Every finding on record at Arabella Health & Wellness of Pensacola

Based on observation, interview, record review, and policy review, the facility failed to adequately supervise 27 identified smokers and failed to secure resident's smoking materials, including lighters and cigarettes. This deficient practice placed the resident and others at risk for serious harm and resulted in the facility being placed in Immediate Jeopardy (IJ) when it was discovered that 1 of these 27 residents (Resident #15) had smoking materials in their possession despite orders for using oxygen, had diagnoses of dementia and schizophrenia, and had a roommate who also used oxygen.The findings include:A review of the facility's smoking policy dated January 2026 documented that all smoking related privileges, restrictions, and concerns must be documented in the resident's care plan and communicated to all personnel involved in the resident's care. The policy further required that any resident with restricted smoking privileges needed to be monitored under the direct supervision of a staff member, family member, visitor, or volunteer at all times while smoking. An observation was conducted of Resident #15 on 04/28/26 at approximately 10:44 AM. Resident #15 was observed sitting up in bed with oxygen in use. Additional observations were conducted of Resident #15 on 4/30/26 at approximately 6:05 PM through 6:30 PM. In these observations, Resident #15 was noted to be sitting in her wheelchair on the smoking patio with a plastic bag containing cigarettes and a lighter in her lap. A joint interview was conducted with Staff B, Certified Nursing Assistant (CNA), and the Facility Activity Director during this observation. They confirmed Resident #15 was identified as an unsafe smoker and required the use of a smoking apron while smoking. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of Resident #15's electronic medical record indicated she was on continuous oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (a progressive lung condition that limits airflow and causes persistent respiratory symptoms such as shortness of breath). Review of Resident #15's care plan revealed she had impaired cognitive function related to dementia, was a supervised smoker, and was required to return all smoking materials to the Activities Department after smoking. Review of a Quarterly Smoking Assessment, dated 02/08/26 documented that Resident #15 required supervision while smoking and that the facility was responsible for storing her lighter and cigarettes. Review of all 27 residents identified as smokers showed that each resident's electronic medical record included a care plan intervention which required them to return all smoking materials to the Activities Department upon re entering the building from the smoking patio. An interview was conducted with the facility Activity Director on 04/29/26 at approximately 9:50 AM. She explained that she was aware that multiple residents kept cigarettes and lighters in their possession. She acknowledged that residents were expected to return their smoking materials to her after smoking. However, she stated that ensuring compliance was a work in progress and that she should begin by auditing all residents. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 4/29/26 at 11:42 AM. Staff A reported that residents were not allowed to keep cigarettes or lighters. Staff A further stated the smoking materials were stored in a locked box at the nurses' station. A joint interview was conducted with the facility MDS Director and MDS Coordinator on 04/30/26 at approximately 2:51 PM. They explained that the care plan for residents who smoke was standardized for all residents, regardless of their Brief Interview for Mental Status (BIMS) score or individual abilities. They stated that all smoking residents were considered to require supervision, and all smoking materials were to be held by the staff. An interview was conducted with Staff I, CNA on 05/01/26 at approximately 4:55 PM. She explained that, outside of the designated smoking times, a box containing smoking materials was kept at the nursing station. However, she stated that most residents kept their smoking materials, including their lighters. She acknowledged being aware that residents kept cigarettes and lighters in their rooms. A joint interview was conducted with the facility Director of Nursing (DON) and Administrator on 05/02/26 at approximately 8:53 AM. The Administrator stated that residents were only permitted to smoke during designated smoking times and were not allowed to smoke in non-designated areas. They stated they have never observed cigarettes or lighters left unattended in resident's room. The administrator explained the facility was responsible for holding and storing resident's lighters. The DON stated lighters were expected to be turned in after each smoking session and that the smoking box used to store the smoking materials was kept at the nurse's station. A telephone interview was conducted with the facility Medical Director on 05/02/26 at approximately 2:56 PM. He explained that, according to the facility policy, residents were not permitted to keep cigarettes or lighters. He further explained that smoking materials were to be supervised by staff regardless of the residents' BIMS score. He emphasized that no residents were allowed to possess lighters and stated that this restriction had always been the facility policy. He indicated that he was not aware of any residents independently possessing smoking materials. He added that residents with a low BIMS score or those receiving oxygen should not have access to smoking materials, as doing so presented significant safety risk.

Based on observations, record reviews, and interviews, the facility administrative staff failed to utilize all the available resources effectively and efficiently to maintain the facility in a safe manner and ensure the facility's smoking policy was properly implemented and that all residents with smoking materials were adequately and accurately assessed. This failure had the potential to cause serious fire hazards, in particular for 1 resident who was identified to have impaired cognition, dementia, and schizophrenia and active oxygen use with smoking materials in their room (Resident #15).The findings included:An observation of the resident's designated smoking patio was conducted on 4/30/26 at approximately 6:05 PM through 6:30 PM. Resident #15 was observed sitting in her wheelchair with a plastic bag in her lap. Closer observation revealed the plastic bag contained cigarettes and a lighter. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) and the facility Activity Director. They acknowledged Resident #15 required use of a smoking apron while she was smoking. They further stated they were going to remove Resident #15's cigarettes from her possession.Review of Resident #15's medical record revealed she had diagnoses including dementia, schizophrenia, and continuous oxygen. In addition, Resident #15 had a roommate who was also ordered to have continuous oxygen.A joint interview was conducted with the facility Director of Nursing (DON) and the Administrator on 05/02/26 at approximately 8:53 AM. The Administrator stated residents were only permitted to smoke during designated smoking times and were not allowed to smoke in non-designated areas. They further stated they have never observed cigarettes or lighters left unattended in resident's room. The Administrator explained the facility staff were responsible for holding and storing residents' lighters. The DON stated lighters were expected to be turned in to staff after each smoking session and that the smoking box (used to store the smoking materials) was kept at the nurse's station. They further acknowledged this restriction was not being enforced by the staff.An interview was conducted with the facility Medical Director on 05/02/26 at approximately 2:56 PM. He explained that, according to facility policy, residents were not permitted to keep cigarettes or lighters. He further explained that smoking materials were to be supervised by staff regardless of the residents' cognitive levels. He emphasized that no residents were allowed to possess lighters and stated this restriction has always been the facility's policy. He added that residents with cognitive issues or those receiving oxygen should not have access to smoking materials, as doing so presented a significant safety risk to all residents.A follow-up interview with the Activity Director revealed that she was aware that multiple residents kept their cigarettes and lighter with them. She added that some families gave smoking supplies to the residents. She confirmed she was aware the residents were supposed to return the cigarettes and lighter to her after smoking. However, she stated that it is a work in progress and she really should start by auditing all the residents so she could get a better idea of which residents had smoking materials. An interview was conducted with the facility Administrator and DON on 5/2/26 at 3:15 PM, The Administrator stated she identified smoking concerns in August 2025 when she was hired at the facility. She explained at that time residents were smoking whenever they wanted, the fire alarm was not working, and the facility did not have a fire watch. The Administrator confirmed she never brought the smoking issue to the Quality Assurance and Performance Improvement (QAPI) committee and there was no Performance Improvement Plan (PIP) in place. She further stated she did not have any active or completed PIP on any identified quality deficiencies since she was hired. The DON stated it was a work in progress, and they planned to discuss the smoking concerns related to residents' keeping their smoking paraphernalia on their person to the next QAPI meeting.The identified smoking situation resulted in the finding of immediate jeopardy. The facility's Administrator was notified of the Immediate Jeopardy findings on April 30, 2026, at 5:50 PM. Immediate Jeopardy was removed on May 5, 2026, at 3:00 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included:1. On 5/2/26, A Safety Meeting was held with the Safety officer, DON, FA to confirm the fire alarm/Life safety systems status and document recent service activities. Annual inspection was completed less than 2 weeks prior to survey. The fire alarm technician was onsite on 5/1/26 to replace smoke detectors and verified the fire alarm system was in working order.2. On 5/3/26 The Nursing Home Administrator received education on the responsibilities, impact, and best practices of the Quality Assurance and Performance Improvement (QAPI) Coordinator. 3. On 5/3/26 at 10:00 AM, An Ad- Hoc QAPI meeting was conducted to review the Immediate Jeopardy (IJ) Abatement plan and corrective action. The meeting attendees included MD, NHA, DON, Maintenance Director/Safety Officer, Director of Rehabilitation, Social Worker, and the Medical Record Director. During the meeting, the IDT reviewed the actions, and confirmed that corrective measures have been implemented, are effective, and are being monitored. Smoking safety risk added as high priority QAPI item. 4. On 5/2/26, Staff education was initiated. Education included review of the smoking policy and procedure to include how cognitive and behavioral impairments increase fire and safety risk for residents who smoke and apply appropriate supervision and safety measures. All staff are assessed after education with a post test. 68 staff educated at the time of exit. 5.100% Smoking Assessments were updated. 14 residents were assessed as independent smokers with 16 residents including Resident #15 assessed as needing assistance with smoking and requiring facility to maintain possession of smoking paraphernalia.6.100 % room rounds for all residents (Including residents identified as non-smokers) to ensure smoking materials were not present outside of the locked storage box.7. The smoking policy was revised/updated on 05/03/2026 and presented to QAPI on 05/03/2026. Residents who have independent smoking privileges shall be permitted to keep smoking materials in a locked box or drawer. The resident must complete the lock box agreement form and must understand and agree to only possess these items on their person when exiting the facility.On 5/4/26, interviews were conducted with staff confirming they were knowledgeable about the facility Smoking policy and had an understanding of how cognitive and behavioral impairment increase fire and safety risk for residents who smoke and apply appropriate supervision and safety. Interviews revealed that staff were knowledgeable of the smoking binder located at the nurse's stations which identified independent smokers, supervised smokers, and smokers who needed a smoking apron. Staff were knowledgeable of unsafe behaviors and could verbalize the process to follow if they identified a resident with unsafe smoking behaviors, and the importance of intervening immediately and safely, removing hazards, and notifying a supervisor or nurse.On 5/3/26 and 5/4/26, interviews and observations were conducted with residents identified as smokers, verifying they understood the importance of always keeping cigarettes in a locked box or drawer. Independent smokers also stated that when they were in the facility, their cigarettes and lighter were stored in their locked box, or locked drawer.On 5/3/26 and 5/4/26, record reviews were conducted for all residents who smoke. Review revealed 100% of residents identified as smokers had updated smoking assessments. Smoking assessments identified if residents were deemed to be independent smokers or if they required supervision. Care plans were updated and correlated with the new assessments.

Based on observations, interviews and record reviews, the facility failed to develop, implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program after identifying residents with smoking material on their person to include a resident with limited cognitive abilities and diagnoses of dementia and schizophrenia and on oxygen. (Resident #15) The facility failed to demonstrate evidence of monitoring after the knowledge of facility policy non-compliance.The findings included:Review of Resident #15's electronic medical record indicated she was on continuous oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (a progressive lung condition that limits airflow and causes persistent respiratory symptoms such as shortness of breath). Review of Resident #15's care plan showed she had impaired cognitive function related to dementia, was a supervised smoker, and was required to return all smoking materials to the Activities Department after smoking. A Quarterly Smoking Assessment, dated 02/08/26 documented Resident #15 required supervision while smoking and that the facility staff were responsible for storing her lighter and cigarettes. Resident #15's Minimum Data Set assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment.Observations of the resident's designated smoking patio were conducted on 4/30/26 at approximately 6:05 PM through 6:30 PM. Resident #15 was observed sitting in her wheelchair with a plastic bag on her lap. Closer observation revealed the plastic bag contained cigarettes and a lighter. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) and the Activities Director. They stated Resident #15 required use of a smoking apron. They stated they were in the process of removing Resident #15's cigarettes from her possession. Review of all 27 residents identified as smokers showed that each resident's electronic record included a care plan intervention which required them to return all smoking materials to the Activities Department upon re entering the building after the designated smoking time ended. An interview was conducted with the facility Medical Director on 05/02/26 at approximately 2:56 PM. He explained that, according to the facility policy, residents were not permitted to keep cigarettes or lighters. He further explained that smoking materials were supposed to be supervised by staff regardless of the resident's BIMS score. He emphasized that no residents were allowed to possess lighters and stated that this restriction had always been the facility policy. He indicated that he was not aware of any residents independently possessing smoking materials. He added that residents with a low BIMS score or those receiving oxygen should not have access to smoking materials, as doing so presented a significant safety risk.On 5/2/26 at 3:15 PM, an interview was conducted with the Facility Administrator (FA) and Director of Nursing (DON). The FA stated she identified smoking concerns in August 2025 when she was hired at the facility. She explained that at that time residents were smoking whenever they wanted, the fire alarm was not working, and the facility did not have a fire watch. The FA confirmed she never brought the smoking issue to Quality Assurance and Performance Improvement (QAPI) and there was not a Performance Improvement Plan (PIP) in place. She further stated she did not have any active or completed PIPs on any identified quality deficiencies since she was hired. The DON stated it was a work in progress, and they planned to bring the identified smoking concerns related to residents' keeping their smoking paraphernalia on their person to the next QAPI meeting.The situation resulted in the finding of immediate jeopardy. The facility's Administrator was notified of the Immediate Jeopardy findings on April 30, 2026, at 5:50 PM. Immediate Jeopardy was removed on May 5, 2026, at 3:00 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included:1. On 5/2/26, A Safety Meeting was held with the Safety officer, DON, FA to confirm the fire alarm/Life safety systems status and document recent service activities. Annual inspection was completed less than 2 weeks prior to survey. The fire alarm technician was onsite on 5/1/26 to replace smoke detectors and verified the fire alarm system was in working order.2. On 5/3/26 The Nursing Home Administrator received education on the responsibilities, impact, and best practices of the Quality Assurance and Performance Improvement (QAPI) Coordinator.3. On 5/3/26 at 10:00 AM, An Ad- Hoc QAPI meeting was conducted to review the Immediate Jeopardy (IJ) Abatement plan and corrective action. The meeting attendees included MD, NHA, DON, Maintenance Director/Safety Officer, Director of Rehabilitation, Social Worker, and the Medical Record Director. During the meeting, the IDT reviewed the actions, and confirmed that corrective measures have been implemented, are effective, and are being monitored. Smoking safety risk added as high priority QAPI item. 4. On 5/2/26, Staff education was initiated. Education included review of the smoking policy and procedure to include how cognitive and behavioral impairments increase fire and safety risk for residents who smoke and apply appropriate supervision and safety measures. All staff are assessed after education with a post test. 68 staff educated at the time of exit.5.100% Smoking Assessments were updated. 14 residents were assessed as independent smokers with 16 residents including Resident #15 assessed as needing assistance with smoking and requiring facility to maintain possession of smoking paraphernalia. 6.100 % room rounds for all residents (Including residents identified as non-smokers) to ensure smoking materials were not present outside of the locked storage box.7. The smoking policy was revised/updated on 05/03/2026 and presented to QAPI on 05/03/2026. Residents who have independent smoking privileges shall be permitted to keep smoking materials in a locked box or drawer. The resident must complete the lock box agreement form and must understand and agree to only possess these items on their person when exiting the facility.On 5/4/26, interviews were conducted with staff confirming they were knowledgeable about the Smoking policy and had an understanding of how cognitive and behavioral impairment increased fire and safety risk for residents who smoke and apply appropriate supervision and safety. Interviews revealed that staff were knowledgeable of the smoking binder located at the nurse's stations which identified independent smokers, supervised smokers, and smokers who needed a smoking apron. Staff were knowledgeable of unsafe behaviors and were able to explain the process if they identified a resident with unsafe smoking behaviors, and the importance of intervening immediately and safely, removing hazards, and notifying a supervisor or nurse.On 5/3/26 and 5/4/26 interviews and observations were conducted with residents identified as smokers, verifying they understood the importance always keeping cigarettes in a locked box or drawer. Independent smokers also stated when they were in the facility, their cigarettes and lighter were stored in their locked box, or locked drawer.On 5/3/26 and 5/4/26 record reviews were conducted for all residents who smoke. Review revealed 100% of residents identified as smokers had updated smoking assessments. Smoking assessments identified if residents were deemed to be independent smokers or if they required supervision. Care plans were updated and correlated with the new assessments.

Based on observations, interviews, and record reviews, the facility failed to provide the required bathing and shower services necessary to maintain residents' overall personal hygiene for 6 out of 6 residents reviewed (Residents #4, #10, #38, #81, #98, #108).The findings include:1. During interviews conducted on 4/27/26 at 11:45 AM and 4/28/26 at 08:25 AM, Resident #4 revealed he needed assistance to get out of bed, and his preference was to get out of bed. He stated, I want to get up in my wheelchair, but the staff are busy. He stated he had asked to get out of bed plenty of times, but it doesn't happen unless he had physical therapy. He stated he got bored lying in bed. He stated he would watch his roommate's television, but watching TV was not something he enjoyed. Resident #4 stated he did not receive a bath every week, and he was not given a choice for a shower or bath by the staff. Observations conducted on 4/28/26 at 8:25 AM, 12:02 PM, and 3:40 PM, on 4/29/26 at 6:25 AM,11:14 AM, and 5:00 PM and 4/30/26 at 8:25 AM revealed Resident # 4 lying in bed dressed in a hospital-type gown. At the time of the observations, interviews were conducted with Resident #4, confirming he had not gotten up, no one had asked him if he wanted to get dressed, or offered to get him out of bed. He stated, It doesn't matter if I ask them to get up or not. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. Resident #4's medical diagnoses included hemiplegia and hemiparesis following a stroke, neurocognitive disorder, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident# 4 required extensive assistance to transfer from the bed to a chair and was dependent on staff for showering or bathing. The MDS also confirmed Resident #4 did not reject care. A review of Resident #4's care plan revealed Resident #4 liked to attend activities of interest, such as monthly birthday parties and special events. It indicated he should be invited to these activities. The care plan reminded and encouraged the staff to provide Resident #4 assistance so he could attend these events. Further review of the care plan revealed Resident #4 had a self-care deficit related to left-sided hemiparesis. A review of Resident #4's admission MDS revealed his preferences included keeping up with the news, doing things with groups of people, going outside to get fresh air, and listening to music. The MDS further indicated it was somewhat important for Resident #4 to choose what clothes to wear and to choose between a shower, bed bath or a sponge bath. On 4/30/26, a review of the documentation for Activities under tasks revealed no documentation for activities or activities participation except on 4/20/26 at 6:35 AM, which stated Not Applicable. A review of Shower/Bath documentation revealed Resident #4 did not have a shower or bath documented for 14 days between 3/31/26 and 4/14/26. (photographic evidence obtained) An interview was conducted with Staff P, Certified Nursing Assistant (CNA) on 4/30/26 at 8:40 AM. Staff P stated Resident #4 would usually ask to get up, but that he had not asked that week. She further stated Resident #4 would refuse to get up or would ask to go back to bed immediately after getting up. Staff P admitted she had not asked Resident #4 this week if he would like to get out of bed. When Staff P asked Resident #4 if he would like to get dressed, and get up, and he replied, I will get up anytime. An interview was conducted with Staff K, Licensed Practical Nurse (LPN) on 4/30/26 at approximately 9:10 AM. Staff K explained Resident #4 did not tolerate being out of bed for very long, and after a couple of hours he wanted to go back to bed. She further stated they tried to get all residents up unless they refused, and the expectation was for the CNAs to ask all residents if they wanted to get up, get dressed, and if they preferred a shower or bath. An interview was conducted with the Facility Administrator on 5/1/26 at approximately 2:30 PM. The Administrator stated she expected the CNAs to ask residents if they wanted to get out of bed. She further stated, it is on a case-by-case basis, and some of the CNAs knew the residents very well and knew if the residents wanted to get up or not. 2. On 04/27/2026 at 11:45 AM, Resident #10 reported that she had not received a good shower in about a month. She said she had only been given a few baths, which did not make her feel clean. She stated that staff had recently informed her the showers were out of service. A review of Resident #10's bathing record revealed she had received four baths in the past 30 days. An interview was conducted with the Facility Maintenance Director on 04/28/2026 at 9:23 AM. The Maintenance Director reported that only one shower in the E hallway was available for all residents. The D hallway shower room had been out of service for two weeks and the facility is currently awaiting funding approval. The B hallway shower room had been out of service for one week for floor tile repairs but was back in service as of 04/27/2026. 3. An interview was conducted with Resident #38 on 04/27/2026 at approximately 10:50 AM. Resident #38 expressed concerns regarding hygiene care, stating she had not received her scheduled showers. She stated she had been informed that the showers were out of service for maintenance. She stated that her last shower was over a week ago. A review of Resident #38's medical record revealed diagnoses of functional quadriplegia (severe physical frailty, requiring total care for daily activities) with significant weakness. Her scheduled shower days were noted to be Wednesdays and Saturdays. There was no recorded documentation for showers being provided to Resident #38 between 04/06/2026 and 04/12/2026 (Photographic evidence obtained). Resident #38 was care planed for activity of daily living self-care deficit related to weakness and impaired mobility with interventions to assist to shower/bathe twice a week. 4. An interview was conducted with Resident #81 on 04/27/2026 at 2:45 PM. Resident #81 stated they did not receive 3 baths per week from the staff. On 4/27/26 a review of the Certified Nurse's Aides (CNA) Tasks form was conducted for Resident #81. Documentation showed that the resident had only had 2 baths in the past 30 days, on 4/13/26 and 4/24/26. There was no documentation noted of refusals or the resident not being available. An interview was conducted with Staff K, Unit Manager on 4/29/26 at approximately 2:23 PM. Staff K stated it was the responsibility of the Director of Nursing, the Minimum Data Set (MDS) coordinator, and unit managers to enter the CNA tasks into the resident's electronic medical records. Staff K stated the nurses were responsible for ensuring care was delivered and documented in the tasks. Staff K independently reviewed Resident #81's medical record and verified the bathing task was not completed and further verified Resident #81 only received 2 baths in the past 30 days. She stated, based on the documentation, it did not look like Resident #81 received her baths. Staff K stated there has been some confusion as the facility had recently switched to a new bath form and not all staff were using the correct form. Staff K stated the CNAs were supposed to document in the electronic record and the nurses were supposed to verify and sign off on the care. 5. An interview was conducted with Resident #98 on 04/27/2026 at 12:20 PM. Resident #98 reported she had not received a bath in more than two months and had not had a shower in two years. Resident #98 stated that she preferred showers and preferred to have them done in the daytime. She explained that staff often deferred her bathing to the next shift, and the next shift did not follow through. She also noted that she required the use of a Hoyer lift for getting out of bed and the staff frequently told her she needed two staff for assistance, which delayed her bathing further. A review of Resident #98 's electronic medical record revealed she had 2 documented baths in the last 30 days. A follow-up interview was conducted with Resident #98 on 05/02/2026 at 9:52 AM. Resident #98 revealed she has not had a bath or shower at all this week. Review of the bath book showed that Resident #98 had a bed bath on 4/29/2026 at night, yet she stated that she did not have one. Resident #98 stated, sometimes they wipe my legs and the back of my neck, but it is not a bath. She stated that she would like to get into the shower and had expressed this to the staff. During an interview with Staff W, a Certified Nurse Assistant (CNA), on 5/02/2026 at 3:34 PM, at Resident #98's bedside, Staff W indicated that baths are documented in the resident's electronic chart after they are completed and should be documented on the bath sheets at the nurse's station. Staff W also confirmed Resident #98 's statement that she has not had a proper bath at all the past 5 days. 6. On 04/28/2026 at 8:20 AM, Resident #108 was observed in her room, sitting in her wheelchair, wearing a facility gown. Resident #108's hair appeared disheveled. An interview was conducted with Resident #108 at this time. Resident #108 stated she had not received a bath since her admission on [DATE]. An interview was conducted with Staff S, Registered Nurse Supervisor on 04/28/2026 at 8:45 AM. Staff S confirmed Resident #108 was scheduled for a bath on Wednesdays and Saturdays. Staff S independently reviewed the bath logbook and confirmed there was no bath documented for 04/18/26, 04/22/26, or 04/25/26. Review of Resident #108's electronic medical record was conducted. The task section for bathing for the past 14 days revealed Resident #108 did not receive a bath on scheduled dates of 04/18/2026, 04/22/2026, 04/25/2026. Resident #108's care plan revealed she had an Activities of Daily Living (ADL) deficit related to weakness and impaired mobility and staff was instructed to provide assistance with mobility and ADLs. The care plan goal documented was for Resident #108 to be clean, odor free, and appropriately dressed daily.

Based on interview, record review, and policy review, the facility failed to ensure consistent implementation of its grievance procedures and failed to document, investigate, track, and follow up on resident grievances in accordance with facility policy for a resident grievance in 2 of 2 grievances reviewed. (Residents #54 and #10) The findings include:On 04/27/2026 at approximately 10:45 AM, an interview was conducted with Resident #54. Resident #54 stated there was an occurrence about a month ago where his clothing items did not return from the laundry. Resident #54 stated his clothes were marked with his name and that he had at least two other occurrences of lost clothing items since admission to the facility. Resident #54 stated he reported his missing clothing items to two unnamed staff members with a reply they would report to the social worker and management. Resident #54 stated he did not receive further information about his missing clothing items.On 04/27/2026 at approximately 11:00 AM, an interview was conducted with Staff BB, a Certified Nurse Assistant (CNA). Staff BB stated that, if a resident informed her of missing clothing items, she reported to the Charge Nurse or Social Worker. Staff BB stated she was not aware of how to obtain or assist a resident with a grievance form.On 04/29/2026 at approximately 1:10 PM, an interview was conducted with the Director of Social Services and the Administrator. The Administrator stated the Director of Social Services is the primary person responsible for grievance management. The Administrator stated Resident #54 had not reported missing items to her. The Director of Social Services stated she had worked at the facility for six weeks and was not aware of a grievance by Resident #54.On 04/29/2026 at approximately 4:30PM during the Resident Council Meeting, Resident #10 stated the charger for her wheelchair was missing and stated a staff member took it. When asked if she reported a grievance, Resident #10 stated she informed the facility and was told they would not pay for it. The Director of Social Services stated they did a search and would order Resident #10 a new charger. The Director of Social Services stated she had not written a grievance about the issue.A review of the facility's grievance logbook for 2025 and 2026 was conducted. It was confirmed that the logbook did not contain grievances for Resident #54 and #10.Review of facility's policy titled, Grievances/Complaints, last revised April 2008, contained the following: Grievances and/or complaints may be submitted orally or in writing. The Administrator has delegated the responsibility for grievance and/or complaint investigation to the Social Services Director. Upon receipt of a grievance and/or complaint, Social Services will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The policy also indicates the resident will be informed of the findings and actions within ten (10) working days.

Based on interviews, record review and facility policy review, the facility failed to revise the comprehensive care plan to reflect a significant change in condition for 1 of 1 record reviewed for care plan revision (Resident #38).The findings include:A review of Resident #38's hospital record dated 04/21/2026 at 12:05 AM revealed that Resident #38 was diagnosed with acute urinary retention and constipation related to neurogenic bowel. This was not reflected in any of her care plansOn 04/27/2026 at approximately 10:50 AM, an interview was conducted with Resident #38. She explained that, in the past, episodes of constipation would lead to urinary retention requiring self-catheterization.On 04/30/2026 at approximately 2:51 PM, an interview was conducted with the MDS Director and MDS Coordinator. They explained that care plans were revised following hospitalizations and with any change in condition requiring adjustments to a resident's plan of care. They stated that they were not aware that Resident #38 had been transferred to the hospital. They acknowledged that the care plan should have been updated to reflect Resident #38's new diagnosis, including appropriate interventions and monitoring to address Resident #38's needs. They further acknowledged that this was an oversight and stated that the care plan should have been updated to ensure coordinated and individualized care following the change in condition.The facility policy titled: Care Plans-Comprehensive revised 09/21/03 was reviewed. It stated, The Comprehensive care plan is based on a thorough assessment. Each residence comprehensive care plan is designed to incorporate identified problem areas; risk factors associated with identified problems; reflect treatment goals timetables and objectives and measurable outcomes; aid in preventing or reducing declines in the residence functional status; reflect currently recognized standards of practice for problem areas and conditions. It also identifies problem areas in their causes, develops interventions that are targeted and meaningful to the residents. The process requires careful data gathering, proper sequencing of events and complex clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition change.

Based on interviews, record review and review of the facility policies, the facility failed to provide proper assessment and assistance in urinary/catheter care for 2 of 2 residents reviewed for urinary care (Resident #5 and #38). The findings included:1. A review of Resident #5's electronic medical record was conducted. On 4/24/26 at 8:03 PM, Staff V, Registered Nurse (RN), documented that Resident #5 requested transfer to the local Emergency Department due to a possible Urinary Tract infection (UTI). Staff V entered a transfer order under the medical director's name. Further review of the record revealed there was no documentation of a physical assessment being performed and no evidence that the medical director was notified of the transfer.Review of Resident #5's progress notes showed no documentation of a resident assessment, no interview regarding signs or symptoms, and no indication that staff offered any alternatives other than transfer to the emergency room.Review of Resident #5's transfer document dated 04/24/26 at approximately 8:03 PM revealed the physician notified field was left blank by the staff.An interview was conducted with Staff AA, RN on 5/1/26 at 12:11 PM. Staff AA stated that when a resident reports symptoms of a UTI, the nurse completes and documents an assessment and notifies the physician. She added that, if the physician or nurse practitioner is unavailable or it is after hours, the staff use the after hours tablet to contact the on call provider.An interview was conducted with the facility Director of Nursing (DON) on 05/01/26 at 1:50 PM. The DON confirmed the facility's procedure for transferring a resident to the emergency room included assessing the resident, notifying the provider, and documenting the process in the electronic record.An interview was conducted with the facility Nurse Practitioner (NP) on 05/01/26 at 2:16 PM. The NP independently reviewed Resident #5's chart and confirmed that Staff V entered the transfer order under the medical director's name. He clarified that the medical director was not on call at that time because it was after hours and stated that staff were instructed to follow the after hours protocol, which included using the tablet to contact the on-call provider.A telephone interview was conducted with Staff V on 05/02/26 at 2:43 PM. Staff V stated she did not remember which physician was contacted regarding Resident #5's UTI concerns and subsequent request for transfer. She reported that another nurse assisted her, but she did not recall who it was. She further stated she did not remember asking the resident about specific symptoms or performing a physical assessment prior to transferring her to the hospital.A telephone interview was conducted with the Medical Director on 05/02/26 at 2:57 PM. The Medical Director reported he did not recall any notification regarding Resident #5's UTI symptoms or transfer request on 04/24/26. He stated he was generally not contacted after hours because the facility had access to an after-hours on-call program.In an interview conducted on 05/02/2026 at 3:00 PM with the facility DON and Administrator, documentation was requested verifying that an on-call provider was contacted for Resident #5 on 04/24/26. The DON and Administrator confirmed they reviewed the after-hours contact log and did not find documentation to show the on call provider was contacted on 04/24/26. 2. An interview was conducted with Resident #38 on 04/27/26 at approximately 10:50 AM. She explained that, in the past, episodes of constipation have led to urinary retention requiring self-catheterization (a procedure in which a thin, flexible, single-use tube is inserted into the bladder through the urethra to drain urine. The tube is removed immediately after the bladder is empty). She explained that, on the evening of 04/20/26 she was experiencing pain because she was unable to urinate. She notified the nurse, explained her medical history, and requested straight catheterization. She further stated that, at first, the nurse told her that she will be back; however, after a few hours, Resident #38 reported that the nurse informed her that straight catheterization was not an option. She further stated that, due to her increasing discomfort, she could not wait any longer and requested to be transferred to the local hospital to receive the care she needed.A review of Resident #38's electronic medical record revealed Resident #38 requested to be transferred to the hospital on [DATE]. During review of physician orders, it was noted that an order was electronically created and confirmed by Staff G, Licensed Practical Nurse (LPN) to send (Resident #38) to the hospital for further evaluation related to the resident not voiding for 24 hours. This was written as a verbal order from the facility's medical director, dated 04/20/26 at 9:39 PM.A review of a nursing progress note written by Staff G on 04/20/26 at 9:43 PM, revealed that Resident #38 stated she had not voided in 24 hours and requested to be straight catheterized. After reporting to the facility's Administration, she notified Resident #38 that straight catheterization was not an option. Resident #38 then stated she wanted to go to urgent care to be seen because of the discomfort she was experiencing.A review of the Emergency Medical Transport record dated 04/20/26 revealed Resident #38 was unable to void and stated she needed to be straight catheterized and is supposed to get Miralax (over the counter laxative to treat constipation), which she is not receiving. The record further noted that Resident #38's abdomen was distended upon assessment.A review of Resident #38's emergency room hospital record dated 04/20/26 at 11:06 PM revealed that Resident #38 presented to a local emergency room and received a urinary catheter insertion which resulted in 450 milliliters of urinary output (considered a full bladder). Resident #38 was diagnosed with acute urinary retention and constipation related to neurogenic bowel. The Emergency Department physician's note revealed that Resident #38 reported to the emergency room staff that the facility will not do a foley catheter.An interview was conducted with Staff G on 04/30/26 at approximately 10:25 AM. Staff G confirmed she was assigned to care for Resident #38 on 04/20/26. She explained that Resident #38 reported to her that she had not voided for 24 hours and requested straight catheterization. Staff G indicated that she informed Resident #38 that a provider order was required to perform a straight catheterization. She continued, saying she told Resident #38 that she could wait for the next day to see the Nurse Practitioner (NP) on site. She acknowledged that she did not document a nursing assessment of Resident #38's change in condition. She stated that the regular provider was not contacted since it was after hours but said she had called the after-hours telehealth provider per facility protocol. Staff G further stated, she did not document the communication. She explained that Resident #38 requested to be transferred to the hospital to be straight catheterize after not voiding for 24 hours. She confirmed that straight catheterization is within her scope of practice as a licensed practical nurse and that catheterization kits are available within the facility.A joint interview was conducted with the facility's Administrator and the DON on 04/30/26 at approximately 11:30 AM. They explained that after hours, the facility utilizes a contracted provider telehealth system for clinical needs and orders. The DON explained that the facility nurses have the capability to perform straight catheterization, and that kits were available in the medication storage cabinet. She further stated that this task is within the scope of practice for a licensed practical nurse. She recalled reminding Staff G, LPN that straight catheterization requires a physician order. Upon independent review of Resident #38 electronic medical record, the DON confirmed that the resident was transferred to the hospital due to urinary retention without a documented nursing assessment, without documented communication with the provider to support the need for transfer, and without evidence that Resident #38 needs could not be met at the facility. She added that the decision to transfer Resident #38 did not make sense, as the facility had the capability to perform the procedure. She stated that the facility also maintains an on-call contract for bladder scanning service as needed, which was also not utilized. She acknowledged that no alternative interventions, including in-house catheterization, were offered to Resident #38 prior to the hospital transfer. She further indicated that it was her expectation that a nursing assessment would be documented in the medical record and a change of condition would be communicated to the provider. The DON stated that a miscommunication breakdown lead the Resident #38 not being appropriately assessed.An interview was conducted with the NP on 04/30/26 at 12:21 PM. He explained that he expected nursing staff to be held accountable for adherence to nursing standards. He acknowledged that a nursing assessment should have been documented and that a provider order for straight catheterization could have been obtained to address the resident symptomatic urinary retention without a hospital transfer.A follow-up joint interview was conducted with the Administrator and the DON on 05/02/26 at approximately 10:10 AM. The Administrator stated every provider telehealth consult was generated and electronically signed. She was unable to retrieve the record of any telehealth communication regarding Resident #38 on 04/20/26. She added that she contacted the telehealth provider company that had no record of being contacted that night.A follow up interview was conducted with the NP on 05/02/26 at approximately 11:30 AM. He indicated that it was his expectation for the clinical staff to contact and report a change of condition to a provider and obtain appropriate orders.A telephone interview was conducted with the Medical Director on 05/02/26 at approximately 2:56 PM. He explained that after hours, the facility utilized the contracted telehealth system for on-call needs and orders, including transfer orders. He didn't recall receiving a call regarding Resident #38 and stated that nurses must talk to the on-call provider to obtain appropriate orders when needed, including transfer order. He explained that nursing staff were responsible for contacting the on-call provider to obtain necessary orders. He further indicated that the facility has the capability to perform straight catheterization for urinary retention and didn't understand why the nursing staff did not contact the on-call provider to obtain an order in this instance. He reiterated that staff are expected to communicate with the on-call provider to obtain appropriate medical orders when needed.Review of the facility's Licensed Practical Nurse job description was conducted. Nursing care functions include performing continual observation and evaluation of each resident's physical, cognitive and emotional status; communicating timely with physicians and/or nurse practitioners related to resident care needs and concerns. Be responsible for implementing and communicating to other caregivers all physician and/or nurse practitioners orders; Document all clinical information in an informative and descriptive manner that reflects the care provided to the residents as well as the residents response to the care. Must be able to relate information concerning a resident's condition.The Facility's Assessment Tool (the evaluation used to determine the facility's resources, staff competencies, and ability to meet resident's care needs) updated 03/23/26 was reviewed. The tool indicated, Services and Care offered based on Resident's Needs revealed the facility offers intermittent or indwelling or other urinary catheter.The facility policy titled: Transfer or Discharge, Emergency, dated 2001 was reviewed. It indicated, Our facility shall make an emergency transfer or discharge when it is in the best interest of a resident. The policy indicated the facility staff would notify the residents' Attending Physician of any change in condition, transfer, or discharge.

Based on observations, interviews, and record review, the facility failed to monitor weights for 1 of 1 resident reviewed for significant weight loss (Resident #13).The findings included: An observation was conducted on 04/28/26 at 8:00 AM of Resident #13 eating her breakfast meal. She appeared thin. She stated that, since she was in the hospital, she had not had much of an appetite but that she was trying to eat. It was noted that there were no supplements present on her meal tray.Record review revealed that Resident #13 weighed 172.2 pounds on 10/13/25. However, on 04/13/26, Resident #13 weighed 145 pounds. This indicates Resident #13 suffered a 15.8% weight loss in 6 months.An interview was conducted with the facility Dietary Manager on 04/29/26 at 2:39 PM. The Dietary Manager revealed that Resident #13 had orders for nutritional supplements three times per day and Liquid Protein supplements 30 milliliters for nutritional needs. The Dietary Manager stated Resident #13 was on a mechanical soft diet and had been changed to a regular diet with thin consistency. She acknowledged that Resident #13 was hospitalized and had lost a lot of weight.An interview was conducted with Resident #13 on 04/30/26 at 10:24 AM. Resident #13 revealed she did not recall receiving any supplements with her meals. She recalled she received some ice cream one time.Review of Resident #13's progress notes revealed an order from the Registered Dietitian stating that Resident #13 was supposed to receive weekly weights. However, closer review of Resident #13's medical record revealed there were no weekly weights documented. On 05/01/2026 at 10:23 AM, a follow up interview with the Dietary Manager was performed concerning the weekly weights. She mentioned that Resident #13 was recently hospitalized for 4 days, but made no mention of why the ordered weekly weights were not followed up on by herself. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 05/01/26 at 10:36 AM. She acknowledged that the ordered weekly weights were not done. She stated that Staff EE, Restorative Certified Nursing Assistant, was responsible for taking and documenting the residents' weights.

Based on observations, interviews and review of facility policy, the facility failed to ensure the accurate and periodic reconciliation and proper disposal of controlled medications.The findings included:Review of the controlled substance destruction records was conducted on 04/29/26 at approximately 9:34 AM with the facility Director of Nursing (DON) and the Administrator. The double locked drawer where discontinued narcotics were stored was noted to be full. Review of the logbook revealed that the last documented destruction of narcotics occurred on 11/06/25. Further review identified that only one out of six pages of the destruction log contained the required witness signature to validate the destruction process and ensure accountability.A joint interview was conducted with the DON and the Administrator on 04/29/26 at approximately 9:34 AM. They reported that all discontinued narcotics were stored in a double locked drawer located in the DON's office and acknowledged a significant accumulation of discontinued controlled substances. The DON stated that, since her hire in December 2025, she had not conducted any narcotic destruction. They independently reviewed the narcotic destruction logbook and confirmed the last documented destruction occurred on 11/06/25 and only one out of 6 pages contained the required witness signature to validate the destruction process and ensure accountability. They acknowledged that this process was not completed in accordance with facility policy and recognized the importance of conducting narcotic destruction at regular intervals to maintain compliance and ensure safe handling of controlled substances.Review of the facility policy titled: Discarding and Destroying Medications dated 2001 and last revised in 2014 was conducted. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The facility may contract with a DEA registered collector for proper disposal of non-hazardous schedule II, III, IV and V controlled substances. If a resident is transferred to another facility or dies while he or she is in lawful possession of the controlled substances, the facility may dispose of the controlled substance(s) by depositing in the authorized on-site collection receptable. Disposal of controlled substances must take place immediately (no longer than 3 days) after discontinuation of use by the resident. The steps for destruction include taking the medication out of the original containers, mix medication, either liquid or solid, with an undesirable substance, sand, coffees, kitty litter, or other absorbent materials. Dispose with the solid waste in the presence of two witnesses. Document the disposal on the medication disposition record and include at least the signature of two witnesses. The medication disposition record will contain the following information:The resident's name;Date medication disposed;The name and strength of the medication;The name of the dispensing pharmacy;The quantity disposed;Method of disposition;Reason for disposition, and;Signature of witnesses.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were under direct observation of the person administering the medications during 1 medication administration observations conducted for Resident #109.The findings included:A medication administration opportunity was conducted with Staff Y, Licensed Practical Nurse (LPN) on 04/29/26 at approximately 7:45 AM. Staff Y was observed preparing to administer medications to Resident #109. During the process of removing medications from a medication bubble pack, 4 pills fell outside of the medication cup and onto the top surface of the medication cart. 3 of the 4 medications were for Resident #109's heart condition. Staff Y acknowledged the 4 tablets fell onto the medication cart and did not immediately secure or dispose of the dropped medications. Rather, Staff Y pushed the 4 pills aside on the medication cart next to the computer (Photographic evidence obtained). Staff Y then locked the medication cart and entered Resident #109's room, leaving the unsecured pills on the top of the cart and out of her direct sight. During this time, other residents were observed self-propelling in wheelchairs in the hallway, with potential access to these unsecured medications.An interview was conducted with Staff Y on 04/29/26 at approximately 8:17 AM. She confirmed that she did not have direct oversight of the medication cart or the unsecured pills while in Resident #109's room. She acknowledged that residents were present in the hallway and that some had a history of confusion. Staff Y further confirmed that leaving medications unsecured on top of a medication cart could allow unauthorized access to dangerous medications, which had the potential to cause harm if a resident were to ingest them.An interview was conducted with the facility Director of Nursing (DON) on 05/01/26 at approximately 3:50 PM. She explained that it was not acceptable for staff to leave medications unattended and this did not meet the facility's expectations of the nursing staff. She acknowledged that some residents were cognitively impaired and that unattended medications posed a safety risk.Review of the facility policy titled: Administering Medications (dated 2001 and revised 12/2012) was conducted. It stated that no medications were kept on top of medication carts. The cart must be clearly visible to the personnel administrating medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observations, interviews, and record reviews, the facility failed to use appropriate personal protective equipment (PPE) during patient care involving 2 of 2 residents with indwelling medical devices to prevent contamination and reduce infection risk (Resident #5, Resident #33)The findings included: An interview was conducted with Resident #5 on 04/27/26 at 11:17 AM. Resident #5 reported that staff do not wear the gowns provided for use during catheter care. Resident #5 further stated that sometimes staff wash their hands. During this interview, it was noted that Personal Protective Equipment (PPE) gowns were located on a hanging organizer on the back of Resident #5's door. It was also noted that signage mandating PPE equipment and EBP sign was present on Resident #5's door. During an observation conducted on 04/29/26 at 10:06 AM, Staff T, Certified Nurse Assistant (CNA) performed catheter care on Resident #5. Staff U, CNA assisted Staff T with the catheter care. Staff T and Staff U performed hand hygiene and wore gloves; however, PPE gowns were not used by the staff. When questioned about Enhanced Barrier Precautions (EBP), Staff T and Staff U incorrectly referenced barrier cream and skin prep rather than PPE requirements, such as gloves and gowns. Staff X, Licensed Practical Nurse (LPN) was also present during this catheter care observation and stated that PPE gowns were required when providing care to a resident with a catheter. An interview was conducted with the facility Director of Nursing (DON) on 05/01/26 at approximately 10:45 AM. The DON stated staff were expected to wear PPE when providing care to residents with wounds or indwelling medical devices such as catheters. She explained that staff had been educated on catheter care and proper use of PPE. The DON provided a binder containing staff signatures confirming completion of this education. Review of the binder showed that Staff T signed a PPE competency form on 02/20/26; however, the form was blank, with no indication that a demonstration was performed. Staff U had a PPE competency form indicating successful demonstration, also signed on 02/20/26. An interview was conducted with Staff S, Interim Infection Prevention Nurse on 05/02/26 at 8:45 AM. Staff S revealed that EBP had been an established expectation in long term care since approximately 2023. She confirmed that staff were required to wear appropriate PPE when providing care to residents with indwelling medical devices, such as catheters. 2. An observation was conducted of Resident #33's room on 04/27/26 at 10:44 AM. A sign for EBP was present on the door to Resident #33's room. Staff I, CNA and Staff Z, CNA were both wearing gloves and Staff Z was holding a full trash bag. it was noted that Staff I and Staff Z were not wearing protective gowns. During this observation, an interview was conducted with Staff I and Staff Z. Staff Z confirmed they just completed incontinent care on Resident #33. When asked about the sign for EBP, Staff I stated she did not know whether Resident #33 was still on EBP. When asked if Resident #33 had a catheter, Staff I replied, yes. When asked if staff should wear a gown and gloves when providing incontinent care to Resident #33, Staff I responded, I wore gloves. Review of Resident #33's electronic medical record revealed a provider's order for Enhanced Barrier Precautions related to suprapubic catheter was entered on 04/11/26 at 1:07 PM. Enhanced Barrier Precautions were also documented in Resident 33's care plan under suprapubic catheter. An interview was conducted with Resident #33 on 04/27/26 at 2:10 PM. Resident #33 stated the staff wore gloves when providing catheter care or incontinence care but that they did not always wear gowns. An interview was conducted with the DON on 04/27/26 at 3:00 PM. The DON confirmed the staff should follow the EBP instructions and wear a gown and gloves when providing incontinent care to a resident with a catheter who has an order for EBP.

Based on observations, interviews, and record review, the facility failed to ensure that 1 of 3 residents reviewed for activities of daily living received the necessary services to maintain grooming and personal hygiene. (Resident #1)The findings include:On 2/25/2026 approximately 10:15 am during an interview with Resident #1, she reported she has not received a bath today or last night. She stated she gets cleaned sometimes during the day shift when she is wet or has a bowel movement. Her hair appeared oily and a noticeable body odor was present. Her skin was dry and flaky and clothes were stained and urine type smells were noted.An interview was conducted on 2/25/2025 at approximately 11:00 am with Staff A, a Licensed Practical Nurse. She stated the resident is scheduled for a bath during the night. She stated that, during shift change, night shift always reports that a bath is not being given for different reasons. Resident #1 did receive incontinent care during the day shift and sometimes a full bath is given when the resident or family request, because the bath was not given during the night shift. Per record review on 2/26/2026, it was found that Resident #1 was scheduled for a bath on Monday, Wednesday and Friday on night shift. However, the documentation showed the following: From 1/10/2026 through 1/25/2026 she only received one bath. From 1/26/2026 through 2/10/2026, she only received 3 bed baths. From 2/11/2026 through 2/26/2026, she received only one bath. On 2/26/2026 at approximately 3:00 pm, the Administrator and Director of Nursing were interviewed. After an extensive review of the records, they could not provide any other documentation for baths given to Resident #1.

Based on observations, interviews, and record reviews, the facility failed to provide medications to meet the needs of 1 of 5 residents sampled for medication administration observation. (Resident #16) The findings include: On 2/19/25 at approximately 10:25 AM, an observation was made of Nurse B, a Licensed Practical Nurse, administering medications to Resident #16. During this observation, it was observed that the scheduled medication Azelastine HCL Nasal Solution 137 micrograms (a medication used to relieve sinus congestion) and Breo Elipta Inhalation aerosol powder 100-25 micrograms/ACT (a medication used to treat Chronic Obstructive Pulmonary Disease) were not available to administer as ordered to Resident #16. On 2/19/25 at approximately 10:40 AM, an interview was conducted with Nurse B, who indicated that she was not sure why the resident was out of these two medications, but that she would contact the pharmacy to have them sent in, and notify the physician to obtain an order to hold the medication until available. On 2/19/25 at approximately 10:50 AM, an interview was conducted with the Regional Nurse, who indicated it was her expectation that all medications be re-ordered from pharmacy in a timely manner. A review was conducted of the facility policy titled 5.0 Reordering, Changing, & Discontinued Medication Orders, states, Policy: The facility will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guidelines and state/federal regulations; thus ensuring standardized process of communication. Procedure: A. All orders must clearly be communicated to the pharmacy by the facility. This includes resident's full name (first and last). B. Reorder/Refill Orders- 1. Refills can be requested by placing the refill strip portion of the medication on the Refill Order Form and faxing to the pharmacy. 4. Electronic Orders: Refill orders can be submitted electronically from a prescriber through their escribing software or through a facilities EMAR (electronic medication record) system as long as the order is not discontinued.

Based on observations, interviews, policy review, and record review, the facility failed to wear proper protective equipment during catheter care for 1 of 1 resident observed during catheter care (Resident #13), failed to maintain sterile processes during tracheostomy care for 1 of 1 residents observed during tracheostomy care (Resident #36), failed to implement their legionella (a water born virus) plan for surveillance and prevention, and failed to follow infection control processes during medication pass for 1 of 5 residents observed during medication pass (Resident #21), The findings included: Resident #13 On 2/19/25 at approximately 9:30 AM, an observation of Staff B, a Certified Nursing Assistant (CNA), was conducted as she provided catheter care for Resident #13. Staff B failed to apply a barrier gown before she provided catheter care for Resident #13, who had been placed on enhanced barrier precautions to protect him from a catheter associated infections. A review of the physician orders for Resident #13 was conducted. A foley catheter was ordered to be inserted for Resident #13 on 1/9/25. Catheter care was ordered to be completed for the resident every shift. A physician order dated 1/14/25 indicated that the resident was to be placed on enhanced barrier precautions. On 2/19/25 at approximately 10:00 AM, an interview was conducted with Staff B. When asked about why she did not apply a gown during catheter care, the CNA indicated that she should have worn a gown while she provided catheter care. On 2/20/25 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON). She was notified that Staff B did not wear a gown during catheter care for Resident #13. The DON indicated that a gown should have been worn. She indicated that staff retraining has already been initiated. A review of the facility policy titled Enhanced Barrier Precautions, dated 3/20/2024, was conducted. The policy states, Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. Enhanced Barrier precautions were indicated to employ targeted gown and glove use during high contact resident care activities. The policy further indicated that Enhanced barrier precautions were to be unutilized for residents with urinary catheters to prevent infections with multi-drug-resistant organisms. Resident #36 On 2/19/25, an observation was made as Nurse C, a Licensed Practical Nurse (LPN), provided tracheostomy care to Resident #36. When she opened the sterile kit, the kit was upside down causing the sterile gloves to come out first and the suction catheter and other items to land on top of the sterile gloves. Nurse C handled the suction catheter, the container to hold the normal saline, and drain sponge prior to applying the sterile gloves, thus rendering those items unsterile. During the process, Nurse C touched multiple surfaces that were not clean as she provided tracheostomy care. Nurse C proceeded to change the inner canula next using the same gloves she applied at the beginning of the process. Immediately after the observation, an interview was conducted with Nurse C. She was asked if tracheostomy care/changing the inner cannula should be conducted as a sterile procedure. She indicated that she will look at the physician orders to double check and see if sterile procedure should have been utilized. She later indicated that changing the inner canula should have been completed utilizing sterile processes. She was asked if she has received training regarding the process for tracheostomy care. She could not recall when she had been trained. On 2/20/25 at approximately 9:00 AM, an interview was conducted with the DON. The DON was notified that there was concerns regarding maintaining sterility during tracheostomy care as Nurse C changed the resident's inner cannula. The DON indicated that training had been completed regarding tracheostomy care by the facility recently. A review of the facility policy for Tracheostomy Care dated 1/5/25 was conducted. The policy indicated that suctioning should be performed utilizing sterile technique. Legionella plan On 2/20/25 at approximately 9:00 AM, the facility's maintenance director was asked to provide information regarding the facility's water surveillance process. The Maintenance Director indicated that water is being tested using test strips. A copy of the facility's water testing logs for the past year along with other documentation regarding the facility's program for prevention of waterborne disease was requested. The Maintenance Director indicated that water was being tested utilizing test strips but not being logged. He was asked to provide any documentation regarding the facility water management program along with a copy of the facility policy and procedure for water management. The Maintenance Director provided a copy of the facility water management program policy. The policy indicated that a risk assessment was to be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The policy indicated that the Maintenance Director would maintain the facility's water management action plan and keep a copy in the facility water management program binder. The policy indicated that control measures were to be applied to address potential hazards at each control point in the water system. The policy further stated that a variety of measures would be utilized including physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. These measures should be specified in the water management program action plan. Testing protocols and control limits will be established for each control measure. Individuals responsible for testing or visual inspections will document findings. The water management team were directed by the policy to regularly verify that the water management program is being implemented as designed. The Maintenance Director did not provide information regarding the annual risk assessment as indicated in the facility's policy. There was no water management provided for review. The facility did not provide documentation that testing was being performed at the time of the survey. 44730 Resident #21 On 2/19/25 at approximately 9:36 AM, an observation was made of Nurse A during medication administration for Resident #21. Nurse A was observed to touch the inside of the medication cup, and the inside of the water cup with her bare hand. Further observations of Nurse A revealed that the nurse failed to clean the hub of the Lantus insulin pen (a medication used to treat Diabetes type II) with an alcohol swab prior to applying the needle. On 2/19/25 at approximately 10:00 AM, an interview was conducted with Nurse A, who indicated that touching the inside of the medication cup and water cup would be considered an infection control issue. Nurse A further confirmed that she did not clean the hub of the Lantus insulin pen prior to applying the needle and this too would be considered an infection control issue. On 2/19/25 at approximately 10:50 AM, an interview was conducted with the Regional Nurse, who indicated that it is the facility's expectation that the nurses do not touch the inside of the medication or water cups, and that the nurses also clean the hub of all insulin pens with alcohol prior to applying the needle. The Lantus SoloStar pen guide states under How to use your Lantus Solostar pen in 6 steps, Step 2. Attach the needle. * Wipe the pen tip (rubber seal) with an alcohol swab. The facility policy titled Infection Prevention and Control Program states, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 4. Standard Precautions: d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.

Based on record reviews and interviews, the facility failed to submit an adverse incident report for 1 of 1 residents sampled for elopement. (Resident #44) The findings include: On 11/30/23, during a review of facility adverse incident reports, it was discovered that Resident #44 eloped from the facility on 10/6/23. There was no evidence that the facility submitted a federal report. On 11/30/23 at approximately 1:00 PM, an interview was conducted with the Administrator. The Administrator stated they did not do a federal report because they were under the impression they only needed to do the adverse incident report to the State. The Administrator stated they were advised by their Corporate Nurse to file the adverse incident which was submitted by their corporate consultant.

Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards in the facility's unit nourishment refrigerators. The findings include: On 11/30/2023 at approximately 11:00 AM, the nourishment refrigerators at the two nurse's stations were inspected. The station #2 refrigerator was found to be filled with a number of resident personal food items that were out of date or unlabeled. Facility supplements were found to be in date but with one opened container. Both the freezer and refrigerator were found to have old food spills that had not been wiped up. (Photographic evidence obtained) The station #1 refrigerator appeared clean. There were no personal Resident food items present. All nourishment containers were unopened and within expiration dates. The floor under the refrigerator was stained with uncleaned food spills. The charge nurse stated she had called maintenance to have the floor cleaned. On 11/30/2023 at approximately 11:00 AM, the charge nurse station #2 verified that opened supplements should be discarded within 24 hours and that this container was outside of the facility policy of 24 hours. She also stated that food brought into the facility by families are supposed to be dated and the resident's name placed on container. She stated that prepared food brought in be family should be discarded after 72 hours. The policy entitled Food brought into residents from outside sources from the Nutrition Services Manual (dated June 2015) revealed, Any food, which is not to be eaten right away, should be transported in a clean, disposable, sealed container .Your nurse will label, date, and store this food in the nursing unit's nourishment refigerator. If the food is not used within 3 days, it will be discarded. The policy titled Cleaning and Sanitizing of Refrigerator, Cooler and Freezer from the Nutrition Services Manual (dated June 2015), Discard all leftover items over 72 hours old or per state/local regulation.

Based on observations, interviews, and record review, the facility failed to maintain infection control practices for 1 of 4 residents observed during medication administration observation. (Resident #5) The findings include: On 11/29/23 at approximately 9:09 AM, an observation was made of Nurse A, a Licensed Practical Nurse (LPN), administering medications to Resident #5. Nurse A placed Resident #5's Azelastine Nasal spray (a medication used to treat sinus allergies), Breo Ellipta Aerosol Powder inhaler (a medication used to treat chronic obstructive pulmonary disease), and Visine ophthalmic solution (eye drops used to treat dry eyes) on Resident #5's over the bed table without placing a barrier between the table and the medications. Nurse A then applied clean gloves and assisted in pulling Resident #5 up in the bed. Nurse A then changed gloves without performing hand hygiene. Nurse A then administered Resident #5's inhaler, nasal spray and eye drops without changing gloves and performing hand hygiene in-between each medication, and between each eye. Nurse A then removed her gloves and performed hand hygiene. On 11/29/23 at approximately 9:28 AM, an interview was conducted with Nurse A. Nurse A confirmed that she did not place a barrier on the over the bed table prior to placing Resident #5's medications on the table. When asked if Nurse A changed gloves and performed hand hygiene after pulling the resident up in bed and administering resident #5's medications, Nurse A stated she changed gloves but did not wash her hands. When asked if Nurse A changed gloves and perform hand hygiene in between administering resident #5's nasal spray and eye drops, Nurse A stated, No I did not, and I know better. Nurse A confirmed that this would be considered an infection control issue. On 11/29/23 at approximately 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that her expectation for infection control during medication administration is for the nurse to place a barrier in between medications and the over the bed table, and for the nurse to change gloves and perform hand hygiene in between administering nasal sprays and eye drops. A review of the facility policy titled Nursing Procedure Manual Medication Administration Nose Drops (dated January 2013) revealed, Purpose: To safely administer nose drops. Procedure: 6. Wash hands and apply gloves. 7. Assist resident/patient to lay back with head slightly lower than shoulders unless contraindicated. 10. Instill the number of drops ordered into each nostril. 12. Wipe any drainage with tissue. 14. Remove gloves and wash hands. A review of the facility policy titled Nursing Procedure Manual Medication Administration Eye Drops (also dated January 2013) revealed: Purpose: To safely administer medications to the eye(s). Procedure: 6. Assist the resident/patient into comfortable position for administration. 7. Wash hands. 8. Apply clean gloves. 16. Wash hands and apply new clean gloves if administering medication to the other eye. 17. Assist resident/patient into a comfortable position with call light in reach. 18. Remove gloves and wash hands.

Based on observation, resident and staff interviews, and record and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 21 sampled residents to self-administer medications. (Resident #16) The findings include: An observation of Resident #16 was conducted on 7/11/2022 at 2:01 PM. A medication cup containing 6 pills was observed to be sitting on her over bed table. No staff were present in the room with the medications and resident. (Photographic evidence obtained) An interview was conducted with Resident #16 on 7/11/2022 at 2:01 PM. Resident #16 stated the nurse does not have to observe her take her pills because she knows she will take them. An interview was conducted with Employee B (Licensed Practical Nurse) on 7/11/2022 at 2:04 PM. Employee B stated she had just walked out of the room and confirmed she leaves the pills with Resident #16 because she is good about taking them. She further confirmed she is supposed to watch the resident take her pills. Review of Resident #16's record revealed no assessments to conclude the resident was capable of self-administration of medications. An interview was conducted with the Director of Nursing (DON) on 7/13/2022 at 3:01 PM. The DON stated Resident #16 had not been assessed to self-administer medications. Review of the policy Medication Management: Self Administration of Medication Review (3F-3.7.1-A) with an original date of 05/2014 revealed the purpose of completing the Self Administration of Medication Review form is to evaluate the resident's ability to safely self-administer medications. The responsible person was listed as the Licensed Nurse. The policy indicated this review should be completed upon admission if the resident requests to self administer, when there is a change in clinical condition, and quarterly. Review of instructions revealed the following: Enter the resident information at the bottom of the form. Explain the questions and required demonstration to the resident. Enter a check mark next to each question that best describes resident's ability to complete task: a. fully capable, b. able with assist, c. unable, d. not applicable. Enter the signature/title and date as the person completing the evaluation. Enter date that the interdisciplinary team reviewed. Enter a check mark to indicate if approval to self-administer was granted. Enter a brief explanation if approval is not granted in the lines provided. Each member of the interdisciplinary team enters signature and title. File in resident's clinical record upon completion. Review of the policy Medication Administration (M 1.1) with an original date of 01/2013 instructed on page 2, item number 16, to remain with the resident until all medication is taken.

Based on resident and staff interviews and record and policy review, the facility failed to assist a resident with filing a grievance regarding missing items after receiving verbal report and failed to ensure prompt efforts to resolve the grievance for 1 of 1 sampled resident with missing items. (Resident #98) The findings include: An interview was conducted with Resident #98 on 7/11/2022 at 1:11 PM. The resident stated she had two (2) blankets missing for a couple of weeks now and had reported the missing items to Employee A (Certified Nurse Aide) a couple of weeks ago. A telephone interview was conducted with Employee A on 7/13/2022 at 9:55 AM. She stated not too long ago Resident #98 reported she had two (2) blankets missing. She further stated that she reported this to a laundry staff member. Employee A stated she did not assist the resident in filing a grievance regarding the missing items and not aware of the facility's grievance policy for missing items. An interview was conducted with the Social Services Director (SSD) on 7/13/2022 at 9:36 AM. The SSD stated she was in charge of grievances but was not aware of the missing blankets. Review of Resident #98's medical record revealed an admission Minimum Data Set (MDS)with an assessment reference date of 6/2/2022 indicating the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. The record indicated the resident was admitted to the facility on [DATE]. Review of the facility grievance logs for May, June, and July 2022 revealed no grievances filed on behalf of Resident #98. Review of Employee A's personnel file revealed she had received education regarding the facility's grievance process on 3/22/2021. Review of the policy Resident/Patient Grievance Process (Version 7.4) reviewed 12/2019 revealed a grievance is a concern or complaint that is unable to be immediately resolved and requires further investigation and action by facility leadership to achieve resolution. A grievance may be initiated at any time by any entity or anonymously upon identification of the grievance or complaint. Assist residents/patients who cannot prepare a written grievance without assistance.

Based on observations, resident and staff interviews and record reviews, the facility failed to ensure staff provided assistance with Activities of Daily Living (ADL) regarding nail care for dependent residents for 2 of 2 residents sampled. (Residents #54 and #98) The findings include: Observations of Resident #54 were conducted on 7/11/2022 at approximately 12:20 PM and 7/13/2022 at approximately 8:30 AM. Fingernails on both hands were observed to be long and discolored. The index fingernails, in particular, were so long they were beginning to twist. The resident's left hand was contracted into the palm. On 7/13/2022 at 8:21 AM, an interview was conducted with Resident #54. The resident stated she was told by a staff member that her nails would be cut but no one ever came to do it. A review of Resident #54's medical record revealed a principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The last quarterly Minimum Data Set (MDS) with an assessment reference date of 5/9/2022 revealed under Section G - Functional Status that the resident requires a one person physical assist with personal hygiene and bathing. Review of the bath/shower schedule revealed the resident receives a bath/shower on Monday, Wednesday, and Friday during the 7AM-3PM shift. A review of the bath/shower questions certified nurse aides (CNAs) chart on electronically in the Kardex revealed no questions concerning nail care. The medical record revealed no offer or refusal of nail care. The current care plan initiated 2/11/2019 and revised 5/12/2022 revealed the resident has a decline in ADL self-care performance after a stroke resulting in immobility on the left side. Interventions indicate staff will meet the resident's needs. Review of the bath/shower sheets maintained in a binder at the nurse's station revealed no completed bath/shower sheets for Resident #54. Further review revealed that nail care does not get documented on the bath/shower sheets. An interview was conducted with Employee C and Employee D, both CNAs, on 7/13/2022 at 8:45 AM. When asked who is responsible for nail care, Employee C stated that CNAs are responsible first, then activities staff. When asked where nail care gets documented, Employee C replied that she did not know. Employee C confirmed that nail care is typically performed on bath/shower days. During the interview, a joint observation was made of Resident #54's fingernails. Both Employees C and D confirmed the nails required attention. Employee D stated CNA staff refer residents to nursing when nails get that long because they are not comfortable cutting the nails themselves. Both Employees C and D reported this resident had not been referred to nursing. On 7/13/2022 at approximately 9:00 AM, an interview was conducted with Employee F, Charge Nurse. Employee F confirmed that bath/shower sheets do not contain a field for documenting completion of nail care. She stated that she expects nurses to identify necessary nail care during rounding and medication pass. She further stated if nursing receives a referral for nail care, she expects nursing to chart it in the medical record once completed. Review of nurse progress notes for Resident #54 for the last 6-months revealed no entries related to nail care referrals or nail care provided. Observations of Resident #98 were conducted on 7/11/2022 at 12:05 PM, 7/12/2022 at 4:20 PM, and 7/13/2022 at 9:00 AM. During these observations the resident was in bed and her fingernails were observed to be discolored and about 1-2 cm long past the nail bed. An interview was conducted with Resident #98 on 7/11/2022 at 12:05 PM. The resident stated the staff do not offer to trim her fingernails. Review of Resident #98's medical record revealed an admission MDS with an assessment reference date of 6/2/2022 indicating the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. Review of Section G - Functional Status revealed she required extensive assist of one person for personal hygiene. Review of the shower schedule revealed she was scheduled to be bathed/showered every Monday, Wednesday, and Friday on 3-11 shift. Review of the bathing documentation forms revealed she was bathed by staff on 6/29, 7/1, 7/7, 7/9, and 7/11. The form did not indicate if fingernail care was offered. The clinical record revealed no documented refusals of nail care. An interview was conducted with Employee F, Charge Nurse, on 7/13/2022 at 9:20 AM. She stated fingernail care and trimming is expected to be performed on bath days. Employee F observed Resident #98's fingernails during the interview and stated the fingernails were about 0.5 inch past the nail bed on her right hand and needed to be trimmed and cleaned: not quite as long on the left hand. She asked the resident if she wanted her nails trimmed and the resident replied, Yes. A review of the policy Nail Care (N 1.0) with an original date of 01/2013 revealed the purpose is to prevent infection and promote healthy nails. Further review revealed on page 2, item number 16, provide nail care according to resident/patient preference and need.

Based on observations, resident interviews, staff interviews, the facility failed to maintain ambient air temperatures at safe and comfortable levels following primary power failure status [REDACTED]. The facility failed to either move residents to cool zones or to monitor resident and ambient air temperatures in the uncooled D and E halls affecting 27 residents on E hall and 5 residents on D hall. The facility also failed to ensure emergency lighting in resident rooms in all 5 halls, A, B, C, D and E affecting all 82 residents in the building. Immediate Jeopardy was identified for concerns related to the facility's failure to ensure safe temperature levels status [REDACTED]. The outside temperature for this location reached 98°F with 40% humidity on 09/18/20. It was determined that without immediate corrective actions, the provider's non-compliance was likely to cause heat-related illness to residents, as temperatures within the facility's uncooled halls rose to as high as 86.5 degrees F. The Immediate Jeopardy was removed when the facility implemented immediate corrective actions of moving residents to cooled areas within the facility, monitoring temperatures and obtaining additional generators and cooling devices. The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy, at 4:30 PM on September 23, 2020. The scope and severity of the Immediate Jeopardy deficiencies were reduced from a K level to a E level, isolated no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Cross Reference to the federal Emergency preparedness Survey State of Deficiencies, Form CMS-2567 (02-99), Event ID OW1211 for E0015 citation, Exit Date 09/19/2020. The findings include: On 9/18/2020 at approximately 2:30 PM, an interview was conducted with the facility's Maintenance Director who stated that the power went out on 9/16/2020 at approximately 3:00 AM, and remained out at this time. He described the facility operations as having phone service, running water, functional sewer, partial HVAC (Heating, Ventilation, and Air Conditioning), life safety systems, and stated some resident rooms do not have lights. On 9/18/20 beginning at approximately 2:45 PM, a tour was conducted of the facility's E hall with the Maintenance Director. The facility had no utility power due to Hurricane Sally, and was operating on a generator. The Maintenance Director stated that the generator did not provide air conditioning to the D and E halls. Upon entering the E hall, the temperature was noticeably warm and uncomfortable. The hall was dark and a large fan was positioned at the end of the hall pointed toward resident rooms and was running. The surveyor and the Maintenance Director entered resident #4's room and observed the resident sitting up in bed with a fan on the bedside table blowing toward him. The fan was covered with a gray fuzz. Resident #4 reported being warm and sweating but added it's been hotter. Resident #4 asked the maintenance director for a flashlight before it gets dark out. At this time a temperature reading was taken, using a Fischer Scientific Hygro-Thermometer and noted the temperature to be 86.5 degrees Fahrenheit (F). (Photographic evidence obtained.) At this time the Maintenance Director left the hall to obtain a facility thermometer. While waiting for the Maintenance Director to return, observations were made of E hall resident #5. The door to the resident's room was open and the resident was observed uncovered, wearing only a brief, non-skid socks and a nasal cannula with an oxygen concentrator running next to the bed. The temperature obtained outside the door with the Hygro-Thermometer was 84.2 degrees F. The maintenance director returned with the facility thermometer (Commercial Electric Infrared Thermometer) and was asked to take a reading in the doorway of room resident #5's room which was 83 degrees F. The location of the thermometer readings was approximately 15 feet away from the large fan running in the hallway. The maintenance director returned resident #4's room and took temperature readings. The facility thermometer reading was 84.5 degrees F and the surveyor thermometer reading was 84.2 degrees F. On 09/18/20 at approximately 2:50 PM, an interview was conducted with E hall resident #10. The resident was fanning herself with a piece of paper. There was not a fan in the room. She said, It has been so hot in here. It has been hot every day. At this time the air temperature was recorded with a Fischer Scientific Hygro-Thermometer the temperature read 82.6 degrees Fahrenheit. On 09/18/20 at approximately 2:53 PM, the air temperature was recorded in room E 5 with a Fischer Scientific Hygro-Thermometer the temperature read 84.3 degrees F. On 09/18/20 at approximately 2:55 PM, an interview was conducted with E hall resident #11 during which she stated I am hot. It started in the middle of the storm. It has been terribly hot since the storm came through. I have told the staff. They have not done anything to make it better. On 09/18/20 at approximately 2:58 PM, the air temperature was recorded in room E 10 with a Fischer Scientific Hygro-Thermometer the temperature read 81.6 degrees F. On 09/18/20 at approximately 3:01 PM, the air temperature was recorded in room E 16 with a Fischer Scientific Hygro-Thermometer the temperature read 81.8 degrees F. On 09/18/20 at approximately 3:05 PM, the air temperature at the D and E hall nurses' station was taken with a Fischer Scientific Hygro-Thermometer the temperature read 82.4 degrees F. On 09/18/20 at approximately 3:10 PM, an interview was conducted with E hall resident #12. The resident said it has been very warm in here. On 09/18/20 at approximately 3:13 PM, an interview was conducted in E hall resident #13. The resident stated, it is too hot in here. On 09/18/20 at approximately 3:15 PM, an interview was conducted with E hall resident #14. The resident stated, the temperature is terrible. On 09/18/20 at approximately 3:20 PM, an interview was conducted with E hall resident #15. The resident stated, it has been kind of warm. Were any of these rooms near the nurse's station? On 09/18/20 at approximately 3:55 PM, the air temperature was rechecked at the D and E hall nurses' station with a Fischer Scientific Hygro-Thermometer the temperature read 82.9 degrees F. On 09/18/20 at approximately 4:00 PM, the Administrator arrived at the facility along with a representative from Emergency Support Function 8 (ESF8, Public Health and Medical Services) of the Emergency Operations Center (EOC) of Escambia County (ESF8 representative). A tour was conducted with the ESF8 representative. During the tour when entering E hall area. The representative stated It is hot in here. I'm hot. The Administrator stated that none of the residents had said anything to the facility about the heat. I just left the facility a few hours ago. We can move the residents to open beds in cooled areas of the facility. On 9/18/2020 at approximately 4:15 PM, the Director of Nursing (DON) said they hadn't been taking resident temperatures in relation to heat because no one had said anything about temperatures being too high. On 9/18/2020 at approximately 4:37 PM, an interview was conducted with the Administrator who stated they didn't take resident temperatures because it was comfortable that morning. The Administrator said she was aware the lights were not working in resident rooms and stated the facility is in a [AGE] year-old building and they've never been required to have emergency lighting in resident rooms. When asked if residents were provided with flashlights, she said they were not. On 9/18/2020 at approximately 5:00 PM, a follow up interview was conducted with the Administrator and DON during which they notified the Department of Emergency Management of the situation in the facility concerning temperatures in excess of 81 degrees F and lack of lighting in resident rooms and an evacuation plan was underway to remove residents from facility. On 9/18/2020 at approximately 5:02 PM, a teleconference was conducted with the Administrator and the corporate Chief Nursing Officer (CNO). The CNO confirmed she was aware the situation had been escalated to the Department of Emergency Management and the Governor's Office and said there were additional generators and coolers on the way to the facility. The CNO said the company wished for the residents to remain in the facility and monitoring of temperatures would occur every 30 minutes. When asked if she was aware the residents also did not have lighting in resident rooms, the CNO said she was not aware and said they would obtain portable flashlights for the residents. On 9/18/2020 at approximately 7:45 PM, the D and E hall Unit Manager was observed going to a linen closet near the D and E wing nurses' station. She stated, I can't see anything and walked away from linen closet to find a flashlight. On 9/18/2020 at approximately 8:00 PM, observations were made of staff members working to relocate residents off the E wing which was still uncomfortably warm. The area was also dark and attempts to take a temperature reading were made difficult because the thermometer did not have backlighting and display could not be read in the dark. On 9/18/2020 at approximately 10:06 PM, an observation was made of a Florida Department of Health Registered Nurse, who had arrived on site to provide rapid COVID-19 testing to residents on the facility's COVID isolation unit, stated that she could not see well enough inside the building to conduct testing. She added that a Certified Nursing Assistant (CNA) brought a resident to her for testing and the resident had been misidentified by the CNA. She was provided a headlamp light by the surveyor and went back inside building and resumed testing. On 9/19/2020 at approximately 2:00 AM, the Immediate Jeopardy was removed after 4 generators with portable air conditioning units were set up and working on the D and E halls. Temperature checks were 70.7 degrees F outside of room E7 on the E hall and 72.4 degrees F outside room D14 on the D hall. The Administrator was informed it was safe to move residents back to rooms on E hall and D hall and out of hallways. This facility became Medicare and Medicaid certified on 03/01/1998.

Based on review of the facility's security recorded camera video, record review, staff interview and policy review, the facility failed to promptly initiate basic life support including Cardio-Pulmonary Resuscitation (CPR) for 1 of 3 residents sampled for emergency care (#1). The facility neglected resident #1's needs for emergency care by failing to commence CPR until almost an hour after resident #1's respirations and heartbeat had ceased. The resident was full code status. The facility's failure to provide CPR, which resulted in a terminal neglect, was identified as past noncompliance Immediate Jeopardy (IJ). There were 109 of residents who were full code status at the time of the event. On [DATE] at 4:15 PM the Director of Nursing and Clinical Services Manager were informed of the determination of IJ. The IJ began on [DATE] at 4:15AM. The facility developed a corrective action plan, and IJ was removed on [DATE]. The facility completed all of their correction actions for the deficient practice on [DATE]. Cross reference to F678. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. Review of the facility's policy regarding abuse and neglect, Abuse Prevention Program & Reporting Policy, revised ,[DATE], revealed each resident has the right to be free from abuse, neglect, and mistreatment. The policy defines neglect as failure of the facility, it's employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. On [DATE] the facility filed a federal immediate report to the state agency for alleged neglect related to Registered Nurse (RN) staff A's delay in providing CPR to resident #1 who was found to be absent of pulse and respirations and was a full code. A nurses note authored by RN staff A on [DATE] documented as a late entry for [DATE] at approximately 4:30 AM documented that she was notified by a Certified Nursing Assistant (CNA) the resident #1 was not breathing, the resident was found to be a full code and CPR was initiated. The note did not detail the time line of the events. On [DATE], the surveyor reviewed the facility's recorded security camera video with the Administrator and Corporate nurse. The Administrator stated the time stamp on the camera is offset (reading early) by about 15 to 20 minutes, but was otherwise accurate. (A 4:00AM timestamp would actually be about 4:15AM). Based on the recorded video, the time line was established as follows (times below were not adjusted): On [DATE] at 4:00 AM, CNA staff B was at the nurses station with RN staff A (CNA staff B during an interview stated she was informing her the resident was not breathing). At 4:03 AM, staff A entered resident #1's room, then exited again and went to the nurse's station. At 4:04:49 AM, Staff A entered the residents room with a stethoscope and exited the room [ROOM NUMBER] seconds later at 4:04:59 AM. At 5:01 AM, Staff A was at a medication cart outside the resident's room and RN staff C approached her to inform her the resident was a full code and CPR was indicated. At 5:02 AM, RN staff C entered the room with the crash cart (a crash cart is a mobile cart equipped with machinery used during CPR). At 5:13 AM, emergency response personnel (EMS) arrived to the resident's room. On [DATE] at approximately 12:45 PM, the surveyor conducted a telephone interview with staff B (CNA) who stated she entered resident #1's room at approximately 4:15 AM and noticed the resident was not breathing. The staff went to the nurse's station and informed the RN staff A the resident was not breathing. The nurse came down to the room and said she had to go get her stethoscope to check for his apical pulse. RN staff A stated the resident was on Hospice so he didn't need CPR. Staff B stated she was standing next to staff A about 45 minutes later when RN staff C approached and told staff A the resident was a full code, and CPR was needed. Staff C and Staff B performed CPR until EMS arrived and pronounced the resident dead. On [DATE] at approximately 9:47 AM, the surveyor conducted a telephone interview with RN staff A. Staff A stated she was informed by the CNA (staff B) the resident was dead. She got her stethoscope and checked the resident who was absent of pulse and not breathing. The nurse stated she had been told the resident was on Hospice so she did not start CPR. The surveyor asked how long she listened for a pulse, and the nurse stated she listened for a full minute. The surveyor asked staff A at what point did she check the resident's record to find his code status? The nurse replied when she was looking for the contact information for the Hospice provider, she saw the resident was a full code. However, since she thought he was on Hospice, she still did not initiate CPR stating, some times these things change and people change their minds. She could not offer further insight as to why she did not initiate CPR other than the resident had last been checked 2 hours prior to this and had obviously been dead for some time. She had not seen the resident herself since rounding at 12:00 AM. The surveyor asked if she participated in providing CPR to resident #1, the nurse responded she did not actively participate because she was getting his record ready and waiting for EMS to arrive. The nurse stated she had a current CPR card and she had been instructed on the facility's CPR/DNR policies and procedures. Staff A stood by her statement she thought the resident was on Hospice, had been dead for some time and CPR was not indicated under those circumstances. On [DATE] at approximately 3:30 PM, the surveyor conducted an interview with the Clinical Services Manager (CSM) who stated the company was aware of the problem with CPR in the industry and had been taking a proactive approach to avoid these situations. However, this one nurse, despite training, decided not to perform CPR on a full code resident. As part of the investigation of this incident, nursing staff records were audited to ensure onboarding education was done. Audits were also done to ensure all staff had been previously educated on resident rights, abuse and neglect prevention and policies and procedures related to advanced directives, and that background checks and license verifications had been conducted. Prior to this incident, mock code drills were conducted at least monthly to cover all shifts and evaluated. After the incident, they conducted audits, additional mock code drills, and reviewed procedures covering all shifts and staff. The facility also conducted an audit of CPR training (verified by audit forms provided as evidence, staff interviews and sampled personnel records). The CSM stated the incident was reported to her in the very early morning on [DATE] and she developed an initial Quality Assurance and Performance Improvement (QAPI) plan to discuss with the QAPI team. Upon arriving to the facility on [DATE], the QAPI team approved and immediately went to work to implement the plan. They conducted a root cause analysis of the event, and determined that processes required to effectively train and communicate the facility's CPR policy and Abuse policy were in place. The root cause analysis identified one previously trained and Basic Life Support (BLS) certified Registered Nurse failed to validate the code status of her resident leading to a delay in the implementation of CPR. As part of the audits, Staff A's personnel file was reviewed and the RN had attended and participated in an abuse/neglect in-service as recently as [DATE] (evidence submitted). The RN participated in the in-service education on advanced directives and CPR as recently as [DATE] (evidence provided) and a mock code drill in (MONTH) 2019. On [DATE] at approximately 9:20 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated prior to the incident, the facility was conducting training on CPR and conducting mock codes. We had an in-service last month both on abuse and on CPR. The abuse training included recognizing, reporting and preventing abuse and the CPR training included checking the chart for code status, what to do when there is no DNR in the chart, and a mock code drill. She stated further, the nurses have annual competency checks and our standard is to conduct monthly in-services with mock code drills at least quarterly. We had 3 mock code drills in (MONTH) 2019 prior to the incident and have had 3 mock drills the day of/after the incident. For one of the mock code drills in April, prior to this incident, I personally came in at 2:30 AM to conduct the drill for the night shift. The DON provided the sign in sheets, which included RN, staff A). On [DATE] at approximately 3:45 PM, the surveyor conducted a telephone interview with the Medical Director who stated he was informed about the incident and involved in the QAPI response plan. The Medical Director stated the resident had many co-morbidities, was deaf and blind and may not have been revived by CPR. However, the resident was a full code and it was not up to any individual nurse to take it upon herself to decide otherwise. He stated CPR should have been initiated when the resident was found without a pulse. Review of personnel files found that RN A had attended training on Abuse policy on [DATE], Abuse Prevention and Reporting on [DATE], a training on Abuse and Resident Rights on [DATE] and [DATE], and took an abuse and neglect test on [DATE]. The facility provided a corrective action plan to the survey team upon arrival on [DATE]. The facility's corrective measures included the following: * The facility held an AdHoc QAPI meeting on [DATE] and on [DATE] with the medical director to discuss this incident, training and processes in place and develop and implement corrective actions. The survey team validated this was completed on [DATE]. * The Administrator/designee completed an audit of abuse screening (completed application, Federal Exclusion lists, background check, 2 references) on [DATE] to validate screening was in place. The survey team validated this was completed on [DATE]. *The Administrator/designee re-educated facility staff beginning [DATE] regarding abuse, neglect and exploitation. At least 90% of staff were re-educated by [DATE]. Staff were required to complete this education prior to working a their next shift. Staff are not be permitted to work until this education is completed. The survey team validated this was completed on [DATE]. *The facility Interdisciplinary Team interviewed all nursing staff working during the incident on [DATE] to identify details of the event and understanding of training. All staff interviewed were able to verbalize how to identify the code status of each resident. All staff interviewed were able to verbalize steps to take when a resident is identified without vital signs including RN A who did not immediately implement CPR. All staff clearly understood residents receiving Hospice services can also have full code status. The survey team validated this by also interviewing staff on [DATE] and on [DATE]. Licensed Practical Nurse (LPN) staff D was interviewed [DATE] at approximately 11:10 AM regarding training including advanced directives, CPR, abuse/neglect and mock code drills. She was able to easily verbalize both code and DNR (do not resuscitate) procedures, and where to locate this information. She confirmed training both before and after the incident and that she participated in a mock code drill yesterday, [DATE]. She added that they have drills all of the time. Registered Nurse (RN) staff C was interviewed [DATE] at approximately 2:56 PM regarding this training. She was also easily able to relate emergency procedures and where to locate advanced directive information. She confirmed training in abuse/neglect and advanced directives including mock codes both before and after the incident, including a mock code conducted the day before on [DATE]. Licensed Practical Nurse (LPN) staff F was interviewed [DATE] at approximately 2:40 PM regarding the emergency procedures and abuse/neglect training. LPN staff F stated they mock code drills every month, and she has participated in several including one yesterday, [DATE]. She stated a resident's code status is in at least 3 places, the hard chart, the electronic chart and the medication administration record. She confirmed training on advanced directives and abuse/neglect both before and after the incident. *The facility Interdisciplinary Team completed an audit on [DATE] to validate resident's advance directives were documented as required. Resident #1's medical record clearly indicated advance directives for a full code. All other current residents audited had clearly documented CPR/advance directives at the time of the audit. The survey team validated this was completed on [DATE]. *The DON/designee completed an audit of licensed nurses' BLS certification to validate all licensed nursing staff have current BLS certification. The survey team confirmed this was completed on [DATE]. *The facility completed an audit of licensed nurse attestations Commitment to Honoring Advance Directives was completed. The survey team validated this audit was completed on [DATE]. *The facility immediately suspended RN staff A, and reported her to the Florida nursing board.

Based on review of the facility's security recorded camera video, record review, staff interview and policy review, the facility failed to promptly initiate basic life support including Cardio-Pulmonary Resuscitation (CPR) for 1 of 3 residents sampled for emergency care (#1). The facility nursing staff did not begin cardio-pulmonary resuscitation until almost an hour after resident #1's respirations and heartbeat had ceased, and the resident died . Resident #1 was full code. The facility's failure to provide CPR, was identified as past non-compliance Immediate Jeopardy (IJ). There were 109 of residents in the facility who were full code status at the time of the event. On [DATE] at 4:15 PM, the Director of Nursing and Clinical Services Manager were informed of the determination of Immediate Jeopardy (IJ). The IJ began on [DATE] at 4:15AM. The facility develop a corrective action plan, and the IJ was removed on [DATE]. The facility completed all of their corrective actions for the deficient practice on [DATE]. Cross reference to F600. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. Review of the facility's policy and procedure for CPR entitled Code Status Orders & Response, with an effective date of (MONTH) (YEAR) revealed CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless there are Advanced Directives or a physician's orders [REDACTED]. In the absence of Advanced Directives or physician orders [REDACTED]. On [DATE] the facility filed a federal immediate report to the state agency for alleged neglect related to Registered Nurse (RN) staff A's delay in providing CPR to resident #1 who was found to be absent of pulse and respirations and was a full code. A nurses note authored by RN staff A on [DATE] documented as a late entry for [DATE] at approximately 4:30 AM documented that she was notified by a Certified Nursing Assistant (CNA) the resident #1 was not breathing, the resident was found to be a full code and CPR was initiated. The note did not detail the time line of the events. On [DATE], the surveyor reviewed the facility's recorded security camera video with the Administrator and Corporate nurse. The Administrator stated the time stamp on the camera is offset (reading early) by about 15 to 20 minutes, but was otherwise accurate. (A 4:00AM timestamp would actually be about 4:15AM). Based on the recorded video, the time line was established as follows (times below were not adjusted): On [DATE] at 4:00 AM, CNA staff B was at the nurses station with RN staff A (CNA staff B during an interview stated she was informing her the resident was not breathing). At 4:03 AM, staff A entered resident #1's room, then exited again and went to the nurse's station. At 4:04:49 AM, Staff A entered the residents room with a stethoscope and exited the room [ROOM NUMBER] seconds later at 4:04:59 AM. At 5:01 AM, Staff A was at a medication cart outside the resident's room and RN staff C approached her to inform her the resident was a full code and CPR was indicated. At 5:02 AM, RN staff C entered the room with the crash cart (a crash cart is a mobile cart equipped with machinery used during CPR). At 5:13 AM, emergency response personnel (EMS) arrived to the resident's room. On [DATE] at approximately 12:45 PM, the surveyor conducted a telephone interview with staff B (CNA) who stated she entered resident #1's room at approximately 4:15 AM and noticed the resident was not breathing. The staff went to the nurse's station and informed the RN staff A the resident was not breathing. The nurse came down to the room and said she had to go get her stethoscope to check for his apical pulse. RN staff A stated the resident was on Hospice so he didn't need CPR. Staff B stated she was standing next to staff A about 45 minutes later when RN staff C approached and told staff A the resident was a full code, and CPR was needed. Staff C and Staff B performed CPR until EMS arrived and pronounced the resident dead. On [DATE] at approximately 9:47 AM, the surveyor conducted a telephone interview with RN staff A. Staff A stated she was informed by the CNA (staff B) the resident was dead. She got her stethoscope and checked the resident who was absent of pulse and not breathing. The nurse stated she had been told the resident was on Hospice so she did not start CPR. The surveyor asked how long she listened for a pulse, and the nurse stated she listened for a full minute. The surveyor asked staff A at what point did she check the resident's record to find his code status? The nurse replied when she was looking for the contact information for the Hospice provider, she saw the resident was a full code. However, since she thought he was on Hospice, she still did not initiate CPR stating, some times these things change and people change their minds. She could not offer further insight as to why she did not initiate CPR other than the resident had last been checked 2 hours prior to this and had obviously been dead for some time. She had not seen the resident herself since rounding at 12:00 AM. The surveyor asked if she participated in providing CPR to resident #1, the nurse responded she did not actively participate because she was getting his record ready and waiting for EMS to arrive. The nurse stated she had a current CPR card and she had been instructed on the facility's CPR/DNR policies and procedures. Staff A stood by her statement she thought the resident was on Hospice, had been dead for some time and CPR was not indicated under those circumstances. On [DATE] at approximately 3:30 PM, the surveyor conducted an interview with the Clinical Services Manager (CSM) who stated the company was aware of the problem with CPR in the industry and had been taking a proactive approach to avoid these situations. However, this one nurse, despite training, decided not to perform CPR on a full code resident. As part of the investigation of this incident, nursing staff records were audited to ensure onboarding education was done. Audits were also done to ensure all staff had been previously educated on resident rights, abuse and neglect prevention and policies and procedures related to advanced directives, and that background checks and license verifications had been conducted. Prior to this incident, mock code drills were conducted at least monthly to cover all shifts and evaluated. After the incident, they conducted audits, additional mock code drills, and reviewed procedures covering all shifts and staff. The facility also conducted an audit of CPR training (verified by audit forms provided as evidence, staff interviews and sampled personnel records). The CSM stated the incident was reported to her in the very early morning on [DATE] and she developed an initial Quality Assurance and Performance Improvement (QAPI) plan to discuss with the QAPI team. Upon arriving to the facility on [DATE], the QAPI team approved and immediately went to work to implement the plan. They conducted a root cause analysis of the event, and determined that processes required to effectively train and communicate the facility's CPR policy and Abuse policy were in place. The root cause analysis identified one previously trained and Basic Life Support (BLS) certified Registered Nurse failed to validate the code status of her resident leading to a delay in the implementation of CPR. As part of the audits, Staff A's personnel file was reviewed and the RN had attended and participated in an abuse/neglect in-service as recently as [DATE] (obtained a copy). The RN participated in the in-service education on advanced directives and CPR as recently as [DATE] (obtained a copy) and a mock code drill in (MONTH) 2019. On [DATE] at approximately 9:20 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated prior to the incident, the facility was conducting training on CPR and conducting mock codes. We had an in-service last month both on abuse and on CPR. The abuse training included recognizing, reporting and preventing abuse and the CPR training included checking the chart for code status, what to do when there is no DNR in the chart, and a mock code drill. She stated further, the nurses have annual competency checks and our standard is to conduct monthly in-services with mock code drills at least quarterly. We had 3 mock code drills in (MONTH) 2019 prior to the incident and have had 3 mock drills the day of/after the incident. For one of the mock code drills in April, prior to this incident, I personally came in at 2:30 AM to conduct the drill for the night shift. The DON provided the sign in sheets, which included RN, staff A). On [DATE] at approximately 3:45 PM, the surveyor conducted a telephone interview with the Medical Director who stated he was informed about the incident and involved in the QAPI response plan. The Medical Director stated the resident had many co-morbidities, was deaf and blind and may not have been revived by CPR. However, the resident was a full code and it was not up to any individual nurse to take it upon herself to decide otherwise. He stated CPR should have been initiated when the resident was found without a pulse. Review of personnel files found that RN staff A had CPR training on [DATE]. RN staff A attended training on CPR, Advanced directives and Code Status on [DATE] and [DATE]. RN staff A participated in a CPR Mock Code on [DATE]. An attestation, Commitment to Honoring Advance Directives was completed without reservations and signed on [DATE] by RN staff A. The facility provided a corrective action plan to the survey team upon arrival on [DATE]. The facility's corrective measures included the following: * The facility held an AdHoc QAPI meeting on [DATE] and on [DATE] with the medical director to discuss this incident, training and processes in place and develop and implement corrective actions. *The facility Interdisciplinary Team interviewed all nursing staff working during the incident on [DATE] to identify details of the event and understanding of training. All staff interviewed were able to verbalize how to identify the code status of each resident. All staff interviewed were able to verbalize steps to take when a resident is identified without vital signs including RN A who did not immediately implement CPR. All staff clearly understood residents receiving Hospice services can also have full code status. The survey team validated this by also interviewing staff on [DATE] and on [DATE]. Licensed Practical Nurse (LPN) staff D was interviewed [DATE] at approximately 11:10 AM regarding training including advanced directives, CPR, abuse/neglect and mock code drills. She was able to easily verbalize both code and DNR (do not resuscitate) procedures, and where to locate this information. She confirmed training both before and after the incident and that she participated in a mock code drill yesterday, [DATE]. She added that they have drills all of the time. Registered Nurse (RN) staff C was interviewed [DATE] at approximately 2:56 PM regarding this training. She was also easily able to relate emergency procedures and where to locate advanced directive information. She confirmed training including mock codes both before and after the incident, including one conducted the day before on [DATE]. Licensed Practical Nurse (LPN) staff F was interviewed [DATE] at approximately 2:40 PM regarding the emergency procedures and abuse/neglect training. LPN staff F stated they mock code drills every month, and she has participated in several including one yesterday, [DATE]. She stated a resident's code status is in at least 3 places, the hard chart, the electronic chart and the medication administration record. She confirmed training on advanced directives and abuse/neglect both before and after the incident. *The facility Interdisciplinary Team completed an audit on [DATE] to validate resident's advance directives were documented as required. Resident #1's medical record clearly indicated advance directives for a full code. All other current residents audited had clearly documented CPR/advance directives at the time of the audit. The survey team validated this was completed on [DATE]. *The DON/designee completed an audit of licensed nurses' BLS certification to validate all licensed nursing staff have current BLS certification. The survey team confirmed this was completed on [DATE]. *The facility completed an audit of licensed nurse attestations Commitment to Honoring Advance Directives was completed. The survey team validated this audit was completed on [DATE]. *The DON/designee re-educated all nursing staff beginning [DATE] regarding the requirement to follow advanced directives, and 90% of staff were retrained by [DATE]. All staff are required to complete the re-education prior to working their next shift. Staff are not permitted to work until this education is completed. *The DON tested the competency of facility staff for code response, by completing a mock code on [DATE]. Mock codes were also conducted on each following shift on [DATE] and [DATE]. The facility had retrained 80 percent of nursing staff by [DATE] and over 90% by survey exit. The facility will continue conducting mock codes on multiple shifts daily until all staff are retrained. Staff are not permitted to work until this education is completed. *The facility immediately suspended RN staff A, and reported her to the Florida nursing board.

Based on record review, staff interview, and review of the facility's policy on smoking, the facility failed to ensure that 1 of 4 residents (#1) was provided adequate assessment and supervision with smoking to prevent injury. Failure resulted in the resident being burned and requiring a higher level of care. The findings are: Resident #1 was admitted to the facility on [DATE]. Admission data collection form indicated that the resident was not a smoker, and the history and physical that accompanied resident to the facility from the hospital also indicated that the resident denied tobacco use. Interview with physical therapy assistant (PTA) employee Aon 3/15/17 at 1:25pm revealed that the PTA had been working with resident #1 around the end of February 2017, when the resident indicated to him that he would like to smoke. The PTA relayed this information to the activities department and a smoking locker was obtained for the resident. An interview with the facility administrator on 3/15/17 at 10:53am revealed resident #1 was not a supervised smoker, as he was alert and oriented. The resident was provided a smoking locker for his cigarettes and other smoking materials. On 3/8/17 at approximately 1:49pm, resident #1 was involved in a smoking incident where he lit a cigarette in his room while in bed and subsequently caught himself and his bed linens on fire. The facility provided first aid to the resident and called emergency medical services (EMS). The resident was taken by EMS to a local hospital and then transferred to a specialized burn center for second degree burns to his groin area. Review of the resident's medical record showed a nursing note entered on 2/28/17 by LPN staff B indicating that resident #1 had been found with cigarettes in his room. The note also indicated that the cigarettes were taken from the resident and it was explained to him that he could not have cigarettes in his room and safe storage of smoking material was discussed with the resident. Further review of the record failed to demonstrate any type of assessment to indicate whether or not the resident was a safe smoker,and there was no plan of care related to the resident's smoking status. Review of the facility's policy on smoking was reviewed by the area office on 3/22/17 at 12:01pm. The policy entitled Smoking was last revised in December of 2015 and stated Smoking is prohibited in any resident rooms. Residents who smoke will be evaluated for smoking safety. Smoking materials will be secured by the facility, and residents who fail to adhere to the smoking policy will not be allowed to smoke. The policy further described the smoking procedure and included the following: (1) Facility will identify resident who requests to smoke and instruct resident on smoking policy. (2) Facility will evaluate the resident for smoking safety, and evaluation will include, but not be limited to, the Admission/Re-admission documents and Initial Care Plan, Smoking Safety Screen, the RAI/MDS, and physician orders. In a follow-up interview with the administrator on 3/22/17 at 10:11am, the administrator stated that the resident's desire to smoke had been brought to the attention of staff originally on 2/14/17 when resident #1 voiced this desire to PTA staff A. He stated that the resident's request was relayed to the activities department who handles implementation of the smoking policy and smoking activities for the residents. The activities department relayed this information to the interdisciplinary team on 2/15/17, and the resident was issued a smoking locker (approved location for storage of smoking material) on 2/16/17 when the facility also assisted him with the purchase of cigarettes. The administrator stated this is when the resident should have had a smoking safety assessment completed, and confirmed that this had not been done for resident #1. He was asked if the incident on 2/28/17, when resident #1 had been found with smoking materials, would have constituted reconsideration of the resident's ability to smoke safely, or independently and stated there was nothing to question his cognition or to indicate that he wouldn't have understood the discussion they held with him after the discovery. The administrator did indicate that the resident was Spanish speaking, but the facility did have a staff member who communicated with him. The administrator also confirmed that resident #1 had received initial education related to the smoking policy when he voiced the desire to smoke. The administrator was asked to provide a copy of the facility's formal smoking safety assessment form, which was reviewed on 3/22/17 at 12:32pm. The assessment entitled, Supervision of Smoking Data Collection, showed the assessor should review the following criteria to determine if the resident required supervision with smoking: (1) Resident's decision making ability and judgement (2) Resident's short and long term memory (3)Resident's awareness of safety needs and ability to communicate needs (4) Resident's ability to independently apply and remove smoking apron (5) Resident's ability to light his/her own cigarette (6) Resident's ability to hold cigarette without burning self (7) Resident's consistent and appropriate use of ashtray to extinguish cigarettes (8) Whether or not residetn provides cigarettes to peers who are cognitively impaired or need supervision (9) If the resident borrows cigarettes inappropriately (10) If the resident smoked only in designated areas (11) If the resident smoked only during designated times (12) If resident used oxygen (13) If resident was able to demonstrate ability and willingness to leave unsafe smoking situation (14) [DIAGNOSES REDACTED]. The assessment then directed staff completing to determine required smoking interventions needed by the resident and to confirm that resident received instruction on facility policiy and procedure including smoking times, and storage of smoking materials.

Based on observation, interview and record review the facility failed to develop a comprehensive plan of care for 1 of 21 sampled residents (#19) related to non-pressure related skin conditions and failed to develop a plan of care related to refusal of splinting devices which negatively impacted functional range of motion for 1 of 1 residents (#63) sampled for Range of Motion/Contractures, resulting in actual harm to resident #63. The findings are: 1. Record review for Resident #63 revealed a [DIAGNOSES REDACTED]. The record indicates the resident was hospitalized from [DATE]-4/1/11 [MEDICAL CONDITION], Pressure Ulcers, and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment with assessment reference date of 4/10/11 revealed the resident is dependent on staff for all activities of daily living (ADL's), is bedbound, has bilateral lower extremity functional impairment, a [DIAGNOSES REDACTED]. The assessment does not indicate the use of splinting devices. A Physical Therapy screen dated 1/23/11 indicates the resident is bedfast, has severe contractures, multiple positioning devices and that skilled therapy services are not warranted at that time, will continue to monitor. Interview with Resident #63's nurse on 5/2/11 at 11:42 AM revealed the resident has contractures to both lower extremities. She stated the resident does not receive either splinting or passive or active range of motion (ROM) services. Observations on 5/2/11 at 3:15 PM revealed Resident #63 sitting in upright in bed, watching TV. The resident was covered by a thin sheet with his legs in a tucked position and no knee splints were visible. The resident was observed in the same position again at 4:00 PM. On 5/3/11 at 9:40 AM the resident was observed sitting upright in bed with eyes closed, legs drawn up in tucked position, no knees splints on. The resident was observed again at 3:00 PM sitting upright in bed watching TV, legs drawn and tucked, no splints in place. On 5/4/11 at 10:50 AM the resident was observed during wound care rounds with the facility wound care doctor. The doctor entered the resident ' s room and found him in bed in semi-upright position with legs drawn up towards buttocks, no splints in place. The doctor immediately began chastising the resident for refusing to wear splints, refusing protein supplements, and refusing repositioning. The doctor went to the closet and pointed the knee splints out to the resident, stating "they don't do you any good up here". He told the resident the splints need to be worn to prevent skin to skin contact and pressure between skin surfaces, he insisted the resident must allow staff to put the splints on for him as ordered. Observations during and immediately following wound care rounds revealed 2 staff CNA's positioning the resident for wound care and dressing changes by a staff LPN. Following completion of the dressing changes, both CNA's left the room without offering or encouraging the use of the knee splints, both had been present in the room during the doctor's lecture to the resident regarding use of the splints. The LPN did not attempt to apply the splints nor ask the resident if he would allow application of the splints either, but did position a pillow between the resident's knees. The LPN was also present during the doctor's rounds. 5/5/11 9:30 AM resident observed sitting upright in beds watching TV, no splints in place, pillow between knees. Resident observed again at 12:50 PM sitting up in bed eating lunch, no splints in place, legs drawn up under him. 5/6/11 at 9:40 AM resident observed sitting upright in bed, legs drawn and tucked under him, no knee splints on. Record review revealed a physician's orders [REDACTED]. The resident was hospitalized from [DATE] to 4/1/11. Progress notes from both nursing and the wound care doctor document a history of non-compliance with care and treatments including refusal of splints, protein supplements, and repositioning. Wound care progress note dated 4/27/11 states "not using dynamic contracture splints - new breakdown", "STILL GROSSLY CONTRACTED, NOT USING SPLINTS, COMPETENT - REFUSES". The record does not contain any documentation of application of splints nor active or passive ROM since readmission on 4/1/11 nor the period of time immediately prior to hospitalization . There is no care plan related to functional limitations, ROM, or splinting, nor of refusal of splinting or ROM. Interview on 5/4/11 at 10:40 AM with the resident's CNA revealed the resident is only able to do minor repositioning for himself, mostly of the upper body. Lower extremity repositioning must be done by staff and the resident usually refuses. She stated he refuses to wear splints to his legs, refuses to have his legs straightened out in the bed, and keeps them tucked up to his butt. Interview on 5/5/11 at 12:45 PM with the unit nursing manager confirmed there is no care plan related to ROM or use of splints, she described the resident's long history of refusal of splinting and other care and treatments and acknowledged the resident had not been reassessed for use of or need for splints following his return from the hospital on [DATE]. Record indicated there was no plan of care related to resident refusal of care. Interview on 5/6/11 at 9:25 AM with the facility Physical Therapist revealed he had just completed a new screen and evaluation on Resident #63 this morning in response to a new MD order. He stated the resident's contractures have gotten worse and therapy will be seeing him 3 times a week for at least 4 weeks for ROM and contracture management followed by a functional maintenance program by floor staff or a restorative nursing program when PT goals have been met. He stated the splints the resident currently have are no longer effective due to his decline in functional condition and the splints must be re-designed. The facility staff did not initiate a treatment plan for the resident's range of motion (ROM) until 5/6/11. This documentation indicates ROM Right lower extremity knee extension: -120 degrees post stretching; Left lower extremity knee extension: -90 degrees post stretching. This assessment was compared to the last one for this resident dated 7/30/10 which indicated Right knee extension: -70 degrees with passive stretching, Left knee extension: -72 degrees with passive stretching. Interview on 5/6/11 at 10:20 AM with the Physical Therapist confirmed these treatment plans document significant decrease in knee extension and worsening of functional ROM for this resident. Interview with the unit nursing manager on 5/6/11 at 10:55 AM revealed the resident has a long history of non-compliance with splinting devices. She stated that although there was no specific order for splints upon return from the hospital on [DATE], she would be under the understanding that the splints would have been continued the same as before the hospitalization . She stated passive range of motion (PROM) is provided by floor staff (CNA's) during provision of routine resident care, this would not be specifically documented. The only PROM documentation would be if the resident were being provided PROM by the restorative nursing staff. Interview with the wound care doctor on 5/6/11 at 11:20 AM revealed continued comments regarding the resident's non-compliance with splinting and other treatments. When asked why an order for [REDACTED]. He stated he writes a new order (renews the order) for splinting "every couple of months" just to stress how important splinting is for this resident. He stated is was his hope/expectation that staff are offering the splints daily, and should have been doing so prior to his renewal order dated 5/4/11. 2. Observations on 5/4/11 at approximately 9:15 AM revealed resident #19 had a small scabbed area on the tip of her nose. The resident stated the scab was from a previous surgery that was done by the Dermatologist. She further stated that it seems to heal and then scabs over again and again. During interview on 5/5/11 at approximately 10:30 AM a staff nurse stated the resident had a [MEDICAL CONDITION] removed by the dermatologist back last fall. She further stated the resident has a [DIAGNOSES REDACTED]. She will just about get the area at the end of her nose healed up and within a day or two she has picked the scab off and irritated again. The area is medicated with antibiotic ointment in an attempt to get it healed. Review of the resident's clinical record revealed a physician order [REDACTED]. Further review of the resident's record revealed a Plan of Care, dated 3/13/11, indicating the resident is at risk for skin impairment, The Problem is documented as: "resident is at risk for skin breakdown due to [DIAGNOSES REDACTED]. She was recently admitted with wounds to leg (right lower extremely)." The Goal and Target Date are documented as: "Wounds will show signs of healing thru nrd (next review date): 6/13/11." The Plan of Care related to resident skin condition does not address the [DIAGNOSES REDACTED]. During interview on 5/5/11 at approximately 2:55 PM, facility staff confirmed the lack of care plan related to the resident's non-healing wound on her nose and stated that this problem should have been addressed on the resident's skin integrity care plan. Further review of the plan of care on 5/6/11 revealed a revision to the care plan by staff on 5/5/11 which reads: Problem - "Resident is noted to have scabbed area to top of nose. Resident has had this area before and staff has noted her to be continuously picking at the noted area and other areas preventing the areas to heal." Interventions added to the care plan on 5/5/11 include: "Staff will encourage resident not to pick at wounds. Psych Consult PRN (as needed) for behaviors."

Based on observation, record review and interview the facility failed to ensure that 1 of 1 sampled residents reviewed related to functional range of motion (#63) received care and services to address refusal of care, which negatively impacted resident care related to potential fot improvement of functional range of motion/ prevention further deterioration in range of motion. This resulted in actual harm to resident #63. The findings are: Record review for Resident #63 revealed a [DIAGNOSES REDACTED]. The record indicates the resident was hospitalized from [DATE]-4/1/11 [MEDICAL CONDITION], Pressure Ulcers, and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment with assessment reference date of 4/10/11 revealed the resident is dependent on staff for all activities of daily living (ADL's), is bedbound, has bilateral lower extremity functional impairment, a [DIAGNOSES REDACTED]. The assessment does not indicate the use of splinting devices. A Physical Therapy screen dated 1/23/11 indicates the resident is bedfast, has severe contractures, multiple positioning devices and that skilled therapy services are not warranted at that time, will continue to monitor. Interview with Resident #63's nurse on 5/2/11 at 11:42 AM revealed the resident has contractures to both lower extremities. She stated the resident does not receive either splinting or passive or active range of motion (ROM) services. Observations on 5/2/11 at 3:15 PM revealed Resident #63 sitting in upright in bed, watching TV. The resident was covered by a thin sheet with his legs in a tucked position and no knee splints were visible. The resident was observed in the same position again at 4:00 PM. On 5/3/11 at 9:40 AM the resident was observed sitting upright in bed with eyes closed, legs drawn up in tucked position, no knees splints on. The resident was observed again at 3:00 PM sitting upright in bed watching TV, legs drawn and tucked, no splints in place. On 5/4/11 at 10:50 AM the resident was observed during wound care rounds with the facility wound care doctor. The doctor entered the resident ' s room and found him in bed in semi-upright position with legs drawn up towards buttocks, no splints in place. The doctor immediately began chastising the resident for refusing to wear splints, refusing protein supplements, and refusing repositioning. The doctor went to the closet and pointed the knee splints out to the resident, stating "they don't do you any good up here". He told the resident the splints need to be worn to prevent skin to skin contact and pressure between skin surfaces, he insisted the resident must allow staff to put the splints on for him as ordered. Observations during and immediately following wound care rounds revealed 2 staff CNA's positioning the resident for wound care and dressing changes by a staff LPN. Following completion of the dressing changes, both CNA's left the room without offering or encouraging the use of the knee splints, both had been present in the room during the doctor's lecture to the resident regarding use of the splints. The LPN did not attempt to apply the splints nor ask the resident if he would allow application of the splints either, but did position a pillow between the resident's knees. The LPN was also present during the doctor's rounds. 5/5/11 9:30 AM resident observed sitting upright in beds watching TV, no splints in place, pillow between knees. Resident observed again at 12:50 PM sitting up in bed eating lunch, no splints in place, legs drawn up under him. 5/6/11 at 9:40 AM resident observed sitting upright in bed, legs drawn and tucked under him, no knee splints on. Record review revealed a physician's orders [REDACTED]. The resident was hospitalized from [DATE] to 4/1/11. None of these orders were resumed upon return from the hospital. An Occupational therapy screen was conducted upon return from the hospital on [DATE] indicating no need for skilled therapy service. No Physical therapy screen was conducted upon return from the hospital. An order from the resident's wound care doctor dated 5/4/11 caledl for contracture splints to knees 24/7. This order was not written until 5/4/11. Progress notes from both nursing and the wound care doctor document a history of non-compliance with care and treatments including refusal of splints, protein supplements, and repositioning. Wound care progress note dated 4/27/11 states "not using dynamic contracture splints - new breakdown", "STILL GROSSLY CONTRACTED, NOT USING SPLINTS, COMPETENT - REFUSES". The record does not contain any documentation of application of splints nor active or passive ROM since readmission on 4/1/11 nor the period of time immediately prior to hospitalization . There is no care plan related to functional limitations, ROM, or splinting, nor of refusal of splinting or ROM. Interview on 5/4/11 at 10:40 AM with the resident's CNA revealed the resident is only able to do minor repositioning for himself, mostly of the upper body. Lower extremity repositioning must be done by staff and the resident usually refuses. She stated he refuses to wear splints to his legs, refuses to have his legs straightened out in the bed, and keeps them tucked up to his butt. Interview on 5/5/11 at 12:45 PM with the unit nursing manager confirmed there is no care plan related to ROM or use of splints, she described the resident's long history of refusal of splinting and other care and treatments and acknowledged the resident had not been reassessed for use of or need for splints following his return from the hospital on [DATE]. Record review failed to demonstrate there was any active care plan for these areas. Interview with the unit nursing manager on 5/6/11 at 10:55 AM revealed the resident has a long history of non-compliance with splinting devices. She stated that although there was no specific order for splints upon return from the hospital on [DATE], she would be under the understanding that the splints would have been continued the same as before the hospitalization . She stated passive range of motion (PROM) is provided by floor staff (CNA's) during provision of routine resident care, this would not be specifically documented. The only PROM documentation would be if the resident were being provided PROM by the restorative nursing staff. Interview with the wound care doctor on 5/6/11 at 11:20 AM revealed continued comments regarding the resident's non-compliance with splinting and other treatments. When asked why an order for [REDACTED]. He stated he writes a new order (renews the order) for splinting "every couple of months" just to stress how important splinting is for this resident. He stated is was his hope/expectation that staff are offering the splints daily, and should have been doing so prior to his renewal order dated 5/4/11. Interview on 5/6/11 at 9:25 AM with the facility Physical Therapist revealed he had just completed a new screen and evaluation on Resident #63 this morning in response to a new MD order. He stated the resident's contractures have gotten worse and therapy will need to see him 3 times a week for at least 4 weeks for ROM and contracture management followed by a functional maintenance program by floor staff or a restorative nursing program when PT goals have been met. He stated the splints the resident currently have are no longer effective due to his decline in functional condition and the splints must be re-designed. The facility staff did not initiate a treatment plan for the resident's range of motion (ROM) until 5/6/11. This documentation indicates ROM Right lower extremity knee extension: -120 degrees post stretching; Left lower extremity knee extension: -90 degrees post stretching. This assessment was compared to the last one for this resident dated 7/30/10 which indicated Right knee extension: -70 degrees with passive stretching, Left knee extension: -72 degrees with passive stretching, indicating a decline. Interview on 5/6/11 at 10:20 AM with the Physical Therapist confirmed these treatment plans document significant decrease in knee extension and worsening of functional ROM for this resident.