**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to timely follow procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and available to nursing staff, and failed to honor an advance directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident reviewed for Death, of a total sample of 42 residents, (#108). These failures contributed to resident #108 receiving CPR against her explicit wish for a natural, dignified death. There was likelihood resident #108 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On Friday, [DATE], at approximately 2:00 PM, resident #108 and her physician signed a Do Not Resuscitate Order (DNRO) form. The Social Services Assistant scanned the completed form to the Electronic Medical Record (EMR) and placed the document in her office. The Social Services Assistant continued her workday until 5:00 PM then left for the weekend. The Social Services Assistant failed to provide a copy of the DNRO to the nursing staff, before she left for the weekend. Upon receipt of the DNR form, the nursing staff, per policy, would have updated the EMR from Full Code status to DNR status. Nursing staff would have also placed the canary yellow DNR form in front of the resident's chart to allow for staff to quickly identify the code status during an emergency. On Sunday, [DATE], at approximately 5:20 AM, resident #108 became unresponsive, was not breathing, and had no pulse. Nurses checked the resident's EMR and paper binder chart and found a physician's order for Full Code status. Nurses determined resident #108 was Full Code status and initiated CPR. Facility staff called 911 at 5:24 AM, and when Emergency Medical Services (EMS) personnel arrived at the resident's bedside, they continued CPR from the resident's room to the ambulance. Resident #108 suffered aggressive resuscitation measures on the way to the hospital and in the Emergency Department (ED) until she was pronounced dead on [DATE] at 6:32 AM. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a DNRO advanced directive at risk for serious psychosocial harm, physical trauma, and a prolonged undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Review of the medical record revealed resident #108, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included metastatic (spread from origin to a distant part of the body) melanoma (deadly skin cancer), chronic congestive heart failure, aortic (heart) valve stenosis (narrowing), complete atrioventricular (heart chamber) block, oxygen dependence, acute respiratory failure, chronic obstructive lung disease, heart disease, cardiac rhythm (heartbeat) dysfunction with pacemaker, chronic peripheral (limb) venous insufficiency (blood flow), intestinal obstruction (blockage), stage 3 chronic kidney disease, type 2 diabetes mellitus, sleep apnea (breathing pause or stop), repeated falls, need for assistance with personal care, and depression. The Minimum Data Set (MDS) Death In Facility tracking assessment with an Assessment Reference Date (ARD) of [DATE] noted resident #108 was discharged from the facility to the hospital. The MDS quarterly assessment with an ARD of [DATE] noted resident #108 had a Brief Interview for Mental Status score of 11 out of 15 which indicated moderate cognitive impairment. The assessment showed the resident had no indicators of psychosis, behavioral symptoms, or rejections of evaluation or care, required extensive assistance from staff to complete her Activities of Daily Living, walked once in her room with staff assistance, did not walk outside of her room, was incontinent of bladder and bowel functions, experienced moderate pain, shortness of breath, and she required supplemental oxygen. For 7 out of 7 days during the look back period, she received injectable insulin, and antidepressant (depression), anticoagulant (blood thinner), diuretic (fluid retention), and opioid (narcotic pain) medications. The Florida Agency for Health Care Administration Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA 5000-3008) dated [DATE] revealed resident #108 did not require a surrogate to make healthcare decisions. The readmission Agreement between the resident and the facility was signed by resident #108 on [DATE] that indicated she made her own medical and financial decisions. The medical record did not include any requests for a capacity evaluation nor a physician's determination of incapacity. The Order Listing Report showed physicians orders dated [DATE] that read, Resident is a Full Code, and [DATE] that read, Transfer to ER. The Comprehensive Care Plan included focus for self-performance care deficits, dependence on staff to complete daily living activities, infections, multiple chronic medical conditions of the heart, lungs, kidneys, muscles, and bones, diabetes with insulin dependence, abdominal surgery, skin injuries, repeated falls, adverse medication effects, depression, anxiety, risk for nutritional and hydration problems, supplemental oxygen dependence, and pain. The care plan did not include a focus for advanced directives or code status. The Psych (Psychiatric) Health Associates progress notes dated [DATE] noted resident #108 was assessed by the Psychiatric Advanced Practice Nurse Practitioner (APRN) who wrote, Thought association is intact, insight and judgement are adequate. Thought process is linear (logical and sequential), . Denies depression or anxiety noted. Denies any suicidal ideation. Patient is adjusting emotionally well to the stressful change the patient is undergoing. On [DATE] at 4:45 PM, during an interview, the Social Services Assistant said she handled most of the facility's code status changes from a full code to Do Not Resuscitate (DNR). She explained the process included her evaluation and determination of residents' cognition, the ability to make their own decisions, and she ensured they understood the full meaning of a DNRO. She stated residents who were not determined by a physician to be incapacitated signed their own DNRO, and it was valid with a physician's signature. She recalled on [DATE] at approximately 2:00 PM, resident #108 was cognitively intact and wished for DNR as part of her treatment plan when she signed the yellow DNRO form. She said the physician was in the facility, and he signed the form immediately after the resident did. She explained it was Friday when she scanned the form into the Electronic Medical Record (EMR) and decided to keep the form in her office until she returned to work on Monday. She explained she planned to give it to nurses on Monday so they could change the order and put the form in the resident's chart. She said she left work that Friday at 5:00 PM and when she returned to work on Monday [DATE], she learned the resident had died. She conveyed she told her supervisor, the Social Services Director about the DNRO and gave the form to the Unit Secretary. She said, I dropped the ball. Review of the State of Florida DO NOT RESUSCITATE ORDER form revealed both resident #108 and her physician signed the form on [DATE]. On [DATE] at 11:28 AM, in a telephone interview, resident #108's son said his mother's health had declined and she was recently diagnosed with cancer. He recalled about a week prior to [DATE] they had conversations about her code status, and she had decided she did not want to be resuscitated. He said on [DATE], the Social Services Assistant was reminded by his husband to have the DNR implemented but he wasn't aware his mother had signed it until about a week after she passed. He said no one from the facility called him, but rather sent messages through his husband. He stated it was very disappointing that no one reached out to him personally. He explained the facility communicated everything through his husband and told him everything was being handled. He spoke about the deep sorrow and anguish he felt because he knew his mother's spiritual beliefs and wishes very well as they were extremely close. He stated he was most affected when he envisioned his mother, over her body looking down and saying to herself, what are you doing to me? That's not what I asked for. On [DATE] at 4:11 PM, the Unit 300 Unit Manager explained when nurses were given a completed DNRO form for a code status change, the process included a revision of the Full Code order in the EMR to DNR and the form placed in front of the resident's paper chart kept at the nurses' station. She stated nurses depended on the EMR and paper chart for a current and accurate code status to initiate or withhold CPR when emergencies arose. On [DATE] at 4:21 PM, the Director of Nursing (DON) said all resident's code status were entered into the EMR as a physician's order and DNRO forms were kept on top in the paper binder/charts kept at the nurse's station. She explained when emergencies with cardiac and respiratory arrest occurred, nurses checked the EMR and paper chart for code status and proceeded with CPR for full code and did not proceed with a DNRO. She stated when staff other than nursing completed a DNRO with a resident who wanted to change their status, the form was given to nurses for order transcription and placement of the form onto the front of the paper chart so it was easily accessible by direct care staff. She referred to residents' wishes to change their full code status to DNR and said, it's a big deal. Review of the Change in Condition progress note dated [DATE] at 5:30 AM revealed Registered Nurse (RN) L assessed resident #108 as unresponsive, pale, and without breathing or a pulse. The note showed nurses checked the resident's records, determined the code status was Full Code, and initiated CPR until EMS personnel arrived and transported her to the hospital, on active CPR. On [DATE] at 12:37 PM, and [DATE] at 9:49 AM, unsuccessful attempts were made to interview RN L by telephone. In a telephone interview on [DATE] at 12:45 PM, the Nurse Night Shift Supervisor described the sequence of events on [DATE], the day resident #108 received CPR. She recalled RN L had called a Code Blue. She explained she entered resident #108's room and observed RN L took vital signs, and told her the resident wasn't breathing. She said nurses verified the code status in the EMR and paper chart and determined the resident was a full code. She stated she told RN L to start CPR, she called 911, and returned to assist nurses with chest compressions and oxygen ventilations via Bag Valve Mask (ambu bag) until EMS arrived and took over. She said facility management never informed her after the incident that resident #108 was a DNR. On [DATE] at 10:12 AM, in a telephone interview, Licensed Practical Nurse (LPN) M recalled resident #108's Code Blue and CPR on [DATE]. She explained when she arrived in the room, she observed that RN L obtained vital signs and initiated CPR. She stated nurses provided 2 rounds of CPR with chest compressions and ventilations by ambu bag until Law Enforcement and EMS personnel arrived. She said she heard from other staff days later there was a DNRO for resident #108. She explained nurses would have known about the DNR if the Social Services Assistant had given them the form to place in front of the medical record. On [DATE] at 10:39 AM, RN N recalled on [DATE], she observed CPR was in progress by nurses for resident #108. She said she assisted them with chest compressions and the ambu bag until EMS personnel transitioned and continued resuscitative measures. On [DATE] at 4:11 PM, the Unit 300 Unit Manager said resident #108's DNRO form was not provided to nurses after the resident and the physician signed it. She said if nurses had received the DNRO on [DATE], they would have withheld CPR. On [DATE] at 10:57 AM, the APRN said resident #108 had multiple chronic conditions, her health had declined, and she had a diagnosis of melanoma in previous months. She recalled she had discussions with resident #108 and her family about a week prior to [DATE], and the resident did not want resuscitation measures. She said resident #108 was able to make her own decisions as she only had mild cognitive impairment. The APRN explained she was upset about the CPR incident as it was preventable, and had the resident survived it likely would have been a bad outcome for her as her quality of life, could have been so much worse. On [DATE] at 2:04 PM, the Medical Director said on [DATE] around 2:00 PM he signed the DNRO yellow form for resident #108 after she had signed it with the Social Services Assistant. He explained his expectation was that the DNRO was an active physician's order that was in effect immediately after he signed it. He recalled resident #108 had good cognition and was able to make the decision to change her code status to DNR. He stated a DNRO was a very important plan of treatment to honor one's wishes. He said he was informed in the weeks after the incident, the facility completed an investigation and determined the Social Services Assistant didn't follow their process. He stated the incident could have been avoided, and had the resident survived, she likely would have suffered a very poor quality of life. He said he was disappointed it happened and accounted the event as, devastating and heartbreaking. On [DATE] at 5:32 PM, resident #108's son-in law said he and his mother-in-law had a very close relationship. He recalled on [DATE] at around 1:30 PM, he reminded the Social Services Assistant that his mother-in-law still wanted to be a DNR. He explained he was not aware she had signed the form until about 10 days after she died. He stated about a week prior to [DATE], the resident and family had discussions about a DNRO, as her health had declined, and he was confident she fully understood that the order meant there would be no CPR. Tearfully, he recalled when his mother-in-law verbalized to him and her son jointly, I definitely want it; once I'm in God's arms I don't want to come back. Review of the Fire Rescue Department Report showed on [DATE] at 5:36 AM, EMS personnel arrived at resident #108's bedside and found her unresponsive while facility staff provided CPR. While CPR continued, EMS transferred the resident to a stretcher and into an ambulance. The report revealed during emergency transport, aggressive Advanced Life Support (ALS) measures were provided that included CPR with orotracheal intubation (tube inserted into the throat to maintain an airway and provide oxygen to the lungs). ALS medications and fluids were administered through an intraosseous (directly through bone into bone marrow) and intravenous (into a vein) infusions. EMS arrived at the hospital emergency room (ER) at 6:20 AM where efforts continued while the resident was transferred from the ambulance into the ER. The ER Provider Notes showed at 6:23 AM on [DATE], EMS arrived in the ER with resident #108 while they provided CPR. Aggressive efforts continued in the ER until she was pronounced dead at 6:32 AM, one hour after CPR was initiated at the facility. On [DATE] at 5:07 PM, the Social Services Director said the Social Services Assistant reported to her and was primarily responsible for processing resident's change of code status and DNROs. She recalled on Monday [DATE], the Social Services Assistant told her that on [DATE] resident #108's completed DNRO was left in her office over the weekend, and she had not provided it to nurses. She stated the Social Services Assistant dropped the ball. On [DATE] at 4:35 PM, the Nursing Home Administrator (NHA) recalled on [DATE], he was notified by the Social Services Director that in the late afternoon on [DATE], the Social Services Assistant assisted resident #108 to complete a DNRO that was signed by the physician the same day. He said the document remained in the Social Services office over the weekend and was not provided to the nurses. He said on [DATE], two days later, the facility discussed the incident at their weekly Risk Meeting with the Risk Manager, and they completed their investigation. He explained there was no incident report completed or adverse event reported to the state agency because nurses followed the code status policy and the team felt they had resolved the issue. On [DATE] at 6:34 PM, the DON said the facility investigated the incident and determined resident #108's DNRO form was never provided to nursing staff and the nurses followed the process. On [DATE] at 2:29 PM, the Risk Manager recalled on [DATE], two weeks after resident #108 died, she was at the facility to investigate an unrelated issue. She said she investigated resident #108's CPR event at that time because there had been an internal corporate complaint related to family dissatisfaction with management communication, and an internal tracking report variance for a resident hospital transfer with CPR. She stated her expectation was that on [DATE], when the NHA learned resident #108 had a DNRO and nurses provided CPR, he should have notified her immediately. She explained the facility had not completed an incident report, and it was concluded that no reportable adverse event had occurred because the DNRO wasn't considered a physician's order, and nurses followed the code status procedure. On [DATE] at 5:31 PM, the Medical Records Coordinator said on [DATE] during a routine check, she found 2 errors with resident's code status orders in medical records that were subsequently corrected by the Unit Manager. She said she informed the DON of her findings and the DON directed that Medical Records was to continue with chart audits monthly. She could not recall if she had completed audits in August or [DATE]. She said she did not recall seeing resident #108's DNRO form when she processed the closed paper medical record after she died. On [DATE] at 9:49 AM, the DON said Medical Records did not complete advanced directive audits in August or [DATE]. She stated additional audits were completed by the Social Services Director on [DATE], and Unit Managers on [DATE]. On [DATE] at 1:09 PM, the Risk Manager said monthly Quality Assurance Performance Improvement (QAPI) meetings included reviews of policies and procedures, variances, regulatory compliance, incidents, and accidents. The NHA, DON, and Risk Manager could not recall any discussions during their last monthly QAPI meeting in [DATE] about resident #108's CPR with a DNRO incident. The Risk Manager checked the meeting minutes record, and confirmed the incident was not discussed. The Risk Manager said regulatory non-compliance related to the incident was not identified or acknowledged by the facility until [DATE], after surveyors investigated resident #108's death. Review of the undated facility Policy and Procedure titled Advanced Directives, read, . 8. All residents have the right to review and revise his/her advanced directives. 9. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 10. b. Nursing staff and/or the social worker will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 12. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. 13. A resident will not be treated against his or her own wishes. 17. our facility has defined advanced directives as preferences regarding treatment options and include . c. Do Not Resuscitate---indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: * On [DATE] the Social Services Director and NHA met with the Social Services Assistant responsible for initiating advanced directives and education was provided on resident rights. * On [DATE] the Social Services Director conducted audits of all residents' medical records to verify the DNRO yellow form and the physician's order was correct and included in the EMR. * On [DATE] additional education of the Advanced Directive policy, Resident Rights, and timeliness was provided to the Social Services Assistant with disciplinary action. * On [DATE] resident #108's CPR event was discussed in the weekly QAPI Risk meeting. * On [DATE] a follow up meeting was conducted with the Social Services Assistant utilizing an audit tool to evaluate her understanding of advanced directives and resident rights. * From [DATE] to [DATE] the Social Services Director conducted weekly follow up and check-in meetings with the Social Services Assistant to review education and process adherence on any new code status changes. * On [DATE] the facility held an Ad-Hoc QAPI meeting that included the Medical Director. * On [DATE] the QAPI team developed licensed nurses and Certified Nursing Assistant (CNA) education that addressed their roles in Advanced Directive policies. * On [DATE] an audit plan was developed for code status verification upon admission to ensure the EMR and paper binder/chart matched. * On [DATE] an audit of all resident's code status was completed by nursing staff and medical records to ensure the EMR and chart/binder paper chart matched. * On [DATE] a plan was developed to complete weekly code status audits for 12 weeks by nursing leadership to ensure orders in the EMR and hard binder/chart matched with findings reported to QAPI. * On [DATE] education for nurses and CNAs began for advanced directives that utilized scenarios with emphasis on timeliness of orders and placement of the DNRO in the chart. * At the end of the day on [DATE], 39% of nurses and 39% of CNAs had received in person education on advanced directives. * On [DATE] the facility's plan for advanced directive education continued utilizing email to staff not scheduled with required return acknowledgement. * On [DATE] nurses and CNAs were required to complete advanced directive education prior to working their next scheduled shift. If education was not completed staff were to be removed from the schedule until their education and acknowledgement was completed. * On [DATE] education materials were sent to the two staffing agencies utilized by the facility for distribution to nurses scheduled to work at the facility that required return acknowledgement prior to working. The schedules were highlighted for any scheduled agency nurses to ensure supervisors provided education prior to working a shift. * On [DATE] at 12:17 PM, 54% of nurses and 54% of CNAs had received in person education. Education included scenarios and emphasis on timeliness of the full completion process to ensure current and correct advanced directives and DNROs were included on the EMR and paper binder/chart to ensure direct care staff had readily available access. Remaining nurses or CNAs were required to receive the education prior to working a shift. Between [DATE] and [DATE], interviews were conducted with one APRN, two RNs, five LPNs, eleven CNAs, one Speech Language Pathologist, the Social Services Assistant, and the Social Services Director regarding the facility's Immediate Jeopardy removal plans and in-service education for Advanced Directives/DNR. Eight of thirty-four nurses, eleven of eighty-four CNAs, and other staff that covered all shifts verbalized their understanding of the education provided. The resident sample was expanded to include six additional residents who died at the facility. Five residents elected DNR status and one elected Full Code status. Interviews and record reviews revealed no concerns for residents #510, #511, #512, #513, #514, and #515 related to advanced directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide care and maintenance for a central line intravenous catheter (CVC) per standards of care for 1 of 1 resident reviewed for CVCs, of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalizations and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the surveyor, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. The facility's failure to identify and provide necessary care and services for maintenance of the central line intravenous catheter contributed to the hospitalization of resident #65 and placed all residents who were admitted /readmitted with medical devices including CVCs at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 12/22/22 and was removed on 9/23/23. Findings: Cross reference F684 and F726. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to his abdomen and severe malnutrition. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. Review of the admission Screening dated 11/15/22 revealed the nurse documented an IV/Sub q/Implanted Port to resident #65's right chest. The screening document was marked, Treatment ordered or required, under the skin assessment section, and indicated Advanced Practice Registered Nurse (APRN) I was notified of the admission and medications were confirmed. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C, lowered the resident's hospital gown to reveal a central venous intravenous catheter under a worn dressing dated in large black marker, 5/15/23. The clear CVC dressing was dirty, lifting up on the sides, and had dried blood at the insertion site. A few minutes later at 1:19 PM, Licensed Practical Nurse (LPN) A confirmed the dressing covering resident #65's CVC was dated 5/15/23, and agreed the dressing needed to be changed. She explained that although LPNs like herself could and should check the dressing site, they were not able to care for a CVC, only a Registered Nurse (RN) could do that. LPN A stated she had not looked at the CVC dressing since last week and could not say why she had not notified the Unit Manager (UM) or a physician to question the presence of the line or for orders to care for the line. Review of the undated Policy and Procedure for Abuse and Neglect revealed the definition of neglect as, .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy statement included residents had the right to be free from neglect, and the interpretation included the administration would develop and implement policies and procedures to aid in preventing neglect of residents. Signs of actual neglect are described in the document as, Inadequate provision of care and Caregiver indifference to resident's personal care and needs. In interviews on 9/18/23 at 1:45 PM and on 9/20/23 at 2:18 PM, the [NAME] Garden LPN Unit Manager (UM) described the facility process for admissions utilized an admission checklist. She described the process for the admitting nurse to assess the resident and the admission paperwork and complete the checklist. She noted within the first business day, the checklist was reviewed during the morning clinical meeting by a supervisor or manager who would often work together to double check the checklist completed by the nurse. She described a section on the checklist for devices such as IVs or urinary catheters which listed all of the orders required for the device. The [NAME] Garden UM described the last piece of the admission checklist was to develop the baseline care plan which included skin assessment which was then reviewed by the clinical team. She detailed her next step after the checklist was completed at the meeting was to meet the resident. The [NAME] Garden UM explained the UMs were responsible for entering any additional care plans based on progress notes, changes in condition or any new orders. She confirmed although she was a LPN she was IV certified, but said she was not aware of resident #65's CVC until it was brought to her attention by the surveyor on 9/18/23. The [NAME] Garden UM stated she rounded with APRN B weekly on resident #65 but said they usually only looked at the wound to his abdomen. She explained she expected the nurses and CNAs to look at the resident's skin and notify her if there were any impairments including an IV dressing. The [NAME] Garden UM stated she didn't know how the nurses missed the CVC dressing on resident #65's chest or notify anyone about the central line. She explained she thought staff saw it but since it had been there for so long they didn't say anything about it. Review of the medical record revealed resident #65 went to the hospital and re-admitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On each of the admission Screening forms nurses documented a full head-to-toe skin assessment was completed as well as auscultation and inspection of the chest and lungs. Four of the admission screenings, the first two (11/15/22 and 11/18/22) and the last two (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but only a single order for weekly dressing changes was ever placed. This order was made on 11/21/22 for 21 days and was discontinued on 12/09/22. Review of the medical record revealed between 11/15/22 and 9/18/23 resident #65 was seen by Physician Q four times, the Medical Director three times and by APRN I 11 times. The providers' documentation included mention of the CVC by the Medical Director on 11/18/22, by Physician Q on 6/20/23, 6/27/23 and 7/06/23, and by APRN I on 12/22/22, 6/14/23 and 6/26/23, but none of the documentation addressed maintenance care, infection prevention or any other orders for the IV. Review of the medical record and documentation provided by the facility revealed during the approximate nine-month period between 12/01/22 and 9/18/23, 99 different licensed nurses were assigned to care for resident #65. Review of nursing progress notes from 11/15/22 to 9/18/23 revealed resident #65's CVC was identified and mentioned only four times by LPN H, RN O and agency RN P. There was no documentation to indicate any of the 99 nurses queried or reported the absence of physician orders or a care plan for resident #65's CVC. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and 9/22/23 at 12:16 PM, the Director of Nursing (DON) explained neglect was failure to provide the needed services or care to a resident. She described her conclusion from her investigation so far was that staff thought someone else was taking care of resident #65's CVC, and no one took ownership of it. She found that some of the admission checklists were incomplete or had not addressed the CVC. The DON explained the licensed nurses, the nursing managers and the supervisors were all part of the check they had in place to ensure admission orders were in place, but somehow the CVC was still missed. The DON acknowledged she had not realized she did not receive some of the admission checklists that UMs were supposed to submit to her for review including for resident #65. The DON explained the assigned licensed nurse was assigned to complete head-to-toe skin checks weekly and also upon admission to the facility. She further detailed the nurse was supposed to get orders for maintenance and care of the CVC but acknowledged that had not been done during the time resident #65 had the CVC from November 2022 to the present. The DON explained resident #65 had been ordered to be sent to the hospital on 9/18/23 and needed to be evaluated by Interventional Radiology to determine the plan for his CVC. The DON stated she reviewed resident #65's medical record from 11/15/22 to 9/18/23 and could not find documentation that showed any of the 13 nurses who performed the weekly skin assessments identified, queried or reported the CVC or absence of any physician orders for the CVC. The DON confirmed all of the nurses in the facility except LPN H were IV certified, and although the LPNs were not supposed to push IV medications they were able to change the CVC dressing and check the site for signs and symptoms of complications. She stated even if the licensed nurse was uncomfortable with a CVC they should ask the RN, supervisor or a UM for help. In an interview on 9/21/23 at 11:49 AM, APRN I explained she was required to do a physical exam or focused assessment when a resident came back from the hospital based on their concerns at the time. She said part of the physical exam included listening to the heart and lungs, but explained she would ask the nurse if the resident had any wounds as part of the skin assessment. The APRN described when a resident was admitted with a device such as a CVC she would see the resident in person and provide orders for their care. She explained she did her best to review all of the orders by utilizing the information in the medical record and any hospital paperwork. The APRN stated the last time she was aware of resident #65's CVC was this past June, but explained she figured it had been removed and did not question whether there were physician orders for it. APRN I could not give a reason why she had not entered orders for resident #65's CVC herself, as she had noted it on some of her documentation. She only explained APRN B usually handled the batch orders. She said she thought it was pretty bad when she learned resident #65 had received only 3 dressing changes since he had been admitted [DATE] with the CVC. The APRN explained she was gravely concerned licensed nurses did not recognize resident #65 had a CVC and had no maintenance orders for it since December 2022. In interviews on 9/18/23 at 3:49 PM and on 9/21/23 at 12:17 PM, APRN B stated she did weekly wound rounds at the facility and regularly saw resident #65. She confirmed she did not know until 9/18/23 that resident #65 still had the CVC in his right chest and assumed it had been removed at some point. APRN B explained care for a central line would include the nurse assessing the site every shift for signs and symptoms of infection, drainage, swelling, or redness. She said other required orders for care would include flushing the line frequently and changing the dressing and accessing the port regularly and as needed to prevent infection, blood stream infection, or blood clots. APRN B stated she expected at the minimum, nurses would have seen the CVC when they performed the weekly skin checks and notify her if he didn't have any orders. On 9/21/23 at 1:46 PM, the Medical Director stated he was familiar with resident #65 and confirmed he was one of his providers. The Medical Director explained he learned of the concerns about resident #65's CVC on 9/19/23. He stated the providers should do a hands-on examination of the residents and then enter orders as required. The Medical Director indicated he felt communication was very important to prevent things like this from happening again. He said it was disappointing that would believe some part of a resident's care was not part of their job. He continued that nurses needed to communicate effectively what they saw and to notify their superiors if there was something going on or to seek guidance if they did not know something. Review of the facility's undated Facility Assessment revealed they provided care for residents with common diseases, conditions, and physical and cognitive disabilities that require complex medical care and management. The policy and procedure indicated if a resident's care was not one of the listed diagnoses, the nursing team was consulted to determine if the resident's care needs could be met. The document detailed that nurse leaders including the DON, and APRNs were consulted to review the resident's medical records to determine what skills were required by nursing staff to care for the resident and to identify any special equipment needed including educational materials. The document further detailed a relationship between itself and the hospital system that made resources readily available and accessed, including education. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: On 9/18/23, central line orders were obtained for resident #65. A dressing change completed. Assessed by nurse practitioner for medical necessity of central line. New order to evaluate line removal at hospital, resident sent via medical ambulance to hospital. *On 9/18/23, an audit was completed by Director of Nursing for all resident records in electronic medical record for orders for IV lines. Orders in place for three residents, however not all appropriately scheduled. Orders were corrected. * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of QAPI admission tool. 100% of nurses scheduled for that day and 65% of C.N.A.s received in-person education. *On 9/18/23, a whole house skin audit was initiated by Director of Nursing and unit managers. *On 9/19/23, skin audit completed on all residents in facility. No IV lines identified other than the three residents already identified from initial audit. * On 9/19/23, A physical assessment of current IV lines in facility by Director of Nursing with no issues found. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 CNAs. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. * On 9/20/23, education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. *On 9/20/23 an Ad-Hoc QAPI meeting was held including Medical Director. * On 9/20/23, 100% of nurses received education on central line policies, skin checks and admission process. Out of 35 staff nurses, 18 completed education in person and 17 received education through email and responded in writing via email understanding of education. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on abuse and neglect. In person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/20/23, DCF and 1 Day AHCA report made by Risk Manager. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 via email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility. The sample was expanded to include 3 other residents identified with IV catheters. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and assessment of a central line intravenous catheter (CVC) for 1 of 1 resident reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalizations and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the surveyor, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. These failures placed resident #65 at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #1 could have developed severe infection, blood clots, vascular damage or bled to death. The facility's failure to obtain appropriate admission orders for central line catheter care, and failure to provide assessments and care to prevent serious adverse outcomes resulted in Immediate Jeopardy starting on 12/22/22. The Immediate Jeopardy was removed on 9/23/23. Findings: Cross reference to F600 and F726 Resident #65, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to the stomach and severe malnutrition. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed resident #65 had moderately impaired cognition, clear speech, and adequate vision. The assessment indicated resident #65 was totally dependent on more than two staff for transfers, bed mobility and toilet use, and totally dependent on one staff for eating, bathing and personal hygiene. The assessment revealed he did not refuse care in the look back period and had received no intravenous medications. On 9/18/23 at 11:24 AM, resident #65 was observed in bed, alert and oriented to self, location, and time. The corner of a worn-looking dressing on his right chest could be seen from the top of his hospital gown. Resident #65 acknowledged the dressing was for an Intravenous catheter (IV) but could not recall when he got it or why he had it. He indicated the facility had inserted another IV in his left arm not long ago for some medications. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C confirmed resident #65 had an IV dressing to his right chest and said she did not recall seeing anyone use it recently. After asking resident #65's permission, she lowered his hospital gown to reveal a central line IV catheter under a worn dressing dated more than four months ago, 5/15/23 in large black marker. The clear CVC dressing was dirty, lifting up on the sides, and had dried blood near the insertion site. A central line venous catheter is an indwelling device inserted into a large central vein like the internal jugular and advanced until part of it rests inside a chamber of the heart or inside the large vein entering the heart. This device is often used for administration of certain medications, hemodialysis or a specific type of nutrition that bypasses the digestive system. After placement of a CVC, nurses must maintain and monitor the line for possible serious complications like bleeding, infection and clots. The nurse and physician should be aware of and keep track of when the line was placed as complication rates increase the longer the line is left in (retrieved from www ncbi.nlm.nih.gov on 9/25/23). On 9/18/23 at 1:19 PM, the assigned Licensed Practical Nurse (LPN) A said she was aware resident #65 had a CVC to his right chest and explained it was to draw blood from occasionally as he was a hard stick. LPN A observed the CVC dressing to the resident's right chest and acknowledged the dressing was dirty, loose, with dried blood under the dressing and the antiseptic foam disc used to help prevent infection floated freely under the clear film. She confirmed the date on the dressing clearly marked in black was 5/15/23. LPN A explained central lines should have orders to assess the IV site every shift, flushes, and dressing changes for maintenance of the line. After returning to the nurses' station LPN A reviewed resident #65's physician orders and said there were no orders for resident #65's CVC. LPN A stated she was unable to provide care for a CVC and explained only a Registered Nurse (RN) could change the dressing or flush the line. She noted even if a LPN could not provide care to a CVC, they could observe the site and should report to a Registered Nurse (RN) if the dressing was old or needed to be changed. She revealed she had not looked at resident #65's CVC dressing since last week and could not explain why she had not questioned why there were no orders for it nor why she did not report it to her supervisor. On 9/18/23 at 1:45 PM, the [NAME] Garden Unit Manager (UM) confirmed resident #65's CVC dressing was dated 5/15/23. She stated she thought resident #65 was admitted to the facility with the CVC. She was unsure how long the line had been there, when it had been placed or the reason for the CVC. The UM explained the protocol for CVCs was to obtain physician orders to assess it regularly, flush it every shift, and change the dressing per orders. She explained a RN could provide care to a CVC, but LPNs were able to assess the site. The [NAME] Garden UM said regular care was important to prevent infection since the intravenous line went right to the heart. She reviewed the physician orders and said although the resident had a midline IV placed in August those orders had been discontinued. She explained she was unable to identify any physician orders for the care of resident #65's CVC. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. The hospital After Visit Summary printed 11/15/22 revealed a hand written, unsigned note on the second page that declared he had a right chest CVC line and a request for the Advanced Practice Registered Nurse (APRN) to please check the orders. The admission Screening dated 11/15/22 indicated resident #65 had a, IV/Sub q(subcutaneous)/Implanted Port to the right chest, and the document indicated treatment was ordered or required. The admission document also detailed APRN I and the physician were notified of the admission and the medications were verified. Review of resident #65's medical record revealed no orders were placed upon admission on [DATE] for resident #65's CVC, nor were any care plans initiated. On 11/16/22, resident #65 was sent back to the hospital for low hemoglobin and returned on 11/18/22. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/18/22 did not include the CVC on resident #65's right chest on the document, nor did the After Visit Summary dated 11/18/22. Although the hospital paperwork did not show the right chest CVC, in the admission Screening Rev 6 dated 11/18/22 the nurse documented the CVC at the right chest and again checked the box, Treatment ordered or required. The nurse also documented on the admission form that APRN B and the physician were notified and that medications were verified. Review of the Order Listing Report for 11/15/22 to 9/20/23 revealed no orders were obtained upon admission for the CVC, and no care plan was initiated. Review of the Order Listing Report for 11/15/22 to 9/20/23 revealed the only orders for the care of resident #65's CVC was a single order placed by APRN B on 11/21/22 for a weekly dressing change, Wednesdays on day shifts for 21 days. The document showed the dressing change order was discontinued on 12/09/22, and never re-ordered. There was an additional IV medication order during the 10-month time period for 60 cubic centimeters of normal saline every shift for abnormal labs for 2 days times 2 liters on 12/20/22 and ending on 12/22/22. Review of the medical record revealed no care plan ever initiated for resident #65's CVC. The medical record indicated resident #65 went to the hospital and re-admitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On the admission Screening form, nurses documented a full head to toe skin assessment as well as auscultation and inspection of the chest and lungs. Only the first two admission screenings (11/15/22 and 11/18/22) and the last two admission screenings (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but no orders were placed for care of resident #65's CVC except the one order for 3 weeks of dressing changes on 11/21/22. Review of resident #65's medical record revealed the resident was assessed at least 18 times by his attending physician, or APRN I from his re-admission on [DATE] to 8/16/23. The first assessment since resident #65 was re-admitted with the CVC, by APRN I on 11/16/22, a physical exam was documented including heart and lung sounds and skin assessment, but no mention of the CVC was made. On 11/18/22, the physician documented the CVC in resident #65's right chest was intact with no redness, swelling or pain to the surrounding tissue, but no orders for CVC care was mentioned or ordered. The CVC was noted present only 8 of the 18 times, but there were no orders placed or any plan for care mentioned. Review of the medical record revealed resident #65 had physician orders for a weekly skin assessment. The medical record showed no documentation of the CVC by 13 different nurses who were assigned the weekly skin assessment over 41 and a half weeks from 11/25/22 until 9/11/23. On 9/19/23 at 9:46 AM, resident #65's assigned LPN D stated she knew resident #65 and had cared for him as recently as the past weekend. LPN D stated caring for the CVC was an RN's job even though she confirmed she was IV certified before she came to the facility. She explained the only education she received at the facility about what she could do regarding CVCs or IVs was learned from other staff she trained with. She stated she was told LPNs could not flush CVCs, could not do dressing changes nor could they assess them. LPN D recalled doing a skin assessment for resident #65 in the past several weeks. She recalled he had the CVC dressing on his chest but was told to only document anything new. She recalled asking the [NAME] Garden UM what the dressing was to resident #65's chest when she started working there in June and was told it was a port. LPN D explained the UM acted like it had been there a while so she didn't think anything of it after that. On 9/20/23 at 12:30 PM, LPN E stated he usually worked on the [NAME] Garden unit and was familiar with resident #65. LPN E explained when a resident was re-admitted to the facility the assigned nurse is responsible to assess the resident, review the hospital paperwork and call the physician to give report including any IVs or other devices. He spoke about a set of orders to be used upon admission for IVs that included regular flushes, dressing changes and assessment of the site for maintenance. He confirmed he was IV certified and said he could perform dressing changes on a CVC but was unsure if an LPN was allowed to flush a CVC. LPN E recalled resident #65 came back from the hospital with the CVC a while ago, and he himself had re-admitted him from the hospital on occasion. He recalled doing the weekly skin assessment for resident #65 but said he couldn't remember if he ever checked to see if there were any orders to care for the CVC. LPN E described care for the IV site which included assessing for drainage, swelling or infection and said the dressing should be changed if it was soiled or if it was time for it to be changed. He said there was no excuse to not change it. He could not recall if he ever looked at the date on resident #65's CVC dressing, and explained nurses should not have to look at the date on the dressing as they should trust staff did what they were supposed to do. Review of the document, Nurses with Skin Checks with dates from 11/25/22 to 9/11/23 provided by the facility revealed LPN E documented weekly skin assessments on resident #65 4 times during this time period, 7/3/23, 7/17/23, 8/28/23 and 9/11/23. LPN E also documented an admission Screening Rev 7 on 6/19/23 in which he detailed the IV/Sub q/Implanted Port to resident #65's chest, and indicated treatment was ordered or required. He documented on the screening form that medications were verified and APRN I was notified of the admission, but no orders were obtained for resident #65's CVC by LPN E. In a telephone interview on 9/21/23 at 9:11 AM, LPN H confirmed she was IV certified in another state and was not allowed to technically touch an IV. She stated she could look at an IV, assess it and know something needed to be done, but was not supposed to do it herself. LPN H stated she got a mixed message on whether nurses were supposed to document an IV like a CVC dressing on the weekly skin assessment. LPN H recounted resident #65 came back with the CVC from the hospital a while ago. She explained she often cared for resident #65 and looked at his skin frequently, noting she had seen the CVC but did not look closely at it. She did not recall noticing the date 5/15/23 on the dressing, and said it never crossed her mind why she had not seen orders to care for the line. LPN H could not say why she had not asked another nurse to change the CVC dressing. Review of the document, Nurses with Skin Checks with dates from 11/25/22 to 9/11/23, revealed LPN H documented weekly skin assessments on resident #65 11 times, on 12/02/22, 12/20/22, 1/02/23, 1/17/23, 1/31/23, 2/14/23, 2/28/23, 7/10/23, 7/24/23, 8/21/23 and 9/4/23. She did not document presence of the CVC on these assessments. LPN H also documented an admission Screening Rev 7 on 6/12/23 in which she detailed the IV/Sub q/Implanted Port to resident #65's chest, and indicated treatment was ordered or required. She also documented on the screening form that medications were verified and APRN I was notified of the admission, but no orders were obtained for resident #65's CVC by LPN H. On 9/21/23 at 11:49 AM, APRN I stated she was very familiar with resident #65, and recalled in June she and APRN B discussed his CVC. She explained she did her best to review all of the residents' orders but said she didn't look at any orders for resident #65's central line. APRN I stated she figured resident #65's CVC had been removed and did not look at the date on the CVC dressing when she examined him this past June and in August. APRN I could not say why she had not put orders in for resident #65's CVC when she had examined him multiple times during his stay including in June. She said she thought APRN B usually put in the orders. She noted it was a grave concern that for almost 9 months nurses had not recognized he had a CVC and there were no orders for care. In interviews on 9/18/23 at 3:49 PM and 9/21/23 at 12:17 PM, APRN B stated she assessed wounds in the facility weekly including for resident #65. She recalled speaking to APRN I in June about resident #65's CVC but did not realize until now that it was still there. APRN B explained she did not usually have anything to do with entering orders unless someone asked her for help. She was unable to say why resident #65 did not have orders to care for the CVC other than the dressing change order that had been discontinued after 3 weeks in December. APRN B stated she was not sure why only the one order for dressing changes was placed and not other care orders like flushes and assessment of the site. She said she assumed his CVC being addressed and that facility nurses would have told her if there were no orders for it. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and on 9/22/23 at 12:16 PM, the Director of Nursing (DON) confirmed resident #65 was sent to the hospital on the evening of 9/18/23 by physician order for evaluation for removal of his CVC. She explained the CVC would have to be removed by Interventional Radiology at the hospital and she was unsure when resident #65 would return. The DON stated nurses were supposed to get orders for the care of the CVC from the physician upon re-admission to the facility. The DON confirmed all nurses working in the facility were IV certified except one, and they were expected to assess the site, change the dressing and flush the line per the physician orders. She explained licensed nurses should have noted resident #65's CVC in their weekly skin assessment, but she found that none of the nurses who performed them had noted his CVC. The DON acknowledged there were major concerns that no care was provided for resident #65's CVC, that there were no orders beyond the one that was discontinued in December and that none of the nurses who cared for him after his re-admission in May noticed his CVC dressing needed to be changed until brought to their attention by the surveyor. She stated she concluded that everyone thought someone else was taking care of it and no one took ownership of it. The policy and procedure document, Central Line Dressing Change dated June 2016, described the purpose was to reduce infections and minimize contamination of the catheter. The policy included the transparent dressing should be changed every 7 days or as needed if soiled or loose, if there was drainage or bleeding from the site the transparent sterile dressing should be changed every 48 hours if dry, the needleless connector attached to the lumen should be changed every 7 days and after every lab draw. The policy also included the insertion site should be monitored at a frequency determined by the symptoms, type of therapy, access type or by facility policy and during dressing change the site should be observed for signs and symptoms of complications and the length of the catheter should be measured. The procedure described the sterile dressing change which included the nurse to observe the insertion site for redness, swelling or drainage, to label the dressing with the date and initials of the nurse who changed the dressing and to document on the medication administration record and the resident's medical record. The undated Facility Assessment indicated the facility cared for residents that required complex medical care and management. The facility assessment also noted the facility was able to meet varied resident care needs which included medications administered by different routes including intravenous central lines. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 9/18/23, central line orders were obtained for resident #65. A dressing change was completed. The resident was assessed by nurse practitioner for medical necessity of central line. A new physician order was obtained to evaluate CVC line removal at the hospital. The resident was sent via medical ambulance to hospital. *On 9/18/23, an audit was completed by Director of Nursing for all residents' electronic medical record for orders for IV lines. Orders were in place for three residents, however not all orders were appropriately scheduled. The orders were corrected. * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool. 100% of nurses scheduled for that day and 65% of CNAs received in-person education. *On 9/18/23, a whole house skin audit was initiated by Director of Nursing and unit managers. *On 9/19/23, skin audits completed on all residents in the facility. No IV lines identified other than the three residents already identified from initial audit. * On 9/19/23, a physical assessment of current IV lines in facility conducted by Director of Nursing with no issues found. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of QAPI admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 CNAs. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. * On 9/20/23, education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23, education packet sent to two agencies that facility currently used for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. *On 9/20/23 an Ad-Hoc QAPI meeting was held that included the Medical Director. * On 9/20/23, 100% of nurses received education on central line policies, skin checks and admission process. Out of 35 staff nurses, 18 completed education in person and 17 received education through email and responded in writing via email understanding of education. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/20/23, Department of Children and Families and 1 Day Agency for Health Care Administration (AHCA) report made by Risk Manager * On 9/200/23, in person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 via email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility including skin assessments, central line education for nurses and admission assessments. The sample was expanded to include 3 other residents identified with IV lines. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services for a central line intravenous catheter (CVC) for 1 of 1 residents reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a CVC to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalizations and re-admittances without receiving care and services to maintain and prevent infection of the CVC. On 9/18/23 the CVC was brought to the attention of the facility staff by the survey team, and he was transferred to the hospital for evaluation and possible removal of the CVC. As of 9/23/23, at the conclusion of the survey, resident #65 had not returned from the hospital. These failures placed resident #65 at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #1 could have developed severe infection, blood clots, vascular damage or bled to death. The facility's failure to obtain appropriate admission orders for central line catheter care, and failure to provide assessments and care to prevent serious adverse outcomes resulted in Immediate Jeopardy starting on 12/22/22. The Immediate Jeopardy was removed on 9/23/23. Findings: Cross reference F600 and F684 Resident #65, a [AGE] year-old man was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stroke, epilepsy, functional quadriplegia, feeding tube to the stomach and severe malnutrition. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/15/22, revealed resident #65 had a CVC tunneled catheter inserted on 11/03/22 through his Internal Jugular vein. A Progress Note dated 11/15/22 at 7:24 PM, by Licensed Practical Nurse (LPN) H indicated resident #65 was alert and oriented when he returned from the hospital for rehabilitation. LPN H documented that she notified Advanced Practice Registered Nurse (APRN) I of the admission and resident #65's medications were confirmed. Review of the admission Screening dated 11/15/22 revealed the nurse documented an IV/Sub q (subcutaneous)/Implanted Port to resident #65's right chest. The screening document was marked, Treatment ordered or required, under the section, skin assessment. On 9/18/23 at 1:11 PM, Certified Nursing Assistant (CNA) C, lowered the resident's hospital gown to reveal a central venous intravenous catheter under a worn dressing dated in large black marker, 5/15/23. The clear CVC dressing was dingy, lifting up on the sides, and had dried blood under it near the insertion site. A few minutes later at 1:19 PM, Licensed Practical Nurse, (LPN) A confirmed the dressing covering resident #65's CVC was dated 5/15/23, and agreed the dressing needed to be changed. She explained that although LPNs like herself could and should check the dressing site, they were not able to care for a CVC, only a Registered Nurse (RN) could do that. LPN A stated she had not looked at the CVC dressing since last week and could not say why she had not notified the Unit Manager (UM) or a physician to question the presence of the line or for orders to care for the line. In interviews on 9/18/23 at 1:45 PM, and on 9/20/23 at 2:18 PM, the [NAME] Garden LPN Unit Manager (UM) confirmed the worn dressing to resident #65's right chest was dated 5/15/23. She stated that although she thought resident #65 came from the hospital with the IV, she was unsure how long he had it, why he had it, or what type of IV it was. She was not sure if there were any orders associated with it, and after reviewing the electronic orders, she stated she could not find any. She described the process for admissions via utilization of an admission checklist by the admitting nurse. First, to assess the resident, then in combination with the admission paperwork to complete the checklist. She continued that within the first business day the checklist was reviewed during the morning clinical meeting by a supervisor or manager who would often work in collaboration to double check the checklist completed by the nurse. She described a section on the checklist for devices such as IVs or urinary catheters which listed all of the orders required for the device. The [NAME] Garden UM described the last piece of the admission checklist was to develop the baseline care plan which included skin assessment, then it was reviewed by the clinical team as they reviewed the chart and discussed the resident. She detailed her next step after the checklist was completed at the meeting was to meet the resident herself. The [NAME] Garden UM explained the UMs were responsible for entering any additional care plans based on progress notes, changes in condition or any new orders. She confirmed she was IV certified, but said she was not aware of resident #65's CVC until it was brought to her attention by the surveyor on 9/18/23. The [NAME] Garden UM stated she rounded with APRN B weekly on resident #65 but said they usually only looked at the wound to his abdomen. She explained she expected the nurses and CNAs to look at the resident's skin and notify her if there were any impairments including an IV dressing. She could not explain how the nurses missed the CVC dressing on resident #65's chest or notify anyone about the central line. She explained she thought staff saw it but since it had been there for so long they didn't say anything about it. Review of the job description, Nursing Manager dated 9/20/17 revealed the position functioned as a clinical generalist and was responsible for providing, managing, and coordinating the comprehensive care to their designated group of residents. Essential functions included assesses to anticipate risk, designs and implements plans of care and provides oversight of the care delivery of their specific group of residents. They also had clinical responsibility accountability and authority for implementing and collaborating the needs of residents to effectively manage their clinical outcome goals. In interviews on 9/18/23 at 3:43 PM, 9/19/23 at 8:50 AM and 4:15 PM, and 9/22/23 at 12:16 PM, the Director of Nursing (DON) explained the assigned licensed nurse was assigned to complete a head-to-toe skin check weekly and also upon each admission to the facility. The DON acknowledged she was unsure how long resident #65 had the IV or exactly what type of IV it was when it was brought to her attention on 9/18/23. She confirmed the seriousness of the concerns regarding the lack of care for resident #65's CVC since November of the past year. The DON explained the nurse who completed the admission assessments only recognized and documented resident #65's CVC on four of the seven admissions he had to the facility since he returned with it on 11/15/22. The DON stated the nurses entered the admission assessment electronically but failed to obtain the proper orders for care of the CVC such as assessments of the site every shift, flushes of the line every shift, and weekly and as needed dressing changes. She stated nurses should have recognized the CVC and called the physician for orders. The DON stated she reviewed resident #65's medical record and found no documentation from 11/15/22 to 9/18/23 that showed any of the 13 nurses who performed the weekly skin assessments identified, queried or reported the CVC nor the absence of any physician orders for the line. The DON confirmed all nurses in the facility except LPN H were IV certified, and although LPNs were not supposed to push IV medications they were able to change the CVC dressing and assess the site for signs and symptoms of complications. She stated even if the nurse was uncomfortable with a CVC they should know to ask a RN, supervisor, or UM for help. The DON stated she also found some of the admission checklists were incomplete or had not addressed the CVC. She explained the licensed nurses, the nurse managers and the supervisors were all part of the check they had in place to ensure admission orders were in place, but somehow it was still missed. The DON acknowledged she had not realized she did not receive some of the admission checklists that UMs were supposed to submit to her for review including for resident #65. Review of the medical record revealed resident #65 went to the hospital and re-admitted /returned to the facility 7 times between 11/15/22 and 9/18/23 for a total of 44 weeks. On each of the admission Screening forms nurses documented a full head-to-toe skin assessment as well as auscultation and inspection of the chest and lungs. Four of the admission screenings, the first two (11/15/22 and 11/18/22) and the last two (6/12/23 and 6/19/23) documented resident #65's right chest CVC. All of the forms detailed either APRN B or APRN I were notified and that medications were verified, but only a single order for weekly dressing changes was ever placed. This order was made on 11/21/22 for 21 days and was discontinued on 12/09/22. Further review of resident #65's medical record revealed no current orders for care or maintenance for the CVC. In an interview on 9/21/23 at 11:49 AM, APRN I explained she was required to do a physical exam or focused assessment when a resident came back from the hospital based on their concerns at the time. She said part of the physical exam included listening to the heart and lungs, but explained she would ask the nurse if the resident had any wounds as part of the skin assessment. The APRN described the admission process for a resident with a CVC. She stated the process was to assess the resident, and provide orders for care of the CVC. She explained she did her best to review all of the orders by utilizing the information in the medical record and any hospital paperwork. The APRN stated the last time she was aware of resident #65's CVC was this past June, but explained she figured it had been removed and did not question whether there were physician orders for care. APRN I could not give a reason why she had not entered orders for resident #65's CVC herself, as she had noted the CVC in her documentation. She only explained APRN B usually handled the batch orders. She said she thought it was pretty bad when she learned resident #65 had received only 3 dressing changes since he had been admitted on [DATE] with the CVC. The APRN explained she was gravely concerned licensed nurses did not recognize resident #65 had a CVC and had no maintenance orders for it since December 2022. Review of the medical record revealed between 11/15/22 and 9/18/23 resident #65 was seen 11 times by APRN I. Her documentation included mention of the CVC on 12/22/22, 6/14/23 and 6/26/23, but none of her documentation addressed maintenance care, infection prevention or any other orders for the IV. In interviews on 9/18/23 at 3:49 PM and on 9/21/23 at 12:17 PM, APRN B stated she did weekly wound rounds at the facility and regularly saw resident #65. She confirmed she did not know until 9/18/23 that resident #65 still had the CVC in his right chest and assumed it had been removed previously. APRN B explained care for a central line would include the nurse's assessment of the site every shift for signs and symptoms of infection, redness, drainage, or swelling. She explained required orders for care included flushing the line frequently and changing the dressing. She noted the line would need to be accessed regularly to prevent infection, including blood stream infection, or blood clots. APRN B noted she expected nurses would have seen the CVC when they performed the weekly skin checks and notify her if they did not have any orders for care. The job description, Nurse Practitioner dated 10/02/17 summarized the Advance Practice Registered Nurse helped with all aspects of resident care, including diagnoses, treatments and consultations. Essential functions of the position included assessment of the physical status of residents through interview, health history and physical exam, and recognition of deviations from normal in the physical examination to formulate treatment plans. Other functions included initiation of appropriate actions to facilitate the implementation of therapeutic plans consistent with continuing healthcare needs of the residents, and communication of appropriate information with the physician and other members of the healthcare team regarding the resident's condition. Further review of the medical record and documentation provided by the facility revealed during the approximate nine-month period between 12/01/22 and 9/18/23, 99 different licensed nurses were assigned to care for resident #65. Review of nursing progress notes from 11/15/22 to 9/18/23 revealed resident #65's CVC was identified and mentioned only four times by only three nurses, LPN H, RN O and agency RN P. There was no documentation to indicate any of the 99 nurses queried or reported the absence of physician orders or a care plan for resident #65's CVC. On 9/21/23 at 11:11 AM, LPN A explained only new skin impairments were documented on the weekly skin assessment. She stated since resident #65's CVC dressing was not a new impairment she did not document it. She stated she was IV certified in school and was told at that time it was not in her scope of practice to do central line dressing changes or flushes. LPN A explained she had not received education from the facility about what LPNs were or were not allowed to do with IVs or CVCs. She confirmed she was taught to look at the date on any dressing but said she did not look at the date on resident #65's dressing because she thought only the RN could do it. LPN A explained with new admission, one nurse did the assessment and the other nurse entered the orders. She said she did not understand how nurses who re-admitted resident #65 missed telling the physician about the CVC or obtain orders for the care of the line. On 9/19/23 at 9:46 AM, LPN D stated she recalled resident #65 having the CVC since she started there in May. LPN D stated she did not remember receiving any education on IVs or specifically central lines since she had been at the facility. She explained she was IV certified from her previous job and understood care for central lines was done by RNs. She stated LPNs were not supposed to assess or change CVC dressings, instead she would have to ask a RN to do it. LPN D recalled she completed a weekly skin assessment on resident #65 recently but did not document the CVC as it had been there previously. She had asked the [NAME] Garden UM about resident #65's CVC, but said they acted like it had been there awhile and were not too concerned. On 9/20/23 at 12:30 PM, LPN E stated he had worked on the [NAME] Garden unit for about 6 years. He said at admission, the resident would be assessed, then the orders would be checked and verified with the physician. He explained there was an order set for IVs that included dressing changes, site assessment and flushes. LPN E recalled he had readmitted resident #65 from the hospital at least once and was aware of the CVC. He said he was IV certified and was allowed to care for CVCs including dressing changes but was unsure whether he was allowed to flush a CVC. LPN E could not recall ever checking to see if there were any orders for resident #65's CVC and said he did not recall documenting it under the weekly skin assessment because it was not a new variance. He recalled doing the weekly skin assessment but did not recall looking at the dressing or the date on it, and explained there was no excuse to not change the dressing if it was dirty or old. LPN E stated he should not have to check the date on the dressing because other staff should be doing what they were supposed to be do. In a telephone interview on 9/21/23 at 9:11 AM, LPN H confirmed she often cared for resident #65 on the 3 PM-11 PM shift. She stated she had IV certification from another state, but the facility did not accept it. LPN H explained she knew about IVs but technically she was not allowed to touch them, so if something needed to be done she would have to ask another IV certified nurse for help. She recalled resident #65 had a lot of frequent issues with his feeding tube in his stomach and then he came back with the CVC from the hospital with it a while ago. LPN H stated she looked at resident #65's skin all the time and had seen the CVC dressing but did not look at it closely. She described collaborating with LPN E often on admissions and said the APRN usually reviewed the orders and made any adjustments as needed when they came to assess the residents themselves. LPN H stated it never crossed her mind why she had never seen any orders for the care of resident #65's CVC and she could not say why she had never looked at the date on his dressing or asked someone to change it. Review of the job description, LPN dated 11/12/18 revealed the LPN provided and documented individualized resident care including evaluation, education, medication administration, IV therapy, treatments under the supervision of the RN. Some essential functions of the LPN included competency in nursing skills, communication of appropriate information regarding the resident's condition to the physician and other members of the healthcare team and assumed an active role in keeping informed about changes in facility policy and procedures. Review of the job description, RN Staff dated 10/02/17 revealed the RN provided and documented individualized resident care to include evaluation, education, medication administration, IV therapy, and treatments. Essential functions included competency in nursing skills as defined by unit specific skills, communication of appropriate information regarding the resident's condition to the physician and other members of the healthcare team and assumed an active role in keeping informed about changes in facility policy and procedures. Finally the RN should demonstrate the knowledge and skill necessary to provide appropriate care. In interviews on 9/20/23 at 4:54 PM, and on 9/21/23 at 5:38 PM, the Clinical Educator stated all staff complete orientation and computer-based learning for resident rights, abuse/neglect, infection control, dementia care, incidents and accidents. She noted after the education, staff worked on the floor with a preceptor based on their experience level. The Clinical Educator explained the nursing staff completed a checklist with their preceptor over the first month or so that included a section on wounds for nurses and on skin checks for CNAs. She explained although IV medications were included on the checklist, care of IVs or specifically CVCs were not part of the checklist. The Clinical Educator stated if the licensed nurse had IV certification, it was expected they would have knowledge of how to care for a CVC or IV. She stated she expected nurses would notify her if they felt uncomfortable or lacked the knowledge to care for a CVC and would receive education. She was unable to provide LPN D's nor LPN E's orientation packet as they could not find it. The Clinical Educator confirmed nurses should document any skin impairments in the nurses note until they were resolved, including IVs. She stated she was surprised to learn resident #65 had not had a dressing change to his CVC nor had any orders for care since December of last year. The undated and untitled packet provided by the facility to agency nurses was reviewed. Policy and procedures for topics such as abuse, neglect and resident rights were included and staff were required to acknowledge their receipt. IVs, CVCs, weekly skin assessments or admission process were not included in the packet. Review of the 2023 Education Calendar revealed topics in the monthly education included basic nursing skills, abuse and neglect, skin and wound management, and effective communication. Review of the undated LPN Competency Skills Check Off and the undated RN Competency Skills Check Off revealed objectives included evaluate resident for potential safety problems, report safety problems to appropriate person in timely manner, review infection control policies and procedures, communicate effectively in professional relationships, complete an admission process, and provide nursing care for wound evaluation including clean dressing change. Additionally, competency section 5 required nurses to identify and utilize the admission checklist, complete admission orders, skin and wound protocols, care plans, knowledge of unit routine including IVs, admission, physician notification and physician orders. Review of nurse education for LPNs D, E and K revealed computer-based learning completed but no Competency Check Off for these LPNs were provided after upon request made to facility. Per the DON and Clinical Educator on 9/21/23, the facility was unable to find the packets for LPN E and LPN D. On 9/21/23 at 1:46 PM, the Medical Director explained he learned of the concerns about resident #65's CVC on 9/19/23. The Medical Director indicated he felt communication from nursing staff was very important to prevent things like this from happening again. He said it was disappointing that staff would believe some part of a resident's care was not part of their job. The Medical Director explained nurses needed to communicate effectively about what they saw and notify their superiors if something was going on. He said nurses should seek guidance if they did not know something. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 9/18/23, initial education began for nurses and CNAs. Topics included skin checks, IV lines and utilization of Quality Assurance Performance Improvement (QAPI) admission tool. 100% of nurses scheduled for that day and 65% of C.N.A.s received in-person education. * On 9/19/23, education continued for nursing staff on skin checks, IV lines and utilization of QAPI admission tool throughout day. In-person education was provided to an additional 4 nurses and 8 C.N.A.s. * On 9/19/23, nurse education developed to include central line policies, reinforcement of weekly skin assessment and admission processes. *On 9/20/23 an Ad-Hoc QAPI meeting was held that included the Medical Director. * On 9/20/23, 100% of nurses completed education for central line policies, admission process and skin assessments began for nurses including APRN. *On 9/20/23 additional education developed with QAPI team for nurses on Central lines to include identification of different types of possible lines with a written competency, and ongoing education that included skills competency checks following written competency. *On 9/20/23, education packet sent to two agencies that facility currently used for supplemental nursing coverage. Agency was to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure agency nurses received education at start of shift. * On 9/20/23, additional education developed with QAPI team for CNAs and nurses on abuse and neglect. In person education began with CNAs and nurses on skin observation for CNAs, IV central line education and identification, admissions and skin check for nurses. *On 9/21/23, education continued with nurses and CNAs in person and via email. 61% of nurses completed education with 22 completed in person and 6 by email. 67% of CNA education completed with 41 done in person and 6 via email. Education to continue. Nurses and CNAs required to complete education by end of day today or will be removed from schedule until education and acknowledgement is completed. * On 9/21/23, education packet sent to two agencies that facility currently uses for supplemental nursing coverage. Agency to distribute to nurses scheduled for facility and send acknowledgement back prior to shift. Facility schedule highlighted with agency nurses in order for supervisors to ensure that agency nurses receive education at start of shift. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 9/20/23, 9/21/23 and 9/23/23 interviews were conducted with 34 of the nursing staff representing all shifts, including 7 RNs, 12 LPNs, and 15 CNAs. All verbalized understanding of the education provided by the facility. The sample was expanded to include 3 other residents identified with IV catheters. No concerns were found regarding these residents. There were no other residents at the facility with central line intravenous catheters.