Every finding on record at Arabella Health & Wellness of Carrabelle

Based on observations and interviews, the facility failed to provide a safe, clean, and sanitary environment at 1 of 4 hallways, 1 of 2 nurses' stations, 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), 1 laundry room, and 2 of 2 shower rooms.The findings include: Hallways: On 3/9/26 at 12:30 PM, an observation of the 400-unit hallway noted a hole in the hallway above the baseboard in between rooms [ROOM NUMBERS]. Equipment was observed sitting in the back hallway that consisted of 2 bed frames, 3 mattresses, and 2 mechanical Hoyer lifts. The handrail on the 400-unit right side has 2 areas on the corners that were missing. Nurses' stations: A large brown and yellow color stain was observed on the ceiling of the nurses' station extending from the metal vent across the ceiling to the curve of the nurses' desk where hallway splits into sections. The trim across the nurses' station desk is broken in several areas and has sharp edges where trim has broken off. The metal vent above the nurse's station appears to have a rusted like appearance, with a blackish color film on the vent grates. Resident rooms: room [ROOM NUMBER]'s bathroom has a black color film at the base of the toilet with an appearance of rust on the handrails. room [ROOM NUMBER] has a rust on the vent grates in the bathroom with a blackish film on the floor at the base of the toilet. Inside room [ROOM NUMBER], a brown color stain was observed with a small hole in the ceiling over the door side bed of the resident. Laundry room: On 03/11/26, an observation of the facility's laundry room was conducted at 09:30 AM. Buckets were sitting in the sink with a spoon sitting next to the faucet handles. A rusted bookshelf was sitting against the right side of the wall, with brooms, dustpans, and a bucket blocking access to the eye wash station. Two maintenance ladders were leaned up against the left side of wall upon entry to the laundry area. The ceiling has the appearance of peeling paint, greyish color stains, rusted like appearance on the door hinges leading to the outside. Rusted grates behind the washing machines were noted with paint peeling on the wall directly above it and has the appearance of water damage along the baseboards extending from the right to the left side and on the wall directly above the floor. While doing this observation, Staff Member H (Laundry Aide) stated, Don't step off the cement or you will fall through the grates in the back. Peeling paint from the ceiling with the appearance of water damage surrounding the light fixture in room was noted. The linen closet's back wall has an interior covering peeled away from the wall. Staff Member H stated, The leaks and water damage has been like that since about 5 months ago. Shower rooms: On 3/11/26 at 10:45 AM, an observation was conducted on the Unit 300-400 shower room. A hole in the wall behind the door was observed with broken tile and the wall inside was exposed. The last shower stall had paint peeling from the ceiling. Wet, soiled towels were laying on the floor in a shower stall. A shower bed with a foam pad sitting in the bathroom area blocked the toilet. The shower bed pad has visible tears on the top surface of the pad and the bottom side of the shower pad. Upon lifting up the foam pad from the shower mesh bed, visible debris was noted. Staff Member F (a Certified Nursing Assistant, CNA) entered the shower room. An interview was conducted that revealed, upon asking how long the hole in the wall has been there, Staff F stated, I am not sure, a while now. He then stated, Are you all here to help us get these things fixed around here, we sure need it. When asked how often staff cleans the shower chairs, shower beds, and pads, he stated, we are supposed to do it after each use. On 3/11/26 at 11:00 AM, an observation of the shower room for halls 100 and 200 revealed a tub that sits on the right-hand side of the shower room that has trash and a pair of shoes and a pair of boots sitting in the tub. The inside of the tub is visibly dirty with a greenish color film noted around the top of the tub near the drain, rusted shower curtain hooks hanging on 2 shower stalls, and black tape on one of the arms of a shower chair noted. The shower chair had a black color substance noted around the screws and connections. A black substance on the tile floor in a shower stall with a greyish color build up on the shower bench legs. Upon exiting the shower room, a shower bed was noted with a foam pad noted in the doorway of a resident's room with visible tears in the foam pad. A black color substance was observed on the rails of the shower bed at the top. Upon lifting the foam pad up from the shower mesh bed, tears in the pad were noted on the bottom side of pad, along with discoloration and the mesh bed has visible debris observed. The Assistant Director of Nurses was interviewed. She stated, The shower beds are cleaned after each use. She is not sure how often the shower pads are replaced. An interview was conducted with the Maintenance Director on 3/11/26 at 11:00AM. He stated that all the equipment in the back hallway was broken, and they have no storage area to store equipment until it can be discarded. He stated that he is trying to repair as he can, but many of the issues existed before he came on board. An interview with the Administrator was conducted on 3/11/26 at 02:30 PM. She stated that she is aware of the environmental concerns. She stated that the facility has not had any maintenance personnel until the last 2 months. She stated corporate people come to the facility to assist with things as well the maintenance director. In the fall of 2025, they had a leak that caused a lot of the water damage to ceiling above the nurses' stations. The leak was fixed, but they just need to work on the cosmetic issues.

Based on observation, interview, and policy review. the facility failed to ensure the ice machine was cleaned and maintained in safe operating condition for 1 of 1 ice machines in facility. The findings include:On 3/9/26 at approximately 11:38 AM, the initial kitchen tour revealed an aged ice machine with speckled reddish-brown areas on the outside. [NAME] discoloration covered the strip of paneling above the black lid along the entire border. Black and brown substances covered the top and the seams of the upper unit inside the actual ice storage compartment. [NAME] discoloration extended downward intermittently along the walls. Water leaked from under the machine and pooled on the tiles underneath. On 3/09/2026 at approximately 1:06 PM, an interview was performed with the Regional Certified Dietary Manager (CDM). She acknowledged the discolorations and agreed the ice storage needed cleaning. On 3/10/26 at approximately 3:15 PM, a follow-up observation was conducted on the ice machine. Staff had significantly reduced the black and brown stains. Some black substance still appeared along the ceiling and seams inside the ice storage compartment. The CDM stated that staining caused the remaining black substance to resist removal during the cleaning.

Based upon observations, interviews, and record reviews, the facility failed to ensure a resident received appropriate care and services for 1 out of 19 residents reviewed. (Resident #23) The findings include:A record review was conducted for Resident #23 on 3/10/26 at 01:00 pm. Resident #23 was admitted to the facility on [DATE]. Current physician orders revealed that compression stockings were to be worn on bilateral lower extremities before getting up out of bed and were to be removed when back in bed every day for edema. Upon review of the medication and treatment records, compression stockings are documented as being completed. An additional physician's note dated 1/26/26 revealed orders from the vascular physician for Resident #23 to wear stronger knee to hip compression stockings. (photographic evidence obtained)On 3/10/26 at 08:30 AM, an observation was conducted for Resident #23, who was awake and alert, sitting in his wheelchair, but no compression stockings were noted on the bilateral lower extremities. At 12:30 pm, Resident #23 was once again observed in his wheelchair without compression stockings on. Additional observations conducted on 3/11/26 at 8:45 am and 1:09 pm revealed Resident #23 not wearing his ordered compression stockings.An interview was conducted with Nurse D on 3/10/26 at 04:30 pm. She stated that Resident #23 refuses to wear his compression stockings at times. She admitted she checked it was completed on the medication record by mistake. An interview was conducted with Resident #23 on 3/11/26 at 8:45 AM, who stated, I would wear the stockings if the facility had them, but they have not had any for the last several weeks. An interview with the Central Supply Staff person was conducted on 3/11/26 at 11:30 AM. She states that the nurses told her a couple weeks ago that Resident #23 needed new compression stockings; however, he wears a size 3 extra-large and they do not keep that size in stock. She stated they have ordered the size he needs, but they will not be in until Friday. The Central Supply staff confirmed that the facility has been out of the size needed for Resident #23 to wear for the last two weeks.

Based on record review and interview, the facility failed to refund money owed to family after the resident expired for 1 out of 3 clients sampled. (Resident #1) The findings include: During a record review of Resident #1's closed file, it was discovered that on [DATE], Resident #1 expired and had a balance of $2,275.00 with the facility after all accounts were settled. On [DATE] at approximately 11:20 AM, the resident's Power of Attorney (POA) was called for an interview. She stated she had been calling the facility to inquire about the refund on a weekly basis for several months after the resident's death. She also stated it was confirmed by the Business Office Manager that money was in fact owed to the family and the money would be refunded soon and sent to her. The POA stated this never happened. Despite repeated calls and emails to local and corporate contacts, she never received a call back. On [DATE] at 11:47 AM, an interview was held with the Business Office Manager and the Facility Administrator. When asked about the refund, the Business Office Manager stated that she was aware it was very late. She had done her part by sending the request to corporate to process the refund, but it had not been done. The Business Office Manager stated that she has been in that position since [DATE] and has been working on getting this refund done since, but does not have the capability to actually sign off on the refund. The process is to send the request to corporate accounts payable, but that position was vacant for a while. The Facility Administrator stated, I understand her frustration, this did take so much longer than it should have. She also stated that that is not the usual time frame, and all refunds should go out within 30 days. On [DATE] at approximately 2:00 PM, the facility received a check from the corporate office and the Administrator stated that she was going to insure the resident's family received the refund. A review of the facility's Procedure called, Conveyance on Residents Funds Upon Death, revealed that the facility will process a refund within 30 days as provided by State law. A review of the Admission Packet stated on the second page, under section C. Security deposits C/3 Moneys paid on behalf of the Resident for services not used shall be refunded to the Residents within thirty (30) days after discharge provided financial balances due for all charges have been paid in full. Any outstanding balanced owed to the facility will be deducted from the refund. In the event of a Residents death, all refund checks will be made out to the Residents estate.

Based on observation and interview, the facility failed to ensure resident furniture was maintained in good repair for 4 of 59 residents observed (Residents #31, #36, #42, #46). The findings include: On 4/18/2022 at approximately 12:00 PM, an initial interview and observation was conducted with Resident #31. The wardrobe closet in Resident #31's room was dented, had pieces of wood protruding, and had a door that was hanging by only one hinge. When asked about the condition of the wardrobe Resident #31 stated, Yeah, it's been like that for a while. The drawer below the closet is hard to open because the door is hanging like that. On 4/18/2022 at approximately 12:30 PM, an initial interview and observation was conducted with Resident #36. The door of Resident #36's wardrobe closet had been completely removed and was sitting beside the wardrobe. When asked about the condition of the wardrobe Resident #36 stated, The door was only hanging by one hinge and I couldn't get into the drawer below it. They weren't fixing it, so I just took matters into my own hands and asked for a screwdriver and removed the door myself. On 4/20/2022 at approximately 9:20 AM, Residents #42 and #46 were observed in their room. The wardrobe closet was observed to have double doors and lower double drawers. At the midsection of both of the double doors, the veneer was separated from the rest of the door, and both of the drawers were very difficult to open. On 4/21/2022 at approximately 8:50 AM, Resident #42 voiced that it was difficult to open the bottom drawer of the closet. On 4/20/2022 at approximately 2:00 PM, an interview was conducted with the Administrator who confirmed she was aware of the damaged furniture. She reported a request had been made to corporate office for replacements. The surveyor informed her some undamaged wardrobes were observed in unoccupied rooms during a tour of the building. She stated she would look into trying to move some unbroken furniture into any rooms currently inhabited by residents.

Based on observation, staff interview and record review, the facility failed to ensure 1 of 11 vulnerable residents at risk for elopement (Resident #49) was not able to exit the building unsupervised on 2/17/21. Additionally, on 3/14/21, the facility failed to ensure all entry/exit doors were closed and secured to prevent subsequent elopements for all residents at risk for elopement (Residents #208, #11, #22, #24, #35, #26, #42, #51, #49, #28, and #31). The facility's failure to prevent an elopement and eliminate potential hazards placed 11 residents at a likelihood of serious injury and death. The facility is located inside a golf course community and the surrounding neighborhood is heavily wooded, occupied by wildlife, and has ponds in various areas on the golf course. The facility is located approximately 3 blocks from Highway-98 which is a heavily traveled 2-lane highway along the Apalachicola Bay with a speed limit of 55 miles per hour. The north side of the highway is lined with wooded areas and the south side of the highway runs alongside the bay. One of the facility entry/exit doors was not fully closed or secured and residents had the potential to exit unsupervised. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/17/21. The facility Administrator was notified of the Immediate Jeopardy finding on 3/17/21 at 6:28 PM, prior to survey exit on 3/18/21. The Immediate Jeopardy was determined to have begun on 2/17/21, the day Resident #1 exited the building unsupervised. Immediate Jeopardy was found removed on 3/17/21 when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity level of a D. The findings include: On 3/14/21 at approximately 12:00 PM, the survey team found the primary entrance door to the facility was located at the rear of the building for visitors and staff. The facility was maintaining a single entrance to ensure Coronavirus Disease 2019 screening for anyone entering the building. The entrance door was not completely closed or locked. The team was able to open the door and enter the facility. No staff were observed in the area monitoring the entrance. This entry/exit door was accessible by all residents through the 100-200 hallway and facility central courtyard area. (Photographic evidence obtained) The survey team proceeded to the nursing station on the 300-400 hallway and observed Resident #49 ambulating in the hallway and around the nursing station. The following similar observations of Resident #49 were made later that day and throughout the survey: On 3/14/21 at 1:24 PM, Resident #49 was observed gently kicking the door with her foot and trying to open the exit door at the end of 400 hallway. On 3/14/21 at 2:00 PM, Resident #49 was observed exiting the dining room side door out to the courtyard area. On 3/14/21 at approximately 3:00 PM, Resident #49 wandered into Resident # 15's room. On 3/15/21 at 1:00 PM, Resident #49 was observed following staff down the main entrance hallway and was redirected back to her hall. On 3/15/21 at 2:35 PM, Resident #49 was observed on the 400-hallway wandering up and down the hallway looking in resident rooms. Further observation revealed the resident proceed to the door and put her hands on the handlebar. On 3/16/21 at 12:30 PM, Resident #49 was observed ambulating in halls with 1:1 staff supervision. Resident #49's Admission History and Physical dated 8/19/20 and Baseline Care Plan dated 8/13/20 revealed the resident was a vulnerable adult due to memory deficits, decreased safety awareness, and exit seeking behaviors. Based on these concerns, the facility placed the resident on 15-minute checks. Resident #49's Quarterly Minimum Data Set (MDS) assessment tool dated 2/19/21 revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of the facility elopement investigation dated 2/17/21 and Interdisciplinary Team (IDT) meeting conducted on 2/18/21 revealed that on 2/17/21 the resident was last seen in the facility by her assigned Certified Nursing Assistant A (CNA A) at 12:45 PM. At 1:00 PM, CNA A attempted to locate the resident but could not find her. At 12:58 PM, Resident #49 was observed walking west on the north side of Highway-98 by the facility's Occupational Therapist while driving east toward the facility. The resident was then returned to the facility without injury. The facility began one to one (1:1) direct supervision for 24-hours for Resident #49, and then resumed the prior 15 minute checks supervision. Highway-98, the road the resident was found on, runs along the Apalachicola Bay and has a speed limit of 55 miles per hour. The facility is located approximately 3 blocks from Highway-98 and is surrounded by a heavily wooded area that includes ponds and wildlife. On 2/17/21, Resident #49's Care Plan and Elopement Risk Assessment were updated to reflect that the resident was determined to be a 10 on a 1-10 elopement risk scale (highest level of risk) and was noted to push on doors attempting to exit. On 2/21/21, Resident #49's Psychiatrist examined the resident and revealed the resident stated she was wanting to call her family and leave. A review of the facility's Elopement Policy with a revision date of 4/2/2018, revealed an elopement assessment score of 4 or higher identifies the resident as an elopement risk. A review of the facility wide Elopement Assessments dated 2/17/21 identified 11 residents #208, #11, #22, #24, #35, #26, #42, #51, #28, #49 and #31, with a risk score of 4 or higher. These 11 residents were present in the facility at the time of the survey. On 3/14/21 at approximately 12:40 PM, the Director of Nursing (DON) was informed of the survey team's finding of the unlocked and unsecured facility entrance at 12:00 PM. The DON indicated the facility's existing process was for staff to call a posted number on the outside of the door and then someone on the inside would access the code pad on the inside and allow entry. She indicated the facility had some staff that would go outside on break and would not pull the door fully closed behind them to allow to re-entry without alerting anyone. On 3/16/21 at 8:30 AM, the DON and Administrator revealed Resident #49 was placed on 1:1 supervision again and after discussion with the resident's family, referrals for potential transfers to facilities with secured units had been pursued. Additionally, the DON indicated the entrance to the facility had been moved from the rear of the building to the side door next to the 100-200 hallway nursing station for better visual surveillance and security. On 3/15/21 at 1:10 PM, an interview was conducted with the Occupational Therapist who stated she saw Resident #49 on Highway-98 walking on the grass on the side of the road. She further stated that she notified the DON and drove the resident back to the facility. The Occupational Therapist was asked about the resident's typical behaviors and she replied that the resident wanders around and tries to open doors. The therapist stated that when this occurs she tries to redirect her with a snack or other activity. On 3/16/21 at 9:00 AM, CNA A stated, she (Resident #49) is always trying to get out the doors. On 3/17/21 at approximately 1:30 PM, a telephone interview was conducted with Resident #49's physician who stated the resident was continuously pushing on the doors and trying to get out. The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions. Interventions immediately following the elopement on 2/17/21 that were implemented prior to the survey team's entrance included the following: On 2/17/21 the facility conducted a head count of all residents. This was verified through interview with the DON. On 2/17/21 a Licensed Practical Nurse (LPN) performed a full body assessment on Resident #49 and notified the physician of the elopement. This was verified by record review of the full body assessment dated [DATE]. On 2/17/21, the facility contacted the Psychiatric MD who placed Resident #49 on 1:1 direct supervision for the next 24-hours and then 15-minute checks thereafter. This was verified by record review of the resident's orders. On 2/17/21 the Social Service Director notified the resident's family of the elopement. This was verified by record review of social service notes. Interventions following facility notification of the unsecured door: On 3/14/21 at approximately 12:30 PM, the DON immediately secured all doors. This was verified by the survey team testing each door in the facility on 3/14/21 and at random times on 3/15/21, 3/16/21, 3/17/21, and 3/18/21, including immediately after the facility experienced a loss of power on 3/18/21. All staff who were working in the building at the time of the survey team's entrance, as well as all staff (including Agency) from other shifts, were reeducated on conducting door checks and the door securement plan throughout 3/14/21 and 3/17/21. Training was verified as completed on 3/17/21. The survey team reviewed training documentation, in-service sign-in logs, and interviews with 8 staff members. On 3/15/21 at 5:00 PM, an ad hoc Quality Assurance Committee Meeting was held to address residents at risk for elopement and door securement. Relocation of the exit door, changing the codes to all exit doors, referring Resident #49 for more appropriate placement outside the facility in conjunction with the family, and assigning the resident to 1:1 direct staff supervision was all discussed. The committee reviewed these new interventions and the results from the monitoring up to that point and agreed to move forward with this the plan of interventions. This was verified through interview with the Administrator and DON as well as record review of the attendance sheets. On 3/15/21 at 5:00 PM, the entrance and exit door was relocated to the side door by the 100-200 hallway for closer monitoring, which is within sight and sound of floor staff at all times. This was verified by observation of facility staff entering and exiting exclusively through this door for the duration of the survey. On 3/15/21 at 5:00 PM, a staff member was assigned to provide 1:1 direct supervision to Resident #49, effective immediately. This was verified by observations obtained throughout the remainder of the survey of the resident being under 1:1 direct supervision by staff. On 3/17/21 the facility assessment was updated to include that the facility does not have a memory care unit and cannot sustain long term 1:1 direct supervision. This was verified by record review of the revised Facility Assessment. On 3/17/21 the facility identified that her needs could not be met in the facility and the process of seeking appropriate placement at another facility was initiated in conjunction with the resident's representative. This was verified through interview with the Social Services Director (SSD) as well as observation of the SSD on the telephone with Resident #49's family discussing options for relocation and transportation. On 3/17/21 at 11:00 AM, the frequency in which door checks were conducted was changed from daily to every 2 hours. The Administrator and DON assign the task every shift. Completion of the task is documented on the form titled Door Securement sheet and includes date, time, proper function of all exit doors, and a signature. This was verified by record review of the Door Securement sheets and observation during the survey.

Based on observation and staff interview, the facility failed to ensure food safety by failing to prepare food in a sanitary environment for 58 out of 61 residents who consume food from the facility kitchen. The findings include: On 3/14/21 beginning approximately 12:30 PM, an initial tour of the kitchen was conducted. At the time of this tour observations of the ceiling, ceiling vents and walls was conducted. The ceiling vents located over food preparation areas were observed to have bubbling and peeling paint and black biological growth. The walls near the entrance that leads to the dining room and close to the dishwashing machine area were observed to be separating at the junction, were warped and had broken areas exposing the area behind the walls. This same area had broken, missing tile/brick base boards. (Photographic evidence obtained) On 3/16/21 at approximately 1:33 PM, an interview was conducted with the Administrator who stated the condition of the ceilings, vents and walls in the kitchen was ongoing since she had become the Administrator in December of 2018. The Administrator stated the former Maintenance Director would make repairs such as cleaning and painting on a routine basis but had not made a full repair of the issues. The Administrator stated Corporate offices toured the facility and were going to make renovations of the kitchen and were going to send out their own contractors but due to Coronavirus Disease 2019, the repairs did not take place. On 3/16/21 at approximately 1:43 PM, an interview was conducted with the current Maintenance Director who stated a contractor visited the facility on 3/16/21 at 7:00 AM to inspect the kitchen to provide an estimate for the repairs. The Maintenance Director stated the estimate should arrive no later than Tuesday and the repairs would begin shortly after. When asked when he had contacted this contractor, the Maintenance Director stated he contacted them 10 minutes after speaking with this surveyor the night before.

Based on observation, staff interview, resident interview and record review, the facility failed to ensure a viable discharge location was documented on the discharge notice and failed to ensure the reasons for discharge were documented in the resident's medical record by a physician for 1 of 1 sampled residents, #1. The findings: On 03/15/2019 at approximately 10:30am, Resident #1 was observed at the facility in bed, and had a custom-fit motorized wheelchair charging in his room. An interview was conducted at that time in which he stated he did not want to leave the facility but could go stay with his parents in Central Florida. He stated that there was another facility which had already accepted him and that would be okay too. He stated that he would make it work if he had to leave but was told by the Ombudsman that he would not be discharged in the end if he went to anger management and followed the rules. He stated he did not want to leave the facility and agreed he would comply with the rules if he did not have to leave. A clinical record review for Resident #1 revealed he was an alert and oriented [AGE] year old male who was admitted to the facility in (MONTH) of 2013. A partial listing of [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] was conducted. Section G, Functional Status, showed that Resident #1 had total dependence with 2+ persons physical assist for bed mobility, transfer, dressing, and total dependence with 1 person assist for toilet use. Resident #1 required extensive assistance with 1 person for personal hygiene. Under section E, Behavior, the MDS documented that Physical behavioral symptoms directed toward others was not exhibited, but verbal behavioral symptoms directed toward others occurred during 1-3 days, and other behaviors symptoms not directed toward others occurred on 4-6 days, but less than daily. Per the MDS, the behaviors did not put either the resident or others at risk for physical illness or injury. The MDS also documented that the behaviors did not the significantly interfere with care or activities or intrude on the privacy or activity of others. The behaviors did significantly disrupt care or living environment. The resident's current behavior status was noted to be worse compared to the prior assessment. A record review was conducted of the 'Nursing Home Transfer and Discharge Notice' issued on 02/13/2019 to Resident #1. The effective date of discharge was 03/13/2019. The discharge location was the home address of the resident's mother. The reasons for discharge were listed as, The health of other individuals in this facility is endangered and The safety of other individuals in this facility is endangered. Under the section for 'Brief explanation to support this action', the facility documented, Refusing to follow tobacco policy, aggressive in motorized wheelchair. The physician signed the form on 02/13/2019. An interview was conducted with the Social Service Director (SSD) at approximately 11:00 am on 03/15/2019 in which she stated that it is often difficulty to get the residents family to communicate with the facility, she states she is working with the residents case worker regarding a well check by the sheriffs department to ensure this is an acceptable location for the resident to go to. A call was placed to the discharge location on 03/15/2019 at approximately 10:45 am and again at 1:00pm. There was no answer, and voice messages were left, but no return call has been received. A review of the resident's medical record regarding the viability of the discharge location was conducted. On 02/13/2019 at 5:00pm, a Social Service Note documented, Resident refused to sign saying he could not discharge to his mother's address. In the same entry, the SSD also documented that 3 attempts were made to call the discharge location and voicemails were left. No documentation was found stating that the discharge location agreed to accept the resident. Additionally, the SSD documented that she contacted the Sheriff's office to conduct a wellcheck of the discharge location, but the Sheriff's office stated they do not do wellchecks on property, only people. A review of the medical record on 03/15/2019 failed to find physician documentation regarding the reason for the discharge. After the survey exit, on 04/02/2019, an interview was conducted with the SSD and a request was made for any physician documentation supporting the discharge. The facility submitted a packet, but no physician documentation was included except for the physician signature on the discharge notice.

Based on observation, staff interview, resident interview and record review, the facility failed to ensure the medical record contained required physician documentation regarding a facility-initiated discharge for 1 of 1 sampled residents, #1. The discharge notice issued to resident #1 alleged that both the resident's clinical and behavioral status endangered residents in the facility. The findings: A record review was conducted of the 'Nursing Home Transfer and Discharge Notice' issued on 02/13/2019 to Resident #1. The effective date of discharge was 03/13/2019. The discharge location was the home address of the resident's mother. The reasons for discharge were listed as, The health of other individuals in this facility is endangered and The safety of other individuals in this facility is endangered. Under the section for 'Brief explanation to support this action', the facility documented, Refusing to follow tobacco policy, aggressive in motorized wheelchair. The physician signed the discharge notice on 02/13/2019. A review of the medical record on 03/15/2019 failed to find physician documentation regarding the reason for the discharge. After the survey exit, on 04/02/2019, an interview was conducted with the Social Services Director (SSD) and a request was made for any physician documentation supporting the need for discharge. The facility submitted a packet, but no physician documentation was included except for the physician signature on the discharge notice. On 03/15/2019 at approximately 10:30am, Resident #1 was observed at the facility in bed, and had a custom-fit motorized wheelchair charging in his room. An interview was conducted at that time in which he stated he did not want to leave the facility but could go stay with his parents in Central Florida. He stated that there was another facility which had already accepted him and that would be okay too. He stated that he would make it work if he had to leave but was told by the Ombudsman that he would not be discharged in the end if he went to anger management and followed the rules. He stated he did not want to leave the facility and agreed he would comply with the rules if he did not have to leave. A clinical record review for Resident #1 revealed he was an alert and oriented [AGE] year old male who was admitted to the facility in (MONTH) of 2013. A partial listing of [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] was conducted. Section G, Functional Status, showed that Resident #1 had total dependence with 2+ persons physical assist for bed mobility, transfer, dressing, and total dependence with 1 person assist for toilet use. Resident #1 required extensive assistance with 1 person for personal hygiene. Under section E, Behavior, the MDS documented that Physical behavioral symptoms directed toward others was not exhibited, but verbal behavioral symptoms directed toward others occurred during 1-3 days, and other behaviors symptoms not directed toward others occurred on 4-6 days, but less than daily. Per section E0600, Impact on Others, the behaviors did not put others at significant risk for physical injury, but the behaviors did significantly disrupt care or living environment. The resident's current behavior status was noted to be worse compared to the prior assessment. An interview was conducted with the director of nursing (DON) on 03/15/2019 at approximately 9:30 am in which the DON stated the resident has been crashing his wheelchair into staff and other residents, she stated the chair is his means of transportation and they felt it was against his rights to take the chair from him. He has agreed to anger management therapy after intervention with the Ombudsman. She stated that they have done everything in their power to accommodate resident #1 and he has continued to break the rules, we do not want to discharge him, but we are unsure what other means to prevent him from hurting staff and other residents. A record review from (MONTH) (YEAR) through (MONTH) 2019 found 2 entries where the resident was aggressive with the motorized wheelchair. Both incidents were directed at staff and occurred about 1 year apart, on on 02/09/2019 and the other on 02/10/2018. Neither note documented actual contact or injuries. The record review also identified 3 incidents where the resident was found vaping in his room on 2/8/19, 2/22/19 and 2/26/19. The facility had previously reviewed and signed the smoking contract with Resident #1 on 1/4/19. An interview was conducted with the resident, the Director of Nursing, on and the Administrator at approximately 12:30 pm on 3/15/2019 in which all agreed to a solution of the DON locking the vape up in a locker and charging it daily for him so it is accessible and charged when he wants to go outside to smoke. He agreed to this, not to vape in his room and to go to anger management therapy as suggested by the Ombudsman. All are in agreement and stated they would draw up a contract and all sign and the resident could resident in the facility. A subsequent interview was conducted with the SSD on 4/02/2019 at approximately 10:13am. The SSD stated that the discharge notice had not been rescinded at this time, but the facility was actively looking for another discharge location because they understood that the current discharge location was not an acceptable plan.

Based on observation, family and staff interviews, review of the maintenance logs, and policy review, the facility failed to ensure that residents' hospital beds were maintained in safe operating condition by ensuring beds were secured and in locked position at all times. The facility also failed to ensure that locking mechanisms were functioning for three out of four halls in the building. The findings included: On 10/9/2017 at 6:09pm, a family interview was conducted for resident #45. During the interview, the family member voiced concern regarding the resident's bed not being locked and moving when the resident was transferred to the bed from his wheelchair which resulted in a fall in May or June of 2017. Injuries from that fall included scratches on the resident's back. The family member stated that he had spoken to the Maintenance Supervisor regarding the bed not locking and was told that parts for the beds were being ordered as the locking mechanisms were not functioning on some of the beds. The family member also stated he was informed by the Maintenance Supervisor that the beds were being replaced as they were old. On 10/10/2017 at approximately 9:30 AM, resident #45's bed was checked and found it could be easily moved when touched. The Unit Manager confirmed that the bed was moving and stated it was not locked. During the observation, the facility's administrator entered the room and verified that the bed was not locked and after the nurse locked the bed she and the administrator noted that the bed could still be moved even with the wheels locked. On 10/10/2017 an interview at approximately 9:40 AM was conducted with Staff A, a licensed practical nurse (LPN), who stated the beds have been a concern for the year and a half that she has been employed at the facility. She revealed she had spoken to the Maintenance Supervisor on many occasions regarding these concerns as well as the Administrator. She was aware that new beds had been ordered. She also stated that she was not aware of any resident falling as a result of the beds being unlocked. On 10/10/2017 at approximately 9:45 AM an interview was conducted with the Unit Manager for 100 & 200 Halls, which she stated that there had been concerns with the beds for a while and that the Maintenance Department and the Administrator were aware. She stated when staff found equipment that was not functioning or in need of repair those concerns were put on the maintenance log and the maintenance staff would check off when the issue was resolved. She stated that previous month's requests are usually kept in the Maintenance log book, but she was unable to locate them at the time of the interview. On 10/10/2017 at 10:00 AM, an interview was conducted with the Unit Manager for the 300 & 400 Halls, who stated there had been issues reported to maintenance in the past related to the beds not locking. She stated these concerns had been noted on the Maintenance logs which were kept at each nursing station. The Unit Manager provided this surveyor with the book for her station, and she stated that when a concern was identified that required maintenance, the staff would make a note on the log. When asked about logs for the previous months she stated they are in the back. The sheet in the front of the book had 9-28-2017 to 10-9-2017. She then attempted to locate the previous months logs and stated he must have taken them out, but they are usually there referring the Maintenance Supervisor. She stated that she announced in morning meetings whenever she had concerns related to maintenance to ensure her concerns were heard by the administrator and the DON. She stated that was how she ensured that issues on her halls were addressed timely. She stated that she was aware that new beds had been ordered but was not aware of when they would be arriving. A review of the Maintenance Log for the 300 & 400 halls found an entry dated 9-28-17 that stated the bed in room 411D was not locking and a check indicating that the issues was resolved. Maintenance Log reviewed for halls 100 & 200 found the following notation on 10/10/2017 Concern 110A - Door; No noted locks on front of bed/or they don't work 108W - No noted locks on front of bed/or they do not work Under these two entries was written ALL BEDS L(NAME)K and these three entries were circled and each entry had a check marked in the final column noted the issued had been resolved. On 10/11/2017 at 12:44 PM, an interview was conducted with the Maintenance Supervisor who stated that he had no knowledge of the beds being broken prior to the surveyor's arrival to the facility on [DATE]. He stated that he has never had a conversation with any family member regarding the beds being broken or needing to be replaced. He stated that he has been called to resident's room for the beds moving but found the beds to be unlocked at the time and simply locked the beds. When asked about the bed in room 411 being identified on 9/28/2017 as not locking on the maintenance log he stated that he found the bed to be unlocked and not broken and that is why he checked it as being resolved. When asked if the bed moving despite the wheels being in locked position was considered a broken locking mechanism he stated they were old. When asked about the comment written in all caps on the maintenance Log ALL BEDS L(NAME)K he stated that all the beds are locked and he is not aware of any of the beds not locking. When shown the bed in room 110D not being locked he stated that he felt the bed was in proper working order despite the fact that the bed did not have locking mechanism that were working. When asked to provide the surveyor with previous maintenance logs he stated I threw them out. An interview was conducted with the facility administrator on 10/11/2017 at approximately 2:30 PM. He stated that 57 new beds had been ordered on [DATE] and that he was not sure when the beds were to arrive at the facility. He stated he was not aware that the beds in the facility were required to be locked and did not feel this provided a safety concern to the residents. When ask why the new beds were ordered he stated it was due to the age of the current beds and not due to safety concerns. A review of the facility's policy titled, Fall Prevention and Fall Management dated April 2010, found the following requirement ensure that bed and wheelchair locks are in working order. A follow up interview was conducted with the Administrator on 10/12/2017 at approximately 9:00 am. He was asked if he considered it a standard of practice to maintain beds in locked position in order to prevent falls and to maintain resident safety and he stated that he would consider it a standard of practice however, he did not believe it was a regulation or within the facility's policy.

Based on observation, interview, and record review, the facility failed to ensure the call system was functioning in all areas for 3 of 33 rooms sampled for call lights. The findings included: On 10/11/2017 at approximately 11:55 AM, a check of the call light system in room 108 found that the call lights for both beds in the room were not functioning. This was verified by the Unit Manager who pressed the call light as the surveyor stayed outside room to see if the light illuminated. She stated I thought that had been fixed. At this time she was asked to demonstrate the call light for room 105W. Upon entering the room the nurse pressed the call light for the bed closest to the window and found it to not be working. She stated that these concerns had been reported to maintenance and that she thought the call lights had been repaired. A review of the maintenance log for the 100 & 200 halls found there to be concerns with call lights not working in three areas. On 10/8/2017 a note was written resident stated call-light was broken. I fixed it but ya'll need to check it. On 10/10/2017 a concern was noted indicating the call light outside of room 108 did not work. Both areas were noted to have check marks indicating the issue had been resolved. On 10/11/2017 at 1:00 PM, an interview was conducted with the Maintenance Supervisor, in which, he was asked about the call lights in the rooms identified on 10/10/17 on the maintenance log as not functioning. He stated that he was not aware that the call lights were not functioning and that there must be an intermittent concern. He stated that he had checked the call lights for this hall on 10/2/17 and found them all to be working and that he would fix the identified call lights. When asked why there was a check mark indicating the issue had been resolved on the maintenance log he replied I'll fix them today.

Based on staff interview, record review, and policy review, the facility failed to allow a resident to return to the facility following a Baker Act for 1 of 1 residents sampled for Admission, Transfer & Discharge Review (Resident #30). The findings were: A review of the medical record for resident #30, admitted to the facility on [DATE], was conducted, and revealed a Baker Act transfer was facilitated for resident #30 on October 4, 2017. Social services notes in the resident's record indicated that resident #30 was Baker Acted after punching an elderly female resident in the face because she had accidently stepped on his foot. Resident #30 was transferred from the facility to a Baker Act receiving facility on 10/4/17 where he was evaluated by clinical staff. An interview was conducted with a clinical staff member at the receiving facility who stated that they had received resident #30 and he had a psychiatric evaluation completed by the receiving facility's psychiatrist. The evaluation showed that the resident was stable and calm, and presented no immediate danger to himself or others. The receiving facility declined to admit resident #30 as he had not demonstrated any unprovoked aggression and did not have any clinical indicators that further psychiatric treatment was needed. An interview was conducted with the Administrator on October 11, 2017 at approximately 3:12pm. He stated, We are not going to take him back to the facility because he is a threat to other residents and the medical doctor here does not want him back as a patient. A review of the facility's policy entitled Discharge Planning Policy with a revised date of April 6, 2017 was conducted. The policy states, When facility transfers or discharges a resident for any circumstance, the discharge/transfer must meet the regulatory requirements for transfer/discharge.

Based on observation, staff interview and policy review the facility failed to ensure staff handled and processed linens in a manner to minimize the risk of spreading infections during 1 of 2 observations of the onsite laundry operations. The findings include: An observation of laundry activities was conducted on 7/14/16 at approximately 10:45 AM. Employee B was working in the laundry. Employee B was observed to pick up linen from the floor with her bare hands and hold it close to her body touching her clothing. She was then observed to fold a pink sheet and allowed the sheet to touch the floor and her clothing. An interview was conducted with employee B on 7/14/16 at approximately 10:45 AM during the observation. Employee B stated she usually worked in housekeeping and had some training for the laundry. She confirmed she would usually wear gloves to handle soiled linen and she did not know linen should not touch clothing. She stated she did not know how to handle soiled isolation linen and had not been trained to do so. There were 2 current residents on isolation for Clostridium difficile toxin. An interview was conducted with employee E (the station 2 unit manager) on 7/15/16 at approximately 10:20 AM. Employee E confirmed the facility was unable to produce any evidence of audits or surveillance regarding handling and processing of linen in the onsite laundry. The facility policy for Laundry Bedding Soiled was reviewed on 7/15/16. The policy stated soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen.

Based on review of facility staffing patterns and resident and staff interviews the facility failed to provide adequate staffing to meet the needs of the residents. The findings are: On 07/11/2016 at 10:41 AM an interview was conducted with resident #2 who stated that there was not enough staff at night and it was really bad. On 07/11/2016 at 10:50 AM an interview was conducted with resident # 54 who stated that the facility did not have enough staff and he has had to wait as long as an hour to get assistance and sometimes it takes so long that he forgets what he needed by the time they get there. On 07/12/2016 at 11:26 AM an interview was conducted with resident #1 who stated that she did not feel like the facility had enough staff and she has to wait a long time to get help and it gets worse after noon. On 07/12/2016 at 5:26 PM an interview was conducted with resident #37 stated that the night shift does not help her. She stated that sometimes they don't even respond to her call light. She said that normally she has to press the light more than once to get someone to come help her, and that there are only two staff on the unit at night and it is not enough. She stated that on more than one occasion she has had accidents in the bed because she was not able to get anyone to help her to the restroom and she was not able to get up and go on her own. She also stated that when these accidents have occurred, she has also had to lay in her bed in her own waste for significant periods of time before she can get staff to come assist her to clean up. She stated that on 7/11/16 she was having trouble going to sleep and she pressed her call light to get the nurse to give her a sleeping pill that she stated she had ordered. She stated that she called several times using her call light but stated that no one ever came and she was not able to get much sleep. On 07/12/2016 at 5:43 PM an interview was conducted with resident #16 who stated that sometimes she had a hard time getting help. She stated that her wait time after using her call light was normally about twenty minutes and stated that it seemed to be worse at night but also happened during the day. She stated that there was just not enough staff for everybody to get what they need. On 07/13/2016 at 12:19 AM an interview was conducted with staff member G who stated that most often there are only two certified nursing assistants (CNAs) for Station One but stated that normally there are always three CNAs on Station Two. She was asked if that was because of the acuity of patients and stated that she thought that was why it was originally like that but stated the acuity of the stations is about the same now and stated that she didn't think administration realized that. On 07/13/2016 at 12:27 AM an interview was conducted with staff member H who stated that she did not feel like there was enough staff for the night shift. She stated that most of the time there are only two staff members and a nurse, and they had two patients that were basically one to one supervision due to their behaviors. She stated that they had to take turns watching these residents while the other staff member is watching the halls and giving showers. She stated that often they have to take one of the residents down the hall with them when they have to answer call lights and they just do the best they can. On 07/13/2016 at 12:42 an interview was conducted with staff member I who stated that the facility did not have enough staff on night shift. She stated that administration was aware of the problem. She also stated that on Station One there were two residents that required pretty much one to one supervision and it was really difficulty. She stated that most staff won't complain because they were afraid that administration would retaliate in some way. On 07/12/2016 at 11:04 AM an interview was conducted with the family of resident #33 who stated that he did not feel like there was not enough staff and there was a lack of supervision on the weekends and that the staff don't do what they are supposed to do. On 07/12/2016 at 10:34 AM an interview was conducted with the daughter for resident #81 who stated that there was not enough staff available in this facility to make sure that residents get the care and assistance they need and stated that there are significant issues in the dining room. She stated that when the residents are having dinner, their plates sit on the tables and they don't eat and then they are wheeled right back out of the dining room without being assisted. They are not offered extra tea or anything. The staff will sit in the corner on their cell phones. Review of the resident council minutes for the past six months showed multiple complaints by the residents related to facility staffing. Resident concerns included water and ice not being passed during the day, CNAs not showing up on time in dining room and staff being late for smoke breaks. They also complained that CNAs were taking a long time to answer call lights, and sheets and linens were not being changed. In June 2016 the residents stated that call lights were not being answered at night, and that residents felt it was due to lack of staffing. Review of the facility grievance log showed that on 7/7/16 a resident, who was no longer at the facility, complained because there were only two CNAs on Station One at night and she had to wait to be changed because one of the CNAs has to sit with a crazy person. On 6/25/16 Resident #47 complained that during night shift he fell sideways in the bed trying to prop himself up on pillows and became stuck with his face against the side rail of his bed. He stated that he pressed his call light and waited 15-20 minutes with no response. He stated that he then began to yell and waited another 15 mins before a CNA came in the room. He stated that he was frustrated and in pain and asked the CNA to move his face off of the side rail. The CNA stated that she would go get help and he stated another 15 minutes went by before another CNA came in and assisted him. On 2-16-16 Resident #45 complained about not getting pain medication timely, waiting 40+ minutes, while in pain during therapy. She also stated that she had only received one bath since admission and did not get regularly scheduled ice. She stated that her call light was not being answered timely, especially during night shift, and her husband reported having to change the bedding, and assist with dressing and providing the resident with a bedpan because of above stated issues. Review of the facility two week staffing pattern immediately prior to entrance was conducted and showed that on three separate days the facility did not meet the state required hours for staffing. Facilities are required to maintain a minimum certified nursing assistant staffing of 2.5 hours of direct care per resident per day. A facility may not staff below one certified nursing assistant per 20 residents, and a minimum licensed nursing staffing of 1.0 hour of direct care per resident per day. A facility may not staff below one licensed nurse per 40 residents. On 6/26/16 CNA hours were 2.17, on 7/5/16 CNA hours were 2.43, and on 7/7/16 nurse hours were 0.94.

Based on observations, interviews and policy reviews, the facility failed to ensure the proper concentration of sanitizing solution was utilized in the 3 compartment sink for 2 of 2 observations of chemical strip testing of the 3 compartment sink. The findins are: On 7/11/16 at 9:50 AM an observation was conducted of water in the sanitizing portion of the facility kitchen's 3 compartment sink. Chemical strip testing revealed the solution to be at 100 parts per million(ppm). Staff A, a cook, stated the procedure for filling sanitation sink following the instructions posted above the sink, was to fill the sink 2/3 with warm water and fill to the line with sanitizing solution to equal 200 ppm. The Dietary Manager stated the instructions posted above the sink were incorrect, and stated the solution coming from the hose was already diluted with warm water. She proceded to empty the sink and re-fill with just the solution coming from the clear hose. The solution was tested again with results of 50 parts per million. The Dietary Manager asked staff A who told her to dilute the solution with more water. Staff A responded that the company representative that hooked up the system had instructed her to fill the sink according to the instructions posted. The Dietary Manager insisted they were incorrect. A review of the three compartment sink policy was conducted. The policy titled, Manual Cleaning and Sanitizing of Utensils and Portable Equipment (Policy #04.005, @2008), revealed the procedure was to follow manufacturer's instructions when using quaternay ammonium compounds. The chemical in use at time of this survey was quantenary anumium componde, trade name Avance Sani Quat. The manufacturer instructions were to fill sink with 2/3 warm water and 200 ppm solution. Photgraphic evidence was obtained.

Based on observation, medical record review, and staff interview the facility failed to follow the plan of care to provide one to one assistance at meals for 1 of 3 residents sampled for activities of daily living (#81). The findings are: On 07/12/2016 at 5:39 PM Resident #81 was observed to be up in her wheelchair in the dining room. She was seated at a table with two other residents and was observed feeding herself. On 07/13/2016 at 12:35 PM resident #81 was again observed in the dining room in her wheelchair, seated at a table with 3 other residents. A staff member was observed delivering the resident's lunch tray. The staff member set up the resident's tray and the resident immediately began to feed herself. Another staff member took a seat at the table where resident #81 was seated, but was on the opposite side of the table from the resident and was providing supervision to the table but not one on one assistance for resident #81. Review of the resident's care plan showed that she had a deficit in her ability to complete activities of daily living (ADLs) and listed one of the interventions as needing one to one assistance for all oral intake. On 07/12/2016 at 10:36 AM a family interview was conducted with the resident's daughter who stated that she did not feel like the resident always received the assistance she needed to complete ADLs. She stated that she came to the facility about three times weekly in the afternoons and would sit with her mother in the dining room. She stated that she worried sometimes that her mother and the other resident did not receive the assistance and services they needed in the dining room. On 07/14/2016 at 2:37 an interview was conducted with staff member F who is employed as a certified nursing assistant (CNA) with the facility. She stated that she was the CNA working with resident #81 that day, and was familiar with the resident. She stated that resident #81 was able to assist with the completion of some ADLs depending on her mood. She stated that for breakfast, resident #81 normally eats in her room. She stated that they just set-up her tray and then she eats on her own. On 07/14/2016 at 3:30 PM an interview was conducted with the facility MDS Coordinator who was asked if she knew why the resident had an intervention on her care plan for one to one assistance with all oral intake. She stated that it had been recommended by therapy services when resident #81 had been on therapy. She stated that the resident had behaviors that were environmentally triggered and that when she was in the dining room, it was easy for her to get distracted and they felt it would be better for her to have a staff member to keep her on tract.

Based on observation, medical record review and staff interview, the facility failed to accurately assess for functional limitation in range of motion for 1 of 2 residents sampled (#33) and for dental status for 1 of 3 residents sampled for dental status (#77). The findings are: On 07/12/2016 a review of the Minimum Data Set (MDS) assessment with assessment reference date of 3/29/16 for resident #77 revealed that in section L (Dental Status) the options were: A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). B. No natural teeth or tooth fragment(s) (edentulous). C. Abnormal mouth tissue (ulcers, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn). D. Obvious or likely cavity or broken natural teeth. E. Inflamed or bleeding gums or loose natural teeth. F. Mouth or facial pain, discomfort or difficulty with chewing G. Unable to examine Z. None of the above were present. The option that was selected in the above referenced assessment was Z. None of the above were present. On 07/13/2016 at 8:50am an interview was conducted with Resident #77 in which he stated that he has no dentures and had no teeth. He stated that no one at the facility had spoken to him regarding his lack of teeth. He also stated that he had not seen a dentist since arrival at the facility. On 07/13/2016 at 8:54am an interview was conducted with the MDS coordinator. She stated that when she conducted an assessment, she spoke to the staff and resident herself. She looked through the resident's record to collect information and assessed the patient herself. She also stated that Resident #77 had not had teeth for many years and did not wear dentures, as that was his preference. The findings are: On 07/12/2016 at 2:50 PM Resident #33 was observed lying in bed. The resident's right leg was straightened out but her left leg was folded up under her and appeared to be fixed in that position. Both of her arms were folded across her chest and appeared to be fixed in that position as well. Subsequent observations on 07/13/2016 at 8:40 AM, 07/14/2016 at 8:41 AM, and 07/14/2016 at 1:57 PM all revealed resident #33 to be contracted in both of her upper extremities and in her left leg. Review of the medical record for resident #33 showed resident's last quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/25/16 showed Section G for Functional Status coded as having no impairment in range of motion to either her upper or lower extremities. Resident's previous assessment was a quarterly assessment with an ARD of 1/28/16. Review of section G for functional status also showed resident to be coded as having no impairment in functional limitation in range of motion for both upper and lower extremities. On 07/14/2016 at 3:25 PM an interview was conducted with the MDS Coordinator who stated that she was familiar with resident #33 and stated that she was pretty sure the resident did have contractures. She stated that she uses the resident's medical record to obtain the information she needed to code resident MDS assessments and stated that she also uses interviews and observations to obtain information. She was asked why the most recent assessment for resident #33 indicated that the resident did not have any limitations in range of motion and she stated that she would get back to me. On 07/15/2016 at 8:49 AM the MDS Coordinator stated that prior to April 2016 there was nothing in the resident's record that would indicate that the resident had contractures and that was why the assessment for resident #33 in April 2016 was coded to show no limitations in the resident's functional range of motion. On 07/15/2016 at 8:57 AM an interview was conducted with staff member C employed as a licensed practical nurse. She stated that she had been working at the facility for over a year. She stated that the resident's arms had been contracted since she began employment at the facility and stated that her leg had always been slightly contracted but stated that it had gotten worse around December 2015 or January 2016. On 07/15/2016 at 9:04 an interview was conducted with staff member D employed as a certified nursing assistant. She stated that she had been working at the facility for about 4 years. She stated that to the best of her knowledge the resident had been contracted for a little over a year. On 07/15/2016 at 9:23 AM an interview was conducted with employee E who was the unit manager for station 2. She stated that the resident had not always had the contractures and stated that the resident's contractures had started around January 2016. She stated that if he resident had an MDS assessment completed since January, it should have showed limitation in the resident's range of motion.

Based on record review, resident and resident representative interview and staff interview, the facility failed to ensure dignity with incontinent care. The facility failed to assess resident needs and preferences or resident representative preferences for the use of incontinent briefs at night for 3 of 3 residents (#1, #2, #3) sampled for incontinent care. The findings: Review of the medical records for residents #1, #2, and #3 showed that each resident was incontinent of bladder and that each required extensive assistance to complete toileting activity. On 1/28/15 at approximately 2:12pm, an interview was conducted with resident #2 who stated that every time the staff have a meeting, they come up with new rules. He stated that several months ago, the staff told the residents that administration was not going to allow them to use briefs for the residents at night. He stated that he told the staff that he had never slept in the nude and that he was not going to start sleeping nude at that time and he stated that after a night or so of him complaining, they allowed him to have his briefs back. On 1/28/15 at approximately 2:34pm, an interview was conducted with resident #3 who stated that the unwritten rule with briefs was that if you were in bed, you didn't need a brief on. He stated that only because he had the knowledge and spoke up did they give him briefs. He stated that the staff would often complain about not having enough sheets because they would all get soiled during the night. He stated that this had been going on for about two months and that the new rule had come from the administrator. he stated that they do this to the residents who couldn't speak up and that it was just terrible treatment if you asked him. On 1/29/15 at approximately 6:33pm, an interview was conducted with a resident representative of resident #1. The resident representative stated that there had been some issues with Resident #1 getting the help he needed from the staff for assistance with toileting. The resident representative stated that the biggest problem was on the night shift and stated that the facility was allowing Resident #1 to urinate on himself and was not changing him in a timely manner. On 1/29/15 at approximately 5:00am, interviews were conducted with two of the certified nursing assistants working the night shift. Staff member "A" stated that it was an unwritten policy for the residents to go without briefs at night unless they requested otherwise. She stated that there were more residents on the other side of the building who actually went without briefs because they were more dependent and couldn't really voice their preferences. Staff member "B" stated that it was the facility policy that residents not have briefs on at night while they were in bed. She stated that many of her residents did go without briefs during the night and that she normally would check and change the residents every two hours and then put briefs on the residents during her last rounds. An interview was conducted with staff member "C", on 1/29/15 at approximately 2:19pm. Staff member "C" stated that the staff often did not have enough wet wipes or briefs to cover all of the residents and that sometimes they were short on bedpans and shampoo as well. Staff member "C" stated that the "higher ups" have told the staff that if the resident was in bed, they should not get a brief. Staff member "C" also stated that the residents who complain did get briefs but that it was the ones who were not able to speak up that did not get the briefs. At about 8:55am on 1/29/15, an interview was conducted with a staff member from the laundry department who stated that there was a large number of sheets that were going through the laundry. She stated that she was not aware of any policy changes but that the linens at night run very heavy and that the laundry is a steady process that never ends. On 1/29/14 at approximately 3:54pm an interview was conducted with the director of nursing services who stated that the facility had not implemented a policy on the use of briefs at night, but they had encouraged the certified nursing assistants not to put briefs on the residents at night in an attempt to try and prevent breakdown. She stated that she did not have any evidence showing that this practice prevented breakdown. She stated that for the residents who requested briefs, they would honor their wishes and that for residents who were not able to speak, they really didn't know what their preference was. She stated that they had made no contact with the residents' families to determine a preference for the nonverbal residents.

Based on facility record review, resident council minutes, and interviews, the facility failed ensure that resident concerns or grievances were resolved in a timely manner. Findings: On 6/17/14 at approximately 3:30pm, an interview conducted with the resident council president revealed that there has been no prompt resolution to resident concerns about their not being adequate amounts of incontinent briefs. The concern about briefs has been coming up for the last 6-7 months in the resident council meetings and the facility has yet to come up with a resolution that satisfies the residents. There have also been several complaints of there not being adequate staff to provide care during the 7pm-7am shifts. Several complaints have been made to the Director of Nursing (DON) that certified nursing assistances have told residents that ask for assistance that " the resident is not their responsibility " and refuse to help the resident. The staff will tell the resident (s) that they will notify the aide that is assigned the resident to come and assist the resident but no staff ever show up to provide assistance or takes sometimes an hour to respond during the 7pm-7am shifts. When this was brought to the attention of the administrator, the resident council president reveals that " he is following the state guidelines and providing the number of staff that is required, so no additional staff would be provided. " A lot of residents require extensive assistance and as a result the number of staff required needs to be increased. On 6/17/14 at approximately 3:59pm an interview was conducted with Resident #16 revealed staff reports to him that often times there are not enough briefs for staff to provide personal care. Resident revealed that there have been times that he has been left for extended periods of time wet or soiled. Resident #16 also reveals that the assistance from staff during the 7p-7a shift takes very long times sometimes going well over 30 minutes and on occasion have waited beyond an hour for assistance. Resident #16 revealed that there has been occasions that staff has came into his room and turned his call light off and either took a long time to return or never actually returned to provide incontinent care. Resident #16 reveals that he has reported the issues several times to staff and management, and the issue has not been resolved. On 6/17/14 at approximately 5:09pm, an interview with the activity director revealed that residents have not complained about supplies to her knowledge. However, she revealed that the resident council has made several complaints about Certified nursing assistants are not working and providing assistance to residents that require assistance with ADLs. She revealed that she submitted a grievance to the Social Services Director about the resident's concerns after the last meeting was held. There were no grievances for resident #16 recorded in the log. 6/19/14 12:38pm interview with the social service director revealed she is the responsible person for the grievance process. There are a couple of pending grievances but none are related to adequate nursing staff. There are some issues with residents complaining about their not being enough staff to provide care. I am not sure if there is an issue with staffing numbers. There were some issues that on the 7pm-7am shift that staff were not providing care or within a timely manner. I am unsure of what the numbers of required staff are. Any staffing concerns are relayed to the ADON because she is in charge of staffing. The end result to the resident's council grievance was that staffing numbers were adequate. The administrator is informed of the resident's grievances and made aware or has part in deciding the resolution. Every morning staffing is discussed in the management meeting. She reports that the only reoccurring issue with no resolution is with the 7pm-7am Shift staff using cell phones on the floor during working hours. Review of the resident council minutes: Resident Council Minutes from 1-8-14 reveals that the administrator and the dietary manager or staff was invited to be in attendance at the resident council meetings. Old business discussed during the meeting was about getting certified nursing assistants to the dining room on time. New business concerns discussed include but not limited to the following: Administration was asked to provide more briefs on the floor. Certified nursing assistants were documented to still be late for meals. Resident Council Minutes from 2-3-14 revealed that the old business discussed during the meeting was in regards to certified nursing assistants getting the dining room on time. The administrator's response about supplies was that the facility has enough supplies. New business discussed during this meeting revealed that a "resident/family concern form" was completed for dietary issues. Resident Council Minutes from 3-3-14 revealed that the old business discussed during the meeting was in regards to Certified nursing assistants being on their cellphones while on the floor. The resolution was that staff would receive disciplinary action if caught. Certified nursing assistants were still not getting to the dining room on time. New business discussed was in regards to certified nursing assistants still late to the dining room and still using phones on the floor. Resident Council Minutes from 4-7-14 revealed that the old business discussed during the meeting was in regards to certified nursing assistants being on time for lunch and dinner meals. The discussed the issues about Certified nursing assistants using their phones on the floor. Resolution was that if staff are caught using their phones while working their phones will be taken until the end of the shift. New business discussed revealed certified nursing assistants are still late for lunch and Dinner. Resident Council Minutes from 5-6-14 revealed that the old business discussed during the meeting was in regards to certified nursing assistants being on time for meals and resolution is that staff will receive disciplinary actions. New Business concerns were that night time nurses need to help out more with resident care. The minutes went on to reveal that Certified nursing assistants are taking a long time to come back and resident would like for briefs in the residents rooms. New business discussed revealed that certified nursing assistants are on time to lunch but are late for supper. Also revealed that certified nursing assistants are still using their phones mostly at supper time. Resident Council Minutes from 6-3-14 revealed that the old business discussed during the meeting was that there is a continuing problem with certified nursing assistants answering call lights and turning the lights off and taking an inadequate time to return to take care of the residents. New business discussed was in regards to call light not being answered and staff not being prepared for care after answering lights. All minutes are signed by the administrator and/or his responsible party. Review of the grievance log: Grievance Log for the Month of June 2014 revealed that a concern was received by resident council on 6/11/14 in reference to certified nursing assistants taking too long to answer call lights and address resident needs. No resolution has been documented at the time of the review. There was no grievance log for the Month of May 2014 in the Grievance Log. Grievance Log for the Month of April 2014 revealed that a concern was submitted by a resident on 4/15/14 about Certified nursing assistants refusing to take resident to the bathroom after several requests. Findings were provide to the person filing the concern on 4-18-14. Staff were in-serviced and Social Services met with residents to ensure more efforts. Grievance Log for the Month of March 2014 revealed that a concern was submitted by a resident alleging that staff left the resident for 2 hours when they were supposed to take him to the bathroom prior to clocking out and never assisted the resident. Findings were providing to the person filing the concern on 3/4/14. The call light was replaced on 2-28-14. Resident asked to speak directly to certified nursing assistants instead of asking others to send messages. Another concern was submitted by a resident that alleged that a C.N.A. yelled at the resident and was on her phone. Also the log alleged that the same C.N.A. helps others before her. Findings provided to the person filing the concern on 4/1/14. The resolution included the C.N.A. being reeducated on helping everyone and consideration of changing this staff from being assigned the resident's room. Grievance Log for the month of February 2014 revealed that a concern was submitted by a resident alleging that certified nursing assistants were not providing help when asked. Findings provided to the person filing the concern on 2-5-14. The result was that certified nursing assistants were slow to help because they have to go in 2's to help the resident making allegations being sexually inappropriate. The Resident council submitted several concerns on 2/3/14. The first concern was in regard to there not being enough certified nursing assistants to help during the night shift and that certified nursing assistants were talking and texting on the phone. Also resident council reveals that staff were stating to resident that "you are not mine." Findings provided to the person filing the concern on 2/7/14. The resolution included the facility hiring more certified nursing assistants so they can have 5 aides on the night shift. Mandatory meeting was to be held with staff in regards to no phones on the floor. Also talked with certified nursing assistants about never saying to a resident that "you are not mine," but help when necessary. Grievance Log for the month of January 2014 revealed that a concern was submitted by a resident on 1/13/14 alleging that Nurses are not making rounds often enough and making excuses. Findings provided to the person filing the concern on 1/14/14. The resolution included that nurses were in-serviced in regards to making rounds. Review of the facility's "Resident Grievances and Concerns" states but not limited to the facility will strive to meet the needs of the residents, their representatives, and staff. However, there may be times that a concern or grievance may be voiced without discrimination or reprisal by the resident or family. The facility will assist the residents, their representatives, and other interested parties in filing grievances or concerns. The facility will investigate all grievances and concerns.

Based on resident interview, staff interview and review of resident council minutes the facility failed to ensure sufficient nursing staff were available on a daily basis to meet residents' needs for nursing care in a manner which promotes each residents' physical, mental and psychosocial well-being for 3 of 22 interviewable residents.(# 3, #16, #68) On 6/16/14 at approximately 4:20 p.m., an interview was conducted with Resident #3 during Stage 1 of the survey revealed she feels that there is not sufficient amounts of staff because she has had to wait long periods of times for staff to bring bed pans for her to empty her [MEDICAL CONDITION] bag. Resident revealed that it takes an hour or more sometimes for a staff to come and assist her after she has called her assistance using her call light. Resident #3 stated that she has to lay in the bed and be still for an hour to keep her bag from bursting or overflowing. Resident #3 revealed this has happened to her on several occasions. On 6/17/14 at approximately 3:30 p.m., an interview conducted with the resident council president revealed that there have been several complaints of there not being adequate staff to provide care during the 7:00 p.m.-7:00 a.m. shifts. Several complaints have been made to the Director of Nursing (DON) that Certified Nursing Assistance (CNA) are telling residents that ask for assistance that " the resident is not their responsibility. " The staff will tell the resident (s) that they will notify the aide that is assigned the resident to come and assist the resident but no staff ever show up to provide assistance or it sometimes takes an hour to respond during the 7:00 p.m.-7:00 a.m. shifts. When this was brought to the attention of the Administrator, the resident council president reveals that " he is following the state guidelines and providing the number of staff that is required, so no additional staff would be provided. " A lot of residents require extensive assistance and as a result the number of staff required need to be increased. Resident Council President revealed additional concerns about residents in wheelchairs. Resident Council President revealed that these residents also require a lot of assistance from staff to transfer in and out of the bed so this is another population that requires a lot of assistance and complain often. There have been several complaints from this population that they have to wait long periods of times to get assistance in and out of the bed and also to the toilet. Some of the residents in the council revealed that they had incontinence incidents while waiting long periods of times for assistance. 6/17/14 3:59 p.m. interview conducted with resident #(16) who reported that there has been times that he has been left for extended periods of time wet or soiled. Res #16 also reveals that the assistance from staff during the 7:00 p.m.-7:00 a.m. shift takes a very long time, sometimes going well over 30 minutes and on occasion have even went longer than an hour. Res #16 revealed that there has been occasions that staff has came into his room and turned his call light off and either took a long time to return or never actually returned to provide incontinent care. Res #16 reveals that he has reported the issues several times to staff and management staff and the issue is yet to be resolved. On 6/18/14 at approximately 11:07 a.m. an interview conducted with staff (J) regarding staffing and resident care. She stated,"I feel that sometimes there are enough staff here to provide care and I think resident care suffers when there is not enough staff. I do not think three staff are enough and if we are under staffed then residents will have to wait to receive assistance. Some days are shorter staffed than others". On 6/18/14 at approximately 11:13 a.m. an interview was conducted with staff (L) regarding staffing and resident care. She stated, "I do not think there are enough staff here to care for the residents. Resident care has suffered as a lack of staffing because it takes us longer to assist multiple residents. I don't think three aides are sufficient". On 6/18/13 at approximately 3:20 p.m. an interview was conducted with staff (M) regarding staffing and resident care. She stated,"I do not feel there are enough staff to perform my duties. We only have two people working in the kitchen and the shortage of staff does effect the residents with regard to the times the meals are served". On 6/18/14 at approximately 4:20 p.m. and interview was conducted with resident #(68) regarding staffing and care received. He reported, " The night shift takes a long time to help you and last night I request pain medicine at 1:00 a.m. and I did not get it until 4:45 a.m.; that happens a lot. I was in pain during that time but I wasn't screaming like a baby, however, I also would not be on [MEDICATION NAME] if I did have issues with pain. I think the problem is a lack of nursing staff. Also during lunch it is hard to get assistance too because everyone is busy feeding people and no one is watching the hall". Review of the resident council minutes: Resident Council Minutes from 1-8-14 reveals that the administrator and the dietary manager or staff was invited to be in attendance at the resident council meetings. Old business discussed during the meeting was about getting Certified Nursing Assistance (CNA) to the dining room on time. New business concerns discussed include but not limited to the following: C.N.A.s were documented to still be late for meals. Resident Council Minutes from 2-3-14 revealed that the old business discussed during the meeting was in regards to C.N.A.s getting the dining room on time. Resident Council Minutes from 3-3-14 revealed that the old business discussed during the meeting was in regards to C.N.A.s being on their cellphones while on the floor. The resolution was that staff would receive disciplinary action if caught. C.N.As were still not getting to the dining room on time. New business discussed was in regards to C.N.A.s still late to the dining room and still using phones on the floor. Resident Council Minutes from 4-7-14 revealed that the old business discussed during the meeting was in regards to C.N.As being on time for lunch and dinner meals. The discussed the issues about C.N.A.s using their phones on the floor. Resolution was that if staff are caught using their phones while working their phones will be taken until the end of the shift. New business discussed revealed C.N.A.s are still late for lunch and Dinner. .