Every finding on record at Apopka Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions during dishwashing operations when the dishwasher was malfunctioning; and failed to ensure hot food was served at safe temperatures.Findings:1.On 1/26/26 at 10:02 AM, during the initial tour of the kitchen, the Certified Dietary Manager (CDM) demonstrated the process of dish sanitization by operating the commercial dishwasher. The temperature gauge reached a maximum of 120 degrees Fahrenheit (F), and he stated that in addition, they do a litmus paper check to ensure optimal sanitization with chlorine, at 50-100 parts per million (PPM). After about four attempts to check the sanitizer, there was no change in the color of the litmus paper, indicating the proper sanitizer solution level had been reached. The CDM verified the litmus paper was not expired, then proceeded to use another set of litmus paper strips. After two more attempts with the new litmus strips, there was still no change in the color of the strips to indicate the correct PPM of chlorine was present.A few minutes later, review of the dishwasher low temperature log sheet posted adjacent to the dishwasher revealed that for breakfast that day the temperature was documented as 120 degrees F and the sanitizer was 100 PPM. The entry had no initials to indicate who recorded the data. Dietary Aide A, assigned to the dishwashing task said he used the dishwasher earlier but did not use the test strips. He explained he knew this was an important step but could not say why he did not do it. Dietary Aide A said he did not document in the log. The CDM was unable to ascertain which staff documented the sanitizer was 100 PPM that morning because of the lack of initials. The CDM stated the log sheet was documented in error and crossed out the documented figures. The CDM acknowledged there was no way to determine whether the dishes were sanitized and directed staff to use disposable utensils for meals until the machine was fixed.On 1/27/26 at 9:57 AM, the CDM explained whenever the bucket with the chemical was changed, it caused air to build up and cause a clog. The CDM acknowledged the sanitizer was not at the required level, and that someone had documented in error that it was. The CDM said staff were supposed to report to him if the PPM of sanitizer was not within the required range.The facility's dishwasher log policy did not address the level of chemical sanitation required for a low temperature dish machine.2. On 1/28/26 at 11:35 AM, during the lunch meal service, the chicken orzo soup in the hot box was at 131 degrees F. The CDM acknowledged per accepted food safety standards, hot foods should be held at 135 degrees F of higher. On 1/29/26 at 10:39 AM, the CDM said the hot box was equipped with a heating element that measured about 175 to 180 degrees F. He explained maybe the soup was left on the counter too long before it was placed in the hot box. He said the cooking temperature was recorded at 213 degrees F, but said the temperature was not rechecked prior to placing it in the hot box. The CDM could not really say what caused the soup to be below the safe temperature for service. The CDM said he was the only one with the Safe Serve Certification in the kitchen.The facility's undated policy on cooking, holding and reheating temperatures for the hot foods service indicated all hot foods must be served at a temperature of at least 135 degrees F.

Based on observation, interview, and record review, the facility failed to ensure medications were administered per physician orders and according to professional standards of practice for 1 of 56 residents reviewed for medication administration, (#71).Findings: Review of resident #71's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, foot ulcer, neuropathy, skin infection, lower limb cellulitis, abnormality gate/mobility, and depression.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 that indicated she was cognitively intact.Review of resident #2's Medication Administration Record (MAR) for January 2026 revealed physician orders for the following medications: Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) apply 4 grams to left hip topically three times a day for left hip pain do not apply more than 16 grams daily to any one affected joint, with an order date of 12/29/25.On 01/04/25 at 9:00 AM, 1:00 PM, 5:00 PM, and 1/13/26 6:00 AM, the MAR for Voltaren External Gel 1% Topical was noted to have an entry code of 9 which according to the facility MAR legend means other/see note with no documentation of why the medication was not administered. On 01/14/25 at 6:00 AM, the MAR for Voltaren External Gel 1% Topical was noted to have an entry code of 9 which according to the facility MAR legend means other/see note. The record did not have documentation stating why the medication was not administered. On 01/29/26 at 12:36 PM, the 200 Unit Manager explained a nursing note should be in place that corresponds to documentation of other on the MAR. She confirmed there was no documentation of the medications being administered or why they were not administered. She acknowledged that the process of medication administration is different for Voltaren External Gel 1% Topical as it is kept in the procedure cart instead of the medication cart.The facility's Medication Administration policy, reviewed on 01/18/2024, reads: It is the policy of the facility to provide care and services related to mediation administration in accordance with state requirements.The facility will have a staff member, who is licensed to administer medications, available to administer medication in accordance with a health care provider's order or prescription label.

Based on observation, interview, and record review, facility staff failed to use appropriate personal protective equipment (PPE) when providing high contact care to a resident per enhanced barrier precautions (EBP), for one of seven residents reviewed for infection control, of a total sample of 56 residents, (#194).Findings:Enhanced Barrier Precautions are an infection control intervention utilized by nursing homes to reduce transmission of multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions involve use of PPE, for example, a gown and gloves, during high-contact resident care activities for residents known to be colonized or infected with a MDRO. EBP is also recommended for residents of nursing homes who are at increased risk of MDRO acquisition e.g., residents with wounds or indwelling medical devices, (retrieved on 2/06/26 from www.cdc.gov).Resident #194 was admitted to the facility on [DATE] with diagnoses that included sepsis, chronic viral hepatitis C, encephalopathy (brain dysfunction) and failure to thrive. admission records revealed resident #194 was admitted with a right chest port and a right pleural catheter.A chest port is a surgically implanted device that allows easy access to a vein for long term or frequent intravenous infusions. One in three people with implanted ports have complications, the most common is infection. Infection raises the risk of sepsis, a life-threatening bodily response to infection, (retrieved on 2/12/26 from myclevelandclinic.org).A pleural catheter is a soft tube inserted by a physician into the lung space to remove fluid that surrounds the lungs that can cause trouble breathing. Complications of a pleural catheter include infections (retrieved on 2/12/26 from thoracic.org). Review of the resident's care plan, initiated on 01/12/26, revealed the resident required EBP and staff were to follow precaution signage and protocol.On 1/28/26 at 10:32 AM, Occupational Therapist Assistant (OTA) D obtained resident #194's blood pressure as she was sitting up at the side of the bed. With the assistance of Physical Therapist Assistant (PTA) E, they both transferred the resident to a lying position by picking up her feet off the ground, then they boosted her up. Both staff members were observed wearing gloves but had not donned gowns. At that time, OTA D and PTA E acknowledged they were not wearing a gown over their clothes and explained they did not know resident #194 was on EBP. OTA D and PTA E acknowledged the EBP signage at the entrance of the resident's room, the EBP signage over her bed, as well as the PPE supplies at the entrance of the room. They both confirmed in addition to gloves, a gown should be worn when providing care to resident #194. They explained they missed it.On 1/29/26 at 10:28 AM, the Director of Nursing and the Assistant Director of Nursing acknowledged the breach of EBP by OTA D and PTA E when caring for resident #194 the previous day. The stated their expectation was for staff to wear the appropriate PPE to reduce the risk and spread of infections for residents on EBP.The facility did not provide a policy on Personal Protective Equipment.

Based on interview and record review, the facility failed to notify resident guardian of missing dentures for 1 of 1 residents reviewed for dental, of a total sample of 56 residents, (# 139).Findings:Resident #139 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbances. Review of the resident's electronic medical record revealed a court determination of the resident's total incapacity dated 10/26/23 related to her diagnosis of Dementia and showing signs of a lack of awareness. On 8/8/24 the court appointed a legal guardian of person and property of resident #139.The admission Record included resident # 139's court appointed legal guardian's name with her associated telephone number and email address.Review of resident's inventory list dated 7/29/24 indicated the resident had upper dentures listed with her belongings.Review of the resident's clinical record revealed a monthly summary progress note on 1/19/26 at 8:05 PM, that stated the resident wears dentures or partials.On 1/27/25 at 12:24 PM, resident #139 was noted in the dining room for lunch. She was noted to not have her dentures in.On 1/28/26 at 3:40 PM, a phone interview with resident #139's legal guardian revealed she was unaware of the resident's missing dentures. She confirmed that the facility never notified her that they were missing at any point.On 1/29/26 at 10:05 AM, the Executive Director stated that sometimes the residents dentures go missing for a few weeks before they turn up again. She stated the staff think resident # 139's dentures have been missing for approximately 3 weeks. She confirmed that she was unaware of the resident's missing dentures before this week during survey. The Executive Director stated they have a dentist who comes to the facility and will determine if the resident is still a candidate for dentures. The facility will determine at that time if reimbursement is necessary. She confirmed that the resident's legal guardian was not notified of the missing dentures since typically they turn up again.Review of the facility policy titled Notification of Changes with no revision date states that when a resident is deemed incapacity the resident's representative would be notified and they would make any decision that need to be made.

Based on interview and record review, the facility failed to timely complete Comprehensive Minimum Data Set (MDS) Assessments for 2 of 6 residents reviewed for Resident Assessment, of a total of 56 residents, (#77, #162).Findings:1. Review of the medical record revealed resident #77, an [AGE] year-old female was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 1/15/25 with diagnoses that included dementia, malnutrition, gastrostomy (feeding tube) status, convulsions, and abnormality of gait (walking) and mobility.Resident #77's most recent MDS Comprehensive Annual Assessment with an Assessment Reference Date (ARD) of 12/27/25 showed a completion date of 1/13/26, 3 days late.2. Review of the medical record revealed resident #162, a [AGE] year-old male was admitted to the facility from another nursing home on 9/05/23 with diagnoses that included gastrostomy status, seizures, encephalopathy (brain dysfunction), hemiplegia and hemiparesis (paralysis) after stroke, right lower leg pressure wound, major depressive disorder, dementia, malnutrition, contractures (muscle tightening/stiffening) of both knees, weakness, and aphasia (difficulty speaking/understanding speech)Resident #162's most recent MDS Comprehensive Annual Assessment with an ARD of 12/12/25 showed a completion date of 1/05/26, 10 days late.During a joint interview on 1/29/26 at 2:41 PM, with the MDS Director, MDS Coordinator, and Regional MDS, the MDS Director said the Resident Assessment Instrument (RAI) timelines were followed and the expectations were for timely completion by the due date, which was 14 days after the ARD. She checked the electronic records and acknowledged that residents #77 and #162's most recent Comprehensive Annual Assessments were completed late. The Registered Nurse (RN) relayed timely assessment completions were important so the Interdisciplinary Team (IDT) would recognize and act on any condition changes, declines, or concerns. She said assessments were tracked by a list and the IDT was reminded of due dates during daily meetings. She said the department was adequately staffed and the Regional MDS covered absences. She said delays occurred during the holidays and staff absences.Review of the facility's undated standards and guidelines for MDS' outlined that the RAI was a method for assessing functional capacity and needs, identification of problems and strengths, and intervention development for which results were used to develop, review, and revise individualized care plans. The policy noted the MDS Coordinator was responsible for tracking and monitoring due dates. The RAI Assessment Summary noted Comprehensive Annual Assessments were due every 366 days from previous Comprehensive Assessments and no later than 14 calendar days after the ARD date.

Based on interview and record review, the facility failed to timely complete Quarterly Minimum Data Set (MDS) Assessments for 4 of 6 residents reviewed for Resident Assessment, of a total of 56 residents, (#2, #127, #142, #151).Findings:1. Review of the medical record revealed resident #2, a [AGE] year-old male was admitted to the facility from an acute care hospital on 9/18/25 with diagnoses that included acute osteomyelitis (bone infection), absence of right toe(s), dysphagia (difficulty swallowing), type 2 diabetes mellitus, history of stroke, peripheral (arms/legs) vascular (veins/arteries) disease, abnormalities of gait (walking) and mobility, major depressive disorder, hypertension (high blood pressure), and unspecified fall.Resident #2's most recent MDS Quarterly Assessment with an Assessment Reference Date (ARD) of 12/26/25 showed a completion date of 1/12/26, 3 days late.2. Review of the medical record revealed resident #127, a [AGE] year-old male was admitted to the facility from an acute care hospital on 5/01/23 with diagnoses that included acute kidney failure, dementia with agitation, major depressive disorder, weakness, and right foot fracture on 7/22/24.Resident #127's most recent MDS Quarterly Assessment with an ARD of 12/28/25 showed a completion date of 1/12/26, 1 day late.3. Review of the medical record revealed resident #142, an [AGE] year-old male was admitted to the facility on [DATE] from an acute care hospital with diagnosis that included left hip fracture, encephalopathy (brain dysfunction), type 2 diabetes mellitus, coronary artery disease, abnormalities of gait and mobility, and weakness.Resident #142's most recent MDS Quarterly Assessment with an ARD of 12/26/25 showed a completion date of 1/12/26, 3 days late.4. Review of the medical record revealed resident #151, a [AGE] year old male was admitted to the facility on [DATE] and re-admitted from from an acute care hospital on [DATE] with diagnosis that included stroke, hemiplegia and hemiparesis (paralysis) on left dominant side after stroke, type 2 diabetes mellitus, anxiety disorder, depression, abnormalities of gait and mobility, and weakness.Resident #151's most recent MDS Quarterly Assessment with an ARD of 12/31/25 showed a completion date of 1/15/26, 1 day late.During a joint interview on 1/29/26 at 2:41 PM, with the MDS Director, MDS Coordinator, and Regional MDS, the MDS Director She said the Resident Assessment Instrument (RAI) timelines were followed and the expectations were for timely completion by the due date, which was 14 days after the ARD. She checked the electronic records and acknowledged that residents #2, #127, #142, and #151's most recent Quarterly Assessments were completed late. The Registered Nurse (RN) relayed timely assessment completions were important so the Interdisciplinary Team (IDT) would recognize and act on any condition changes, declines, or concerns. She said assessments were tracked by a list and the IDT was reminded of due dates during daily meetings. She said the department was adequately staffed and the Regional MDS covered absences. She said delays occurred during the holidays and staff absences.Review of the facility's undated standards and guidelines for MDS' outlined that the RAI was a method for assessing functional capacity and needs, identification of problems and strengths, and intervention development for which results were used to develop, review, and revise individualized care plans. The policy noted the MDS Coordinator was responsible for tracking and monitoring due dates. The RAI Assessment Summary noted Quarterly Assessments were due no later than 14 calendar days after the ARD date.

Based on interview and record review, the facility failed to ensure a resident with a positive Preadmission Screening and Resident Review (PASRR) level I who required a level II, was evaluated for required specialized services for 1 of 1 residents (#82) reviewed for mood and behavior out of a total sample of 56 residents.Findings:A Level I PASRR screen identified whether an individual applying for admission into a skilled nursing facility (SNF) had or was suspected of having a serious mental illness (SMI), intellectual disability (ID), or both. The Level II PASRR confirmed or ruled out an SMI, ID or both. It was an in-depth evaluation of the individual and a determination of the need for SNF services. If an SNF was the most integrated setting appropriate to meet the individual's long-term care needs, the Level II PASRR would also evaluate what specialized services, if any, would be recommended for the individual during their SNF stay, retrieved from( https://ahca.myflorida.com/medicaid/preadmission-screening-and-resident-review-process-pasrr).Resident #82 was admitted to the facility from an acute care hospital on 1/20/23 with diagnoses that included a history of cerebral infarction, bipolar disorder, seizures, generalized anxiety, and schizoaffective disorder.Review of resident #82's hospital records dated 4/17/24, revealed she had been admitted to the hospital from the facility due to a fall. The hospital records showed she had a history of head trauma, schizophrenia, bipolar disorder, depression, and dementia.Resident #82's most recent PASRR dated 6/24/25, revealed she was diagnosed with anxiety disorder, bipolar disorder, and schizoaffective disorder and required a level II PASRR evaluation due to serious mental illness. The level I evaluation had been completed by the Assistant Director of Nursing (ADON).Review of resident #82's Quarterly Minimal Data Set assessment dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which was moderately impaired cognition.Review of the care plan for resident #82, revealed a care plan for behaviors initiated on 04/22/24, which showed she had behavior problems related to schizoaffective disorder, bipolar disorder and anxiety. She had episodes of severe confusion, forgetfulness, anxiousness, and agitation. Resident #82 also had a care plan for elopement and wandering, which was initiated on 06/23/23, and had interventions that included seeking a referral for mental health evaluation as needed. She had other behaviors such as shower refusals and mood problems related to depression, bipolar disorder, and schizoaffective disorder.On 1/27/26 at 11:04 AM, the level II PASSR for resident #82 was requested from ADON, who was responsible for PASRRs, but she did not provide it. Then on 01/28/26 at 11:00 AM, the ADON stated that there was no level II PASRR completed but that the psychiatrist had evaluated the resident on 01/26/26 and reviewed the level I PASSR. She provided this as an explanation for why the Level II PASRR was not obtained, however the level II was requested on 06/24/25 and the psychiatrist evaluation was completed seven months later. Review of resident #82's psychiatrist progress note dated 01/26/26 revealed the psychiatrist conducted a review of the resident's Level I PASRR and prior psychiatric provider's notes to reevaluate the accuracy of the diagnosis of schizoaffective disorder. The note concluded that the resident did not exhibit any signs or symptoms related to schizophrenia or schizoaffective disorder, so the records were updated to reflect that schizoaffective disorder had been resolved. However, the resident would continue to be treated for depression, bipolar disorder, and anxiety, which were still listed as SMI in the Level I PASRR, so a Level II PASRR was still required. Previous psychiatric notes dated 05/30/25, 11/11/25, and 12/24/25 were reviewed and these showed resident #82 was treated for schizoaffective disorder and behaviors.On 01/29/26 at 12:52 PM, the ADON stated she was the only staff member responsible for ensuring PASRRs were completed and submitted in a timely manner. She admitted the process for tracking the completion and accuracy of PASRRs had not been effective and that is why resident #82's Level II PASRR had been missed.Review of the facility's Policy and Procedures for PASRR dated 03/202, revealed it was the facility's policy to ensure all residents admitted to the facility received a PASRR screening in accordance with state and federal regulations. Staff responsible for the completion of the PASRR were to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into the resident's assessment, care planning, and transitions of care. Furthermore, residents who presented with newly evident or possible serious mental disorder, intellectual disability, or a related condition were to be referred for a level II resident review upon a significant change in status assessment.

Based on interview and record review the facility failed to ensure medical records were accurate pertaining to splint application for 1 of 1 resident reviewed for Range of Motion (ROM)/Mobility, (#66), and failed to ensure medical records were accurate, and systematically organized for 1 resident (#136), of a total sample of 48 residents. Findings: 1. Resident #66, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side, aphasia (inability to speak), major depressive disorder, conversion disorder with seizures or convulsions, and weakness. The resident's physician's order dated 10/23/23 directed staff to apply a splint to his right wrist following morning care, and to doff the splint prior to bedtime. Instructions were, Monitor skin integrity when applying and removing, discontinue wear if skin becomes red or pt (patient) is in pain. Review of the resident's Treatment Administration Record (TAR) for the period 3/01/24 through 4/03/24 revealed that nurses signed off on the task. However, there was ambiguity pertaining to what was being signed off, the donning of the splint, or the monitoring of the resident's skin integrity. Observations on 4/01/24 at 11:50 AM, 4/02/24 at 10:00 AM, and on 4/02/24 at 3:42 PM, showed resident #66 sitting up in bed watching television. The resident had right hand weakness and did not have a splint on. The splint was noted on the resident's chest of drawers. Resident #66 said the splint was not placed by Therapy, and when asked who placed the splint on, the resident's response was no one. On 4/03/24 at 11:28 AM, and at 11:35 AM, Licensed Practical Nurse (LPN) J stated the resident's right hand splint was placed by the Certified Nursing Assistant (CNA) or Therapy, and nurses signed off on the TAR to indicate that the splint was applied. Observation of the resident conducted with the LPN, showed no splint to the resident's right hand, and the splint was again noted on the resident's bedside table. This was acknowledged by the LPN, who also acknowledged the physician order to don the right hand splint following morning care, and to doff prior to bedtime. LPN J stated the administration details on the resident's TAR revealed documentation and signatures by nurses which indicated the splint was applied, and there were no problems. LPN J's signature was noted on the resident's TAR fourteen (14) times for the period reviewed. On 4/03/24 at 11:39 AM, CNA L stated he worked on the 7 AM to 3 PM shift and provided care for resident #66. He stated the resident required total assistance with activities of daily living, and he was aware of the resident's splint. CNA L said he had not signed off on the task for donning the resident's splint and confirmed PT had not been applying the splint. He said the resident's splint had not been applied for a couple of days, since the resident was no longer on therapy caseload, and he could not apply the splint since he was not trained to don/doff the splint. On 4/04/24 at 9:47 AM, the Assistant DON (ADON) reviewed physician orders for resident #66, and stated the order pertaining to the splint was inclusive of donning the splint and monitoring skin integrity. The ADON stated she was not sure if nurses were checking off regarding donning the splint or for monitoring of the resident's skin integrity. She stated they should be checking for skin integrity prior to applying the resident's splint. On 4/04/24 at 10:00 AM, LPN K stated she signed off on the resident's TAR to indicate she monitored the resident's skin for redness, irritation, and pain. LPN K verbalized that on 4/01/24, she did not apply the resident's splint, but signed off on the TAR for monitoring the resident's skin integrity. LPN K's signature was noted on the resident's TAR three (3) times for the period reviewed. 2. Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospitalization . Her diagnoses included metabolic encephalopathy, hemiplegia/hemiparesis following cerebral infarction (stroke) affecting the left non dominant side, acute and chronic respiratory failure, dysphagia following cerebral infarction, tracheostomy status, gastrostomy status, diabetes type II, major depressive disorder, and hypertension. Review of the resident's Electronic Medical Record (EMR) revealed the Provider progress notes dated 5/20/23, 6/11/23, 6/14/23, 6/23/23, 7/07/23, 8/12/23, 9/03/23, 9/22/23, 9/24/23, 10/08/23, 11/12/23,12/11/23, 12/24/23,1/05/24, 1/09/24, 1/25/24, 1/27/24, 1/31/24, 2/05/24, and 2/21/24 for another resident were uploaded to resident #136's EMR. A total of twenty (20) progress notes in resident #136's medical record did not belong to resident #136. On 4/04/24 at 2:47 PM, the Regional Director of Clinical Services reviewed the resident's EMR, and acknowledged scanned documents were for another resident. She stated the facility's Health Information Coordinator was currently on leave, and findings would be reported to the Executive Director, who would contact the facility's legal department for correction of the affected residents' EMR. On 4/04/24 at 3:06 PM, resident #136's EMR was reviewed with the Executive Director. She acknowledged the Provider progress notes uploaded to the resident's EMR for the dates listed belonged to another resident. The Executive Director stated it, Looked like an oversight, and verbalized she had contacted the facility's Corporate office and informed them of the discrepancy. When asked who reviewed EMR to ensure accuracy, the Executive Director stated she did not know who reviewed the residents' EMRs to ensure documents uploaded belonged to the correct resident. The Standards and Guidelines: Disposition of Medical Records after Scanning/Imaging issued 2/19/2016, and revised 3/27/21 read, Documents should be scanned and uploaded individually .Ensure that the document was uploaded to the correct patient's EHR (Electronic Health Record).

Based on interview, and record review, the facility failed to ensure a copy of the notice for transfer/discharge to the hospital was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents reviewed for hospitalization , of a total sample of 48 residents, (#136). Findings: Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospitalization . Her diagnoses included metabolic encephalopathy, hemiplegia/hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, acute and chronic respiratory failure, dysphagia following cerebral infarction, tracheostomy status, gastrostomy status, diabetes type II, major depressive disorder, and hypertension. Review of the resident census revealed resident #136 was hospitalized on [DATE], and readmitted to the facility on [DATE]. The eInteract Change in Condition Evaluation form dated 2/29/24 indicated the resident was sent to the Emergency Department for further evaluation and treatment. Review of the resident's clinical records revealed the Nursing Home Transfer and Discharge Notice for the resident could not be found. On 4/04/24 at 3:26 PM, the Social Services Director (SSD) stated that Social Services was responsible to submit a copy of the Nursing Home Transfer and Discharge Notice to the office of the Ombudsman. She stated the notifications were submitted monthly. Review of the resident's medical record, and a binder located in the SSD's office did not reveal a copy of the Nursing Home Transfer and Discharge Notice, or any evidence to indicate a copy of the notice was submitted to the Ombudsman. This was acknowledged by the SSD, who explained she was hired three weeks ago and was told all documents would be scanned into the facility's electronic medical record. On 4/04/24 at approximately 5:00 PM, and at 5:17 PM, the SSD provided a Nursing Home Transfer and Discharge Notice for the resident dated 2/29/24. However, no documentation/evidence could be identified to indicate the notice was submitted to the Ombudsman's office. The SSD then provided a fax transmission log dated 4/01/24 for discharges for March 2024 that were submitted to the office of the Ombudsman. She stated she could not locate a transmission log to indicate discharges/transfer for February 2024 were submitted to the Ombudsman's office as required. Review of the facility's discharges revealed that fifteen (15) residents were discharged to the hospital for the period 2/01/24 to 2/29/24. The facility could not provide documentation to indicate the Ombudsman office was provided with a list/copy of the discharges for February 2024. Request to the facility for a corresponding policy/procedure regarding notification of discharges was not met.

Based on observation, interview, and record review the facility failed to provide care and services for an intravenous (IV) access site according to professional standards of practice to prevent infection for 1 of 1 resident reviewed for IVs, of a total sample of 48 residents, (#18). Findings: Review of the medical record revealed resident #18 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included ischemic cardiomyopathy, moderate protein-calorie malnutrition, type 2 diabetes, and dementia. Review of the Minimum Data Set (MDS) Medicare Part A Discharge assessment with assessment reference date of 3/12/24 revealed resident #18 received antibiotic medication during the seven day look back period. Review of the medical record revealed an Infectious Disease Consultant Provider Note dated 3/26/24. The specialist physician assessed resident #18 and noted a non-healing right heel wound with osteomyelitis or a bone infection. The note read, Plan: Will start Ertapenem as the wound had a foul smell and had profuse drainage. Ertapenem is an antibiotic that is used to treat severe infections. It is administered by injection into a muscle or infused through a vein (retrieved on 4/18/24 from www.drugs.com/mtm/ertapenem.html). Review of the Order Summary Report revealed resident #18 had a physician order dated 3/27/24 for Ertapenem 1 gram IV once daily for 14 days, to treat his wound infection. There was an order dated 3/28/24 for insertion of a midline IV and orders dated 3/29/24 to change the transparent dressing every seven days and as needed. The physician orders instructed nurses to measure the external catheter length during dressing changes and observe for leakage, loosening or soiling of the dressing, and for signs and symptoms of infection, infiltration, and extravasation, or leaking from the IV into surrounding tissue. A midline catheter is a small tube that is inserted into a vein in the arm. The catheter is used to administer medications and take blood samples and can remain in place for up to 30 days. After insertion, the catheter is secured with a sterile, transparent dressing which prevents infection and permits easy monitoring of the insertion site for signs of infection. The dressing should be changed as directed or whenever it is loose, wet, or soiled, (retrieved on 4/18/24 from www.drugs.com/cg/midline-catheter.html). Resident #18 had a care plan for IV therapy related to a wound infection initiated on 3/29/24. The goal was the resident would not suffer any complications related to IV therapy. The interventions instructed nurses to change the IV dressing and maintain the IV device per the facility standard, and monitor the catheter insertion site every shift for signs of infiltration and infection. On 4/01/24 at 12:28 PM, resident #18 had a left upper arm IV access line with a transparent dressing dated 3/30/24 covering the insertion site. Beneath the clear dressing, there was a bloody, folded gauze pad at the insertion site. On 4/01/24 at 12:34 PM, Licensed Practical Nurse (LPN) M confirmed resident #18 had a bloody gauze under his left arm dressing. She recalled she was informed the area bled a lot when the IV was inserted. LPN M confirmed she was assigned to care for resident #18 during the 7:00 AM to 7:00 PM shift but she had not yet assessed the resident's IV access site. When asked if the dressing needed to be changed, LPN M stated she was unsure as it was scheduled once weekly. On 4/03/24 at 1:53 PM and 2:11 PM, LPN N stated she was aware resident #18 had a midline to the left upper arm. She confirmed she had not inspected the dressing since the start of the 7:00 AM shift as she would check the site close to the end of her shift when she administered his IV medication at 6:00 PM. LPN N was asked to check the resident's dressing. She confirmed there were no initials on the dressing to indicate which nurse performed IV site care and said, It's just dated, 3/30/24 on dressing. Joint observation of the transparent dressing revealed the gauze was now totally saturated with blood and yellow-colored fluid. Review of the Medication Administration Record for March 2024 revealed LPN N initialed the document to confirm she changed resident #18's IV dressing on 3/30/24. On 4/03/24 at 2:02 PM and 2:16 PM, the 400 unit Unit Manager (UM) reviewed resident #18's medical record and noted the midline was inserted on 3/28/24 but the resident pulled it out and another midline was inserted on 3/29/24. He explained the gauze must have been placed during a dressing change done over the weekend. The UM reviewed nursing progress notes and acknowledged there was no documentation of issues with bleeding at the site or the need to use gauze, and no instructions to change the dressing more frequently due to bleeding. On 4/03/24 at 2:25 PM, the Regional Director of Clinical operations assessed resident#18's left upper arm IV site and validated the bloody gauze remained under the transparent dressing for four days, since 3/30/24. She was informed when the issue was brought to LPN M's attention on 4/01/24, the nurse stated the dressing was to be changed every seven days. The Regional Director of Clinical operations confirmed the current dressing posed an infection control concern and stated her expectation was nurses would monitor IV sites appropriately and address concerns in a timely manner. On 4/03/24 at 2:32 PM, the facility's Medical Director validated the bloody gauze pad left underneath resident #18's transparent dressing placed him at risk for infection as it was a medium for bacterial growth. On 4/05/24 at 11:22 AM, the Assistant Director of Nursing (ADON) stated she discovered the gauze was placed under the resident's transparent dressing by LPN N as the site was still bleeding the day after the midline was inserted. The ADON explained if it was necessary to use gauze, the dressing should be changed every 48 hours to prevent negative outcomes. Review of the Pharmascript Infusion IV Access Line Maintenance Protocol, effective 2/07/20, revealed midline transparent dressings should be changed 24 hours after insertion and then weekly as needed. The document read, Gauze should only be used if patients are sensitive to clear, transparent dressings and must be changed[every] 2 days. The facility's policy and procedure for Site Care of Peripheral Venous Catheter, revised in February 2019, provided general guidance on routine IV insertion site inspection, site care, and application of a sterile dressing to reduce or prevent the complications of catheter related infection. The document indicated a sterile, transparent dressing would be used to cover IV sites and the dressing would be labeled with the date, the nurse's initials, and the insertion date from the previous dressing. The policy revealed nurses would document the dressing change procedure, characteristics of the site.

Based on observation, interview, and record review, the facility failed to promote the right to self-administer medication for 2 of 7 residents reviewed for choices, out of a total sample of 48 residents, (#87 and #161). Findings: 1. Review of the medical record revealed resident #87 was admitted to the facility on [DATE] with diagnoses including accidental poisoning by unspecified drugs, spinal stenosis, abnormality of gait and mobility, and weakness. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date (ARD) of 2/01/24 revealed resident #87 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he had moderate cognitive impairment. The document revealed the resident had no behavioral symptoms and did not exhibit inattention, disorganized thinking, or altered level of consciousness in the look back period. The MDS assessment showed resident #87 received scheduled and as needed pain medication for occasional, moderate pain. Review of the medical record revealed a care plan for potential and/or actual pain was initiated on 7/25/23. The goals were the resident would not experience an overall decline in function or have an interruption in normal activities due to pain. The interventions included administer pain medication as ordered and monitor for effectiveness, consider premedication for treatments, and report changes in type and location of pain. On 4/02/24 at 10:07 AM, a bottle of Biofreeze was observed on resident #87's tray table. The container was approximately 1/3 full and the resident explained he purchased the medication and used it regularly. He said, I put it on my legs and CNAs [Certified Nursing Assistants] put it on my back. Biofreeze is a topical medication used to treat muscle or joint pain. The manufacturer's instructions read, Use exactly as directed on the label, or as prescribed by your doctor. (Retrieved on 4/08/24 from www.drugs.com/mtm/biofreeze.html). On 4/02/24 at 10:11 AM, the 400 unit Unit Manager (UM) explained residents were not permitted to keep any medication at the bedside unless there was a physician order for the drug and the resident was assessed for the ability to self-administer the medication safely. The UM was not aware resident #87 had a container of Biofreeze in his room. He reviewed the resident's electronic medical record (EMR) and stated there was no physician order for Biofreeze and no documentation of an assessment for safe self-administration of medication. On 4/02/24 at 10:14 AM, resident #87's assigned nurse, Licensed Practical Nurse (LPN) M validated the bottle of Biofreeze remained on the resident's tray table. The resident informed LPN M he had been using the medication and wanted to keep it in his room. 2. Review of the medical record revealed resident #161 was admitted to the facility on [DATE] with diagnoses including right hip fracture, neuropathy, and generalized muscle weakness. The MDS Admission assessment with ARD of 3/18/24 revealed resident #161 had adequate hearing and vision. She had a BIMS score of 13 which indicated she was cognitively intact. On 4/02/24 at 9:21 AM, resident #161 had a box with a bottle of eye drops on her tray table. The pharmacy label on the box indicated the bottle contained Polymyxin B-Trimethoprim Ophthalmic Solution to be administered to the left eye, four times daily. The resident also had a small tube of antibiotic ointment on the tray table. The resident pointed across the room at a box of Refresh lubricant eye drops and explained she had been using the non-prescription eye drops but it had not been effective. She stated she called her eye doctor who prescribed new eye drops, and her husband retrieved the medication from the pharmacy. Resident #161 stated she managed her medications at home, and she had been doing her own eye drops, which she kept in her room, since admission to the facility. On 4/02/24 at 10:35 AM, LPN O checked resident #161's room and discovered Polymyxin B-Trimethoprim eye drops with a box of Refresh eye drops. She confirmed all medication used in the facility required a physician order. LPN O explained resident #161 was not supposed to have any medication at the bedside unless she was assessed to verify she was capable of safely administering her own medication. Polymyxin B and Trimethoprim ophthalmic solution is a medication used to treat bacterial eye infections (retrieved on 4/08/24 from www.drugs.com/mtm/polymyxin-b-and-trimethoprim-ophthalmic.html). On 4/02/24 at 10:52 AM, the 300 unit UM validated residents were not allowed to have medication in their rooms unless facility staff completed the appropriate self-administration assessment. She explained if staff determined the resident could safely administer her medication, a nurse would obtain physician orders for the medication and authorization to keep it at bedside. The 300 unit UM acknowledged the facility's policy and procedures were not implemented. Review of the Order Summary Report revealed as of 4/02/24 at approximately 11:00 AM, there was no physician order for resident #161's eye drops and no assessment to show the resident was capable of administering her medications safely. Review of the facility's policy and procedure for Self-Administration of Meds, revised on 3/27/21, read, .residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. The guidelines indicated staff would assess the resident's mental and physical abilities to determine if he/she was capable of self-administering medications. The policy revealed the assessment would include the resident's ability to read and understand labels, comprehension of the purpose and proper dosage and administration times, and the ability to recognize the risks and side effects of medications. The document indicated medications would be stored in a safe and secure place in the resident's room and nurses were responsible for documenting the doses administered by the resident.

Based on observation, interview, and record review, the facility failed to honor resident's rights to choose their preferred shower days and time for 1 of 9 residents reviewed for choices, of a total sample of 48 residents (#21). Findings: Review of the medical record revealed resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, morbid (severe) obesity, abnormalities of gait and mobility, heart failure, and type 2 diabetes. Resident #21's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/15/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she did not have cognitive impairment. The MDS assessment also indicated resident #21 required maximal assistance with bathing and participated in her assessment and goal setting. The MDS assessment dated [DATE] revealed it was very important to the resident to choose her bathing preferences. It also noted the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Review of resident #21's medical record revealed a care plan was initiated on 1/18/22. The care plan indicated the resident expressed personal and lifestyle preferences with goals that included resident's preferences would be honored as able and interventions that included showers as her bathing preference on Monday, Wednesday, and Friday during the day shift. The bathing task report for resident #21 noted her scheduled shower days were Tuesday and Fridays on the 3-11 shift. In March and April 2024, the task report revealed she had a bed/towel bath on Tuesday, March 5th, at 10:50 PM. Additionally, she received showers on Friday, March 8th, at 6:06 PM and the following Tuesdays: March 12th, at 10:48 PM, March 19th, at 10:16 PM, and March 26th, at 8:38 PM. However, the task report indicated she refused bathing on the following Fridays: March 15th, at 8:16 PM, March 22nd, at 7:49 PM, and March 29th, at 9:59 PM, as well as on Tuesday April 2nd, at 9:55 PM. On 4/01/24 at 11:52 AM, resident #21 stated the Certified Nursing Assistants (CNA)s consistently offered her baths in the evening and on days she did not prefer. She conveyed she had made known to staff she preferred showers on Monday, Wednesday, and Fridays, however, staff insisted those were not her shower days and did not accommodate her preference. On 4/03/24 at 1:04 PM, CNA H confirmed resident #21 received showers on the 3-11 PM shift. On 4/03/24 at 11:33 AM, resident #21 stated she was again offered a shower the previous evening, Tuesday, April 2nd, but declined because she was feeling tired. On 4/03/24 at 11:45 AM, the Licensed Practical Nurse Unit Manager (UM) on the 200 unit accessed resident #21's care plan and confirmed the care plan, initiated on 1/18/22, indicated the resident preferred to receive showers on Mondays, Wednesdays, and Fridays during the day shift. Upon checking the resident's CNA task report, she commented the resident was scheduled to receive showers on Tuesday and Friday during the 3-11 shift, rather than the preferred day shift. The UM acknowledged resident #21's current shower schedule did not honor the resident's choices and stressed it was very important the resident received showers on the days and times she selected, as it was her right. On 4/03/24 at 12:40 PM, the Assistant Director of Nursing stated resident #21's care plan indicated a preference for showers on Monday, Wednesday, and Friday during the day. She verified the resident's scheduled shower days were Tuesday and Friday in the evening, which did not honor the resident's choices. She emphasized the importance of ensuring resident #21's right to receive showers on the days she preferred. The facility's Resident Right's policy read, The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility .The facility will make every effort to assist each resident in exercising his/her rights .observing resident's choices whenever able .The facility will provide for residence and reception of services with reasonable accommodation of resident needs and preferences .

Based on observation, interview and record review, the facility failed to ensure resident's wishes for a Do Not Resuscitate Order (DNRO) were honored for 1 of 3 residents reviewed for hospice, of a total sample of 48 residents (#151) . Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The Admission Minimum Data Set assessment with Assessment Reference date [DATE], revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of ,d+[DATE]. The assessment indicated she required partial to moderate assistance with her activities of daily living. Review of the resident's physician orders on [DATE] revealed an Advanced Directive order dated [DATE] for full code. This order conflicted with an order dated [DATE] which was signed by the resident and hospice physician for DNRO. The yellow DNRO order was noted in the Hospice notebook found on the counter of the 300-unit nurses' station. The current comprehensive care plan initiated on [DATE], showed resident #151 to be a full code with the goal: If the resident's heart stops, or if they stop breathing, Cardio Pulmonary Resuscitation (CPR) be initiated in honor with their full code wishes. On [DATE] at 1:10 PM, resident #151 was observed in her room, alert and oriented to person, place, and time. She sat in her wheelchair feeding herself lunch and said it was her choice to have Hospice services. Review of the medical record showed a Hospice Medicare Election form signed and dated by the resident on [DATE] and a certification of terminal illness for [DATE] to [DATE] with primary diagnosis of idiopathic pulmonary fibrosis. On [DATE] at 4:01 PM, Licensed Practical Nurse (LPN) A said she was the usual day nurse for resident #151 and was familiar with her care. LPN A stated should she find the resident without a pulse or not breathing she would first look on the dashboard on the computer. LPN A confirmed the dashboard for resident #151 currently had her code status as full code, so she would call the code and start CPR. LPN A added they also have a DNR Code Status Book on the code cart which she checked and did not find a DNRO for the resident #151. LPN A verified she would not look in the Hospice notebook at the nurses' station for a residents' code status. On [DATE] at 4:18 PM, a telephone interview was conducted with Hospice Team manager B who verified that it was Hospice physician D who signed the DNRO order for the resident #151 on [DATE]. Hospice Team Manager B explained the process when Hospice Registered Nurse (RN) I did the admission she would have placed the DNRO form in the Hospice notebook at the nurses' station. Hospice Team manager B reviewed RN I's notes and said the nurse only mentioned having a discussion with the patient regarding the DNR but did not document any communication with the facility staff regarding the change in code status. Hospice Team manager B said she would inform Hospice Admission manager E about the concerns regarding lack of communication with the facility staff for change in code status. On [DATE] at 5 PM, the Director of Nursing acknowledged resident #151's Advanced Directive would not have been honored from [DATE] to [DATE] till brought to their attention by surveyor on [DATE]. On [DATE] at 10:19 AM, a telephone interview was conducted with Hospice Admission manager E and Hospice Clinical Team Lead F. They were informed the facility staff was not aware of the change in code status for resident #151 which was obtained by Hospice RN I while doing the admission on [DATE]. The hospice management staff was also made aware that resident went 6 weeks with potential that the facility or emergency medical staff could have performed CPR on her if her breathing or heart stopped. Admission manager E stated, she would follow up with Hospice Executive Director regarding concern the Hospice staff did not communicate code status with the facility staff regarding change in Advance Directive from Full code to DNR. Review of the facility Standards and Guidelines for Advance Directive revised [DATE] read, It will be the standard of this facility that the resident has the right to request, refuse, an/or discontinue treatment Advance Care Planning is a process of communication between individuals and their healthcare agent

Based on interview and record review, the facility failed to complete a significant change in status assessment within the required timeframe of 14 days for 1 of 3 resident reviewed for Hospice services, of a total sample of 48 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The Admission Minimum Data Set assessment with assessment reference date (ARD) 1/23/24, revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of 14/15, and she required partial to moderate assistance with her activities of daily living. The assessment did not indicate resident #151 received Hospice services. Although the physician order in the electronic medical record for Hospice services was dated 3/10/24 resident #151 had signed the election for Medicare Election Statement on 2/15/24. The facility payer source showed Hospice Medicaid pending status as of 2/15/24. On 4/03/24 a telephone interview was conducted with the Hospice Case manager C who said her start of care date for Hospice services was on 2/15/24. Review of the medical record for resident #151 revealed certification of terminal illness for period dates: 2/15/24 to 5/15/24 with primary diagnosis of idiopathic pulmonary fibrosis. Review of the facility documentation in the electronic medical record showed the most recent MDS assessment with the ARD 1/23/24. No Significant Change in Status Assessment (SCSA) MDS was located in resident #151's medical record. On 4/03/24 at 4:32 PM, the Registered Nurse MDS Coordinator confirmed the SCSA had not been initiated by the facility and should have been done within 14 days when resident #151 went on Hospice 2/15/24. She stated the reason it was not done in a timely manner was due to a lack of communication between Social Services, MDS and nursing staff. She explained the usual process was at the morning or clinical meeting they would go over who went onto Hospice then they would update care plans, Advanced Directives as well as initiate the SCSA. The MDS Coordinator verified the SCSA was now out of compliance, and they were not aware till brought to their attention by surveyor. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment instrument Version 3.0 Manual, October 2023 Chapter 2 Page 2-25 read, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being

Based on observation, interview, and record review the facility failed to develop comprehensive person-centered plan of care for end-of-life care for 1 of 3 residents reviewed for Hospice, of a total sample of 48 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The Admission Minimum Data Set (MDS) assessment with Assessment Reference date 1/23/24, revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of 14/15, and she required partial to moderate assistance with her activities of daily living. Review of the medical record showed a Hospice Medicare Election form signed and dated by the resident on 2/15/24 and a certification of terminal illness for 2/15/24 to 5/15/24 with primary diagnosis of idiopathic pulmonary fibrosis. Further review revealed no care plan for Hospice or end-of-life care for resident #151 in her medical record. On 4/01/24 at 1:10 PM, resident #151 was observed in her room alert and oriented to person, place, and time. She sat in a wheelchair feeding herself lunch and indicated it was her choice to receive Hospice services. On 4/03/24, a telephone interview was conducted with Hospice case manager C who said resident #151's start of care date for Hospice services was 2/15/24. On 4/03/24 at 4:32 PM, the Registered Nurse MDS Coordinator acknowledged a comprehensive person center care plan was never initiated for resident #151 when she went onto Hospice service for end-of-life care on 2/15/24. She stated the reason it was not done was due to a lack of communication between Social Services, MDS and nursing staff. She explained the usual process was at the morning or clinical meeting they would go over who went onto hospice then update the care plans, advanced directives, as well as initiate the significant change in status assessment. Review of the facility policies and procedures for Comprehensive Assessments and Care Plans revised on 4/05/21 read, The facility will develop and implement a comprehensive person-centered care plan for each resident .prepared by the interdisciplinary team to formulate and advance directive and participate in advance care planning .

Based on interview and record review, the facility failed to ensure an effective discharge planning process to prevent a delay in provision of necessary care and services after discharge from the facility for 1 of 4 residents reviewed for discharge planning, out of a total sample of 48 residents, (#166). Findings: Review of the medical record revealed resident #166 was admitted to the facility on [DATE] with diagnoses including left hip fracture, abnormal gait and mobility, weakness, stroke with left side weakness and paralysis, and brain cancer. The face sheet indicated the resident was discharged home with family on 1/23/24, with no Home Health Care (HHC) services. The Minimum Data Set (MDS) Discharge - return not anticipated assessment, with assessment reference date of 1/23/24, revealed resident #166 required supervision or touching assistance for bathing and lower body dressing, and set up assistance for placing or removing footwear and completing personal hygiene tasks. Review of the medical record revealed resident #166 had a care plan for wish to be discharged to his prior living arrangement, initiated on 1/03/24. The interventions included establish a pre-discharge plan with the resident and family, evaluate progress, and revise the plan as needed. The document indicated Social Services staff and nurses would make arrangements with required community resources such as HHC and physician services to support the resident's independence post discharge, and prepare and give the resident, family member, caregiver contact numbers for all community referrals as indicated. A care plan for activities of daily living (ADL) self-care performance deficit initiated on 1/03/24, revealed resident #166 needed assistance with ADLs due to weakness and fatigue. A care plan for actual skin impairment, initiated on 1/17/24 revealed resident #166 developed a left buttock abscess in the facility. The interventions included administer and apply ointments as ordered by the physician and report any changes in skin status. Review of the medical record revealed resident #166 had a physician order dated 1/22/24 for discharge home with all medications and HHC for skilled nursing, physical therapy, and occupational therapy services. Another order dated 1/22/24 indicated the resident was to be discharged home with wound care orders to, cleanse the left buttock wound with [normal saline], pat dry, apply skin prep to the peri-wound, apply Mupirocin 2% [antibiotic] ointment to the wound bed, cover with a superabsorbent pad, cover with gauze, cover with a waterproof island border dressing. The physician order revealed wound care and dressing changes were to be done once daily and as needed. Review of an Interdisciplinary Discharge Home form dated 1/19/24 revealed resident #166 had a planned discharge scheduled for 1/23/24. The document included contact information for the HHC agency that was to provide the physician-ordered services in the resident's home. The facility's Rehabilitation Director noted the resident required a commode and a wheelchair. However, the facility's Social Services Director (SSD) at that time added a final discharge note that indicated resident #166 did not require arrangements for durable medical equipment as he had all necessary items. The Discharge Form revealed resident #166 left the facility with his son on 1/23/24 at approximately 10:00 AM. On 4/01/24 at 12:53 PM and 4/05/24 at 8:49 AM, in a telephone interview, resident #166's son explained he had concerns regarding his father's transition from the facility to home. He recalled he was told the HHC agency would order all necessary medical equipment, but that did not happen. The son stated his father was not independently ambulatory, and he required a significant amount of assistance to get into and around the house as he was not provided with a walker. The resident's son said, When I contacted the Home Health Care company, I was informed that my father was not in their network. I received a follow up call from the same company telling me the facility was having a hard time finding a home healthcare company that was in [insurance] network. The son explained he called the facility and spoke with the Business Office Manager (BOM) about his concerns. He explained the facility never arranged the HHC services for his father and he had to purchase a walker and do the dressing changes until he found a HHC agency, with the assistance of personnel at the initially referred HHC agency, that took his father's insurance. The resident's son said, I was taken aback that I had to arrange home health myself. On 4/02/24 at 4:15 PM, the BOM confirmed resident #166's son called the facility on the day his father was discharged home. She said, He was beyond ballistic that his father could not get [medical equipment] and [the Home Health Care agency] did not take his insurance. The BOM stated she immediately notified the previous SSD by telephone and he stated it was a misunderstanding with the insurance company as services should be covered. On 4/02/24 at 4:27 PM, the Administrator stated she became aware of issues surrounding resident #166's discharge when his son posted a negative online review in February 2024, approximately one month after the resident left the facility. She stated the previous SSD arranged home health services with [name of HHC agency] and the resident was discharged on [DATE]. The Administrator provided email communication dated 1/22/24, the day before discharge, from the HHC agency to the facility with notification that they checked the resident's insurance and discovered they were not in his network. The Administrator stated the previous SSD communicated with the staff at the HHC agency who informed him they would forward the referral to another HHC agency. Review of an email from the second HHC agency revealed resident #166's start of care date for skilled nursing and therapy services was 1/26/24, three days after discharge from the facility. The Administrator confirmed she did not know the staff at the first HHC agency, but she relied on their promise regarding making arrangements with the second HHC agency. She acknowledged the facility's Social Services department, not an outside provider, was ultimately responsible for planning and ensuring a safe discharge. On 4/02/24 at 5:44 PM, the facility's Senior SSD validated if discharge referrals fell through while resident #166 was still in the facility, it was possible to extend the resident's stay if another referral could not be made in a timely manner. She acknowledged there was no documentation by the previous SSD of any issues related to the discharge or confirmation of another HHC referral. The Senior SSD validated it was not acceptable that the resident was discharged home without the care and services ordered by the physician. She explained Social Services staff were expected to oversee discharge arrangements and provide necessary follow-up. On 4/03/24 at 4:15 PM, the Rehabilitation Director confirmed resident #166 required a walker for mobility and prior to discharge, Social Services staff were to order medical equipment and arrange for delivery to ensure the resident's safety at home. On 4/05/24 at 8:29 AM, the Wound Nurse recalled when she last assessed resident #166's buttock wound it had drainage. She said, Treatments should be done as ordered. If ordered daily it should be done to allow for assessment and healing. The Wound Nurse explained the topical antibiotic was necessary for healing, and if the dressing was not changed, there was increased risk of infection and maceration of the skin caused by moisture from the drainage. The facility's policy and procedure for Discharge Planning Process, revised 3/21/21, read, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals.and effectively transition them to post-discharge care. The document indicated the discharge planning process began with identification of each resident's goals and needs and continued with development, implementation, and evaluation of interventions throughout the resident's stay to ensure a successful discharge. The policy revealed the facility would identify post-discharge needs to include nursing and therapy services, and medical equipment.

Based on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs) related to bathing, skin care, and shaving for 2 of 3 residents reviewed for ADLs, out of a total sample of 48 residents, (#134 and #87). Findings: 1. Review of the medical record revealed resident #134 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, recurrent depressive disorder, and weakness. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 3/07/24 revealed resident #134 had clear speech and a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. The document showed during the look back period, resident #134 had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed the resident depended on staff for assistance with self-care as his performance was either unsafe or of poor quality. He required partial to moderate assistance for personal hygiene and bathing, and substantial to maximal assistance for lower body dressing and putting on and taking off footwear. Review of the medical record revealed a care plan for personal and lifestyle preferences was initiated on 6/08/23. The interventions included the resident's preference for three bed baths or showers every week during the day shift. A care plan for ADL self-care performance deficit related to limited mobility, initiated on 6/03/23, had a goal the resident would be free of complications related to ADL deficit. The interventions included assistance of one to two staff for ADL care and praise all efforts at self-care. On 4/01/24 at 11:25 AM, resident #134 showed his hands and all fingernails were square-shaped with sharp edges and approximately one third inch long. The resident's hair was long and greasy and his facial hair was unkempt. The resident explained nursing staff did not cut his fingernails or shave him regularly. He stated he felt those tasks took more time than the staff wanted to spend. Resident #134 stated he received occasional bed baths, got showers approximately once monthly, and nursing staff, Pass the water through my hair once a week or so. The resident complained his hair was too long and he needed someone to check his toenails. On 4/01/24 at 11:32 AM, the 400 unit Unit Manager (UM) stated resident #134 was scheduled for baths twice weekly, on Wednesdays and Saturdays. He explained nail care was to be done on these days and additionally as needed. He validated the resident's fingernails were over 1/3 inch long and described them as, way longer than normal. The UM confirmed the resident's fingernails should definitely have been cut by staff, and nurses who completed his weekly skin checks should have noticed the issue. Resident #134 informed the UM he wanted to be shaved daily and the UM acknowledged the resident did not have a well-groomed appearance. The UM removed the resident's socks and a large amount of dried skin flakes fell from each sock, visibly landing on the mattress and forming a small pile. On 4/01/24 at 11:45 AM, the 400 unit UM provided a shower sheet dated Wednesday 3/27/24 which indicated resident #134 refused a shower but the Certified Nursing Assistant (CNA) gave a bed bath instead. The UM stated he was not able to find a shower sheet for Saturday 3/30/24. He confirmed CNAs were expected to wash the resident's entire body during a bed bath, which required removing his socks to wash his feet. The UM validated the appearance of resident #134's feet and the quantity of dried skin in his socks indicated he probably did not receive a full bed bath or shower as scheduled. Review of the 400 unit Shower Schedule revealed resident #134 was to have showers on Wednesdays and Saturdays during the 3:00 PM to 11:00 PM shift and as needed on Sundays. The document read, Please notify the nurses of any shower refusals and skin impairments. Review of nursing progress notes dated 3/01/24 to 4/05/24 revealed no documentation of refusal of ADL care by resident #134. 2. Review of the medical record revealed resident #87 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, type 2 diabetes, spinal stenosis, and abnormality of gait and mobility. The MDS Significant Change in Status assessment with ARD of 2/01/24 revealed resident #87 had a BIMS score of 12 which indicated moderate cognitive impairment. The document showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed the resident required substantial to maximal assistance for bathing and partial to moderate assist for personal hygiene tasks. A care plan for ADL self-care performance deficit related to limited mobility and weakness, dated 7/25/23, revealed goals to keep the resident clean and comfortable and maintain his current level of ADL function. The interventions instructed staff to assist resident #87 with ADLs. On 4/01/24 at 11:54 AM, resident #87 had a scruffy appearance. His moustache was thick and untrimmed, and he had a significant amount of unkempt, long facial hair on his cheeks and chin. The resident explained he preferred a moustache only and staff either assisted with shaving him or he attempted to shave himself if provided with razors. He said, I've been asking all my CNAs for razors for the past three days. Nobody brings them. The resident stated no staff had offered to shave him for a while. On 4/01/24 at 12:02 PM, the 400 unit UM confirmed resident #87's facial hair was untidy and stated he definitely needed to be shaved. Review of the 400 unit Shower Schedule revealed resident #87 was to have showers on Wednesdays and Saturdays during the 7:00 AM to 3:00 PM shift and as needed on Sundays. The document read, Please notify the nurses of any shower refusals and skin impairments. Review of nursing progress notes dated 3/01/24 to 4/05/24 revealed no documentation of refusal of ADL care by resident #87. Review of the CNA job description (undated) revealed CNAs would perform necessary care and services for residents. Essential job functions and duties included, Assist residents with activities of daily living including bathing, grooming. The document revealed CNAs would ensure residents' comfort while assisting them to achieve their highest functional level. The expectation for implementation of nursing care was CNAs would provide hygiene care, nail care, bathing and grooming according to residents' plans of care. Review of the facility's policy and procedure for ADL Care and Assistance revised on 3/27/21, revealed the facility would provide residents with assistance for bathing and maintenance of personal hygiene.

Based on observation, interview and record review, the facility failed to ensure a right-hand resting splint was applied per physician order and the resident's plan of care, for 1 of 1 resident reviewed for range of motion/mobility, of a total sample of 48 residents, (#66). Findings: Resident #66, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side, aphasia, major depressive disorder, conversion disorder with seizures or convulsions, and weakness. Review of the quarterly Minimum Data Set assessment with Assessment Reference date of 1/22/24, revealed resident #66 was rarely/never understood, and was assessed with functional limitation in range of motion (ROM) to one side of his upper and lower extremities. The resident's physician's order dated 10/23/23 directed staff to apply splint to his right wrist following morning care, and doff the splint prior to bedtime. Instructions were, Monitor skin integrity when applying and removing, discontinue wear if skin becomes red or pt (patient) is in pain. Review of the Physical Therapy/Occupational Therapy (PT/OT) annual screen conducted on 3/05/24 revealed the, Therapist completed OT screen today (3/05/24) and found pt (patient) has decrease in RUE (right upper extremity) ROM. Recommendation: OT indicated. Review of the Occupational Therapy discharge summary for dates of service 3/05/24 through 3/25/24 revealed upper extremity resting hand splint training was provided for staff. The training sign-in sheet dated 10/16/23, indicated staff were trained how, To don/doff resting hand splint and the wear schedule was Don in AM, doff in PM Observations on 4/01/24 at 11:50 AM, 4/02/24 at 10:00 AM, and on 4/02/24 at 3:42 PM, showed resident #66 sat up in bed watching television. The resident had right hand weakness and did not have a splint on. The splint was noted on the resident's chest of drawers. Resident #66 said the splint was not applied by therapy, and when asked who applied the splint, the resident's response was, No one. On 4/03/24 at 11:28 AM, and at 11:35 AM, Licensed Practical Nurse (LPN) J stated resident # 66 was awake, alert, oriented, had right arm paresis/hemiplegia, wore a splint on his right hand, and was currently on therapy caseload. The LPN stated the resident's right hand splint was applied by the Certified Nursing Assistant (CNA) or therapy, and nurses signed off on the Treatment Administration Record (TAR) to indicate the splint was applied. The surveyor shared with LPN J there were no observations of resident #66 wearing his splint for the days of survey to date, and the splint was seen on the resident's bed side table. Observation of the resident conducted with the LPN, showed no splint to the resident's right hand, and the splint was again noted on the resident's bedside table. This was acknowledged by the LPN, who also acknowledged the physician order to don the right hand splint following morning care, and to doff prior to bedtime. LPN J stated the administration details on the resident's TAR revealed documentation and signatures by nurses which indicated the splint was applied, and there were no problems. On 4/03/24 at 11:39 AM, CNA L stated he worked on the 7 AM to 3 PM shift and provided care for resident #66. He stated the resident required total assistance with activities of daily living, and he was aware of the resident's splint. CNA L said he had not signed off on the task for donning the resident's splint and confirmed PT had not been applying the splint. He said the resident's splint had not been applied for a couple of days, since the resident was no longer on therapy caseload, and he could not apply the splint since he was not trained to don/doff the splint. On 4/03/24 at 3:34 PM, the Rehabilitation Director stated once splint/orthotics had been trialed on residents, and deemed to be safe, the CNAs were trained to perform the task by therapy. The Rehabilitation Director stated when the resident was discharged from therapy, nursing staff were then responsible to apply the splint/orthotic. She stated resident #66 was discharged from OT on 3/25/24, and nursing was responsible for the splint application. On 4/03/24 at 4:00 PM, the Director of Nursing stated the expectation was for nurses to follow physician orders in the electronic medical record, and sign off on the TAR to indicate the resident's splint was applied, and skin integrity monitored. On 4/04/24 at 9:47 AM, the Assistant DON (ADON) reviewed physician orders for the resident, and stated the order pertaining to the splint was inclusive of donning the splint and monitoring skin integrity. The ADON stated she was not sure if nurses were checking off on the TAR regarding donning the splint or for monitoring the resident's skin integrity. She stated they should be checking for skin integrity prior to applying the resident's splint. On 4/04/24 at 10:00 AM, LPN K stated if the resident was on therapy caseload, they would apply the splint, otherwise the splint would be placed by nursing staff on the unit. She stated she signed off on the resident's TAR to indicate she monitored the resident's skin for redness, irritation, and pain. LPN K verbalized that on 4/01/24, she did not apply the resident's splint, but signed off on the TAR for monitoring the resident's skin integrity. The facility did not provide a policy pertaining to splint application.

Based on interview, and record review, the facility failed to ensure tube feeding formula was available for 1 of 4 residents receiving gastric tube (GT) feedings of a total sample of 20 residents, (#61). Findings: Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set assessment dated [DATE] noted the resident was cognitively impaired with short and long-term memory problems, required extensive to total assistance of two staff for activities of daily living, and required tube feedings to meet nutritional needs. Review of the care plan dated 1/25/22 for required tube feeding related to swallowing problems included interventions to administer tube feeding formula and flushes as ordered and resident not to consume anything by mouth. Review of the most recent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/24/22 at 10:45 AM, the Central Supply staff explained a few months ago, the facility ran out of Vital 1.5 for a resident for about 2 weeks as it was on back order. She stated she notified all nursing staff on 9/22/22, when she noticed they were out of the formula and it was on backorder. She acknowledged she was responsible for ordering the tube feedings and recalled she sent a group text to the Director of Nursing (DON), Unit Managers and the Administrator to notify they did not have the formula available. On 10/24/22 at 12:31 PM, the DON stated she was notified by Central Supply staff on 9/22/22 along with Unit Managers and the Administrator they were out of Vital 1.5. She explained the nurse should have contacted the dietician to see if a different formula could have been ordered but this was not done. She acknowledged the resident was sent to the hospital for tube feedings when they ran out of Vital 1.5. On 10/25/22 at 1:38 PM, the Administrator stated she was not made aware by Central Supply staff that the resident was out of tube feeding formula and found out after the fact. On 10/25/22 at 1:45 PM, Central supply staff in the presence of the Administrator provided cell phone group chat text messages dated Thursday 9/22/22 at 10:10 AM, with notification to the Assistant Director of Nursing (ADON), both Unit Managers, DON, Administrator and two supervisors one being the 3 PM to 11 PM supervisor. The text message read, Vital [MEDICATION(S)], osmolyte 1.5 are all on backorder, I do not have enough for the wknd (weekend) can someone please reach out to the dietitian to see if something different can be used. Vital 1.5 is my main concern. A reply text message was received on 9/22/22 at 10:47 AM, from the unit manager on the 300 hallway that read, I will follow up and see. Review of resident #61's medical record revealed a progress note dated 9/25/22 at 12:02 AM, which showed the on coming agency nurse was informed at 1:30 AM, that resident #61 was out of her tube feed formula, Vital and there was none in the facility. The off going agency nurse informed that facility staff were aware. The progress note indicated the nurse called the dietician at 1:45 AM with no response and a message was left. The nurse also called the physician but there was no answer. The nurse then contacted the hospital emergency room (ER) and explained the facility did not have the required tube feeding formula for the resident. The nurse then called non emergent transport services to transfer the resident to the hospital at 4:10 AM and the resident was transferred to the hospital. The ER nurse called the facility at shift change and stated the resident would be sent back with a supply of Vital 1.5 tube feeding formula. Review of the hospital record showed documentation dated 9/25/22 at 11:56 AM, that resident #61 was sent from the skilled nursing facility on 9/25/22 at 7:58 AM, as they ran out of tube feedings. The record indicated that according to the nurse, she was unsure the last time the resident was fed. Will send patient with additional few bottles to tube feed for the nursing facility. Follow up with nurse from facility and she agrees resident only sent to emergency room for tube feeding. On 10/25/22 at 2:56 PM, the Registered Dietitian stated that Vital was an elemental formula and was used for residents who could not tolerate any other formula. That is one I would not want to run out of. We would need to find another company or find it by some other means. He stated that normal practice if the formula was not available would be to try another formula but the resident would need close monitoring or the feeding would be administered at a reduced rate. He reiterated this is the last formula you would want to run out of. He vaguely remembered a phone call on Monday 9/26/22 saying the facility had run out of Vital formula. On 10/25/22 at 5:25 PM, Licensed Practical Nurse (LPN) B stated she remembered an agency nurse informed her she did not have any Vital for resident #61. She recalled they went to Central Supply room to check, and did not find any Vital formula. LPN B said she told the agency nurse to inform the attending physician. She said the second agency nurse came to work at 11:00 PM, and asked about the resident's tube feeding. She again told this agency nurse to call the physician and she would try to contact the dietician. She said she also gave the agency nurse the number for the on call supervisor. The agency nurse informed her later during the shift that she sent the resident out to the hospital as she was not able to reach neither the physician, the supervisor nor the dietician and was not sure how long it had been since the resident had received feedings. On 10/26/22 at 1:43 PM, the Pharmacy Consultant stated pharmacy did not receive tube feeding orders for the residents as they did not provide the formulas to the facility. On 10/26/22 at 5:29 PM, resident #61's son recalled he received a call from the hospital and it was explained the facility had run out of tube feeding formula. On 10/26/22 at 5:47 PM, the 300 Unit Manager stated, I was going to get the order to change out the tube feeding formula. She explained the Registered Dietitian had given the order to change tube feeding formula from Vital to Glucerna 1.5 on Thursday 9/22/22 and she forgot to put the order into the system. I was getting the order so when it ran out, we had an alternative. She said they still had 2 boxes of Vital in the facility. I don't know why they sent the resident out to the hospital. It is my fault, I forgot to write the progress note or put in the order. I was going to notify the family when the feeding actual changed. Review of the facility's Policy Standards and Guidelines for Enteral Tube Feeding Number 12.07.13.008 revealed Standard: It will be the standard of this facility to provide nourishment to the resident who is unable to obtain adequate nourishment orally via use of enteral tube feeding.

Based on interview, and record review, the facility failed to provide pharmaceutical services to ensure medications were administered as ordered for for 3 of 12 residents reviewed for medication administration out of a total sample of 20 residents, (#61, #68 and #69). Findings: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, gastrostomy status, convulsions, and dementia. The resident's quarterly Minimum Data Set assessment dated [DATE] showed she was cognitively impaired with short- and long-term memory problems, and was on scheduled pain medication regimen and required a feeding tube. A care plan dated 12/28/21 showed focus for impaired cognitive function and interventions to administer medications as ordered. On 10/25/22 at 11:15 AM, review of the September Medication Administration Record (MAR) with the Assistant Director of Nursing (ADON) revealed the following physician orders which were to be given at 9:00 PM: 1/25/22 [MEDICATION(S)] Solution 0.03% instill 1 drop in both eyes in the evening 2/8/22 [MEDICATION(S)] solution 250 milligrams (mg)/5 milliliters (ml) give 15 ml via peg tube at hour of sleep 2/3/22 [MEDICATION(S)] 50 mg give 1 tablet via peg tube twice a day. The MAR showed missing documentation of the above medications on 9/24/22 at 9:00 PM. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses of fracture of right femur, [CONDITION(S)] right ankle and foot, [CONDITION(S)], and hypertension. Review of the resident's care plan for infection dated 9/20//22 noted to administer medications as ordered by the physician. On 10/26/22 at 10:59 AM, resident #68 stated he did not remember if he missed getting some medications in the month of September. On 10/25/22 at 11:30 AM, review of the September MAR with the ADON revealed the following physician ordered medications which were due to be given at 9:00 PM: 9/20/22 [MEDICATION(S)] 5 mg give 1 tablet by mouth every 12 hours 9/21/22 [MEDICATION(S)] 300 mg give 1 by mouth twice a day, 9/22/22 [MEDICATION(S)] 2 grams (gm) - intravenously (IV) give 2 gm intravenously three times a day 9/20/22 [MEDICATION(S)] 4 mg tab give 1 by mouth every 8 hours 9/21/22 Blood sugar with sliding scale coverage monitor and inject subcutaneous if blood sugar 200 or greater, notify physician if blood sugar 400 or above. The September MAR showed no documentation on 9/24/22 for blood sugar monitoring or if sliding scale coverage was needed and no documentation for medications being administered at 9:00 PM. 3. Resident #68 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, [CONDITION(S)], and dementia. The resident's quarterly MDS assessment dated [DATE] showed the resident had severe cognitive impairment. A care plan dated 9/20/22 showed altered respiratory status with interventions to administer medications as ordered. On 10/25/22 at 11:25 AM, review of the September MAR with the ADON revealed the following physician orders which were to be given at 9:00 PM: 3/31/22 [MEDICATION(S)] 30 mg give 1 tab by mouth at bedtime 8/30/22 [MEDICATION(S)] 50 mg tab give 0.5 mg by mouth at bedtime 3/31/22 [MEDICATION(S)] 0.5 mg give 0.5 mg by mouth twice a day 3/16/22 [MEDICATION(S)] 12.5 mg tablet give 1 tab by mouth twice a day 9/19/22 [MEDICATION(S)] cream 1% apply to right elbow, and right axilla topically twice a day 6/10/22 [MEDICATION(S)] 25 mg give 1 tab by mouth twice a day 3/29/22 [MEDICATION(S)] 300 mg give 1 tab by mouth three times a day 3/16/22 [MEDICATION(S)] 10 mg give 1 tab by mouth four times a day Review of the MAR showed no documentation to show the medications were administered at 9:00 PM on 9/24/22. The 9 PM space for the medications was blank. On 10/25/22 at 5:14 PM, the ADON stated she was unsure if the medications for residents #61, #68 and #69 were given on 9/24/22 at 9:00 PM. She stated she usually reviewed the facility dashboard every morning and if any medication was not given, it would show as red dot on the dashboard. She stated she, the Unit Mangers (UM) and the Director of Nursing (DON) were responsible to ensure medications were given as ordered. She did not explain why the missed medications did not flag on the dashboard. She explained if a medication was missed, they would notify the physician and investigate to determine why the resident did not get the medication. On 10/25/22 at 5:21 PM, the DON stated UMs were responsible to review the facility dashboard daily for missed medications. She indicated they would print a report of the missed medication, call the responsible nurse to find out why the medication was not given and follow up. The DON said she was on leave when this occurred and the ADON said she did not receive a telephone call. The DON said the medication cart was opened early in the morning. On 10/26/22 at 4:37 PM, during a telephone interview, agency Licensed Practical Nurse (LPN) A said she worked the evening shift on 9/24/22. She explained that evening, the supervisor left the facility at 8:00 PM and took both sets of medication cart keys with her. She said she called the DON but there was no answer. She said one of the supervisors called the ADON. She indicated the medication cart was still locked at 9:45 PM and residents #61, #68 and #69 did not receive their 9:00 PM medications. She did not explain why she did not notify the physician. Review of the facility's Standards and Guidelines Medication Administration Policy Number 12.07.09.032 issued 12/20/24 and revised on 3/27/21 noted: It will be the standard of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Under Guidelines: Number 2. showed, The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and respond timely to exit door alarms for 1 of 3 residents reviewed for elopement of a total sample of 7 residents, (#10). On 09/03/22 at approximately 6 PM, the facility failed to prevent resident #10, a physically and cognitively impaired resident, identified at high risk for elopement from exiting the facility unsupervised. The resident left her room and walked down the 300 unit hallway, pressed the emergency egress door crash bar which allowed the door to open, the alarm sounded and the resident exited the facility with her walker. Facility staff failed to respond appropriately to the door alarm despite being recently trained on elopement procedures from a previous resident elopement which occurred in the same manner on 07/17/2022 which resulted in Immediate Jeopardy. Once outside the facility, resident #10 walked down a sloping walkway that led to the parking lot then proceeded across a grassy area, total of approximately 88 feet until a staff member happened to see the resident through a window. While resident #10 was outside the facility unsupervised, there was likelihood she could have fallen, wandered away from the facility or been hit by a car. The facility's failure to provide adequate supervision to a resident with identified risk for elopement and the failure of staff to respond to door alarms contributed to resident #10's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 9/3/22 and was removed on 9/9/22. Findings: Cross reference F867 Review of the medical record revealed resident #10 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of heart failure, dementia, and unsteadiness on feet. The Minimum Data Set Medicare 5-day assessment with assessment reference date of 08/18/22 revealed resident #10 had a Brief Interview for Mental Status score of 09 out of 15 which indicated she had moderate cognitive impairment. The assessment showed the resident required assistance of one person for ambulation, and noted she was unsteady when walking and was only able to stabilize with assistance from staff when walking. She required a wheelchair or walker when ambulating. A facility wide elopement assessment was completed for all residents due to a resident elopement on 07/17/22. Resident #10's elopement risk assessment dated [DATE] noted a score of 10 and identified the resident had anxiety and wandered, looking for her husband. A score of 5 or higher indicated a high risk for wandering/elopement. An elopement care plan dated 7/25/22 indicated the resident was an elopement risk related to being disoriented to place and having impaired safety awareness. The care plan goal was resident will not leave facility unattended. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and monitor for tailgating when visitors were in the building. The care plan for elopement risk was resolved on 7/28/22 and revised again on 9/01/22. On 9/03/22, interventions were added to initiate one to one (1:1) supervision and reassess/re-evaluate elopement risk at least quarterly. A nursing progress note dated 9/03/22 at 6:42 PM, read the resident was found outside of the exit door by room 319. She was seen by a Certified Nursing Assistant (CNA) and was brought inside by another CNA. The resident did not have any injuries and her vital signs were stable. The Director of Nursing (DON) was notified of the incident and requested resident to be placed on 1:1 supervision due to safety. On 09/07/22 at 4:30 PM, the Physical Therapist (PT) stated resident #10 was on PT case load and used a two-wheeled walker with stand by assist. He explained she was not safe as she had poor safety awareness and was a fall risk. He said the resident could not safely position herself with the walker without prompts and was unstable without holding on to the walker. He recalled prior to coming to the facility, the resident had left her house, got lost and family searched for her. He conveyed she would not be safe outside alone as she was at risk for falls and would get lost. On 09/06/22 at 6:13 PM, during a telephone interview, CNA B stated she worked on the 300 Unit on 09/03/22 but was not assigned to resident #10 when she got out of the facility. She remembered it was about 6:00 PM and staff were passing dinner trays when she heard the exit door alarm and noticed the door was ajar. She explained another CNA, A was in the hallway and told her she did not see anyone go out the door. CNA B stated she pulled the door closed and reset the alarm. She stated she did not go outside to see if perhaps a resident exited or call a code green as per protocol as CNA A told her no one went out the door. CNA B recalled a few minutes later, CNA A yelled there was a resident outside. CNA B said she was close to the door so she ran out and saw resident #10 in the grassy area and brought her back inside the facility. Review from the facility's camera recording dated 9/03/22 showed the resident walking along the 300 Unit hall toward the exit door at 5:57 PM. At 5: 58 PM, the resident was standing at the door with her hand on the crash bar. The light at the intersecting halls flashed green that indicated the exit door was opened. At 5:59 PM the resident opened the door and walked out to the sidewalk. At 5:59 PM, CNA A was seen at the intersecting halls placing a food tray into the food cart and looked at the light and the door. She spoke to someone in the hall and at 6:00 PM, CNA B walked down the hall, closed the door and reset the alarm. At 6:00:45 PM CNA A, CNA B and Registered Nurse (RN) C were observed in the hall talking. At 6:01 both CNAs and RN were observed running down the hall toward the door and CNA B exited the door. The resident was seen picking up her walker as she attempted to walk on the grassy area. At 6:03 PM, CNA B brought resident #10 back into the building. On 9/08/22 at 11:15 AM, during a telephone interview, CNA A stated she was assigned to resident #10's care on 09/03/22. She indicated she was not aware the resident was an elopement risk as she did not get report on her residents. She explained this was the first day she worked on the floor by herself after she received orientation. She did not recall education about alarms during orientation. She said she was placing trays in the food cart when she heard the alarm sound and the nurse and CNA B asked if I saw anyone by the exit door. I told them I had not. She remembered the alarm was turned off and she returned to picking up meal trays. When she went into room 312 to pick up the tray, she saw resident #10 outside by the window. She said she went to the hall and yelled there was a resident outside and the other CNA went outside and brought the resident back. On 09/07/22 at 2:00 PM, RN C recalled she was at the medication cart on 9/3/22 when the alarm sounded. She said she proceeded to the nurses' station to see which door was activated then went to the door where the CNA had turned the alarm off. She remembered she asked if everything was okay and CNA B told her no one had exited by the door. She said she returned to the medication cart then heard CNA A yell there was a resident outside the window. She acknowledged she did not follow protocol to check outside when the alarm sounded and did not call a Code Green over the intercom. She explained she did not call a Code Green as both CNAs A and B told her they did not see anyone exit the door. It took some time for RN C to explain what needed to be done when an alarm sounds. On 09/07/22 at 2:25 PM, both the Executive Director (ED) and the Regional Director of Clinical Services (RDCS) acknowledged RN C did not appear to understand the education provided for elopement. On 09/07/22 at 3:44 PM, the Maintenance Director recalled the exit door by which the resident exited was checked after the incident on 09/03/22 at 9:50 PM and the door functioned properly and the light came on in five seconds. He said the door had been checked on 08/25/22 prior to the elopement as part of their weekly checks. He explained this door was a fire exit door with a magnetic lock equipped with a delayed egress. He said when resident #10 pushed on the exit door's bar, the alarm sounded but the door remained locked. After 15 seconds of pressing the bar, the magnetic lock released and the door opened. He noted this allowed facility staff at least 15 seconds to react to the alarm and prevent the resident from exiting. On 09/07/22 at 12:18 PM, the Clinical Educator stated all staff received education on elopement on day one of orientation and clinical staff also received elopement education on day two. She explained there were door alarms on every unit and staff were taught if an alarm sounded, they must go outside and check the surrounding area to determine if a resident exited. She acknowledged the first thing that went wrong during resident #10's elopement was CNA A did not know what to do when the alarm sounded and CNA B did not go outside to check the area. She added, a Code Green should have been called when RN C met the two CNAs in the hall. On 9/08/22 at 11:53 AM, during an interview with the Executive Director and DON revealed the DON was called by the on-call nurse regarding resident #10's elopement on 09/03/22. The DON acknowledged CNA B did not follow proper procedure by going outside to check the surroundings when she heard the exit door alarm and CNA A did not know what to do as it was her second day working on the unit after orientation. The DON did not explain why staff did not respond to door alarms as per education recently provided. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 09/03/22, resident #10 was re-evaluated by licensed nurse. A full body assessment completed noted no injuries and the resident was placed on 1:1 supervision. The physician and family were notified of the elopement incident. Care plan and Kardex reviewed to ensure accuracy. On 09/04/22 resident #10 was evaluated by psychiatry via Telehealth and onsite on 09/06/22. * On 09/03/22, facility conducted head count of residents and all were accounted for and safe. Doors were assessed to ensure proper functioning with no concerns identified. Elopement risk binders reviewed to ensure resident picture and demographics in place. * On 09/03/22, elopement drills were done and to continue monthly on each shift * On 09/05/22, all residents were reviewed for elopement risk. Residents identified at risk were reviewed by the DON for elopement screen, care plan, Kardex and elopement binder. * On 09/03/22, staff were educated on: components of F689, elopement standards and guidelines, resident evaluation to include 1:1 increased supervision, door/egress checks by maintenance weekly, responding to alarms, response to missing resident, elopement triggers, proactive interventions for residents at risk for wandering/elopement, abuse and neglect, physician, family notification and care plan update * On 09/08/22 staff were reeducated on components of F689, door alarm response, elopement, elopement competency tool and attestation statement * On 09/09/22 the facility implemented an elopement competency tool in the form of posttest to validate understanding of education; elopement will be reviewed during clinical meetings and QAPI process * On 09/03/22, 09/08/22 and 09/09/22 Ad Hoc Quality Assurance Performance Improvement meetings were held to review the components of ongoing elopement removal plan From 09/06/22 to 09/09/22, education logs were reviewed and interviews were conducted with 19 staff members. All staff, including 9 CNAs, 5 LPNs, 3 RNs, and 2 housekeepers were able to verbalize understanding of the education provided. The resident sample was expanded to include 2 additional residents who were at risk for elopement. Observations, interviews, and record review revealed no concerns related to elopement for residents #17 and #18.

Based on record review and interview, the facility failed to provide a timely written notice of discharge to the residents or their representatives for 1 of 5 residents reviewed for discharge in a total sample of 9 residents, (#17). Resident #17 had severe cognitive impairment, applying the reasonable person concept, the reaction of a reasonable person to being transferred abruptly to another nursing home without notice caused psychosocial harm, such as distress and mood decline that the resident was unable to express. The resident was transferred to another nursing home that was further away from his spouse and family, making visitation more difficult and the resident's family wasn't notified in advance so they could explore other options. Finding: Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status score of 7 out of 15 which indicated severe cognitive impairment. The MDS assessment did not indicate any issues with mood or [CONDITION(S)] nor any wandering behaviors. The facility's elopement Risk Screen dated 8/30/22 noted the resident was at risk for elopement. The assessment read, Resident with increased confusion and wanders around the nurse station. There was no evidence on the elopement Risk Screen that the resident was placed on one-to-one supervision. The resident's elopement care plan, dated 9/3/22, indicated that one-to-one supervision was initiated on 9/6/22. Review of the Interdisciplinary Team Note, dated 9/9/22 at 11:08 AM, noted, .Resident triggers for elopement risk. Placed on constant supervision monitoring. Family made aware. Resident being followed by psych. Will continue with current plan of care. The nurse's progress note, dated the same day, 9/9/22 at 3:29 PM, noted, .Resident is for transfer to [Name of receiving facility]. Relatives aware of transfer. During an interview on 9/9/22 at 3:45 PM, Registered Nurse (RN) C stated the resident was discharged to another facility at 3:30 PM today in [NAME], Florida by a contracted transport company. RN C stated resident #17 was an elopement risk and the new facility was more secure. On 9/9/22 at 5:32 PM, during a telephone interview, resident #17's son stated he found out today his father was transferred to another facility and was surprised as they were not given any advance warning. He said he visited his father weekly and no one had told him about any plans to discharge his father to another facility. The son said they were grateful when his father was admitted to this nursing home in June as it was new and close for his mother, about 10 to 15 minute drive. He explained his mother visited his father every day and the facility his father was transferred to was at least 20 miles from this facility. He said they were concerned about his father's falls and were pleased when the facility started one-to-one supervision for his father. The resident's son said it was explained to the family that his father wandered and looked for exit doors and the facility was not secure. He reported his father was recently placed on the medication, [MEDICATION(S)], to improve his wandering behaviors, so the discharge was a surprise turn around. He recalled his brother had commented it was too soon for the medication to take effect, and the facility did not give the new medication time to see if would be effective before they discharged him. He stated he found out about the discharge when the receiving facility called him to welcome his father and the family, and that his mother had no idea this was happening. He said the facility told them there were no options on the table but to transfer his father to the other facility. The son stated, it felt rushed and did not understand why the discharge was an emergency. He added if his mother had known his father was going to be discharged , she would have called him to prepare him for the transfer to the other facility. He noted they did not know anything about this facility or how long it would take to drive there as it was it in a different city. He explained he would have at least wanted an opportunity to tour the receiving facility before his father was transferred. He conveyed he had to cancel all his plans for the next few days to go to the receiving facility and handle the new situation. He said he wanted to talk to the new staff that would be taking care of his father. There was no indication the son or the family were provided with a written transfer/discharge notice explaining why his father had to be discharged so quickly to the other facility. On 9/9/22 at 6:25 PM, the Director of Nursing, (DON) stated the 300 Wing Unit Manger had informed her resident #17 had attempted to elope. She was told the resident was at the front lobby area looking for his wife. The DON stated the 300 Wing Unit Manger did an evaluation on 8/30/22 as the resident was wandering and had increased confusion. She explained the resident was placed on one-to-one supervision due to his wandering behaviors. The resident's medical record was reviewed with the DON, which included all nursing progress notes, the Risk Screen for elopement dated 8/30/22 and the resident's care plan. The DON acknowledged the only written evidence the resident was placed on one-to-one supervision was the Care Plan, that noted one-to-one was initiated on 9/6/22. There was no evidence to indicate the resident was started on one to one supervision earlier than 9/6/22 but the DON was insistent that one-to-one supervision started on 8/30/22. The DON was not able to provide any documented evidence that resident #17 was actively exit seeking. She did not provide any evidence of a written discharge plan for resident #17 or any supporting documentation as to why the facility could not meet the resident's needs. She stated the facility did not have a Social Worker and the nurses needed to do better documentation. She indicated that once a resident was placed on one-to-one supervision, the facility started looking for alternate placement. She added, we can't keep a resident on one-to-one forever. She noted the receiving facility had an available bed and were willing to accept resident #17, so we transferred him.

Based on observation, interview, and record review, the facility failed to identify and implement appropriate interventions and provide adequate staff supervision to prevent falls for 1 of 5 residents reviewed for falls, (#2) and failed to provide supervision and respond timely to exit door alarms for 1 of 3 residents reviewed for elopement, (#3) of a total sample of 9 residents. Resident #2 was a physically and cognitively impaired resident with a known history of falls. Ten days after admission, the resident fell , hit his head, and was hospitalized with a hematoma or brain bleed. The resident returned to the facility on [DATE], and seven days later he fell and hit his head again. He was hospitalized for six days with skull fractures and another hematoma. On re-admission, he was given a protective helmet and although the facility determined the resident would benefit from one-on-one (1:1) supervision, this approach was never implemented. Instead, the facility relied on safety equipment and staff monitoring at 15-minute intervals to prevent falls. These approaches proved ineffective as resident #2 had five additional falls over the next four weeks. On 7/30/22, the resident slid from his wheelchair to the floor. On 8/01/22, resident #2 fell and struck his head. He was not wearing the helmet and sustained a laceration on the forehead that required sutures. On 8/06/22, the resident was found on the floor with two dresser drawers on top of his body and had superficial abrasions and scratches. On 8/09/22, a staff member left him unattended in the bathroom and he slipped on the wet floor and fell , narrowly avoiding another head injury. On 8/17/22, he stood up from his wheelchair and fell to the floor. Despite resident #2's continuous pattern of falls, the facility deemed 15-minute monitoring to be effective and did not increase the level of staff supervision or ensure staff implemented interventions in the plan of care. On 7/17/22 at approximately 6 PM, the facility failed to prevent resident #3, a physically and cognitively impaired resident from exiting the facility unsupervised. The resident left her room and walked past the 200 unit nurse's station, breached the fire doors and exited the facility without an ambulating assistive device. Once outside the facility, she walked down a sloping walkway that led to the employee parking lot on the south side of the building then walked parallel to the south side of the facility. She then proceeded toward the front of the facility where a staff member happened to be waiting for food delivery. The resident traveled approximately 448 feet before she was observed by a facility staff member. The facility's failure to develop and implement appropriate fall prevention interventions and provide the level of staff supervision required to ensure his safety contributed to resident #2's falls with major injuries and placed all residents who were at risk for falls at risk for serious injury/impairment/death. The facility's failure to provide adequate supervision to a resident with identified risk for elopement and the failure of staff to respond to exit door alarms contributed to resident #3's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 7/4/2022 and was removed on 8/25/22. Findings: Cross reference F600 and F607. 1. Review of the medical record revealed resident #2, an [AGE] year-old male, was admitted to the facility from another skilled nursing facility on 6/24/22. His diagnoses included dementia, seizures, and repeated falls. The resident was readmitted from the hospital on 7/07/22 with new diagnoses of traumatic subdural hematoma, stroke, [CONDITION(S)], and anxiety. The resident was hospitalized on [DATE] and readmitted on [DATE] with additional diagnoses of occipital and temporal bone skull fractures, weakness, unsteadiness on his feet, and abnormalities of gait and mobility. A subdural hematoma is usually caused by bleeding associated with a severe head injury and can be life-threatening. It is a collection of blood under the membrane that covers the brain which exerts increased pressure on the brain (retrieved on 8/30/22 from www.WebMD.com). Resident #2's pre-admission packet, transmitted to the facility on [DATE], included a physician's progress note dated 6/14/22 regarding a recent transfer to the hospital after a fall with a head laceration. An interdisciplinary team (IDT) meeting note dated 6/15/22 at 3:45 PM, documented discussion of resident #2's falls and aggressive behavior. The note indicated the resident required a fall focus program for enhanced supervision. A nursing progress note dated 6/15/22 at 5:41 PM, revealed resident #2 returned from the hospital and was . noncompliant with plan of care, not easily redirected, placed on enhanced supervision. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 6/24/22, provided by resident #2's previous skilled nursing facility, revealed his primary diagnosis was a head laceration post fall. The document indicated the resident had a risk alert for falls, and was alert, disoriented, but could follow simple instructions. Review of the Admission/Re-Admission Nursing Note dated 6/24/22 revealed resident #2 had a Fall Screen that indicated he overestimated or forgot limits. A fall risk evaluation score of 70 indicated high risk for falls, and triggered a baseline care plan. The interventions included anticipate and meet the resident's needs, keep his bed in the lowest position and remind the resident to call for assistance. The Functional Status evaluation revealed resident #2 required assistance with activities of daily living (ADLs) and the triggered baseline care plan read, Safety Intervention: Increased frequency of monitoring. Review of an SBAR [Situation, Background, Assessment, Recommendation] Communication Form dated 7/04/22 revealed resident #2 fell and exhibited increased confusion, disorientation, abnormal speech, altered level of consciousness and dizziness or unsteadiness post fall. The resident showed non-verbal signs of new onset of pain to the back of his head and his mid to upper back including occasional moaning and a sad, frightened, frowning facial expression. The form revealed the resident was transferred to the hospital for evaluation and treatment. The Minimum Data Set (MDS) Discharge - Return Anticipated assessment with assessment reference date (ARD) of 7/04/22 revealed resident #2 had a fall with injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, and required limited assistance for walking and eating. Review of the hospital record revealed a History and Physical Note dated 7/04/22 that showed resident #2 suffered a Traumatic head injury from standing level. The resident was diagnosed with a subdural hematoma to the posterior (back) left side of his head and a possible right frontal subdural hematoma. On 8/24/22 at 11:34 AM, Certified Nursing Assistant (CNA) F recalled on 7/04/22, she was instructed by the Social Services Director (SSD) to be 1:1 with resident #2. CNA F stated she was aware the resident was at risk for falls and had erratic behavior, but sat just outside his room where she could see him through a gap in the curtain. She said, I guess it was my mistake to sit out there. I guess I thought it was best for him not to see me completely. CNA F recalled she was seated there for less than ten minutes and was looking down at her lap. She explained the resident was in bed, and when she next looked up, he was already standing. She stated by the time she stood up to assist him, he suddenly fell backwards and landed on his head. Resident #2's care plan for risk for falls related to impaired cognition and impaired safety awareness, initiated on 7/05/22, had a goal to prevent a serious fall related injury. An updated intervention dated 7/05/22 was to check the environment for clutter or trip hazards and area is well lit. There was no supportive information in the medical record to show the resident tripped or that his room was cluttered. In addition, the care plan was not revised to address the resident's need for increased supervision and close monitoring due to his impulsive movements. Review of an SBAR Communication Form dated 7/14/22 revealed resident #2 fell again and the physician gave an order to send him to the hospital for further evaluation. A hospital Inpatient Neurology Consultation note dated 7/15/22 revealed resident #2 was seen for a fall-related head injury and brain contusion. The note indicated a computerized tomography (CT) scan of the head showed an area in the right frontal lobe of the brain that was suspicious for swelling and bleeding. Diagnostic imaging revealed resident #2 had a midline fracture of the occipital bone which forms the back of the skull. The fracture extended into the adjacent right temporal bone and there was an associated collection of fluid behind the right ear. Review of medical record revealed resident #2's care plan for ADLs was revised on 7/18/22 to include provide adaptive/safety equipment: helmet. The care plan for risk for falls was revised on 7/20/22 to direct staff to provide 15-minute checks when the resident was in bed or did not wear the helmet. An IDT Care Plan/Care Conference note dated 7/21/22 at 4:09 PM, revealed the facility's IDT met with resident #2's family to discuss his readmission on the previous evening and his increased behavioral symptoms. The note read, Family was informed that resident continues to try to get out of bed and would benefit from one on one. Family stated that they would provide one on one care until resident's behaviors subside. The IDT members in attendance were the facility's previous Executive Director (ED), Unit Manager (UM) AA, MDS Coordinator G, and the Social Services Assistant (SSA). The MDS Admission assessment with ARD of 7/27/22 revealed resident #2's Brief Interview for Mental Status score was 0 which indicated severe cognitive impairment. The assessment showed a decline in ADL status as the resident now required extensive assistance for walking and eating. He had unsteady balance during transitions and walking and was only able to stabilize with staff assistance. The assessment indicated resident #2 had fall-related fractures in the six months prior to admission. Review of resident #2's Order Summary Report revealed on 7/21/22, after the second fall with head injury, the physician downgraded his diet from a regular texture to pureed texture. Review of resident #2's electronic medical record Therapy section revealed precautions were necessary due to his high fall risk related to cognitive, motor, perceptual and sensory deficits, low endurance, impulsiveness, and seizures. Therapy staff were instructed to restrict patient performance in unsupervised tasks. An Occupational Therapy progress note dated 7/26/22 indicated resident #2 required maximum assistance to complete self-feeding. Review of the Speech Therapy plan of care dated 8/16/22 revealed resident #2 had a regular diet upon initial admission, and after readmission required pureed foods. Occupational Therapy treatment notes from 8/17/22 to 8/24/22 revealed resident #2 had a decline in status as staff had to provide total assistance with feeding. An SBAR Communication Form dated 7/30/22 revealed resident #2 had another fall. The care plan for risk for falls was revised on 8/01/22 to reflect a referral to Occupational Therapy for a reclining wheelchair. There were no revisions to the care plan regarding increased frequency of monitoring by staff. Two days later, on 8/01/22, an SBAR Communication Form documented the resident fell again with findings of a laceration and new onset of pain. The nurse notified the resident's daughter at 12:00 PM and a progress note dated 8/02/22 at 2:35 AM indicated an Advanced Practice Registered Nurse (APRN) assessed resident #2 and noted stitches over his right eyebrow. On 8/22/22 at 1:52 PM, Licensed Practical Nurse (LPN) D stated she was assigned to resident #2 on the day he fell and struck his forehead. She recalled 30 minutes prior to the incident, he was in bed, and she awakened him to administer medications. LPN D stated she then went to another hallway and was inside another resident's room when she heard the housekeeper exclaim, He's up! LPN D stated she instantly knew it was resident #2 and ran towards his room, but he fell in the hallway before she could catch him. She acknowledged he was not wearing the helmet and she was unsure if the assigned CNA checked on him since she last saw him. She stated 15-minute checks were not adequate for this resident. LPN D explained the resident's family members visited often, but they could not be at the facility all the time. She stated on a few occasions she called the resident's daughter to help when he had behaviors, but she was not always able to come in at that exact moment. LPN D recalled the resident's daughter was upset the facility would not provide 1:1 supervision for her father. On 8/22/22 at 2:08 PM, CNA E stated he was assigned to resident #2 on the day he fell and hit his forehead. He could not recall how long before the incident he saw the resident and explained he had a full assignment, so he was probably in another resident's room. He explained monitoring resident #2 every 15 minutes was even more difficult if his assignment was split between two separate hallways. CNA E said, There is only one 100% way to keep him safe, and that is 1:1. Review of the fall risk care plan showed revisions on 8/02/22 to offer scheduled toileting before and after meals and encourage non-skid footwear. There was no documentation in the medical record to indicate the resident needed to be toileted at the time he fell . The care plan did not show any revisions regarding an increased level of supervision to prevent falls and injuries although the resident got out of bed and ambulated to the hallway while on 15-minute checks. A Health Status Note dated 8/06/22 read, A loud thud was heard from the patients room, when the nurse walked in patient was observed on the floor next to his bed with the night table [drawers] on top of him. The fall risk care plan was revised on 8/08/22 to reflect the addition of a device, bedside floor mats, but no approaches related to increased staff supervision. A SBAR Communication Form dated 8/09/22 revealed resident #2 was toileted and left in the bathroom by a CNA. The resident was not wearing non-skid socks or his helmet and when he attempted to walk without assistance, he slipped and fell . The fall risk care plan was revised on 8/10/22 to show staff were educated regarding not leaving the resident unattended in the bathroom. On 8/23/22 at 10:50 AM, CNA C stated the day resident #2 fell in the bathroom was the first time she was assigned to care for him. She recalled it was after breakfast, and she was on her way to attend to another resident when UM AA instructed her to take resident #2 to the bathroom immediately as his family was in the room. CNA C stated she asked the two family members in the room if the resident was able to walk as she did not know him. CNA C explained resident #2 could not make it to the toilet and urinated on the bathroom floor. She recalled he wore regular socks which were by then soaked with urine. CNA C stated she placed the resident to sit on the toilet, told him to wait there, then left him to get a clean brief and socks from his cupboard. She stated the resident exited the bathroom and slipped and fell , almost hitting his head on his roommate's bed. CNA C said, He did not have the helmet on that day. I did not know he had a helmet. I did not know he was a 15-minute check. It was my first day and I saw it later on when I went to chart. CNA C stated she usually relied on verbal change of shift report, but the off-going CNA did not share that information with her. She explained she did not always have time to look at the Kardex at the start of the shift and sometimes could not do 15-minute checks on time if she had a full assignment of ten or more residents. Review of a Health Status Note dated 8/17/22 revealed resident #2 slipped on the floor from his wheelchair. The note indicated he fell while his assigned nurse was occupied at her medication cart nearby, and resident later transferred back to wheelchair and closely monitored. The fall risk care plan was revised on 8/18/22 to include another device, a wedge cushion in the resident's wheelchair, but did not show any updates related to increased staff supervision to prevent falls. On 8/21/22 at 5:20 PM, resident #2 was seated in his wheelchair at the 400-unit nurses' station. He was positioned in front of an empty tray table with the wheelchair brakes locked, did not make eye contact or respond to his name, and had four sutures above his right eyebrow. CNAs collected dinner trays from rooms in the middle to far end of the hallways that led away from the nurses' station, and there were no nursing staff observed in the resident's vicinity. In addition, the resident did not wear a helmet or have a wedge cushion in his wheelchair as documented in the plan of care. On 8/21/22 at 5:24 PM, CNA A paused as she approached nurses' station. She stated she was assigned to the resident but did not remember his name as this was her first day caring for him. CNA A stated she was informed in change of shift report the resident was on 15-minute checks. On 8/21/22 at 5:25 PM, LPN D, resident #2's assigned day shift nurse, returned to the nurses' station. She stated she had been administering medications to another resident and did not know how long resident #2 was seated at the nurses' station unattended. LPN D explained resident #2 overestimated his abilities and had fallen several times, so assigned staff were to check on his location and status at least every 15 minutes. On 8/21/22 at 8:42 PM, resident #2 was in bed with his eyes open, repeatedly rolling from side to side. The bed height was about two feet above the floor and the curtain was partially closed. On 8/21/22 at 8:45 PM, LPN B, the resident's assigned night shift nurse, stood at her medication cart at the farthest end of the hallway away from his room. She stated resident #2 fell regularly and she tried to check on him as often as she could. LPN B explained monitoring the resident was very difficult as he was confused, unpredictable and stood up quickly. She said, He needs 1:1 observation. I don't know what they put in place for him. I don't know if he has 15-minutes checks. When asked if she had access to care plans to review instructions for the resident's care, LPN B said, I'm new to the building. I would have to ask. I have not reached that point yet. On 8/21/22 at 8:50 PM, CNA A was asked to access resident #2's electronic care plan or Kardex. She looked at the screen for a few minutes and had to be prompted to select the link that read Kardex. She confirmed care directives indicated the resident should wear a helmet awake in bed or out of bed and get checked every 15 minutes while in bed or when the helmet was not worn. She was informed the nursing care plan indicated resident #2 should have a wedge cushion in his wheelchair. CNA A stated she was not aware resident #2 had a helmet. She confirmed she did not review the Kardex prior to caring for resident #2 for the first time. CNA A was accompanied to resident #2's room where LPN B stood with the bed control in her hand, and the bed was now noted to be lowered to the floor. CNA A searched the resident's room and confirmed there was no wheelchair wedge cushion. On 8/22/22 at 10:09 AM, the Rehab Director stated she was a member of the IDT and participated in discussions on resident #2's falls and possible interventions. She confirmed the Therapy Department provided a reclining high back wheelchair and ordered a wedge cushion for resident #2. She was informed he did not have a wheelchair cushion yesterday and she said, It is not in yet. The Rehab Director stated resident #2 could not walk safely on his own and required staff assistance for ambulation. She acknowledged although devices could be helpful, there was no device guaranteed to prevent falls and keep the resident safe. On 8/22/22 at 11:11 AM, the Physical Therapy Assistant (PTA) stated resident #2 had decreased lower extremity strength which affected his ability to walk and perform safe transfers. The PTA explained resident #2 required strong handheld assistance at all times while walking. He said, I have to really hold on to him. I am under the arm holding him. Absolutely not safe walking on his own. On 8/22/22 at 11:28 AM, in a telephone interview and on 8/23/22 at 3:51 PM during an onsite interview, resident #2's daughter explained her father had a history of repeated falls with injuries including facial bone fractures and head lacerations prior to admission. She stated during pre-admission discussions, the family informed the facility's Care Manager (CM) that her father fell regularly. Resident #2's daughter explained in the previous facility her father utilized a body-length pillow when in bed and was in a Fall Focus fall prevention program where he was closely monitored. She recounted details of her father's multiple falls and injuries during less than two months in the current facility. The daughter stated after her father's first fall he was more confused and did not recognize her or known family members for approximately two weeks. She said, That fall seemed to trigger a decline in him and ten days later he fell again. She stated her father fractured his skull in the second fall, became even more disoriented, and since then required more assistance to walk, tired easily, and no longer fed himself. Resident #2's daughter recalled another fall incident when she walked into her father's room and saw him on the floor with drawers from the nearby dresser on top of his body. She showed photographs of abrasions she noted on her father's neck. She stated a few days later, she actually witnessed her father fall when a CNA took him into the bathroom and left him there alone. The daughter explained she was seated in the room and saw her father walk out of the bathroom, slip in urine on the floor and fall, almost colliding with the bed. She stated her father wore regular socks instead of non-skid socks. Resident #2's daughter recalled after her father's first fall, facility staff told her they would observe him for a week or two to identify patterns and determine appropriate fall interventions. She stated over the following weeks, the facility informed her of fall and injury prevention interventions that were implemented such as floor mats beside his bed and a helmet. Resident #2's daughter recalled a care plan meeting on 7/21/22, after the second fall. When asked if the facility mentioned increased supervision to prevent further falls and injuries, resident #2's daughter said, During the meeting [name of previous ED] said 'As you guys know, your dad requires a 1:1 and we do not have the staffing to provide 1:1 care for your dad. Is there any way that you guys can be a part of his care?' She told us there were healthcare advocate programs that we can contact and try to get someone for hire to sit with dad. They asked us if we wanted to hire a private sitter. After review of the IDT progress note that indicated the family agreed to provide one-on-one care, resident #2's daughter clarified the family did not commit to provide this level of care. She emphasized, They said to us he needed a 1:1 and they could not provide it unless we help. Why they don't have him on 1:1 is a mystery to me. She stated at the end of the meeting there was no final decision or schedule made regarding 1:1 care. The daughter recalled the discussion ended with the family agreeing the facility would call them whenever her father needed someone to sit with him. She explained family members still visited frequently and spent as much time with her father as possible. She expressed concerns regarding sometimes finding her father's helmet on the chair or table in his room and regular encounters with staff who were not knowledgeable of his high risk for falls of interventions in the plan of care. The daughter said, The staff have a hard time watching him because they are busy. On 8/22/22 at 12:29 PM, the SSA stated during the care plan meeting with resident #2's family, MDS Coordinator G suggested 1:1 supervision was a possible solution as he made continuous attempts to get out of bed and was at risk for falls. The SSA said, The understanding at the end of the meeting was the family would come in and take shifts to provide 1:1 care. The SSD stated she recalled the family was willing to provided 1:1 supervision for the resident. The SSD did not respond when asked why the family would agree to provide continuous 1:1 care in the facility rather than take the resident home with them. She stated the nursing department was responsible for updating the plan of care related to increased staff supervision. She acknowledged there was no documentation of arrangements made at the care plan meeting and confirmed neither the family nor the facility provided continuous 1:1 supervision for resident #2 after the care plan meeting. On 8/22/22 at 12:51 PM, MDS Coordinator G stated the facility held the care plan meeting on 7/21/22 to address concerns related to resident #2's impulsive behaviors and fall risk. She explained the goal was to identify interventions that would prevent him from falling. MDS Coordinator G said, The facility suggested or asked the family to provided supervision. We did not ask them to stay 24 hours, but they volunteered to do so. She stated she informed the family members they should call the facility if they were unable to provide 1:1 care. MDS Coordinator G could not say if the previous ED and Director of Nursing (DON) authorized staffing for 1:1 supervision when family members were not available. She acknowledged the care plan was never revised to reflect the resident's need for 1:1 supervision rather than 15-minute checks. She validated there was no other documentation to notify nurses or CNAs that the resident required 1:1 supervision, nor to educate staff on collaboration with the family regarding assisting with resident #2's care. MDS Coordinator G acknowledged if 1:1 supervision was deemed necessary, the facility was ultimately responsible, even if the family was willing to help. On 8/22/22 at 2:24 PM, Registered Nurse (RN) UM M stated resident #2 was at high risk for falls and required fall and injury prevention approaches including a helmet. UM M reviewed the resident's medical record and showed a physician order dated 8/15/22 that read, Helmet to be worn at all times while out of bed. She was informed resident #2 was observed at the nurses' station on the previous evening without a helmet, his assigned CNA was not aware of the intervention, and the assigned nurse did not ensure the protective device was in place. UM M stated the expectation was CNAs would read the Kardex and nurses would review all physician orders at the start of the shift, before providing care for residents. She said, He is fast, and we have to keep checking on him. When asked about resident #2's repeated falls despite 15-minute checks, UM M stated she felt the intervention would be effective if staff were consistent with monitoring and toileting him. UM M acknowledged resident #2's last fall occurred at the nurses' station while she and the assigned nurse worked nearby. She did not respond when asked if that fall suggested the need for even closer monitoring or 1:1 supervision to prevent the resident's falls. On 8/23/22 at 2:11 PM, in a telephone interview, the Care Manager stated she conducted a pre-admission assessment for resident #2 which included observing him at the previous skilled nursing facility and interviewing that facility's SSD, the resident's UM and his direct care CNA. The Care Manager stated she was informed he was at risk for falls, but if he was toileted regularly, he would not fall. The Care Manager stated she reviewed the resident's medical record and hospital admissions and was not aware of any falls with fractures or major injuries. She was informed the pre-admission packet provided by the previous facility included information on the resident's fall risk, an injury that required a transfer to the Emergency Department a few days prior to admission, and the need for increased supervision. The Care Manager stated she was aware of the resident's recent falls in the current facility. She said, There was some oversight on my part.This was a big oversight on my part. The Care Manager explained the facility usually avoided admitting residents who would be high risk for needing 1:1 supervision because of insufficient staff. She confirmed she did not involve the Director of Nursing (DON) or any other members of the IDT in discussions about resident #2's fall risk, level of supervision required, and did not communicate information she received on fall prevention intervention(s) implemented at the previous facility. On 8/21/22 at 8:02 PM, 8/22/22 at 11:49 AM, and 8/23/22 at 3:38 PM, resident #2's seven fall incidents were reviewed with the facility's administrative team composed of the Regional Director of Clinical Operations (RDCO), ED, and the DON. Interview findings were: The RDCO confirmed resident #2 was identified as high risk for falls on admission to the facility. She explained the initial nursing assessment automatically triggered a baseline care plans with appropriate interventions. She stated the facility's process did not include implementation of frequent checks as an admission approach. When the RDCO was informed the baseline care plan indicated from the day of admission resident #2 required increased frequency of monitoring, she said, It is not defined as to what increased monitoring involves. She acknowledged staff interpretation of that intervention could vary widely. The RDCO stated she could not speak to discussions that occurred in clinical meeting reviews as she was not present, but her review of the baseline plan of care revealed no changes were made. She acknowledged the baseline care plan intervention to remind the resident to call for assistance was not appropriate due to his severe cognitive issues. The RDCO was informed the facility was made aware of resident #2's extreme risk for falls and major injuries through a pre-admission packet that included documentation on recent falls, aggressive behaviors, and the need for enhanced supervision in a fall prevention program. She was told that prior to admission, the CM was informed resident #2 required a regular toileting schedule. She said, I can't speak to the admission process. We use a standard guide for admissions and some residents will score high, [that] would include any type of fall in the last 90 days.We monitor all new admissions the same. The RDCO verified the IDT initiated 15-minute checks on 7/20/22, after resident #2 suffered two falls with major head injuries. She acknowledged the resident had five additional falls over a four-week period after that intervention was initiated. When asked if she felt 15-minute monitoring was successful, the RDCO stated the intervention was effective as without it, the resident would have fallen much more often, probably even daily. She said, The team did not feel he required a 1:1 provided by staff every day. We can't prevent all falls, but we can reduce the risk of injury. The ED, RDCO, and DON reviewed the care plan meeting note dated 7/21/22 which indicated the IDT informed the resident's family members that they determined he would benefit from 1:1 supervision. The RDCO stated her understanding was the family wanted to provide the 1:1 care. However, she acknowledged there was no documentation to show the IDT and nursing staff followed the normal proc [TRUNCATED]

Based on observation, interview, and record review, the facility neglected to communicate essential information and ensure provision of necessary care and services to prevent falls and major injuries for a vulnerable resident; and the facility's nursing staff neglected to follow the plan of care related to safety devices and monitoring for 1 of 5 residents reviewed for falls of a total sample of 9 residents, (#2). Resident #2 had repeated falls and sustained severe head injuries. He suffered significant pain, had increased confusion and disorientation, and experienced a decline in his functional status. Resident #2 was a physically and cognitively impaired resident with a known history of falls. Ten days after admission, the resident fell , hit his head, and was hospitalized with a hematoma or brain bleed. The resident returned to the facility on [DATE], and seven days later he fell and hit his head again. He was hospitalized for six days with skull fractures and another hematoma. On re-admission, he was given a protective helmet and although the facility determined the resident would benefit from one-on-one (1:1) supervision, this approach was never implemented. Instead, the facility relied on safety equipment and staff monitoring at 15-minute intervals to prevent falls. These approaches proved ineffective as resident #2 had five additional falls over the next four weeks. On 7/30/22, the resident slid from his wheelchair to the floor. On 8/01/22, resident #2 fell and struck his head. He was not wearing the helmet and sustained a laceration on the forehead that required sutures. On 8/06/22, the resident was found on the floor with two dresser drawers on top of his body and had superficial abrasions and scratches. On 8/09/22, a staff member left him unattended in the bathroom and he slipped on the wet floor and fell , narrowly avoiding another head injury. On 8/17/22, he stood up from his wheelchair and fell to the floor. Despite resident #2's continuous pattern of falls, the facility deemed 15-minute monitoring to be effective and did not increase the level of staff supervision or ensure staff implemented interventions in the plan of care. The facility's failure to provide necessary fall prevention care and services to mitigate a known high risk for falls contributed to resident #2's falls with major injuries and placed all residents at risk for neglect and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 7/04/22 and was removed on 8/25/22. Findings: Cross reference F607 and F689. Review of the medical record revealed resident #2, an [AGE] year-old male, was admitted to the facility from another skilled nursing facility on 6/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A subdural hematoma is usually caused by bleeding associated with a severe head injury and can be life-threatening. It is a collection of blood under the membrane that covers the brain which exerts increased pressure on the brain (retrieved on 8/30/22 from www.WebMD.com). The Minimum Data Set (MDS) Admission assessment with assessment reference date of 7/27/22 revealed resident #2's Brief Interview for Mental Status (BIMS) score was 0 which indicated severe cognitive impairment. The assessment showed a decline in functional status since the previous assessment as the resident now required extensive instead of limited assistance for walking and eating. He had unsteady balance during transitions and walking and was only able to stabilize with staff assistance. The assessment indicated resident #2 had fall-related fractures in the six months prior to this admission. Review of the Order Summary Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The diet order was discontinued after the resident's second fall with head injuries, and the physician downgraded his diet to a pureed texture on 7/21/22. The document included a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed resident #2 had a care plan for risk for falls related to impaired cognition, impaired safety awareness, and a history of falls, initiated on 7/05/22, with a goal to prevent a serious fall related injury. The interventions were to anticipate and meet his needs, check the environment for hazards, provide a protective helmet, perform 15-minute checks, use a reclining wheelchair, ensure non-skid footwear worn when out of bed, offer toileting before and after meals, bedside floor mats, wedge cushion to his wheelchair, and participate in the Starlite program for supervision when out of bed. The care plan indicated staff were educated on fall interventions. The Certified Nursing Assistant (CNA) care plan or Kardex included a safety directive to perform 15-minute checks while resident #2 was in bed or when he did not wear his helmet. The Kardex read, Encourage and assist resident to use helmet when out of bed or awake in bed. Resident care instructions for CNAs included resident #2 required extensive assistance for bed mobility and transfers, and he was dependent on staff for eating, toilet use and personal hygiene. The Kardex was incomplete as the sections for instructions on level of assistance required for walking and locomotion were left blank. On 8/21/22 at 5:20 PM, resident #2 was seated in his wheelchair at the 400-unit nurses' station. There were no nursing staff in the vicinity and resident #2 did not wear a helmet or have a wedge cushion in his wheelchair as documented in the plan of care. On 8/21/22 at 5:24 PM, CNA A stated she was assigned to the resident but did not remember his name as this was her first day caring for him. CNA A stated she was informed in change of shift report that the resident was on 15-minute checks. On 8/21/22 at 5:25 PM, Licensed Practical Nurse (LPN) D, resident #2's assigned day shift nurse, returned to the nurses' station. She stated she had been administering medications to another resident and did not know how long resident #2 was seated at the nurses' station unattended. On 8/21/22 at 8:42 PM, resident #2 was in bed with his eyes open and he repeatedly rolled from side to side. The bed height was about two feet above the floor rather than in the lowest position and the curtain was partially closed. On 8/21/22 at 8:45 PM, LPN B, the resident's assigned night shift nurse stated resident #2 fell regularly and she tried to check on him as often as she could. LPN B explained monitoring the resident was very difficult as he was confused, unpredictable and stood up quickly. She said, He needs 1:1 observation. I don't know what they put in place for him. I don't know if he has 15-minutes checks. LPN B stated she did not know how to access the resident's care plans in the medical record to obtain this information. On 8/21/22 at 8:50 PM, CNA A was asked to access resident #2's Kardex. She looked at the screen for a few minutes and had to be prompted to select the link that read Kardex. She confirmed care directives indicated the resident should wear a helmet awake in bed or out of bed and be checked every 15 minutes while in bed or when the helmet was not worn. She was informed the nursing care plan indicated resident #2 should have a wedge cushion in his wheelchair. CNA A stated she was not aware resident #2 required a helmet or a wedge cushion and explained she did not review the Kardex prior to caring for him for the first time today. On 8/22/22 at 11:11 AM, the Physical Therapy Assistant (PTA) stated resident #2 had decreased lower extremity strength that affected his ability to walk and perform safe transfers. The PTA explained during therapy sessions, resident #2 required strong handheld assistance at all times while walking and was not safe walking on his own. He explained at the end of his sessions, he usually returned resident #2 to his original location but did not necessarily communicate to nursing staff that the resident was back on the unit or in his room. On 8/22/22 at 1:52 PM, LPN D stated she was assigned to resident #2 on the day he fell and struck his forehead. She recalled she had seen him in his room [ROOM NUMBER] minutes prior to the incident but was unsure whether the assigned CNA had done a 15-minute check on him since she last saw the resident. She said, I have suggested that the resident be on 1:1. I told management. I have to roll him in his wheelchair with me sometimes while giving medication to other residents. I leave him outside the rooms and rush back. On 8/22/22 at 2:08 PM, CNA E stated he was assigned to resident #2 on the day he fell and hit his forehead. He could not recall how long before the incident he saw the resident and explained he had a full assignment, so he was probably in another resident's room. He explained monitoring resident #2 every 15 minutes was even more difficult if he was split or assigned to residents on two separate halls. CNA E said, There is only one 100% way to keep him safe, and that is 1:1. On 8/23/22 at 10:50 AM, CNA C stated the day resident #2 fell in the bathroom was the first time she was assigned to care for him. CNA C stated there were two family members in the room and she had to ask them if the resident was able to walk as she did not know him. She explained resident #2 could not make it to the toilet and urinated on the bathroom floor. She recalled he wore regular socks instead of non-skid socks, which were by then soaked with urine. CNA C stated she placed the resident to sit on the toilet, told him to wait there, then left him to get a clean brief and socks from his cupboard. She stated the resident exited the bathroom and slipped and fell , almost hitting his head on his roommate's bed. CNA C said, He did not have the helmet on that day. I did not know he had a helmet. I did not know he was a 15-minute check. It was my first day and I saw it later on when I went to chart. CNA C stated she usually relied on verbal change of shift report, but the off-going CNA did not share that information with her. She explained she did not always have time to look at the Kardex at the start of the shift and was not able to do every 15-minute check if she had a full assignment of ten or more residents. On 8/24/22 at 11:19 AM, in a telephone interview, LPN N stated on 7/04/22, she did not recall anyone telling her exactly why the resident needed a sitter, and she told CNA F who was assigned to sit with him, He must be 1:1 for a reason. LPN N stated not long after CNA F entered the room, she came out to inform her she had taken her eyes off the resident, and he fell and hit his head. On 8/24/22 at 11:34 AM, CNA F recalled on 7/04/22, she was instructed by the Social Services Director to sit with resident #2 but was not given a reason. CNA F stated she was aware the resident was at risk for falls and had erratic behavior, but she chose to sit just outside his room where she could see him through a gap in the curtain. She said, I guess it was my mistake to sit out there. I guess I thought it was best for him not to see me completely. CNA F recalled she was seated there for less than ten minutes and was looking down at her lap. She explained the resident was in bed, and when she next looked up, he was already standing. She stated by the time she stood up to assist him, he suddenly fell backwards and landed on his head. On 8/24/22 at 12:32 PM, CNA O stated she was usually assigned to care for 10 or 11 residents on day shift, but sometimes it could be as many as 14 residents. She explained 14 residents was a normal assignment for the evening shift. CNA O said, It is not possible to do 15-minute checks if you have 10 residents, much less 14. She explained CNAs were expected to respond to call lights in a timely manner, give showers, and assist residents who could not feed themselves. CNA O stated some residents required two CNAs for personal care, showers or transfers which meant while they were both occupied with one resident their other 27 residents were the responsibility of other staff who had their own assignments. She stated sometimes CNAs also had to take turns to do 30-minute rotations in the Starlite program to monitor other residents. She said, That means I would be off my assignment and the other CNAs would have to do my residents and answer the call lights for 30 minutes. On 8/25/22 at 12:50 PM, CNA S stated her current assignment included a resident who was at high risk for falls, and she had to ask other staff members to keep an eye on the resident whenever she attended to other duties. She explained the resident required increased monitoring, and for weeks staff had tried to watch her continuously because she could get up quickly. During the interview, a call light sounded and CNA S asked Registered Nurse (RN) P if she could stand in the hallway to watch the resident while she was gone. RN P stopped passing medications and stood in the hallway to monitor the resident who was at risk for falls. When CNA S returned, she informed RN P that the resident she checked on seemed confused and was unsteady on her feet. CNA S stated she was now concerned about the other resident's safety as well. She said, It makes everybody's job hard because the nurse has to stop what she is doing, or another CNA has to leave their residents to help me. She pointed to the center of the unit and indicated there were no other clinical or non-clinical staff available to assist. On 8/25/22 at 12:53 PM, CNA T stated she was regularly assigned to between 11 and 13 residents on the day shift and explained it was impossible to check on anyone every 15 minutes with that many residents. She stated it could often take almost 30 minutes to give a shower or feed a resident. CNA T stated administration was aware of the issue as CNAs had requested more staff or assignment adjustments many times. On 8/25/22 at 12:58 PM, CNA U stated checking on a resident every 15 minutes in addition to caring for another nine or more assigned residents was challenging. She said, It cannot be done every 15 minutes in the busy times. CNA U explained staff all tried to work together, but each assignment had residents who were at risk for falls and needed to be monitored. On 8/21/22 at 12:22 PM, in a telephone interview, LPN Q recalled she had a resident at high risk for falls and requested a 1:1 sitter but was told there was not enough staff to provide this service. LPN Q stated she stopped working at the facility as working conditions were not safe due to management not providing enough staff to monitor residents at high risk for falls. On 8/22/22 at 11:28 AM, in a telephone interview, and on 8/23/22 at 3:51 PM in an interview onsite, resident #2's daughter explained her father had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The daughter explained her father sustained facial bone fractures, a head laceration, and bruising during the three-month period before he was transferred from the previous facility to the current facility, all of which were in his medical record. Resident #2's daughter explained in the previous facility her father utilized a body-length pillow when in bed and remained in a Fall Focus fall prevention program during the day until 7:00 PM where he was closely monitored. The daughter said, They gave him increased supervision. She recounted details of her father's multiple falls and injuries in the current facility which included brain injuries and fractures. She explained he was now more confused, had difficulty walking and no longer fed himself. The daughter recalled one fall that she actually witnessed when a CNA took him into the bathroom and left him there alone. The daughter explained her father walked out of the bathroom, slipped in urine on the floor and fell , and almost collided with the bed. She stated her father wore regular socks instead of non-skid socks and said, This one was definitely neglect. The CNA said she did not review his chart.She did not know he was a fall risk. The daughter explained CNAs regularly stated they did not know information on how to care for her father. She said, I have asked if they read the chart and they say they just got here, or this is their first day. Resident #2's daughter recalled a care plan meeting on 7/21/22 when staff informed her that her father required 1:1 supervision, but the facility could not provide this service due to staffing issues. She recalled the previous Executive Director (ED) told her the family could either provide this service themselves or hire a private sitter, but a final decision was never made. She explained family members still visited the facility frequently and spent as much time with her father as possible but in between their visits staff had difficulty watching him as they were busy. On 8/23/22 at 2:08 PM, the Admissions Director explained the decision to admit a new resident was made by the facility's marketer or Care Manager. She explained if there was a challenging potential resident or abnormal circumstances, the Care Manager would discuss it with the Director of Nursing (DON). The Admissions Director stated the facility received resident #2's medical record from the previous nursing facility days before he was admitted , but she could not say if the record was reviewed by the interdisciplinary team (IDT) as a group or by any member of nursing administration. On 8/23/22 at 2:11 PM, in a telephone interview, the Care Manager stated during resident #2's pre-admission assessment she interviewed staff at the previous facility and obtained information from his daughter. She validated she was informed the resident was at risk for falls, and also that an effective fall prevention intervention was scheduled toileting. The Care Manager stated she also reviewed the resident's medical record to check for recent hospital admissions and noted he had none. She acknowledged she researched inpatient admissions but not Emergency Department visits. The Care Manager was informed the pre-admission packet provided by the previous facility included information on the resident's fall risk, an injury that required a transfer to the Emergency Department a few days prior to admission, and the need for increased supervision. She said, There was some oversight on my part.This is a big oversight on my part.I would not admit anyone who required 1:1. The Care Manager confirmed she did not contact the DON or any member of the IDT to discuss resident #2's care needs related to his fall risk, level of supervision required and did not communicate fall prevention interventions that were implemented at the previous facility. Review of an IDT Care Plan/Care Conference note dated 7/21/22 at 4:09 PM, revealed the facility met with resident #2's family to discuss his re-admission on the previous evening and his increased behavioral symptoms. The note read, Family was informed that resident continues to try to get out of bed and would benefit from one on one. Family stated that they would provide one on one care until resident's behaviors subside. On 8/22/22 at 12:08 PM, Unit Manager (UM) AA confirmed she was present at the care plan meeting when increased supervision for resident #2 was discussed. She said, We watch him when the family is not there. UM AA validated resident #2 remained on 15-minute checks and acknowledged there was no arrangement for staff to provide 1:1 supervision when the resident's family members completed their visits and left the building. UM AA confirmed the 15-minute checks were not a good intervention since the resident kept falling. On 8/22/22 at 12:51 PM, MDS Coordinator G recalled the care plan meeting held on 7/21/22 to address concerns related to resident #2's impulsive behaviors and fall risk. She said, The facility suggested or asked the family to provide supervision.We did not ask them to stay 24 hours, but they volunteered to do so. MDS Coordinator G could not say if the ED and DON authorized the necessary staffing for 1:1 supervision when family members were not available. MDS Coordinator G acknowledged if 1:1 supervision was deemed necessary, the facility was ultimately responsible, even if the family was willing to help. On 8/21/22 at 8:02 PM, 8/22/22 at 11:49 AM, and 8/23/22 at 3:38 PM, resident #2's seven fall incidents were reviewed with the facility's administrative team composed of the Regional Director of Clinical Operations (RDCO), ED and the DON. Interview findings were: The RDCO was informed the facility was made aware of resident #2's extreme risk for falls and major injuries through a pre-admission packet that included documentation on recent falls, aggressive behaviors, and the need for enhanced supervision in a fall prevention program. She was told that prior to admission, the CM was aware resident #2 required a regular toileting schedule. She said, I can't speak to the admission process. We use a standard guide for admissions and some residents will score high, [that] would include any type of fall in the last 90 days.We monitor all new admissions the same. She stated admissions staff could contact the DON for any clinical concerns including fall risk and history. When the RDCO was informed the baseline care plan indicated from the day of admission resident #2 required increased frequency of monitoring, she said, It is not defined as to what increased monitoring involves. The RDCO verified the IDT initiated 15-minute checks on 7/20/22, only after resident #2 suffered two falls with major head injuries. She acknowledged the resident had five additional falls over a four-week period after that intervention was initiated. When asked if she felt the intervention was successful, the RDCO stated felt 15-minute checks were effective as without this intervention the resident would have fallen much more often, probably even daily. She said, The team did not feel he required a 1:1 provided by staff every day. We can't prevent all falls, but we can reduce the risk of injury. The ED, RDCO, and DON reviewed the care plan meeting note dated 7/21/22 which indicated the IDT informed the resident's family members that they determined he would benefit from 1:1 supervision. The RDCS acknowledged there was no documentation to show the IDT and nursing staff followed the normal process of coordinating care with the resident's family to ensure necessary supervision was provided. The DON could not explain why multiple staff did not check the Kardex or orders prior to resident care, and why care plan interventions were not in place during observations on 8/21/22. She stated she was never informed the resident had not received his wedge cushion and acknowledged there was no interim intervention implemented. The DON stated although the resident continued to fall, she felt a 15-minute monitoring schedule was appropriate. She denied knowledge of concerns from nursing staff regarding their inability to monitor any resident every 15 minutes with an assigned workload of 10 to 15 residents, and particularly resident #2 as he was very impulsive, confused, and unsteady. The DON stated she felt it was possible if staff worked together but she could not provide details on how this could be accomplished when all staff had a full workload and also had to attend to other residents who were at risk for falls. On 8/24/22 at 4:52 PM, the ED explained the facility scheduled sufficient staff every shift to meet residents' needs according to the census and residents' acuity. She said, We have more than enough CNAs. The ED stated she was not aware staff had concerns regarding workload and their ability to monitor residents at high risk for falls when they had a full assignment. The DON acknowledged CNAs usually had up to 14 assigned residents on the 3:00 PM to 11:00 PM shift. She stated the facility exceeded the State requirements related to minimum staffing ratios and resident care hours. When asked if achieving minimum staffing ensured residents' care needs were met, she replied, I believe in providing residents with what they need. She stated she was not aware a nurse was pushing resident #2 along with her during medication administration task, and that was not her expectation of care for any resident. The DON reiterated staffing numbers and ratios did not need to be adjusted to accommodate resident #2 who required more frequent monitoring. She said, They must work together and it can be done. Review of the facility's Standards and Guidelines for ANE [Abuse, Neglect, Exploitation] and Investigations revised on 3/27/21 revealed Neglect was defined 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. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 8/23/22, resident #2 was place on increased 1:1 supervision. *On 8/24/22, resident #2 was re-evaluated by a Registered Nurse. A full body assessment revealed no new concerns. *On 8/24/22, skin evaluations were conducted to identify signs of abuse or neglect for all residents with a BIMS score of 11 or lower. *As of 8/24/22, the facility's ED/designee and DON/designee will focus on the structures and processes to ensure residents receive necessary care and services to prevent neglect, and will ensure resident safety and well-bring related to Abuse and Neglect is maintained by the continued participation, evaluation, and intervention through: stand-up and stand-down meetings, walking rounds, and resident interview, follow up to voiced concerns and grievances, monitoring for injuries of unknown origin, Resident Council, and maintaining Quality Assurance and Performance Improvement (QAPI) process. *As of 8/24/22, the facility's DON/designee will conduct a weekly audit of ten residents weekly for four weeks, and then every two weeks for two months on the components of Abuse and Neglect to include: medical record review to identify any concerns that would rise to that level, interviews and/or skin evaluations to identify allegations. *As of 8/24/22, the ED/designee and DON/designee will review findings of audits and report to the QAPI committee until substantial compliance is achieved, and monthly monitoring is recommended by the RDCO when completing systems review. *On 8/24/22, the facility held an Ad Hoc QAPI meeting to review findings related to the F600 IJ template. The Removal Plan was reviewed with and accepted by the Medical Director. Weekly meetings will be conducted until substantial compliance is achieved. *On 8/25/22, residents with BIMS scores of 12 or higher were interviewed to identify abuse or neglect. *On 8/25/22, the facility filed an immediate Federal report related to the allegation of neglect for resident #3, notified the Department of Children and Families, the physician and the resident's representative, and initiated a full investigation. *On 8/25/22, the ED and DON were re-educated by the Senior Vice President of Operations on the systems and processes to prevent and identify neglect. *On 8/25/22, the DON/designee re-educated staff on components of the regulation F600, Abuse / Neglect / Exploitation / Misappropriation / Mistreatment / Injury of Unknown Origin (ANEMMI) with indicators of Neglect. The facility's Standard and Guideline SG ANE and Investigations to include: screening, training, prevention, identification, investigation, protection, and reporting. *On 8/25/22, 114 out of 158 facility staff members were re-educated in person onsite, and 158 staff via U.S. Mail. No staff will be permitted to work without receiving in person education. Newly hired staff will receive the above education in orientation. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics listed above. From 8/23/22 to 8/25/22, interviews were conducted with 13 staff members who represented all shifts. All staff, including 6 CNAs, 2 LPNs, 3 RNs, the Activities Director and a Speech Therapist verbalized understanding of the education provided. The resident sample was expanded to include 4 additional residents at risk for falls and 2 additional residents who were at risk for elopement. Observations, interviews, and record review revealed no concerns related to Neglect for residents #1, #3, #4, #6, #7 and #8.

Based on record review and interview, the facility failed to allow resident to remain in the facility and failed to provide rationale as to why the resident's care needs could not be met by the facility for 1 of 1 discharged resident in a total sample of 9 residents, (#3). Findings: Cross Reference F689 Review of resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], a nursing progress note indicated the resident fell in her room, hit her head and was transferred to the hospital. She returned to the facility on [DATE] with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's quarterly MDS assessment with Assessment Reference Date [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The assessment showed the resident required extensive assistance of 1 staff for both bed mobility and transfers and required supervision by staff for locomotion on and off the nursing unit. The resident did not display any indications of [CONDITION(S)], behaviors and the facility assessed the resident as not to exhibit wandering. A comprehensive care plan for elopement was initiated [DATE] that noted one-to-one supervision was implemented [DATE]. On [DATE] the facility failed to provide one-to-one supervision and the resident eloped from the facility at approximately 6 PM. She was observed outside the facility, unsupervised and the staff brought the resident back inside at approximately 6:10 PM. The resident was assessed and determined to have no injuries and the resident was placed on one-to-one supervision. Review of the clinical record revealed the resident had no further elopements from the facility while she was on one-to-one supervision. A Social Service Director, (SSD) progress noted dated [DATE] noted the resident had eloped on [DATE] and a conversation with the resident's daughter followed. The note revealed the SSD informed the resident's daughter that due to exit seeking behavior, the facility would not be able to meet the resident's needs and the SSD would be sending out referrals to secure memory care Assisted Living Facilities to transfer the resident. The record revealed the resident was discharged a week later, on [DATE]. On [DATE] at 4 PM, the SSD confirmed she spoke to resident #3's daughter and that she found alternate placement for the resident. The SSD stated the resident was exit seeking and we are not an exit seeking facility. She indicated the resident's elopement was discussed at the morning meeting and the Executive Director instructed her to start looking for another facility. The SSD stated she agreed with the discharge as the resident was constantly trying to get out. The SSD stated she always tried to work with families but acknowledged she had not asked resident #3's daughter if she wanted her mother to remain in the facility. On [DATE] at 5:43 PM, during a telephone interview, resident #3's daughter spoke about how beautiful the facility was and that her mom was one of the original residents that had transferred into the facility, when it first opened. She explained her mother was unhappy to leave her roommate and that her mother had been at the facility for almost 2 years. The daughter stated she lived only 6 minutes away from the facility which was very convenient but the facility where her mother transferred to was about 45 minutes away and she was not familiar with the area. She said she was told her mother had attempted to leave many times and that is why she could not stay. She recalled the SSD told her the facility was a Health & Rehabilitation Center and it did not provide one-to-one supervision. She stated after the event, the facility staff made her mother feel, unwelcome, and they just wanted her out of the facility as soon as possible. The daughter remembered she had to make a quick decision because she had to decide where her mother was going to live. She recalled while she signed admitting papers at the Assisted Living Facility (ALF) on a Friday, the facility called the ALF and wanted her mother to transfer that day. The daughter noted she did not want her mother moved to another facility and said, she spent 12 hours in the new facility and died , so no I did not want her to be moved. On [DATE] at 2:51 PM, during a telephone interview, the Psych APRN stated the resident had erratic behaviors prior to elopement and that she had been trying to increase her [MEDICATION(S)], medication used to treat mood disorder for some time. The Psych APRN said that after resident #3 eloped from the facility, the [MEDICATION(S)] was increased from 250 milligrams three-times-a-day (TID) to 500 mg TID on [DATE]. The Psych APRN stated after increasing the medication it was possible to see the benefits in about 12 hours with decreased irritability and agitation. She was aware the resident had been discharged and added she would have liked to have seen if the [MEDICATION(S)] had reached a therapeutic level. On [DATE] at 3:50 PM, during a telephone interview, the resident's attending physician stated he was aware resident #3 had eloped from the facility and noted he had not initiated the discharge. He described the process in which the facility staff placed orders in his box and he signed them. When asked if the resident could have remained in the facility under direct supervision, he said, sure. Review of the medical record did not reveal a rationale by the physician as to why the resident's care needs could not be met at the facility.