Health inspection·May 24, 2023

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy and procedure review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate (DNR) for 1 of 3 residents, Resident #1, when found unresponsive and absent of vital signs. This has the potential to affect 46 residents with advance directives of do not resuscitate. The findings include: Review of the medical record for Resident #1, documented the resident was admitted into the facility on 5/13/2023 at 5:53 PM with diagnosis to include chronic kidney disease, stage 4 severe, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, peripheral vascular disease, diabetes mellitus type 2, major depressive disorder, chronic respiratory failure with hypercapnia [happens when you have too much carbon dioxide in your blood, if your body can not get rid of the carbon dioxide, a waste product, there is not room for your blood cells to carry oxygen], and gastroesophageal reflux disease. Review of the State of Florida Do Not Resuscitate Order documented the form was dated 5/05/2023 and signed by [responsible party's name] and [physician's name]. Review of the physician orders dated 5/14/2023 at 00:57 [12:57 AM] reads, DO NOT RESUSCITATE. Advance Directive Status: Current and Verified. Order Type: Advanced Directive. Review of the nursing progress note completed by Staff B, RN (Registered Nurse) dated 5/15/2023 at 00:10 [sic 12:10 AM] read, Approximately at 0110 AM [1:10 AM] on May 15 the nurse assigned to patient called me to the Pt's [Patient] room, she stated Pt had a change in condition. Dr. was being notified of this change when the CNA [Certified Nursing Assistant] came to the desk and stated conditioning worsening. The patient was noted to be a DNR but initially we could not locate it. 911 was called, Reassessment of patient was done and was found without a pulse and no respirations were noted. CPR [cardiopulmonary resuscitation] was initially started. Upon finding DNR compressions were stopped. 911 arrived and pronounced deceased at 01:37 [AM]. Review of the nursing progress note completed by Staff, A, LPN (Licensed Practical Nurse) dated 5/15/2023 at 02:21 AM read, At 0110 this nurse noticed a change in patient condition and put a call out to the doctor, while speaking to the NP [Nurse Practitioner] regarding this patient the CNA came to the desk reporting worsening distress. This nurse noted patient to be a DNR, but could not initially find the DNR, upon assessment of patient this nurse noted the patient was without pulse, and respirations, 911 called, CPR initiated while 2nd nurse looked for DNR, DNR found, CPR stopped, 911 Page 1 of 8 105413 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 arrived and declared at 0137 [1:37 AM]. Level of Harm - Immediate jeopardy to resident health or safety Review of the Discharge Summary completed by [physician's name] on 5/21/2023 at 5:44 AM for [name of physician's office] read, Death Diagnoses: Congestive heart failure, coronary artery disease, chronic kidney disease, COPD, diabetes mellitus. Death Summary: Patient was admitted to Herons pt. SNF [skilled nursing facility] status post hospitalization 5/13/23. Per review of nursing documentation it appears the patient had a change of condition at 1:10 AM on 5/15/2023. It appears the patient was DNR however DNR documentation could not be initially found and CPR was initiated. 911 was called and EMS arrived to the scene. After the DNR documentation was eventually found BLS [basic life support] protocol was stopped and the patient was pronounced by 911 services at 1:37 AM. Medical service was notified after all events occurred and patient expired. Residents Affected - Few During an interview on 5/23/2023 at 9:41 AM the Director of Nursing (DON) stated, My nurses, we had a situation where the pt came in on the 13th [May] at 5:37 PM around that time. The pt. admitted , the chart didn't get put together, they put the orders in. The night nurse put the DNR in PCC [Point Click Care]. This means she would have seen the yellow sheet. It happened on Mother's Day night the status of the resident changed. The chart was not put together. The agency nurse couldn't find the code status. There was a call made to the doctor who gave an order to send the resident to the hospital. The resident coded while the nurse was on the call. The nurse tried to find the DNR and couldn't find it. Our nurse that was on that was an RN made the decision to perform CPR. They only had the code status in PCC. She initiated CPR. It was a couple of minutes later the nurse came down to the room after she got off the phone with 911 and took over CPR. Another nurse from the other wing then took over and did CPR until 1:35 AM when EMS arrived and took over CPR. One of nurses went to the station to get the paperwork ready for transfer. When she pulled the chart there was a packet at the back of the chart that fell out and she went through the packet, and this is when she saw the DNR. She immediately took the DNR to EMS. EMS stopped CPR and EMS called the time of death at 1:37 AM. She came in on the weekend. The chart was not put together. That was determined by our root cause analysis. CPR should not have been started. We did not honor her wishes [Resident #1], her advance directives, and initiated CPR. During an interview on 5/23/2023 at 10:07 AM the Medical Director stated, Usually, when we discuss with the patient and with medical, we have a meeting if we have patients or family asking for a DNR or POA we talk about it. If there is a DNR, then the no CPR order is to be followed. That is what I would expect. If CPR is done it can cause harm to occur. What can happen is broken ribs, trauma, a lot of emotional and psychological harm for the patient and with the family. During a telephone interview on 5/23/2023 at 3:56 PM Staff B, RN stated, The nurse that was assigned to her [Resident #1] came to me and said that she was unresponsive. I went to the chart to find the DNR. The chart had not been put together. I couldn't find the DNR, so I started CPR. I didn't see it in PCC [code status]. I won't say that it wasn't there, but I didn't see it, you are in a rush when this happens. It wasn't in the chart where it should have been. All we had was this big stack of papers and we were shuffling through them as fast as we could. Time is of the essence, so I said we are going to start CPR because if they wanted CPR and it wasn't started; I erred on the side of caution. It could have gone the other way. In the moment there is not a lot of time to waste, we did proceed. Normally, the DNR is the first page [in the chart], you flip and there it is. In this case it wasn't there. During a telephone interview on 5/24/2023 at 12:43 PM Staff A, Agency LPN stated, I had training when I started to work there about DNR and the yellow DNR and the verification process. During report, 105413 Page 2 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few I was told that she [Resident #1] has some respiratory issues and that she was on oxygen at 3 liters. I finished report, and all that, and I went to check on her and she was resting. At around 11:30 PM I went in and repositioned her to make her comfortable. There were no medications for her that were ordered during my shift. I went and took care of others and then went and checked on her at around 12:30 PM. She said she was thirsty, and I raised the head of the bed and gave her some thickened liquids. She then said she wanted her head lowered. I put a pillow under her head and her heels. She seemed to be breathing harder. I spoke with another nurse about where I could find the doctor's number to tell her about [Resident #1's name] and asked the nurse to check on her [Resident #1]. I called the doctor and left a message. I went in with the nurse to check on her [Resident #1] and the ARNP [Advanced Registered Nurse Practitioner] called back as I was going to the desk to call 911. The ARNP asked if I had called 911 and I told her I was going to call now. Got off the phone with her and I called 911. I went to check the resident's chart because I know the DNR form is supposed to be in the front of the chart. I couldn't find it. The computer said she was a DNR, but I wanted to check the form. I went back to the room and the other nurse had already started CPR. EMS arrived and they took over. They said they needed a face sheet. I went to the chart to find the face sheet and that is when I saw the DNR form at the back of the chart. I took the form to EMS, and they stopped CPR, and they pronounced her. Review of the Policies and Procedures titled, Florida Do Not Resuscitate (DNR) last reviewed on 01/03/2023 read, Policy: The center will follow Florida law regarding obtaining and honoring Do Not Resuscitate orders. Procedure: 2. When the resident has executed a DNRO, the form shall be printed on yellow paper and have the words DO NOT RESUSCITATE ORDER printed in black and displayed across the top of the form. DH Form 1896 may be duplicated, provided that the content of the form is unaltered, the reproduction is of good quality, and it is duplicated on yellow paper. The shade of yellow does not have to be an exact duplicate. 3. The properly executed DNRO will be placed in the resident's medical record. Review of the Policies and Procedure titled, Florida Cardiopulmonary Resuscitation (CPR) Last reviewed 01/03/2023 read, Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: Resident identification. Fully executed Florida Do Not Resuscitate order (DH 1896), located in the advanced directive section of the medical record. 3. Use the paging system and call Code Blue to Room Number or location of the event three times. Review of the Plan to Remove Immediate Jeopardy dated 5/24/2023 reads: As of 5/15/2023 an advance directive quality review of current residents was conducted by [Social Services Director's name]. As of 5/15/2023 Staff A, LPN, Staff B, RN, and Staff C, LPN were suspended pending investigation. Staff B, RN received 1:1 education on 5/15/23 from [DON's name] r/t [related to] resident rights, abuse policy and procedure, following physician orders, plans of care, admission process, code blue/CPR, advanced directives, Florida DNR, Nurse Practice Act. On 5/15/23 a Performance Improvement Plan (PIP) was developed and initiated based upon Root Cause Analysis. It was determined a patient who had an active Florida DNR was provided CPR due to the nurses being unable to locate the yellow copy of the Florida DNR in the chart. The chart was not assembled and organized per internal admission process with the Florida DNR on yellow paper in the front of the chart. 5/15/23 a review of current licensed nurses CPR certification completed by [DON's name] and completed on 5/16/2023. As of 5/16/2023 all nurses were in compliance. On 5/15/23, Seventeen (17) Administrative staff were educated related to Advanced Directives, Florida DNR, Code Blue Policies and procedures and chart organization. Eighty-five (85) facility staff to include but not limited to licensed, 105413 Page 3 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few certified, housekeeping, dietary, reception, and clerical staff received education on procedure for Code Blue, FL [Florida] yellow DNRO sheets -2 nurses validating code status and advanced directives completed upon admission to the center and placed in the front of the chart and chart organization following internal admissions process. Internal process for chart organization with emphasis on the FL DNR being located in the front of the chart. Current Licensed Nursing staff including agency staff received education by [DON's name and additional administrative staffs' names] beginning on 5/15/2023 regarding: procedure for Code Blue, FL yellow DNRO sheets - 2 nurses validating code status and advanced directives completed upon admission to the center and placed in the front of the chart and chart organization following internal admissions process. Internal process for chart organization with emphasis on the FL DNR being located in the front of the chart. [NAME] Pointe Health & Rehab currently has 31 licensed nurses including 9 agency nurses [who have been educated] related to DNR, Code Blue Policy and Procedures and chart organization since 5/15/23. Twentynine/thirty-one (29/31) had education beginning on 5/15/23 that was completed on 5/17/23. Current rate of education compliance for licensed nurses [as of 5/17/23] is: 94%. The 2 remaining licensed nurses are out and not able to come into the facility, but will complete their education prior to returning to accept an assignment. Current rate of education compliance for licensed nurses is: 94% as of 5/17/23. (94%) nursing staff beginning 5/15/2023 attended mock code drills on various shifts to include the 7-3, 3-11, and 11-7 shifts. Mock code drills will continue to be held twice weekly on all shifts to include weekends. Licensed nurses, agency nurses and CNAs were given a post-test r/t Florida DNRO after education was provided. All scoring greater than 80%. One hundred five (105) residents of [NAME] Pointe Health & Rehab had the potential to be affected by the deficient practice and potentially suffer a serious outcome as a result of their code status wishes not being honored due to non-compliance with current policies and procedures surround validating code status that honor the residents/resident representatives wishes. On 5/17/23 @ 3:15pm no harm longer existed for the residents of [NAME] Pointe Health & rehab. Newly hired staff will receive education in orientation. As part of the quality review the advanced directives discussion document was competed for current residents. Based upon the wishes of the resident/resident's responsible party the below was completed: FL Yellow DNRO form for those who wish for CPR to be withheld. Form placed in front of the medical record. EHR/PCC [electronic health record] checked to ensure order accuracy. CP [care plan] reviewed to ensure accuracy. Actions to prevent further deficient practice r/t code status began on 5/15/2023 are as follows: education for current licensed nurses as stated above, mock code drills conducted on various shifts/various days to include the weekends, quality review of advanced directives discussion form, quality review of current residents to ensure their code status is honored, orders are correct in the EHR/PCC and the CP is current. An ADHOC [created or done for a particular purpose as necessary] Quality Improvement Performance Committee meeting was held on 5/15/2023 to review the results of facility wide quality reviews completed. The following team members were in attendance: Executive Director, Regional Director of clinical Services, Medical Director, activities Director, and Assistant Director of Clinical Services. The ADHOC QAPI [Quality Assurance and Performance Improvement] Committee approved the recommendations. All plans put in place, are effective and we respectfully request that the immediacy of likelihood of serious harm and/or death to be removed as of 5/17/23. Review of the PIP revealed: PIP-Not Following Advance Directives [NAME] Pointe Date: May 15, 2023. Objective & Goal: Immediate correction and attaining and maintaining regulatory compliance regarding Advanced Directives Center wide. 1. Immediate corrections to ensure safety of affected Patient(s)/Resident(s). 2. Identification of any other Patient(s)/Resident) (s) who may be affected or at risk. 3. Interventions put into 105413 Page 4 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: Full census wide quality review performed of code status. Responsible Person(s) ED, SSD, DON. Target Date: May 15, 2023. Status: 100% completed. Staff Interviews conducted for anyone involved. Document on Witness Statements. Responsible Person(s): ED, DON. Target Date: May 15, 2023. Status: 100% Completed. Establish DNR list from full chart review. Responsible Person(s): ED, DON, SSD. Target Date: Blank. Status: 100% Completed. Complete and validate DNRO Quality Review. Responsible Person(s): ED, SSD. Target Date: Blank. Status: 100% Completed. Educate staff regarding: Internal Tool/Centers Practice: Advanced Directives (SS-124). Policy/Procedure CPR (N302). Responsible Person(s). ADON. Target Date: Blank. Status: 98% Clinical/Non-clinical in building. 100% HSG (Housekeeping/Dietary) Staff. 100% Therapy Department. Educate staff regarding policy/procedures: Abuse/Neglect. Resident Rights. Responsible Person(s): ADON [Assistant Director of Nursing]. Target Date: Blank. Status: 98% Clinical/Non-clinical in building. 100% HSG (Housekeeping/Dietary) Staff. 100% Therapy Department. Educate staff regarding following physician orders, following care plan: Responsible Person(s) ADON. Status: 98% of Clinical/Non-Clinical in building. 100% HSG (Housekeeping/Dietary) Staff, 100% Therapy Department. Educate Licensed Nursing staff regarding Nurse Practice Act. (No staff member will be permitted to work on the floor until all in-services are completed. This would include all facility employees and agency Staff): Responsible Person(s) ADON. Status: 98% Clinical Nurses, 100% non-Clinical. Newly hired nursing staff will receive education to include 'Advanced Directives' during the orientation period. Responsible Party: ADON. Status: No New Hires. Review CPR certification for all licensed nurses. Responsible Person(s): HR [Human Resources], DON. Target Date: May 15th started. Status: 100% Completed. Conduct MOCK code drills q [every] shift until all licensed nurses have attended and competency is documented. Responsible Person(s) DON, ADON. Target Date: May 15, 16. Status: Conducted MOCK code drills Q shift. On-going. Establish detailed 'TIMELINE': Responsible Person(s): ED [Executive Director]. Status: 100% Completed. Root Cause Analysis: Determined that the Internal Tool/Center Practice was not followed prior to starting CPR to ensure residents choice were followed. Responsible Person(s) ED, DON, Medical Director. Target Date: May 15th, 2023. Status: 100% Completed. Ad Hoc QAPI with IDT [Interdisciplinary Team] & Medical Director. QAPI Ongoing: DNRO Quality 105413 Page 5 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Reviews. Social Services and ED will conduct. Findings of these Quality Reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly. Responsible Person(s) ED, DON, Medical Director. Target Date: May 15, 2023. Status: 100% Completed. Decision: Reportable Event (Immediate, 5 Day, Adverse). Responsible Person(s) ED, DON. Target Date May 15, 2023. Status: The Initial Report Completed. The investigation started. Residents Affected - Few Review RTH [Return to Hospital] and Death medical records x previous 3 months to audit code procedures. Responsible Person(s) DON. Status: 100% Completed. Full census wide quality review performed of code status. Responsible Person(s) ED, SSD [Social Service Director], DON. Target Date: May 15, 2023. Status: 100% Completed. Staff Interviews conducted for anyone involved. Document on 'Witness Statements'. Responsible Person(s): ED, DON. Target Date: May 15, 2023. Status: 100% Completed. Establish DNR list from full chart review. Responsible Person(s): ED, DON, SSD. Status: 100% Completed. Complete and validate DNRO Quality Review. Responsible Person(s): ED, SSD. Status: 100% Completed. Weekend/After Hours Admissions & Chart Audit Compliance Tool. Responsible Person(s) DON. Target Date: May 16, 2023. Status: 100% Completed. Agency Staff Education/Orientation Compliance Process. Responsible Person(s): DON/Staff Coordinator. Target Date: May 15, 2023. Status: On-going. Review of the audits for residents' advanced directives documented 100% of the residents' advanced directives were audited dated 5/15/2023 for a total of 102 residents. Review of the current employees' roster did not document Staff B, RN as an active employee. Review of the do not return list documented Staff A, LPN and Staff C, LPN on the list. Review of the in-service sign in sheet dated 5/15/2023 documented [Staff B's name] received training on Nurse Practice Act/Scope of Practice with summary of training sessions: Be sure to know your nursing scope of practice @ all times. You can find your Care Plans, abuse, neglect, [NAME] Pointe has an admission process that includes all nurses (initially the admitting nurse) assistance to thoroughly review the chart and put chart together. You can use the to Nursing Resource Binder located @ each nurses station to guide you through the process. This is a 24 hr. facility - pick up where left off. All physician orders must be carried out appropriately including advanced directives/code status. Two nurses will verify code status during a code blue.: Review of the QAPI Five Whys Tool For Root Cause Analysis dated 5/15/2023 documented: Problem Statement: CPR preformed on Resident with DNR in place. Why? Advanced Directives not followed. Why? Code status discrepancy between PCC and paper chart. Why? DNR form not able to be located in resident's chart. Why? Resident chart not assembled appropriately. Why? Internal admission process failure. Root Cause(s) 1. Internal admission process failure. 2. Not abiding to facility internal practice and processes in handling of Admissions processes. 3. Orientation and staff education for agency. 105413 Page 6 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the CPR Certification audits for licensed staff for the period of 5/15/2023 through 5/23/2023 documents audits were conducted daily for all licensed nursing staff for a 22 of 22 licensed staff. Review of the CPR Certification of Agency staff documented 16 agency staff were audited for up-to-date CPR and were audited daily for the period of 5/16/2023 to 5/23/2023. Review of the in-service sign in sheet titled, Florida DNR dated 5/15/2023 documented the administrative staff signed as having attended the training to include the Dietary, CDM/CFPP [Certified Dietary Manager, Certified Food Protection Professional], Staffing Coordinator, MDS, Social Services Director, Medical Records Director, Assistant Director of Nursing, Director of Maintenance, two Unit Managers, AIT [Associate Information Technology], the Account Manager for Housekeeping; 17 signed in as having attended the training. Review of the in-service sign in sheet titled, Abuse, Neglect, Exploitation, Misappropriation dated for the period of 5/15/2023 through 5/17/2023 113 staff signed as having attended the training r/t the facilities P & P [Policy and Procedures] tilted, Abuse, Neglect, Exploitation, Misappropriation to include licensed staff, administrative staff, housekeeping staff, laundry staff, therapy staff, certified staff, and agency staff. Review of the in-services sign in sheets titled, Advanced Directives and Florida DNR dated 5/15/2023 with training of the P & P and chart organization documented 85 staff members signed as having attended the training. Consisting of 10 RNs, 21 CNAs, 13 LPNs, 1 PCA, BOM, 9 housekeeping staff, 2 social services, Dietary Manager, MDS, medical records, Director of Maintenance, AIT, Admissions, 6 to include the Activities Director, Central Supply, 11 Dietary personnel, 2 smoking monitors, receptionist, and 1 clerical. Review of the agency staffing Post Test-Florida DNRO to include the Orientation Checklist: Agency Staff and Full or Part Time Contractors (Agency Nursing Staff, Therapy, Dietary, Housekeeping, and Laundry) dated 5/16/2023 through 5/20/2023 documented 98 staff completed the post-test. Review of the Code Blue Quality Assurance Drills documented 5/15/23 drills were conducted on the 7/3-3/11 shift and the 11-7 shift. Dated 5/16/23 drills were conducted on the 7-3/3-11 and 11-7 shifts. Dated 5/17/2023 a drill was conducted on the 7-3/3-11 shift. Review of the Timeline dated 5/15/2023 documented the sequence of events related to the incident for Resident #1 for the period of time of the start of the event to the notification family and removal of the deceased . Review of the interviews and witness statements documented for the period of 5/15/2023 through 5/17/2023 Staff A, LPN, Staff B, LPN, Staff C, LPN, and additional staff were interviewed and completed witness statements. Interviews were conducted on 05/23/2023 to 05/24/2023 with 1 Patient Care Assistant, 7 CNAs to include 2 agency CNAs, 9 LPNs to include 3 agency LPNs, 3 RNs to include 1 agency RN, 1 housekeeper, the Rehabilitation Director, Business Office Manager, Assistant Social Services Director, Social Services Director, and Director of Maintenance for a total of 26 interviews from three shifts to verify participation in training, understanding of training, with explanation of the implementation of Advance Directive location and what actions would be taken in the future if the Advance Directive was 105413 Page 7 of 8 105413 05/24/2023 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0578 documented in PCC, but not in the hard copy record. Level of Harm - Immediate jeopardy to resident health or safety Review of the Weekend/After Hours Admissions & Chart Audit Compliance Tool documented audits were conducted for four week-end admissions dated 5/21/2023. Review of a new admission record provides a Check List guide for the chart organization. Residents Affected - Few Review of the seven new admissions since 5/15/2023 found the records were organized and provided for advanced directives. Review of the Admission/Discharge To/From Report for the period of 3/15/2023 through 5/20/2023 documented there were three deaths that occurred in the facility, and each was investigated. There were no deaths that occurred in the facility since 5/15/2023. Review of Human Resources records for the period of 5/15/2023 through 5/23/2023 revealed there were no new hires for this period of time. Review of the Ad Hoc Quality Assurance Performance Improvement Meeting dated 5/15/2023 documented the Administrator, DON, Medical Director, Social Services, Activities Director, Dining/Nutrition, MDS [Minimum Data Set], Plant Services, Business Development, Housekeeping/Laundry, Business Office, and six additional attendees signed in as having attended the meeting. Reason for Ad Hoc Meeting: this space is blank. Opportunity for Improvement: Re-Implementation of all company policies. Newly hired nursing staff will receive education to include 'Advance Directives' during the orientation period. Conduct MOCK code drills Q shift. Educate staff-Following Physician orders & following Care Plans educate Licensed staff regarding Nurse Practice Act. Data: Not abiding to company policy and procedures in the admission process of new admits. Analysis (Root Cause Analysis) PCC (EMAR System) was noted with an order for DNR. The yellow Florida DNR form was not found in the residents chart. Because the Florida DNR form was not in the chart, CPR was initiated on the resident. Plan: In-servicing of all departments and staff. (Please refer to Performance Improvement Plan of 5-15-2023 which is attached to QAPI Ad hoc). Responsible Team Members: Clinical Team: DON, ADON, Unit Managers, Nurses, CNAs, Admissions Team. Housekeeping Team, Dietary Team, Social Services Team, Maintenance Team Administration. 105413 Page 8 of 8