Every finding on record at Avante at Boca Raton, Inc.

Based on observation and interviews the facility failed to follow their tracheostomy care policy by ensuring nurses are trained and competent according to professional standards of care. The facility failed to ensure sterility was maintained during tracheostomy suctioning for 1 of 3 sampled residents (Resident #3). The findings included: A record review of the facility's policy titled, Respiratory/Tracheostomy Care and Suctioning, revised on 03/26/21, documented the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive care plan and residents goals and preferences (Policy). The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice (Procedures: 5). Records review revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. A review of the most recent Minimum Data Set (MDS) dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 9 indicating Resident #3 had moderately impaired cognition. A review of orders dated 06/10/26, documented that the resident may be suctioned every 2 hours, and as needed via tracheostomy. During an observation conducted on 08/11/26 at 2:08 PM with Staff C, a Registered Nurse (RN,), and the DON who stated that they are ready for the tracheostomy suctioning for Resident #3.Staff C, RN entered the room and kept Resident 3's door open for the entire procedure, while the DON was standing outside the door.Staff C, RN performed hand washing, donned Personal Protective Equipment (PPE) gown, gloves and mask. She went straight to the overbed table on resident's left side and started touching the supplies on top of it.The supplies observed were a rolled white [NAME] towel, a face shield, a yankeur suction kit, a blue PPE gown, an irrigation syringe plastic package, a tracheostomy kit, and 2 small, 15 milliter (ml) sterile saline containers.The tracheostomy kit contained a 500-cc tray, a cleaning brush, two 4x4 non-woven gauzes, 2 pipe cleaners, 1 pair of vinyl gloves, 2 cotton tipped applicators, 1 twill tape, 1 tracheostomy dressing, 1 waterproof drape, and 1 pop-up basin. Staff without informing the resident what she will be performing, placed the rolled white [NAME] towel on top of resident's left side. She did not unroll the towel. The resident had an oxygen mask on top of tracheostomy site and was observed to have some pinkish, thick secretions on the left side of the mask, on the tracheostomy site. Staff C, RN, without informing the resident what she is going to do, tried to untie the tracheostomy collar on the left side of the resident. When she was unsuccessful on that side, she went to the resident's right side. The resident started coughing, and secretions came out of the right side of her mouth. There were more pinkish, thick secretions observed on the tracheostomy site. Staff C, RN continued what she was doing, until the surveyor told her to perform suctioning because the resident seemed to be having anxiety, and was having a lot of pinkish, thick secretions collecting on the tracheostomy site. Staff C, RN stopped the collar untying and grabbed a yankeur suction tip inside a partially opened plastic bag and connected to an undated suction tubing on top of the bedside table. Staff C, RN turned on the suction machine after connecting the yankeur suction tip onto the suction tubing. She started suctioning the resident's mouth. The resident would not let go of the yankeur suction tip. Staff C, RN begged the resident multiple times to let go of the yankeur suction tip. When the resident let go of the yankeur suction tip, Staff C, RN put it back on top of the bedside table inside it's package. When asked how often to change the suction tip and tubing, she did not respond.Staff removed her gloves, did not perform hand hygiene and then applied the pulse oximeter on the resident's left pointer finger. Staff C did not state the oxygen saturation reading. Staff C, RN opened the sterile tracheostomy kit. With bare hands she picked up the sterile package of gloves from the kit and donned them on both hands. With sterile gloved hands, she picked up the plastic lined pop-up basin from the tracheostomy kit and placed it on the left side of the overbed table. With the same sterile gloved hands, she picked up one 15 ml saline container on top of the table and squirted its contents onto the pop-up basin. When she was asked if she had followed sterile technique, she did not respond. Staff C, RN , then picked up a sterile suction tubing from the tracheostomy kit, then opened the resident's drawer, then attached the end of the sterile suction tubing onto the end of the undated suction tubing connected to the suction machine. Staff C, RN inserted the end of the sterile suction tip inside the resident's tracheostomy. She used her right hand to insert the suction and the left hand to control the suctioning. Staff C, RN, performed it a few times, then she pulled out the suction tip and placed it on top of the kit. With the same gloves, she went back into the resident's bedside drawer. She did not verbalize what she was looking for. She then went back to the overbed table, took a sponge from the tracheostomy kit, squirted some saline solution on top of the gauze sponge and cleansed the right tracheostomy site. She did not cleanse the left side. Staff C, RN went to the drawer again, then on the overbed table, picked up a split dressing sponge, and used it to cleanse at the top of tracheostomy site. Then applied the dressing to the tracheotomy site on 08/11/26 at 2:42 PM. The DON was informed outside the resident's door that the staff did not follow the sterile technique and did not seem to know when to start suctioning . The DON was asked for the training sheets for tracheostomy care for all staff nurses. In a continuing interview conducted with the Director of Nursing (DON) on 08/11/26 at approximately 2:45 PM, when asked if staff receive tracheostomy training, he did not respond. When asked who assesses the skills of staff regarding tracheostomy care, he did not respond. In an interview conducted on 08/11/26 with Staff B, RN who has been working in the facility for one year, when asked if she had received tracheostomy training, she responded, no. When asked if they have Nursing Staff Educator or Staff Development Coordinator, she did not respond.The DON, who was present during this interview, stated that staff get training every other Thursday. Staff B, RN added that she is off every Thursday, and no one informed her to attend the meeting and in-service training every other Thursday. When the DON was asked to submit the sign in sheet for those in-services every other Thursday, he did not respond. When asked to submit the staff in-services regarding tracheostomy care, he did not respond. No staff in services sign in sheets were submitted to the surveyor. When Staff B, RN asked how she would perform tracheostomy care to a resident, she responded, she does not have any resident with a tracheostomy. When asked if she had taken care of a resident with tracheostomy, she responded, yes, a few months ago.When asked her complete process on how she would provide tracheostomy suctioning, she verbalized the process, but she failed to ensure sterile technique is followed. She also did not know what to do when the resident is showing signs and symptoms of respiratory distress during tracheostomy care. In an interview conducted on 08/11/26 at 2:04 PM with Staff D, a RN who has been working in the facility since 2019, when asked to verbalize her process in tracheostomy care, she also failed to verbalize her process following aseptic technique.She tried 3 times to verbalize the step-by-step process but failed to explain how she would maintain sterile technique.When asked if she had attended in-services regarding tracheostomy care, she responded, no, no one gave them training. When asked if she had been taking care of residents with tracheostomy, she responded, yes, all the time. When asked how she knew how to perform tracheostomy care, she responded, she learned it from nursing school. When asked if the DON assess their skills and knowledge in performing tracheostomy care, she responded, no, no one checks us.

Based on interview and record review the facility failed to provide care and services to meet the needs for 2 of 3 residents investigated for Quality of Care, Resident #1 and Resident #2.The findings include:(1) Resident #1 did not receive necessary doses of an expensive multidrug antibiotic and subsequently returned to the hospital to continue treatment. On 12/08/25 at 2:26 PM, an interview was conducted with the Admissions Director (AD). The AD explained that the admission process can start a week prior to admission, which was the case for Resident #1. The AD stated that he would receive the admissions information from the hospital to determine if the facility was appropriate for the admission. According to the AD, he enters the medication list into the pharmacy's computer system to check for availability for all medications required. The AD stated that when he entered the information for the IV Antibiotic Recarbio, he entered the wrong dosage amount by entering milligrams instead of grams. This error caused the pharmacy's computer system to not flag the medication as expensive. The AD explained that when Resident #1 physically arrived at the facility the AD saw the actual dosage and when he re-entered the dosage it flagged as an expensive medication. This caused the medication to be rejected. The AD further explained that since the error occurred, he was not certain if the facility put in any measures to try to prevent this error from occurring again. On 12/09/25 at 2:30 PM, The Regional Nurse Consultant (RNC) was interviewed regarding the antibiotic issue for Resident #1. The RNC stated she had investigated the problem with the IV antibiotic. The RNC stated that the medication had to be compounded at the pharmacy's [NAME] facility and then shipped to the Long-Term Care facility. The RNC stated she was informed by the pharmacy that it would take 24 to 48 hours before the product would arrive. The RNC stated that when the family was informed, they requested Resident #1 be sent back to the hospital to continue treatment. This request was granted. On 12/09/25 at 9:11 AM, the Medication Administration Record (MAR) was reviewed for Resident #1. Resident #1 missed 5 antibiotic doses spanning between admission and his transfer back to the hospital. (2) On 12/08/25 at approximately 11:00 AM, during a record review for Resident #2, a nurse's progress note documented Resident #2 had been experiencing a nosebleed (Epistaxis). The nurse documented that he instructed Resident #2 to sit forward and pinch her nose. The note documented that the nurse called the Director of Nursing (DON) and the doctor. The note was dated 11/27/25 at 22:36 (10:36 PM). A second note dated 11/28/25 at 6:50 AM indicated that Resident #2 had a change in condition and was sent to the hospital with a low blood pressure of 78/50. Resident #2 was described as lethargic. Doctor's Orders revealed Resident #2 had been ordered Ticagrelor 90 mg tablets twice a day and Aspirin 81 mg once a day. Ticagrelor is an antiplatelet medication. Aspirin also has antiplatelet properties. On 12/08/25 at 2:13 PM, an interview was conducted with Staff A who was the primary nurse for Resident #2. Staff A had worked the 3:00 PM to 11:00 PM shift on 11/27/25 and continued working from 11:00 PM on 11/27/25 to 7:00 AM 11/28/25. During the interview Staff A explained that when he was rounding at 22:36 (10:36 PM) he noted Resident #2 was having a nosebleed. Staff A stated he had Resident #2 pinch her nose and to lean forward to stop the bleeding. Staff A stated Resident #2 felt uncomfortable leaning forward and she leaned back instead. Staff A stated he called the doctor and the DON, but it seemed like the bleeding stopped not too long after. When Staff A was asked if he monitored Resident #2 throughout the night, he stated he had. When asked why there was no documentation of observations throughout the night, Staff A answered he must have forgotten but that didn't mean he wasn't monitoring Resident #2. On 12/09/25 at 11:01 AM, a telephone interview was conducted with Staff B, who was the Certified Nursing Assistant (CNA) assigned to Resident #2 from 3:00 PM to 11:00 PM on 11/27/25. Staff B stated that around 10:30 PM she checked on Resident #2 and saw the resident had a nosebleed. Staff B then reported the nosebleed to the nurse. Staff B stated she did not check Resident #2 after that because it was the end of her shift and she was going home. When asked to describe Resident #2's nosebleed she stated it was a little bit, like a trickle. On 12/09/25 at 11:16 AM, a telephone interview was conducted with Staff C, who was the CNA assigned to Resident #2 from 11:00 PM 11/27/25 to 7:00 AM 11/28/2025. Staff C stated that when she came on Resident #2 was bleeding a lot. Staff C stated she had to clean the floor, and the bed from all the blood. Staff C stated that she had to change Resident #2's clothing also. Staff C stated that she provided a towel to Resident #2 so she could wipe the blood from her face. Staff C stated that she replaced the towel 3 times. Staff C stated that at some time during her shift Resident #2 asked to be put in a diaper because she felt too tired to get up and go to the bathroom. Staff C stated she told the nurse and he called the doctor. Staff C stated she was not sure when she told the nurse and when the nurse called the doctor.

Based on observations, interviews and record reviews, the facility failed to store, serve and prepare foods in a sanitary manner in accordance with standards for food safety professionals. The findings included: 1. During the initial kitchen tour, on 09/02/25 at 9:40 AM, accompanied by the Dietary Manager and the Certified Dietary Manager (CDM) from a sister facility, the following were noted: a. There was an accumulation of residue on the handles of the ovens.b. There was an accumulation of dust and debris on pipes over cooking equipment and food preparation table. c. In the walk-in cooler, there was a full sized six-inch-deep pan of raw chicken stored on a shelf directly over a five-pound package of raw ground beef on speed rack. d. There was peeling paint, dust and rust in the vents of the a/c [air-conditioner] handler over a cart that was stored in the area that contained coffee and single service condiments (sugar, creamers).e. There was an accumulation of condensation in the opening from the processing area to the room where the air handler was located and the cart containing coffee and single service condiments (sugar, creamers).f. There was an accumulation of food debris on exterior of the doors of the mechanical ware washing machine. 2. During an observation of the kitchen, on 09/03/25 at 6:55 AM, the following were noted: a. The handles of utensils that were in the three-compartment sink appeared to be damaged in a manner indicative of being melted and determined to no longer be easily cleanable. b. A portion of the wall over the sanitizer basin of the three-compartment sink was cracked and the corner of the window frame was coming apart. 3. During the follow up kitchen tour, on 09/04/25 at 11:23 AM, accompanied by the Dietary Manager and the CDM from a sister facility, the following were noted:a. Staff K, Dietary Aide, was observed with her bare thumb in direct contact with cleaned and sanitized, mouth and food contact surfaces of utensils while portioning for lunch. b. Staff K, Dietary Aide was observed drying cleaned and sanitized utensils with paper napkin prior to wrapping for the lunch meal.c. Staff K, Dietary Aide was noted to be wearing a watch while handling cleaned and sanitized utensils. Staff K was directed to remove the watch and perform hand hygiene before continuing to handle the wares.d. Staff L, Dietary Aide was observed handling dirty wares inserting them into the dirty side of the mechanical ware washing machine. As the cleaned and sanitized wares were coming out of the machine, the machine became backed up and Staff L was unable to put more items in the machine and began handling the cleaned and sanitized wares with same gloved hands as handling the dirty wares. e. Portions of the shelf that supports trays while staff are plating the meal held with duct tape.

Based on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 18 of 90 resident rooms in the facility affecting rooms 122, 125, 129, 130, 202, 204, 208, 109, 111, 112, 300, 313, 315, 325, 215, 219, 228, and 230, 1 of 3 nursing stations (nursing station for 200 Unit), in 1 of 1 entrance in front of kitchen, and 1 of 1 smoking patio. The findings included: Review of the facility's policy titled, Resident Right- Safe/Clean/Comfortable Homelike Environment, issued and revised date of 03/02/19, included in part the following: It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights. Observation revealed the following: 1. On 09/02/25 at 10:50 AM, an observation was made in room [ROOM NUMBER] of an overwhelming odor of urine in the room. 2. On 09/02/25 at 11:00 AM, an observation was made in room [ROOM NUMBER] of a resident in wheelchair in the doorway of the bathroom with the emergency pull cord wrapped around the grab bar. 3. On 09/02/25 at 11:05 AM, an observation was made in room [ROOM NUMBER] in bathroom of the emergency pull cord about 12 inches from the floor (short cord). 4. On 09/02/25 at 9:55 AM an observation was made in room [ROOM NUMBER] in the bathroom of the emergency pull cord wrapped around the grab bar. 5a. On 09/02/25 at 10:36 AM, an observation was made in room [ROOM NUMBER] of air conditioning (A/C) not blowing cold air, just cool air. The A/C temperature was set at 60 degrees Fahrenheit (F), and emergency pull cord in bathroom was wrapped around the grab bar. 5b. On 09/02/25 at 10:40 AM, an observation was made in room [ROOM NUMBER]-1 of the bed which did not go up and down, and a cut cord from the bed was on the floor under the bed. 6. On 09/02/25 at 10:30 AM, an observation was made in room [ROOM NUMBER]-2 of privacy curtain with reddish brown marks, strong smell of urine and the bathroom emergency pull cord approximately 18 inches from the floor (short cord). 7 On 09/02/25 at 10:26 AM an observation was made in bathroom of room [ROOM NUMBER] of emergency pull cord approximately 24 inches from the floor (short cord) and missing tile on wall behind toilet. An interview was conducted on 09/03/25 at 2:10 PM with the Director of Maintenance (DOM), who stated he has worked at the facility in maintenance department for 11 years and in the Director role for the past 1.5 years. When asked about issues with maintenance, he stated the staff can report this to the maintenance department in several ways. They can put the issue in TELS system located in the computer or put it in one of the log books located at each of the 2 the nursing stations, or Managers can put it in a group chat (text type on phone) that is seen in real time. The DOM stated that most staff put the issues directly into the TELS system. The DOM stated his department checks the log books located at the nursing stations minimally every morning. During a tour of part of the facility conducted on 09/03/25 at 2:25 PM with the DOM, he acknowledged the above findings. 8. On 09/02/25 at 10:55 AM, observation revealed a loose Air Conditioning (AC) console's cover in resident's room [ROOM NUMBER] and visible dust at the AC vents. On 09/03/25 at 1:45 PM, a side-by-side observation of room [ROOM NUMBER] Air Conditioning (AC) console's cover was conducted with the Director of Plant Operations (DOPO) and the Housekeeping Supervisor. The Housekeeping Supervisor confirmed the AC dust and stated it would be cleaned immediately. The DOPO stated when they (staff) cleaned the AC, the removable cover was not put back properly. 9. On 09/02/25 at 10:45 AM, observation revealed a loose AC console's cover and visible dust on the AC vent in resident's room [ROOM NUMBER]. On 09/03/25 at 1:57 PM, a side-by-side observation of room [ROOM NUMBER] AC console's cover was conducted with the DOPO and the Housekeeping supervisor. The Housekeeping supervisor confirmed the AC dust and stated it would be cleaned immediately. The DOPO stated when they clean the AC, the removable cover was not put back properly. 10. On 09/02/25 at 10:45 AM, during an interview, the resident in room [ROOM NUMBER] stated the AC needs to be cleaned, it is all dusty. Observation revealed visible dust in the resident's AC vents. On 09/03/2025 at 1:50 PM, a side-by-side observation of resident room [ROOM NUMBER] AC vents was conducted with the DOPO and the Housekeeping supervisor. The Housekeeping supervisor confirmed the AC vents needed to be cleaned. 11. On 09/02/25 at 2:33 PM, an observation was conducted of room [ROOM NUMBER] of a recliner chair. The chair had a large tattered and torn area located on the front back resting area and on the corner end of both arms. There were multiple brown rust-colored areas located on the middle bottom stand of the resident's overbed table and two (2) reddish colored stains on the tile floor near and to the side of the resident's recliner chair. 12. On 09/02/25 at 2:32 PM, an observation was conducted of room [ROOM NUMBER] and a resting recliner that had tattered and torn back and arms in the resident's room. 13. On 09/03/25 at 10:02 AM, an observation was conducted of room [ROOM NUMBER], and the left side half (1/2) bedrail was observed broken and half hanging off the bed and resting on the floor. 14. On 09/03/25 at 10:30 AM, an observation was conducted of Room# 325, and a resting recliner that had tattered and torn back and arms in the resident's room. 15. Observation In room [ROOM NUMBER] revealed the cover on the arms of the resident's wheelchair were worn to the point that the foam underneath was exposed and there was an accumulation of residue on the handles of the brakes. The surface of the lounger in the room was worn and there was an accumulation of residue on the overbed table. 16. In room [ROOM NUMBER], the waste baskets were overflowing onto the floor. 17. In room [ROOM NUMBER], the seat of the room chair was torn. 18. The wall in the corridor between the 200 and 300 units, where food trolleys are stored at the entrance to the kitchen, was damaged in a manner indicative of repeatedly being hit by the food trolleys. 19. There was an accumulation of dust on the air vent over the nurse's station on the 200 unit. 20. On the outside smoking patio, there were cigarette butts strewn about the patio and in the landscaping as well as some trash.

Based on observations, interviews and record reviews, the facility failed to follow the menu and the approved recipe for lunch served on 09/02/25 and the menu for lunch on 09/04/25. The findings included:1. The approved menu for the lunch meal on 09/02/25 documented that the residents were to receive 'Ginger-Barbecue chicken'. During an observation of lunch served to the residents in the Dining room on the 200 unit, on 09/02/25 at 12:20 PM, it was noted that the residents were served one (1) bone in chicken leg as the protein for the meal. At the time of the observation, the Surveyor entered the kitchen and asked the Dietary Manager how much of the protein that residents were to receive for the meal. The Dietary Manager stated that the residents should receive three (3) ounces of the protein for the meal. At the request of the Surveyor, the Dietary Manager placed a piece of the bone-in chicken leg on the facility's kitchen scale and the portion weighed 2 ounces - half of which is non-edible bone and cartilage. The Dietary Manager acknowledged that the chicken leg was not enough protein per the facility's menu and stated that the facility was using boneless and skinless chicken thighs until the residents requested the bone in chicken leg, and that the recipe and menu were not updated to reflect the residents' request. 2. The approved recipe for the 'Ginger-Barbecue Chicken' that was on approved menu for the lunch meal served on 09/02/25 documented that the facility was to use boneless and skinless chicken thighs. During an observation of lunch served to the residents in their rooms, on 09/02/25 at 12:20 PM, it was noted that the residents were served one (1) bone in chicken leg. At the time of the observation, the Surveyor entered the kitchen and inquired about the protein being served. The Dietary Manager stated that the residents had requested to have the bone in chicken leg and acknowledged that the recipe had not been updated to reflect the residents' requests. 3. The posted menu that was posted outside of the Dining Room on the second floor for the lunch meal being served on 09/04/25 documented that the residents were to receive 'choice of roll'. During the follow up tour of the kitchen, on 09/04/25 at 11:23 AM, it was noted that, while staff were plating the meal, they were placing two (2) pieces of sliced bread on the plates with the rest of the meal. When the Dietary Manager was asked about not serving the rolls with the meal, the Dietary Manager stated that the rolls did not come in on the delivery that was received on 09/01/25 (the most recent delivery from the food supplier). The Dietary Manager acknowledged that the menu was not changed so that the residents could be notified of the change in the menu.

Based on observations, interviews and record review, the facility failed to bring incontinent supplies with the resident to an outside appointment for 1 of 1 sampled resident reviewed for Activities of Daily Living, Resident #80; and failed to follow up after a Foot and Ankle Surgeon consultation related to a fracture for 1 of 2 sampled residents reviewed for falls, Resident #72. The findings included: 1. Record review revealed Resident #80 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly MDS, with a reference date of 06/03/25, documented Resident #80 had a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severe cognitive impairment. The MDS documented that Resident #80 was dependent upon staff for all Activities of Daily Living (ADLs), except for eating, dependent upon staff for ambulation via manual wheelchair and was 'always incontinent of urine and bowel without the use of a device. Resident #80's diagnoses at the time of the assessment included: Coronary Artery Disease, Hypertension, Hyperlipidemia, Hemiplegia, Muscle weakness, Dysphagia, and Constipation. Review of a progress note, dated 08/26/25 at 10:58 [AM], documented, Resident departed the facility for a scheduled medical appointment at [hospital name]. Resident exited the unit in stable condition via wheelchair, accompanied by a facility [Certified Nursing Assistant] CNA and transportation attendee. Departure occurred following lunch. Resident was appropriately dressed, well groomed, with no signs of incontinence or soiling, and had right arm sling in place. All scheduled morning medications were administered prior to transport. Profile sheet and current medication list were sent with the resident. No complaints voiced. During an interview, on 09/03/25 at 9:13 with Resident #80's son, when asked about Resident #80's appointment on 08/26/25, the son replied, She had an aide with her. I was pulling her out of her wheelchair, and she was went to her knees. We got her out of the wheelchair and got the diaper off of her and the urine smell was so strong that it had to have been there for a while. The facility said that she left around 12:00 PM, and she wasn't like that when she left. Transportation called me at 1:45 PM that she was at the facility to pick up – they keep sending her out in that condition. For her to go home (referring to returning to the facility), the nurse had to tape chucks around her and wear the same clothes back to the facility. I met with the new administrator after the appointment, and she said that she is making changes – the same as the other 5 Administrators have said. During an interview, on 09/05/25 at 9:39 AM, Staff E, Licensed Practical Nurse / Unit Manager (LPN/UM), when asked about the incident, Staff E replied, when she went to [hospital name], she went with a CNA, and her son met them there. She was changed prior to leaving for the appointment. She should have went with an extra brief. She did not go with an extra brief. During an interview, on 09/05/25 at 12:01 PM, Staff J, CNA, when asked about the incident, replied, I changed her prior to leaving. When asked about bringing extra incontinence supplies, Staff J replied, I did not take any, I was in the dining room and they called me and told me that transportation was waiting for us, she went to her room, and her CNA changed her and then we went to the appointment. I was in a hurry and didn't get the supplies to take with us. When she was wet, the doctor's office had a chuck that we used. The nurse at the [hospital name] told me that the hospital did not have any briefs. 2. Review of the facility policy titled, Physician Services, provided by the Administrator revised 03/02/19 documented in the Policy Statement: It is the policy of the facility to provide Physician Services in accordance to State and Federal Regulations.All Physician's orders will be followed, as prescribed, and if not followed, the reason shall be recorded on the resident's medical record during that shift. Record review revealed Resident #72 was admitted to the facility on Tuesday 08/12/25 with diagnoses which included Nondisplaced Fracture of Greater Trochanter of Left Femur, Pain in Left Hip, Periprosthetic Fracture around Prosthetic, Spinal Stenosis, Lumbar Region, Difficulty in Walking, Rhabdomyolysis and Personal History of (healed) Traumatic fracture, Left Foot Drop, Major Depressive Disorder and Insomnia. The record documented a Brief Interview Mental Status (BIMS) score of 13, indicative of intact cognition. Record review of the Resident #72's face sheet form documented that his Medical/Health insurance was listed as a HMO. For most traditional HMO plans, a referral is required from the Primary Care Provider (PCP) to see a specialist for authorization of payment for services. Record review of the Resident #72's Pain Care plan initiated 08/14/25 and revised 09/04/25 indicated Focus: Resident has an alteration in comfort related to left hip fracture, Neuropathy, Lower Back and generalized pain. Interventions: .Medicate as ordered, Observe for non-verbal indications of pain: facial grimaces, restlessness, moaning, mood/behavior changes. Obtain resident rating of the pain scale face/verbal descriptor and document.Remind resident to alert staff if experiencing pain/discomfort.Goal: Resident #72 will have pain/discomfort recognized and controlled by next review date. Record review of the Resident #72's Activities of Daily Living (ADL) Care plan initiated 08/13/25 and revised 09/04/25 indicated Focus: Resident requires assistance with self-care and mobility related to Diagnosis of Fracture Left Femur . Interventions: . Notify Physician if any significant changes. Observe for changes in ADL status . Report to licensed nurse any decrease in ability to complete ADL tasks . The Goal included: Resident #72 will receive the amount of necessary ADL assistance to improve/maintain quality of life. Record review of the Orthopedic Trauma Specialist Progress note from the hospital dated 08/11/25 indicated There is a nondisplaced fracture of the left greater trochanter. Full consult to follow and see as needed. Review of the Neurosurgery consult note from the hospital dated 08/11/25 documented, .suddenly the left leg was having severe pain and gave out . Having difficulty walking around. There is a disc herniation of L5-S1 with extruded fragment going inferiorly towards the left. Therefore, his presentation is with acute pain. Potential referral to Pain Management. Can follow-up with me in a few weeks. Surgery, microdiscectomy, would be an option after a reasonable period of time if he is not improving. Review of Resident #72's After Visit / Hospital Discharge summary dated [DATE] documented for follow-up with both the Orthopedic and Neurosurgeon specialists. On 08/12/25 the Physician's Order documented Percocet 5-325mg tablets 2 tablets every 4-6 hours as needed for pain. For the months of August and September 2025, the Medication Administration Record (MAR) documented Resident#72's pain level range was recorded, at the time of the visit, as: 6-7/10 on Thursday 08/28/25, the 1st time of travel to the Orthopedic office. On Tuesday on 09/02/25, the 2nd time of travel to the Neurosurgeon office, the pain level range was recorded, at the time of the visit, as: 5-7/10. An interview was conducted on 09/02/25 at 2:14 PM with Resident #72 who stated he had been experiencing a constant, lower left hip pain, which radiated down his leg to his knee with a pain level range of 8 out of 10. He stated the ordered pain pills did help a little. He verbalized that last month and today, he was taken to 2 separate specialists' offices, an Orthopedic and a Neurosurgeon, for appointments. He stated that on each of these 2 occasions, it turned out to be a waste of both his and the doctor's time, as he had been tired, had been in pain, and that nobody seemed to care about whether or not he had seen the specialist doctor or not. Resident #72 stated that on both times he had been unable to see either specialist due to not having a referral obtained under his Health Maintenance Organization (HMO) insurance. The resident stated he was only provided a copy of what he was told was a referral for the appointment for today 09/02/25 at 1:30 PM. During this interview, the Resident #72 showed the surveyor a copy of what he said was the referral. Upon review of the referral, it was actually a copy of the physician's order authorizing the visit only, but not an actual referral, for purposes of direct insurance payment. Resident #72 expressed his disappointment, and he said that he didn't understand how this could have happened twice. The resident stated that ever since he had been residing in this facility (since 08/12/25) he had been having terrible pain the entire time for which he had still not been seen by any of his specialists. On 08/28/25, the physician's order, the Schedule and the Transportation Form, each documented the Orthopedic follow-up appointment's address of the physician's office was in Fort [NAME], the time of the appointment was at 9:45 AM, the transportation company's number, the pick-up time was at 8AM, and the confirmation number and the expected time of resolution (ETR) was at 10:45 AM. On 09/02/25, the physician's order, the Schedule and the Transportation Form, each documented the Neurosurgeon follow-up appointment's address of the physician's office was in Plantation, the time of the appointment was at 10:45 AM, the transportation company's number, the pick-up time was at 9 AM-9:30 AM, and the confirmation number and the expected time of resolution (ETR) was at 11:45 AM. During an interview conducted on 09/04/25 at 1:56 PM with the Director of Therapy, she stated Resident #72 had received therapy services for Physical Therapy (PT) from 08/13/25 to 09/02/25, five (5) days per week; and Occupational Therapy (OT) from 08/13/25 to 09/02/25, five (5) days per week. The Therapy Director stated Resident #72 had documented generalized hip pain at a level range starting at 8/10 and was decreased to 5/10. On 09/04/25 at 4:21 PM, an interview and side-by-side record review of the Transportation Schedule Form was conducted with the Staffing Coordinator/Scheduler, who stated that she handles and schedules the transportation piece for the residents, and she functions as a back-up, only if the Medical Records Custodian is not available to directly contact the resident's specialist office, for an appointment. She stated, if necessary, she would either go the Unit Manager, ADON or to the DON, to inform them that a referral would be needed from the PCP for the resident to be able to go to a specialist appointment, if needed or applicable. In the case of Resident # 72, the Staffing Coordinator/Scheduler stated that she did not schedule either of his two (2) different specialist appointments: Orthopedic (08/28/25) and Neurosurgery (09/02/25); and that these were both scheduled by the Medical Records / Credentialing Coordinator. The Staffing Coordinator / Scheduler indicated that she only generated the forms which were immediately visible in the facility's Point-Click-Care (PCC) computer system for the nurse staff to be able to see and to be aware of. The Staffing Coordinator / Scheduler revealed she had scheduled the transportation for Resident #72's 2 appointments, through the resident's HMO insurance and she said that he was picked up and taken to both appointments on the respective days and brought back to the facility. The Staffing Coordinator / Scheduler indicated that she keeps a hard copy of this form in a manilla envelope in her office. She stated she was not aware of whether or not the resident had actually been seen in the office or seen by the specialists on either of those days, as ordered. On 09/04/25 at 5:22 PM, an interview and side-by-side record review was conducted of the Appointment Scheduling documentation with the Medical Records / Credentialing Coordinator, who stated she gets the Physician's orders from the nursing department or sometimes directly from the Nurse Practitioner, in order to schedule any resident's appointments. In the case of Resident #72, she stated that he had a total of 2 appointments scheduled, 1 with the: Orthopedic on 08/28/25 and another with the Neurosurgeon on 09/02/25. She stated she passes this information to the Staffing Coordinator /Scheduler, who, in turn, takes a copy of this form to set up transportation to the specialist appointment for the resident. The Medical Records / Credentialing Coordinator indicated she scheduled these two (2) appointments by contacting the specialist office directly and they would run this through the resident's Humana HMO insurance. She revealed there was no way for her to confirm that the specialist, would accept the insurance, nor whether a referral would be needed. She stated she only calls to speak with someone in the office to schedule the appointment. During the interview, the Medical Records / Credentialing Coordinator revealed she had called the Specialist offices and was not sure of the exact difference between a physician's order and an insurance referral, nor did she verify the requirements for the visit at the time of the calls. She stated she did not contact the 2 specialist offices the day before or the day of, in order to confirm that a referral had been sent or needed to be sent from the PCP to the specialist office. She added that she did not or could not provide a reason why and was not aware of whether or not the resident had actually been seen in the office either of those days and seen by the specialist doctors. On 09/05/25 at 11:43 AM, a telephone interview was conducted with the Office Receptionist for the Orthopedic office, on the day of Thursday 08/28/25, regarding whether or not Resident #72 had shown up and was seen and treated at the specialist's office for an appointment that day. The Office Receptionist stated that this resident did not have an appointment with their office, and she provided a different phone number for the surveyor to call and follow-up with. On 09/05/25 at 10:59 AM, a general voice mail was left for the Neurosurgeon's office in order to ascertain whether or not Resident #72 had shown up and been seen and treated in the office by the specialist on the day of Wednesday 09/02/25, and if a referral had been required; requested a call back and awaiting a response. Ultimately, this office was not available for interview or comment, during the survey. On 09/05/25 at 11:22 AM, an interview was conducted with Staff D, Registered Nurse (RN), who acknowledged that the Medical Records/Credentialing Coordinator had scheduled Resident #72 for his 2 appointments: the Orthopedic Physician on 08/28/25 and the Neurosurgeon on 09/02/25. She stated she had documented in the progress notes that the resident had been picked up and taken to the appointment on that day and brought back to the facility. Staff D, revealed that she had not been aware, nor made aware of whether or not the resident had actually been seen in either of the specialists offices on the respective days, nor was she able to provide a reason why neither of the specialists offices had not been contacted afterwards, in order to confirm whether or not Resident #72 had been at the appointment to see if new orders or physician's progress notes had been obtained. Staff D stated she had not notified her Unit Manager of any of the above. On 09/05/25 at 11:48 AM, a telephone interview was then conducted with the Centralized Scheduling Department's phone number provided by the receptionist for the Orthopedic office, on the day of Thursday 08/28/25, in order to ascertain whether or not Resident #72 had shown up and was seen and treated there in the specialist's office for an appointment that day. The only information that the Centralized Scheduling Department was able to provide, regarding this appointment with the Orthopedic office on that day, was that this appointment, had been cancelled by someone on 08/28/25; with no reason given and no additional information provided. During a telephone interview conducted on 09/05/25 at 2:18 PM, with the RN Weekend Nursing Supervisor, she revealed that in the progress notes that, Patient returned from Orthopedic appointment, states he wasn't seen because he did not have correct referral. Patient states his pain is not managed.Patient reported pain score 5 . On 09/05/25 at 2:42 PM, an interview was conducted with Staff E, Licensed Practical Nurse (LPN/Unit Manager), who stated that he was not made aware that Resident #72 had not been seen by the Orthopedic specialist on 08/28/25. He stated he did not call the specialist physicians' offices to try to follow-up to see if there were any progress notes or any new orders given. Staff E stated he had been informed by Resident #72 that he had not been seen by the Neurosurgeon specialist on 09/02/25, he had not documented this in the resident's record. During an interview conducted on 09/05/25 at 2:50 PM with the RN, Assistant Director of Nursing (ADON), he stated that after the Medical Records / Credentialing Coordinator schedules the appointment, he would receive a copy of the scheduled appointment and would relay this message via an App link to all of the nurses to inform them of an upcoming appointment. The RN/ADON said that he does not obtain any referrals for the resident's appointments. He stated that he does not recall getting a schedule for this resident and was not able to recall any information about the resident with regard to his appointments. He stated that if a resident has a physician's order for a specialist follow-up appointment, that these should be honored and should be followed up to ensure appropriate resident evaluation and treatment. He stated he was not aware of whether or not the resident had actually been seen in the office on either of the 2 days by the specialist doctor. Resident #72 had been provided with only a physician's order, as authorization for treatment and evaluation. There was no evidence to show that a prior referral, authorizing payment for services, had ever been obtained by the facility, and sent over to the specialist office, in order for the resident to be seen, re-assessed and re-evaluated by the Specialist, for appropriate follow-up care and services. The Director of Nursing (DON) acknowledged on 09/05/25 at 3:25 PM that if a resident has a physician's order for follow-up with a specialist for care and treatment, that this should be done. The DON stated the insurance part has nothing to do with her; and she only looks at the clinical piece, and another department deals with the insurance aspect. On 09/05/25 at 4:47 PM, an interview was conducted with the Administrator who stated that the person responsible for scheduling the resident's appointments is the Medical Records personnel. The Administrator said that to her knowledge, Resident #72 was sent over with a referral but as to the exact type of referral, was the question.

Based on observations, interviews and record reviews, the facility failed to resolve grievances voiced by active members of the Residents and Resident Council, including Residents #97, #101, #104, #115, #142, #15, and #10, in a timely manner. The findings included: Review of the facility's policy, titled, 'Grievances', with a reference date of 11/28/16 and updated 01/2019, documented:I. Policy Statement:It is the policy of the Facility to quickly act on concerns or grievances and arrive at an appropriate resolution.III. Implementation:In implementing this policy, the Facility recognizes each resident's right to:* Prompt efforts to resolve grievances the resident may have, including those with respect to the behavior of other residents. Prompt efforts .to resolve include facility actively working toward resolution of that complaint/grievance.IV. Procedures:Any resident, family member of a resident, representative of a resident, person acting on behalf of a resident or employee may initiate a Resident Grievance if they have a concerns or express dissatisfaction regarding the Facility's services. The report may be made verbally or in writing and the reporter has the option of remaining anonymous. Record review for Resident #10 documented on the Quarterly Minimum Data Set (MDS), with a reference date of 07/14/25, a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.An interview was conducted with Resident #10 interview on 09/03/25 at 11:54 AM and Resident #10, when asked about food served in the facility, replied, breakfast and lunch are great - dinner is usually not hot. They don't use the hot plates during dinner. We talk about it at Food Committee.An interview was conducted on 09/02/25 at 12:02 PM with Resident #112, who has a documented BIMS score of 15, according to a Quarterly MDS with a reference date of 06/06/25, and when asked about the food served in the facility, Resident #112 replied, I tell them all the time at Resident Council and they don't do anything about it.Review of the Resident Council Meeting Minutes, on 09/03/25 at 12:08 PM, with the permission of the Resident Council President to review, revealed the following:April 31, 2025, the Resident Council President provided a list of concerns to the DON [Director Of Nursing]:*Use of cell phones and ear buds in front of residents during care and at the desk.*Foreign language constantly heard in halls, at desk and during care*Call bell response is slow, especially during 3-11 shift and on weekends.*CNAs [Certified Nursing Assistants] are often rude and short at times*3-11 shift staff seem to all go on break at once and it is very hard to find people after dinner time.*The residents feel that overall, on the 3-11 shift, and the weekends the level of care changes because of the management staff is not around and the building is not the same.*Food carts come up and it takes a long time for trays to be passed and sometimes trays area cold. CNAs sometimes don't pass trays to rooms not on their assignment, so it gets cold.*Medications sometimes run out because they aren't ordered enough in advance. June 5, 2025:*Use of cell phones and ear buds in front of residents during care and at the desk.*Foreign language constantly heard in halls, at desk and during care if 2 CNAs are working together (little improvement).*Call bell response is slow, especially during 3-11 shift and on weekends. (no improvement).*They feel the CNAs in general have attitudes and are often rude and short at times.*3-11 shift staff seem to all go on break at once and it is very hard to find people after dinner time. (no improvement).*The residents feel that overall 3-11 shift, and the weekends the level of care changes because of the management staff is not around and the building is not the same.*Food carts come up and it takes a long time for trays to be passed and sometimes trays area cold. CNAs sometimes don't pass trays to rooms not on their assignment so it gets cold. (slight improvement). July 30, 2025:*Use of cell phones and ear buds in front of residents during care and at the desk. Continues all shifts, but worse on 3-11 and weekend - stated particularly upsetting because the nurses do it while administering medications. Residents also state that staff sometimes hide in their room or bathroom and use the phone.*Foreign language constantly heard in halls, at desk and during care if two CNAs are working together. continues*Call bell response is slow, especially during 3-11 shift and on weekends. continues*3-11 shift staff seem to all go on break at once and it is very hard to find people after dinner time. continues*The residents feel that overall, 3-11 shift, and the weekends the level of care changes because of the management staff is not around and the building is not the same. continues*Food carts come up and it takes a long time for trays to be passed and sometimes trays area cold. CNAs sometimes don't pass trays to rooms not on their assignment, so it gets cold. continues August 30, 2025*Use of cell phones and ear buds in front of residents during care and at the desk. Continues all shifts, but worse on 3-11 and weekend - stated particularly upsetting because the nurse do it while administering medications.*Foreign language constantly heard in halls, at desk and during care. continues*Call bell response is slow, especially during 3-11 shift and on weekends. continues*3-11 shift staff seem to all go on break at once and it is very hard to find people after dinner time. continues*The residents feel that overall 3-11 shift, and the weekends the level of care changes because of the management staff is not around and the building is not the same. continues*Food carts come up and it takes a long time for trays to be passed and sometimes trays area cold. CNAs sometimes don't pass trays to rooms not on their assignment, so it gets cold. continues* Medications sometimes run out because they aren't ordered enough in advance. An interview was conducted on 09/03/25 at 12:41 PM with the Resident Council President who confirmed the documentation was accurate and the concerns still exist. An interview was conducted with active members of the Resident Council on 09/03/2025 3:35 PM, including Resident #97 with a Brief Interview for Mental Status (BIMS) score of 11 according to an End of PPS Part A Stay Minimum Data Set (MDS) with a reference date of 07/30/25; Resident #101 with a BIMS score of 15 according to an Annual MDS with a reference date of 07/18/25; Resident #104 with a BIMS score of 15 according to a Quarterly MDS with a reference date of 06/17/25; Resident #115 with a BIMS score of 15 according to a Medicare 5-day MDS with a reference date of 08/19/25, and Resident #142 with a BIMS score of 15 according to a Significant Change MDS, with a reference date of 07/17/25, who when asked about the concerns related to staff cell phone use, the attendees agreed that the concern had not been resolved.When asked about the staff speaking foreign languages, all of the attendees agreed that the concern had not been resolved. Resident #97 stated, when I came, I thought that I was in a third world country. Record review revealed the resident was admitted on [DATE].When asked about the staffing concerns on the 3PM-11PM shift and on the weekends, all of the attendees agreed that the concern had not been resolved. Resident #104 stated, I had someone banging on my door for like an hour and a half because there was nobody there to redirect her. Resident #142 stated, - 3-11 is the worst - on Thursday, they do the 'Thursday slide' into the weekend. They (referring to the CNAs) disappear into the break room and just disappear every night all night. All they do is complain about their jobs. When asked about the concerns regarding the food served to the residents by the facility, all of the attendees agreed that the concern had not been resolved. Resident #115 stated, portions are too small and the distance between meals (Resident #115 began using a significant amount of profanity to respond to the concern). I have to sign up for food deliveries. Oatmeal and eggs are always cold.Resident #97 stated, whatever money I have, I spend on food. it is cold, I love oatmeal, but I have to eat it cold.Resident #104 stated, don't like it. It is cold and flavorless. mystery meat.Resident #142 stated, cold breakfast except for breakfast today. tasteless food and you don't know what it is. They don't use the pellet plates for dinner.Resident #101 stated, I like sugar on my oatmeal, and they never have any condiments on the trays. They will serve us a burger without ketchup or mustard and a baked potato with no butter or sour cream. An interview was conducted on 09/05/25 at 10:14 AM with the Activities Director, who when asked about the concerns voiced by the member of the Resident Council and the Food Committee, the Activities Director replied, food on the weekends is not hot a lot of times, it varies by meal and there is less supervision on the weekends. The Administrator and the Director of Nursing (DON) were not able to attend the last meeting because they got held up, so it was rescheduled for them to attend. When asked of what measures had been taken to resolve the concerns, the Activities Director replied, in-servicing, town hall, there is a lot of new staff, and they like a lot of the new staff. An interview was conducted on 09/05/25 at 12:34 PM with the Social Services Assistant and the Regional Social Services Director, who when asked about the grievances by the Resident Council being resolved, the Social Services Assistant stated that she had not been invited to the Resident Council meeting. The Social Services Assistant stated, when the former Social Services Director left, there were mountains of things not done. An interview was conducted on 09/05/25 at 12:54 PM with the Administrator and the DON, who stated that they were not aware of the food concerns. The Administrator stated, I stumbled across some of the education that was done in the past. The DON stated, We are doing Angel Rounds, Management is focusing on these issues when they are doing Angel Rounds. We are setting up break times for the CNAs and the nurse so that they can't go on break at the same time. They brought it up to me a month ago.

Based on interviews and record review, the facility failed to make prompt efforts to resolve the residents' grievances for 2 of 2 residents' sampled for missing property, Residents #37 and #122. The findings included:Review of the facility's policy titled Grievances updated on 01/2019 documented, in part, .the intent of this policy is to support each resident's right to voice their concerns and grievances (for example, . lost clothing.it is the policy of the facility to quickly act on concerns or grievances and arrive at an appropriate resolution.1. Record review documented Resident #37 had an admission on [DATE] with medical diagnoses to include Seizures and Chronic Obstructive Pulmonary Disease (COPD). The resident's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 indicating no cognition impairment. On 09/02/25 at 10:45 AM, an interview was conducted with Resident #37 who stated he was transferred to a local hospital in December 2024 and on his return on 12/27/2024, found out that his room was emptied, everything was gone, including his personal belongings. The resident added that in July 2025, he brought brand new clothes, 10 pair of underwear, socks, sweatpants, T-shirts that were label with his name, the clothing went to the laundry, and they were all lost. The resident stated he filed a complaint and has not heard from anyone, and no replacement was made. The resident stated he bought a new cell phone and showed A15 5G cell phone because the staff poured water over it while it was on his table. He added he reported it, and he has not been reimbursed for it. Resident #37 stated he had called the Social Worker many times and left messages and has not heard back from anyone.Review of the facility's grievances from December 2024 to August 2025 did not document any grievances related to Resident #37's missing clothes or damaged cell phone.On 09/03/25 at 2:57 PM, an interview with the Administrator was conducted who was apprised of Resident #37 voiced complaint to the surveyor. The administrator stated they have not checked the previous Social Worker's phone for messages. The administrator stated the staff do an inventory of the resident's belongings on admission and periodically when something is brought in. The administrator stated she did not see any written grievances from December 2025 and January 2025 for Resident #37.On 09/03/25 at 3:13 PM, a joint interview was conducted with the administrator and the Social Worker Assistant who stated she did not see an inventory sheet for Resident #37. The administrator stated she would do a federal report related to Resident #37 missing property. 2.Record review documented Resident #12 had an admission on [DATE] and a readmission on [DATE] with diagnoses to include Primary Generalized Osteoarthritis and Anxiety Disorder. The resident's MDS quarterly assessment dated [DATE] documented a BIMS score of 15 indicating no cognition impairment. On 09/02/25 at 1:15 PM, an interview was conducted with Resident #122 who stated that about eight (8) months ago she reported to [name] the previous administrator that her pearls ($3,000) were stolen from her purse. The resident stated she has not heard anything back from anybody. Review of the facility's grievances from December 2024 to August 2025 did not document any grievances related to Resident #122's stolen pearls. On 09/03/25 at 2:25 PM, an interview was conducted with the Administrator who stated working at the facility since 07/30/25. The administrator was apprised of Resident #122 report of her pearls stolen from her purse. The administrator stated the staff do an inventory of the resident's belongings on admission and periodically when something is brought in. The administrator confirmed that there were not written grievances from December 2025 and January 2025 for Resident #122. The administrator was asked to submit Resident #122's inventory sheet. A side-by-side review of the resident's inventory sheet dated 10/16/18 documented Pt refused. The inventory sheet dated 06/20/19 documented No new belongings on readmission.On 09/04/25 at 9:58 AM, an interview was conducted with the administrator who stated she completed a federal report related to Resident #122's missing pearls.

Based on record review, observation, and interview, the facility failed to follow physician's orders for scheduled specialist medical appointment in a timely manner for 2 of 2 sampled residents reviewed for choices, Resident #37 and #142. The findings included: Review of the facility's policy, titled, Quality of Care, revised on 03/02/19, documented .the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices . assist the resident in making appointments. 1. Record review for Resident #37 documented an admission on [DATE] and a readmission on [DATE] with medical diagnoses to include Seizures and Chronic Obstructive Pulmonary Disease (COPD). The resident's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 indicating no cognition impairment. Resident #37's clinical record documented a comprehensive care plan titled Resident #37 has a diagnosis of Seizures disorder with interventions to include give medications as order, monitor labs, notify nurse if seizure occur and post seizure tx (treatment). Review of Resident #37's clinical record documented an active physician order dated 06/19/25 for a Neurology Consult for Seizure disorder and an order dated 01/08/25 for Levetiracetam (a medication for seizures) 500 mg two tablets by mouth two times a day for Seizure. On 09/02/25 at 10:45 AM, an interview was conducted with Resident #37 who stated he was transferred to a local hospital due to a seizure at the facility, broke his back, ribs and had not been seen by an orthopedic doctor, continues to have seizures, had a brain biopsy, taking Keppra for it and had not been seen by a neurologist. The resident stated he had asked for a neurologist consult and was told his insurance does not pay for it, has called the Social Worker (SW) many times and does not get a call back. The resident stated he did not know who the SW was, does not know what insurance coverage he has and would like to sign up for Humana Insurance. On 09/02/25 at 11:00 AM, an interview was conducted with the Social Services Assistant (SSA) who stated the facility has not had a SW for about a month, but the Regional SW helps with anything that she needs help with and was in facility last Wednesday and is coming tomorrow. The SSA was made aware of Resident #37's concerns. On 09/04/25 at 11:19 AM, a joint interview with the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Nurse Practitioner (NP) was conducted. The ADON stated that he was not aware of any outside doctor consult issues. The NP stated Resident #37 was initially admitted to the facility on [DATE] with a diagnosis of Seizures disorder. The NP stated Resident #37 requested to be seen by a neurologist and an order was written on 06/19/25 for a neurologist consult. The NP stated according to record the resident has not been seen by a neurologist as of today and added she recalled that there were some insurance issues. The NP could not confirm if Resident #37 was seen by a neurologist at a local hospital. The DON stated she would look for the last neurologist consult and added usually the residents are seen annually by a neurologist unless they are having seizures. The DON was reminded that the resident requested to be seen. On 09/04/25 at 12:04 PM, an interview was conducted with the Medical Record / Credentialing Coordinator (MRCC) who stated she has been doing residents appointment since July 2025. The MRCC stated when a resident comes from a hospital or an outside consult and with any orders, the clinical team has to give her the doctors' orders to make the appointment. The MRCC was asked regarding the appointment schedule for Resident #37 and provided a copy of the NP order dated 06/19/25 for Neurology consult and stated she wrote on the order can't make appointment, no provider is taking Medicaid. The MRCC was asked what she did once she could not find a provider and stated when she can't find a provider to see a resident, she tells the NP and nursing. On 09/04/25 at 12:55 PM, during an interview, the DON stated that the MRCC mentioned that she was having trouble finding a doctor for Resident #37 last week. On 09/04/25 at 12:35 PM, a joint interview was conducted with the Regional Director of Social Worker (RDSW) and the SSA who were apprised of Resident #37 had not being seen by a neurologist due to insurance issue. The RDSW provided a copy of the hospital consultation notes. Review of Resident #37's local hospital consultation notes dated 09/09/24, almost a year ago, documented .MRI June 22, 2024, the patient was noticed to have a small lesion.suspected to be a cavernoma.Recommend that the patient is re-evaluated for the same concerns. On 09/04/25 at 12:55PM, an interview was conducted with the Administrator who stated she was not aware of insurance issues for Resident #37. She was informed that the resident reported that he had called the SW and had not heard back from the SW. The administrator stated they have not checked the SW phone for messages. 2. Record review revealed Resident #142 had an admission on [DATE] with no readmissions. The resident's diagnoses included Displaced Bimalleolar Fracture of Left Lower Extremity, Injury of Head, Contusion of Unspecified Knee- Unspecified fall 07/04/25; Spondylopathy Lumbar Sacral Region, Chronic Obstructive Pulmonary Disorder (COPD), Pleural Effusion, Persistent Mood disorders, Osteoarthritis left shoulder, Generalized Anxiety Disorder (GAD), Major Depressive Disorder, Implantable Cardiac Defibrillator, Acute Embolism of Deep Vein (LUE) Left Upper Extremity, Insomnia, (CHF) Congestive Heart Failure, Iron deficiency, Hypoglycemia and Hypothyroidism. Review of the facility's 'fall log' documented Resident #142 had a fall with Major Injury on 07/04/25. Review of Resident #142's care plans revealed the following; *Resident #142 has a potential for pain symptoms as evidenced of impaired mobility and osteoarthritis. LLE (left lower extremity) fracture. The care plan was initiated on 05/13/22 and revised 08/10/25 with no new interventions. *Resident #142 is at risk for further falls related to gait balance problems. Psychoactive drug use. LLE fracture. The care plan was initiated on 05/30/22 and revised on 08/10/25; and had interventions to include re-educate in using call when assistance is needed prn; Pt (patient) screen, neuro checks, re-educated on using the call light system to request assistance, created on 09/02/25 by the Regional MDS coordinator. On 09/02/25 at 12:57 PM, an interview conducted with Resident #142 who stated she fell and broke her foot. Observation revealed a beige colored bandage. On 09/04/25 at 10:02 AM, an interview and a side-by-side review of Resident #142's fall with major injury was conducted with the DON. The DON stated on 07/04/25 at 6:15 AM, the resident was found (observed) on the floor, had a BIMS (Brief Interview Mental Status) score of 15 and the resident description of the fall was that she was going to the bathroom and fell, and couldn't put weigh to her left leg. The DON stated the resident was alert and oriented, had no signs of concussion, left leg and ankle visible were swollen without laceration or bleeding, and the nurse received orders for fibula and ankle and foot X-rays. X-rays results revealed an Acute fracture of Bilateral Malleolus on left tibia and fibula, and left ankle. The DON stated Resident #142 was transferred to the hospital at 12:10 PM on 07/04/25, was not admitted , and came back to the facility the same day at 2305 (11:05 PM). The DON stated the resident returned with a wrapping like a partial cast on it. The DON stated Resident #142 was seen by Foot and Ankle Surgeon on 07/08/25 who recommended surgery to the ankle, and that a CT scan was done in office. A side-by-side review with the DON of Resident #142's Foot and Ankle Surgeon request for medical clearance for surgery and surgery scheduling form was conducted. The DON was asked why the surgery had not been done and she was unable to provide written documentation of why the surgery was not scheduled nor done as recommended by the Foot and Ankle Surgeon. On 09/04/25 at 11:00 AM, a joint interview was conducted with the ADON and DON. The ADON stated he follows up with the appointments scheduler (MRCC); she schedules the resident's appointments; and once they have everything schedule, they will inform him of appointment time and date. The ADON was asked if he was aware of Resident #142 needing surgery or refusing surgery and stated he was not aware of that and added that the NP told him last week to call the resident's Foot and Ankle Surgeon to see if they want to see the resident again. He stated he not aware that the resident needed surgery and has not had a chance to call the Foot and Ankle Surgeon's office yet. On 09/04/25 at 11:10 AM, a joint interview was conducted with Resident #142's in-house NP, DON and ADON. The NP stated, honestly, she did not know that surgery was not done, and stated she told the ADON towards the end of last week to call the Foot and Ankle Surgeon's office. The hiccup was that the office did not say the date of surgery. The ADON, DON and the NP were apprised that the Foot and Ankle Surgeon appointment was almost two months ago and no one had followed up on the consult recommendations or discuss the recommendations with Resident #142. On 09/04/25 at 11:40 AM, observation revealed the DON received a call from the Foot and Ankle Surgery office staff, and the DON stated that she was informed that Resident #142 refused to have the surgery at the office, as the resident thought because of surgery she was afraid that the facility will kick her out. On 09/04/25 at 11:53 AM, a joint interview was conducted with Resident #142 and the ADON. The resident stated she did not recall when she went to the Foot and Ankle Surgeon. The resident recalled that the doctor wanted to do surgery, and she did not want it because she was going to be out of the facility and did not want to lose her bed. The resident was asked if she told anybody about it and stated she believes she spoke with the NP. On 09/04/25 at 3:38 PM, an interview was conducted with Resident #142 who stated her foot pain rate is about 5 out of 10 and she can't put her leg straight and has a soft splint on her left leg. Observation revealed left foot turned outward, stated she takes pain medications every day. The resident stated prior to the fall on 07/04/25, she was able to walk slow. The resident was asked if she would like to have her foot surgery done and stated Yes but would like to have X-rays before. On 09/05/25 at 12:08 PM, an interview and a side-by-side review of Resident #142's MDS assessment was conducted with Staff C, MDS Coordinator, who stated the resident had a significant change assessment completed on 07/17/25 due to a decline on three (3) areas; the resident is unable to walk independently after a fall, was sit to stand independently before now needs partial to moderate assistance; and prior to the fall was independently transfer to wheelchair, now needs partial to moderate assistance. The resident's BIMS score was 15 indicating no cognition impairment. Staff C stated Resident #142 was independent with her Activities of Daily Living (ADLs) now she needs partial to moderate assistance after the fall. Resident #142's Annual MDS assessment dated [DATE] documented the resident was independent with her mobility and had no functional limitation in ROM (Range of Motion), no lower extremity impairment. On 09/05/25 at 1:10 PM, an interview was conducted with the facility dedicated Wound Care Nurse (WCN) who stated she was monitoring Resident #142's dressing for signs of infection, or if it needs to be reinforced. The WCN stated the resident had a non-removeable dressing since around July due to a fracture left foot and added she is supposed to go to the Foot and Ankle Surgeon and was not sure when.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it followed professional standards for 1 of 3 sampled residents observed for Urinary Foley Catheter and Peri-care, Resident #153. The findings included: Review of the facility policy titled Enhanced Barrier Precautions (EBP) provided by Director of Nursing (DON) issued 04/01/24 documented in the Policy Statement: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: EBP refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and gloves use during high contact resident care activities 2. Initiation of EBP. b. An order for EBP will be obtained for residents with any of the following.Urinary Catheters 3. Implementation of EBP: a. Make gowns and gloves available immediately near or outside of the resident's room [ROOM NUMBER]. High contact resident care activities include.g. Device care or use.Urinary Catheters.Review of the facility policy titled, Incontinent Care for the Male Resident Steps of the Procedure Skill Competency Form, provided by the DON reviewed 04/2020, documented in the Policy Statement: .4. if the resident has a Foley.8. Ensure resident's safety at all times and uses Infection Control Procedures appropriately. Record review revealed Resident #153 was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Retention of Urine, Benign Prostatic Hyperplasia and Parkinson's Disease. He had a documented Brief Interview Mental Status (BIMS) score of 13, indicative of intact cognition.Record review Resident #153's Foley Catheter Care plan initiated 08/20/25 and revised 09/03/25 indicated Focus: Resident has an indwelling urinary catheter related to Obstructive Uropathy .Interventions: .Anchor catheter tubing to thigh to decrease risk of trauma. Goal: Resident #153 will be/remain free from catheter-related trauma through the next review date.Resident #153 will have no complications through the next review date.Record review of Resident #153's Enhanced Barrier Precautions Care plan initiated 08/22/25 and revised 08/22/25 indicated Focus: Resident is at risk for multi-drug Organisms (MDRO) related to indwelling medical devices (urinary catheter) requiring Enhanced Barrier Precautions during high contact resident care activities in room, therapy gym or shower room .Interventions: Wear gown gloves during resident high-contact activities in room, therapy, gym, or shower room (i.e.Urinary Catheter.) Goal: Minimize risk of transmission of colonized or infection with MDROs.Observation on 09/04/25 at 11:00 AM revealed no signage or indication at or near the door that Resident #153 was on Enhanced Barrier Precautions (EBP). There was no container or caddy with Personal Protective Equipment (PPE) at or near the door of Resident #153. Observation of Foley catheter and peri care was conducted on 09/04/25 at 11 AM for Resident #153 and performed by Staff A, Certified Nursing Assistant (CNA). At the start of the procedure, Staff A donned a pair of clean gloves only, but she failed to don a protective gown prior to or during performing the procedure. Resident #153 was observed not having his Foley catheter and tubing properly secured and anchored in place to decrease the risk of trauma or pulling on the catheter. On 08/19/25, the physician's order documented, Maintain Indwelling Catheter for Urinary Retention. Foley Catheter care every shift and as needed every shift for monitoring. Change indwelling Foley catheter when medically necessary and as needed every 72 hours as needed for follow-up. May irrigate indwelling Foley catheter with 60 ml of normal saline for blockage, occlusion, leakage, etc. every 42 hours as needed for follow-up. On 09/04/25 at 11:08 AM, an interview was conducted with the CNA, Staff A, immediately following the catheter and peri care, who was asked if the resident was on EBP. Staff A replied she did not know, since there was no sign on the outside door. The CNA was then asked whether or not she should have been wearing a gown prior to, during and throughout the procedure and she stated no, only if there is a sign placed on the door. She added that whenever she does Foley catheter and peri-care for a resident, she does not put a gown on. She was asked if the resident had a Foley catheter and an anchor in place and she responded, no, but said that he should have one.On 09/04/25 at 11:24 AM, an interview and side-by-side computerized record review was conducted with the nurse, Staff D, who acknowledged this resident should have been on and should have had a physician's order for EBP. She stated Resident #153 did not currently have orders for EBP related to his Foley Catheter due to high contact activity. She further acknowledged that a gown should have been worn by staff when completing Foley catheter care for this resident, and that a Foley catheter anchor with strap should have been in place. On 09/04/25 at 11:34 AM, an interview was conducted with Staff E who stated that this resident should have been on EBP for his Foley Catheter and had a physician. He acknowledged that the staff members should have been wearing a gown prior to the start, during and throughout the Foley catheter care and the resident should've had a Foley catheter strap with anchor in place. On 09/04/25 at 09/04/25 at 1:30 PM, the Director Of Nursing (DON) stated an order for EBP should have been obtained with appropriate signage placed on the resident's door. The DON acknowledged that appropriate PPE should always be worn during care and the resident's Foley catheter should have been properly anchored and secured in place.

Based on observations, interviews and record review, the facility failed to follow physicians' orders for 1 of 3 sampled resident reviewed for tube feeding, Resident #20. The findings included: Review of the facility's policy titled, Physician's Services, with an issued and revised date of 03/02/19, included in part the following: All physician orders will be followed as prescribed and if no followed, the reason shall be recorded on the resident's medical record during that shift. Review of the facility's policy titled, Residents admitted to the Facility with Tube Feedings Already in Place, documented, in part, A resident who is fed by gastrostomy tube shall receive appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal eating skills.Record review for Resident #20 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Other Seizures, Encounter for Attention to Gastrostomy, and Aphasia. The MDS dated [DATE] documented in Section C, a Brief Interview of Mental Status (BIMS) could not be completed due to the resident is rarely/never understood. Review of the physician's orders for Resident #20 revealed an order dated 07/17/25 for two times a day Isosource 1.5 or Jevity 1.5 (formulary type) at 80 milliliter (ml) for 20 hour (hr.) via J-tube. On 2:00PM off 10:00 AM (Total 1600ml/24 hr.Review of the Care Plan for Resident #20 dated 01/02/25 with a focus on the resident requires tube feeding related to dysphagia. The goals were for the resident to remain free of side effects or complications related to tube feeding and will be free of aspiration through next review date. The interventions included in part the following: Provide tube feeding and water flushes. See MD orders for current feeding orders. On 09/02/25 at 9:55 AM, an observation was made of Resident #20 receiving tube feeding of Isosource 1.5 (formulary type) at 75ml/hr. via pump.On 09/02/25 at 5:00 PM, an observation was made of Resident #20 receiving tube feeding of Isosource 1.5 at 75ml/hr. via pump. The tube feeding bag was labeled with a date of 09/02/25 with no time and rate of 85ml/hr. An interview was conducted on 09/03/25 at 12:10 PM with Staff B, Registered Nurse (RN), who stated she has worked at the facility for about 8 years. When asked if she cared for Resident #20 yesterday, she said yes. When asked about tube feeding for Resident #20, that it was running at the wrong rate yesterday in the morning and in the late afternoon, she said she stopped the tube feeding at 10:00 AM and restarted it at 2:00 PM per the physician's orders. When asked if she verifies the rate, the RN stated she does not really look at the rate. The RN stated she only verifies the rate when the tube feeding runs out and she puts up a new bag because in the morning the tube feeding does not run too much on her shift, and she trusted the nurses before her to do the right thing.

Based on observations, interviews and record review, the facility failed to attempt to use appropriate alternatives and obtain informed consent prior to installing bedside rails, and failed to provide regular inspection and maintenance to identify areas of possible entrapment for 1 of 1 sampled resident, reviewed for bedrails, Resident #90. The findings included:Review of the facility's policy titled, Bed Rails with an issued and revised date of 03/02/19, included in part, the following: The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practical physical, mental and psychosocial well-being. Procedure: 2. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bedrails, including but not limited to the following elements: a) Assess the resident for risk of entrapment from bed rails prior to installation. b) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. c) Ensure that the bed's dimensions are appropriate for the resident's size and weight. D) Follow the manufacturers' recommendations and specifications for installing and maintaining bedrails. 5. When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the admitting nurse will review risks and benefits and obtain informed consent. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Budd-Chiari Syndrome (a narrowing or a blockage {obstruction} in one or more of the veins that drain your liver {hepatic veins}), Obesity, and Weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognitive response. Review of the physician's orders for Resident #90 revealed an order dated 12/03/22 for bilateral enablers/side rails for use as mobility aid for positioning. Record review for Resident #90 revealed the resident had a height of 61 inches and a weight of 206.2 pounds on 08/05/25. Review of the Side Rail Evaluation for Resident #90 dated 12/03/22 documented in part the following: Resident request. Recommended type of side rail(s): left upper and right upper. Recommended use of side rail(s): anytime. There were no additional Side Rail Evaluations for Resident #90. Review of the Side Rail Informed Consent and Release with a date that the month was unclear, but the day was the 15 and the year was 2022 did not have the resident's name on it, but only the date of birth . The consent was signed by a nurse assessor but not signed by the resident or the family representative. Review of the Care Plan for Resident #90 revealed no care plan for side rails/enablers. There were care plans that included side rails/enablers as an intervention. On 09/02/25 at 11:27 AM, an observation was made of Resident #90's bed. The observation revealed loose side rails on each side of the bed, the one on the right side of the bed was very loose and at an approximate 30-degree angle. An interview was conducted on 09/02/25 at 1:47 PM with Resident #90 who was asked how long the side rails have been on his bed, and he stated 'since day 1 when he got here.' When asked if he uses the side rails to get in and out of bed, he said yes. When asked if he thinks the side rails are loose, he said they are not too loose, I don't think they would come off. On 09/03/25 at 10:00 AM, an additional observation was made of Resident #90's bed with loose side rails on each side of the bed, the one on the right side of the bed was very loose and at an approximate 30-degree angle. An interview was conducted on 09/03/25 at 12:10 PM with Staff B, Registered Nurse (RN), who stated she has worked at the facility for about 8 years. When asked about side rails or enablers, the RN stated the resident is assessed / evaluated on admission and if the resident wants or needs them, they will get permission (consent) from the family or the patient if the patient is able to give permission. When asked who puts the side rails/enablers on the bed, she said she thinks the beds come with them. When asked who inspects the bed rails, she said maintenance. When asked about reassessing or re-evaluating for the bed rails, she said that it is just ongoing, and they document it as ongoing safety measures in place. An interview was conducted on 09/03/25 at 2:10 PM with the Director of Maintenance (DOM) who stated he has worked at the facility in maintenance department for 11 years and in the Director role for the past 1.5 years. When asked about issues with maintenance, he stated the staff can report this to the maintenance department in several ways, they can put the issue in TELS system located in the computer or put it in one of the log books located at each of the 2 the nursing station or Managers can put it in a group chat (text type on phone) that is seen in real time. The DOM stated that most staff put the issues directly into the TELS system. The DOM stated his department checks the log books located at the nursing stations minimally every morning. They also have guardian angel rounds conducted by management team that goes into each resident's room daily and checks to see if there are any issues that need to be addressed. When asked about how many types of beds they have, he stated they only have 2 types of bed brands Invacare and [NAME]. The DOM stated new beds come in with the side rails separate (unattached to the bed) and he will attach the side rails to the bed before he delivers the bed to the residents' rooms. The only time he does not attach the side rails is if the resident refuses the side rails. The DOM stated everybody has bed rails or if there are no bed rails then the resident had refused the bed rails, but most everyone has bed rails. When asked if he knows how many beds have side rails attached and how many have no side rails attached, he said he does not know that information. When asked who does the inspection of bed rails, the DOM said it is done by himself, or his 1 assistant and they are checked every month. When asked if he keeps a log of what beds have had the side rails inspected by the Maintenance Department, he said they do not keep a log, they just inspect them for cleanliness or being loose. If they are dirty he informs housekeeping, if they are loose, they are tightened immediately. When asked if the side rails are compatible with the bed per manufacturer's guidelines, he said all of the beds have the original side rails. When asked if the mattress is changed, such as putting on an air mattress, do they inspect the bed and rails to ensure the bed is safe and no entrapment can occur, he said when the mattress is changed, they use the same size mattress. During a tour of part of the facility conducted on 09/03/25 at 2:25 PM with the Director of Maintenance acknowledged the above findings. A random room (Room # 118-1) was randomly selected, and the DOM was asked what type of bed was in use, he had to look under the bed and stated it was a Basic American Metal Product bed not the Invacare and [NAME]. The DOM then stated only the new beds coming into the facility were the Invacare and [NAME] beds and there may be additional beds in the facility.In observation of Resident #90's bed with the DOM, he acknowledged both side rails were loose. An interview was conducted on 09/05/25 at 1:05 PM with the Wound Care Nurse who stated she has been working at the facility for about 2 years. She stated she is part of the guardian angel program, and she has an assignment that includes Resident #90. When asked what does the guardian angel program include, she checks the room every morning Monday through Friday to see if the call light works, the remote for the bed, the position of the resident, any clutter in the room, side rails and if the resident has any concerns. If there are any issues, she will report them to the appropriate person.

Based on review of policy and procedure, observation and interview, the facility failed to ensure that it maintained a currently dated posting for the Nurse Staffing Information, which had documented dates of two (2) incorrect days, for 1 of 4 days observed, at the start of this survey, for day of 09/02/25. The findings included:Record review of the facility policy and procedure, titled, Staffing, provided by the Administrator effective and revised 04/16/25 documented in the Policy Statement: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing document will be posted on a daily basis and will contain the following information:.b. The current date.2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be:.b. In a prominent place readily accessible to residents, staff, and visitors.An observation on entrance tour to the facility, located at front desk, conducted on Tuesday 09/02/25 at 8:30 AM revealed that the posted Nurse Staffing Information was not dated correctly. The posting had an inaccurate date of Saturday 08/30/25, which was representative of 2 calendar days earlier than the start of the survey on Tuesday 09/02/25.An interview was conducted with the Staffing Coordinator / Scheduler, on 09/03/25 at 12:30 PM, regarding the Nurse Staff Postings, who stated she posts the daily Nurse Staffing Information everyday Monday through Friday at 8:30 AM. On the weekends, she said that she would prepare the document to include the census on Fridays for the Weekend Day Supervisor / Manager on Duty (MOD) or the receptionist who sits at the front desk for the weekend in order for them to post this on Saturday or Sunday. Staff stated that the receptionist forgot to change this over the holiday weekend. The Staffing Coordinator / Scheduler acknowledged that Nurse Staff Posting Form dated as Saturday 08/30/25 was the incorrect one and the correct, current form should have been posted. On 09/04/25 at 10 AM, the Administrator and the Director of Nursing (DON) both acknowledged the Nurse Staffing Information Form must be posted daily with the current date.

Based on interview and record review, the facility failed to ensure the attending physician documented in the residents' medical records that the identified irregularity by the consulting pharmacist had been reviewed and what, if any, action has been taken to address it, as evidenced by lack of documentation by the attending physician, if no change in the medication, of his or her rationale in the residents' medical records for 2 of 5 sampled residents reviewed for unnecessary medications, Residents #14 and #142. The findings included: Review of the facility's policy titled, Medication Regimen Review with a revised date of 06/01/24, included in part the following: The consultant pharmacist will provide the resident's MRRs (Medical Record Review) to the facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. The attending physician/prescriber should address the consultant's pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident per facility policy, or applicable state and federal regulations. 1. Record review revealed Resident #14 was originally admitted on [DATE] with most recent readmission on [DATE], with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease, Polyneuropathy, Major Depressive Disorder, Generalized Anxiety Disorder, Primary Insomnia, Drug induced Subacute Dyskinesia, and Fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognitive response. Review of the Physician's Orders for Resident #14 included in part the following: An order dated for 05/07/25 for phenazopyridine HCL (Pyridium) 100mg tab by mouth every hour hours for bladder spasm was discontinued on 05/15/25, An order dated 07/25/25 for zolpidem tartrate tab 10mg by mouth daily for insomnia An order dated 07/25/25 for Amiodarone HCL tab 200mg by mouth once a day for Antiarrhythmics. Review of the Pharmacy Consultant Report with a Recommendation date of 04/12/25 for Resident #14 included in part the following: Resident receives amiodarone, which is only intended for use for life=threatening arrhythmias and has a Boxed Warning about substantial toxicities. Amiodarone should be closely and continually assessed both clinically and through appropriate lab monitoring. Recommendation: The following monitoring plan is recommended: thyroid function tests, followed by a TSH (Thyroid Stimulating Hormone) concentration every 6 months. Hepatic function at baseline and every 6 months thereafter. Pulmonary function test at baseline and periodically based on symptoms especially in individuals with underlying lung disease. Chest x-ray at baseline and periodically thereafter. ECG (Electrocardiogram) at baseline and at least annually. Ophthalmological evaluation baseline and annually. Blood Pressure and apical pulse at lease weekly. Monitor gastrointestinal side effects especially during initiation and titration. There was no response from the physician or ARPN. Review of the Pharmacy Consultant Report with a Recommendation date of 05/08/25 for Resident #14 included in part the following: Resident has received phenazopyridine for symptomatic relief of dysuria for greater than 2 days. Prolonged use may mask the symptoms of unresolved cystitis and increase the risk of complications. Recommendation: Please discontinue phenazopyridine. There was no response from the physician or ARPN. An interview was conducted on 09/05/25 at 9:00 AM with the Director of Nursing (DON) who was asked about the pharmacy review and recommendations. The DON stated she identified there were no responses from the physician or ARNP (Advanced Registered Nurse Practitioner) in regard to the pharmacist recommendations. This was identified after the facility did an audit of the pharmacy recommendations during the recertification survey after surveyors requested pharmacy reviews / recommendations. The facility put a PIP (Performance Improvement Plan) in place on 09/03/25. 2. Review of Resident #142's clinical record documents an admission on [DATE] with no readmissions. The residents diagnoses included Displaced Bimalleolar Fracture of Left Lower Extremity, Injury of Head, Contusion of Unspecified Knee- Unspecified fall 07/04/25, Spondylopathy Lumbar Sacral Region, Chronic Obstructive Pulmonary Disorder (COPD), Pleural Effusion, Persistent Mood disorders, Generalized Anxiety Disorder (GAD), Major Depressive Disorder, Implantable Cardiac Defibrillator, Acute Embolism of Deep Vein (LUE) Left Upper Extremity, Insomnia, (CHF) Congestive Heart Failure, Hypoglycemia and Hypothyroidism. Review of Resident #142's active physician orders included: *Amiodarone 200 mg one time a day for abnormal heart rhythm *Eliquis 5 mg every 12 hours for DVT (Deep Vein Thrombosis) * Zolpidem (Ambien) 10 mg at HS for Insomnia Review of the Consultant Pharmacist Medication Regimen Review (MRR) documents the following: *March 1, 2025, through August 31, 2025 - Comment: Resident #142 has received Ambien 10 mg at bedtime for insomnia; Recommendation: For initial attempt at gradual dose reduction (GDR). The report revealed no written response form the physician. *June 1, 2025, through June 30, 2025 - Comment: Resident #142 receives Amiodarone which is only intended for use for life-threatening arrythmias and has a boxed warning about substantial toxicities (i.e., pulmonary, hepatic and cardiac toxicity); Recommendations: Hepatic function at baseline and every 6 months thereafter, pulmonary function tests at baseline and periodically based on symptoms especially with underlying lung disease, Ophthalmological evaluation using funduscopic examination at baseline.and annually. The physician response documented, I accept the recommendations, please implement as written. *June 1, 2025, through June 30, 2025- Comment: Resident #142 receives an oral anticoagulant, Eliquis, Recommendations: LFT (Liver Function Test) at least annually. The physician response documented, I accept the recommendations, please implement as written. On 09/05/25 at 3:45 PM, during an interview, Staff C, MDS Coordinator was asked to check with the DON regarding copies of the supportive documents for the Consultant pharmacist recommendations carried out for Resident #142. On 09/05/25 at 5:27 PM, during an interview, the Regional Clinical Services/RN stated the following recommendations had not been done for Resident #142: *GDR for Ambien recommended in March 2025. *Hepatic function at baseline and every 6 months thereafter, pulmonary function tests at baseline and periodically based on symptoms especially with underlying lung disease, Ophthalmological evaluation using funduscopic examination at baseline.and annually recommended and accepted by the physician in June 2025. *LFT recommended and accepted by the physician in June 2025.

Based on observation, interview and review of policy and procedure, the facility failed to ensure that only authorized staff had access to the first-floor medication cart #1's keys as evidenced by the Registered Nurse (RN) handed the medication cart keys to a Certified Nursing Aide (CNA) to open the smoking room; failed to ensure that residents medications were properly supervised / stored as evidenced by medications being left unattended on the resident's bedside table during a Medication Administration Observation for 1 of 9 sampled residents (Resident #79); failed to ensure that expired wound care dressings were removed from 2 of 2 treatment carts located in the medical preparation room in the first floor and the second floor units; failed to ensure that 2 of 2 Medical Preparation / medication storage room reviewed had readily accessible soap and/or alcohol-based hand rub (ABHR) to perform hand hygiene; and failed to ensure the medication storage room was free of resident's personal belongings as evidenced by a plastic bag with personal belongings observed in 2 of 2 medication storage rooms reviewed (First and Second Floor units). The findings included: Review of the facility's policy titled General Dose Preparation and Medication Administration revised on [DATE] documented, .facility staff should not leave medications or chemical unattended.1. On [DATE] at 4:16 PM, observation revealed Staff F, Registered Nurse (RN), handed her medication cart keys to Staff G, Certified Nursing Assistant (CNA). Consequently, an interview was conducted with Staff G who stated she was assigned to open the smoking room, and the nurse had the key. Observation revealed Staff G walked 20-35 feet away from Staff F and opened the smoking room. At 4:20 PM, observation revealed Staff F received the medication cart keys from Staff G. On [DATE] at 9:05 AM, observation revealed the facility's Director of Plant Operations (DPO) was asking Staff H, Licensed Practical Nurse (LPN), for the smoking-room keys, as he needed to open the room for the life safety surveyor. On [DATE] at 9:11 AM, observation revealed Staff H handed her medication cart keys to the Director of Nursing (DON). The DON stated she can have the keys and added I'm a nurse. The DON was asked if only nurses can have the key and stated Yes, only nurses can have the medication cart keys.On [DATE] at 4:36 PM, an interview was conducted with Staff F, RN, who was asked about her handing the medication cart keys to Staff G, CNA, on [DATE]. Staff F stated she was busy and was giving the keys to the CNA but was told by another nurse not to give the key to a CNA. 2. On [DATE] at 5:01 PM, observation of medication administration for Resident #79 performed by Staff I, LPN, was conducted. Staff I poured the following medications: Lactulose oral solution 10 millimeters (ml) for constipation, Carbidopa-Levodopa oral tablet 25-100 milligrams (mg) for Parkinson's and Entacapone oral tablet 200 mg for Parkinson's. Staff I entered the resident's room with the poured medications in a cup on a foam tray, placed the foam tray on top of the resident's bedside table and walked away to the bathroom to perform handwashing. Staff I was unable to supervise and keep an eyesight on the medication. Observation revealed Resident #79 was out of bed sitting in a wheelchair and moving back and forth in the wheelchair. The resident was mumbling and not responding to questions asked. On [DATE] at 4:42 PM, an interview was conducted with Staff I who stated he should not have left Resident #79's medications on the table out of his sight. Staff I stated he was to have the medications on his sight at all times until he administers them and added he should've washed his hands first. 3. On [DATE] at 1:05 PM, a side-by-side review of the facility's 1st floor unit's Medical Preparation room (medication storage room) was conducted with Staff H, LPN. The review revealed an unlocked treatment cart in the room with the following:*One opened bottle of Hydro Peroxide with an expiration date on 05/24.*One opened bottle of Dermal Wound cleanser undated; Staff H was not able to read the bottle expiration date.*One unopened bottle of Geri-Lanta (antiacid medication). Staff H stated it should not be in the treatment cart.*One Xeroform Medicated Petrolatum dressing with an expiration date on 05/2025.*One opened and undated Super Absorbent dressing. Staff H stated it should not be in the cart. *29 Calcium Alginate Dressings with an expiration date on [DATE].*One opened 0.25% Acetic acid with not an opening or expiration date noted.Staff H, LPN confirmed all listed items expiration dates and stated the floor nurses, and the wound care nurse uses dressing supplies from the treatment cart. On [DATE] at 1:10 PM, during the side-by-side review of the facility's 1st floor unit's Medical Preparation room (medication storage room) with Staff H, LPN, the surveyor's hand got sticky and there was no soap or hand sanitizer in the room to perform hand hygiene. Staff H confirmed there was no soap in the room. Staff H pulled a hand sanitizer bottle from her pocket. Staff H stated she did not know why there was no soap in the room and added she would tell someone. Further observation revealed an accumulation of ice in the refrigerator freezer located in the medical preparation room on the first floor (Photographic Evidence Obtained). Staff H did not know who was responsible to clean it. The refrigerator was filled with residents' medications. The review revealed an unidentified plastic bag with a pair of dirty boots (Photographic Evidence Obtained). On [DATE] at 4:27 PM, during an interview, Staff E, Unit Manager, was apprised of the first-floor medication storage refrigerator with accumulation of ice, photographic evidence was shown, expired items found and what looks like residents' belongings, on the first floor. He stated he would let the Assistant Director of Nursing (ADON) know. 4. On [DATE] at 4:08 PM, a side-by-side review of the facility's second floor Medical Preparation room (medication storage room) was conducted with Staff E, Unit Manager. The review revealed the following:*A labeled plastic bag for Resident #150 with personal belongings such as a cell phone, a phone charger and a wallet, in a drawer. Staff E stated residents' personal belongings should not be in the medication storage room. Review of Resident #150's clinical record documented a discharge to a local hospital on [DATE]. *An unlocked treatment cart with 29- Xeroform Petrolatum Dressing with an expiration date on 05/2025. During an interview, Staff E stated the treatment cart should be locked and added there was only one key for both carts, but they were getting another one. During the review, the surveyor attempted to do handwashing and there was no soap in the medication storage room. Staff E stated there should be soap in the room for the staff to do handwashing. On [DATE] at 1:10 PM, an interview was conducted with the facility's dedicated Wound Care Nurse (WCN) who stated she works Monday through Friday, and the floor nurses do the residents wound care on the weekends. The WCN stated each nurse's station has a treatment cart and that she uses supplies from those unit's cart, and every Friday she checks all treatment carts supply for expiration dates and added the floor nurses needs to check for expiration dates also. On [DATE] at 2:13 PM, a side-by-side review of the Medical Preparation room was conducted with the Regional Clinical Services and the Director of Nursing (DON). They were apprised of the two-rooms lacking soap.

Based on observations, interviews and record reviews, the facility failed to provide food in correct form (mechanical soft), as ordered by the physician for Resident #56. The census at the time of survey was 135. The findings included: Record review revealed Resident #56 was admitted to the facility on [DATE]. Review of the most recent complete assessment, an admission MDS, with a reference date of 07/23/25, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident was cognitively intact. Resident #56's diagnoses at the time of the assessment included: Cancer, Hypertension, Hyperlipidemia, Thyroid disorder, Malnutrition, and Chronic Lung Disease. Review of Resident #56's physician diet orders included: Regular Diet, Mechanical Soft texture, dated 08/27/25. During an observation of the lunch meal served to the residents in the Dining room on the 200 unit, on 09/02/25 at 12:20 PM, Resident #56 was observed with a piece of bone-in chicken with skin on it. The resident was attempting to eat the chicken with a fork. It was noted that the resident ate very little of the chicken (approximately one quarter of the served chicken). During an interview, on 09/03/25 at 9:42 AM, with the Speech Language Pathologist (SLP), when asked about the resident being served the bone-in chicken leg with the skin on, the SLP stated, it is not appropriate for her because she has left-sided weakness and left-sided droop and can't masticate food properly and that is why she needs mechanical soft.

Based on observations, interviews, and record review, the facility failed to maintain 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 for 3 of 38 residents on Enhanced Barrier Precautions (Residents #20, #77, #14); failed to disinfect reusable equipment between residents' use (Resident #128 and #79); and failed to perform hand hygiene during medication administration observation for 2 of 9 residents (Resident #95 and #127). The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with an issued date of 04/01/24 included in part the following: Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. Policy Explanation and Compliance: 1. Prompt recognition of need: a) All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions. b) All staff receive training on high-risk activities and common organisms that require EBP. C) The facility will have the discretion of how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of EBP: b)An order for EBP will be obtained for residents with any of the following: Wounds, and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of EBP: a) Make gown and gloves available immediately near or outside of the resident's room. 4. High-contact resident care activities include: d)Providing hygiene, g)Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy /ventilator tubes. 1. Record review for Resident #20 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Other Seizures, Encounter for Attention to Gastrostomy, and Aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented in Section C that a Brief Interview of Mental Status (BIMS) could not be completed due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #20 revealed in part the following: An order dated 07/17/25 for 'two times a day Isosource 1.5 or Jevity 1.5 at 80 ml/20hr via J-tube. On 2:00PM off 10:00 AM (Total 1600ml/24 hr.).' An order dated 04/30/24 for 'Enhanced Barrier Precautions every shift.' Review of the Care Plan for Resident #20 dated 07/07/25 documented a focus for Enhanced Barrier Precautions (EBP) for the resident is at risk for multidrug resistant organisms (MDRO) related to feeding tube requiring EBP during high contact resident care activities. The goal was to minimize risk of transmission of colonized or infection with MDROs. The interventions included in part the following: Wear gown and gloves during resident high contact activities in room, therapy gym or shower room (i.e. dressing bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use. On 09/02/25 at 9:55 AM, an observation was made of Resident #20 receiving tube feeding of Isosource 1.5 (formulary type) at 75ml/hr. via pump. There was no EBP sign inside or outside of the resident's room or evidence the resident was on EBP, and there were no disposable gowns or masks in the room or in close proximity to the room. On 09/02/25 at 5:00 PM, an observation was made of Resident #20 receiving tube feeding of Isosource 1.5 at 75ml/hr. via pump. The tube feeding bag was labeled with a date of 09/02/25 with no time and rate of 85ml/hr. There continued to be no EBP signage outside or inside the room and no gowns in the room or in close proximity to the room. On 09/03/25 at 9:30 AM, an observation was made of Resident #20 receiving tube feeding of Isosource 1.5 at 80ml/hr. via pump. The tube feeding bag was labeled with a date of 09/03/25 and rate of 80ml/hr. There still was no EBP signage outside or inside the room and no gowns in the room or in close proximity to the room. An interview was conducted on 09/04/25 at 12:45 PM with the Assistant Director of Nursing / Infection Preventionist (ADON/IP) who acknowledged Resident #20 had an EBP care plan since 07/07/25 and should have had EBP in place long before that. 2. Record review for Resident #77 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Other Osteomyelitis Lower Leg and Obstructive and Reflux Uropathy. The MDS assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #77 revealed in part the following: An order dated 03/07.25 for Enhanced Barrier Precautions - Chronic Wound and Suprapubic Catheter medical device. An order dated 07/24/25 to monitor suprapubic catheter for signs and symptoms of infection and leakage. An order dated 07/24/25 to cleanse suprapubic catheter with normal saline, pat dry and apply dressing every shift and as needed. Review of the Care Plan for Resident #77 dated 03/31/25 documented a focus on 'the resident has a Suprapubic catheter related to Urethral Stricture'. The goals were for the resident to be/remain free from catheter related trauma and to show no signs/symptoms of urinary tract infection through the next review date. The interventions included in part the following: Change catheter as ordered. Change drainage bag per policy. May irrigate suprapubic catheter with 60mls of normal saline every shift as needed for blockage, occlusion, leakage etc. Review of the Care Plan for Resident #77 dated 03/31/25 documented a focus on Enhanced Barrier Precautions (EBP): resident is at risk for multidrug resistant organisms (MDRO) related to chronic wounds and suprapubic catheter requiring EBP during high contact resident care activities in room, therapy gym or shower room, urinary catheter. The goal was to minimize risk of transmission of colonized or infection with MDROs. The interventions included in part the following: Wear gown and gloves during resident high contact activities in room, therapy gym, or shower room (i.e. dressing, bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use, urinary catheter). On 09/02/25 at 10:30 AM, an observation was made of Resident #77 lying in bed with the urinary drainage bag on side of bed covered with privacy cover. There was no EBP sign outside or inside of room, no evidence the resident was on EBP, and no gowns in the room or in close proximity to the room. 3. Record review for Resident #14 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Urinary Tract Infection, Parkinson's Disease, and Obstructive and Reflux Uropathy. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #14 revealed in part the following: An order dated 07/25/25 for Foley Catheter care every shift and as needed. An order dated 07/25/25 for Enhanced Barrier Precautions every shift. Review of the Care Plan for Resident #14 dated 04/29/24 documented a focus on Enhanced Barrier Precautions (EBP) resident is at risk for multidrug resistant organism (MDRO) related to indwelling medical devices requiring EBP during high contact resident care activities in room, therapy gym or shower room. The goal was to minimize risk of transmission of colonized or infection with MDROs. The interventions included in part the following: Wear gown and gloves during resident high-contact activities in room, therapy gym or shower room (i.e. dressing, bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use). Review of the Care Plan for Resident #14 dated 05/27/21 documented a focus on resident has a suprapubic catheter and bilateral nephrostomy tubes related to Neurogenic bladder. He also has indwelling catheter post urethral surgery. The goals were resident will show no signs/symptoms of urinary infection and will be/remain free from catheter related trauma through review date. The interventions included in part the following: Maintain indwelling catheter for obstructive uropathy size 18 French 10 cc balloon. On 09/02/25 at 11:05 AM, an observation was made of Resident #14 in the wheelchair returning to his room followed by Staff B, Registered Nurse (RN), to the resident's side of bed. The RN pulled the curtain and applied gloves, did not put on a gown, and proceeded to touch the catheter tubing and drainage bag. There was no EBP sign on the door or inside the resident's room, no evidence the resident was on EBP, and there were no gowns in the room or in close proximity to the room. An interview was conducted on 09/02/25 at 11:18 AM with Staff B who was asked what she did with the catheter for Resident #14. She stated it was dragging on the floor and so she had him come back to his room so she could adjust it. When asked about not wearing a gown, she replied, she just wore gloves. An interview was conducted on 09/02/25 at 1:44 PM with Staff A, Certified Nursing Assistant (CNA), who stated she has worked at the facility for about 9 years. When asked about Enhanced Barrier Precautions (EBP), she said you needed to wash your hands, and if there is a sign on the door for EBP, you need to put on a gown to do care, take the gown and gloves off in the room, bag it up and throw it away properly. When asked where the personal protective equipment (PPE) including gown, gloves and masks are kept, she said they are usually on the door either inside or outside of the room. An interview was conducted on 09/03/25 at 12:10 PM with Staff B, RN, who stated she has worked at the facility for about 8 years. When asked about who would require Enhanced Barrier Precautions (EBP), she said any resident with an invasive device like a catheter, foley, intravenous access, dialysis or wound. When asked if they need an order for EBP, she said they should have an order, the physician gives the order. When asked about a care plan for EBP, she said they should, but she does not put it in the care plans. When asked if a sign needs to be posted for EBP, she said yes it should be on the outside of the door. When asked if there are 2 residents in the room and a sign on the door, how do they know which resident the EBP sign is for, she said she works here so she just knows. When asked about gowns, she said usually they are in a caddy on the resident's door or in a caddy in the hallway. She acknowledged there was no EBP signage on the door for Resident #20 or Resident #14, and only Resident #14 had a caddy on the door with gowns. When asked about no gowns yesterday in the hallway near Residents #20 and #14 rooms, she said sometimes they run out of the gowns. During a side-by-side observation conducted on 09/03/25 at 4:25 PM with the DON and the Assistant Director of Nursing / Infection Preventionist (ADON/IP) who acknowledged there was no EBP sign on the door for Resident #20 nor was there any isolation gowns in the room or readily available. During a telephone interview conducted on 09/03/25 at 4:35 PM with the Central Supply Clerk (CSC), who stated he has worked at the facility for 7 years and with the ADON/IP present for the interview. The CSC was asked about the supply of gowns, he said they had no supply, all stock was placed on the floor earlier today and they are expecting a shipment tomorrow. When the ADON/IP was asked if he was aware that the facility did not have any ample supply of gowns, he said we only have what the facility will provide. When asked if he has discussed this with the Director of Nursing (DON) or the Administrator, he said no. During an interview conducted on 09/03/25 at 5:00 PM with the ADON/Infection Preventionist who stated he has worked at the facility for 4 months. When asked about what the criteria is that would require a resident the need to be on EBP, the ADON/IP stated the residents who should be on EBP were residents with (urinary) foley, wound, IV (intravenous access), PEG (Percutaneous Endoscopic Gastrostomy) a type of feeding tube and trach. When asked if they need an EBP sign on the door of the room, the ADON/IP said yes and they need gowns and gloves as well, most will have a caddy for the personal protective equipment (PPE) (i.e. gowns and gloves) on the resident's room door, or it will be located in a caddy in the hallway. When asked if they had any issues with not having enough supplies of PPE specifically the gowns, he said he was unsure. When asked if they follow the CDC (Center for Disease Control) guidelines, he said yes. 4. Review of the facility's policy titled General Dose Preparation and Medication Administration revised on 01/01/22 documented .prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy (e.g., handwashing) .after medication administration, facility staff should take all measures required by facility policy.including.clean any reusable equipment or supplies. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Equipment revised on 01/01/25 documented .reusable multiple-resident items are items [NAME] may be used multiple items for multiple residents. Examples include.blood pressure cuffs.multiple-resident use equipment shall be cleaned and disinfected after each use. Review of the facility's policy titled Infection Control-Hand Hygiene revised on 03/02/19 documented .hand hygiene should be performed.upon and after coming in contact with a resident (e.g.lifting a resident.after removing gloves. On 09/02/25 at 4:38 PM, medication observation for Resident #128 performed by Staff I, Licensed Practical Nurse (LPN) was conducted. Staff I entered the resident's room, performed handwashing and donned gloves, then placed the blood pressure machine with the cuff and the pulse oximeter (device to check the blood oxygen saturation) on top of the resident's bed linen. Staff I placed the blood pressure cuff on the resident's left arm and the pulse oximeter on the resident's left-hand finger, upon completion of vital signs check, Staff I removed the blood pressure cuff and machine and the pulse oximeter from the resident and placed the equipment on top of the chair in the room. Further observation revealed Staff I returned to the medication cart with the reusable equipment and placed the equipment (blood pressure and the pulse oximeter) on top of the medication cart without disinfecting the equipment. 5. On 09/02/25 at 5:01 PM, medication observation for Resident #79, performed by Staff I, Licensed Practical Nurse (LPN), was conducted. Staff I entered the resident's room and without disinfecting the reusable equipment, placed the reusable blood pressure machine with the cuff and the pulse oximeter on top of Resident #79's over the bed table. Staff I proceeded to do hand hygiene, placed the blood pressure cuff on the resident's right arm, and the pulse oximeter on the right-hand finger. On 09/02/25 at 5:16 PM, an interview with Staff I was conducted who stated he cleans the reusable equipment after every patient (resident) and confirmed he did not clean/disinfect the equipment in between Resident #128 and Resident #79 during medication administration observation. Staff I stated he was under a little pressure. 6. On 09/03/25 at 9:30 AM, medication administration for Resident #95, performed by Staff H, LPN was conducted. Observation revealed Resident #95 was self-transferring from the wheelchair to the bed with great difficulty and landed on top of a box of tissues. Staff H assisted the resident by lifting her to remove the box of tissue from underneath the resident, the resident refused to take her medications. Further observation revealed Staff H exited the room without performing handwashing, dropped the resident's oral medication into the drug buster bottle, then walked to the nurse's station, without performing hand hygiene, logged in to the desktop computer and dialed on the telephone pad. Staff H then proceeded to the medication cart and started to pour medications for Resident #127 without performing hand hygiene. Consequently, an interview was conducted with Staff H who stated the facility's handwashing policy was to wash her hands after care, after medications administration and added it is very important to do hand washing. Staff H was apprised of the observation findings and replied she did use hand sanitizer. Staff H was apprised that she was not observed doing hand hygiene.

Based on observations, interviews, and record reviews, the facility failed to thoroughly investigate a neglect allegation related to wound care for 1 of 3 residents reviewed for wound care (Resident #3).The findings included:Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment, Misappropriate of Property and Injury of Unknown Source Prevention (ANEMMI), dated 03/02/19, included the following: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to ensure that the facility is doing all that is within its control to prevent occurrences.Investigation:Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting results to the proper authorities.Reporting/Response:Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences.In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: Have evidence that all alleged violations are thoroughly investigated. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Wedge Compression Fracture of Third Lumbar Vertebra, Type 2 Diabetes Mellitus without Complications, Bacteremia, Overactive Bladder and History of Falling. On 07/05/25, Resident #3 was discharged to the hospital from the facility. Review of Section C of the 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) of 14/15, indicating his cognition was intact. Review of Section H revealed Resident #3 had an indwelling catheter and Section M revealed Resident #3 had an unstageable pressure ulcer/injury. Review of the Physician's Orders showed Resident #3 had orders dated 07/02/25 for Wound consult; change indwelling foley catheter when medically necessary and PRN; and May irrigate indwelling Foley catheter with 60ml of NS q shift PRN for blockage, occlusion or leakage. Further review of the Physician's orders revealed Resident #3 had an order dated 07/05/25 for Piperacillin sod-Tazobactam So Solution Reconstituted 3-0.375 grams (GM), Use intravenously (IV) every 8 hours for wound infection until 07/14/25; and an order dated 07/09/25 for Wound care: Cleanse Sacrum wound with wound cleanser, pat dry, add honey fiber to wound bed, and cover/secure with bordered gauze daily and PRN if soiled or displaced until resolved. On 07/23/25, a review of the facility's investigation folder for Resident #3's neglect allegation related to wound care was conducted. The facility investigation included the following: Resident #3's diagnosis, skin check evaluation, previous hospitalization dated 06/20/25-06/30/25, and interviews with current residents related to neglect. Further review revealed no staff interviews were conducted and no record review of Resident #3's wounds or if care was provided for the wounds. In addition, there was no documentation noted in the investigation of what occurred with Resident #3's wounds (as to explain why there was a neglect allegation) and no procedures in place to prevent further occurrences.An interview was conducted on 07/23/25 at 5:10 PM with the Administrator/Risk Manager, who stated he felt that a thorough investigation was conducted for Resident #3's neglect allegations. When asked if he conducted any staff interviews regarding wound care, he stated yes with Staff C, Registered Nurse (RN) and weekend nurse supervisor, who was the one present when the resident was sent out to the hospital due to profusely bleeding from his penis. Then, the Administrator was asked about the wounds of Resident #3, and did he investigate the relation of the wounds to the neglect allegation, he again stated he interviewed Staff C, RN, who advised the aides to be gentle with Resident #3 since he was bleeding profusely. However, the Administrator was unable to answer the question or provide information regarding Resident #3's wounds.

Based on observation, interview and record review, the facility failed to ensure treatment measures were implemented for pressure ulcers for 1 of 3 sample residents, Resident #3, reviewed for Pressure Ulcer/Injury, as evidenced by physician orders for wound care and intravenous (IV) antibiotic therapy were not followed, increasing the risk of pressure ulcer worsening for Resident #3.The findings included: Review of the facility's policy titled, Clean Dressing Change, dated 03/02/19, included the following: It is the policy of the facility to ensure change dressings in accordance with State and federal Regulations, and national guidelines.Procedure:1.Verify and review physician's order for procedure. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Wedge Compression Fracture of Third Lumbar Vertebra, Type 2 Diabetes Mellitus without Complications, Bacteremia, Overactive Bladder and History of Falling. On 07/05/25, Resident #3 was discharged to the hospital from the facility. Review of Section C of the 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) of 14/15, indicating cognition was intact. Review of Section M revealed Resident #3 had an unstageable pressure ulcer/injury. Review of the Physician's Orders showed Resident #3 had orders dated 07/02/25 for Wound consult. Further review of the Physician's orders revealed Resident #3 had an order dated 07/02/25 for Piperacillin sod-Tazobactam So Solution Reconstituted 3-0.375 grams (GM), Use intravenously (IV) every 8 hours for wound infection until 07/14/25; and an order dated 07/09/25 for Wound care: Cleanse Sacrum wound with wound cleanser, pat dry, add honey fiber to wound bed, and cover/secure with bordered gauze daily and PRN if soiled or displaced until resolved (Resident #3 was discharged to the hospital on [DATE]).Review of the admission care Plan revealed for Resident #3's pressure ulcers no interventions were developed.Record review of the July Treatment Administration Record (TAR) for Resident #3 documented no wound care treatment for Resident #3's pressure ulcers from 07/02/25 to 07/05/25. In addition, review of the Medication Administration Record (MAR) indicated Resident #3 was not administered Piperacillin intravenously (IV) every 8 hours for wound infection from 07/02/25 to 07/05/25 (Resident #3 was at the facility from 07/02-07/05/25 without treatment for his wounds).Record review of Resident #3's AHCA 3008-form dated 07/01/25 (part of the hospital discharge paperwork to the facility), the physician wrote under comments: Please see attached IV antibiotics and wound care orders.During an interview conducted on 07/23/25 at 10:58 AM with Staff D, Licensed Practical Nurse (LPN) and wound care nurse, who stated she has been the full-time wound care nurse for 8-9 months and works Monday-Friday. Upon admission of a resident, she stated assessment of wounds is done the next day of admission. She stated she reviews hospital orders and follows the orders upon admission; if need to change the hospital's orders then she will contact the wound care Nurse practitioner (ARNP). She was asked if she assessed Resident #3's wounds upon admission; she stated yes. Further along in the interview, Staff D acknowledged she was scheduled as floor nurse on 07/02/25 instead of the wound care nurse. She further stated on 07/03/25 she was scheduled for documentation for wound care, meaning she would review orders, call family members for updates and future doctor's appointments. Staff D then stated she was off on 07/04/25 and she does not work on the weekends. She stated she saw Resident #3 on 07/02/25 and did a skin assessment because the resident's assigned nurse mentioned to her that the sacrum wound was big. Staff D stated she ordered the wound treatment at that time (Review of the physician's orders for wound treatment was created on 07/09/25, however start date 07/02/25). Then Staff D again added she was assigned as a floor nurse on 07/02/25, assessed Resident #3 briefly and was unable to review the hospital records. A side-by-side review of the July TAR was conducted at this time and Staff D was asked why Resident #3 did not receive wound treatment from 07/02-07/05/25. She stated she was not sure, the floor nurses are responsible for doing the wound treatments when she is not at the facility or when she is assigned as a floor nurse herself. She was also asked why the wound care order was created on 07/09/25 with a 07/02/25 start date, she then stated she was not sure (order was created by Staff D).During an interview conducted on 07/23/25 at 2:03 PM with Staff A, Registered Nurse (RN), who stated she has worked at the facility for 3 months and in July her assignment was on the 2nd floor. She stated she recalls Resident #3 had a wound, however, wound treatment is done by the wound care nurse unless the dressing is soiled and then she would change it, if the wound care nurse is not available, and wound care orders are put in by the wound care nurse.On 07/23/25 at 2:49 PM an interview was conducted with Staff E, ARNP, who stated she has worked at the facility for over a year as the primary ARNP and she comes into the facility Monday-Friday. She stated she saw Resident #3 on 07/02/25 and saw that the resident came in with orders. She then stated she sees newly admitted residents first and conducts an assessment. Staff E stated a few days later she conducted a deep dive into Resident #3's chart and noticed there was an order for IV antibiotic in the hospital discharge packet, which was not in the orders at the facility, so she added it to the chart on 07/05/25. She then stated that when a resident comes into the facility, the admitting nurse would enter all the orders from the hospital discharge documents.On 07/23/25 at 3:31 PM an interview was conducted with Staff B, RN, who stated she has worked at the facility for 35-36 years and in the last few years she has been assigned to the 2nd floor, her shift is 3PM-11PM. She stated medication orders are entered by the admitting nurse, but sometimes she does ask either the nurse supervisor or another nurse to assist in entering the orders. She stated orders come in with the hospital paperwork packet including diet and medications. Staff B confirmed that she was the admitting nurse for Resident #3 on 07/01/25. She stated Resident #3 was alert and oriented, had a Peripheral Inserted Central Catheter (PICC) line, Foley Catheter and had a few wounds. She stated she does not recall where all the wounds were, however, she removed the dressing from the sacral wound to assess how the wound looked and changed the dressing. She then acknowledged not documenting the wound dressing change on 07/01/25. She stated two other nurses assisted her in entering the orders for Resident #3 since it was toward the end of her shift. Staff B cannot recall why Resident #3 had a PICC line. She then stated she did see an order for IV medication, but it was not during her shift (Piperacillin sod-Tazobactam So Solution Reconstituted 3-0.375 grams, use IV every 8 hours for wound infection). She confirmed she was the assigned 3PM-11PM nurse for Resident #3 on 07/02/25, 07/03/25, and 07/05/25. Staff B was asked if she saw the wound care orders for the resident since she was the assigned nurse. At this time, Staff B became very upset and defensive, stating that she is not the only one to blame, this is on every nurse, the wound care nurse would be the one that would address the wound care orders, and it is obvious that Resident #3's physician orders were not all entered.On 07/24/25 at 9:26 AM an interview was conducted with Staff C, RN, who stated she has worked at the facility for 9 months as weekend supervisor. On 07/05/25, she recalls the nurse calling her to the unit because there was a concern with Resident #3, who was bleeding profusely between the thighs; she was unable to locate exactly where the blood was coming from. She stated she looked at the catheter bag and saw no blood in the urine and thought he might be bleeding from the rectum. At this time the doctor and 911 were called and Resident #3 was transferred to the hospital.On 07/23/25 at 11:45 AM an interview was conducted with the DON and Administrator, who were informed that Resident #3 never had wound care orders or IV antibiotic therapy during his stay at the facility. They stated that there was an order for wound care. At this time, a side-by-side review of the orders was conducted and noted that the order for the IV antibiotic was created on 07/05/25 and the wound care order was created on 07/09/25 which was after the resident was transferred to the hospital on [DATE]. They acknowledged that Resident #3 was not receiving the proper care for his wounds.

Based on interviews and record reviews, the facility failed to enter orders for indwelling catheter care for a resident admitted with an indwelling catheter for 1 of 1 resident sampled for an indwelling catheter (Resident #3). The findings included: Review of the facility's policy titled, Infection Control-Indwelling Catheter Care, dated 03/02/19, included the following: It is the policy of the facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Wedge Compression Fracture of Third Lumbar Vertebra, Type 2 Diabetes Mellitus without Complications, Bacteremia and Overactive Bladder. On 07/05/25, Resident #3 was discharged to the hospital from the facility. Review of Section C of the 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) of 14/15, indicating his cognition was intact. Review of Section H revealed Resident #3 had an indwelling catheter. Review of the Physician's Orders showed Resident #3 had orders dated 07/02/25 for change indwelling foley catheter when medically necessary and PRN; and May irrigate indwelling Foley catheter with 60ml of NS q shift PRN for blockage, occlusion or leakage; however, no order for the indwelling Foley catheter care every shift and as needed (PRN) was entered into Resident #3's chart.Review of the Certified Nursing Assistant (CNA) Tasks for Resident #3 dated 07/02/25 - 07/05/25 had no documentation that indwelling Foley catheter care was done.Review of the nursing admission notes dated 07/01/25 documented Resident #3 had a indwelling Foley catheter in place.During an interview conducted on 07/23/25 at 2:03 PM with Staff A, Registered Nurse (RN), who stated she has worked at the facility for 3 months and in July her assignment was on the 2nd floor. She stated she recalls Resident #3 had a urinary foley catheter. Staff A stated she would know if the resident had a foley care order because it will pop-up in the computer system and then she will consult with the Certified Nursing Assistant (CNA) to make sure the care was done.On 07/23/25 at 3:31 PM an interview was conducted with Staff B, RN, who stated she has worked at the facility for 35-36 years and in the last few years she has been assigned to the 2nd floor, her shift is 3PM-11PM. She stated medication and other orders are entered into the computer by the admitting nurse, but sometimes she does ask either the nurse supervisor or another nurse to assist in entering the orders. She stated orders come in with the hospital paperwork packet including diet and medications. Staff B confirmed that she was the admitting nurse for Resident #3 on 07/01/25. She stated Resident #3 was alert and oriented, had a Peripheral Inserted Central Catheter (PICC) line, Foley Catheter and had a few wounds. She stated two other nurses assisted her in entering the orders for Resident #3 since it was toward the end of her shift. She then stated she assessed the foley catheter and did not see any concerns. She acknowledged that the order for foley catheter care should have been entered into the computer.On 07/24/25 at 9:26 AM an interview was conducted with Staff C, RN, who stated she has worked at the facility for 9 months as weekend supervisor. On 07/05/25, she recalls the nurse calling her to the unit because there was a concern with Resident #3, who was bleeding profusely between the thighs. She stated she looked at the catheter bag and saw no blood in the urine and thought he might be bleeding from the rectum. At this time the doctor and 911 were called and Resident #3 was transferred to the hospital.On 07/23/25 at 11:45 AM an interview was conducted with the DON and Administrator, who were informed that Resident #3 never had orders for indwelling Foley catheter care to be done every shift. They acknowledged that Resident #3 was not receiving the proper care for his indwelling Foley catheter.

Based on observations, interviews, and record review, the facility failed to provide nutritional assessments and interventions in a timely manner and failed to prevent significant weight loss and pressure ulcer development for 2 of 4 residents reviewed for nutrition (Resident #80 and Resident #75). The findings included: A review of the facility's policy titled Weight Management dated 03/2/2019 showed the following: 1. All Residents admitted to the facility will be weighed on admission. 2. Residents will be weighed monthly unless otherwise ordered by the physician or deemed necessary by the dietician and the interdisciplinary team. 3. Monthly weights will be completed each month. 4. Dietary will evaluate all weights each month. 5. A reweigh will be obtained for any weight change of +/- 5 pounds from the previous weight unless the physician has ordered other parameters. 1. Resident #80 was admitted on [DATE] with diagnoses of Parkinson, Cerebral infarction, and Muscle Weakness. The Minimum Data Set (MDS) dated [DATE] showed that Resident #80 has a Brief interview of Mental Status (BIMS) score of 15, which indicated he is cognitively intact. Section G of the MDS showed that for eating, Resident #80 is with limited assistance and one person's assist. Admitting order was noted for Consistent Carbohydrate, No Added Salt (CCD, NAS) diet Regular texture dated 12/14/22. Health Shake (nutritional supplement) one time a day for nutrition support at lunch was ordered on 12/20/22, 6 days after his admission to the facility. In an interview conducted on 02/13/23 at 5:25 PM with Resident #80, he stated he cannot eat well with his hands and cannot use his right hand for eating. He tries to eat with his left hand but with incredible difficulty. He further said he is right-handed, wants to eat well, and has a great appetite but needs help during meals. Resident #80 said that he is also very restless at night, constantly moving his legs nonstop and not sleeping at night. According to Resident #80, he told multiple staff in the past that he needs help cutting his food and that he wanted softer food choices with sauces. In an observation conducted on 02/13/23 at 5:38 PM, Resident #80 was in his room with the dinner tray. Closer observation showed a fish sandwich, cut pieces of fish, rice, a slice of tomato, chocolate pudding, and juice. In this observation, Resident #80 had difficulties attempting to lift the food with the fork and tried alternating lifting the food with the spoon on the tray. He only used his left hand and could not lift the bun with the utensils or his bare hands. At one point, he let go of the utensils and lifted that piece of fish with his bare hands. Continued observation showed some food on Resident #80's bedding, and the bun was untouched, with most of the rice on the plate. Resident #80 said to the Surveyor, I could not eat the bun or the rice. During the entire meal, Resident #80 was frustrated and asked the Surveyor if they could help him with his tray. In an interview conducted on 02/14/23 at 8:17 AM, Resident #80 was noted in his room with the breakfast tray. When asked by Surveyor how he was doing this morning he said that he was restless all night with twitching and could not sleep. He then pointed at his breakfast tray and said, they just dropped the food and walked away. The breakfast tray was noted with scrambled eggs, toast, oatmeal, and a carton of milk. Resident #80 was observed attempting to pick up the eggs with his left hand and alternating between the spoon and the fork. Some of the scrambled eggs fell on his lap as he attempted to eat. The milk carton was noted with no cups or straw, and the 4 ounces of juice had a straw in it. In this observation, Resident #80 attempted to cut the toast into smaller pieces and place them into the oatmeal bowl. He poured milk on top of the bread and waited for the bread to soften. He then said that it is easier to eat the bread softer since the toast was too hard. He had difficulty eating the toast inside the oatmeal bowl and stopped to rest between bites. Resident #80 looked at the Surveyor and said it is tiring to eat on my own. In an observation conducted on 02/14/23 at 12:20 PM, the lunch tray was brought into Resident #80's room and was left at the bedside. Closer observation showed a lunch tray with chunks of grilled chicken, beans, coleslaw, slices of oranges, and whole wheat bread. In this observation, Resident #80 stated that he would not be able to eat the grilled chicken because it is too hard to chew and lift off the plate. He further said, everything needs to be chopped, it looks good, but I cannot eat it .He proceeded to eat a few spoons of the beans, and the coleslaw but did not eat any of the bread or the grilled chicken. He then asked Surveyor if they can help open the wrapping around the orange container so he can eat some of the oranges. At 12:46 PM, Staff B, Registered Nurse, came into the room and asked Resident #80 if he needed help with his lunch meal. Resident #80 said that he would not be able to eat the grilled chicken since it was too hard to chew and it did not have a sauce. Staff B said to the Surveyor I told the kitchen multiple times that he needed his food chopped and that he loves barbecue sauce, but they do not listen. She then asked Resident #80 if he wanted his chicken chopped, and he said, no, take it away. I'm afraid I am going to choke. A change of diet meal ticket dated 12/25/22 showed an order to change the diet to Regular Texture Mechanical that was never changed in the diet system or current orders. An order was noted for wound care consultation for a right buttock open area dated 01/08/23, which was addressed on 01/17/23, nine days later. A Review of the Weekly Wound Evaluations dated 01/17/23 - 01/24/23 and 01/31/23, all showed that Resident #80 had an unstageable Pressure ulcer in the sacrum area which was in-house acquired. The care plan dated 12/15/22 showed the following: Resident #80 has a nutritional problem or potential nutritional problem related to Parkinsons, and Cerebral Infarction. The Resident will maintain adequate nutritional status as evidenced by maintaining weight within (5) % of (180), having no signs and symptoms of malnutrition, and consuming at least (51-75) % of meals daily through the review date. Observe for signs of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Observe/report any muscle wasting or significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Occupational therapy to screen and provide adaptive equipment for feeding as needed. Provide and serve supplements as ordered. Provide and serve diet as ordered. Monitor intake of meals and weight per facility protocol. A review of the Nutrition Comprehensive Evaluation and Risk Screen dated 12/20/22, which was completed six days after his admission, showed that the Resident's admission weight was 180 pounds. In this note, Resident #80's meal intake was between 50 to 100%, and his Usual Body Weight was noted between 174 pounds to 175 pounds. It further showed that Resident #80 was at risk for developing pressure ulcers and it was recommended to provide 1 can of Health Shake (nutritional supplement) once a day to give an extra 200 calories and 6 grams of protein daily. A review of the weights showed that Resident #80 had an admission weight of 180 pounds on 12/14/22, 180.1 pounds on 01/20/23, and a weight of 135.6 pounds on 02/09/23. That is 44.5 pounds of weight loss, a severe 24.7 percent weight loss in 3 weeks. A review of the Wound Care Doctor's evaluation dated 01/31/23 showed to maintain adequate nutrition and hydration and medication/supplement as per Primary Care Recommendations to promote wound healing. In this note, the Wound care Doctor requested a Dietary/Nutrition consult dated 12/27/22, which was not addressed. It was noted that Resident #80 had in-house pressure wounds to his mid-back, Sacrum, Left leg lateral, and Right leg medial. A review of the Wound Care Doctor's evaluation dated 02/07/23 showed to maintain adequate nutrition and hydration and medication/supplement as per Primary Care Recommendations to promote wound healing. Further review of the orders did not show that any wound healing supplements or extra nutritional supplements were ordered for Resident #80. An interview conducted on 02/14/23 at 9:47 AM with the Food Service Director who stated that he sees the residents, obtains food preferences, and attends the care plan meetings. Staff F, Dietary Technician, comes in once a week on Tuesdays, and Staff J, Registered Dietitian, comes in a few times a month. For any assessments that need to be addressed right away, they will call Staff J and Staff F on the phone, and they can complete the assessments remotely. When asked about nutrition consultations, he said that Nursing would contact him or Staff F to inform them of any pending dietary consultation. The Food Service Director participates in the care plan meeting twice weekly to discuss the residents' nutritional status. Weights are taken on admission and monthly after that, and Nursing will notify of any weight loss, and any nutritional supplement recommendations will be placed in the system by nursing. Staff F oversees tracking all weight loss and weight gain trends. An interview conducted on 02/14/23 at 10:55 AM with Staff F, Dietary Technician, who stated that she comes to the facility on ce a week for 7 hours and that the Consultant Dietitian comes to the facility 2 to 3 days a month. She will complete all the assessments due for the day and any of the new Resident's Initial Nutrition Assessments. The nursing staff and the Director of Nursing will contact her for any recommendations for the high nutritional-risk residents admitted on the days she is not here. Staff F said that she could also complete assessments remotely when needed. As soon as she can visit the facility, she looks at admission reports and looks for any high-risk parameters they may have. She then meets with the Director of Nursing for any pending dietary consults or any high-risk changes that are needed follow-up on. The weights reports are reviewed as well for any significant weight loss changes. The wound rounds are done on Tuesdays, and she will check any residents with new wounds. Staff F stated that the Director of Nursing would also contact her for any significant weight loss, that is, 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. When asked what is considered as high nutritionally risk residents, she said any residents with malnutrition, failure to thrive, pressure wounds, dialysis, tube feeding, and any residents who come in with poor intake. For nutritional supplements, she likes to order the Health Shake, which has 200 calories and 6 grams of protein per can, and the Frozen Threat, which provides 300 calories and 9 grams of protein. When asked about weights, she said that the staff takes the weight on residents upon admission and then monthly after that. For any weight discrepancies, she will ask the Director of Nursing to retake the weights. The Dietitian Consultant reviews any of the high-risk residents, and she uses a system to identify the high-risk residents in the facility. Staff F reported that the 7 hours a week in the facility is enough to see all residents. When asked about the timing of assessments, she said that they are done on admission, quarterly, and as needed. According to Staff F, Residents with Parkinson's disease have higher caloric needs due to their exuberated movements that cause them to burn extra calories. After Surveyor's intervention, a Dietary progress note dated 02/14/23 showed that Resident #80 is underweight for his age. Resident #80 had significant weight losses of 44.5 pounds (24.7%) x 3 weeks and 44 pounds (24.4%) x 2 months since admission. She further stated the admission weight was likely an error because Resident #80 reported a Usual Body Weight of 145 pounds. A protein supplement of 30 milliliters (ml) once a day to provide (100 kcal, 17g protein), zinc 1 50 milligrams once a day x 30 days for nutrition support. Liberalizing diet to regular related to advanced age with tray set up and assistance as needed was recommended. Resident requesting additional supplement, recommend Health Shake with all meals to providing an additional (600 kcal, 18g protein). The Resident asked for extra sauce/gravy with meals and reports difficulties using utensils. This was the first time additional nutritional interventions and protein supplements were implemented since Resident #80's admission on 12/14/22. The resident's weight was not taken to verify accuracy after this note that was completed on 02/14/23. An interview conducted on 02/15/23 at 11:03 AM with Staff K, Occupation Therapy Assistant, who stated Resident #80 was seen by therapy in the past but is no longer on caseload. His latest Occupational Therapy (OT) ended on 02/10/23. She further said that Resident #80 would need frequent rests between therapy. In this interview, she was asked to reassess Resident #80 for his ability to eat on his own. In an interview conducted on 02/15/23 at 2:30 PM with the Director of Rehab, she stated Resident #80 was reassessed and was picked up for OT again. The assessment on 02/15/23 showed that Resident #80 must be set up, with food cut up, and positioned correctly in bed or chair at the midline. The Resident was recommended a tablespoon instead of a teaspoon, and he easily fatigues when sitting in the chair to feed himself and requires longer breaks. The Speech Therapy Evaluation, dated 02/15/23, revealed that Resident #80 has a physical impairment that is associated with functions deficit and that without therapeutic interventions, the Resident is at risk for further decline and weight loss. In an interview conducted on 02/16/23 at 8:55 AM, Staff H, License Practical Nurse, stated that the Certified Nursing Assistants assigned to the residents take the weights when needed. An interview conducted on 02/16/23 at 9:11 AM with the Director of Nursing, she stated that there is a specific Restorative Certified Nursing Assistant, that takes the weights on all residents. In an observation conducted on 02/16/23 at 11:20 AM, Staff I, a Certified Nursing Assistant, was observed taking the weight on Resident #80 as requested by Surveyor. Resident #80 was taken to the standing scale room accompanied by Staff H, a Licensed Practical Nurse. Staff I stated that the weight of Resident #80's wheelchair is 47.6 pounds, including the legs and the cushion. Continued observation showed that Resident #80's weight was noted at 177 pounds. This showed a current weight of 129.4 pounds by taking the weight of 177 pounds minus the weight of the wheelchair, which was 47.6 pounds. This is an additional 4.6 percent weight loss from 135.6 to 129.4 in one week. In an interview on 02/16/23 at 12:15 PM, Staff J, Registered Dietitian, stated that he only comes into the facility two times a month for about 20 hours. He first checks with the Administrator and the Nursing team for any residents who needed to be seen, as well as the Unit Managers. He looks over residents who are at high risk nutritionally, such as residents on tube feeding, dialysis and any residents admitted with pressure wounds. He always makes sure that on the days that he comes in it is on the days that Staff F is working as well. Staff J said that he does not have the wound care report, and it was told to him verbally by the nursing staff. Any consultations are given to him verbally or handwritten while in the facility. Staff F is responsible for trending weight loss because she is here more often. He will look over any assessment with weight loss for residents with a pressure ulcer, on tube feeding, or on dialysis. For any weight discrepancies, he will ask the Director of Nursing for a reweigh on that Resident. Sometimes reweigh may be taken differently than asked and may be taken the next day. According to him, the best practice is to see high-risk residents at least once a month for a follow-up. 2. Resident #75 was readmitted to the facility on [DATE] with diagnoses of adult failure to thrive, unspecific dementia, and anemia. In an observation conducted on 02/13/23 at 12:05 PM, the lunch tray arrived at Resident #75's room and was placed at the bedside. Staff set up the tray for Resident #75 and left the room. The meal ticket showed an order for No Added Salt (NAS) Regular diet with chopped meat. The tray had food items: breaded pork chops 2-3 inches in size, spinach, sweet potatoes, and 4 ounces of apple juice. No nutritional supplements were noted on the tray. Continued observation at 12:26 PM showed that Resident #75 was eating on his own and only ate a few bites of his lunch meal. In an observation conducted on 02/13/23 at 5:10 PM, the dinner tray was brought into Resident #75's room. The staff set up the tray and left the room. Closer observation showed a dinner tray with chopped fish, mashed potatoes, and a health shake. At 5:28 PM, the Resident was noted in the room eating his dinner tray without assistance from staff. Food was noted all over the tray, with an intake of 75% of the dinner meal. In an observation conducted on 02/14/23 at 12:20 PM, showed that Resident #75 received his lunch tray in the room. At 1:00 PM, he only ate about 50% of his lunch meal. The Nutrition Comprehensive Evaluation dated 11/29/22, almost two weeks after Resident #75 was admitted , showed the following: weight of 129 pounds taken from the admitted [DATE]. Resident #75 was at risk for pressure ulcers with a skin tear to the right forearm. At risk for varied intake related to dementia and it was recommended to provide one can of Health Shake (nutritional supplement) at lunch. The supplement would provide an extra 200 calories and 6 grams of protein daily for support. In this note, Resident #75's weight was to be monitored times four weeks with the intake of meals. A month later, a Dietary Progress note dated 12/27/22 showed that nursing staff informed that Resident #75 has varying intake, and his diet was downgraded to a Mechanical Soft. Intake was noted between 26 to 100 percent, and in this note, it was recommended to increase the Health Shake to two times a day which was six weeks after Resident #75's admission. It further showed to monitor weights and intake, and the next weight that was taken was only on 02/09/23. The weight log showed 129 pounds on 11/16/22, and the next weight taken was not after four weeks but over 85 days later, which was recorded at 113.2 pounds. This showed a 12.3 percent weight loss in less than three months which is severe weight loss. The MDS dated [DATE] showed that Resident #75 had a BIMS score of 03 which is severe cognitive impairment, and under section G for eating, it showed that Resident #75 eats independently with set up only. The care plan initiated on 11/29/22 showed the following: Resident #75 has a nutritional problem or potential nutritional problem related to Dementia, Anemia, and Dysphagia. The Resident will maintain adequate nutritional status as evidenced by maintaining weight within (5) % of (129#), having no signs of malnutrition, and consuming at least (51-75) % of meals daily through the review date. Observe/report signs of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months-the Clinical Dietitian to evaluate and make diet change recommendations and weigh per facility protocol order. Progress note, dated 2/16/2023, seven days after Resident #75's severe weight loss, showed that Resident #75 has been in close observation due to weight loss. Reweigh has been done, and there is still a significant weight loss. The dietary supervisor and Nurse Practitioner were made aware and asked to reevaluate the resident for weight loss. Another Dietary progress note completed on 2/16/23 showed the following: Resident #75's Body Mass Index (BMI) dropped from 22.8 to 20.4, which is underweight for his age. He also had a significant weight loss of 13.8# (10.7%) x 3 months. Weight loss may be contributed to an overall decline in status, discussed with nursing. A speech consult was in place, and his diet was downgraded to Puree on this date. Resident eats meals independently after tray set up, consumed 76-100% of meals, and occasionally <75%; however, suspect intakes are not meeting nutritional needs. On this note, the Clinical Dietitian increased the Health Shake supplements to 3 times a day and added another Frozen treat supplement for lunch for further nutrition support. It further showed to Initiate weekly weight x 4 weeks. These interventions were put in place three months after Resident #75's admission. In an interview conducted on 02/16/23 at 5:00 PM with the Administrator, he was informed of the findings.

Based on observation, interviews, record review, and review of facility policy, it was determined that the facility failed to adequately supervise a resident in order to prevent an Elopement from the facility premises, for (1) of (6) sampled residents who are identified as elopement risk (Resident #1). Resident #1 exited the facility without staff knowledge on 12/03/20 between 7:00 - 7:30 PM. The facility's system failure was a lack of adequate supervision, and an accessible interior fire exit door to a service hallway which led to an emergency exit door, which allowed the resident to elope without staff knowledge and wander outside of the facility unsupervised. Resident #1 was returned to the facility, unharmed, by facility staff and police at 8:00 PM on 12/03/20. While resident #1 was out of the facility unsupervised there was the likelihood she could have been struck by a car, could have fallen from her wheelchair, or become lost, resulting in serious injury, harm, or death. These actions resulted in Immediate Jeopardy. At the time of this complaint survey, there were 5 other residents who were identified as elopement risk. The findings included: Facility policy on Elopement, dated 3/2/2019, stated it is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable. Its definition of Elopement is: Elopement includes when a resident leaves the premises or a safe area without authorization and/or necessary supervision placing the resident at risk for harm or injury. Resident #1, who was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder, Major Depressive Disorder, Ataxia, [CONDITION(S)], [CONDITION(S)], and Muscle weakness. Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], indicated she has a Brief Interview of Mental Status (BIMS) score of 0 out of 15, indicating she is severely cognitively impaired. Section G, Functional Status, indicates Resident #1 is independent with locomotion on the unit, and is self-sufficient once in the wheelchair. In Section E 0900, Wandering-Presence & Frequency, it indicated Wandering behavior occurred 1 to 3 days. On 04/20/21 at 3:51 PM, a review was conducted of the resident's care plan for Elopement dated 07/01/20 in which it revealed that the resident is at risk for Elopement as evidenced by episodic periods of wandering. The interventions included: identify pattern of wandering, and observe resident location. Goal: Safety will be maintained through review date. Record review of the Elopement Screening Tool, dated 12/01/20, indicated Resident #1 verbally expressed the desire to go home, packed belongings to go home and stayed near an exit. This form also indicates that the wandering behavior is a pattern and goal directed with a specific destination in mind, going home. The family/responsible party voiced concerns that the resident may have wandering tendencies to try to leave, and the resident is at risk for Elopement/Wandering, as evidenced by periods of agitation followed by exit seeking behaviors. On 04/19/21 at 9:30 AM, record review of facility provided investigational documentation revealed that on 12/03/20 between the time of 7:29-7:32 PM, Resident #1 left her unit and exited through the service hallway to the back of the building, in her wheelchair. On 04/20/21 at 10:30 AM, an interview was conducted with a Department of Children and Families (DCF) investigator, who stated that (DCF) had accepted the case from a call. The (DCF) investigator stated that in his report, he indicated that Resident #1 had wandered away from the facility and was found by Law Enforcement in the middle of the road, in her wheelchair. During an interview conducted on 04/19/21 at 12:41 PM with the Director of Social Services, she indicated that she had already clocked out and she was outside of the facility, off-duty. As she was getting into her car, her cell phone rang and she got a call from Staff B, a Registered Nurse, (RN) evening 3-11 PM supervisor on-duty. She said to the Director of Social Services that Resident #1 was outside of the facility. She stated that she parked her car across the street in the grassy area at N.W. 12th Avenue and went over to the resident. By the time she was physically near the resident, she stated that the resident had self-propelled off the sidewalk toward the street side. Another former co-worker who was also leaving came over to assist her, after parking her car. The Social Services Director stated that instead of wheeling the resident back into the facility down the sidewalk from the side she was on, she said that she and the co-worker wheeled the resident across the two-way street over to the opposite sidewalk across the street in order to wheel her back into the facility to the front entrance and she stated that is where the Police was heading North and saw them on the opposite side of the street, on the sidewalk. She said that there were a couple of cars going back and forth down the street. She stated that when she physically first saw the resident after coming around the corner, she was seated in her wheelchair in the grassy area, off the premises (wheelchair was partially on the sidewalk and partially on the grass on the street side of the sidewalk, by herself, in the direction of the street. The resident was seated between an electrical light pole. The Police were not on scene when she saw and approached the resident. She said that she and the other co-worker wheeled the resident across the two-lane roadway street to the opposite sidewalk in order to wheel her back inside instead of wheeling her directly down the sidewalk on the same side, when the Police approached heading North and saw them. She said she had no idea who called the Police. She admitted that in her written statement to the facility that she had not recorded exactly where the resident was found. She further stated that the resident was not found 1-3 blocks away from the facility when she approached. However, she was off the premises and onto the public sidewalk, the side nearest to the street. The Social Services Director said that the Police followed them both back to the building and spoke with them briefly, but provided no other information. An interview was conducted on 04/19/21 at 4:20 PM, with Staff A, a Certified Nursing Assistant (CNA) she indicated that she was adjusting a resident's blinds in his room, when looking out of the window, she observed Resident #1 outside alone. She was in the grass next to the sidewalk and two-lane roadway. The CNA stated that she called the supervisor, Staff B, who called the Social Services Director to go and get her. She was told by the Supervisor, to stay by the window and to keep eyes on the resident. This is what she did for about 5 minutes until the Social Worker came over to the resident from wherever she was and wheeled the resident back into the facility. During an interview conducted on 04/21/21 at 1 PM with resident #1's son, he stated that he was told first by the Police on 12/04/20 at 3 AM in the morning, that Resident #1 pushed through a couple of facility doors. He said that around 8 or 9 AM later that morning that the facility then called him. He says that he does not remember who he spoke with at the facility. The son stated that the Police told him that someone (unknown) had called and found the resident about one (1) block away from where the facility is located. At that point, he said that the Police brought her back to the facility. He said that he does not believe that the resident even remembers what happened. He said that the facility told him that the resident was back in her room and she was ok and that they would have someone to sit with her and monitor her. He stated that at the time, he was worried especially due to her condition. He said that he was aware that the resident was a wanderer that would try to escape; she was able to ambulate for short distances and use her wheelchair. He added that even when the resident was at home, she tried many times to leave her home through the front door. An observational walking tour of the facility's first floor utility service hallway was conducted with both the Administrator and with the Director of Maintenance, on 04/19/21 beginning at 12:50 PM. This utility service hallway was entered from the first floor back lobby area by an interior, unlocked, door at its entrance. The utility service hallway is approximately 120-foot long and consists of the following office areas: the Maintenance and Housekeeping Directors' offices, the Laundry area, and one office room located at the far end of this hallway was observed to be filled with various janitorial supplies. During this tour, the following was observed located along the cluttered service hallway: resident beds awaiting maintenance and repair, multiple uncovered oxygen concentrators and large floor cleaning machines. The emergency exit push door, which opens directly to the outside of the facility, has a fifteen (15) second delay and alarm. However, this low-sounding emergency exit door alarm does not enunciate anywhere else in the facility. Once outside, there is no exterior enclosed barrier of the facility property, and a person can reach the public sidewalk on the west side of the facility. During this tour, the Maintenance Director stated he locks this utility service door every evening before he leaves for the day. When the surveyor went to the laundry area on 04/20/21 at 6:42 PM to conduct staff interviews, the door was closed, and unlocked. Subsequently, during an observational tour of the facility's exterior, conducted on 04/19/21 at 1:30 PM, with both the Administrator and the Director of Maintenance, the adjacent two-lane roadway was noted some portions of the roadway contained turning lanes on each side of the street, making it, in essence four-lanes at certain sections. During an interview conducted on 04/20/21 at 6:42 PM with Staff D, a first-floor laundry aide, she was asked if the entry door to the first floor utility service hallway was locked. She answered, no, and stated that for the past two weeks this utility door has been unlocked and she added that she does not have a key. During an interview conducted on 04/20/21 at 7 PM with Staff E, a floor cleaning technician, he acknowledged that currently, the service utility door was only closed and not locked. He stated that he cleans the first and second floors with a machine, for about 1 or 2 hours and he said that he comes back downstairs through this unlocked door to clean his floor machine just inside of the service hallway entrance. He stated that from 3-11 PM this utility service door is always unlocked so they can go back and forth. When he leaves at 11 PM, he said that he believes that one of the nurse (supervisor) locks this door with a key; he said he does not have a key to this door. On 04/21/21 at 6:45 PM, a telephone interview was conducted with Staff B, (a Registered Nurse), and evening 3-11 PM supervisor. She stated she had last seen Resident #1, sitting in her room in her wheelchair looking at some magazines. Staff B said that she first noticed the resident to be missing from the facility, when she received a call from Staff A, a (CNA), informing her that she had observed Resident #1 in her wheelchair propelling herself in the grass in the back of the building. Staff B stated that she had just seen one of her co-workers, the Social Services Director, leave the facility. Staff B told this surveyor that she called and asked the Social Services Director to go and see what was going on since Staff A, a (CNA) had just told her that the resident was outside in the grass. At that point, she said that she hung up the phone, then went outside thru the front entrance. Resident #1 was at the back of the building seated in her wheelchair. She said that she walked along the sidewalk heading South, and the resident was heading North, being pushed in the wheelchair by the Social Services Director. She then proceeded to take over and push Resident #1 back into the building a little after 8 PM while it was getting dark. An interview was conducted with the Director of Nursing (DON) on 04/22/21 at 2:43 PM where she affirmed all the statements made by the facility staff. Record review of the facility's Incidents by Incident Type form reflects that the facility categorized this event as an Elopement Incident on 12/03/20. Record review on 04/19/21 at 2:10 PM, noted that on Sunday 11/29/20 at 22:51 hours (10:22 PM), Staff C, a RN, documented in the electronic progress notes under Behavior, Patient noted to be agitated throughout shift, wandering the hallways. Patient attempted to go down on the elevator which was prohibited. Non-pharmacological Interventions: gentle touch and redirection. Outcome of interventions: Patient calmed down and returned to room, laying in bed. Resident #1 was exhibiting wandering and exit-seeking behaviors, just four (4) days prior to the 12/03/20 Elopement event. The Police report, dated 12/03/20 at 7:38 PM, indicated the officer responded to a call involving an elderly patient in the roadway, at the intersection of NW 12th Ave and NW 13th Street. The officer was assisted by four (4) other officers. The Officer stated upon arrival, an elderly female in a wheelchair was now on the sidewalk accompanied by two females, later identified as the Social Service Director and a former employee. The resident was without injury, spoke only Spanish, seemed confused, and was unable to recall her own date of birth. The two females advised they worked at the Avante facility down the street, and that staff was unaware Resident #1 had left the premises. Both said they were leaving the facility in their vehicles and recognized Resident #1 due to her clothing, who was in her wheelchair in the middle turning lane of the intersection. The Social Service Director escorted Resident #1 back to the facility while the Officer followed. At the facility, the Officer spoke with Staff C, who was assigned to Resident #1's care, and was unaware of her departure from the facility. The Officer contacted DCF and was advised the incident did meet legal criteria for a report to be generated and that an investigator would be assigned. The Police case supplemental report, indicated on 12/04/20 at 1224 hours, two officers were dispatched to the facility to follow up with DCF regarding a prior event. On 12/3/20 at approximately 1935 hours Resident #1 was found in the roadway west of the facility. They spoke with the Social Service Director, who stated as she was driving, she saw Resident #1's bright red sweater, moved her vehicle to block traffic and began moving Resident #1 out of the roadway. A telephone interview was conducted with the primary Police Officer on 4/22/21 at 7:09 PM. She stated the incident occurred at the intersection of NW 12th Ave and NW 13th Street. She had received the police call for elderly person in the middle of the intersection. She put on her lights and siren. Upon arrival she found an elderly woman in a wheelchair on the sidewalk, on the west side of NW 12th Ave, with 2 female staff from Avante. One of them said she pulled the resident from the road onto the sidewalk. Photographic evidence obtained during survey. The facility's Immediate Jeopardy Removal plan and Corrective Actions included: 1. Resident was placed on 1:1 supervision initially, until she was seen by the physician on 12/10/20, and then was placed on 1:1 monitoring for safety rotation. The rotation is documented the same way the 1:1 supervision. The 1:1 rotation is every C.N.A that is assigned to that unit sits with the resident for 30-45 minutes at a time through out every shift. The resident remains on rotation as of today. The C.N.A. records were reviewed for December, January, February, March, and April, which staff initialed every shift. Observations of the resident and staff interactions, and interviews with staff, verified this intervention was currently being implemented. Education on supervison and monitoring of residents were conducted on 12/19/20, 12/21/20, 12/23/20, 12/29/20, 1/4/21, 1/7/21, 1/12/21, 1/13/21, 1/15/21, 1/19/21, 1/22/21, 1/28/21, 2/1/21, 2/9/21, 2/16/21, 2/26/21, 3/2/21, 3/16/21, 3/24/21, 3/28/21, 4/6/21, 4/10/21. 2. All residents were accounted for on 12/3/20, with no issues noted. 3. An immediate investigation was started that evening by the Executive Director and Director of Nursing. Ad Hoc QA meeting was conducted on 12/3/20 at 9:15 PM. Recommendations were to continue with elopement competencies and education; continue with resident on 1 on 1 supervision until Psych Evaluation completed; and elevator monitoring to identify any similar behaviors of any other residents. 4. Camera footage was reviewed to identify the time and exit route. 5. Elevator monitoring was initiated on 12/03/20. Staff member was assigned to elevator watch to ensure residents identified at risk had no elopement attempts. The IDT and QA committee met and reviewed the tracking and trending of elevator observations and resident behaviors with no incidents identified, and discontinued the elevator monitoring on 1/31/21. Review of their elevator monitoring documentation and interview with the Nursing Home Administrator, verified the elevator monitoring was conducted until the team deemed it could be discontinued. 6. Facility exit doors were checked for locking and functioning, with no issues noted. Observations of exit doors, interview with staff, and review of audits conducted by Maintenance, verified emergency exits doors were locked and functional. Training on the Back Hallway Exit Door was presented by the Housekeeping Director that the use of the back door is limited only for authorized maintenance services or emergency situations. Employees are not allowed to access that door at any time, this door is an emergency exit only. 7. Door screamers were assessed and implemented where needed and adjusted to continuously sound when activated. No malfunctions noted. Observed doors and interviewed staff, sound verified. 8. Root care analysis (RCA) was completed on 12/10/20 after speaking with the Psych physician and after their internal investigation was completed. The ADON did complete the RCA while receiving input from the interdisciplinary team and it was reviewed at their following QA meeting. 9. Re-educated all staff on elopement policy prior to the start of their next shift. Daily missing resident drills completed on varying shifts for 2 weeks, then monthly. Competency of staff was verified by an elopement post-test. Documentation of all education materials, sign-in sheets, drills, and post-tests were reviewed. Of the 183 employees on the roster at the time of the incident, 6 are on LOA, and 19 either resigned or never worked, two are duplicates, and the remaining 156 were all in-serviced. Daily drills were conducted between 12/3/20 - 12/17/20; then monthly drills conducted 1/6/21, 2/28/21, and 3/30/21. 10. Results of elopement drills and progress on re-education presented to Executive Director during QAPI meetings, until February 23, 2021.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's eating needs that are identified in the comprehensive assessment for supervising meals for residents diagnosed with [REDACTED].#1) . The facility actions resulted in Immediate Jeopardy. This has the potential to affect 28 out of 104 residents with a [DIAGNOSES REDACTED]. The Administrator was informed of the existence of the Immediate Jeopardy on [DATE] at 4:10 PM. The immediate jeopardy was on-going at the time of the exit on [DATE]. The findings included: A review of the facility's Policy and Procedures: Comprehensive Care Plans, revised [DATE], documented: The services provided or arranged by the facility as outlined by the comprehensive care plan, will meet professional standards of quality. Each discipline will check and/or add interventions/approaches to include but not limited to the intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes. Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The tracheotomy had been removed, and the resident was received nutrition from the feeding tube only at night from 8 PM to 6 AM, along with a Pureed diet and honey thick fluids. The feeding tube was eventually removed. A review of the most recent annual Minimum Data Set (MDS) Comprehensive Assessment, dated [DATE], documented Resident #1 was rarely/never understood. The assessment further documented the resident was moderately cognitive impaired (decisions poor, cues/supervision required), and she required supervision with eating. Supervision is defined as oversight, encouragement, or cueing. A Certified Nursing Assistant (CNA) meal consumption log from [DATE]-[DATE] was reviewed. The log documented Resident #1 received supervision with meals. Supervision was defined as oversight, encouragement, or cueing, A review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for at nutritional risk related to swallowing difficulty relating to dysphagia (difficulty swallowing). The goal was for the resident to remain free from episodes of choking or signs and symptoms of aspiration. Interventions included adjust meal selections as needed, and advance diet per speech (speech therapist) recommendations and doctor orders. Resident #1's care plan relating to swallowing difficulty relating to dysphagia lacked intervention of supervision while eating, as assessed in the annual Comprehensive assessment dated [DATE]. A review of Resident #1's physician orders [REDACTED]. NAS (no added salt) was added to the order on [DATE]. An interview was conducted with the two MDS coordinators, on [DATE] at 2:00 PM. They stated the ADL (activities for daily living) care plan does not address eating, and do not know why. They are the ones responsible for the ADL portion of the care plan. They do not care plan supervision for eating. The Nutrition care plan is for dietary. They confirmed supervision with eating is not specified on a care plan for Resident #1. A review of Resident #1's progress notes revealed a note dated [DATE] at 10:00 AM documented: Resident was observed propelling self in wheelchair going back to her room. This writer heard breathing pattern unusual. Upon Assessment res (resident)noted very agitated and combative, not allowing staff to touch her. Resident noted gasping for air and noted with a peanut butter smell coming from her mouth. It appeared that the resident was choking. Resident was unable to speak. Abdominal thrusts started. Resident started to make verbal sounds and staff attempted to look into mouth and she pushed staff away. Res then propelled self into bathroom and drink water from the sink and shortly after she collapsed. Resident was transferred from the wheel chair to the bed. Noted unresponsive. No pulse felt. No respirations. 911 called. CPR initiated until paramedics arrived and took over. MD called and made aware. Family notified. A review of the hospital's Emergency Documentation dated [DATE] and signed at 5:28 AM, revealed Resident #1 had a witnessed episode of chocking on peanut butter that lead to respiratory and [MEDICAL CONDITION] about 30 minutes prior to arrival. A review of the hospital's Discharge Documentation revealed an admission date of [DATE] and a discharge date of [DATE] for Resident #1. The discharge [DIAGNOSES REDACTED].

Based on interview, facility record review, facility policy review, and hospital record review, the facility failed to provide adequate supervision during eating for a cognitively impaired resident with difficulty swallowing, for 1 of 3 sampled residents (Resident #1) . Resident #1 acquired a peanut butter sandwich and choked while eating it. The resident became unresponsive, required emergency care and hospitalization , and death. The facility actions resulted in Immediate Jeopardy. This has the potential to affect 28 out of 104 residents with a [DIAGNOSES REDACTED]. The Administrator was informed of the existence of the Immediate Jeopardy on [DATE] at 4:10 PM. The immediate jeopardy was on-going at the time of the exit on [DATE]. The findings included: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The tracheotomy had been removed, and the resident was received nutrition from the feeding tube only at night from 8 PM to 6 AM, along with a Pureed diet and honey thick fluids. The feeding tube was eventually removed. A review of the most recent annual Minimum Data Set (MDS) Comprehensive Assessment, dated [DATE], documented Resident #1 was rarely/never understood. The assessment further documented the resident was moderately cognitive impaired (decisions poor, cues/supervision required), and required supervision with eating. A review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for at nutritional risk related to swallowing difficulty relating to dysphagia (difficulty swallowing). The goal was for the resident to remain free from episodes of choking or signs and symptoms of aspiration. Interventions included adjust meal selections as needed, and advance diet per speech (speech therapist) recommendations and doctor orders. Resident #1's care plan also indicated the resident had a nutrition risk related to dementia/psych (psychiatric) [DIAGNOSES REDACTED]. Interventions included monitor/document/report to physician signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals. Resident #1's care plan for swallowing difficulty relating to dysphagia lacked intervention of supervision while eating, as assessed in the annual Comprehensive assessment dated [DATE]. Resident #1's records lacked documentation of monitoring/documenting/reporting to physician signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals. A review of Resident #1's physician orders [REDACTED]. NAS (no added salt) was added to the order on [DATE]. A progress note, written by Staff I, LPN assigned to Resident #1, dated [DATE] at 10:00 AM documented the following: Resident was observed propelling self in wheelchair going back to her room. This writer heard breathing pattern unusual. Upon Assessment res (resident)noted very agitated and combative, not allowing staff to touch her. Resident noted gasping for air and noted with a peanut butter smell coming from her mouth. It appeared that the resident was choking. Resident was unable to speak. Abdominal thrusts started. Resident started to make verbal sounds and staff attempted to look into mouth and she pushed staff away. Res then propelled self into bathroom and drink water from the sink and shortly after she collapsed. Resident was transferred from the wheel chair to the bed. Noted unresponsive. No pulse felt. No respirations. 911 called. CPR initiated until paramedics arrived and took over. MD called and made aware. Family notified. A progress note written by Staff I, LPN who was assigned to Resident #1, dated [DATE] at 9:07 PM documented the following: Clarification of events for CPR code; at around 4 AM Resident noted placing a peanut butter sandwich on nursing cart by nursing staff. The resident propelled self in front of nursing station. Upon assessment resident noted gasping for air, and peanut butter smell coming from her mouth. Resident appeared to be choking. Unable to speak. Abdominal thrust started, residue of peanut butter noted inside of her mouth. Resident started to make verbal sounds, and staff try to look into residence mouth resident pushed staff away. Resident then proceeded to go into her room inside her room inside the bathroom with nursing staff member. She turned on the water and placed water into her mouth. Shortly after she collapsed in her wheelchair towards the left side in her wheelchair. Approximately at 4:05 to 4:10 AM resident was without vitals cold status checked resident was a full called 911 initiated CPR initiated. Resident was transferred from the wheelchair to the bed. At approximately 4:15 AM fire rescue arrived and took over CPR. Approximately 4:25 AM resident was transported to Boca regional Hospital. At approximately 4:26 AM family member notified. At approximately 4:30 AM call placed to MD. A review of the hospital's Emergency Documentation dated [DATE] and signed at 5:28 AM, revealed Resident #1 had a witnessed episode of chocking on peanut butter that lead to respiratory and [MEDICAL CONDITION] about 30 minutes prior to arrival. The Emergency Documentation further stated by the time emergency arrived at 4:03 AM Resident #1 was pulseless (had no pulse) and apneic (was not breathing), rhythm was asystole (no heartbeat) and bystander cardiopulmonary resuscitation (CPR) was in progress. They cleared large amounts of peanut butter from the airway. Patient was intubated (breathing tube placed in air way) and ACLS (advanced cardiac life support) protocols were followed. Patient arrived with a systolic blood pressure of 60 mmHg (critically low) and heart rate 130 (abnormally high), but is neurologically unresponsive. A review of the hospital's Discharge Documentation revealed an admission date of [DATE] and an expiration date of [DATE] for Resident #1. The discharge [DIAGNOSES REDACTED]. A tour of the facility's second floor was conducted on [DATE] at 12:40 PM. The room that Resident #1 resided in was located directly across from the nursing station. Next to the nursing station was a nourishment room. The surveyor entered the nourishment room with the assistance of staff. Upon entering the nourishment room, surveyor noted the door remained in the open position. There were no snacks/sandwiches observed in the nourishment room/refrigerator. Upon leaving the nourishment room, the surveyor had to physically close the door, because it would not latch shut. The door was not self-closing. The surveyor conducted an interview with the facility's Speech Language Pathologist (SLP), on [DATE] at 1:04 PM. When questioned, the SLP stated peanut butter was an appropriate food for a mechanical soft diet, though her professional preference would like to see liquids with alternating bites of the sandwich. The SLP stated Resident #1's last screening for speech therapy was in (MONTH) (YEAR), and there were no changes. Surveyor asked for a policy regarding speech therapy evaluations for a resident with difficulty swallowing and on a mechanical soft diet. The SLP left the interview to find the answer to the surveyor's question. The SLP returned with the Director of Rehabilitation. The Director stated screening is to be done quarterly and as needed with a decline in function. The surveyor conducted a subsequent interview with the Director of Rehabilitation on [DATE] at 1:57 PM. The Director stated there was no policy, but they try to coordinate screenings with quarterly comprehensive assessments and care plan meetings. A review of Resident #1's record revealed a Speech Therapy Screening Tool dated [DATE]. The tool documented the following: Patient screened. Diet will remain mechanical soft/thin liquids. The screening tool further documented: Therapy screening constitutes a review of the medical record, interview of the patient/family and caregivers, and handsoff observation. Screenings are not a substitute for therapy evaluation and cannot be used as a basis for therapeutic interventions. There was no further documentation of a speech therapy screening or evaluation for Resident #1, since (MONTH) (YEAR). A review of three of Resident #1's Avante Weekly Summaries, dated [DATE], [DATE], and [DATE], all documented the resident required extensive assistance with eating. A Certified Nursing Assistant (CNA) meal consumption log from [DATE]-[DATE] was reviewed. The log documented Resident #1 received supervision with meals. Supervision was defined as oversight, encouragement, or cueing, The surveyor conducted an interview with the acting Dietary Manager (DM) on [DATE] at 1:44 PM. The DM stated ordered snacks and extra snacks/sandwiches are sent to the nourishment room, and the nurses/aides give to the residents from the nourishment rooms. The DM produced a tray ticket for Resident #1 that documented the resident was on a Level 2 mechanical soft diet. A review of the facility's diet manual, Sysco Menu Guide Fall/Winter 2019 documented: Level 2: Mechanically Altered is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist. At times, pureed versions of the menu items must be served to ensure integrity of the diet. The diet manual further documented: Meals need to be modified to suit individual resident tolerance as determined by appropriate personnel at the facility level. The resident's acceptance and tolerance of the diet determines the extent of texture modification. Individual preferences should be considered when planning the patient meal. The surveyor conducted an interview with Staff A, a CNA, on [DATE] at 3:15 PM. Staff A stated snacks were usually brought up from the kitchen around 8:00 PM. Staff A stated the snacks consist of peanut butter and jelly sandwiches, yogurt, and applesauce. The surveyor conducted an interview with Staff B, a CNA, on [DATE] at 4:15 PM. Staff B stated Resident #1 would self propel in a wheel chair around the facility. Staff B further stated she would take the resident outside to smoke. Staff stated the resident would use the call light if anything was needed. Staff B further stated the resident would get a snack from the nourishment room, as it was open and unlocked at night sometimes. The surveyor conducted an interview with Staff C and Staff D, both CNAs, concurrently on [DATE] at 10:00 AM. Staff C and Staff D stated the pantry door was supposed to be closed to prevent residents from entering. Staff C and Staff D further stated they have seen the second floor pantry door opened. They have to make sure the door closes tightly, or it can be pushed open. Staff C and Staff D further stated the first floor pantry door closes automatically. The facility's quick reference guide for facility snacks in nourishment room, revised (MONTH) 2, 2019, documented the nourishment room doors are to be kept locked. Nursing staff are to provide snacks per resident request and per physician ordered diet. On [DATE] at 3:00 PM, the surveyor called Staff E, a CNA who works on the night shift, and left a voice message. Staff [NAME] returned the call within 30 minutes, and stated she was assigned to Resident #1 the night of the choking incident. She did her rounds at 11:00 PM when she came on shift. She was in a room with another resident during the incident, and was told later that Resident #1 was choking. On [DATE] at 3:30 PM, the surveyor placed a call to Staff F, a CNA who works on the night shift, and left a voice message. Staff F returned the call a short time later, and stated she heard someone call out for help. She came to room and saw CPR in progress in the resident's room. On [DATE] at 10:00 AM, the surveyor interviewed Staff G, a Registered Nurse who works on the night shift. She stated at around 2:30 AM she saw Resident #1 coming out of the room. Resident would roam around in the middle of the night. The resident stopped and got a cup in the hallway from the nurse's medication cart, and she placed a bag on top of the cart. Asked why, but the resident did not answer. She would normally eat everything and does not put anything on the cart, she would put it in the garbage. The resident was attempting to go back to her room. She heard a noise, saw the resident was choking, and immediately left the nursing station to go help her. The nurse tried to do the [MEDICATION NAME] Manuever. She saw residue of peanut butter, and the resident tried to say something to us. I tried to look inside her mouth, but she pushed herself away and wheeled to bathroom. The resident drank from the bathroom faucet and then collapsed. We both tried to perform the [MEDICATION NAME], and did back blows. The surveyor asked Staff G about the bag the resident placed on top of the cart, and she responded the plastic bags are used for the peanut butter sandwiches. She did not recall if the pantry door was open or closed. To open the pantry door, you usually have to put in a code. You also have to pull the door closed behind you. She has seen the pantry door open, but she always closes the door behind her. On [DATE] at 6:00 PM, the surveyor received a return phone call from Staff I, a Licensed Practical Nurse, who was assigned to care for Resident #1 on the night of the choking incident. She stated she did not know where the resident got the sandwich. The pantry door is to remain closed. She did not see the pantry door open. She does not recall ever seeing the resident eat a peanut butter sandwich. Peanut butter and/or peanut butter sandwiches are brought from the kitchen to the pantry. The dietary progress note, dated (MONTH) 25, 2019 at 6:38 PM, documented the following:Written note received from brother. Call placed for follow-up. Per discussion, brother reporting soup is salty, that staff are putting salt in broth. Also requesting soup be watered down and ice cubes be added to cool soup. Discussed food quality and temperature regulations with limited success. Brother also stating patient is having difficulty chewing certain foods on mechanical soft diet and that she needs soup to assist with swallowing. Brother stated that patient needs proper nutrition to prevent weight-loss. Offered to refer patient to speech therapy for eval, decline but after multiple re-attempts now agreeable as may be barrier to eating optimally. Brother also aware of patient choice and refusing to be weighed and eating as desired. Brother agreeable to the following: Change diet to mechanical soft no added salt diet, and referred to speech for evaluation. The surveyor interviewed the Speech Therapist on [DATE] at 2:00 PM. She confirmed the last screening by a Speech Therapist was on [DATE], and the resident had not been seen by Speech Therapy since that time. She reviewed the ST notes, and confirmed no evaluation for diet change from a pureed diet. She also was not aware of the dietary request for a speech evaluation or diet change. She stated it has to be ordered/communicated to speech. The surveyor conducted an interview on [DATE] at 2:30 PM with the Registered Dietitian, she stated peanut butter is appropriate on a mechanical soft diet. She started working at the facility on [DATE]. If she thought ST was needed, she would write inthe notes and tell them face to face or send an email. The texture of food is determined by ST they are the experts. Snacks are delivered by dietary to the nourishment rooms, and nursing staff provide the snacks depending on the resident's therapeutic diet. Snacks include: crackers (graham, saltine); cookies; pudding; ice cream, fruit, sandwiches (peanut butter and jelly); and beverages. The nourishment rooms are for staff only. On average ,[DATE] half sandwiches are made per unit, except for seaside which is smaller. The surveyor interviewed the Plant Operations Director on [DATE] at 3:00 PM. He stated when he started working at the facility, he repaired the 1st floor pantry door. There have been no repairs on the other doors other than replacing batteries on the combination lock. On [DATE] at 7:45 PM, the surveyor observed the delivery of snacks to nourishment/pantry room on the second floor with staff. Eight (8) half peanut butter and jelly sandwiches and 3 half tuna sandwiches were noted on the counter in the room, and they were placed in plastic sandwich bags. The surveyor interviewed the Director of Nursing (DON) on [DATE] at 4:30 PM. The DON provided an incident report dated [DATE] at 10:00 AM related to Resident #1. The DON stated she did not report this incident as an adverse incident to the Florida State Survey Agency, as required by state and federal law, because they did not know where the resident got the peanut butter sandwich.

Based on observation, interview and record review, it was determined the facility failed to accurately assess, care plan, and monitor skin status and failed to provide necessary care and services to prevent neglect of 1 of 6 sampled residents (Resident #2), as evidenced by a lack of timely communication between the staff members and physicians, inaccurate skin assessments, and ineffective nursing interventions to prevent the worsening of a wound. The findings include: 1) Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was subsequently transferred to the hospital on [DATE] at 6:30 PM by the nephrologist to evaluate [MEDICAL CONDITION]. In the emergency department, it was determined by the triage nurse that the resident had a Stage 4 wound to the right foot, with purulent, foul smelling drainage between the great and second toe with necrotic tissue to bottom of the foot. The left foot, in between the great toe and second toe, was found to be the same as the right foot. There were also "flying bugs on bottom of the left foot around wound." The emergency room physician documented the web space between toes was macerated and eroded. A podiatry consult provided on 05/13/2014 indicated that there was full-thickness ulcerations in the first interdigital space which probes deeply. There is exposed bone and malodor. The remainder of the interspaces are extremely macerated. A miscellaneous culture of the right foot revealed heavy Staph aureus. The podiatrist further documented the resident "will likely require some sort of surgical intervention, in some form of amputation. However, due to her vascular status and her overall health status, she may not tolerate this operation very well. Therefore, it is possible that she may require more hospice than anything." A review of Resident #2's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/12/2014 revealed the resident is coded as cognitively intact and exhibits no moods or behaviors. Resident #2 requires extensive assistance of 1 person for positioning in bed, transferring between surfaces, dressing and personal hygiene. Resident #2 is identified as a risk for developing pressure ulcers and is identified as having one Stage 1 unhealed pressure ulcer. A review of the Medication Administration Record [REDACTED]. A review of the Treatment Administration Record (TAR) for the month of May 2014 revealed the following orders: On 12/10/13, an order for [REDACTED]. On 12/10/13, an order for [REDACTED]. On 12/20/2013, an order to cleanse the left lower foot with normal saline (NS), apply triple antibiotic ointment (TAO) and cover with a dry dressing 3 times a week on day shift every Sunday, Wednesday, and Friday, and as needed (PRN). On 3/21/14, an order for [REDACTED]. All medications and treatments are documented as being completed. A review of the Weekly Skin Observation Sheets dated 4/11/2014, 4/18/2014, 04/25/2014 and 05/05/2014 revealed no evidence of documentation of a wound to the right toe. There is no evidence of any skin condition to the left lower foot. The skin assessment on 04/11/2014 and 04/25/2014 do not indicate the resident had redness to the sacrum. A review of the care plan dated 2/17/14 for risk of skin integrity with an identified skin tear to left arm 11/06/2013 and a skin tear beneath small toe of left foot 11/13/13. There is no stage 1 ulcer listed. A review of the Activities of Daily Living (ADL) care plan indicates Resident #2 needs assistance of one staff member for bathing and dressing and for the staff to observe for redness and open areas and report to a nurse. There is no indication on the care plan that there is any type of wound to the spaces between Resident #2 ' s toes, scaly areas to the arms and legs or redness to the buttocks. An interview was conducted with Licensed Practical Nurse (LPN) J on 05/15/2014 at 12:43 PM which revealed the aide should be reporting to the nurse if they saw something "different on the resident" and then the resident would get assessed; otherwise, skin assessments are completed on 3-11 or 11-7 shift. Nurse J stated Resident #2 had a previous concern with her toe that had resolved. She stated to the surveyor that she had been in the room with Certified Nursing Assistant (CNA) D for AM care the morning the resident had been transferred to the hospital and there were no open areas observed on the resident's body. An interview was conducted with CNA D on 05/15/2014 at 12:47 PM, who was the aide providing care for Resident #2 on 05/12/2014, prior to her hospital transfer. She stated she looks at the resident's skin while she is cleaning the resident or giving a bath/shower. She stated if she sees something on the skin she will call the nurse to come and check out the resident. She stated when she does a bath; she looks in all the cracks, folds and areas between the toes. The nurse gave her a cream to put on her toes which she does. CNA D further stated Resident #2 had an open area in her toes last month that had gotten better. She confirmed LPN J had been in the room with her during AM care and had assessed the resident and there were no open areas. A subsequent interview with CNA D on 05/16/2014 at 8:21 AM revealed the resident did not sleep with socks on and she would put cream on the resident's feet and give her a clean pair of socks. She stated she had a clean pair of socks the morning of 05/12/2014. An interview was conducted with CNA E on 05/15/2014 at 3:00 PM which conflicted with the statements given by CNA D and LPN J regarding the status of the wound. CNA E stated she had provided care to Resident #2 on the 3-11 shift prior to the hospital transfer and the resident was noted to have an open area in between the toes of the right foot. CNA E verified the wound was draining and had a foul odor. She further stated the draining wound did not have a dressing applied the day before the hospital transfer and the resident had been wearing socks. LPN I confirmed the open wound on 05/15/2014 at 3:36 PM by stating the resident had an opened area of skin between the great toe and second toe and there was ongoing treatment to the area. LPN I further added that Resident #2 had some redness to the buttocks of which barrier cream was being applied. She did not check the resident's skin the evening of her transfer to the hospital because she was concerned of her general condition. An interview was conducted with LPN E on 05/16/2014 at 7:06 AM. She verified that she had cared for Resident #2 on the night shift prior to her being transferred to the hospital. She stated the resident was being treated for [REDACTED]." The wound was "a dark wound, fairly deep, more opened towards the bottom of her foot and in between her first and second toes." LPN E denied any odor or drainage to the wound, just a "crust." LPN E further stated she had completed the Weekly Skin Observation assessment on 04/18/2014. She acknowledged that she did not put the information regarding the treatment to the right great toe on the assessment. LPN E also stated that she would have to remove Resident #2's socks 9 out of 10 times to put the medication on her toe because the resident liked to sleep with socks on. LPN E stated she did not give the wound information in report as the information should pop up on the Treatment Administration Record (TAR). An interview was conducted jointly with the Administrator and the 2nd floor Unit Manager on 05/16/2014 at 7:39 AM. Both stated "it makes no sense regarding the wound; she had had an open wound that had closed." The Administrator stated the regular staff knows the residents well but LPN E was not a regular nurse on that assignment. He further stated the only skin condition Resident #2 had upon transfer from the facility was redness to her buttocks. Her heels were intact and the laceration/scratch to the buttock had been resolved. The Unit Manger went further to say LPN E was a new nurse and was learning and did not correctly identify the wound. Neither the Administrator nor the Unit Manager was able to determine why other staff members were stating there was an open wound between the toes. Both staff members did review the care plan and acknowledged that there is no indication that there had ever been a care plan for the toe wound or buttock wound. They further verified to the surveyor there was no evidence of wound documentation for the buttock laceration or the treatments to the left foot or right great toe. There is no indication in the chart if these wounds were current or healed. A review of the facility Wound Monitoring Guidelines revealed, #3 to update care plans as appropriate, and #4 to review current treatment. If treatment has been in place for 14 days and the wound has not improved or worsened, notify the physician for a change in treatment and document appropriately. An interview was conducted with the wound care nurse on 05/16/2014 at 8:18 AM who stated she will follow a resident if they are being seen by the wound care physician. If a nurse determines the wound is not healing after 2 weeks, they would put in a consult for her to evaluate. She stated Resident #2 had no skin issues that she was aware of and was not involved in her care. She confirmed she had not gotten a wound consult for the resident. A review of the laboratory report, dated 4/13/14 revealed a right toe culture with a moderate growth of [MEDICAL CONDITION] (MRSA) and Pseudomonas aeruginosa. The report states, "Critical result called to (LPN F) on 4/13/2014 at 3:30 PM. There is a handwritten note on the report that documents, "STAT, bactoban 2% to right with dry dress daily." An interview was conducted with the podiatrist on 05/16/2014 at 9:31 AM. He confirmed the staff must have notified him of [MEDICAL CONDITION] and he approved the medication because "OK" is written on the lab report. He further stated the wound did not need antibiotics and he is conservative with [MEDICAL TREATMENT] residents. He is careful of prescribing antibiotics because the residents get infections and [MEDICAL CONDITION]. The podiatrist further stated he did not discuss [MEDICAL CONDITION] with the nephrologist because he did not feel it was needed, the topical antibiotic was enough. There is no evidence in the medical record that the nurses, aides or physicians were aware of [MEDICAL CONDITION] condition, except for the nurse who received the lab report. There is no further mention [MEDICAL CONDITION] in any progress note by nurse or physician. A review of [MEDICAL CONDITION] guidelines revealed residents with known or suspected to [MEDICAL CONDITION] infection will be placed on contact precautions and placed in a private room if the attending physician, in conjunction with the infection control coordinator, judges the case to meet specific clinical criteria, including: There is more than one documented case [MEDICAL CONDITION] in the facility and transmission is likely. A review of the infection control log documents 2 other residents have documented cases [MEDICAL CONDITION], one on the 1st floor and one on the same floor as Resident #2. On 05/16/2014 at 10:59 AM, the Assistant Director of Nursing (ADON) and the Clinical Manager stated [MEDICAL CONDITION] policy which was requested by the surveyor is just a guideline and does not have to be followed completely. The ADON further stated since the physician did not feel the need for isolation, the resident was not placed on isolation. They both agreed there were other cases [MEDICAL CONDITION] in the facility but there was no risk of contamination. The ADON stated a dry dressing was placed on the cream administration but it was not documented. He was unable to provide documentation that the attending physician was made aware of [MEDICAL CONDITION] status as per the guidelines. An interview was conducted with Resident #11, the roommate of Resident #2, on 05/16/2014 at 10:40 AM. She stated Resident #2 was not able to get out of bed without assistance and the staff washed her in bed almost every day. She stated the resident must have [MEDICAL CONDITION] on her feet and skin because there was a "terrible odor" in the room. Resident #11 stated it was not a fecal smell. A review of the Quarterly MDS with an ARD of 02/02/2014 coded Resident #11 as cognitively intact.

Based on observation, interview and record review, it was determined the facility staff failed to provide nursing care that meets the professional standards of quality as evidenced by: a failure to maintain a comprehensive care plan, a failure to communicate between nurses and physicians regarding wound status and treatment for 1 of 6 sampled residents (Resident # 2); and failure to accurately assess wounds during weekly skin assessments for 4 of 10 sampled residents with skin conditions (Residents #2, 17, 13 and 16). The findings include: The ANA Standards of Professional Performance describes a competent level of behavior in the professional role, including activities related to quality of care, performance appraisal , education, collegiality, ethics, collaboration, research, and resource utilization, this document serves as objective guidelines for nurses to be accountable for their actions, their patients, and their peers . The standards provide a method to assure clients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measure are in place to determine whether the care meets the standards. The Standards of Care in the ANA Nursing: Scopes and Standards of practice (2004) describe a competent level of nursing care. The levels of care are demonstrated through the nursing process. The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to clients. Within these are the nursing responsibilities for diversity, safety, education, health promotion, treatment , self-care, and planning for the continuity of care 1) Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was subsequently transferred to the hospital on [DATE] at 6:30 PM by the nephrologist to evaluate [MEDICAL CONDITION]. In the emergency department, it was determined by the triage nurse that the resident had a Stage 4 wound to the right foot, with purulent, foul smelling drainage between the great and second toe with necrotic tissue to bottom of the foot. The left foot, in between the great toe and second toe, was found to be the same as the right foot. There were also "flying bugs on bottom of the left foot around wound." The emergency room physician documented the web space between toes was macerated and eroded. A consult provided on 05/13/2014 by a podiatrist indicated that there was full-thickness ulcerations in the first interdigital space which probes deeply. There is exposed bone and malodor. The remainder of the interspaces are extremely macerated. The podiatrist further documented the resident "will likely require some sort of surgical intervention, in some form of amputation." A review of Resident #2's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/12/2014 revealed the resident is coded as cognitively intact and exhibits no moods or behaviors. Resident #2 is identified as a risk for developing pressure ulcers and is identified as having one Stage 1 unhealed pressure ulcer. A review of the Medication Administration Record [REDACTED]. A review of the Treatment Administration Record (TAR) for the month of May 2014 revealed the following orders: On 12/10/13, an order for [REDACTED]. On 12/10/13, an order for [REDACTED]. On 12/20/2013, an order to cleanse the left lower foot with normal saline (NS), apply triple antibiotic ointment (TAO) and cover with a dry dressing 3 times a week on day shift every Sunday, Wednesday, and Friday, and as needed (PRN). On 3/21/14, an order for [REDACTED]. All medications and treatments are documented as being completed. A review of the Weekly Skin Observation Sheets dated 4/11/2014, 4/18/2014, 04/25/2014 and 05/05/2014 revealed inconsistencies, and no evidence of documentation of a wound to the right toe and no evidence of any skin condition to the left lower foot, which was under treatment. The skin assessment on 04/11/2014 and 04/25/2014 do not indicate the resident had redness to the sacrum. A review of the care plan dated 2/17/14 for risk of skin integrity with an identified skin tear to left arm 11/06/2013 and a skin tear beneath small toe of left foot 11/13/13. There is no indication on the care plan that there is any type of wound to the spaces between Resident #2 ' s toes, scaly areas to the arms and legs or redness to the buttocks. An interview was conducted with Licensed Practical Nurse (LPN) J on 05/15/2014 at 12:43 PM which revealed the aide should be reporting to the nurse if they saw something "different on the resident" and then the resident would get assessed; otherwise, skin assessments are completed on 3-11 or 11-7 shift. Nurse J stated Resident #2 had a previous concern with her toe that had resolved. She stated to the surveyor that she had been in the room with Certified Nursing Assistant (CNA) D for AM care the morning the resident had been transferred to the hospital and there were no open areas observed on the resident's body. An interview was conducted with CNA D on 05/15/2014 at 12:47 PM, who was the aide providing care for Resident #2 on 05/12/2014, prior to her hospital transfer, which revealed she looks at the resident's skin while she is cleaning the resident or giving a bath/shower. She stated if she sees something on the skin she will call the nurse to come and check out the resident. She stated when she does a bath, she looks in all the cracks, folds and areas between the toes. The nurse gave her a cream to put on her toes which she does. CNA D further stated Resident #2 had an open area in her toes last month that had gotten better. She confirmed LPN J had been in the room with her during AM care and had assessed the resident and there were no open areas. A subsequent interview with CNA D on 05/16/2014 at 8:21 AM revealed the resident did not sleep with socks on and she would put cream on the resident's feet and give her a clean pair of socks. She stated she had a clean pair of socks the morning of 05/12/2014. An interview was conducted with CNA E on 05/15/2014 at 3:00 PM which conflicted with the statements given by CNA D and LPN J regarding the status of the wound. CNA E stated she had provided care to Resident #2 on the 3-11 shift prior to the hospital transfer and the resident was noted to have an open area in between the toes of the right foot. CNA E verified the wound was draining and had a foul odor. She further stated the draining wound did not have a dressing applied the day before the hospital transfer and the resident had been wearing socks. LPN I confirmed the open wound on 05/15/2014 at 3:36 PM by stating the resident had an open area of skin between the great toe and second toe and there was ongoing treatment to the area. LPN I further added that Resident #2 had some redness to the buttocks of which barrier cream was being applied. She did not check the resident's skin the evening of her transfer to the hospital because she was concerned of her general condition. An interview was conducted with LPN E on 05/16/2014 at 7:06 AM. She verified that she had cared for Resident #2 on the night shift prior to her being transferred to the hospital. She stated the resident was being treated for [REDACTED]." The wound was "a dark wound, fairly deep, more opened towards the bottom of her foot and in between her first and second toes." LPN E denied any odor or drainage to the wound, just a "crust." LPN E further stated she had completed the Weekly Skin Observation assessment on 04/18/2014. She acknowledged that she did not put the information regarding the treatment to the right great toe on the assessment. LPN E also stated that she would have to remove Resident #2's socks 9 out of 10 times to put the medication on her toe because the resident liked to sleep with socks on. LPN E stated she did not give the wound information in report as the information should pop up on the Treatment Administration Record (TAR). An interview was conducted jointly with the Administrator and the 2nd floor Unit Manager on 05/16/2014 at 7:39 AM. Both stated "it makes no sense regarding the wound; she had had an open wound that had closed." The Administrator stated the regular staff knows the residents well but LPN E was not a regular nurse on that assignment. He further stated the only skin condition Resident #2 had upon transfer from the facility was redness to her buttocks. Her heels were intact and the laceration/scratch to the buttock had been resolved. Both staff members did review the care plan and acknowledged that there is no indication that there had ever been a care plan for the toe wound or buttock wound. They further verified to the surveyor there was no evidence of wound documentation for the buttock laceration or the treatments to the left foot or right great toe. There is no indication in the chart if these wounds were current or healed. A review of the facility Wound Monitoring Guidelines revealed, #3 to update care plans as appropriate, and #4 to review current treatment. If treatment has been in place for 14 days and the wound has not improved or worsened, notify the physician for a change in treatment and document appropriately. An interview was conducted with the wound care nurse on 05/16/2014 at 8:18 AM who stated she will follow a resident if they are being seen by the wound care physician. If a nurse determines the wound is not healing after 2 weeks, they would put in a consult for her to evaluate. She stated Resident #2 had no skin issues that she was aware of and was not involved in her care. She confirmed she had not gotten a wound consult for the resident. A review of the laboratory reports revealed a right toe culture with a moderate growth of [MEDICAL CONDITION] (MRSA) and Pseudomonas aeruginosa. There is a handwritten note on the report that documents " STAT, bactoban 2% to right with dry dress daily." An interview was conducted with the podiatrist on 05/16/2014 at 9:31 AM. He confirmed the staff must have notified him of [MEDICAL CONDITION] and he approved the medication because "OK" is written on the lab report. He further stated the wound did not need antibiotics and he is conservative with [MEDICAL TREATMENT] residents. The podiatrist further stated he did not discuss [MEDICAL CONDITION] with the nephrologist because he did not feel it was needed, the topical antibiotic was enough. There is no evidence in the medical record that the nurses, aides or physicians were aware of [MEDICAL CONDITION] condition, except for the nurse who received the lab report. There is no further mention [MEDICAL CONDITION] in any progress note by nurse or physician. On 05/16/2014 at 10:59 AM, the Assistant Director of Nursing (ADON) and the Clinical Manager stated [MEDICAL CONDITION] policy which was requested by the surveyor is just a guideline and does not have to be followed completely. The ADON further stated since the physician did not feel the need for isolation, the resident was not placed on isolation. They both agreed there were other cases [MEDICAL CONDITION] in the facility but there was no risk of contamination. The ADON stated a dry dressing was placed on the cream administration but it was not documented. He was unable to provide documentation that the attending physician was made aware of [MEDICAL CONDITION] status as per the guidelines. An interview was conducted with Resident #11, the roommate of Resident #2, on 05/16/2014 at 10:40 AM. She stated Resident #2 was not able to get out of bed without assistance and the staff washed her in bed almost every day. She stated the resident must have [MEDICAL CONDITION] on her feet and skin because there was a "terrible odor" in the room. Resident #11 stated it was not a fecal smell. A review of the Quarterly MDS with an ARD of 02/02/2014 coded Resident #11 as cognitively intact. 2) Skin assessment rounds were completed with the Clinical Manager on 05/15/2014 at 11:05 AM to observe all the residents who were totally dependent on staff for assistance. Resident #17 was observed at 11:09 AM and had multiple scabbed areas to both feet. The 3rd toe on the right foot had a blackened area to the tip and a blister was noted to the right great toe. The blister was intact. There was a large blackish scab observed on the left inner ankle taht was oozing a greenish yellow material mixed with bright red material onto the sheet. The clinical manager stated "we must have aggravated it when moving her." A review of the Skin Conditions sheet for Resident #17 dated 05/13/2014 revealed multiple blisters to the body. There is no evidence of documentation of the multiple areas observed by the surveyor and clinical manager. The Clinical Manager reviewed the Skin Condition sheet and verified that the skin assessment was not accurate and stated she will check into it. 3) Skin assessment rounds were completed with the Clinical Manager on 05/15/2014. At 11:23 AM Resident #13 was observed in bed with two large foot/ankle dressings. His buttocks were not red, but pink and blanchable. A review of the Skin Condition sheet dated 05/12/2014 revealed redness to buttocks. There is no documentation regarding the bilateral foot dressings. This was verified by the Clinical Manager. 4) Skin assessment rounds were completed with the Clinical Manager on 05/15/2014. At 12:10 PM Resident #16 was observed in bed with the wound care physician. The wound care physician stated he was treating the resident for a wound to the elbow and a toe on the right foot. A review of the Skin Condition sheet dated 05/13/2014 revealed no documentation of any skin conditions. This was confirmed by the Clinical Manager.

Based on interview, record review, and facility policy, the facility failed to follow the Advance Directive in place for a resident regarding a Do Not Resuscitate (DNR) order, as evidenced by initiating cardio-pulmonary resuscitation (CPR) for 1 of 3 sampled residents reviewed for Advance Directives (Resident #1). The initiation of CPR treatment included chest compressions, forced on the resident against her wishes. A facility audit of Advance Directives was conducted on [DATE], 30 of the 121 current residents had DNRO paperwork, which indicated they were not to be provided life sustaining procedures should they be found without respirations or pulse. The findings constituted the determination of immediate jeopardy, due to a staff member failing to determine the code status for Resident #1, prior to initiating CPR. The immediate jeopardy existed beginning [DATE], and was removed [DATE]. The scope and severity level was decreased from a "J" level to a "D" level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The findings include: Per record review, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a pacemaker and a history of [MEDICAL CONDITION] Fibrillation. The resident had signed a "Health Care Surrogate Designation" form on [DATE], designating her daughter as her Health Care Surrogate (HCS). The resident had a DNR in place, effective [DATE], per review of the "Florida Do Not Resuscitate Order" form, dated [DATE]. The resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident returned from the hospital without information regarding her DNR status. The resident, with the assistance of her daughter per the resident's request, validated through interview with the Assistant Administrator/Director of Social Services on [DATE], completed another "Florida Do Not Resuscitate Order" form, dated [DATE]. The physician signed the DNR form on [DATE]. An interview was conducted with the resident's daughter on [DATE] at 9:07 AM, and the daughter expressed her mother was clear on a DNR order, stating "my mother said they beat on her chest once and said never again". The daughter stated her mother wanted it "pasted on her bed". The resident had a Minimum Data Set (MDS) assessment completed for admission with a reference date of [DATE]. The MDS indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1's cognition was intact. A review of the medical record was conducted on [DATE]. The following sequence of events was revealed: On [DATE] at 6:25 AM, the resident who was being progressively weaned off of the ventilator, was placed back on ventilator support. Between 6:15 AM and 6:25 AM, on [DATE], the resident became non-responsive with a heart rate of 56 beats per minute and respiratory rate of 10. Her oxygen saturation level was 87%. After being placed back on the ventilator, her oxygen saturation increased to 98%, her respirations increased to 13, however her heart rate decreased to 50 beats per minute. A Respiratory Therapist who functioned in the capacity of the Director of Respiratory Therapy, present in the facility on [DATE] at 6:45 AM was summoned to the resident's room. Shortly thereafter, while on ventilator support, the resident was unable to be aroused, with an absence of carotid pulses, and CPR was initiated by the Respiratory Therapist. The facility called 911. An interview was conducted with the Respiratory Therapist/Director of Respiratory Therapy on [DATE] at 10:57 AM. He validated he was summoned to the resident's room at 6:45 AM on [DATE], and was unable to arouse the resident, as well as obtain any carotid pulses. He validated he initiated CPR on the resident, when he was unable to obtain a carotid pulse. He stated he was not aware the resident had a DNR in place. He stated he did not check the resident's chart himself prior, or designate a staff member to check the resident's chart for the DNR status, while he remained with the resident. He expressed a vulnerability relating to a conflict with the resident's daughter prior to [DATE] and "jumped into reactive mode." He validated he was aware of determining a resident's code status before initiating CPR and stated, "My bad. I really screwed up." He acknowledged the resident's code status was located in the resident's chart, near the front, under a tab called "Advance Directives". He acknowledged he was familar with the facility policy on checking the resident's chart for code status, before any initiation of CPR to any resident. He acknowledged after the incident the resident had a DNR in place. An investigation of the incident was completed by the Administrator on a form entitled "Potential Adverse Incident Investigation Worksheet". The form did not indicate when it was completed. The form validated the incident occurred on [DATE] and under the section "Describe circumstances of the incident" notation read "Resident had an advanced directive in her records which was not observed @ the time". Under the section "Were there any staff errors or omissions related to the incident?" the notation read, "Advance Directive was overlooked." A review of the facility's policy entitled "Advance Directives Guidelines (DNR)" validated under the guideline denoted as Number 2: "Document Resident/Responsible Party wishes in the medical record." The policy did not contain a date. Under the "purpose" section of the policy, the following was contained, "To insure that all Residents will be given the option of formulating an advance directive (DNR) and documents will be completed and kept up to date in the medical record." An interview was conducted with the Director of Nursing (DON) and the Assistant Administrator on [DATE] at 11:00 AM and ongoing throughout the survey. Both staff members validated the Advance Directive, DNR, for Resident #1 was legally sound and in place at the time the Respiratory Therapist initiated CPR. Both validated the facility policy was to check the resident's chart before initiating CPR to determine code status and this was not done. Both validated on [DATE], Resident's #1's medical record contained the most current, yellow DNR form, dated [DATE], under the section/tab of "Advanced Directives". The DON stated all staff are aware of the procedure, and neither the DON or the Assistant Administrator were aware of a conflict with the family and the Respiratory Therapist. Both denied any issues were reported to them from the Respiratory Department or Respiratory Therapist/Director of Respiratory Therapy at any time prior to the incident. The DON and the Assistant Administrator together outlined for the surveyor, the steps taken to correct the situation after the event and the measures put in place to prevent recurrence. The measures were described as follows: 1. All residents were audited for their current and correct code status. 2. All resident charts were audited to ensure the section labelled " Advance Directives " contained no errors. 3. The topic of Advance Directives was added to the daily agenda for the interdisciplinary meeting held every morning. 4. The topic of Advance Directives was added to the agenda of the weekly Risk/Quality of Life meeting. 5. Forty-five (45) of 45 licensed nursing staff (RNs and LPNs), were re-educated on the Advance Directive procedure, including determining code status on a resident first, through reviewing the proper section in the chart. 6. Thirteen (13) of the 15 Respiratory Therapy staff were re-educated on the Advance Directive policies and procedures, including the first step in checking the resident ' s chart for code status, before initiating CPR. Two of the RTs are still on medical leave. 7. A " Stop and Watch " program was instituted for all staff, including all ancillary departments. The program was designed for staff to stay alert and keep everyone informed of changes in a resident ' s status or condition, as they arise. It included reporting any changes or issues to the proper clinical and administrative staff immediately. 8. The topic of Advanced Directives was added to the general orientation program provided to all new staff. 9. A yellow laminated, pocket-sized card (same color as the DNR form) was created and the information contained within reflected all the necessary items and topics the admission nurse/admission process must cover, as soon as a resident enters the facility. A card was given to each nurse employed, as well as posted near each computer in the facility. 10. SBAR (Situation/Baseline/Assessment/Report) form was instituted for the nursing staff, which included reviewing the Advance Directives, as part of the assessment. 11. The Director of Respiratory Therapy was counselled regarding the untoward event on [DATE] related to his actions. He resigned on [DATE]. 12. A " Daily Scrub " of each new admission ' s medical record will be performed by Administration and all clinical services, within the resident ' s first 24 hours. The scrub was designed to ensure all the necessary paperwork is contained in the record. 13. The Administration making plans to improve hospital relations to ensure a new admission comes to the facility with all paperwork intact. 14. Administration preparing to remind all staff to promptly report resident and family concerns, conflicts, and problems to the appropriate staff. The surveyor reviewed 2 additional residents who were recently readmitted to the facility, and 9 resident records, to ensure the Advance Directive section of the records reflected the correct code status of the resident. No concerns with any of the residents ' Advance Directives were noted.

Based on interview, record review, and facility policy, the facility failed to follow the Advance Directive in place for Do Not Resuscitate (DNR) order by initiating cardio-pulmonary resuscitation (CPR); for 1 of 3 sampled residents reviewed for Advance Directives (Resident #1). The initiation of CPR treatment included chest compressions, forced on the resident against her wishes. A facility audit of Advance Directives was conducted on [DATE], 30 of the 121 current residents had DNRO paperwork, which indicated they were not to be provided life sustaining procedures, and were at risk should they be found without respirations or pulse. The findings constituted the determination of immediate jeopardy, due to a direct care staff member failing to determine the code status for the resident, prior to initiating CPR. The immediate jeopardy existed beginning [DATE], and was removed on [DATE]. The scope and severity level was decreased from a "J" level to a "D" level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. Additionally, the facility failed to communicate an ongoing, problematic relationship with a resident's responsible party, which had a potential impact on the initiation of CPR for Resident #1, against her DNR order. The findings include: Per record review, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a pacemaker and a history of [MEDICAL CONDITION] Fibrillation. The resident had signed a "Health Care Surrogate Designation" form on [DATE], designating her daughter as her Health Care Surrogate (HCS). The resident had a DNR in place, effective [DATE], per review of the "Florida Do Not Resuscitate Order" form, dated [DATE]. The resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident returned from the hospital without information regarding her DNR status. The resident, with the assistance of her daughter per the resident's request, validated through interview with the Assistant Administrator on [DATE], completed another "Florida Do Not Resuscitate Order" form, dated [DATE]. The physician signed the form on [DATE]. An interview was conducted with the resident's daughter on [DATE] at 9:07 AM, and the daughter expressed her mother was clear on a DNR order, stating "my mother said they beat on her chest once and said never again". The daughter stated her mother wanted it "pasted on her bed". The resident had a Minimum Data Set (MDS) assessment completed for admission with a reference date of [DATE]. The MDS indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated her cognition was intact. A review of the medical record was conducted on [DATE]. The following sequence of events was revealed: On [DATE] at 6:25 AM, the resident who was being progressively weaned off of the ventilator, was placed back on ventilator support. Between 6:15 AM and 6:25 AM, on [DATE], the resident became non-responsive with a heart rate of 56 beats per minute and respiratory rate of 10. Her oxygen saturation level was 87%. After being placed back on the ventilator, her oxygen saturation increased to 98%, her respirations increased to 13, however her heart rate decreased to 50 beats per minute. A Respiratory Therapist who functioned in the capacity of the Director of Respiratory Therapy, present in the facility on [DATE] at 6:45 AM was summoned to the resident's room. Shortly thereafter, while on ventilator support, the resident was unable to be aroused, with an absence of carotid pulses, and CPR was initiated by the Respiratory Therapist. The facility called 911. Review of the facility's Adverse Incident Report stated the resident had been revived, post CPR services rendered, but later passed away in the hospital. An interview was conducted with the Respiratory Therapist/Director of Respiratory Therapy on [DATE] at 10:57 AM. He validated he was summoned to the resident's room at 6:45 AM on [DATE], and was unable to arouse the resident, as well as obtain any carotid pulses. He validated he initiated CPR on the resident, when he was unable to obtain a carotid pulse. He stated he was not aware the resident had a DNR in place. He stated he did not check the resident's chart himself prior, or delegate a staff member to check the resident's chart for the DNR status, while he remained with the resident. He expressed a vulnerability relating to a conflict with the resident's daughter prior to [DATE] and "jumped into reactive mode." He validated he was aware of determining a resident's code status before initiating CPR and stated, "My bad. I really screwed up." He acknowledged the resident's code status was located in the resident's chart, near the front, under a tab called "Advance Directives". Further discussion revealed he was experiencing issues with the resident's responsible party that were progressive, and at one point he stated he was accused of trying to kill the resident. He expressed the staff he supervised reported issues with the responsible party to him on several occassions. He was unable to answer why he failed to report the issues to Administration, the Director of Nursing, and/or the Director of Social Services as they occurred. He stated he did not fully understand the term "Interdisciplinary" and stated, "I do not know Long Term Care". When asked if he was aware of the facility's grievance policy and procedure, he did not answer. He acknowledged he attends daily meetings held with other departments, in a forum where residents issues are discussed. Additionally he added, he re-inserviced all the respiratory staff on the procedure to determine code status involving the review of the chart, after the incident on [DATE], involving himself. He denied speaking to the staff he supervises about reporting conflicts to Administration and/or Social Services. On [DATE], the Administrator informed the surveyor, the Respiratory Therapist resigned on [DATE]. An investigation of the incident was completed by the Administrator on a form entitled "Potential Adverse Incident Investigation Worksheet". The form did not indicate when it was completed. The form validated the incident occurred on [DATE] and under the section "Describe curcumstances of the incident" notation read "resident had an advanced directive in her records which was not observed @ the time". Under the section "Were there any staff errors or omissions related to the incident?" the notation read "Advanced directive was overlooked." A typed, unsigned statement supplied by the Respiratory Therapist, as part of the Administrator's investigation, revealed the following: "Given the history of my interaction with the daughter, I felt it necessary to do everything to save the patient. Especially since the daughter had accused me before of wanting to pull the plug on her mother. The daughter and I had a few intense interactions before where she was yelling at me and the staff over the care of her mother." During the interview with the employee, he stated he supplied a statement to administration when the event was investigated. A review of the facility's policy entitled "Advanced Directives Guidelines (DNR)" validated under the guideline denoted as "Number 2: Document Resident/Responsible Party wishes in the medical record." The policy did not contain a date. Under the "purpose" section of the policy, the following was contained, "To insure that all Residents will be given the option of formulating an advance directive (DNR) and documents will be completed and kept up to date in the medical record." An interview was conducted with the Director of Nursing (DON) and the Assistant Administrator/Director of Social Services on [DATE] at 11:00 AM and ongoing throughout the survey. Both staff members validated the Advance Directive, DNR, for Resident #1 was legally sound and in place at the time the Respiratory Therapist initiated CPR. Both validated the facility policy was to check the resident's chart before initiating CPR to determine code status and this was not done. Both validated on [DATE], Resident's #1's medical record contained the most current, yellow DNR form, dated [DATE], under the section/tab of "Advanced Directives". The DON stated all staff are aware of the procedure, and neither the DON or the Assistant Administrator were aware of a conflict with the family, prior to the event of [DATE]. Both denied any issues were reported to them from the Respiratory Department or the Respiratory Therapist/Director of Respiratory Therapy. The DON stated she re-inserviced all the nursing staff on the procedure after the incident, beginning [DATE] and ending [DATE]. The DON and Assistant Administrator discussed with the surveyor, a daily meeting is held with staff where issues regarding the resident's care and concerns, including family issues, are reported and discussed. They validated the daily meetings are part of ongoing operations and the Respiratory Therapist/Director of Respiratory Therapy has attended these regularly, as required. Review of a log kept by the Assistant Administrator indicated Resident #1 had a "HCS" (Health Care Surrogate) and DNR in place. A review of the facility's policy entitled "Avante Resident Grievance Policy" dated [DATE], documented under the section, "Scope of Policy"..."Contractors not employed by Avante that have direct contact or provide direct medical care to residents within the Avante facility will be given a copy of this policy and be expected to assist in this process where appropriate." A further review of the Respiratory Therapist's personnel file was conducted. Evidence revealed he received training in his orientation program on [DATE], on the topics of Resident Rights, Abuse and Neglect, Avante Grievance Policy, and Risk Management. An interview was conducted with the Administrator on [DATE] at 10:00 AM, and he validated the training was provided to the employee. The Administrator stated, "All staff are provided this training and all are are spoken to about Advance Directives." He expressed this employee has been a part of all interdisciplinary meetings, including care plan meetings. He stated he was not made aware this employee or others in the Respiratory Department had issues with the resident's responsible party. He stated the respiratory services are provided under a contract to service the facility, all provide direct hands-on care to residents, and the Respiratory Therapist worked full-time, functioning as a Long Term Care Depatment Head in the facility. An interview was conducted on [DATE] at 1:47 PM, with the President of the contracted respiratory service, who validated the contract services provided, the employees provide direct, hands-on care, and the Respiratory Therapist, worked full-time in the facility, and functioned as the director of the department in a long term care setting. The DON and the Assistant Administrator together outlined for the surveyor, the steps taken to correct the situation after the event and the measures put in place to prevent recurrence. The measures were described as follows: 1. All residents were audited for their current and correct code status. 2. All resident charts were audited to ensure the section labelled " Advance Directives " contained no errors. 3. The topic of Advance Directives was added to the daily agenda for the interdisciplinary meeting held every morning. 4. The topic of Advance Directives was added to the agenda of the weekly Risk/Quality of Life meeting. 5. Forty-five (45) of 45 licensed nursing staff (RNs and LPNs), were re-educated on the Advance Directive procedure, including determining code status on a resident first, through reviewing the proper section in the chart. 6. Thirteen (13) of the 15 Respiratory Therapy staff were re-educated on the Advance Directive policies and procedures, including the first step in checking the resident ' s chart for code status, before initiating CPR. Two of the RTs are still on medical leave. 7. A " Stop and Watch " program was instituted for all staff, including all ancillary departments. The program was designed for staff to stay alert and keep everyone informed of changes in a resident ' s status or condition, as they arise. It included reporting any changes or issues to the proper clinical and administrative staff immediately. 8. The topic of Advanced Directives was added to the general orientation program provided to all new staff. 9. A yellow laminated, pocket-sized card (same color as the DNR form) was created and the information contained within reflected all the necessary items and topics the admission nurse/admission process must cover, as soon as a resident enters the facility. A card was given to each nurse employed, as well as posted near each computer in the facility. 10. SBAR (Situation/Baseline/Assessment/Report) form was instituted for the nursing staff, which included reviewing the Advance Directives, as part of the assessment. 11. The Director of Respiratory Therapy was counselled regarding the untoward event on [DATE] related to his actions. He resigned on [DATE]. 12. A " Daily Scrub " of each new admission ' s medical record will be performed by Administration and all clinical services, within the resident ' s first 24 hours. The scrub was designed to ensure all the necessary paperwork is contained in the record. 13. The Administration making plans to improve hospital relations to ensure a new admission comes to the facility with all paperwork intact. 14. Administration preparing to remind all staff to promptly report resident and family concerns, conflicts, and problems to the appropriate staff. The surveyor reviewed 2 additional residents who were recently readmitted to the facility, and 9 resident records, to ensure the Advance Directive section of the records reflected the correct code status of the resident. No concerns with any of the residents ' Advance Directives were noted.

Based on interviews, record review, facility policy, and according to Florida Statue, Chapter 468, Part V, the Respiratory Therapy Act, the facility failed to provide the appropriate services for 1 of 3 sampled residents reviewed for Advance Directives (Resident #1), who was on a ventilator and experienced a cardiac event. The Respiratory Therapist failed to follow a Do Not Resuscitate (DNR) order for Resident #1. The findings constituted the determination of immediate jeopardy, due to a staff member at the facility, a Respiratory Therapist, who serves as the Director of Respiratory Therapy, failing to determine the code status for the resident, prior to initiating CPR. The immediate jeopardy existed beginning [DATE], and was removed on [DATE]. The scope and severity level was decreased from a "J" level to a "D" level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The Respiratory Therapy Act, Florida Statues Chapter 468, Part V, defines the "Practice of respiratory care" or "respiratory therapy" means the allied health specialty associated with the cardiopulmonary system that is practiced under the orders of a physician licensed under Chapter 458 or Chapter 459 and in accordance with protocols, policies, and procedures established by a hospital or other health care provider or the board, including the assessment, diagnostic evaluation, treatment, management, control, rehabilitation, education, and care of patients in all care settings. The findings include: Per record review, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a pacemaker and a history of [MEDICAL CONDITION] Fibrillation. The resident had signed a "Health Care Surrogate Designation" form on [DATE], designating her daughter as her Health Care Surrogate (HCS). The resident had a DNR in place, effective [DATE], per review of the "Florida Do Not Resuscitate Order" form, dated [DATE]. The resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident returned from the hospital without information regarding her DNR status. The resident, with the assistance of her daughter per the resident's request, validated through interview with the Assistant Administrator on [DATE], completed another "Florida Do Not Resuscitate Order" form, dated [DATE]. The physician signed the form on [DATE]. An interview was conducted with the resident's daughter on [DATE] at 9:07 AM, and the daughter expressed her mother was clear on a DNR order, stating "my mother said they beat on her chest once and said never again". The daughter stated her mother wanted it "pasted on her bed". The resident had a Minimum Data Set (MDS) assessment completed for admission with a reference date of [DATE]. The MDS indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated her cognition was intact. A review of the medical record was conducted on [DATE]. The following sequence of events was revealed: On [DATE] at 6:25 AM, the resident who was being progressively weaned off of the ventilator, was placed back on ventilator support. Between 6:15 AM and 6:25 AM, on [DATE], the resident became non-responsive with a heart rate of 56 beats per minute and respiratory rate of 10. Her oxygen saturation level was 87%. After being placed back on the ventilator, her oxygen saturation increased to 98%, her respirations increased to 13, however her heart rate decreased to 50 beats per minute. A Respiratory Therapist, who functions in the capacity of the Director of Respiratory Therapy, present in the facility on [DATE] at 6:45 AM was summoned to the resident's room. Shortly thereafter, while on ventilator support, the resident was unable to be aroused, with an absence of carotid pulses, and CPR was initiated by the Respiratory Therapist. The facility called 911. Review of the facility's Adverse Incident Report stated the resident had been revived, post CPR services rendered, but later passed away in the hospital. An interview was conducted with the Respiratory Therapist/Director of Respiratory Therapy on [DATE] at 10:57 AM. He validated he was summoned to the resident's room at 6:45 AM on [DATE], and was unable to arouse the resident, as well as obtain any carotid pulses. He validated he initiated CPR on the resident, when he was unable to obtain a carotid pulse. He stated he was not aware the resident had a DNR in place. He stated he did not check the resident's chart himself prior, or designate a staff member to check the resident's chart for the DNR status, while he remained with the resident. He expressed a vulnerability relating to a conflict with the resident's daughter prior to [DATE] and "jumped into reactive mode." He validated he was aware of determining a resident's code status before initiating CPR and stated, "My bad. I really screwed up." He acknowledged the resident's code status was located in the resident's chart, near the front, under a tab called "Advance Directives". He explained his job requires him to provide direct care and to place residents on ventilators and off ventilators frequently. He stated most residents are full code status, however at times a resident will request a DNR order. He was aware the form is yellow in color, as a standard measure for a DNR. Further discussion revealed he was experiencing issues with the resident's responsible party that were progressive, and at one point he stated he was accused of trying to kill the resident. He expressed the staff he supervised reported issues with the responsible party to him on several occassions. He was unable to answer why he failed to report the issues to Administration, the Director of Nursing, and/or the Assistant Administrator/Director of Social Services, as they occurred. He stated he did not fully understand the term "Interdisciplinary" and stated, "I do not know Long Term Care". When asked if he was aware of the facility's grievance policy and procedure, he did not answer. Additionally he added, he re-inserviced all the respiratory staff on the procedure to determine code status, after the incident on [DATE], involving himself. He denied speaking to the staff he supervises about reporting conflicts to Administration and/or Social Services. On [DATE], the Administrator informed the surveyor, the Respiratory Therapist resigned on [DATE]. An investigation of the incident was completed by the Administrator on a form entitled "Potential Adverse Incident Investigation Worksheet". The form did not indicate when it was completed. The form validated the incident occurred on [DATE] and under the section "Describe curcumstances of the incident" notation read "resident had an andvanced directive in her records which was not observed @ the time". Under the section "Were there any staff errors or omissions related to the incident?" the notation read "Advanced directive was overlooked." A typed, unsigned statement supplied by the Respiratory Therapist, as part of the Administrator's investigation, revealed the following: "Given the history of my interaction with the daughter, I felt it necessary to do everything to save the patient. Especially since the daughter had accused me before of wanting to pull the plug on her mother. The daughter and I had a few intense interactions before where she was yelling at me and the staff over the care of her mother." During the interview with the employee, he stated he supplied a statement to administration when the event was investigated. A review of the facility's policy entitled "Advanced Directives Guidelines (DNR)" validated under the guideline denoted as "Number 2: Document Resident/Responsible Party wishes in the medical record." The policy did not contain a date. Under the "purpose" section of the policy, the following was contained, "To insure that all Residents will be given the option of formulating an advance directive (DNR) and documents will be completed and kept up to date in the medical record." An interview was conducted with the Director of Nursing (DON) and the Assistant Administrator on [DATE] at 11:00 AM and ongoing throughout the survey. Both staff members validated the Advance Directive, DNR, for Resident #1 was legally sound and in place at the time the Respiratory Therapist initiated CPR. Both validated the facility policy was to check the resident's chart before initiating CPR to determine code status and this was not done. Both validated on [DATE], Resident's #1's medical record contained the most current, yellow DNR form, dated [DATE], under the section/tab of "Advanced Directives". The DON stated all staff are aware of the procedure, and neither the DON or the Assistant Administrator were aware of a conflict with the family, prior to the event on [DATE]. Both denied any issues were reported to them from the Respiratory Department or Respiratory Therapist/Director of Respiratory Therapy. The DON stated she re-inserviced all the nursing staff on the procedure after the incident, beginning [DATE] and ending [DATE]. The DON and Assistant Administrator discussed with the surveyor, a daily meeting is held with staff where issues regarding the resident's care and concerns, including family issues, are reported and discussed. They validated the daily meetings are part of ongoing operations and the Respiratory Therapist has attended these regularly, as required. A further review of the Respiratory Therapist's personnel file was conducted. Evidence revealed he received training in his orientation program on [DATE], on the topics of Resident Rights, Abuse and Neglect, Avante Grievance Policy, and Risk Management. An interview was conducted with the Administrator on [DATE] at 10:00 AM, and he validated the training was provided to the employee. The Administrator stated, "All staff are provided this training and all are are spoken to about Advance Directives." He expressed the employee has been a part of all interdisciplinary meetings, including care plan meetings. He stated the respiratory services are provided under a contract to service the facility, all provide direct hands-on care to residents, and the Respiratory Therapist worked full-time, functioning as a Long Term Care Depatment Head in the facility. A copy of a current CPR certification was found in the employee's file which was issued February 2013 and expires on February 2015. A review of the employee's file revealed he was a licensed respiratory therapist in the state of Florida. An interview was conducted on [DATE] at 1:47 PM, with the President of the contracted respiratory service, who validated the contract services provided, the employees provide direct, hands-on care, and the Respiratory Therapist, worked full-time in the facility, and functioned as the director of the department in a long term care setting.

Based on interview, record review, and facility policy, the facility failed to administer in a manner that enables a resident to attain his/her highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for Advance Directives (Resident #1). The findings constituted the determination of immediate jeopardy, due to a staff member at the facility failing to determine the code status for the resident, prior to initiating cardio-pulmonary resuscitation (CPR). A facility audit of Advance Directives was conducted on [DATE], 30 of the 121 current residents had DNRO paperwork, which indicated they were not to be provided life sustaining procedures should they be found without respirations or pulse. The facility administration failed to ensure care and services met professional standards resulting in immediate jeopardy. The immediate jeopardy existed beginning [DATE], and was removed on [DATE]. The scope and severity level was decreased from a "J" level to a "D" level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. Additionally, the facility failed to communicate an ongoing, problematic relationship with a resident's responsible party, which had a potential impact on the initiation of CPR for Resident #1, against her DNR order. The findings include: Per record review, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a pacemaker and a history of [MEDICAL CONDITION] Fibrillation. The resident had signed a "Health Care Surrogate Designation" form on [DATE], designating her daughter as her Health Care Surrogate (HCS). The resident had a DNR in place, effective [DATE], per review of the "Florida Do Not Resuscitate Order" form, dated [DATE]. The resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident returned from the hospital without information regarding her DNR status. The resident, with the assistance of her daughter per the resident's request, validated through interview with the Assistant Administrator on [DATE], completed another "Florida Do Not Resuscitate Order" form, dated [DATE]. The physician signed the form on [DATE]. An interview was conducted with the resident's daughter on [DATE] at 9:07 AM, and the daughter expressed her mother was clear on a DNR order, stating "my mother said they beat on her chest once and said never again". The daughter stated her mother wanted it "pasted on her bed". The resident had a Minimum Data Set (MDS) assessment completed for admission with a reference date of [DATE]. The MDS indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated her cognition was intact. A review of the medical record was conducted on [DATE]. The following sequence of events was revealed: On [DATE] at 6:25 AM, the resident who was being progressively weaned off of the ventilator, was placed back on ventilator support. Between 6:15 AM and 6:25 AM, on [DATE], the resident became non-responsive with a heart rate of 56 beats per minute and respiratory rate of 10. Her oxygen saturation level was 87%. After being placed back on the ventilator, her oxygen saturation increased to 98%, her respirations increased to 13, however her heart rate decreased to 50 beats per minute. A Respiratory Therapist, who functions in the capacity as the Director of Respiratory Therapy, present in the facility on [DATE] at 6:45 AM was summoned to the resident's room. Shortly thereafter, while on ventilator support, the resident was unable to be aroused, with an absence of carotid pulses, and CPR was initiated by the Respiratory Therapist. The facility called 911. Review of the facility's Adverse Incident Report stated the resident had been revived, post CPR services rendered, but later passed away in the hospital. An interview was conducted with the Respiratory Therapist/Director of Respiratory Therapy on [DATE] at 10:57 AM. He validated he was summoned to the resident's room at 6:45 AM on [DATE], and was unable to arouse the resident, as well as obtain any carotid pulses. He validated he initiated CPR on the resident, when he was unable to obtain a carotid pulse. He stated he was not aware the resident had a DNR in place. He stated he did not check the resident's chart himself prior, or designate a staff member to check the resident's chart for the DNR status, while he remained with the resident. He expressed a vulnerability relating to a conflict with the resident's daughter prior to [DATE] and "jumped into reactive mode." He validated he was aware of determining a resident's code status before initiating CPR and stated, "My bad. I really screwed up." He acknowledged the resident's code status was located in the resident's chart, near the front, under a tab called "Advance Directives". Further discussion revealed he was experiencing issues with the resident's responsible party that were progressive, and at one point he stated he was accused of trying to kill the resident. He expressed the staff he supervised reported issues with the responsible party to him on several occassions. He was unable to answer why he failed to report the issues to Administration, the Director of Nursing, and/or the Director of Social Services as they occurred. He stated he did not fully understand the term "Interdisciplinary" and stated, "I do not know Long Term Care". When asked if he was aware of the facility's grievance policy and procedure, he did not answer. He acknowledged he attends daily meetings held with other departments, where residents issues are discussed. Additionally he added, he re-inserviced all the respiratory staff on the procedure to determine code status, after the incident on [DATE], involving himself. He denied speaking to the staff he supervises about reporting conflicts to Administration and/or Social Services. On [DATE], the Administrator informed the surveyor, the Respiratory Therapist resigned at the end of the work day on [DATE]. An investigation of the incident was completed by the Administrator on a form entitled "Potential Adverse Incident Investigation Worksheet". The form did not indicate when it was completed. The form validated the incident occurred on [DATE] and under the section "Describe curcumstances of the incident" notation read "resident had an andvanced directive in her records which was not observed @ the time". Under the section "Were there any staff errors or omissions related to the incident?" the notation read "Advanced directive was overlooked." A typed, unsigned statement supplied by the Respiratory Therapist, as part of the Administrator's investigation, revealed the following: "Given the history of my interaction with the daughter, I felt it necessary to do everything to save the patient. Especially since the daughter had accused me before of wanting to pull the plug on her mother. The daughter and I had a few intense interactions before where she was yelling at me and the staff over the care of her mother." During the interview with the employee, he stated he supplied a statement to administration when the event was investigated. A review of the facility's policy entitled "Advanced Directives Guidelines (DNR)" validated under the guideline denoted as "Number 2: Document Resident/Responsible Party wishes in the medical record." The policy did not contain a date. Under the "purpose" section of the policy, the following was contained, "To insure that all Residents will be given the option of formulating an advance directive (DNR) and documents will be completed and kept up to date in the medical record." An interview was conducted with the Director of Nursing (DON) and the Assistant Administrator on [DATE] at 11:00 AM and ongoing throughout the survey. Both staff members validated the Advance Directive, DNR, for Resident #1 was legally sound and in place at the time the Respiratory Therapist initiated CPR. Both validated the facility policy was to check the resident's chart before initiating CPR to determine code status and this was not done. Both validated on [DATE], Resident's #1's medical record contained the most current, yellow DNR form, dated [DATE], under the section/tab of "Advanced Directives". The DON stated all staff are aware of the procedure, and neither DON or the Assistant Administrator were aware of a conflict with the family. Both denied any issues reported to them from the Respiratory Department or Respiratory Therapist/Director of Respiratory Therapy. The DON stated she re-inserviced all the nursing staff on the procedure after the incident, beginning [DATE] and ending [DATE]. The DON and Assistant Administrator discussed with the surveyor, a daily meeting is held with staff where issues regarding the resident's care and concerns, including family issues, are reported and discussed. They validated the daily meetings are part of ongoing operations and the Respiratory Therapist has attended these regularly, as required. A further review of the Respiratory Therapist's personnel file was conducted. Evidence revealed he received training in his orientation program on [DATE], on the topics of Resident Rights, Abuse and Neglect, Avante Grievance Policy, and Risk Management. An interview was conducted with the Administrator on [DATE] at 10:00 AM, and he validated the training was provided to the employee. The Administrator stated, "All staff are provided this training and all are are spoken to about Advance Directives." He expressed this employee has been a part of all interdisciplinary meetings, including care plan meetings. He stated he was not made aware this employee or others in the Respiratory Department had issues with the resident's responsible party. TheAdministrator was not present in the facility on [DATE], however was present on [DATE], and validated Administration was responsible overall for all nursing home operations. He expressed he was unclear why the employee expressed a lack of knowledge in his job responsibilities. A review of the job decription for the nursing home administrator was conducted. Under the section entitiled "purpose", documentation revealed "To direct day-to-day functions of the facility in accordance with current federal, state, and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times". Under the section entitled, Administrative functions/duties", documentation revealed "ensure that each resident receives the necessary nursing, medical, and psychological services to attain and maintain the highest possible mental and physical functional status; plan, develop, organize, implement, evaluate, maintain, monitor, supervise and direct all facility departments and overall operations"...."assist department directors in developing and using department policies and procedures and establish rapport among all departments; interpret and ensure compliance with all facility policies and procedures by all employees, residents, families, visitors, government agencies and the genral public". The administrator signed the job description dated [DATE]. The DON and the Assistant Administrator together outlined for the surveyor, the steps taken to correct the situation after the event and the measures put in place to prevent recurrence. The measures were described as follows: 1. All residents were audited for their current and correct code status. 2. All resident charts were audited to ensure the section labelled " Advance Directives " contained no errors. 3. The topic of Advance Directives was added to the daily agenda for the interdisciplinary meeting held every morning. 4. The topic of Advance Directives was added to the agenda of the weekly Risk/Quality of Life meeting. 5. Forty-five (45) of 45 licensed nursing staff (RNs and LPNs), were re-educated on the Advance Directive procedure, including determining code status on a resident first, through reviewing the proper section in the chart. 6. Thirteen (13) of the 15 Respiratory Therapy staff were re-educated on the Advance Directive policies and procedures, including the first step in checking the resident ' s chart for code status, before initiating CPR. Two of the RTs are still on medical leave. 7. A " Stop and Watch " program was instituted for all staff, including all ancillary departments. The program was designed for staff to stay alert and keep everyone informed of changes in a resident ' s status or condition, as they arise. It included reporting any changes or issues to the proper clinical and administrative staff immediately. 8. The topic of Advanced Directives was added to the general orientation program provided to all new staff. 9. A yellow laminated, pocket-sized card (same color as the DNR form) was created and the information contained within reflected all the necessary items and topics the admission nurse/admission process must cover, as soon as a resident enters the facility. A card was given to each nurse employed, as well as posted near each computer in the facility. 10. SBAR (Situation/Baseline/Assessment/Report) form was instituted for the nursing staff, which included reviewing the Advance Directives, as part of the assessment. 11. The Director of Respiratory Therapy was counselled regarding the untoward event on [DATE] related to his actions. He resigned on [DATE]. 12. A " Daily Scrub " of each new admission ' s medical record will be performed by Administration and all clinical services, within the resident ' s first 24 hours. The scrub was designed to ensure all the necessary paperwork is contained in the record. 13. The Administration making plans to improve hospital relations to ensure a new admission comes to the facility with all paperwork intact. 14. Administration preparing to remind all staff to promptly report resident and family concerns, conflicts, and problems to the appropriate staff. The surveyor reviewed 2 additional residents who were recently readmitted to the facility, and 9 resident records, to ensure the Advance Directive section of the records reflected the correct code status of the resident. No concerns with any of the residents ' Advance Directives were noted.

Based on observation, interview and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 5 residents reviewed (Resident #5), as evidenced by an inaccurate assessment, lack of a care plan, poor pain management and failure to follow facility policy for a resident with loose stools and abdominal pain, which may have resulted in a delay in treatment. The findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had a [DIAGNOSES REDACTED]. There is further evidence of [MEDICAL CONDITION] by an order for [REDACTED]. Resident #5 was readmitted to the facility on [DATE] with the same [DIAGNOSES REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There were no missed or held doses between 07/28/2013 and 08/06/2013. Adverse reactions with the use of [MEDICATION NAME] include diarrhea and abdominal cramping (Epocrates.com). The MAR indicated [REDACTED]. Other than the held dose, there were no missed doses documented. Review of the Plan of Care (POC) documentation reveals Resident #5 is incontinent of bowel daily. It further documents the resident had diarrhea/loose stools on 08/01/2013 for 2 shifts, 08/02/2013 for two shifts, 08/03/2013 for 1 shift, 08/04/2013 for 1 shift and 08/05/2013 for 2 shifts. The documentation does not indicate how many incontinent episodes occur each shift. There is no evidence that Resident #5 had any constipation. There is no evidence that the [MEDICATION NAME] was held for loose stools. Review of the Care Plan for Resident #5 revealed there was no evidence of a plan of care for [MEDICAL CONDITION], hydration, diarrhea and bowel incontinence. An interview was conducted with the MDS Coordinator on 10/15/2013 at 1:54 PM. She stated that if there is a [DIAGNOSES REDACTED]. She further stated care is also followed by the physician orders, but there should be a care plan as well. The MDS Coordinator reviewed the care plan and was unable to find evidence that hydration, diarrhea, bowel incontinence, and [MEDICAL CONDITION] was being monitored. Review of the Nursing and Skilled Progress notes reveal the following: On 08/02/2013 at 12:15PM, the resident was medicated for pain with [MEDICATION NAME] 5/500mg. There is no pain scale or location of pain noted. There is no follow up for results of the pain medication. On 08/02/2013 at 21:01, it is documented to continue to monitor for signs and symptoms of diarrhea, none noted since the two earlier episodes and the physician is aware. On 08/03/2013 at 20:53, the resident has a poor appetite and only consumed a small amount of dinner with encouragement. On 08/04/2013 at 08:44AM, the resident received 2 tablets of Tylenol 325mg for pain in the lower abdomen. There is no pain scale or follow up of results of the pain medication. On 08/04/2013 at 19:30, the resident is complaining of abdominal pain. The abdomen is soft, non distended, with positive bowel sounds. The resident is grimacing and guarding her abdomen upon palpation. The physician was called and orders given which includes an order for [REDACTED]. On 08/05/2013 at 14:23, the resident is complaining of discomfort on abdominal assessment and has had a loose stool x1 during the shift. Review of the MAR indicated [REDACTED]. There is a phone order at 15:19 for stool culture for [MEDICAL CONDITION]. On 08/06/2013 at 15:29, the resident is still complaining of abdominal discomfort and pain. There is no evidence the resident was treated for [REDACTED]. Review of the Physician order [REDACTED]. A review of the transfer sheet dated 08/06/2013 documents transfer patient to ER (emergency room ) per family request, complaining of abdominal pain. Review of the lab work for Resident #5 reveals on 08/02/2013 the physician ordered a basic metabolic panel (BMP) which revealed a glucose of 267 (normal(n) 70 - 99), BUN (blood urea nitrogen) 38 (n 6-20) and a creatinine of 1.9 (n 0.5-1.2). The Potassium is 4.2 (n 3.3-5.1). The physician ordered a repeat BMP on Monday (08/05/2013). On 08/05/2013 the BUN is 47, the Creatinine is 2.0 and the Calcium is 8.3 (n 8.6-10.2). The Potassium is 3.0. New orders are written across the bottom of the report. The physician ordered Potassium 40 mEq by mouth for one dose. A Complete Blood Count (CBC) was also drawn on 08/05/2013 which revealed a normal hemoglobin and hematocrit, and white blood cells within a normal limit. A KUB (x-ray of the kidneys, ureters and bladder/abdomen) was also completed on 08/05/2013 which revealed no bowel obstruction or free air seen. A review of the labs drawn on 08/06/2013 reveals a urinalysis with trace bacteria and protein, and a BMP with a Calcium of 8.4, BUN of 51, and a creatinine of 2.2. Results from the [MEDICAL CONDITION] culture were called to the facility on [DATE] at 3:08 PM by the lab, reporting positive stool culture for [MEDICAL CONDITION]. The printed report dated 08/06/2013 3:36 PM documents a Positive result of [MEDICAL CONDITION] and HOSP is written across the report. An interview was conducted with the attending physician on 10/14/2013 at 5:09 PM. She stated that she will usually order a stool culture for [MEDICAL CONDITION] if a resident has diarrhea. "It is a standard." The physician further stated she will automatically order [MEDICAL CONDITION] on a resident with loose stools who is complaining of abdominal pain. She stated that Resident #5 is a very frail older woman. She also stated that geriatric patients usually get a urinary tract infection which is why she ran those tests. A KUB (x-ray of the abdomen) was the next step. "I wasn't here and can only make a judgment call based upon what I am told." An interview was conducted with Licensed Practical Nurse (LPN) #4 on 10/15/2013 at 12:12 PM. She stated Resident #5 had multiple loose stools daily. The resident was awake and alert with periods of confusion. Resident #5 had been ambulatory with assistance and was incontinent of bowel and bladder. She stated she would call the physician if her resident had 3 or more loose stools on her shift. LPN #4 stated Resident #5 would complain of diarrhea and when the aides would check it was either only a little bit or nothing there. For complaints of diarrhea, she stated she would monitor abdominal discomfort, pain and loose stools. An interview was conducted with the Medical Director on 10/15/2013 at 12:55 PM. She reviewed the chart for Resident #5 and stated her general impression was that Resident #5 is a sick lady. She stated the physicians were giving orders based upon lab results. She stated the resident did not have an elevated WBC (white blood cells) or abnormal vital signs, and was afebrile. There was no vomiting or signs of a GI (gastrointestinal) bleed. She acknowledged that there were periods when the resident was comfortable and periods when the resident was in pain. She stated that she was not the treating physician and cannot speak for her, but she can see that the attending physician had done some interventions. She did acknowledge that persistent pain should have further work up or evaluation and guarding of one's abdomen is "worrisome." She was unable to explain why the family members had to initiate the transfer to a hospital. Review of the Policy for [MEDICAL CONDITION] reveals "Residents considered at high risk of developing symptoms associated with [MEDICAL CONDITION] include those with ...previous GI illness caused by [MEDICAL CONDITION]. When residents with these risks have symptoms of diarrhea (i.e. three loose stools in a twenty-four hour period), [MEDICAL CONDITION] should be considered as a cause. Residents with previous infection who develop diarrhea should be evaluated as soon as practical. " The policy further documents to consider [MEDICAL CONDITION] in differential diagnosis, especially in residents with high risk factors.

Based on interview and record review, the facility failed to provide services which meet professional standards of quality, as evidenced by two nurses failing to properly assessment and provide treatment after finding a resident on the floor, resulting in a 10-hour delay in treatment, for 1 of 3 sampled residents (#1). The Florida Nurse Practice Act, Chapter 464, states: (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified the resident as being at risk for falls. The Fall Risk Screen was completed and the resident scored 18 with score of 10 or above being high risk. The Admission Skilled Nurse Assessment stated the resident requires extensive assistance of one person for bed mobility, transferring, and toilet use. A review of the nurse notes revealed on 10/04/2010 at 10 PM, the resident was found on the floor in his/her room next to the bed. The resident was observed on the floor next to bed calling "get me up." She was unable to explain how she got on the floor. At 11:30 PM the 11-7 nurse reported no injury noted. In an interview at 2:20 PM on 10/19/2010, the Interim Director of Nurses (DON) stated that if the fall is not witnessed, the protocol is to call 911. If the resident refuses to go to the hospital, then it is their choice. The nurse is to call 911, call the doctor, alert the supervisor, order X-rays and start neurological checks. The DON further stated, according to the facility internal investigation of the incident, the 3-11 nurse did not call 911, did not inform the supervisor, or family. She picked the resident up and put her back in bed. She did not even check vital signs. The 11-7 nurse had no neurochecks written on the form, but she pulled them out from unknown area and they were filled in 2 days later. The DON stated that the filled in neurochecks were inconsistent with the condition in which the resident was found on 10/5/10 at 7:45 AM. Review of the Fall Prevention Program, which was provided as the policy and procedure on post-fall assessment, did not specify the actions to be taken by the nursing staff such as calling 911 if an unwitnessed fall occurred, calling the doctor, alerting the supervisor, ordering X-rays, and starting neurological checks. In an interview at 3:05 PM on 10/19/2010 the DON stated that it is "basic nursing judgement." In the Change of Condition/Alert Documentation Nursing Progress Note dated 10/05/2010 at 7:45 AM the resident was assessed as having a change of condition: lethargic, SOB (shortness of breath), and [MEDICAL CONDITION] The physician was contacted. The resident was sent 911 at 8:45 AM to a local Hospital and admitted to Intensive Care. It has been reported to the Administrator that the resident has a fractured rib, punctured lung and is intubated.

Based on interview and record review the facility failed to ensure that a resident received adequate supervision to prevent accidents as evidenced by a resident falling out of bed and not being assessed for injuries and changes in condition for 9 hours after the fall. This resulted in the resident being hospitalized and placed in intensive care with a fractured rib, punctured lung and intubation. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified the resident as being at risk for falls. The Fall Risk Screen was completed and the resident scored 18 with score of 10 or above being high risk. The Admission Skilled Nurse Assessment stated the resident requires extensive assistance of one person for bed mobility, transferring, and toilet use. The Admission Care Plan dated 9/27/2010 identified risk of falls as a potential concern due to status [REDACTED]. Approaches on the Admission Care Plan were: Complete Fall Risk Screen on admission; Place call bell within easy reach; Cue for safety awareness; Assist for toileting & tranfers PRN; Keep environment safe; Falling Star Program; Observe for side effects from medications; and Sensor bed alarm. A review of the nurse notes revealed on 10/04/2010 at 10 PM, the resident was found on the floor in his/her room next to the bed. The resident was observed on the floor next to bed calling "get me up." She was unable to explain how she got on the floor. The doctor was notified, and an order was obtained for x-ray of lumbar spine and sacrum. At 11:30 PM the 11-7 nurse reported no injury noted. In an interview at 2:20 PM on 10/19/2010, the Interim Director of Nurses (DON) stated that if the fall is not witnessed, the protocol is to call 911. If the resident refuses to go to the hospital, then it is their choice. The nurse is to call 911, call the doctor, alert the supervisor, order X-rays and start neurological checks. The DON further stated, according to the facility internal investigation of the incident, the 3-11 nurse did not call 911, did not inform the supervisor, or family. She picked the resident up and put her back in bed. She did not even check vital signs. The 11-7 nurse had no neurochecks written on the form, but she pulled them out from unknown area and they were filled in 2 days later. The DON stated that the filled in neurochecks were inconsistent with the condition in which the resident was found on 10/5/10 at 7:45 AM. Review of the Fall Prevention Program, which was provided as the policy and procedure on post-fall assessment, did not specify the actions to be taken by the nursing staff such as calling 911 if an unwitnessed fall occurred, calling the doctor, alerting the supervisor, ordering X-rays, and starting neurological checks. In an interview at 3:05 PM on 10/19/2010 the DON stated that it is "basic nursing judgement." In the Change of Condition/Alert Documentation Nursing Progress Note dated 10/05/2010 at 7:45 AM the resident was assessed as having a change of condition: lethargic, SOB (shortness of breath), and Tachycardia. The physician was contacted. The resident was sent 911 at 8:45 AM to a local Hospital and admitted to Intensive Care. It has been reported to the Administrator that the resident has a fractured rib, punctured lung and is intubated.