the tube came out on 3-11 shift stating it had come out on 11-7 shift. Staff G, LPN stated Staff F, DON had informed the 11-7 shift nurse per policy the facility nurses' could put a G-tube in. Staff G stated the G-tube was inserted, didn't get any residual and some liquid came from the side of it, resident was sent to hospital, and the hospital was able to verify placement. An interview was conducted with Staff F, DON on 1/23/24 at 2:45 p.m. The DON reported receiving a (telephone) call (on 1/19/24) from the night shift supervisor informing her Resident #82 was going to be sent out (to hospital) but Staff M, Interim DON, had informed the supervisor nurses could put it (G-tube) back in within 2 hours. The DON reported the resident's nurse had already called Emergency Medical Services (EMS) to transfer however it was the policy to call the DON or Regional Nurse before calling EMS, if non-emergent staff were to call the DON and talk with them to prevent a return to the hospital. Staff F stated the supervisor had informed her that Staff M had informed her nurses could put in a G-tube as long as there was no trauma and no pain. Staff F reported the supervisor had put a Foley in the area until Staff F could get to the facility and educate staff on the procedure. Staff F reported educating and completing competencies with the supervisor, Staff C, and Staff G (on the reinsertion of GTube). The DON reported she had taken the Foley out and inserted the G-tube while Staff C, Staff G, and the supervisor were at bedside watching her do it. Staff F reported receiving orders from the Nurse Practitioner (NP) to put in the G-tube and within 30 minutes the NP was in the building. The staff member stated Resident #82 was sent out for verification of placement. During an interview on 1/23/24 at 2:45 p.m., the DON (Staff F) reviewed the progress notes for Resident #82 and stated it should be documented on whether or not the G-tube was out and there should be documentation regarding the resident status, where the G-tube was found, the procedure for putting a Foley into the site, and the status of the site. An interview was conducted with the NP on 1/23/24 at 3:13 p.m. The NP reported giving the order to insert a Foley to keep the area open. During an interview on 1/23/24 at 3:56 p.m. with Staff F, DON and Staff M, Interim DON (IDON), Staff F provided the competency for Staff C, dated 1/19/24, regarding Emergency Enteral (G-tube) Tubing Changes. Staff F stated the facility does not have a policy regarding the reinsertion of PEG/G-tube, they have the competency for staff. The staff members provided a copy of a physician order from the NP dated 1/19/24 for GTube Reinsertion. An interview was conducted with Staff F, DON on 1/24/24 at 9:28 a.m. The DON said the old DON had notified her recently of the policy allowing staff to reinsert a G-tube and she had not had a chance to educate the night shift or review the competency. The staff member stated the electronic record automatically puts the last documented vitals signs into the forms, but staff could press new and freehand the (new) vital signs. Staff F stated the expectation was to document the residents current vital signs for a transfer/change in condition. A review of the Emergency Enteral (G-tube) Tubing Changes competency, undated, showed the nurse would Call MD [Medical Doctor], obtain order for replacement if tube tract was greater than 6 weeks healed and only a GTube after trained and with MD order and If the tube tract was less than 6 weeks placed, insert largest size Foley or urinary catheter tubing and obtain order to send resident to hospital non-emergent. The competency did not educate staff on whether or not documentation was required pre or post procedure. 48823 3) On 01/21/2024 at 9:00 a.m. Resident #41 was observed in bed. His Midline Intravenous (IV) site dressing on right upper arm inner aspect was dated 01/12/2024. (Photographic Evidence Provided). On 01/22/2024 at 9:30 a.m. Resident #41 was observed resting in bed, his midline intravenous (IV) dressing site was dated 01/21/2024 and was detached from the inner aspect of the right upper arm leaving the insertion site uncovered. the resident was unable to provide information regarding the IV. On 01/23/24 11:19 a.m. Resident #41 was observed resting in resident in bed, resting. The IV dressing remains loose and detached from the inner aspect of the right upper arm. During an interview on 1/23/2024 at 11:25 a.m. with the DON she confirmed the dressing was not intact, she stated the dressing should not be like that. A review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses to include hemiplegia/hemiparesis following a cerebral infarction affecting left non-dominant side, urinary tract infection and obstructive uropathy. The Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of physician orders, dated 12/8/2023 revealed the following: 1. Admit to skilled nursing 2. Change IV dressing every seven days as well as whenever necessary (PRN) soiling and/or dislodgement on evening shift ordered 01/16/2024. 3. Document IV site appearance every shift U=unremarkable, R=redress, S=swollen, W=warm to touch, D=drainage, report any changes to physician, ordered 01/16/2024 4. Use 10 milliliter (ml) syringe with all flushes for IV every shift for flushes for seven days ordered 01/12/2024. 5. IV was inserted on 01/12/2024 6. Ceftazidime injection one gram IV every eight hours for seven days ordered 01/12/2024 for urinary tract infection and discontinue IV on 01/23/2024 A review of the daily skilled note evaluation, dated 01/16/2024 - 01/21/2024, for IV revealed - midline IV with dressing intact documented on all five days. A review of progress notes for 01/01/2024 - 01/24/2024 revealed documentation for midline IV dressing intact. A review of the Medication Administration Record (MAR) documentation for 01/01/2024 - 01/23/2025 revealed: 1. IV dressing changed on 01/16/2024 2. Ceftazidime one gram IV administered 01/13/2024 - 01/20/2024 every eight hours with missed dose on 01/14/2024 at 1400 (2:00 p.m.) 3. IV appearance documented 01/16/2024 night shift - 01/23/2024 day shift revealed U=unremarkable 4. IV flushes documented 01/12/2024 night shift - 01/19/2024 evening shift 5. IV inserted on 01/12/2024 at 1948 (9:48 p.m.) 6. Change IV whenever needed (PRN) dates available on [DATE]/16/2024 - 01/23/2024 revealed no documentation. A review of the policy titled Infusion Therapy Procedure, dated 08/2016, Dressing change for Vascular access Devices revealed the following: Purpose: To prevent local and systemic infection related to the IV catheter. Procedure: 5. A dressing is changed immediately if: a. The dressing is non-occlusive or soiled. b. There is drainage or moisture under the dressing. c. There are signs of irritation or inflammation at the insertion site. 9. Suggested charting/documentation a. Site assessment b. preparation used c. Type of dressing d. Catheter securement (integrity of sutures, other devices) e. Resident response to procedure.

Based on observations, interviews, and record review, the facility failed to ensure hydration was provided to residents residing on the secured unit in a sanitary manner during two lunch meals (1/21/24 and 1/22/24) out of two lunch meal observed. Findings included: On 1/21/24 at 12:43 p.m. a meal cart was delivered to the 300-hall. On 1/21/24 at 12:48 p.m., Staff K, CNA, removed a tray of pre-filled uncovered cups of three different colored liquids from the second shelf of a three shelf cart and placed the tray onto the top of the meal cart. The staff member stated the cups were pre-filled on the unit. On 1/21/24 at 12:55 p.m. an observation was made of the meal cart on 300-hall moving from between rooms [ROOM NUMBERS] to outside of room [ROOM NUMBER] with the same above mentioned pre-filled uncovered cups on top. Staff were observed removing trays from the cart then placing the pre-filled cups on the tray before delivering to resident rooms. (Photographic evidence was obtained). On 1/22/24 at 12:35 p.m. an observation was made of pre-filled uncovered cups containing a pink liquid sitting on a table top in the far corner of the 300-hall dining room. Staff L, Certified Nursing Assistant (CNA) removed the tray of pre-filled cups from the dining room and placed it on the bottom shelf of a 3-shelf rolling cart then moved the cart to the area between rooms [ROOM NUMBERS]. The second shelf of the cart held pre-filled cups of a light tan liquid. The observation showed staff's shoes were approximately 4 inches from the cups on the bottom shelf and multiple staff were removing the cups, placing them on the meal trays, then delivering to the residents in their rooms. An interview was conducted on 1/24/24 at 10:05 a.m., with the Registered Dietitian (RD). The RD stated drinks were covered when coming from kitchen, and stated she did not know what the facility policy was on the subject. An interview was conducted on 1/24/24 at 10:30 a.m. with the Certified Dietary Manager (CDM). The CDM stated empty cups were on trays from the kitchen and containers of juice, tea, and coffee were sent to the units. She stated the CNA's are allowed to serve 2 doorways from the cart without the cups being covered. A review of photographic evidence was conducted with the CDM and she stated it was not appropriate to have the pre-filled drinks on the tray and staff should not be pre-pouring drinks in that manner. She reviewed the photo of the tray of drinks on the top of the meal cart and stated, Oh no they shouldn't be doing that. A review of the policy entitled Dining Service, effective January 2021, revealed the following: Purpose: To provide Residents a pleasurable dining experience by offering nutritious, attractive meals served in a courteous and dignified manner. Procedure: The following items were placed on each room tray: other beverage cup (if requested), milk glass, condiments, and food items according to menu. The room service procedure revealed all glassware on tray was to be inverted as space allowed and to provide pitchers of liquid on a separate cart for staff to pour, and to cover and/or wrap all items on tray with a lid or plastic wrap prior to the tray leaving the kitchen to protect food and fluids from contamination during transportation.

Based on observations, interviews, and record review, the facility failed to provide one resident (#109) with dignity and respect related to bowel and bladder needs out of one resident sampled for dignity. Findings included: On 01/22/24 at 9:30 a.m. an interview was conducted with Resident #109. The resident stated he had been in the facility for about two months for rehabilitation after suffering a fractured hip. He stated he had limited weight bearing abilities. He stated he used a urinal due to his limited abilities. Two urinals were observed at the bedside. Resident #109 appeared embarrassed to admit he has to have assistance with toileting. On 01/23/2024 at 9:29 a.m. Resident #109 was observed lying in bed. The resident stated he was waiting for a care giver to provide assistance following a bowel movement. Resident #109 stated his brief was dirty because he cannot use the bed pan. He stated the bed pans are too small for him to use and he was embarrassed when staff have to clean his bottom after having a bowel movement in his brief. A review of the Admission Record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, unsteadiness on feet, and other abnormalities of gait and mobility. A review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the following: --Section H: Bowel and Bladder--No urinary toileting program trial initiated, urinary incontinence response three-always incontinent, bowel incontinent response three- always incontinent with no bowel program and no identification of bowel pattern. --Section GG:toileting resident requires substantial/maximal assistance. --Section C: Cognitive patterns-Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A review of the 3008 transfer form revealed Resident #109 had a left hip fracture, open reduction internal fixation (ORIF) while in hospital, transfer for rehabilitation, no infection issues on transfer, no skin pressure issues on transfer, no history of falls during hospital stay, Resident #109 was continent of urine and stool, can ambulate with assistance, partial weight bearing on left leg, full weight bearing on right leg, and used a wheelchair for ambulation. A review of Physician Orders, dated 11/27/2023, revealed physical therapy, occupational therapy five times per week for four weeks, admit to skilled unit, monitor left hip surgical site for signs and symptoms of infection, and restorative nursing as needed. A review of the comprehensive care plan, dated 12/3/2023, revealed the following: Focus area for activities of daily living related to toileting. Resident is incontinent of bowel and bladder and is not a candidate for a toileting program. Intervention for toileting was an assist of one and to use bedpan/urinal. A review the progress notes for Resident #109 revealed the following: --Progress Note 12/18/2023 resident uses a manual wheelchair for ambulation, and resident is incontinent. --Progress note of 12/25/2023 resident is continent of his bladder and urine is clear yellow. --Progress notes from 12/26/23 to 1/21/2024 resident is continent of bladder and bowel. During an interview on 01/23/2024 at 11:00 a.m. with Resident #109 he stated he can tell when he has to use the urinal and when he has to have a bowel movement. He stated he only had one episode of bowel incontinence since his admission and it was on the first night in the facility. He stated the bedpan he was given was too small and no one had discussed his bowel and bladder concerns with him. During an interview on 01/23/24 at 11:37 a.m. Staff C, Registered Nurse (RN) stated the Resident #109 had not been incontinent that she was aware of, and the resident uses the urinal and a brief for bowel movements. During an interview on 01/23/24 at 11:44 a.m. Staff D, Staffing Coordinator/Central Supply stated there are two sizes of bed pans available, a small one and a larger one. She stated she was not aware of a policy on sizing the appropriate one for a resident. During an interview on 01/23/2024 at 1:30 p.m. the Interim Director of Nursing (IDON) stated the facility did not have a policy regarding use of bedpans and sizing for a resident.

Based on observations, interviews, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one resident (#82) of five residents sampled for comprehensive care plans. Findings included: A review of Resident #82's Admission Record showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record showed diagnoses not limited to not elsewhere classified anoxic brain damage, unspecified intractable epilepsy with status epilepticus, and adult failure to thrive. A review of Resident #82's medical record showed a completed Hospital Transfer Form dated 1/19/24. The form showed the reason for transfer was the Replacement of G-tube. The form revealed the resident was sent to an acute care hospital on 1/19/24. On 1/23/24 at 1:49 p.m. Resident #82 was observed lying in bed, bilateral legs were contracted at bilateral knees, hands held near the head region, and the resident remained nonverbal but followed this writer and Staff C, Registered Nurse (RN) with eyes without moving head. Staff C reported the resident had been sent out on Monday or maybe Friday to have the Percutaneous Endoscopic Gastrostomy (PEG)/G-tube replaced. An observation was conducted with Staff C of cleaning the resident's g-tube. The area around the insertion point was open to air, clean, without redness or drainage. The staff member reported the resident often pulls the g-tube out. An interview was conducted with the Nurse Practitioner (NP) on 1/23/24 at 2:29 p.m. The NP reported Resident #82 frequently pulls out the G-tube. The NP stated sometimes they will find the balloon at skin level, and often (staff) finds the G-tube lying beside the resident in bed. A review of Resident #82's Comprehensive Care Plan revealed the resident had been noted With the following behaviors: will place parts of her gown in her mouth and is resistive to removal. Will grab and pull at clothing, sheets, (and) g-tube. A review of the item changes related to the behavioral care plan showed, Will grab and pull at clothing, sheets, (and) g-tube was added on 1/24/24. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 1/24/24 at 9:17 a.m. The Coordinator stated the nursing team had come to her in the morning (1/24/24) and informed her the resident had been seen, as she had also witnessed, of Resident #82 pulling at G-tube and gown, so the care plan had been revised to add G-tube to the behaviors, This morning. The Coordinator stated that if it (pulling at G-tube) was a behavior it would be discussed in morning meeting and she would be told to add it to the care plan or nursing could have added it. An additional interview was conducted with the Coordinator on 1/24/24 at 10:00 a.m., she confirmed she had Added this line today then read Will grab and pull at clothing, sheets, g-tube. During an interview on 1/24/24 at 9:28 a.m., Staff F, Director of Nursing (DON) stated the care plan should have included the behavior of Resident #82 to pull on G-tube. The staff member reported feeling the resident was constantly being sent to the hospital (for G-tube replacement). A review of the policy entitled Care Plan Interdisciplinary Plan of Care from Interim to Meeting, revised 9/23, showed the following: The facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Daily updates to care plans are added by a member of the interdisciplinary team (IDT) at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. The comprehensive care plan describes or includes adequate information provided to make informed choices regarding treatment. The care plan meeting include nursing which will Review current diagnosis, tests, or procedures, treatments (wounds, rashes, etcetera (etc.). discuss current interventions and risk of further breakdown if applicable, recent or pending referrals, Physician Consults, Restorative, medications, pain management plan, behavioral management plan, special needs, risk of falls and current interventions, and recent falls or other issues (informed consents, isolation, etc.).

Based on observations, interviews and record review the facility failed to provide activities of daily living (ADL) for one resident (#18) out of four residents sampled for ADL care related to personal hygiene and bathing. Findings included: 1) An observation on 01/21/24 at 11:05 AM revealed Resident #18 lying in his bed. The resident was able to verbalize his name and introduce himself. Closer observation of the resident revealed the resident was noted with stubbly white facial hair and long fingernails. The resident was asked if he preferred facial hair and he stated, No, I need a shave, you gonna shave me? An observation of Resident #18 on 01/22/24 at 10:07 AM revealed the resident resting in bed. The resident was noted with his face still unshaven with gray stubbly hair covering his face and chin. The resident's fingernails were noted to still be elongated on his bilateral hands. The resident reported he was still waiting to be shaved and does not like the hair on his face and would like for his nails to be shorter. A review of the significant change of status Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assist of one person for personal hygiene. A review of the Comprehensive Care Plan related to ADL's with a start date of 3/28/13 revealed the resident Has an ADL Self Care Performance Deficit as evidence by: Cannot complete ADL tasks independently and requires individualized interventions because weakness, bilateral BKA [below knee amputation], fatigue. Review of the interventions revealed they included: Resident is total dependent upon staff for ADL's. An observation of Resident #18 on 01/22/24 at 02:56 PM revealed the resident was still unshaved and his fingernails were still elongated. The resident reported he would like to be shaved and his fingernails cut. The resident asked if he could get shaved now. An interview on 01/22/24 at 03:00 PM with Staff A, Licensed Practical Nurse (LPN) revealed she was assigned to the carts for the 100 hall. She reported typically staff are made aware of resident ADL needs from the Kardex system. She reported Certified Nursing Assistant (CNA)'s are responsible for shaving the resident as needed or requested. She reported for nail care if the resident is diabetic the nurse will cut the fingernails. She stated if the resident is not diabetic the CNA should make the activities department aware and activities would cut the fingernails. An interview on 01/22/24 at 03:03 PM with Staff B, CNA revealed she is assigned to the middle 100 hall. She reported she would know if a resident needed to be shaved and if nail care is needed by visualizing the resident daily during care. An observation and interview on 01/22/24 at 03:05 PM of Resident #18, with Staff F, DON, Staff A, LPN, and Staff B, CNA present, the resident reported he would like to be shaved now and would also like his nails cut. The resident asked if he could get the razor so he could shave himself. Staff F, DON encouraged the resident to allow the staff to shave him and the resident was agreeable. Staff F, DON and Staff A, LPN confirmed the resident was in need of a shave and his fingernails were long and needed to be cut. At this time, policies related to ADL's, grooming, nailcare, and personal care were requested of Staff F, DON. On 01/23/24 at 09:57 AM an interview with Staff F, DON revealed the facility does not have a policy on ADL's but they follow the CNA job description. The CNA job description was requested. A policy on grooming was also requested at this time. On 01/23/24 at 01:30 PM with Staff M, Interim DON revealed the facility does not have a policy on grooming and the CNA job description would be provided. The facility did not provide the CNA job description as requested by the end of the survey.

Based on observations, interviews, and record review the facility failed to provide care and services according to physician's orders related to catheter care for one resident (Resident #36) out of the two sampled residents. Findings included: On 01/21/24 at 10:10 a.m., the resident was observed in bed in his room. There was a foul urine smell in the room. Resident #36 was verbal but was not able to answer questions appropriately during an attempt to interview him. A review of the Admission Record for Resident #36 showed he was admitted on [DATE] with diagnosis of personal history of urinary tract infection and neuromuscular dysfunction of bladder. Section C: Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating severe cognitive impairment. Section H: Bladder and Bowel showed the resident had an indwelling catheter. The Order Summary Report with active orders as of 11/01/23 revealed the following: Suprapubic Catheter: Drain suprapubic catheter bag every shift as needed and record amount (07/15/23). A review of the Treatment Administration Record (TAR) for 11/01/23-11/30/23, 12/01/23-12/31/23, and 01/01/24-01/31/23 showed the amount of urine output was not recorded every shift per physician order. A review of the comprehensive care plan revealed the following: Focus: Indwelling/other catheter-Resident #36 uses a supra pubic urinary catheter with risk for infection and/or complications related to obstructive uropathy. (initiated on 12/16/22). Interventions included: observe/document/report to doctor for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 01/23/24 at 1:15 p.m. Staff C, Registered Nurse (RN), stated she provided catheter care and sometimes he was not compliant with care. She confirmed she was not documenting the output for urine per the physician's orders. On 1/23/24 at 1:20 p.m., the Director of Nursing (DON) stated she expects there to be documentation recorded for the urine output per the physician's orders. She stated on the order there should have been a place for nurses to document the output on the TAR. The DON confirmed there was no documentation for the output on the TAR.

Based on observations, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's attending physician, and review of clinical and medical records, policies and procedures it was determined that the facility failed to ensure the residents were free from harm and neglect. On [DATE] the facility failed to render assistance to Resident #1, a food seeking resident, with an order for [REDACTED].#1 was found lying on the floor by a visitor. Two staff members were made aware he was on the floor and did not render care and services creating a delay in emergency care. The resident had been left unsupervised with access to the food product he was allergic to, a peanut butter and jelly sandwich. Resident #1 was known to have a [DEVICE] (gastrostomy feeding tube) and to be on nothing by mouth as of [DATE]. The resident's code status was Full Code. The lack of timely care and services included Cardiopulmonary Resuscitation (CPR). The resident was transferred and admitted to an acute care hospital where he received emergency care and was transferred to the intensive care unit on a ventilator according to the hospital records. This resulted in the findings of Immediate Jeopardy, occurring on [DATE] and removed at 6:00 p.m. on [DATE] with the scope and severity reduced to a D Findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed a re-admission with an ADMISSION RECORD document that included the following information: admitted : [DATE]. Initial admitted : [DATE], Allergies Peanut. The 5-day admission Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 99 meaning the resident was rarely / never understood. The resident required limited assistance of one for bed mobility, transfers, and toileting. He was independent for walking in his room and required assistance of one to move on and off the unit. He was not steady without staff for moving and walking. He was dependent on staff for eating. The Speech Therapy (ST) evaluation on [DATE] showed the resident was inappropriate for therapy at this time. The resident was previously on ST caseload and made no gains due to poor participation and inability to follow directions. Recommend a swallow study for further assessment to determine safest diet for him at this time. The staff was educated on resident's NPO status and aspiration risk. Resident was on tube feeding and NPO. Signed by Staff J Speech Therapist (ST) Review of the Swallow Study performed at the hospital on [DATE] showed patient NPO with PEG (percutaneous endoscopic gastrostomy) tube for nutrition/hydration at SNF (Skilled Nursing Facility). Patient impulsive, grabbing for food. SNF requesting assessment to determine potential for resuming oral intake. Assessment and Findings included The patient was confused and unable to follow one step commands. Patient presents with severe oral and severe pharyngeal dysphagia. at risk of aspiration with hard solids due to oral deficits. At risk of aspiration with thin liquids due to penetration and aspiration given by teaspoon. Weak cough. High risk of aspiration due to decreased airway protection and majority of material remaining within pyriform sinuses from decreased laryngeal elevation. Recommendations: NPO with alternative means of nutrition/hydration/medication. The ST evaluation on [DATE] showed the resident was NPO with recurrent aspiration pneumonias. The resident was unable to follow commands due to developmental delays and was not willing to participate in therapy. He can be reassessed at a later date if the resident demonstrates improvement. Signed by Staff J Speech Therapist (ST) Record review of the medical record showed under the allergy section that Resident #1 had a moderately severe allergy to peanuts, creating a reaction of [MEDICATION NAME] and a sub-reaction of laryngeal [MEDICAL CONDITION]. Review of Resident #1's order summary report dated [DATE] (print date), page 1 of 7 showed Admission: [DATE], Allergies: Peanut, an active physician order [REDACTED]. Total volume to be infused is 1500 ML/24 hours, start date [DATE]. Record review of the Comprehensive Nutrition Assessments dated [DATE] and [DATE] showed the resident had a physician order [REDACTED]. Record review of Order Appointing Successor Guardian Advocate dated (MONTH) 16, 2000, showed Resident #1 had a guardian due to developmental disabilities. Review of Resident #1's order summary report dated [DATE] (print date), page 3 of 7 showed an order for [REDACTED]. Record review of the Physician and Nursing Progress Notes showed Resident #1 was able to get out of bed into his wheelchair and self-propel throughout the hallways. On [DATE] at 8:21 a.m. the physician progress notes [REDACTED]. The resident required assistance and supervision with Activities of Daily Living (ADLs). On [DATE] at 23:34 (11:34 p.m.) the physician progress notes [REDACTED]. He was not able to follow commands with repeated max cues. The therapist reported that resident does not follow command. On [DATE] at 13:42 or 1:42 p.m., the nursing progress note showed, the resident does stay in the dining room the majority of the shift and attempted to obtain food off the tables. He was given redirection and distraction which was effective for short periods of time. On [DATE] at 2:49 a.m. the nursing progress note showed, the physician was in visiting the resident and made aware of the resident eating from another resident's food tray. The physician was made aware and requested for the resident to be evaluated for Occupational Therapy. The Change in Condition form in the resident's record, dated [DATE], at 21:10 or 9:10 p.m. showed Resident #1 was unresponsive and was allergic to peanuts. The resident was in the dining room at approximately 2100 (9:00 p.m.) when a supervising staff member identified a change in condition. The staff member notified the licensed nurse who attended the resident immediately. Pulse and respirations were not present during the head-to-toe evaluation. A Code Blue was announced. The chart and Emergency Cart were brought by the attending staff. The Emergency Medical System (EMS) was activated via the 911 system and the Resident Representative was contacted and the physician was notified. The EMS arrived and transported the resident to the local Emergency Department. The resident was admitted to the hospital. The Resident Representative was called on [DATE] at 2120 (9:20 p.m.). The Physician was notified on [DATE] at 21:10 (9:10 p.m.). Signed by the Director of Nursing (DON) on [DATE]. There was no focus area or care plan put into place related to food allergy or food seeking behaviors for Resident #1. 2. Record review of the Code Blue Worksheet dated [DATE] showed the following: Location: dining room Unconscious Resident identified at 8:43 p.m. by visitor Emergency Cart arrival: 8:45 p.m. Chart Arrival: 8:44 p.m. CPR initiated if indicated: 8:47 p.m. 911 called: 8;50 p.m. EMS arrival: 9:06 p.m. Physician Notified: 10;45 p.m. Physician Name: attending physician / ARNP Family Notified: called with no answer Resident sent to: hospital Employees present: Staff E, RN; Staff G, LPN; Staff A, LPN DON notified: 9:03 p.m. Administrator notified: 9:19 p.m. Supervisor called nurse at 9:18 p.m. The person column providing the care to the resident was blank 3. Record review of the EMS report summary dated [DATE] reflected the following: Call Received: 21:03 (9:03 p.m.) Dispatched: 21:04 (9:04 p.m.) En Route: 21:05 (9:05 p.m.) On Scene: 21:09 (9:09 p.m.) Patient Contact: 21:10 (9:10 p.m.) Left Scene: 21:29 (9:29 p.m.) At destination (hospital): 21:35 (9:35 p.m.) Transfer of Care: 21:37 (9:37 p.m.) Resident was unresponsive. Patient was eating a peanut butter and jelly sandwich and started to choke on it. Staff members stated he was allergic to it. Staff members stated he went unresponsive, had no pulse and CPR was initiated by staff. The patient was placed on a monitor and was asystole. The first dose of epi was given. The patient's mouth was looked into, and he had peanut butter still in his airway. Laryngoscope and forceps were used to try to get some of the peanut butter out. His mouth was also suctioned, was only able to get some out. Second round of epi was given. The patient went into ventricular fibrillation and then shock. CPR was continued. The patient was given the third dose of epi. The patient was placed on the stretcher and placed in the ambulance. The patient was given the fourth dose of epi. The patient was placed on an epi drip, en route. 4. Review of the emergency room Report dated [DATE] revealed the patient was admitted with [MEDICAL CONDITION] after food was found in his throat. He was allergic to peanuts and was eating a peanut butter and jelly sandwich. He apparently choked on a peanut butter sandwich at the nursing home. He was down for 20 minutes and they attempted to remove peanut butter stuck in the patient's throat en route. He was given [MEDICATION NAME] times 4 doses. The patient was subsequently intubated on arrival to the emergency room . The pupils were unequal with left pupillary deficit. The patient was not regaining neurologic improvement despite no sedation. He had return of spontaneous circulation. The patient was critically ill. 5. During an interview on [DATE] at 2:34 p.m., Staff J, Speech Therapist (ST) stated that Resident #1 was originally admitted with a peg tube and had an order for [REDACTED]. He was on a puree diet and thickened liquids possibly while living there. The group home knew he was aspirating, and they were still feeding him. So, they performed a modified [MEDICATION NAME] swallow study and found that he was aspirating all items. He was unable to follow directions or clear his throat with coughing. She stated that she tried to work with him, but he was resistant to care and could not follow commands. He would also become aggressive. He pulled out his [DEVICE] and was sent to the hospital and then returned. ST did not pick him up after the hospitalization s because he would not do anything. The only thing to do was to do more testing. He coughed on his own sputum and with the use of lemon [MEDICATION NAME] swabs. Staff J, ST, stated that If someone was allergic to nuts, you do not bring nuts into the area at all, not anywhere near them. She stated that they don't keep snacks in the therapy room because of food allergies and food intolerances. She evaluates the residents for dysphagia in the dining room or in their rooms because of that. She stated that she did not know Resident #1 had a peanut allergy because she did not work with him with food, because he was NPO. She stated that she does not know if he choked, he may have had a few particles go down, but he had a food allergy. An allergic reaction causes the throat to close and the resident cannot breathe. She felt it was an allergic reaction to the peanut butter allergy versus choking on the sandwich. During an interview on [DATE] at 10:00 a.m. with Resident #1's attending physician stated that he knew Resident #1. On [DATE] he ate something he was allergic to. He was placed in the facility due to having a peg tube, nothing by mouth and being confused. He was redirectable. He was chronically ill. He was food seeking a lot. He was made aware that the resident was admitted to the hospital. The resident found a sandwich and ate it. The unfortunate thing was he was allergic to peanuts and he ate a peanut butter and jelly sandwich. He was not aware how he got it because he was not there. He was told another resident had asked for 2 sandwiches and they gave Resident #1 one of them. He coded and had to be intubated and admitted to the hospital. The incident occurred he believes because of both choking on a sandwich and him being allergic to peanuts and having an allergic reaction. The EMS was called and treated him with [MEDICATION NAME] for an allergic reaction to the peanut butter. He stated that he needed redirecting the whole time. He stated that he felt the facility watched him closely. He stated that the resident grabbed a meal tray and ate off it while in the hospital. He stated that he felt it was unavoidable. When asked if he felt they could have supervised him more closely, or placed him on one-on-one supervision, he stated that he was told that the nurses kept him close by. They could not restrain him. He was kept in the dining room which was a big area, someone was watching him. He stated that he was not sure how to prevent. He stated that as of Monday, [DATE], the resident was still in the hospital intubated. During an interview on ,[DATE] at 3:07 p.m. the Registered Dietician stated that today was her first day at the facility. She stated that typically the peanut allergy, was the number one food allergy, she found; that and seafood. She stated that the facility should want everyone to be aware of the allergies. Some people may have minor reactions, and some may need to go to the hospital. During a phone interview on [DATE] at 12:11 p.m. Staff I, LPN Weekend supervisor stated that she was the LPN night supervisor on the evening of [DATE]. She stated that she had just taken a resident to the secure unit and was making her rounds in the facility. She had left Station II and was coming up the hallway toward Station I and the dining room when she saw Staff H, aide. Staff H, aide was she was looking for Resident #1's nurse, because the resident was on the dining room floor. Staff I, stated, Staff A was just walking down the hallway, no excitement. I have no earthly idea why Staff A was not rendering aid to a resident that may have been injured, incapacitated, lying on the floor. Staff I, LPN stated that she was walking toward the dining room and Staff A, LPN was walking away from the resident on the floor. She stated that it was her expectation that a nurse would attend to a resident on the floor, you would expect that she would care for him. She stated that she rushed to the dining room and the way he was positioned on his side he looked in need, he was turning a dusky color. She stated that she felt his back and felt no breathing and felt for a radial pulse. She did not feel anything. She ran around the nursing desk and grabbed chart, to check code status. He was a full code. By that time, Staff H, aide was at the nursing desk and a couple more staff members. She announced she needed the crash cart and called a Code Blue in the dining room. When asked she stated she did not know exactly who initiated CPR. There were a couple of nurses and aides present. She does not remember if it was Staff E, RN or Staff G, LPN. One of them started CPR. When asked if she recalled seeing Staff A, LPN anywhere, she stated she did not remember. She stated while they were performing CPR, she was on the phone with 911. She stated that she saw Staff H, aide first, and then she saw Staff A, LPN asking Staff H, aide about Resident #1's nurse. She stated that when she went to the resident was there was not any other staff member in the dining room, she was the first person to get to him. She stated that Resident #1 had to be redirected several times because of his food seeking behaviors. He would sit in the dining room and be up in his wheelchair around the facility. He was not confined to a specific area. She stated that his peanut allergy was in his chart. She added it when he was initially admitted . She was not aware of him eating a sandwich at the beginning of the code. She stated that she thought he saw someone eating and just got it and ate it. She stated that she was not aware of Resident #1's nurse being out on her break. When the staff goes out on break, they are supposed to sign out and let the other nurse on the floor know they are on break. The partner on the station was responsible for those residents while the other nurse was on break. She stated that she would expect to see documentation in the chart related to the Code Blue including a timeline and all should be completed by the end of shift. She stated that she did not document in the chart. During an interview on [DATE] at 5:10 p.m. Staff H, Certified Nursing Assistant (CNA) stated that she did not have Resident #1 that night, she had the middle rooms, ,[DATE]. She stated that he was not supposed to eat because he was NPO. The resident would be put to bed, but he did not stay there much. He would be in the wheelchair and would get up and walk. He mostly self-propelled himself in the wheelchair, independently. Resident #1 would try to beg for food, put his hand out. We would have to redirect him, he would beg from the residents from table to table. He could self-propel himself into the dining room. We never kept him from going into the dining room. He never had one-on-one supervision. He was independent to the building. She stated that she did not know he was allergic to anything. She stated that she went to dinner at 7:57 p.m. and was back at 8:20 p.m. She was on her hallway and checking on her residents. She was going back toward Station II (away from the dining room), toward the activity room and saw Resident #1 at Station II at about 8:40 p.m. She was in room [ROOM NUMBER], a good way from the dining room, talking to the ladies and was walking to the end of the hallway just checking on the residents. She stated that she did not know where the aide that was assigned to Resident #1 was, maybe at dinner. Staff A, LPN came past the dining room coming toward her and asked if she had Resident #1 that he was on the dining room floor. Staff H stated that Staff A, LPN passed Resident #1 to come and get her to tell her he was on the floor. She stated that it was odd, that Staff A, LPN did not call for a Rapid Response or Code Blue instead of coming to get her. Staff H, CNA stated that between 8:50 p.m. and 8:55 p.m. she saw Resident #1 on the floor. She stated that one of the nurses from Station I was at room [ROOM NUMBER], Staff A, LPN. Staff H, CNA stated that she went to check on the resident. She stated that she saw him out of his chair on the floor and could see his face on the floor. She stated she saw Staff I, LPN Weekend Supervisor coming down the hallway from Station II toward the dining room and she called Staff I, LPN called for Resident #1 on the floor. Staff I, LPN called a Code Blue. She stated that no one called for Rapid Response. She stated that when Staff I, LPN called Code Blue the crash cart was brought over. The Code Blue was called and Staff E, RN started doing CPR. The EMS came in and started doing their job too. She stated that she saw a piece of a sandwich beside him. She does not know how he found the sandwich or how he got it. She stated that she does not remember if there were any other residents in the dining room or not. Staff H, CNA stated that Staff A, LPN went back to her medication cart while Staff I, LPN was calling a Code Blue. Staff C, LPN which was the resident's nurse was at lunch at the time. She stated that she did not know who was in charge of Staff C, LPN's residents while she was at lunch. The aides tell the nurses they are going to lunch but not necessarily another aide. She stated that she liked Resident #1. Apparently, he was still hungry and wanted something to eat. During an interview on [DATE] at 12:15 p.m. Staff A, LPN, stated that a Resident #1 had an order for [REDACTED]. If they are allergic to anything you have watch for their allergy. Yes, she was working, on ,[DATE] when Resident #1 had his event. Her assignment was the 101 to 115 rooms. She knew he had a [DEVICE] and the resident would sometimes walk with and without his wheelchair. He was NPO. He was allergic to peanuts. She was not sure if she knew he had a peanut allergy before the event, because she did not usually work with him. She stated that on that day she was in the hallway passing meds at the end of the hallway, when an aide called out to her. The aide was standing close to the nursing station about to the open the door for an unknown visitor to go out. She stated that the visitor had told the aide that somebody was on the floor. When the aide called out to her about Resident #1 being on the floor, she was between rooms [ROOM NUMBERS]. She locked her medication cart and went to the area where the aide was standing near the nursing station. She stated as she was walking down the hall toward the dining room the aide let the visitor out the door. She stated that she came down the hallway toward the hallway juncture in front of the nursing station, and saw Staff I, LPN coming down from the other hallway. She stated that we entered the dining room at the same time. Staff I, LPN checked Resident #1 for a pulse and she checked the book / chart for the code status. She stated that she yelled that the resident was a full code. She stated that he was lying on the floor on his side with the wheelchair behind him. She stated that she did not remember if there was anyone else in the dining room or not. She stated that she did not speak with anyone else. She stated that the event occurred between 8:30 p.m. and 9:00 p.m., she thought, she does not remember exactly the time. She stated that she went and got the crash cart and took it to the dining room. Staff E, RN started CPR while someone called the EMS. She stated that the resident was not discolored. She stated that she did not do any assessment of the resident, Staff I, LPN did it. She stated that she was checking the blood pressure, oxygen saturation and pulse. She stated that she does not remember who was performing the respirations with the ambu bag, but someone was. She stated that they have a Code Blue Worksheet, and someone was filling it out. She stated that she did not chart in the computer on the resident or event. She stated that It was not for her to document, we do not do that here. Staff I, LPN was doing something like that. Staff I, LPN was doing the progress note and following up with the family. Staff C, LPN was assigned to the resident that night. She was on break at the time of the event. She stated that she did not remember if Staff C, LPN told her she was on break or not, she remembers hearing it. She stated that we are responsible for the other nurse's residents while they are on break. If an aide walks by a room and finds a resident on the floor, what do you expect the aide to do? She stated that the aide can call for a nurse, if nobody was close by, the aide can call for Rapid Response. Rapid Response was for an emergency, everyone will come. She stated that she did not talk to Staff H, CNA at all that evening. She stated that she knew Staff H, CNA was on the floor that day but did not talk to her. Record review of the statement of Staff B, Certified Nursing Assistant (CNA) dated [DATE] showed that she saw Resident #1 around 7 p.m. and did not see him again until a visitor called her and showed her that Resident #1 was on the floor. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that on interview with Staff B, CNA, she had stated that the visitor was trying to get out of the building, and the visitor found Staff B, to let her out of the building. Staff B told the DON and the NHA that she found the resident maybe a little after 9 p.m. on the dining room floor and had summoned the Staff A, LPN. She told Staff A, LPN that the visitor had reported Resident #1 was on the floor. Staff B, aide, stated that she could see the resident on the floor and went to get help. A follow-up interview by Staff U, Regional RN with Staff B, aide, showed a visitor was leaving and told Staff B she saw him lying there on the floor in the dining room. Staff B ran for the nurse down 100 hallway. Staff B went to the dining room, Staff B went to finish taking care of the resident she was caring for. During an interview on [DATE] at 3:29 p.m. Staff E, Registered Nurse (RN), stated that she was working on the night of [DATE]. She stated that she had worked with Resident #1 and was familiar with him. The facility knew what he needed and what he had (peanut allergy). He had a [DEVICE] and was not supposed to take anything by mouth. She stated that she saw him try to take and ask for food. She stated that you would tell him he cannot have food. He understood what we were saying to him. He may be hungry, and we would give him his [DEVICE] feeding. He pointed to food. He could walk and roam the building. He could self-propel his wheelchair and could stand up. She stated that she was never his direct nurse. He would follow through on your directions, but he would try it again, i.e. standing. He had an allergy to some food, but not medication. I think he was allergic to peanut butter. She stated that she found out he was allergic to peanut butter on the day the EMS came because they asked if he had any allergies. She stated that we can see the allergies on the computer. The EMS asked if he was allergic, because there was a peanut butter sandwich next to him. She stated that she was doing the CPR compressions. There was a lot of staff around. She stated that she was on break in the breakroom on the phone and heard the Code Blue overhead at 8:48 p.m. She stated that the crash cart was there. Resident #1 was in the dining room and there was sandwich debris on the floor. A Station 1 nurse was there. Staff E, RN stated that she checked the vitals and started CPR. She did not know if another nurse had already started CPR prior to her or not. She stated that the nurses are the only staff to do CPR. We are supposed to document what we do and what we saw. She stated that she did a progress note in the chart. She stated that the Code Blue Worksheet was supposed to be done also. She stated that the EMS came in and the EMS guy relieved her. The EMS did suction him and took things out of the resident's mouth. The automatic compression machine was applied. EMS did ask if he had any allergies. The nurse he had that night said, yes, he had a peanut allergy. When the nurse told them, he was allergic to peanuts, they gave him a shot of something in the IV. She stated that she did not know what it was. When they put him on the stretcher she went back to her floor. During an interview on [DATE] at 4:07 p.m. Staff C, Licensed Practical Nurse (LPN) stated that she was familiar with Resident #1. She stated that Resident #1 would try to get food many times. He was cognitively impaired. He would go to the dining room while others were eating. We would get in front of him and put him by the medication cart until the other residents finished eating. He was independent in his wheelchair and was impaired cognitively. We did not want him to grab things / food and put it in his mouth, because he was NPO. She stated that she was aware he had an allergy to peanuts and peanut butter. She stated as a nurse we are to provide a safe environment, related to an allergy, we would normally keep him in sight, and ask the staff to keep an eye on him. He would like to go to food. When we saw him near the food, we would move him away. She stated that she would take the responsibility to bring him to the medication cart while the aides were serving the meal trays or were in the dining room, when food was present. She stated that she was on her break on the evening it happened. She was the nurse for him that evening. She stated that Staff A, LPN was on Station 1 with her that night. She stated that she did not clock out for her break and had to do a missed punch form. She left the building at 8:45 p.m. on break and went to get something to eat. She was called to come back by the evening supervisor at 9:18 p.m. and she got back at 9:20 p.m. When she got back, she saw that there was many paramedics and police officers there. Resident #1 was on a stretcher and being transported to the hospital. She did not do any documentation, the other staff told her they were going to do the documentation from the Director of Nursing (DON). Staff C stated that she did not do a progress note, or any other documentation. Staff C stated that she did not participate in the Code Blue. Before the incident, the snacks were kept in front of the nursing station on an open cart. That night dietary had put the snack cart in front of the nursing station, Staff C stated that she put it behind the nursing station before she left to go on break. At that time, she left Resident #1 in the hallway, not right near the snack cart. The only person present was an aide, Staff D, Certified Nursing Assistant (CNA) washing her hands in the dining room area. If a resident was being non-compliant and reaching for food other than what they are supposed to have, they need to be moved. She stated that she moved Resident #1 to the first dining room table before she left. She stated that there were no other residents or staff in the dining room. We put them there so they can be observed when someone was passing by. She stated that we do not know how Resident #1 got the sandwich. It was documented prior that he was trying to eat. She stated that when she got back, she thought he had a [MEDICAL CONDITION] that night. Review Staff C, LPN had multiple written statements that were reviewed with the DON and the NH[NAME] On [DATE] at 10:54 p.m. I was on my break, when the supervisor called and told me that Resident #1 coded and I needed to come in. When I arrived, I saw him on the stretcher. A second statement dated [DATE] at 3:37 p.m. showed about 16:30 (4:30 p.m.) I noticed Resident #1 was eating food from other resident's tray in the dining room. There was no evidence of choking or respiratory distress. I, the nurse had to redirect the resident from the dining room. Then the resident continued to wheel himself back and forth throughout the building. At 8:45 p.m. I left for a break and received a phone call from the supervisor stating the resident had coded and she needed to come in. When I arrived, I saw him on the stretcher with the EMS was performing CPR. Before I left for my break, I parked the resident in the dining room. A third statement dated [DATE] showed at 8:30 p.m. the snack cart was left in front of the nursing station and he was observed at the nursing station grabbing at things on the snack cart and another resident was by him at this time. Resident #8 asked for 2 sandwiches. I gave them to her. At 8:30 p.m. she put the snack cart behind nursing station. At 8:45 p.m. the resident was at the table closest to the hallway. The Resident with the sandwiches was outside the dining room in the hallway rolling back and forth. At 8:45 p.m. I left for break and told nurse Staff A, LPN and Staff D,CN[NAME] prior to going on break, there was an aide washing her hands. During an interview on [DATE] at 6:04 p.m., Staff F, LPN, stated that she did know Resident #1, she had him as a resident. He needed constant monitoring because he was a wanderer. He was mentally impaired, and he did not grasp that he was only supposed to eat through his tube and was always seeking food in the dining room. He was familiar with everyone eating and he knew where the food was at. She stated that she saw him eat once, while the aides were cleaning up the meal trays. Another resident had given him a tray to eat. We removed him and removed the food. We spoke to the resident

Based on observations, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's attending physician, and review of clinical and medical records, policies and procedures it was determined that the facility failed to conduct a complete and comprehensive investigation for Resident #1 who was found lying on the floor by a visitor. Resident #1 had a physician order [REDACTED]. The resident was left unsupervised and had access to the food product he was allergic to being a peanut butter and jelly sandwich. The lack of timely care and services rendered included Cardiopulmonary Resuscitation (CPR). He was transferred and admitted to an acute care hospital where he received emergency care and was transferred to the intensive care unit on a ventilator according to the hospital records. This resulted in the findings of Immediate Jeopardy, occurring on [DATE] and removed at 6:00 p.m. on [DATE] with the scope and severity reduced to a D Findings included: 1. Record review of the facility's policy, Abuse Prevention Program dated (MONTH) 2019 revealed the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, and mistreatment and misappropriation of resident's property. Procedure: The Administrator, DON (Director of Nurses) and Risk Management Specialist are also ultimately responsible for the following: Implementation, Ongoing monitoring, Investigation, Reporting and Tracking and Trending. Investigation: An Event Report is initiated. Nursing Home Administrator (NHA) or designee is notified and, in collaboration with Risk Management Specialist, will initiate and conclude complete and thorough investigation within the specified time-frame. 2. Record Review of the Event Analysis Worksheet, dated [DATE] by, the Regional Risk Manager (RM) Consultant found, the signature had no date, showed the Administrator (NHA) was notified on [DATE], and the Risk Manager Specialist was notified on [DATE]. The event happened at 9 p.m. in the dining room. The Immediate corrective actions initiated by staff: Resident #1 noted to be unresponsive. An observation was completed by a nurse. The chart check revealed he was a full code. 911 was activated and CPR was initiated. The listing of persons with knowledge/information included: Staff C, LPN and Staff I, LPN. A clear description of the event: Resident was unresponsive, chart revealed he was a full code, CPR was initiated, a call was activated EMT was on scene. The resident had what appeared to be bread next to him. The Root Cause of event: the resident with NPO status and appeared to have bread. The resident had a [DIAGNOSES REDACTED]. Additional interventions / actions: the resident was admitted to the hospital. Care plan updated, no. Kardex updated, no; Nurses notes document incident, assessment, interventions, and effectiveness? No. If no, what corrective actions have been taken? This area was blank. Reporting to Law enforcement on ,[DATE]; Suspected crime: no; Abuse hotline notification on [DATE]; Federal immediate on [DATE]; Federal 5-day on [DATE] and State adverse (15) was blank. During an interview on [DATE] at 5:14 p.m. the NHA and the DON stated the Regional RM Consultant reviewed all of the employee statements and chart. The NHA and the DON stated that they were trying to find out who was where. They stated they could have done better by putting the pieces together better. When asked where Staff A, LPN was during this, they stated that they did not have a written timeline. The NHA stated that she had contacted EMS and received, verbally, the following times: 911 was called 21:04 or 9:04 p.m. and arrived at 9:09 p.m. and the resident contact was at 9:10 p.m. and they left the scene at 9:29 p.m. and arrived at the hospital at 9:35 p.m. An interview occurred on [DATE] at 3:56 p.m., with the NHA, the Regional RM Consultant, the DON, and Staff U, Regional RN. The NHA stated she had been here since (MONTH) 2019. She stated that she received training when she was hired related to performing an investigation including abuse, neglect and exploitation, as well as reporting. She felt she can identify things and know what was going on. The Regional RM stated she had been in RM for about 9 years and a regional position since (MONTH) 2019 and at this facility since September. The RM stated that she had some training in RM which included misappropriation, how to investigate, abuse, neglect, federal and adverse reporting, and the responsibilities as a consultant. Staff U, Regional RN, stated that she had formal RM training. The DON stated that she had been educated by the facility on abuse and neglect, reporting with identifying and the importance of root cause and implementation. They produced a timeline at this time. The Surveyors stated they had requested a time line on [DATE] and the DON and the NHA had stated one had not been done. The Regional RM stated it was in the event folder. The surveyors reviewed that folder completely and a timeline had not been there. They stated that the investigation was performed by the DON, the Interdisciplinary Team (DT), the NHA and the Regional RM. The investigation was left up to the risk team. The NHA and the DON took statements and the Regional RN started educating on what they thought was the problem. Staff U, RN stated that they met as a team to identify the issues surrounding this case. They reviewed the statements from the staff. The team of staff who investigated included the NHA, the DON, Staff U, RM, and the MDS consultant, and another Risk Management consultant as well as the Regional VP. This was the core team right here. We had interviews, got statements, and had team meetings. We reviewed the statements and identified areas we could improve upon. Staff U, RN stated that they had suspended somebody today due to an allegation of neglect, that began on Tuesday, [DATE], at around 5:00 p.m. and that there was a potential concern for neglectful practice. They stated that they first reported to the Protective Services Agency on [DATE] at 5 or 5:15 p.m. due to the police coming in for their investigation of the event on ,[DATE]. They were asking if he was on the secure unit or not. They were also asking supervision questions. Before the police officer exited, he told facility staff there was a Protective Services agency investigation. They were asked again about the lack of the Code Blue sheet being filled out, that it only had times and no names. They stated that they had not had any in-services on documentation, on clocking in and out, on the type of communication to report and report when leaving and who was responsible for the residents when they were on break. During an interview on [DATE] at 1:00 p.m., the DON stated that the event on [DATE] was perceived as not being an adverse event at the time of the incident. That was why they did a Federal 1-day and 5-day report. After it was brought up about the possible neglect for possibly not providing care timely, we decided we may need to do an adverse report. During an interview on [DATE] at 1:49 p.m. Staff U, Regional RN, stated that the staff had called her regarding the incident on [DATE]. She came to the facility to assist. She stated that she sat at the time clock accepting the statements that night from the staff before they left to go home. She got the notification they were doing CPR on a full code resident. She reviewed the statement of Staff B, CN[NAME] She asked the aide to clarify her statement and the aide stated that the visitor was leaving, but, needed the code to get out the door. The visitor saw Resident #1 lying on the floor. Staff B, aide was doing care on a resident and the visitor stuck her head in the door and stated the resident was on the floor. Staff B stated that the nurse was a couple of doors down and she ran and got the nurse. Staff U, RN stated that she did not know who the nurse was. Staff B told her that the nurse went to the dining room. The statement was vague, so Staff U, RN stated that she wanted to get more specifics. She stated that the Risk Team was going to follow-up with the staff for more details, not her. The aide stated that she got the nurse and left to go back to the resident she was caring for, at the time. Staff U stated that she was not aware if the nurse started CPR or not. She was not involved with the continuing investigation. She stated that she was acting in the role of Staff Development since the facility employee had left. The Surveyor asked if any education was provided regarding Code Blue education. Staff U, RN stated that we did a global plan. She stated, we did not identify a CPR issue in this case. She stated that the nurse, from her understanding, assessed the resident and found him pulseless and started CPR. She was not aware of which nurse was involved. She stated she stepped out of the Risk Manager role into the education role. 3. Resident #1 was admitted to the facility on [DATE] for the following [DIAGNOSES REDACTED]. Record review of the 5-day admission Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 99 or was rarely / never understood. The resident required limited assistance of one for bed mobility, transfers, and toileting. He was independent for walking in his room and required assistance of one to move on and off the unit. He was not steady without staff for moving and walking He was dependent on the facility staff for eating. Record review of Order Appointing Successor Guardian Advocate dated (MONTH) 16, 2000, showed Resident #1 had a guardian due to developmental disabilities. Review of the Swallow Study performed at the hospital on [DATE] showed patient NPO with PEG (percutaneous endoscopic gastrostomy) tube for nutrition/hydration at SNF (Skilled Nursing Facility). Patient impulsive, grabbing for food. SNF requesting assessment to determine potential for resuming oral intake. Assessment and Findings included The patient was confused and unable to follow one step commands. Patient presents with severe oral and severe pharyngeal dysphagia. at risk of aspiration with hard solids due to oral deficits. At risk of aspiration with thin liquids due to penetration and aspiration given by teaspoon. Weak cough. High risk of aspiration due to decreased airway protection and majority of material remaining within pyriform sinuses from decreased laryngeal elevation. Recommendations: NPO with alternative means of nutrition/hydration/medication. Record review of the medical record showed under the allergy section that Resident #1 had a moderately severe allergy to peanuts, creating a reaction of [MEDICATION NAME] and a sub-reaction of laryngeal [MEDICAL CONDITION]. Record review of physician orders [REDACTED]. The resident is code status was Full Code. Record review of the Physician and Nursing Progress Notes reflected Resident #1 was able to get out of bed into his wheelchair and self-propels throughout the hallways. On [DATE] at 8:21 a.m. the physician progress notes [REDACTED]. The resident required assistance and supervision with Activities of Daily Living (ADLs). The resident had a peanut allergy. On [DATE] at 23:34 (11:34 p.m.) the physician progress notes [REDACTED]. He was not able to follow commands with repeated max cues. Therapist reports that resident does not follow command. On [DATE] at 13:42 or 1:42 p.m., the nursing progress note showed, the resident does stay in the dining room the majority of the shift and attempted to obtain food off the tables. He was given redirection and distraction which was effective for short periods of time. The Change in Condition dated [DATE] at 21:10 or 9:10 p.m. reflected Resident #1 was unresponsive and was allergic to peanuts. The resident was in the dining room at approximately 2100 (9:00 p.m.) when a supervising staff member identified a change in condition. The staff member notified the licensed nurse who attended the resident immediately. Pulse and respirations were not present during the head-to-toe evaluation. A Code Blue was announced. The chart and Emergency Cart were brought by the attending staff. The Emergency Medical System (EMS) was activated via the 911 system and the Resident Representative was contacted and the physician was notified. The EMS arrived and transported the resident to the local Emergency Department. The resident was admitted to the hospital. The Resident Representative was called on [DATE] at 2120 (9:20 p.m.). The Physician was notified on [DATE] at 21:10 (9:10 p.m.). Signed by the Director of Nursing (DON) on [DATE] Record review of the Code Blue Worksheet dated [DATE] showed the following: Location: dining room Unconscious Resident identified at 8:43 p.m. by visitor Emergency Cart arrival: 8:45 p.m. Chart Arrival: 8:44 p.m. CPR initiated if indicated: 8:47 p.m. 911 called: 8;50 p.m. EMS arrival: 9:06 p.m. Physician Notified: 10;45 p.m. Physician Name: attending physician / ARNP Family Notified: called with no answer Resident sent to: hospital Employees present: Staff E, RN; Staff G, LPN; Staff A, LPN DON notified: 9:03 p.m. Administrator notified: 9:19 p.m. Supervisor called nurse at 9:18 p.m. The person column was blank providing the care to the resident was blank 4. Record review of the EMS report summary dated [DATE] showed the following: Call Received: 21:03 (9:03 p.m.) Dispatched: 21:04 (9:04 p.m.) En Route: 21:05 (9:05 p.m.) On Scene: 21:09 (9:09 p.m.) Patient Contact: 21:10 (9:10 p.m.) Left Scene: 21:29 (9:29 p.m.) At destination (hospital): 21:35 (9:35 p.m.) Transfer of Care: 21:37 (9:37 p.m.) Resident was unresponsive. Patient was eating a peanut butter and jelly sandwich and started to choke on it. Staff members stated he was allergic to it. Staff members stated he went unresponsive, had no pulse and CPR was initiated by staff. The patient was placed on a monitor and was asystole. The first dose of epi was given. The patient's mouth was looked into, and he had peanut butter still in his airway. Laryngoscope and forceps were used to try to get some of the peanut butter out. His mouth was also suctioned, was only able to get some out. Second round of epi was given. The patient went into ventricular fibrillation and then shock. CPR was continued. The patient was given the third dose of epi. The patient was placed on the stretcher and placed in the ambulance. The patient was given the fourth dose of epi. The patient was placed on an epi drip, en route. 5. Review of the emergency room Report dated [DATE] revealed the patient was admitted with [MEDICAL CONDITION] after food was found in his throat. He was allergic to peanuts and was eating a peanut butter and jelly sandwich. He apparently choked on a peanut butter sandwich at the nursing home. He was down for 20 minutes and they attempted to remove peanut butter stuck in the patient's throat en route. He was given [MEDICATION NAME] times 4 doses. The patient was subsequently intubated on arrival to the emergency room . The pupils were unequal with left pupillary deficit. The patient was not regaining neurologic improvement despite no sedation. He had return of spontaneous circulation. The patient was critically ill. 6. During an interview on [DATE] at 10:00 a.m., Resident #1's attending physician stated that he knew Resident #1. On [DATE] he ate something he was allergic to. He was placed in the facility due to having a peg tube, nothing by mouth and being confused. He was redirectable. He was chronically ill. He was food seeking a lot. He was made aware that the resident was admitted to the hospital. The resident found a sandwich and ate it. The unfortunate thing was he was allergic to peanuts and he ate a peanut butter and jelly sandwich. He was not aware how he got it because he was not there. He was told another resident had asked for 2 sandwiches and they gave Resident #1 one of them. He coded and had to be intubated and admitted to the hospital. The incident occurred, he believed, because of both choking on a sandwich and him being allergic to peanuts and having an allergic reaction. The EMS was called and treated him with [MEDICATION NAME] for an allergic reaction to the peanut butter. He stated that he needed redirecting the whole time. He stated that he felt the facility watched him closely. He stated that the resident grabbed a meal tray and ate off it while in the hospital. He stated that he felt it was unavoidable. When asked if he felt they could have supervised him more closely, or placed him on one-on-one supervision, he stated that he was told that the nurses kept him close by. They could not restrain him. He was kept in the dining room which was a big area, someone was watching him. He stated that he was not sure how to prevent. He stated that as of Monday, [DATE], he was still in the hospital intubated. During a phone interview on [DATE] at 12:11 p.m. Staff I, LPN Weekend supervisor stated that she was the LPN night supervisor on the evening of [DATE]. She stated that she had just taken a resident to the secure unit and was making her rounds in the facility. She had left Station II and was coming up the hallway toward Station I and the dining room when she saw Staff H, aide. Staff H, aide was looking for Resident #1's nurse, because the resident was on the dining room floor. Staff I, stated, Staff A was just walking down the hallway, no excitement. I have no earthly idea why Staff A was not rendering aid to a resident that may have been injured, incapacitated, lying on the floor. Staff I, LPN stated that she was walking toward the dining room and Staff A, LPN was walking away from the resident on the floor. She stated that it was her expectation that a nurse would attend to a resident on the floor, you would expect that she would care for him. She stated that she rushed to the dining room and the way he was positioned on his side he looked in need, he was turning a dusky color. She stated that she felt his back and felt no breathing and felt for a radial pulse. She did not feel anything. She ran around the nursing desk and grabbed chart, to check code status. He was a full code. By that time, Staff H, aide was at the nursing desk and a couple more staff members. She announced she needed the crash cart and called a Code Blue in the dining room. When asked she stated she did not know exactly who initiated CPR. There were a couple of nurses and aides present. She does not remember if it was Staff E, RN or Staff G, LPN. One of them started CPR. When asked if she recalled seeing Staff A, LPN anywhere, she stated she did not remember. She stated while they were performing CPR, she was on the phone with 911. She stated that she saw Staff H, aide first, and then she saw Staff A, LPN asking Staff H, aide about Resident #1's nurse. She stated that when she went to the resident there was not any other staff member in the dining room, she was the first person to get to him. She stated that Resident #1 had to be redirected several times because of his food seeking behaviors. He would sit in the dining room and be up in his wheelchair around the facility. He was not confined to a specific area. She stated that his peanut allergy was in his chart, she added it when he was initially admitted . She was not aware of him eating a sandwich at the beginning of the code. She stated that she thought he saw someone eating and just got it and ate it. She stated that she was not aware of Resident #1's nurse being out on her break. When the staff goes out on break, they are supposed to sign out and let the other nurse on the floor know they are on break. The partner on the station was responsible for those residents while the other nurse was on break. She stated that she would expect to see documentation in the chart related to the Code Blue including a timeline and all should be completed by the end of shift. She stated that she did not document in the chart. During an interview on [DATE] at 5:10 p.m. Staff H, Certified Nursing Assistant (CNA) stated that she did not have Resident #1 that night, she had the middle rooms, ,[DATE]. She stated that he was not supposed to eat because he was NPO. The resident would be put to bed, but he did not stay there much. He would be in the wheelchair and would get up and walk. He mostly self-propelled himself in the wheelchair, independently. Resident #1 would try to beg for food, put his hand out. We would have to redirect him, he would beg from the residents from table to table. He could self-propel himself into the dining room. We never kept him from going into the dining room. He never had one-on-one supervision, he was independent to the building. She stated that she did not know he was allergic to anything. She stated that she went to dinner at 7:57 p.m. and was back at 8:20 p.m. she was on her hallway and checking on her residents. She was going back toward Station II (away from the dining room), toward the activity room and saw Resident #1 at Station II at about 8:40 p.m. She was in room [ROOM NUMBER], a good way from the dining room, talking to the ladies and was walking to the end of the hallway just checking on the residents. She stated that she did not know where the aide that was assigned to Resident #1 was, maybe at dinner. Staff A, LPN came past the dining room coming toward her and asked if she had Resident #1 that he was on the dining room floor. Staff H stated that Staff A, LPN passed Resident #1 to come and get her to tell her he was on the floor. She stated that it was odd, that Staff A, LPN did not call for a Rapid Response or Code Blue instead of coming to get her. Staff H, CAN, stated that between 8:50 p.m. and 8:55 p.m. she saw Resident #1 on the floor. She stated that one of the nurses from Station I was at room [ROOM NUMBER], Staff A, LPN. Staff H, CNA stated that she went to check on the resident. She stated that she saw him out of his chair on the floor and could see his face on the floor. She stated she saw Staff I, LPN Weekend Supervisor coming down the hallway from Station II toward the dining room and she called Staff I, LPN for Resident #1 on the floor. Staff I, LPN called a Code Blue. She stated that no one called for Rapid Response. She stated that when Staff I, LPN called Code Blue, the crash cart was brought over. The Code Blue was called and Staff E, RN started doing CPR. The EMS came in and started doing their job too. She stated that she saw a piece of a sandwich beside him. She does not know how he found the sandwich or how he got it. She stated that she did not remember if there were any other residents in the dining room or not. Staff H, CNA stated that Staff A, LPN went back to her medication cart while Staff I, LPN was calling a Code Blue. Staff C, LPN which was the resident's nurse was gone to lunch at the time. She stated that she did not know who was in charge of Staff C, LPN's residents while she was at lunch. The aides tell the nurses they are going to lunch but not necessarily another aide. She stated that she liked Resident #1. Apparently, he was still hungry and wanted something to eat. During an interview on [DATE] at 12:15 p.m. Staff A, LPN, stated that Resident #1 had an order for [REDACTED]. If they are allergic to anything you have watch for their allergy. Yes, she was working, on ,[DATE] when Resident #1 had his event. Her assignment was the 101 to 115 rooms. She knew he had a [DEVICE] and the resident would, sometimes, walk with and without his wheelchair. He was NPO. He was allergic to peanuts. She was not sure if she knew he had a peanut allergy before the event, because she did not usually work with him. She stated that, on that day, she was in the hallway passing meds at the end of the hallway, when an aide called out to her. The aide was standing close to the nursing station about to the open the door for an unknown visitor to go out. She stated that the visitor had told the aide that somebody was on the floor. When the aide called out to her about Resident #1 being on the floor, she was between rooms [ROOM NUMBERS]. She locked her medication cart and went to the area where the aide was standing near the nursing station. She stated as she was walking down the hall toward the dining room the aide let the visitor out the door. She stated that she came down the hallway toward the hallway juncture in front of the nursing station, and saw Staff I, LPN coming down from the other hallway. She stated that we entered the dining room at the same time. Staff I, LPN checked Resident #1 for a pulse and she checked the book / chart for the code status. She stated that she yelled that the resident was a full code. She stated that he was lying on the floor on his side with the wheelchair behind him. She stated that she did not remember if there was anyone else in the dining room or not. She stated that she did not speak with anyone else. She stated that the event occurred between 8:30 p.m. and 9:00 p.m., she thought, she did not remember exactly the time. She stated that she went and got the crash cart and took it to the dining room. Staff E, RN, started CPR while someone called the EMS. She stated that the resident was not discolored. She stated that she did not do any assessment of the resident, Staff I, LPN did it. She stated that she was checking the blood pressure, oxygen saturation and pulse. She stated that she did not remember who was performing the respirations with the ambu bag, but someone was. She stated that they have a Code Blue Worksheet, and someone was filling it out. She stated that she did not chart in the computer on the resident or event. She stated that It was not for her to document, we do not do that here. Staff I, LPN was doing something like that. Staff I, LPN was doing the progress note and following up with the family. Staff C, LPN was assigned to the resident that night. She was on break at the time of the event. She stated that she did not remember if Staff C, LPN told her she was on break or not, she remembers hearing it. She stated that we are responsible for the other nurse's residents while they are on break. If an aide walks by a room and finds a resident on the floor, what do you expect the aide to do, she stated that the aide can call for a nurse, if nobody was close by, the aide can call for Rapid Response. Rapid Response was for an emergency, everyone will come. She stated that she did not talk to Staff H, CNA at all that evening. She stated that she knew Staff H, CNA was on the floor that day but did not talk to her. Record review of the statement of Staff B, Certified Nursing Assistant (CNA) dated [DATE] showed that she saw Resident #1 around 7 p.m. and did not see him again until a visitor called her and showed her that Resident #1 was on the floor. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that on interview with Staff B, CNA, she had stated that the visitor was trying to get out of the building, and the visitor found Staff B, to let her out of the building. Staff B told the DON and the NHA that she found the resident maybe a little after 9 p.m. on the dining room floor and had summoned the Staff A, LPN. She told Staff A, LPN that the visitor had reported Resident #1 was on the floor. Staff B, aide, stated that she could see the resident on the floor and went to get help. A follow-up interview by Staff U, Regional RN with Staff B, aide, showed a visitor was leaving and told Staff B she saw him lying there on the floor in the dining room. Staff B ran for the nurse down 100 hallway. Staff B went to the dining room, Staff B went to finish taking care of the resident she was caring for. During an interview on [DATE] at 3:29 p.m. Staff E, Registered Nurse (RN), stated that she was working on the night of [DATE]. She stated that she had worked with Resident #1 and was familiar with him. The facility knew what he needed and what he had (peanut allergy). He had a [DEVICE] and was not supposed to take anything by mouth. She stated that she saw him try to take and ask for food. She stated that you would tell him he cannot have food. He understood what we were saying to him. He may be hungry, and we would give him his [DEVICE] feeding. He pointed to food. He could walk and roam the building. He could self-propel his wheelchair and could stand up. She stated that she was never his direct nurse. He would follow through on your directions, but he would try it again, i.e. standing. He had an allergy to some food, but not medication. I think he was allergic to peanut butter. She stated that she found out he was allergic to peanut butter on the day the EMS came because they asked if he had any allergies [REDACTED]. She stated that she was doing the CPR compressions. There was a lot of staff around. She stated that she was on break in the breakroom on the phone and heard the Code Blue overhead at 8:48 p.m. She stated that the crash cart was there. Resident #1 was in the dining room and there was sandwich debris on the floor. A Station 1 nurse was there. Staff E, RN stated that she checked the vitals and started CPR. She did not know if another nurse had already started CPR prior to her or not. She stated that the nurses are the only staff to do CPR. We are supposed to document what we do and what we saw. She stated that she did a progress note in the chart. She stated that the Code Blue Worksheet was supposed to be done also. She stated that the EMS came in and the EMS guy relieved her. The EMS did suction him and took things out of the resident's mouth. The automatic compression machine was applied. EMS did ask if he had any allergies [REDACTED]. When the nurse told them, he was allergic to peanuts, they gave him a shot of something in the IV. She stated that she did not know what it was. When they put him on the stretcher she went back to her floor. During an interview on [DATE] at 4:07 p.m. Staff C, Licensed Practical Nurse (LPN) stated that she was familiar with Resident #1. She stated that Resident #1 would try to get food many times. He was cognitively impaired. He would go to the dining room while others were eating. We would get in front of him and put him by the medication cart until the other residents finished eating. He was independent in his wheelchair and was impaired cognitively. We did not want him to grab things / food and put it in his mouth, because he was NPO. She stated that she was aware he had an allergy to peanuts and peanut butter. She stated as a nurse we are to provide a safe environment, related to an allergy, we would normally keep him in sight, and ask the staff to keep an eye on him. He would like to go to food. When we saw him near the food, we would move him away. She stated that she would take the responsibility to bring him to the medication cart while the aides were serving the meal trays or were in the dining room, when food was present. She stated that she was on her break on the evening it happened. She was the nurse for him that evening. She stated that Staff A, LPN was on Station 1 with her that night. She stated that she did not clock out for her break and had to do a missed punch form. She left the building at 8:45 p.m. on break and went

Based on observations, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's attending physician, and review of clinical and medical records, policies and procedures it was determined that the facility failed to ensure Resident #1's Person-Centered Comprehensive Care Plan was reviewed, revised and completed by the Interdisciplinary Team (IDT) to include interventions to prevent aspiration and allergic reactions. The facility staff was aware Resident #1, who was [AGE] years old, rarely understood, had food seeking behaviors, with an order for [REDACTED].#1 was found lying on the floor by a visitor. The resident had been left unsupervised with access to the food product he was allergic to, a peanut butter and jelly sandwich. Resident #1 was known to have a [DEVICE] (gastrostomy feeding tube) and to be on nothing by mouth as of [DATE]. The resident was transferred and admitted to an acute care hospital where he received emergency care and was transferred to the intensive care unit on a ventilator according to the hospital records. This resulted in the findings of Immediate Jeopardy, occurring on [DATE] and removed at 6:00 p.m. on [DATE] with the scope and severity reduced to a D. Findings included: 1. Record review of the facility's policy, Care Plan-Interdisciplinary Plan of Care from Interim to Meeting, dated (MONTH) (YEAR) found the facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to the individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. Managing risk factors to the extent possible or indicating the limits of such interventions. Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. New, revised or discontinued Problems, Goals or Interventions are dated for the date the documentation is made. Problems and Goals have IDT approaches and Interventions to assist the resident in their goal attainment. 2. Record review of the Care Plans showed Resident #1 had a care plan for tube feeding initiated on [DATE] due to receiving enteral nutrition. There was no focus area or care plan put into place related to food allergy or food seeking behaviors for Resident #1. Resident # 1 had a Nutritional care plan, initiated on [DATE], related to a nutritional problem or potential nutritional problem related to swallowing problem, weight loss, NPO, AMS (altered mental status), post aspiration pneumonia, and developmental delay. The interventions included but were not limited to Resident is NPO, do not provide food or fluids by mouth. See the nurse. RD (Registered Dietitian) consult and follow PRN. He had a preference/choice care plan, initiated on [DATE], and revised on [DATE] which reflected he refused care, sat in the dining room during dining hours. Interventions included but were not limited to explain the potential negative outcomes of preferences/choice. Potential negative outcomes include: (blank). Notify physician as needed for any change in condition. The resident had a Behavioral Care plan, initiated on [DATE], and revised on [DATE] due to the potential to demonstrate physical behaviors related to [MEDICAL CONDITION], including rejection of care, striking and kicking staff. Interventions included but were not limited to: analyze of key times, places, circumstances, triggers and what de-escalates behavior and document; communication; give the resident as many choices as possible about care and activities. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 5-day admission Minimum Data Set (MDS), dated [DATE], found a Brief Interview for Mental Status (BIMS) score of 99 meaning the resident was rarely / never understood. The resident required limited assistance of one for bed mobility, transfers, and toileting. He was independent for walking in his room and required assistance of one to move on and off the unit. He was not steady without staff for moving and walking. He was dependent on staff for eating. Review of Resident #1's order summary report dated [DATE], page 1 of 7 showed the following physician orders: Enteral Feed Order three times a day [MEDICATION NAME] via peg tube, bolus 500ml, total volume to be infused is 1500 ML/24 hours, start date [DATE] Flush enteral tube with 30 ML of water every 6 hours to maintain patency, start date [DATE] Flush feeding tube with 5 ml of water between meds every shift to maintain patency, start date [DATE] Flush tube with 100 ml of water before and after med administration and feeding every shift to maintain patency, start date [DATE] Free water flushes via feeding tube of 200 ml every 4 hours for free water, start date [DATE] Evaluate for displacement of tube by observing for abdominal distress, nausea/vomiting, pain, distention. If displacement is suspected, clamp tube, call MD, every shift, start date [DATE] G tube site may be left open to air if clean and not drainage, every shift for skin integrity monitor for changes every shift, start date [DATE] May give medications via tube, every shift, start date [DATE] Review of Resident #1's order summary report dated [DATE], page 3 of 7 showed an order for [REDACTED]. Record review of Order Appointing Successor Guardian Advocate dated (MONTH) 16, 2000, showed Resident #1 had a guardian due to developmental disabilities. The Guardian was listed on the Emergency Contact face sheet. Review of the Swallow Study performed at the hospital on [DATE] showed patient NPO with PEG (percutaneous endoscopic gastrostomy) tube for nutrition/hydration at SNF (Skilled Nursing Facility). Patient impulsive, grabbing for food. SNF requesting assessment to determine potential for resuming oral intake. Assessment and Findings included The patient was confused and unable to follow one step commands. Patient presents with severe oral and severe pharyngeal dysphagia. at risk of aspiration with hard solids due to oral deficits. At risk of aspiration with thin liquids due to penetration and aspiration given by teaspoon. Weak cough. High risk of aspiration due to decreased airway protection and majority of material remaining within pyriform sinuses from decreased laryngeal elevation. Recommendations: NPO with alternative means of nutrition/hydration/medication. Record review of the medical record showed under the allergy section that Resident #1 had a moderately severe allergy to peanuts, creating a reaction of [MEDICATION NAME] and a sub-reaction of laryngeal [MEDICAL CONDITION]. Record review of physician orders [REDACTED]. The resident code status was Full Code. Record review of the Physician and Nursing Progress Notes reflected Resident #1 was able to get out of bed into his wheelchair and self-propel throughout the hallways. On [DATE] at 8:21 a.m. the physician progress notes [REDACTED]. The resident required assistance and supervision with Activities of Daily Living (ADLs). The resident had a peanut allergy. On [DATE] at 23:34 (11:34 p.m.) the physician progress notes [REDACTED]. He was not able to follow commands with repeated max cues. The therapist reported that resident does not follow command. On [DATE] at 13:42 or 1:42 p.m., the nursing progress note showed, the resident does stay in the dining room the majority of the shift and attempted to obtain food off the tables. He was given redirection and distraction which was effective for short periods of time. On [DATE] at 2:49 a.m. the nursing progress note showed, the physician was in visiting the resident and made aware of the resident eating from another resident's food tray. The physician was made aware and requested for the resident to be evaluated for Occupational Therapy. The Change in Condition form in the resident's record, dated [DATE], at 21:10 or 9:10 p.m., reflected Resident #1 was unresponsive and was allergic to peanuts. The resident was in the dining room at approximately 2100 (9:00 p.m.) when a supervising staff member identified a change in condition. The staff member notified the licensed nurse who attended the resident immediately. Pulse and respirations were not present during the head-to-toe evaluation. A Code Blue was announced. The chart and Emergency Cart were brought by the attending staff. The Emergency Medical System (EMS) was activated via the 911 system and the Resident Representative was contacted and the physician was notified. The EMS arrived and transported the resident to the local Emergency Department. The resident was admitted to the hospital. The Resident Representative was called on [DATE] at 2120 (9:20 p.m.). The Physician was notified on [DATE] at 21:10 (9:10 p.m.). Signed by the Director of Nursing (DON) on [DATE]. The record review of the Aide Kardex showed the resident had a peanut allergy and had an order for [REDACTED].>3. Record review of the Code Blue Worksheet dated [DATE] showed the following: Location: dining room Unconscious Resident identified at 8:43 p.m. by visitor Emergency Cart arrival: 8:45 p.m. Chart Arrival: 8:44 p.m. CPR initiated if indicated: 8:47 p.m. 911 called: 8;50 p.m. EMS arrival: 9:06 p.m. Physician Notified: 10;45 p.m. Physician Name: attending physician / ARNP Family Notified: called with no answer Resident sent to: hospital Employees present: Staff E, RN; Staff G, LPN; Staff A, LPN DON notified: 9:03 p.m. Administrator notified: 9:19 p.m. Supervisor called nurse at 9:18 p.m. The person column providing the care to the resident was blank 4. Record review of the EMS report summary dated [DATE] reflected the following: Call Received: 21:03 (9:03 p.m.) Dispatched: 21:04 (9:04 p.m.) En Route: 21:05 (9:05 p.m.) On Scene: 21:09 (9:09 p.m.) Patient Contact: 21:10 (9:10 p.m.) Left Scene: 21:29 (9:29 p.m.) At destination (hospital): 21:35 (9:35 p.m.) Transfer of Care: 21:37 (9:37 p.m.) Resident was unresponsive. Patient was eating a peanut butter and jelly sandwich and started to choke on it. Staff members stated he was allergic to it. Staff members stated he went unresponsive, had no pulse and CPR was initiated by staff. The patient was placed on a monitor and was asystole. The first dose of epi was given. The patient's mouth was looked into, and he had peanut butter still in his airway. Laryngoscope and forceps were used to try to get some of the peanut butter out. His mouth was also suctioned, was only able to get some out. Second round of epi was given. The patient went into ventricular fibrillation and then shock. CPR was continued. The patient was given the third dose of epi. The patient was placed on the stretcher and placed in the ambulance. The patient was given the fourth dose of epi. The patient was placed on an epi drip, en route. 5. Review of the emergency room Report dated [DATE], revealed the patient was admitted with [MEDICAL CONDITION] after food was found in his throat. He was allergic to peanuts and was eating a peanut butter and jelly sandwich. He apparently choked on a peanut butter sandwich at the nursing home. He was down for 20 minutes and they attempted to remove peanut butter stuck in the patient's throat en route. He was given [MEDICATION NAME] times 4 doses. The patient was subsequently intubated on arrival to the emergency room . The pupils were unequal with left pupillary deficit. The patient was not regaining neurologic improvement despite no sedation. He had return of spontaneous circulation. The patient was critically ill. 6. During an interview on [DATE] at 10:00 a.m. with Resident #1's attending physician stated that he knew Resident #1. On [DATE] he ate something he was allergic to. He was placed in the facility due to having a peg tube, nothing by mouth and being confused. He was redirectable. He was chronically ill. He was food seeking a lot. He was made aware that the resident was admitted to the hospital. The resident found a sandwich and ate it. The unfortunate thing was he was allergic to peanuts and he ate a peanut butter and jelly sandwich. He was not aware how he got it because he was not there. He was told another resident had asked for 2 sandwiches and they gave Resident #1 one of them. He coded and had to be intubated and admitted to the hospital. The incident occurred he believes because of both choking on a sandwich and him being allergic to peanuts and having an allergic reaction. The EMS was called and treated him with [MEDICATION NAME] for an allergic reaction to the peanut butter. He stated that he needed redirecting the whole time. He stated that he felt the facility watched him closely. He stated that the resident grabbed a meal tray and ate off it while in the hospital. He stated that he felt it was unavoidable. When asked if he felt they could have supervised him more closely, or placed him on one-on-one supervision, he stated that he was told that the nurses kept him close by. They could not restrain him. He was kept in the dining room which was a big area, someone was watching him. He stated that he was not sure how to prevent. He stated that as of Monday, [DATE], the resident was still in the hospital intubated. During a phone interview on [DATE] at 12:11 p.m. Staff I, LPN Weekend supervisor stated that she was the LPN night supervisor on the evening of [DATE]. She stated that Resident #1 had to be redirected several times because of his food seeking behaviors. He would sit in the dining room and be up in his wheelchair around the facility. He was not confined to a specific area. She stated that his peanut allergy was in his chart. She added it when he was initially admitted . She was not aware of him eating a sandwich at the beginning of the code. She stated that she thought he saw someone eating and just got it and ate it. She stated that she was not aware of Resident #1's nurse being out on her break. The partner on the station was responsible for those residents while the other nurse was on break. During an interview on [DATE] at 5:10 p.m. Staff H, Certified Nursing Assistant (CNA) stated that she did not have Resident #1 that night, she had the middle rooms, ,[DATE]. She stated that he was not supposed to eat because he was NPO. The resident would be put to bed, but he did not stay there much. He would be in the wheelchair and would get up and walk. He mostly self-propelled himself in the wheelchair, independently. Resident #1 would try to beg for food, put his hand out. We would have to redirect him, he would beg from the residents from table to table. He could self-propel himself into the dining room. We never kept him from going into the dining room. He never had one-on-one supervision. He was independent to the building. She stated that she did not know he was allergic to anything. She stated that she liked Resident #1. Apparently, he was still hungry and wanted something to eat. During an interview on [DATE] at 12:15 p.m. Staff A, LPN, stated that a Resident #1 had an order for [REDACTED]. If they are allergic to anything you have watch for their allergy. Yes, she was working, on ,[DATE] when Resident #1 had his event. Her assignment was the 101 to 115 rooms. She knew he had a [DEVICE] and the resident would sometimes walk with and without his wheelchair. He was NPO. He was allergic to peanuts. She was not sure if she knew he had a peanut allergy before the event, because she did not usually work with him. During an interview on [DATE] at 3:29 p.m. Staff E, Registered Nurse (RN), stated that she was working on the night of [DATE]. She stated that she had worked with Resident #1 and was familiar with him. The facility knew what he needed and what he had (peanut allergy). He had a [DEVICE] and was not supposed to take anything by mouth. She stated that she saw him try to take and ask for food. She stated that you would tell him he cannot have food. He understood what we were saying to him. He may be hungry, and we would give him his [DEVICE] feeding. He pointed to food. He could walk and roam the building. He could self-propel his wheelchair and could stand up. She stated that she was never his direct nurse. He would follow through on your directions, but he would try it again, i.e. standing. He had an allergy to some food, but not medication. I think he was allergic to peanut butter. She stated that she found out he was allergic to peanut butter on the day the EMS came because they asked if he had any allergies. She stated that we can see the allergies on the computer. The EMS asked if he was allergic, because there was a peanut butter sandwich next to him. During an interview on [DATE] at 4:07 p.m. Staff C, Licensed Practical Nurse (LPN) stated that she was familiar with Resident #1. She stated that Resident #1 would try to get food many times. He was cognitively impaired. He would go to the dining room while others were eating. We would get in front of him and put him by the medication cart until the other residents finished eating. He was independent in his wheelchair and was impaired cognitively. We did not want him to grab things / food and put it in his mouth, because he was NPO. She stated that she was aware he had an allergy to peanuts and peanut butter. She stated as a nurse we are to provide a safe environment, related to an allergy, we would normally keep him in sight, and ask the staff to keep an eye on him. He would like to go to food. When we saw him near the food, we would move him away. She stated that she would take the responsibility to bring him to the medication cart while the aides were serving the meal trays or were in the dining room, when food was present. She stated that she was on her break on the evening it happened. Staff C, LPN, wrote multiple written statements that were reviewed with the DON and the NH[NAME] On [DATE] at 10:54 p.m. I was on my break, when the supervisor called and told me that Resident #1 coded and I needed to come in. When I arrived, I saw him on the stretcher. A second statement, dated [DATE] at 3:37 p.m., showed about 16:30 (4:30 p.m.) I noticed Resident #1 was eating food from other resident's tray in the dining room. There was no evidence of choking or respiratory distress. I, the nurse had to redirect the resident from the dining room. Then the resident continued to wheel himself back and forth throughout the building. At 8:45 p.m. I left for a break and received a phone call from the supervisor stating the resident had coded and she needed to come in. When I arrived, I saw him on the stretcher with the EMS was performing CPR. Before I left for my break, I parked the resident in the dining room. A third statement, dated [DATE], showed at 8:30 p.m. the snack cart was left in front of the nursing station and he was observed at the nursing station grabbing at things on the snack cart and another resident was by him at this time. Resident #8 asked for 2 sandwiches. I gave them to her. At 8:30 p.m. she put the snack cart behind nursing station. At 8:45 p.m. the resident was at the table closest to the hallway. The Resident with the sandwiches was outside the dining room in the hallway rolling back and forth. At 8:45 p.m. I left for break and told nurse Staff A, LPN and Staff D,CN[NAME] prior to going on break, there was an aide washing her hands. During an interview on [DATE] at 6:04 p.m., Staff F, LPN, stated that she did know Resident #1, she had him as a resident. He needed constant monitoring because he was a wanderer. He was mentally impaired, and he did not grasp that he was only supposed to eat through his tube and was always seeking food in the dining room. He was familiar with everyone eating and he knew where the food was at. She stated that she saw him eat once, while the aides were cleaning up the meal trays. Another resident had given him a tray to eat. We removed him and removed the food. We spoke to the resident that gave him the food tray that she cannot feed him because he cannot eat. She did not care, she stated she was going on to keep feeding him. The resident that give him the food was still housed on Station I. During an interview on [DATE] at 4:36 p.m. Staff R, CNA, stated that Resident #1 went everywhere. He was not to have anything by mouth, but he was always looking for something to eat. He would try to grab something off the snack cart. She stated she did not know what happened that night. She stated he was not supposed to eat, and we were to watch for him. During an interview on [DATE] at 9:19 a.m. the Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that she was familiar with Resident #1. The DON stated that he was alert but non-verbal, he was ambulatory, but mainly used the wheelchair. Resident #1 frequently refused care and pulled his [DEVICE] out he also removed his clothes. He did what he wanted to do. He had been at the facility for about ,[DATE] weeks. The Resident went to the dining room, it was his favorite place to hang out. The DON stated that she had not seen the resident grab or eat food but was told he tried to grab food. The NHA stated that she had never seen him grab or eat food but after the investigation she was informed of it. They stated that they reviewed the clinical chart, and an occurrence was documented, that he had obtained a food product. The DON stated that she was not informed of the resident eating. It was shared at the time of the investigation that he was food seeking. The DON agreed that as the DON she would want to know about an activity that a resident was demonstrating that he was seeking out food and had a physician order [REDACTED]. The DON stated that if she had known the resident was showing risky behaviors, such as being an NPO resident, allergic to peanuts and was trying to eat, she would have probably placed him in an intervention of every 15- minute checks. The DON stated that this intervention was not put into place. When asked how they proactively kept peanuts from his proximity, the DON stated that they followed the policies but sometimes the resident does not. Both the DON and NHA stopped speaking. When asked what happened? No comment from either. They stated that the DON got the phone call from the facility just after 9 p.m. from Staff I, LPN, weekend supervisor. The EMS was still in the building and he was receiving CPR. When asked if they had a time line? They both stated, no. They stated that they got statements from everybody that night. The NHA stated that she was the Risk Manager and she was asked what her conclusions were? She stated that it revealed to us that prior to the Code Blue, Staff C, LPN was his nurse for the evening. Staff C, LPN stated that she had given 2 peanut butter and jelly sandwiches to Resident #8. She stated that she gave her the sandwiches and then pushed the snack cart behind the nursing station. She then went on break out of the building. She stated that Staff C, LPN did not recall when she left because she did not clock out. The expectation was for every employee to clock out. She left the building but was on the property in her car. They stated that Resident #8 was very nurturing. They could see her having 2 sandwiches and thinking one for me and one for him. We tried to validate that, but her BIMS score was about a 5. We spoke with her that night. She could not remember if she had a snack or not. The next day she did not remember getting a snack either. The DON reviewed the nursing notes in the chart and stated there was no documentation about Resident #1 obtaining food products earlier in the evening. The DON stated that she would expect to see this in the notes, including the reporting and intervening. The DON stated this was so the IDT can protect the resident and put interventions into place. The DON stated that they had a system failure with the snack cart delivery, leaving it behind at the nursing stations. The residents were not allowed behind the nursing stations. The NHA stated that the snack cart was in front of the nursing station and then was placed behind it. Resident #1 was able to self-propel himself, but it was so tight getting a wheelchair in and out from behind the nursing station. It seemed highly unlikely he was able to get behind the nursing station with his wheelchair. They stated to help prevent an occurrence from happening again they entered the night of the event, interviewed and began investigating the event. They stated that all allergies can be life threatening and it was important for the facility to know if someone had a peanut allergy. They were asked for their plan If you have a resident with a peanut allergy, do you have a plan in place to keep that resident safe. They stated that all new admissions have a check list and allergy verifying is on the check list. We do an admission audit, review hospital allergies, interview resident or family, verify. We make sure the audit tool was done. The allergy was put in the care plan and it moves over to the Kardex. We have an allergy care plan now. Resident #1 did not have an allergy care plan. After having a heightened risk that this resident had, and people were aware of it, but there were no specific interventions in the care plan to keep him safe. They have been in-serviced on how to communicate findings: speak to identify the resident with food diet concerns, residents with physician orders [REDACTED]. 6. During an interview on [DATE] at 5:34 p.m., the DON stated that everyone had been educated either face-to-face or verbally over the phone. The staffing person has met with the staff needing face-to-face and the administrative staff will schedule dates and times to be here to provide that in-service, again, and a sign-in sheet. They also performed Code Blue during the education. She stated that they have sign-in sheets as [DATE] at 4:30 p.m. for 100% of the staff. The in-servicing included: change in condition and responding immediately, never leaving a resident, communicating with each other including hand-off reports for break, documenting after events or care rendered regardless of assignment, clocking in and out for breaks is mandatory as [DATE] at 4:30 p.m. They provided the in-service they have had in the past. She stated that they were going to have to do a daily audit and re-educate. The staff was finally getting the seriousness of the issues. 7. Removal Plan for Immediate Jeopardy (MONTH) 7, 2019 at 6:00 p.m. given to the survey team at 7:15 p.m. 1. A full house audit was immediately conducted to ensure the appropriate level of monitoring is provided to: Residents with NPO diets Residents with Food Allergies Chain of custody for food tray delivery and snacks Response related to change of condition Neglect and brisk response with change in condition Staff break periods and validated supervision Leadership team members reviewed documentation related to the change in condition in the resident's record. 2. The facility immediately conducted assessments / audits of: Residents with NPO diets to ensure food seeking behaviors are addressed with strategies in the plan of care Residents with Food Allergies matching orders to the Dietary Tracker and validation of care plan interventions Immediate system implemented to ensure chain of custody for food tray delivery and snacks Staff response related to change of condition house wide clinical staff Reviewed 24-hour reports to ensure no other potential neglect needing intervention was identified and a brisk response occurred with change in condition Staff practices related to break periods and validation practices to ensure supervision Event documentation related to change in condition to identify focused education opportunities 3. The facility Immediately ensured: Residents with NPO diets were assessed to ensure food seeking behaviors are addressed with strategies in the plan of care Residents with Food Allergies were assessed for orders, dietary tracker, care plans and Kardex updates to reflect appropriate food allergies A system was implemented to ensure chain of custody of food tray delivery and snacks Staff members understood the requirement for an immediate response relate dot change of condition Staff understood the potential for neglect if a brisk response with change in condition was not facilitated Staff members were providing verbal transition with covering team members prior to exiting the unit and upon return from break periods to validate supervision Leadership team members immediately ensured documentation of events related to the change in condition was entered into the residents record to memorialize clinical conditions as well as actions and services provided. Staff members were immediately educated related to: NPO diets and food seeking behaviors How to identify residents with food allergies and care plan any behaviors for not meeting physician orders [REDACTED]. The newly implemented system for food tray delivery and snack tray chain of custody Neglect and brisk response to change in condition Requirement for verbal transition prior to exiting for breaks and upon return from authorized breaks The requirement for documenting key elements of a change in condition including but not limited to the resident's condition change, actions taken and required notification (s) 4. DON or designee will be completing observations related to residents with NPO diets to ensure any new food seeking behaviors are addressed in the plan of care. NPO diets and food allergies will be communicated to the staff, food tray delivery and snack delivery are supervised by facility team members including chain of custody with food delivery, components of change in condition are followed including random observations of staff actions with change in condition, staff members are compliant with verbal communication / transition of team members prior to exiting for break and upon return to duty, and each even

Based on observations, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's attending physician, and review of clinical and medical records, policies and procedures it was determined that the facility failed to ensure Resident #1 was provided with the level of supervision needed to prevent access to orally consumed foods and ensuring non-oral means of nutritional support were provided. On [DATE] the facility failed to provide supervision for Resident #1, a food seeking resident, with an order for [REDACTED].#1 was found lying on the floor by a visitor after being left unsupervised in the dining room. The resident had been left unsupervised with access to the food product he was allergic to, a peanut butter and jelly sandwich. Two staff members were made aware he was on the floor and did not render care and services creating a delay in emergency care including cardiopulmonary resuscitation. Resident #1 was known to have a [DEVICE] (gastrostomy feeding tube) and to be on nothing by mouth as of [DATE]. The resident's code status was Full Code. Resident #1 was transferred and admitted to an acute care hospital where he received emergency care and was transferred to the intensive care unit on a ventilator according to the hospital records. This resulted in the findings of Immediate Jeopardy, occurring on [DATE] and removed at 6:00 p.m. on [DATE] with the scope and severity reduced to a D. Resident #1 was transferred to the hospital on four separate occasions during his 37-days at the facility. He was transferred on both [DATE] and [DATE] for removing his [DEVICE]. He was admitted to the hospital on [DATE] through [DATE] for removing his [DEVICE] and suspected healthcare acquired pneumonia involving left lung of a probable aspiration etiology. Findings included: 1.Review of the emergency room Report dated [DATE] revealed Resident #1 was admitted with [MEDICAL CONDITION] after food was found in his throat. He was allergic to peanuts and was eating a peanut butter and jelly sandwich. He apparently choked on a peanut butter sandwich at the nursing home. He was down for 20 minutes and they attempted to remove peanut butter stuck in the patient's throat en route. He was given [MEDICATION NAME] times 4 doses. The patient was subsequently intubated on arrival in the emergency room . The pupils were unequal with left pupillary deficit. The patient was not regaining neurologic improvement despite no sedation. He had return of spontaneous circulation. The patient was critically ill. 2. Record review of the EMS report summary dated [DATE] reflected the following: Call Received: 21:03 (9:03 p.m.) Dispatched: 21:04 (9:04 p.m.) En Route: 21:05 (9:05 p.m.) On Scene: 21:09 (9:09 p.m.) Patient Contact: 21:10 (9:10 p.m.) Left Scene: 21:29 (9:29 p.m.) At destination (hospital): 21:35 (9:35 p.m.) Transfer of Care: 21:37 (9:37 p.m.) Resident was unresponsive. Patient was eating a peanut butter and jelly sandwich and started to choke on it. Staff members stated, he was allergic to it. Staff members stated he went unresponsive, had no pulse and CPR was initiated by staff. The patient was placed on a monitor and was asystole. The first dose of epi was given. The patient's mouth was looked into, and he had peanut butter still in his airway. Laryngoscope and forceps were used to try to get some of the peanut butter out. His mouth was also suctioned, was only able to get some out. Second round of epi was given. The patient went into ventricular fibrillation and then shock. CPR was continued. The patient was given the third dose of epi. The patient was placed on the stretcher and placed in the ambulance. The patient was given the fourth dose of epi. The patient was placed on an epi drip, en route. 3. Record review of the Code Blue Worksheet dated [DATE] showed the following: Location: dining room Unconscious Resident identified at 8:43 p.m. by visitor Emergency Cart arrival: 8:45 p.m. Chart Arrival: 8:44 p.m. CPR initiated if indicated: 8:47 p.m. 911 called: 8:50 p.m. EMS arrival: 9:06 p.m. Physician Notified: 10;45 p.m. Physician Name: attending physician / ARNP Family Notified: called with no answer Resident sent to: hospital Employees present: Staff E, RN; Staff G, LPN; Staff A, LPN DON notified: 9:03 p.m. Administrator notified: 9:19 p.m. Supervisor called nurse at 9:18 p.m. The person column providing the care to the resident was blank 4. The Change in Condition form in the resident's record, dated [DATE], at 21:10 or 9:10 p.m. reflected Resident #1 was unresponsive and was allergic to peanuts. The resident was in the dining room at approximately 2100 (9:00 p.m.) when a supervising staff member identified a change in condition. The staff member notified the licensed nurse who attended the resident immediately. Pulse and respirations were not present during the head-to-toe evaluation. A Code Blue was announced. The chart and Emergency Cart were brought by the attending staff. The Emergency Medical System (EMS) was activated via the 911 system and the Resident Representative was contacted and the physician was notified. The EMS arrived and transported the resident to the local Emergency Department. The resident was admitted to the hospital. The Resident Representative was called on [DATE] at 2120 (9:20 p.m.). The Physician was notified on [DATE] at 21:10 (9:10 p.m.). Signed by the Director of Nursing (DON) on [DATE]. 5. In an interview on [DATE] at 10:00 a.m. with Resident #1's attending physician, he stated that he knew Resident #1. On [DATE] he ate something he was allergic to. He was placed in the facility due to having a peg tube, nothing by mouth and being confused. He was redirectable. He was chronically ill. He was food seeking a lot. He was made aware that the resident was admitted to the hospital. The resident found a sandwich and ate it. The unfortunate thing was he was allergic to peanuts and he ate a peanut butter and jelly sandwich. He was not aware how he got it because he was not there. He was told another resident had asked for 2 sandwiches and they gave Resident #1 one of them. He coded and had to be intubated and admitted to the hospital. The incident occurred he believes because of both choking on a sandwich and him being allergic to peanuts and having an allergic reaction. The EMS was called and treated him with [MEDICATION NAME] for an allergic reaction to the peanut butter. He stated that he needed redirecting the whole time. He stated that he felt the facility watched him closely. He stated that the resident grabbed a meal tray and ate off it while in the hospital. He stated that he felt it was unavoidable. When asked if he felt they could have supervised him more closely, or placed him on one-on-one supervision, he stated that he was told that the nurses kept him close by. They could not restrain him. He was kept in the dining room which was a big area, someone was watching him. He stated that he was not sure how to prevent. He stated that as of Monday, [DATE], the resident was still in the hospital intubated. Record Review of Statement Document by Regional RM Consultant on [DATE] at 10:50 a.m. with the visitor indicated the following: She stated on the night of [DATE] she saw a resident on the floor. She called for staff, and someone came right away. She then saw other staff members running toward the dining room. She stated things were happening fast, then she was going out door she saw 911 pull up. During an interview on [DATE] at 4:07 p.m. Staff C, Licensed Practical Nurse (LPN) stated that she was familiar with Resident #1. She stated that Resident #1 would try to get food many times. He was cognitively impaired. He would go to the dining room while others were eating. We would get in front of him and put him by the medication cart until the other residents finished eating. He was independent in his wheelchair and was impaired cognitively. We did not want him to grab things / food and put it in his mouth, because he was NPO. She stated that she was aware he had an allergy to peanuts and peanut butter. She stated as a nurse we are to provide a safe environment, related to an allergy, we would normally keep him in sight, and ask the staff to keep an eye on him. He would like to go to food. When we saw him near the food, we would move him away. She stated that she would take the responsibility to bring him to the medication cart while the aides were serving the meal trays or were in the dining room, when food was present. She stated that she was on her break on the evening it happened. She was the nurse for him that evening. She stated that Staff A, LPN was on Station 1 with her that night. She stated that she did not clock out for her break and had to do a missed punch form. She left the building at 8:45 p.m. on break and went to get something to eat. She was called to come back by the evening supervisor at 9:18 p.m. and she got back at 9:20 p.m. When she got back, she saw that there were many paramedics and police officers there. Resident #1 was on a stretcher and being transported to the hospital. She did not do any documentation, the other staff told her they were going to do the documentation from the Director of Nursing (DON). Staff C stated that she did not do a progress note, or any other documentation. Staff C stated that she did not participate in the Code Blue. Before the incident, the snacks were kept in front of the nursing station on an open cart. That night dietary had put the snack cart in front of the nursing station, Staff C stated that she put it behind the nursing station before she left to go on break. At that time, she left Resident #1 in the hallway, not right near the snack cart. The only person present was an aide, Staff D, Certified Nursing Assistant (CNA) washing her hands in the dining room area. If a resident was being non-compliant and reaching for food other than what they are supposed to have, they need to be moved. She stated that she moved Resident #1 to the first dining room table before she left. She stated that there were no other residents or staff in the dining room. We put them there so they can be observed when someone was passing by. She stated that we do not know how Resident #1 got the sandwich. It was documented prior to that he was trying to eat. She stated that when she got back, she thought he had a [MEDICAL CONDITION] that night. Staff C, LPN had multiple written statements that were reviewed with the DON and the NH[NAME] On [DATE] at 10:54 p.m. I was on my break, when the supervisor called and told me that Resident #1 coded and I needed to come in. When I arrived, I saw him on the stretcher. A second statement, dated [DATE] at 3:37 p.m., showed about 16:30 (4:30 p.m.) I noticed Resident #1 was eating food from other resident's tray in the dining room. There was no evidence of choking or respiratory distress. I, the nurse had to redirect the resident from the dining room. Then the resident continued to wheel himself back and forth throughout the building. At 8:45 p.m. I left for a break and received a phone call from the supervisor stating the resident had coded and she needed to come in. When I arrived, I saw him on the stretcher with the EMS was performing CPR. Before I left for my break, I parked the resident in the dining room. A third statement, dated [DATE], showed at 8:30 p.m. the snack cart was left in front of the nursing station and he was observed at the nursing station grabbing at things on the snack cart and another resident was by him at this time. Resident #8 asked for 2 sandwiches. I gave them to her. At 8:30 p.m. she put the snack cart behind nursing station. At 8:45 p.m. the resident was at the table closest to the hallway. The Resident with the sandwiches was outside the dining room in the hallway rolling back and forth. At 8:45 p.m. I left for break and told nurse Staff A, LPN and Staff D,CN[NAME] prior to going on break, there was an aide washing her hands. Record review of the statement of Staff B, Certified Nursing Assistant (CNA) dated [DATE] showed that she saw Resident #1 around 7 p.m. and did not see him again until a visitor called her and showed her that Resident #1 was on the floor. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that on interview with Staff B, CNA, she had stated that the visitor was trying to get out of the building, and the visitor found Staff B, to let her out of the building. Staff B told the DON and the NHA that she found the resident maybe a little after 9 p.m. on the dining room floor and had summoned the Staff A, LPN. She told Staff A, LPN that the visitor had reported Resident #1 was on the floor. Staff B, aide, stated that she could see the resident on the floor and went to get help. A follow-up interview by Staff U, Regional RN with Staff B, aide, showed a visitor was leaving and told Staff B she saw him lying there on the floor in the dining room. Staff B ran for the nurse down 100 hallway. Staff B went to the dining room. Staff B went to finish taking care of the resident she was caring for. During an interview on [DATE] at 12:15 p.m. Staff A, LPN, stated that a Resident #1 had an order for [REDACTED]. If they are allergic to anything you have watch for their allergy. Yes, she was working, on ,[DATE] when Resident #1 had his event. Her assignment was the 101 to 115 rooms. She knew he had a [DEVICE] and the resident would sometimes walk with and without his wheelchair. He was NPO. He was allergic to peanuts. She was not sure if she knew he had a peanut allergy before the event, because she did not usually work with him. She stated that on that day she was in the hallway passing meds at the end of the hallway, when an aide called out to her. The aide was standing close to the nursing station about to the open the door for an unknown visitor to go out. She stated that the visitor had told the aide that somebody was on the floor. When the aide called out to her about Resident #1 being on the floor, she was between rooms [ROOM NUMBERS]. She locked her medication cart and went to the area where the aide was standing near the nursing station. She stated as she was walking down the hall toward the dining room the aide let the visitor out the door. She stated that she came down the hallway toward the hallway juncture in front of the nursing station, and saw Staff I, LPN coming down from the other hallway. She stated that we entered the dining room at the same time. Staff I, LPN checked Resident #1 for a pulse and she checked the book / chart for the code status. She stated that she yelled that the resident was a full code. She stated that he was lying on the floor on his side with the wheelchair behind him. She stated that she did not remember if there was anyone else in the dining room or not. She stated that she did not speak with anyone else. She stated that the event occurred between 8:30 p.m. and 9:00 p.m., she thought, she does not remember exactly the time. She stated that she went and got the crash cart and took it to the dining room. Staff E, RN started CPR while someone called the EMS. She stated that the resident was not discolored. She stated that she did not do any assessment of the resident, Staff I, LPN did it. She stated that she was checking the blood pressure, oxygen saturation and pulse. She stated that she does not remember who was performing the respirations with the ambu bag, but someone was. She stated that they have a Code Blue Worksheet, and someone was filling it out. She stated that she did not chart in the computer on the resident or event. She stated that It was not for her to document, we do not do that here. Staff I, LPN was doing something like that. Staff I, LPN was doing the progress note and following up with the family. Staff C, LPN was assigned to the resident that night. She was on break at the time of the event. She stated that she did not remember if Staff C, LPN told her she was on break or not, she remembers hearing it. She stated that we are responsible for the other nurse's residents while they are on break. If an aide walks by a room and finds a resident on the floor, what do you expect the aide to do? She stated that the aide can call for a nurse, if nobody was close by, the aide can call for Rapid Response. Rapid Response was for an emergency, everyone will come. She stated that she did not talk to Staff H, CNA at all that evening. She stated that she knew Staff H, CNA was on the floor that day but did not talk to her. During an interview on [DATE] at 5:10 p.m. Staff H, Certified Nursing Assistant (CNA) stated that she did not have Resident #1 that night, she had the middle rooms, ,[DATE]. She stated that he was not supposed to eat because he was NPO. The resident would be put to bed, but he did not stay there much. He would be in the wheelchair and would get up and walk. He mostly self-propelled himself in the wheelchair, independently. Resident #1 would try to beg for food, put his hand out. We would have to redirect him, he would beg from the residents from table to table. He could self-propel himself into the dining room. We never kept him from going into the dining room. He never had one-on-one supervision. He was independent to the building. She stated that she did not know he was allergic to anything. She stated that she went to dinner at 7:57 p.m. and was back at 8:20 p.m. She was on her hallway and checking on her residents. She was going back toward Station II (away from the dining room), toward the activity room and saw Resident #1 at Station II at about 8:40 p.m. She was in room [ROOM NUMBER], a good way from the dining room, talking to the ladies and was walking to the end of the hallway just checking on the residents. She stated that she did not know where the aide that was assigned to Resident #1 was, maybe at dinner. Staff A, LPN came past the dining room coming toward her and asked if she had Resident #1 that he was on the dining room floor. Staff H stated that Staff A, LPN passed Resident #1 to come and get her to tell her he was on the floor. She stated that it was odd, that Staff A, LPN did not call for a Rapid Response or Code Blue instead of coming to get her. Staff H, CNA stated that between 8:50 p.m. and 8:55 p.m. she saw Resident #1 on the floor. She stated that one of the nurses from Station I was at room [ROOM NUMBER], Staff A, LPN. Staff H, CNA stated that she went to check on the resident. She stated that she saw him out of his chair on the floor and could see his face on the floor. She stated she saw Staff I, LPN Weekend Supervisor coming down the hallway from Station II toward the dining room and she called Staff I, LPN called for Resident #1 on the floor. Staff I, LPN called a Code Blue. She stated that no one called for Rapid Response. She stated that when Staff I, LPN called Code Blue the crash cart was brought over. The Code Blue was called and Staff E, RN started doing CPR. The EMS came in and started doing their job too. She stated that she saw a piece of a sandwich beside him. She does not know how he found the sandwich or how he got it. She stated that she did not remember if there were any other residents in the dining room or not. Staff H, CNA stated that Staff A, LPN went back to her medication cart while Staff I, LPN was calling a Code Blue. Staff C, LPN which was the resident's nurse was at lunch at the time. She stated that she did not know who was in charge of Staff C, LPN's residents while she was at lunch. The aides tell the nurses they are going to lunch but not necessarily another aide. She stated that she liked Resident #1. Apparently, he was still hungry and wanted something to eat. During a phone interview on [DATE] at 12:11 p.m. Staff I, LPN Weekend supervisor stated that she was the LPN night supervisor on the evening of [DATE]. She stated that she had just taken a resident to the secure unit and was making her rounds in the facility. She had left Station II and was coming up the hallway toward Station I and the dining room when she saw Staff H, aide. Staff H, aide was she was looking for Resident #1's nurse, because the resident was on the dining room floor. Staff I, stated, Staff A was just walking down the hallway, no excitement. I have no earthly idea why Staff A was not rendering aid to a resident that may have been injured, incapacitated, lying on the floor. Staff I, LPN stated that she was walking toward the dining room and Staff A, LPN was walking away from the resident on the floor. She stated that it was her expectation that a nurse would attend to a resident on the floor, you would expect that she would care for him. She stated that she rushed to the dining room and the way he was positioned on his side he looked in need, he was turning a dusky color. She stated that she felt his back and felt no breathing and felt for a radial pulse. She did not feel anything. She ran around the nursing desk and grabbed chart, to check code status. He was a full code. By that time, Staff H, aide was at the nursing desk and a couple more staff members. She announced she needed the crash cart and called a Code Blue in the dining room. When asked she stated she did not know exactly who initiated CPR. There were a couple of nurses and aides present. She did not remember if it was Staff E, RN or Staff G, LPN. One of them started CPR. When asked if she recalled seeing Staff A, LPN anywhere, she stated she did not remember. She stated while they were performing CPR, she was on the phone with 911. She stated that she saw Staff H, aide, first, and then, she saw Staff A, LPN, asking Staff H, aide, about Resident #1's nurse. She stated that when she went to the resident, there was no other staff member in the dining room. She was the first person to get to him. She stated that Resident #1 had to be redirected several times because of his food seeking behaviors. He would sit in the dining room and be up in his wheelchair around the facility. He was not confined to a specific area. She stated that his peanut allergy was in his chart. She added it when he was initially admitted . She was not aware of him eating a sandwich at the beginning of the code. She stated that she thought he saw someone eating and just got it and ate it. She stated that she was not aware of Resident #1's nurse being out on her break. When the staff goes out on break, they are supposed to sign out and let the other nurse on the floor know they are on break. The partner on the station was responsible for those residents while the other nurse was on break. She stated that she would expect to see documentation in the chart related to the Code Blue including a timeline and all should be completed by the end of shift. She stated that she did not document in the chart. During an interview on [DATE] at 3:29 p.m. Staff E, Registered Nurse (RN), stated that she was working on the night of [DATE]. She stated that she had worked with Resident #1 and was familiar with him. The facility knew what he needed and what he had (peanut allergy). He had a [DEVICE] and was not supposed to take anything by mouth. She stated that she saw him try to take and ask for food. She stated that you would tell him he cannot have food. He understood what we were saying to him. He may be hungry, and we would give him his [DEVICE] feeding. He pointed to food. He could walk and roam the building. He could self-propel his wheelchair and could stand up. She stated that she was never his direct nurse. He would follow through on your directions, but he would try it again, i.e. standing. He had an allergy to some food, but not medication. I think he was allergic to peanut butter. She stated that she found out he was allergic to peanut butter on the day the EMS came because they asked if he had any allergies. She stated that we can see the allergies on the computer. The EMS asked if he was allergic, because there was a peanut butter sandwich next to him. She stated that she was doing the CPR compressions. There was a lot of staff around. She stated that she was on break in the breakroom on the phone and heard the Code Blue overhead at 8:48 p.m. She stated that the crash cart was there. Resident #1 was in the dining room and there was sandwich debris on the floor. A Station 1 nurse was there. Staff E, RN stated that she checked the vitals and started CPR. She did not know if another nurse had already started CPR prior to her or not. She stated that the nurses are the only staff to do CPR. We are supposed to document what we do and what we saw. She stated that she did a progress note in the chart. She stated that the Code Blue Worksheet was supposed to be done also. She stated that the EMS came in and the EMS guy relieved her. The EMS did suction him and took things out of the resident's mouth. The automatic compression machine was applied. EMS did ask if he had any allergies. The nurse he had that night said, yes, he had a peanut allergy. When the nurse told them, he was allergic to peanuts, they gave him a shot of something in the IV. She stated that she did not know what it was. When they put him on the stretcher she went back to her floor. During an interview on [DATE] at 6:04 p.m., Staff F, LPN, stated that she did know Resident #1. She had him as a resident. He needed constant monitoring because he was a wanderer. He was mentally impaired, and he did not grasp that he was only supposed to eat through his tube and was always seeking food in the dining room. He was familiar with everyone eating and he knew where the food was at. She stated that she saw him eat once, while the aides were cleaning up the meal trays. Another resident had given him a tray to eat. We removed him and removed the food. We spoke to the resident that gave him the food tray that she cannot feed him because he cannot eat. She did not care, she stated she was going on to keep feeding him. The resident that gave him the food was still housed on Station I. She heard the Code Blue called. She stated that herself and Staff T, LPN, the other Station III nurse ran to the front. Resident #1 was on the dining room floor. Staff E, RN was getting down on the floor and started CPR. She stated that Staff E, RN was the first nurse she saw doing CPR. Someone was doing the ambu bag, but she does not remember who. Before she could relieve Staff E, RN, from CPR, the EMS came in and they started compressions. She stated that she noticed a portion of an eaten sandwich on the floor. She stated that someone was talking that he had eaten a Peanut butter and jelly sandwich. She stated that she told the EMS and the nurse that he had a peanut allergy. Staff T, LPN said, He had a peanut allergy? Staff T, LPN went to the computer to verify the peanut allergy. She stated that you could smell the peanut butter that night. Staff E, RN had done a finger sweep and brought out some peanut butter, a nice size clump of peanut butter. The EMS gave him epi. EMS put the chest compression machine on him and put him on the stretcher. She stated that she does not know if the Code Blue Worksheet was on the cart or not. She stated that she did not know who Staff A, LPN was. She stated that Staff C, LPN was not there initially, EMS was already there before Staff C, LPN showed up. She was his nurse and she was on lunch break. Staff I, LPN ,the weekend supervisor was there. She was the one who called the Code Blue. Staff F, LPN stated that it bothered her that he was lying there. The speculation was that Resident #1 got the sandwich from the snack cart outside the nursing station. She stated that you would normally see the snack cart outside the nursing station, sometimes, behind the nursing station. She stated that she thought he went into anaphylactic shock because of the peanut allergy, it cut off his air. She stated that she did not think he choked because she had seen him eat before and he got it down. During an interview on [DATE] at 4:36 p.m. Staff R, CNA, stated that Resident #1 went everywhere. He was not to have anything by mouth, but he was always looking for something to eat. He would try to grab something off the snack cart. She stated she did not know what happened that night. She stated he was not supposed to eat, and we were to watch for him. She did hear the Code Blue called but did not know exactly when. She did see Resident #1 on the floor. One nurse was on break and one nurse was here. By the time she got to the dining room, the EMS was here. During an interview on [DATE] at 2:34 p.m., Staff J, Speech Therapist (ST) stated that Resident #1 was originally admitted with a peg tube and had an order for [REDACTED]. He was on a puree diet and thickened liquids possibly while living there. The group home knew he was aspirating, and they were still feeding him. So, they performed a modified [MEDICATION NAME] swallow study and found that he was aspirating all items. He was unable to follow directions or clear his throat with coughing. She stated that she tried to work with him, but he was resistant to care and could not follow commands. He would also become aggressive. He pulled out his [DEVICE] and was sent to the hospital and then returned. ST did not pick him up after the hospitalization s because he would not do anything. The only thing to do was to do more testing. He coughed on his own sputum and with the use of lemon [MEDICATION NAME] swabs. Staff J, ST, stated that If someone was allergic to nuts, you do not bring nuts into the area at all, not anywhere near them. She stated that they don't keep snacks in the therapy room because of food allergies and food intolerances. She evaluates the residents for dysphagia in the dining room or in their rooms because of that. She stated that she did not know Resident #1 had a peanut allergy because she did not work with him with food, because he was NPO. She stated that she did not know if he choked, he may have had a few particles go down, but he had a food allergy. An allergic reaction causes the throat to close and the resident cannot breathe. She felt it was an allergic reaction to the peanut butter allergy versus choking on the sandwich. During an interview on ,[DATE] at 3:07 p.m. the Registered Dietician stated that today was her first day at the facility. She stated that typically the peanut allergy, was the number one food allergy, she found; that and seafood. She stated that the facility should want everyone to be aware of the allergies. Some people may have minor reactions, and some may need to go to the hospital. 6. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 5-day admission Minimum Data Set (MDS), dated [DATE], found a Brief Interview for Mental Status (BIMS) score of 99 meaning the resident was rarely/never understood. The resident required limited assistance of one for bed mobility, transfers, and toileting. He was independent for walking in his room and required assistance of one to move on and off the unit. He was not steady without staff for moving and walking. He was dependent on staff for eating. Review of the Resident #1's medical chart showed an ADMISSION RECORD document that included the following information: admitted : [DATE]. Initial admitted : [DATE], Age: 58, Occupation: Disabled/Never worked, Allergies Peanut, Contacts: Responsible Party: The Resident, Emergency Contact #1: Guardian. Review of Resident #1's order summary report dated [DATE], page 1 of 7 showed Admission: [DATE], Allergies: Peanut, an active physician order [REDACTED]. Total volume to be infused is 1500 ML/24 hours, start date [DATE]. Re

Based on review of facility policy and procedures, interviews with staff, and family member, and record review, it was determined that the facility failed to protect the rights for one (#1) of 14 sampled residents related to Advanced Directives. The facility did not initiate Cardiopulmonary Resuscitation when the resident was found unresponsive, without heart rate or respirations and, the facility did not call 911 for emergency assistance per Policy and Procedure related to Code Status Orders and Response for residents with full code status , effective, ,[DATE], revised ,[DATE] and ,[DATE]. Due to a breakdown in communication, the facility failed to take immediate action to initiate CPR, failed to consult a physician prior to writing an order, failed to accurately review physician ' s monthly orders, and most seriously, failed to honor the advanced directives as expressed on [DATE] by the resident ' s Durable Power of Attorney (POA) and Health Care Surrogate (HCS). Failure of the facility staff to correctly implement advance directives resulted in findings of immediate jeopardy which were removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings include: Review of the facility ' s Policy and Procedure related to the Topic: Code Status Orders and Response effective, [DATE] and revised January, 2011 and November, 2011, reads as follows: #4 d. " If the resident is a full code, the respondent to the call for help will immediately overhead page a code blue & indicate the room number, or the location of the resident/patient & deliver the Medical Record and Emergency Cart and AED if applicable to the location of the Code Blue. " #4 f. " If code status includes Full Code, Begin Cardiopulmonary resuscitation. " #4 g. " If code status is not designated, the resident is a FULL CODE & CPR will be initiated Review of the medical record for resident #1 revealed a face sheet which documented the resident was originally admitted to the facility [DATE]. On [DATE] the resident was determined to be incapacitated of making medical decisions. On [DATE], a family member was legally designated as Durable Power of Attorney (DPOA) and Health Care Proxy (HCP). On [DATE], the HCP executed advanced directives including consent for CPR. The Cardiopulmonary Resuscitation Consent form (AD-0012 ,[DATE]) documented the health care proxy ' s expressed desire to have CPR done in the event of a [MEDICAL CONDITION]. The form also includes the statement " I understand that I may change my above choice at any time by completing a new form. " This form was signed by the HCP/DPOA on [DATE]. Review of the record belonging to resident #1 revealed a hospital history and physical documenting the resident was brought to the hospital [DATE] with complaints of vomiting, [MEDICAL CONDITION] and aspiration pneumonia. The resident was readmitted to the facility [DATE] per the admission face sheet located in the resident ' s chart. The resident ' s record did not include a Do Not Resuscitate (DNR) form. In an interview on [DATE] @ 2:45 p.m. with the social services director, it was revealed that no DNR form had been sent with the resident when he was transported back to the facility. The resident ' s record revealed a nurse ' s note, dated [DATE] at 3:00 p.m. , that documented the POA was called to obtain consent for treatment. During the telephone conversation, the POA verbalized that she had consented to DNR status while the family member was hospitalized , and wished to continue with DNR status in the facility. The nurse documented that the physician was notified by telephone for the DNR order. A social service note, dated [DATE], documented a telephone conversation with the POA/HCP about advanced directives. The HCP wanted to change the resident ' s code status from full code to DNR. Per SSD during [DATE] interview at 11:15 a.m., the HCP was requested to complete and return the forms (yellow DNR form and consent for CPR). A social service note documented the forms were sent to the HCP on [DATE]. Per the resident ' s medical record, a DNR order was obtained on [DATE]. The resident ' s physician signed the order. A social service note, dated [DATE], documented a telephone call was made to the resident ' s HCP inquiring about the DNR status. During an interview on [DATE] at 11:15 a.m. with the social services director, it was learned that the follow up call was initiated because the DNR paper work had not been returned to the facility. At the time of the [DATE] telephone call, it was documented that the health care proxy had changed her mind and wanted the resident to be a Full Code. A CPR consent form was mailed to the HCP on [DATE]. When the social services director (SSD) was interviewed on [DATE] @ 11:15 a.m. it was revealed the HCP told the SSD that she just could not bring herself to make the resident a DNR. The SSD reported that she immediately went to the Director of Nursing (no longer employed at the facility and not available by telephone) and informed her of the POA/HCP ' s wishes to change the resident ' s code status. The resident ' s record revealed a [DATE] telephone order written by the director of nursing as follows: " Full Code per HCP - Cx DNR. " The order was countersigned by a different nurse, dated [DATE], and the bottom of the form was checked that it had been faxed to the pharmacy. The order was not signed by the physician. During an interview on [DATE] at 4:00 p.m. with the facility administrator, it was revealed that the written telephone order, dated [DATE], completed by the DON (no longer employed at facility) and co-signed by another nurse to cancel the DNR and change resident ' s code status to Full Code, had never been discussed with the physician prior to writing the order. However, since the written telephone order, dated [DATE], had been faxed to the pharmacy per the facility ' s protocol, the monthly physician's order [REDACTED].**FULL RESUSCITATE** " . The POS was reviewed and signed [DATE] by the interim director of nursing, and reviewed and signed by the physician, but not dated. The resident ' s physician was not available for comment; however, a signed statement written [DATE] documented that the physician did not give an order on [DATE] to rescind the resident ' s DNR status was provided by the administrator. In an interview on [DATE] at 9:45 a.m. with the interim director of nursing, it was revealed that she was the nurse who had reviewed the monthly physician's order [REDACTED]. She reported she had not been aware that the [DATE] telephone physician's order [REDACTED]. for review and signature the next time the physician comes to the facility. The second and third copies (pink and yellow) are torn off and collected by the DON for review. The DON brings all pink and yellow copies of telephone orders to the facility stand-up meeting the next morning. The fourth (also white) copy remains on the resident ' s record. During an interview on [DATE] at 10:30 a.m., the Regional Vice President and administrator were unable to explain what had happened to the pink and yellow copies of the [DATE] telephone order written by the DON relative to the resident ' s health care proxy ' s wishes to change the resident ' s code status from DNR to full code. The Regional Vice President was also unable to explain why, during routine chart audits, the unsigned telephone order had not been identified and addressed. A social service note, dated [DATE], documented resident, " is alert, unable to make needs known. Resident is a Full Code, have not yet received CPR consent form from family. " Further review of the resident ' s record revealed the following nurses ' notes: LPN note: [DATE] @ 12:00 a.m. " Resident in bed, resting. No concerns " RN note: [DATE] @ 1:45 a.m. " LPN came to RN for assistance in resident #1 ' s room Resident found in bed, eyes closed, no pulse, no respiratory effort, pupils fixed and dilated, pallor to lower lip, DNR status confirmed with order on chart. " During a telephone interview on [DATE] at 8:00 a.m. with the LPN on duty when the resident expired, it was explained that, when the certified nurse assistant (CNA) was doing rounds during the 11:00 p.m. to 7:00 a.m. shift on [DATE] to [DATE], she approached the LPN to go into the resident ' s room because the resident " did not look good. " Per the nurse, the resident did not appear to be breathing. The LPN called for an RN to assist her. As the RN assessed the resident, the LPN noted that resident did not have on a yellow bracelet (procedure for DNR status). The resident ' s chart was checked and a DNR telephone order (dated [DATE]) was found. CPR was not initiated. A 911 call was not made. An interview on [DATE] at 8:15 a.m. with the certified nurse assistant (cna) who was assigned to resident #1 on [DATE] revealed that, when she checked the resident at 1:15 a.m. during rounds, she became concerned about the resident ' s lack of breathing. She was unable to obtain a radial pulse. The resident did not have a yellow wrist band. The aide called the nurse, who checked the resident ' s pulse and blood pressure. An interview was conducted on [DATE] at 8:30 a.m. with the RN who was on duty, but on a different unit, on [DATE]. The RN reported that the LPN from station 1 called for help with resident #1. Upon assessment, she could not obtain a heart rate and no chest movement was observed. The RN checked the resident ' s eyes using a pen light and determined the resident ' s eyes were fixed and the pupils were dilated. She reported when the resident ' s chart was checked, a physician's order [REDACTED]. She then turned the follow-up back to the LPN to complete documentation and notifications. During an interview on [DATE] at 10:00 a.m. with the resident ' s POA/HCP, it was revealed that when the resident was hospitalized in [DATE], the POA was made aware that the resident ' s health was deteriorating, so the POA/HCP signed a DNR. When the resident returned to the facility, the POA reported that she spoke with a nurse (thinks it may have been the head nurse) and explained that after giving it some thought, she did not want the resident to be a DNR because, even though the resident was sick, he was still alert and strong willed. The POA continued to speak, stating that the evening before the resident expired, a friend had visited the resident. The friend reported that it appeared the resident was doing better and that they had a good visit. The POA was shocked when, on [DATE] at approximately 3:00 a.m. she received a call from the facility with notification that the resident had expired. During an interview on [DATE] at 4:00 p.m. with the administrator, and regional vice president (RVP), it was revealed that the administrator learned about the incident on [DATE] when a representative from a state advocacy agency arrived at the facility and reported that a resident had died because the facility did not perform CPR. Per the administrator, the director of nursing (DON), who wrote the telephone order to cancel DNR without consulting the physician first, and without follow up, had been terminated. Per the RVP, the management team was notified immediately and a Performance Improvement Plan was generated as follows: 1. An Ad Hoc meeting was conducted [DATE] with Quality Assurance Committee members to develop a Performance Improvement Plan (PIP) 2. 100% of resident chart audits for advanced directives was completed effective, [DATE].. 3. 100% of staff have been in-serviced about advanced directives, code status, documentation 4. Code drills were implemented immediately for three days on all shifts and will continue monthly for 3 months. 5. New system implemented: DNR form with physician's order [REDACTED]. Yellow wrist band to be utilized for residents with DNR status. If there is no DNR under Advanced Directives tab, then resident is a Full Code; begin CPR, call 911. 6. A follow-up Quality Assurance meeting was held [DATE] to follow up on PIP. The next Quality Assurance committee meeting is scheduled for [DATE]. Review of the effectiveness of the performance improvement plan revealed the following: 1. Fourteen residents ' records were reviewed to confirm that audits were completed. DNR orders were found in the assigned chart location. Code status found under the advanced directives tab matched physician's order [REDACTED]. 2. Many residents were observed wearing yellow wrist bands 3. Training logs were compared against current employee list and it was confirmed that 100% of staff had been in-serviced as of [DATE] related to: Codes, advanced directive, and documentation. Interviews were conducted with 18 staff members including aides, nurses, housekeeping, and dietary staff assigned to work all 3 shifts. All staff interviewed confirmed they had attended recent training, and, they were able to verbalize current procedures related to code status. 4. An attempt was made to contact the Director of Nursing involved in the incident, but she has been terminated and did not return the surveyor ' s call. 5. The attending physician (also the medical director) was not available for contact. 6. Observation of an ongoing code on [DATE] at 7:15 a.m. revealed the facility responded in keeping with resident wishes and policies when a resident was found unresponsive at 7:08 a.m. The resident had recently had the code status changed (per family request) from DNR to Full Code. The nursing staff followed the family ' s wishes, initiated CPR, and called 911. The resident was successfully resuscitated and was transported to the hospital with a heart rate of 70. The immediate jeopardy was found to be removed on [DATE] at 4:30 p.m. and severity and scope was reduced to a D.

Based on interviews with family and staff, review of facility policy related to physician's order [REDACTED].#1) of 14 residents sampled relative to code status. The facility did not initiate cardiopulmonary resuscitation (CPR), nor did they call 911 when the resident was found unresponsive, with no heart rate or respirations. The facility did not honor the expressed wishes of the resident ' s family member, the designated Durable Power of Attorney (POA) and Health Care Proxy (HCP). The omission of services (CPR) necessary to avoid physical harm to the resident resulted in findings of immediate jeopardy which was removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings include: 1. An interview was conducted with the family member (HCP) via telephone on [DATE] at 10:00 a.m. Per the HCP; the resident had recently been hospitalized , from [DATE] to [DATE]. The HCP signed a Do Not Resuscitate (DNR) order at the hospital due to the resident ' s deteriorating health status at that time. The resident returned to the facility on [DATE]. The HCP reported that she spoke with someone from the facility regarding the resident ' s code status. The HCP explained that she did not want the resident to be a DNR while at the facility, because even though he was sick, he was still alert and strong willed. The HCP proceeded to tell the surveyor that one of the resident ' s friends had visited the evening before the resident expired and explained that, per the visitor, the resident seemed better based on the laughter and enjoyment of their visit. 2. Review of the facility ' s policy and procedure related to the topic of physician's order [REDACTED]. Confirm verbal and telephone orders by repeating back to the physician Obtain physician ' s countersignature within the required time frame as defined by State law. In the absence of State law, the countersignature will be obtained within seven days. Confirm accuracy of orders when the new monthly orders arrive from pharmacy: transcription errors, errors of omission 3. Review of the resident ' s medical record revealed a nurse ' s note, dated [DATE] at 3:00 p.m. that documented a telephone conversation between the nurse and the HCP. During the phone conversation, the HCP stated that the resident had been a DNR while in the hospital and she wanted to continue the DNR status in the facility. The resident ' s physician was notified and a telephone order was received [DATE] for DNR status. The telephone order was signed by two nurses and the physician. 4. Review of a social service note, dated [DATE], documented a telephone call with the HCP who, on that date, gave verbal consent for the resident to be DNR status. The yellow DNR form was sent to the HCP for signature, to be returned to the facility. The form was never returned to the facility. On [DATE] at 11:15 a.m. an interview was conducted with the facility ' s social services director (SSD). Per the SSD, the family member is the Durable Power of Attorney as well as Health Care Proxy for resident #1. Per the SSD, resident #1 had been a full code while at the facility prior to going out to the hospital. When the resident was readmitted to the facility [DATE], no DNR form was sent along with hospital records. Per the SSD, to her knowledge, a resident is always considered a full code if they arrive at the facility without a DNR form. The SSD revealed during the [DATE] interview at 11:15 a.m., the DNR form sent to the HCP on [DATE] had not been signed and sent back to the facility. A follow up telephone call was made on [DATE] to the HCP to inquire about the status of the form. According to the SSD, it was learned during the [DATE] phone call, that the HCP had changed her mind. Per the SSD, the HCP just could not bring herself to make the resident a DNR; she verbalized directives to change the resident ' s code status to full code. The SSD stated that she notified the Director of Nursing (DON) about the HCPs wishes for the change in the resident ' s code status. 5. The resident ' s record revealed a telephone order, dated [DATE], as follows: " Full Code per HCP - cancel DNR " . The telephone order was signed by the Director of Nursing and was checked off that it was faxed to the pharmacy. The resident ' s record revealed physician ' s progress notes, dated [DATE] and [DATE], which documented the physician had been in to see the resident. The physician did not sign the [DATE] order for change in code status during either of those two visits. 6. The resident ' s record revealed the monthly physician's order [REDACTED]. The current physician's order [REDACTED].**FULL RESUSCITATE** " . The current physician's order [REDACTED]. 7. During an interview on [DATE] at 4:30 p.m. with the administrator and regional vice president (RVP), it was revealed that, per their knowledge, the only physician's order [REDACTED]. They reported that, when resident #1 became unresponsive, the nurses checked the chart. There was no yellow DNR form, but there was a physician's order [REDACTED]. As a result, when the resident became unresponsive and without heart rate or respirations on [DATE], CPR was not initiated and 911 was not called, because nurses had followed the [DATE] physician's order [REDACTED]. The administrator and RVP did confirm that the physician ' s signature was prominent on the monthly orders for February 2012 designating the resident as a " **FULL RESUSCITATE**. " The RVP also confirmed that the monthly orders for February, 2012 were reviewed and signed off by the current interim DON. A statement was signed by the physician on [DATE] (per RVP) with the following: " I did not give an order on [DATE] to rescind (the resident ' s name) DNR. " 8. Further review of the resident ' s record revealed an admission face sheet that documented the resident ' s readmission to the facility [DATE] following a 4-day hospitalization admission related to aspiration pneumonia and gastrostomy tube revision. A Minimum Data Set (MDS) quarterly assessment and care screening was completed [DATE]. Per review of the assessment and interview on [DATE] at 10:30 a.m. with the MDS coordinator, it was revealed that resident #1 was determined to be severely impaired relative to cognition and decision making skills. A care plan was reviewed and updated [DATE]. The care plan addressed problem areas including cognitive loss. The care plan did not address the resident ' s advanced directives. A social service note, dated [DATE], documented resident was a full code and " is alert, unable to make needs known. Resident is a Full Code, has not yet received CPR consent form from family. " 9. Further review of the resident ' s record revealed the following nurses ' notes: 10. LPN note: [DATE] @ 12:00 a.m. " Resident in bed, resting. No concerns " 11. RN note: [DATE] @ 1:45 a.m. " LPN came to RN for assistance in resident #1 ' s room Resident found in bed, eyes closed, no pulse, no respiratory effort, pupils fixed and dilated, pallor to lower lip, DNR status confirmed with order on chart. " 12. During a telephone interview on [DATE] at 8:00 a.m. with the LPN on duty when the resident expired, it was explained that, when the certified nurse assistant (CNA) was doing rounds during the 11:00 p.m. to 7:00 a.m. shift on [DATE] to [DATE], she approached the LPN to go into the resident ' s room because the resident " did not look good. " Per the nurse, the resident did not appear to be breathing. The LPN called for an RN to assist her. As the RN assessed the resident, the LPN noted that resident did not have on a yellow bracelet (procedure for DNR status). The resident ' s chart was checked and a DNR telephone order (dated [DATE]) was found. CPR was not initiated. A 911 call was not made. 13. An interview on [DATE] at 8:15 a.m. with the certified nurse assistant (cna) who was assigned to resident #1 on [DATE] revealed that, when she checked the resident at 1:15 a.m. during rounds, she became concerned about the resident ' s lack of breathing. She was unable to obtain a radial pulse. The resident did not have a yellow wrist band. The aide called the nurse, who checked the resident ' s pulse and blood pressure. 14. An interview was conducted on [DATE] at 8:30 a.m. with the RN who was on duty, but on a different unit, on [DATE]. The RN reported that the LPN from station 1 called for help with resident #1. Upon assessment, she could not obtain a heart rate and no chest movement was observed. The RN checked the resident ' s eyes using a pen light and determined the resident ' s eyes were fixed and the pupils were dilated. She reported when the resident ' s chart was checked, a physician's order [REDACTED]. She then turned the follow-up back to the LPN to complete documentation and notifications. 15. Review of the facility ' s reporting system revealed mandated Federal reports were completed and submitted in a timely manner. A summary, as documented by the Risk Manager (no longer at facility) revealed: During a follow-up phone call with the HCP on [DATE], the HCP notified the SSD that she had changed her mind and wanted resident #1 to be a full code (cancel DNR status.) The DON, as of [DATE], wrote an order to cancel the DNR status; however, she failed to call the physician for this order. On [DATE], the resident was found unresponsive without pulse or respirations. Due to the nurse ' s failure to appropriately follow through with the code status change, the only order on the chart, at that time, signed by a physician was a DNR order dated [DATE]. It was determined that the nurse did not follow the appropriate process. The nurse who failed to follow through with verification of physician's order [REDACTED]. A performance improvement plan (PIP) was initiated ,[DATE] and ,[DATE] and implementation commenced immediately. Review of the PIP revealed 100% of resident records were audited for the presence of advanced directives; code drills were completed for three days on all shifts, 100% of staff members were re-educated re: code status, advanced directives and documentation. Interviews conducted with 19 staff members from all departments and all shifts revealed evidence that training was completed and the information was communicated. New procedures have been implemented and verified via chart audits. The facility continues to closely monitor for the accuracy of resident ' s code status through ongoing chart audits, in-services, and code drills. The immediate jeopardy was found to be removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D.

Based on review of the Florida Nurse Practice Act, record review, staff interviews, facility policy review, and disciplinary action report, it was determined that the facility did not meet professional standards of quality. The director of nursing failed to follow facility procedure for writing a telephone order, failed to communicate with staff, and failed to follow through with a family member ' s request to change resuscitation code status for one (#1) of 14 sampled residents from DNR to full code. The facility failed to implement their policy and procedure related to Physician order [REDACTED]. The facility did not initiate Cardiopulmonary resuscitation (CPR) when the resident was found with no heartbeat and no respirations. This resulted in findings of immediate jeopardy which was removed [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings Include: 1. The Florida Department of Health, Florida Board of Nursing Nurse Practice Act, Chapter 464, FS Rules of the Board of Nursing, Chapter 64B9, F.A.C, 464.003 Definitions state: " (3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. " 2. Review of resident #1 ' s medical record revealed a face sheet which documented the resident was readmitted to the facility [DATE] following a 4 day hospitalization admission related to Aspiration pneumonia, and gastrostomy tube. The record revealed that prior to hospitalization on [DATE]; the resident had been a Full Code status. 3. Review of the nurse ' s notes dated [DATE] at 3:00 p.m. revealed a telephone conversation between a nurse and the resident ' s health care proxy (HCP) had taken place. During that conversation, the HCP verbalized wishes to make resident #1 a do not resuscitate (DNR). Per the social service notes, the appropriate paperwork (Florida Do Not Resuscitate form and consent for CPR form) was sent to the HCP with instructions to review, sign and return it to the facility. In the meantime, the nurse wrote a telephone order on [DATE] for DNR status which was signed by the physician and placed in the resident ' s medical record under the Advanced Directives tab. 4. Further review of social service notes revealed a telephone conversation with the HCP on [DATE] to follow up on code status. During an interview on [DATE] at 11:15 a.m. with the social services director, it was learned that the follow up call was initiated because the DNR paper work had not been returned to the facility. At the time of the [DATE] telephone call, it was documented that the health care proxy has changed her mind and wanted the resident to be a Full Code. A CPR consent form was mailed to the HCP on [DATE]. When the social services director (SSD) was interviewed on [DATE] @ 11:15 a.m. it was revealed the HCP told the SSD that she just could not bring herself to make the resident a DNR. The SSD reported that she immediately went to the Director of Nursing (no longer employed at the facility and not available by telephone) and informed her of the POA/HCP ' s wishes to change the resident ' s code status. 5. The resident ' s record revealed a [DATE] telephone order written by the director of nursing as follows: " Full Code per HCP - Cx DNR " . The order was countersigned by a different nurse, and dated [DATE] and checked that the order had been faxed to the pharmacy. There was no evidence in the resident ' s record that the verbal order had been signed by the physician. The Director of Nursing ' s actions on [DATE] were not in compliance with Professional Nurse Requirements as defined in the Florida Nurse Practice Act due to failing to obtain an order for [REDACTED]. When the resident became unresponsive on [DATE], CPR was not initiated, and 911 was not called. 6. Per the facility ' s policy relative to Physician order [REDACTED]. a. Confirm verbal and telephone orders by repeating back to physician. b. Obtain physician ' s countersignature within the required time frame as determined by State law. In the absence of State law, the countersignature will be obtained within seven days. c. Confirm accuracy of orders when the new monthly orders arrive from pharmacy. 7. Review of the physician ' s progress notes revealed documentation that the physician had visited the resident on [DATE] and [DATE]. The order was written by the nurse on [DATE]. 8. A social service note, dated [DATE], documented resident, " is alert, unable to make needs known. Resident is a Full Code, has not yet received CPR consent form from family. " 9. Further review of the resident ' s record revealed the following nurses ' notes: LPN note: [DATE] @ 12:00 a.m. " Resident in bed, resting. No concerns " RN note: [DATE] @ 1:45 a.m. " LPN came to RN for assistance in resident #1 ' s room Resident found in bed, eyes closed, no pulse, no respiratory effort, pupils fixed and dilated, pallor to lower lip, DNR status confirmed with order on chart. " During a telephone interview on [DATE] at 8:00 a.m. with the LPN on duty when the resident expired, it was explained that, when the certified nurse assistant (CNA) was doing rounds during the 11:00 p.m. to 7:00 a.m. shift on [DATE] to [DATE], she approached the LPN to go into the resident ' s room because the resident " did not look good. " Per the nurse, the resident did not appear to be breathing. The LPN called for an RN to assist her. As the RN assessed the resident, the LPN noted that resident did not have on a yellow bracelet (procedure for DNR status). The resident ' s chart was checked and a DNR telephone order (dated [DATE]) was found. CPR was not initiated. A 911 call was not made. An interview on [DATE] at 8:15 a.m. with the certified nurse assistant (cna) who was assigned to resident #1 on [DATE] revealed that, when she checked the resident at 1:15 a.m. during rounds, she became concerned about the resident ' s lack of breathing. She was unable to obtain a radial pulse. The resident did not have a yellow wrist band. The aide called the nurse, who checked the resident ' s pulse and blood pressure. An interview was conducted on [DATE] at 8:30 a.m. with the RN who was on duty, but on a different unit, on [DATE]. The RN reported that the LPN from station 1 called for help with resident #1. Upon assessment, she could not obtain a heart rate and no chest movement was observed. The RN checked the resident ' s eyes using a pen light and determined the resident ' s eyes were fixed and the pupils were dilated. She reported when the resident ' s chart was checked, a physician's order [REDACTED]. She then turned the follow-up back to the LPN to complete documentation and notifications. 10. During an interview on [DATE] at 4:00 p.m. with the facility administrator, it was revealed that the written telephone order dated [DATE], completed by the DON (no longer employed at facility) to cancel the DNR and change the resident ' s code status to Full Code, had never been discussed with the physician prior to writing the order. The administrator stated that the telephone orders were not brought to the next morning ' s stand up meeting as was usual facility practice. The physician wrote a statement [DATE] that he had not given orders on [DATE] to rescind the resident ' s DNR status. 11. The [DATE] telephone order was checked at the bottom and faxed to the pharmacy per facility practice when a telephone order is received and written. As a result, the monthly physician's order [REDACTED].**FULL RESUSCITATE** " . The POS was reviewed and signed [DATE] by the interim director of nursing and reviewed and signed by the physician. 12. Per nurse ' s note dated [DATE] at 1:45 a.m., " resident found in bed, eyes closed, no pulse, no respiratory effort, pupils fixed and dilated, pallor noted to lower lip, no response to pain; DNR status confirmed with order on chart. " 13. In an interview on [DATE] at 9:45 a.m. with the current interim director of nursing, it was explained that new monthly orders are compared against the previous month ' s orders and other verbal, telephone or written orders that accumulated during the month. The interim DON reviewed the February orders on [DATE] but did not follow up that the [DATE] telephone order had not yet been signed. She also confirmed that she did not notice the change in the resident ' s code status documented at the top of the February, 2012 physician's order [REDACTED]. 14. On [DATE], the facility began implementation of a performance improvement plan to correct discrepancies associated with resident code status. All employees were in-serviced, as evidenced by sign-in sheets and random interviews. Chart audits were completed to confirm current code status. Code drills were conducted on all shifts. A new system was implemented where the yellow DNR form is kept in the resident ' s medical record, in a plastic sleeve directly under the Advanced Directives tab, and easy for staff to access. Residents continue to wear yellow wrist bands if they are DNR status. Staff reported that, " when in doubt, begin CPR. " The Director of Nursing was terminated and was reported to the professional board. Because a performance improvement plan is in effect and ongoing monitoring continues, the immediate jeopardy was found to be removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D.

Based on record review, facility policy and procedure review, employee job description reviews, and interviews with facility staff, it was determined that administration failed to provide resource management to meet the needs for one (#1) of 14 sampled residents who was not resuscitated by facility staff when found unresponsive. Administration failed to ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. Administration failed to implement policies and procedures relative to the legal representative ' s authority to make decisions on the resident ' s behalf. Administration failed to ensure that physician's order [REDACTED]. As a result, the highest degree of attention and care not provided to a resident with wishes for full code response. The actions resulted in findings of immediate jeopardy, which were removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the job description for the Administrator (undated), provided by the administrator on [DATE], revealed the following relevant information: Summary of Position: The nursing home administrator (NHA) is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents. Essential Duties and Responsibilities: Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations and guidelines are available and followed. 2. Review of the medical record for resident #1 revealed a face sheet which documented the resident was originally admitted to the facility on [DATE]. On [DATE] the resident was determined to be incapacitated of making medical decisions. On [DATE], a family member was legally designated as Durable Power of Attorney (DPOA) and Health Care Proxy (HCP). On [DATE], the HCP executed advanced directives including consent for CPR. The Cardiopulmonary Resuscitation Consent form (AD-0012 ,[DATE]) documented the health care proxy ' s expressed desire to have CPR done in the event of a [MEDICAL CONDITION]. The form also includes the statement " I understand that I may change my above choice at any time by completing a new form. " This form was signed by the HCP/DPOA on [DATE]. Review of the record belonging to resident #1 revealed a hospital history and physical documenting the resident was admitted to the hospital [DATE] with complaints of vomiting, [MEDICAL CONDITION] and aspiration pneumonia. The resident was readmitted to the facility on [DATE] per the admission face sheet located in the resident ' s chart. The resident ' s record did not include a Do Not Resuscitate (DNR) form. In an interview on [DATE] @ 2:45 p.m. with the social services director (SSD), it was revealed that no DNR form had been sent with the resident when he was transported back to the facility. The resident ' s record revealed a nurse ' s note, dated [DATE] at 3:00 p.m., that documented the POA was called to obtain consent for treatment. During the telephone conversation, the POA verbalized that she had consented to DNR status while the family member was hospitalized , and wished to continue with DNR status in facility. The nurse documented that the physician was notified by telephone for a DNR order. A social service note, dated [DATE], documented a telephone conversation with the POA/HCP about advanced directives. The HCP wanted to change the resident ' s code status from full code to DNR. Per the SSD, during the [DATE] interview at 11:15 a.m., the HCP was requested to complete and return the forms (yellow DNR form and consent for CPR, AD-0013). A social service note documented the forms were sent to the HCP on [DATE]. The yellow form includes both a patient ' s statement with signature block for the resident/patient or surrogate, proxy, court appointed guardian or durable power of attorney if not signed by the resident. Following that, there is a " Physician ' s Statement " with signature block and date. Per the resident ' s medical record, a DNR order was obtained on [DATE]. The resident ' s physician signed the order. A social service note, dated [DATE], documented a telephone call was made to the resident ' s HCP inquiring about the DNR status. During an interview on [DATE] at 11:15 a.m. with the social services director, it was learned that the follow-up call was initiated because the DNR paper work, as referenced above, had not been returned to the facility. At the time of the [DATE] telephone call, it was documented that the health care proxy has changed her mind and wanted the resident to be a Full Code. A CPR consent form was mailed out on [DATE]. The resident ' s record revealed a [DATE] telephone order written by the director of nursing as follows: " Full Code per HCP - Cx DNR. " The order was countersigned by a different nurse, dated [DATE], and the box at the bottom of the telephone order form was checked that the order had been faxed to the pharmacy. The order was not signed by the physician. During an interview [DATE] at 4:00 p.m. with the facility administrator, it was revealed that the written telephone order dated [DATE], completed by the DON (no longer employed at facility) and co-signed by another nurse to cancel the DNR and change resident ' s code status to Full Code, had never been discussed with the physician prior to writing the order. However, since the written telephone order, dated [DATE], had been faxed to the pharmacy per the facility ' s protocol, the monthly physician's order [REDACTED].**FULL RESUSCITATE** " . The POS was reviewed and signed [DATE] by the interim director of nursing and reviewed and signed by the physician, but not dated. 3. A telephone interview was conducted on [DATE] at 10:00 a.m. with the resident ' s health care proxy (HCP) who stated that she just could not bring herself to make resident #1 a DNR because he seemed to be doing better, was alert and was still strong-willed. The HCP reiterated that she was very surprised upon receiving notification from the facility that the resident had expired, because the evening before his death, a friend had visited the resident and reported back to the HCP that the resident was doing better and that they had a good visit. 4. Further review of the resident ' s record revealed the following nurse ' s notes: [DATE] at 12:00 a.m. " Resident in bed resting. No concerns documented. " [DATE] at 1:45 a.m., RN note: " LPN came to me for assistance in room [ROOM NUMBER]-A; resident found in bed, eyes closed, no apical heart tones, no radial pulse palpable, no respiratory effort, pupils fixed and dilated, pallor noted to lower lip, no response to pain, DNR status confirmed with order on chart. " [DATE] at 1:50 a.m. LPN note: " Physician notified, new orders obtained " [DATE] at 2:00 a.m. LPN note: " Family member notified " 5. A review of the [DATE] physician's order [REDACTED]. " This order was written and signed by the director of nursing on [DATE]. The telephone order revealed another nurse reviewed and signed the order as well. 6. During an interview on [DATE] at 4:30 p.m. with the administrator, it was revealed that the [DATE] order written by the director of nursing (no longer at the facility) was never communicated to the physician. In addition, the orders were not brought to the stand-up meeting the next day as per facility protocol. As a result of the breakdown in communication, cardiopulmonary resuscitation was not initiated in accordance with the health care proxy ' s verbal directives during a phone call on [DATE] to cancel the DNR status and make the resident a full code. 7. The administrator and regional vice president were interviewed [DATE] at 4:00 p.m. They confirmed that they were not made aware of the resident ' s change in code status until [DATE] when a representative from an advocacy agency arrived at the facility and stated someone died because CPR was not performed. The Administrator and regional vice president confirmed that facility systems include 24-hour chart audits, and monthly medication and treatment order reviews. They agreed that the unsigned telephone order, written [DATE], was not identified at the time the daily and monthly physician orders [REDACTED]. 8. Review of the facility ' s Advanced Medical Directives policy, effective January, 2006 revealed: An attorney-in-fact under the durable power of attorney for health care may give medical decision-making directives for the resident. 9. Review of the facility ' s policy and procedure related to physician's order [REDACTED]. a) All physicians orders will be dated and signed according to State and Federal regulations b) Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician ' s Telephone Order form as an " Order Clarification. " c) Obtain physician ' s countersignature within the required time frame as defined by State law. In the absence of State law, the countersignature will be obtained within seven days. d) Assure appropriate departments are aware of applicable orders. e) Confirm accuracy of orders when the new monthly orders arrive from pharmacy 10. Review of the resident ' s record revealed the telephone order written [DATE] was never identified as needing a physician ' s signature, and it was never communicated to other nurses that there had been a request for a change in the resident ' s code status. The facility ' s systems failed. As a result, when the resident was found unresponsive, without pulse or respirations on [DATE] at 1:45a.m., cardiopulmonary resuscitation was not initiated and 911 was not called. 11. In an interview on [DATE] at 4:00 p.m. with the administrator, it was revealed the facility acted immediately when they learned about the incident. A quality assurance meeting was held the next day, [DATE], to develop a performance plan that included the following: staff education, chart audits, implementation of new procedures for identification of code status, code drills, and ongoing monitoring. The performance improvement plan was implemented [DATE]. All staff were trained effective [DATE]. Monitoring of charts and code drills remain ongoing. 12. Random in-person and telephone interviews were conducted with nurses and aides from all shifts on ,[DATE], ,[DATE] and [DATE] to determine attendance and comprehension of recent training. All interviewed staff was able to verbalize an understanding as to how to proceed if a resident was found unresponsive. All staff was retrained on facility protocol for honoring advance directives. A performance improvement plan (PIP) was initiated ,[DATE] and ,[DATE] and implementation commenced immediately. Review of the PIP revealed 100% of resident records were audited for the presence of advanced directives; code drills were completed for three days on all shifts, 100% of staff members were re-educated re: code status, advanced directives and documentation. Interviews conducted with 19 staff members from all departments and all shifts revealed evidence that training was completed and the information was communicated. New procedures have been implemented and verified via chart audits. The facility continues to closely monitor for the accuracy of resident ' s code status through ongoing chart audits, in-services, and code drills. The immediate jeopardy was found to be removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D.