Every finding on record at Avante at Lake Worth, Inc.

Based on observation, interview, and record review, the facility failed to treat 3 of 3 sampled residents in a dignified manner as evidenced by the failure to honor the request to use a shower bed with subsequent non-dignified comments by staff toward Resident #1; failure to speak to and treat Resident #3 in a dignified manner related to requested assistance and food; and failure to speak kindly about residents in a foreign language as heard by Resident #4 who spoke that foreign language.The findings included:1) Review of the record revealed Resident #1 was admitted to the facility on [DATE] and moved to his current room on the Flamingo unit on 11/14/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident had impairment on both sides of his body and was totally dependent upon staff for assistance with all Activities of Daily Living (ADLs).Review of the current care plan dated 10/21/25 documented Resident #1 had an alteration in musculoskeletal status related to quadriplegia (inability to use all four limbs)/paraplegia (inability to use two limbs) and bilateral upper extremity contractures (permanent shortening and hardening of muscles, tendons or ligaments causing rigid, abnormal joint positioning). A second care plan dated 02/26/26 documented the resident had an ADL self-care performance deficit related to limited mobility and musculoskeletal impairment. An intervention documented the resident was totally dependent on one staff to provide bath/shower and totally depended upon two staff for transfers.During an interview on 05/05/26 at 10:56 AM, Resident #1 stated the staff are not nice to me. The nurses don't speak nicely or in English. When asked if the resident preferred the shower chair or shower bed, the resident stated, I want to use the shower bed. They won't let me. The resident further stated his shower days were Tuesday and Friday and that he wanted them around 11 or 11:30 AM.During the continued interview at 11:17 AM, Resident #1 stated he wanted a shower and asked the surveyor to assist. The resident pushed the call light, and it was answered by Staff A, Concierge Certified Nursing Assistant (CNA), who informed him that she would let his CNA know he wanted a shower. Staff A left the room, and the resident immediately pushed the call light again. Staff A again explained she would let his CNA know he wanted a shower. Resident #1 refused to let the CNA turn off the call light, so the light remained on. Staff A proceeded to get the shower chair and brought it to the entrance of the resident's room at 11:31 AM. When asked if that chair reclined like a bed, as it was noted to be reclined at about 45 degrees, the CNA stated it did not. When asked if they had a shower bed, Staff A stated they did, but it was hard to fit into the resident's room. Resident #1 resided in a double occupancy room, but his was the only bed in the room, and there was room to maneuver about the bed and or move the bed as needed. When asked the resident's preference, Staff A stated, He changes his mind every day, but you just have to do what he wants.During the continued observation, Staff A took the shower chair into the resident's room at 11:33 AM, and Resident #1 began yelling over and over again, shower bed, shower bed, shower bed. Staff A attempted to talk him into the shower chair, stating that the resident had used the shower chair in the past and the bed was difficult to get into the room. At 11:36 AM Staff A stated, You have a choice, the shower chair or no shower again stating the shower bed was too big. At 11:40 AM the Corporate Nurse arrived and spoke with the resident. The Corporate Nurse listened to the resident and agreed to use the shower bed, instructing the staff to obtain the bed. The Corporate Nurse and Unit Manager gave the resident a shower using the shower bed.During an interview outside of the room on 05/05/26 at 11:51 AM, when asked why she told Resident #1 that he had to use the shower chair, Staff A, CNA, denied saying it and stated he previously used the shower bed but had been using the chair recently. When reminded she had told the surveyor that he changes his mind every day, the CNA agreed. When asked again why she would not use the shower bed, the CNA denied the comment.During an interview outside of the room on 05/05/26 at 11:53 AM, the Corporate Nurse volunteered that Resident #1 changes his mind and this was not the only time they had had issues with showers. The Corporate Nurse agreed the CNAs could use either the shower chair or shower bed, depending upon the resident's request. When told the observation of Staff A and the verbal altercation between Staff A and the resident, the Corporate Nurse stated she would do one-on-one education and agreed with the findings.During an interview on 05/05/26 at 1:32 PM, when asked about the shower chair vs. the shower bed for Resident #1, the Unit Manager stated he was quite complicated and which was not a problem, as the CNAs could use either. The Unit Manager stated he likes the bed because he feels he gets cleaned better but that he will also use the chair at times.2) During an interview on 05/05/26 at 3:32 PM, when asked if customer service had improved since her grievance filed on 04/23/26, Resident #4 stated, Nothing has changed. Resident #4 stated the staff speak Creole in front of English-speaking residents, while caring for the resident. The resident explained she speaks both English and Creole, and further stated the staff are not speaking kindly about the residents. Resident #4 further stated the staff are not happy and they have a bad attitude. Resident #4 stated she witnessed a CNA refuse to give a resident a washcloth to wash her own feet.Review of the record revealed Resident #4 had a current BIMS of 11, on a 0 to 15 scale, indicating the resident had mild cognitive impairment.3) During an interview on 05/05/26 at 3:46 PM, when asked if customer service had improved since her grievance filed on 04/06/26, Resident #3 stated it had not. When asked her concerns, the resident stated the staff attitudes are horrible. The resident stated she had recently asked a staff for assistance to wash her feet and the staff responded, I have been here for 14 years and never washed no one's feet and I'm not gonna start now. The resident stated the CNA would not even hand her a washcloth to do her own feet. Resident #3 explained another time she was having difficulty holding a small plastic cup, explaining that it was crumpling up as she lacked motor control. The resident stated she asked a staff to help her with the cup and the staff responded, You can't even hold the f___ing cup? Resident #3 stated the Creole speaking staff talk about the size of other resident's bowel movements or that they are too big to transfer in the mechanical lift. The resident questioned, If they are saying those things about other residents in front of me, what are they saying about me to other residents? Resident #3 finally stated when she calls the kitchen in the evening for a turkey sandwich the staff had responded, This isn't Burger King . you can't get it your way.Review of the current MDS documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact.

Based on record review and interview, the facility failed to ensure physician ordered medications were provided to 1 of 3 sampled residents, as evidenced by the failure to administer three doses of Medrol 4 mg (milligrams) to Resident #2.The findings included:Review of the record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and diabetes. Review of the admission physician order dated 04/30/26 documented the resident was to receive Medrol 4 mg (milligrams) four times daily starting on 04/30/26 at 6 PM.Review of the corresponding Medication Administration Record (MAR) revealed the nurses failed to administer the medication on 04/30/26 at 6 PM, on 04/30/26 at 9 PM, and on 05/01/26 at 6 AM. The record lacked any reason for the lack of administration.During an interview on 05/05/26 at 10:46 AM, when asked the process for obtaining medications for newly admitted residents, Staff B, Licensed Practical Nurse (LPN) and admission nurse for Resident #2, stated after clarifying the medication orders and entering them into the computer, the medications are delivered in the late afternoon or early morning. When asked if they had an automated system of stock or emergency medication at the facility, the LPN was unsure.During a side-by-side record review and interview on 05/05/26 at 2:07 PM, when asked if Resident #2 should have received the physician ordered Medrol during her stay at the facility, the Unit Manager agreed she should have. When asked if they had an automated system with medications, the Unit Manager confirmed they did. An observation of the inventory at that time revealed the Medrol was available for use by the nursing staff.

Based on facility policy, record review and interview, the facility failed to honor resident preferences for 1 of 4 sampled residents, as evidenced by failure to allow Resident #4 to have an air mattress.The findings included: Review of facility policy titled Avante Mattress Protocol updated June 2022, documented in part.Grade II Intermediate Support Surface: Definition: A powered alternating pressure reducing mattress. Who Do I use it On: 3. Residents non-compliant with turning and reposition and at high risk for skin breakdown with approval from Regional of Clinical Services.Record review revealed that Resident #4 was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, on a 0-15 scale indicating no cognitive impairment. Review of section GG of the quarterly MDS assessment, revealed Resident #4 required maximum assistance to roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed.Review of the care plan dated 07/16/25, revealed a focus that Resident #4 had a ADL (activities of daily living) self-care performance deficit related to decreased mobility and required set-up to total assistance by 1 or more people. Ability varies due to a diagnosis of hemiplegia (paralyzed on one side), obesity, anxiety, generalized weakness, with a goal that she will maintain current level of function. Another focus revealed that Resident #4 had a potential for impairment to skin integrity related to limited mobility, incontinence, with a goal that the resident will maintain clean and intact skin.Review of a wound care visit report dated 09/29/25 documented Resident #4 had nonhealing moisture associated skin damage to the right and left ischium (bone at base of pelvis).During an observation on 10/07/25 at 9:20 AM, Resident #4 was observed in her room, sitting upright in bed wearing oxygen via nasal cannula. No air mattress was noted on her bed.During an interview on 10/07/25 at 11:08 AM, when asked do you still have wounds on your buttocks that are being treated, Resident #4 stated yes. When asked had the wounds gotten better, she stated, No, my daughter is involved now because I have been asking for an air mattress for over a year. Before I went to the hospital last year I had one for almost 6 years and they don't know what happened to it. They couldn't find it when I got back. I feel that the air mattress would have prevented my buttocks from getting worse. My case manager with the insurance company has been trying to get me an air mattress, but the people here at the facility will not give him what he needs to submit the paperwork to the insurance company. I don't understand. I really would like to stay here, but I can't if they will not do what's needed to help me to get better. When asked has the wound care nurse done your wound care already, she stated Yes.During an interview on 10/07/25 at 1:32 PM, When asked if there was a reason why Resident #4 doesn't have an air mattress, the Director of Nursing (DON) stated in the presence of the Wound Care Nurse, She doesn't qualify. She must have a stage 2 or worse pressure wound. When asked, Do you know anything about her insurance regarding submission of paperwork to get her an air mattress, he stated No. During an interview on 10/07/25 on 1:40 PM, when asked how a resident qualifies for an air mattress, the Regional Nurse stated in the presence of the Administrator, All of our mattresses are considered pressure relieving except when they have a stage 2 or greater wound they will receive an air mattress. I know which resident you are referring to because this has been going on for a while, when I was the DON in the facility. We had spoken to the brother regarding the air mattress and from a clinical standpoint he understood that the resident is on a pressure-relieving mattress that is sufficient for the wound that she has, and he seemed to be ok. Every time we speak to Resident#1 about the air mattress she doesn't seem to have an issue. When asked, is there any other reason why she can't have an air mattress, she stated, I'm not sure, I will have to ask the DON, if the physician writes an order for it and specify that the resident needs it then we can order it. When asked does the resident have to have a pressure ulcer, she stated No, not if the doctor orders it. I know that Resident #4 had an air mattress before, but I will have to go back and look to see why she doesn't have one now. During an interview on 10/07/25 at 2:31 PM, when asked are you the Case Manager for Resident #4, he stated, Yes. When asked if he has tried to request an air mattress for the resident, he stated Yes, the insurance provided an air mattress for the resident prior to her going to the hospital and when she returned to the facility, she didn't have it. Since I met her last year, I was informed that her insurance could provide one and we just needed a referral or an order from the facility to provide to the insurance company. I spoke to the previous social worker, the nurse and the new social worker and told them we just need an order or referral, but the response was they didn't know how to get the prescription and asked if I could get it. I told them, I am a case manager, and I can't do that. I asked multiple times if they could please get a prescription. They kept telling me they don't deal with prescriptions. I go to many facilities, and I know that there is a providing physician who can write an order. During an interview on 10/07/25 at 4:00 PM, Resident #4's daughter stated, My mother still does not have an air mattress. I didn't get to look at her wound on the weekend. When asked did you speak to anyone in Administration regarding the air mattress she stated, Yes, I spoke to the Administrator who told me that the wound care nurse was responsible for determining who gets an air mattress. On 10/08/25 at 2:21 PM, during an interview with the Supervisor of the insurance company; she stated, We have tried for a long period of time to get Resident #4 an air mattress and her request for an air mattress was denied by the facility due to facility protocol. The Case Manager has been seeing the resident for about 6 months now. We have spoken with the Administrator on several occasions with a request for a physician order and clinicals to submit to the insurance company to get approval for an air mattress. We even told them that they could submit the information directly to the medical company they use, and the insurance would pay for it.

Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for catheter care for 3 of 3 sampled residents with catheters (Resident #1, #2, and #3).The findings included:1. Review of the record revealed Resident #1 was admitted to the facility 02/13/24 with diagnoses of Paraplegia (a condition characterized by paralysis or loss of movement in both legs) and Neuromuscular Dysfunction Of Bladder (when there is damage or dysfunction in the nerves or muscles that control bladder function.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #1 had a urinary catheter.Review of Resident #1's care plan dated 08/21/25 documented, Resident #1 has (Indwelling Foley) Catheter: Neurogenic bladder with a goal of, Resident #1 will show no signs or symptoms of urinary infection through review date and interventions that documented, Foley Catheter: Foley Cath care every shift and PRN (as needed).Review of the current orders revealed Resident #1 had an indwelling catheter for neurogenic bladder and an order that documented, Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention dated 06/05/25.Review of the TAR (Treatment Administration Record) for September 2025 and October 2025 revealed the order Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention Start Date 06/05/25 was entered as an as needed order with no documentation of catheter care ever being done.During an interview on 10/07/25 at 9:15 AM, when asked how her care was, Resident #1 was visibly upset and stated she did not like how they take care of her urinary catheter and most times she would just take care of it herself. Resident #1 stated she did not trust staff around her private area.During an interview on 10/07/25 at 10:55 AM when asked to observe catheter care, Staff A, Registered Nurse (RN) Unit Manager stated that Resident #1 was very particular on who cleans her private area and sometimes she cleans herself as she often refuses assistance.During an interview on 10/07/25 at 1:26 PM, when asked how would you care for a resident who has a urinary catheter, Staff B, Licensed Practical Nurse (LPN) stated she was a new nurse who had only been working for 2 weeks and hadn't cared for any residents who had urinary catheters yet. When asked if she received any training on how to care for a Resident with a urinary catheter she stated she did not receive any training and had seen a nurse she was training with perform catheter care but that's all she knew.On 10/07/25 at 1:40 PM Staff A was asked how they cared for Resident #1's catheter if she refused the staff's assistance, Staff A stated they would find a staff member she was okay with and stated she would help clean her herself when Resident #1 let her or she would get assistance from her family. When asked if she had received incontinence and catheter care today, Staff A stated she would go check.On 10/07/25 at 2:45 PM Staff A let the surveyor know that that Resident #1 let the staff allow her to get cleaned up and received care. Staff A stated the Residents in the 300 unit had already received catheter care for this shift and would not be performed until next shift, the surveyor requested to observe catheter care next shift and Staff A agreed. The surveyor was not made aware again to observe catheter care during the remainder of the survey time.2. Review of the record revealed Resident #2 was initially admitted to the facility 07/16/25 and re-admitted [DATE] with diagnoses including Fractures to the Right Femur and Neuromuscular Dysfunction Of Bladder. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #2 had a urinary catheter.Review of Resident #2's care plan dated 09/28/25 documented Focus: The resident has indwelling foley catheter related to neurogenic bladder . date created on 10/07/25 with a goal that documented, the resident will be/remain free from catheter-related trauma through review date . date created on 10/07/25. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks PRN, empty catheter bag every shift, observe for pain/discomfort due to catheter, observe for signs and symptoms of discomfort on urination and frequency . date created on 10/07/25. Another section of this same care plan documented, Focus Enhanced Barrier Precautions: The resident is at risk for multidrug-resident organism (MDRO) r/t indwelling medical/Urinary Catheter . date created on 10/07/25; Goal: Minimize risk of transmission of colonized or infection with MDROs . date created on 10/07/25; Interventions: Enhanced Barrier Precautions: 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; central line, urinary catheter, feeding tube, Inform resident/representative precautions will be in place until the resolution of the wound or discontinuation of indwelling medical device. Restriction to room or limit ability to participate in group activities is not required. Observe for change in condition. Notify MD as indicated. date created on 10/07/25. Resident #2 did not have any catheter care interventions from admission time until date survey was conducted.Review of Resident #2's active orders related to catheter care documented as followed: Enhanced Barrier Precautions: Indwelling Medical Device every shift for Multiple drug-resistant organism precautions.Maintain Indwelling Catheter Size: 16 FR 10cc Balloon. May irrigate indwelling Foley catheter with 60ml of NS q shift PRN for blockage, occlusion leakage etc. as needed.Change bed side drainage bag of Urinary Catheter PRN as needed for Catheter careChange indwelling Foley catheter when Medically Necessary and PRN as needed.Foley Catheter: Foley Cath care every shift and PRN every shift AND as needed.The above orders were all entered on 10/07/25 at 11:49 AM. The discontinued and completed orders were also reviewed and the only catheter related order was one that documented Change bed side drainage bag of Urinary Catheter PRN Started date of 09/26/25 and end date of 10/7/25.During an interview on 10/07/25 at 4:00 PM, Resident #2 stated she has had the urinary catheter since approximately 09/18/25 and this was the second catheter she has had.3. Review of the record revealed Resident #3 was admitted to the facility 09/22/25 with diagnoses of Acquired absence of other parts of urinary tract; Acquired absence of other genital organ(s) and leakage of other urinary catheter, subsequent encounter. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #3 had a urinary catheter.Review of Resident #3's care plan dated 09/23/25 documented, Focus: Resident #3 has a suprapubic urinary catheter related to: Bladder removal due to cancer.Review of Resident #3's active order revealed she had a suprapubic catheter (a thin, flexible tube inserted into the bladder through a small incision in the lower abdomen (pubic area) to drain urine. ) The orders documented as followed:Monitor suprapubic catheter for signs and symptoms of infection and leakage. every shift.Cleanse suprapubic catheter with normal saline pat dry. Leave open to air every night shift.May irrigate suprapubic catheter with 60ml of NS q shift PRN for blockage, occlusion leakage etc. every 4 hours as needed for Catheter care.Change indwelling suprapubic catheter when Medically Necessary and PRN as needed.All orders were entered on 10/7/25 at 11:45 AM (the day the survey was conducted.) Discontinued and completed orders were also reviewed and revealed orders for an indwelling catheter which Resident #3 did not have. These incorrect orders were discontinued 10/07/2025.During an interview on 10/07/25 at 4:05 PM, Resident #3 stated she came to the facility with her catheter and it was inserted for about 2 weeks now.During an interview with the Director of Nursing (DON) on 10/07/25 at 4:10 PM a side-by-side review of Resident #1, #2 and #3 orders were reviewed.During review of Resident #1's orders, when asked to explain how the order: Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention was written (if it was a PRN or a every shift order), the DON stated that the orders covered both PRN and every shift care. When asked to provide the every shift catheter care documentation, the DON was not able to find it. The only documentation available for that order was a PRN section which was also blank. When asked how they keep track of catheter care being completed or refusal if there is not a way to document through the order, the DON stated he agreed there was no way to keep track of catheter care and was not able to provide documentation of it being completed.During review of Resident #2's orders, the DON pointed out to the surveyor, Resident #2's orders for catheter care have the option to document every shift and PRN care and Resident #2's orders should have entered this way. When asked why all Resident #2's catheter related orders were entered today and asked if Resident #2 had catheter orders from 09/26/25 (date of readmission) - 10/07/25, the DON was not able to provide an answer. When asked what was done for Resident #2 from 09/26/25 -10/07/25 the DON was not able to answer.During review of Resident #3's orders, when asked why catheter orders were placed for the Resident on 10/07/25 and what was done for the resident since the admission date of 09/22/25, the DON could not state what happened. When asked what the process of reviewing orders for accuracy was, the DON stated, when the resident comes in, their chart gets broken down and discussed with the clinical team, they make sure the orders are there, make sure they look at diagnosis, and follow up batch orders or re-order what is need. When asked who is in charge of making sure orders are started and continued, the DON stated, I am but stated these orders were unfortunately missed. The DON agreed with the findings.

Based on observations, interviews, and record reviews, the facility failed to provide supervision to prevent an elopement, for 1 of 3 sampled residents reviewed for an elopement (Resident #1). The facility's failure to prevent an elopement placed Resident #1 at a likelihood of serious harm, injury or death. While out of the facility on 08/23/25, Resident #1 got lost, and was assisted by a stranger who called law enforcement. She was confused and could not tell them where she currently lived. The facility was not aware the resident was missing for two hours. Two people came to the facility to inform the receptionist there was a person walking around who looked lost and confused, but the receptionist denied the person was a resident of the facility. During dinner time the nursing staff became aware the resident was missing, and a staff member went out with her car to search for the resident. When the staff member observed the police vehicle, she drove over to it, and recognized Resident #1.Resident #1 was then returned to the facility by the police and the staff member. The census at the time of the survey was 104 residents. There were 27 residents identified as elopement risk. The facility's administrator was notified of Immediate Jeopardy (IJ) and given the IJ Template on 09/03/25 at 3:35 PM. The Immediate Jeopardy was Ongoing at the time of the survey exit on 09/04/25 at 5:00 PM. The findings included:Review of the facility's policy titled, Policies and Procedures: Elopement, dated 03/02/19, included the following: It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable. This is with the intent of not invading privacy but to identify possible elopement. Definition: 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.Procedure:1) In the event that any staff member identifies that they cannot find a resident in a place that the resident is anticipated to be, the staff member will alert their supervisor for assistance once affirming that the resident was not signed out on leave.2) The supervisor would assume control of the search.3) The supervisor would alert staff of the identity of the resident and direct designated staff to participate in the search.4) The supervisor in charge of the search will not assume that the resident has left the facility and will:a. Re-affirm if the resident could be out of the facility on an authorized leave or pass by reviewing the facility sign out process;b. Determine if it is prudent to call the Residents family or other visitors if there is a possible concern that the resident was taken out and potentially they did not sign resident out;c. If the resident is not authorized to leave the facility independently, initiate a search of the facility and premises by assigning staff to look in various areas;d. If the resident is not located in a reasonable amount of time, the Administrator and the Director of Nursing (DON), the resident's representative, the Attending Physician, and law enforcement officials will be notified as indicated; ande. If the resident remains unable to be located and or is not authorized to leave the facility independently; Initiate an extensive search of the surrounding area.5) When a missing resident is not located within the confines of the facility building, then the supervisor in charge would direct designated staff to participate in an outside facility grounds search, which may include but not limited to the roof of the building, the parking lot, and any outside parked vehicles, etc. Review of the facility's policy titled, Policies and Procedures: Therapeutic Leave, dated 03/02/19, and revised on 04/16/25 included the following: It is the policy of this facility to allow residents to leave the facility for a non-medical visit, thereby known as therapeutic leave. Each resident will be permitted to return to the facility after therapeutic leave, regardless of payment source.Definition: Therapeutic Leave-Resident absences for purposes other than required hospitalization. The facility's Leave of Absence (LOA) policy and procedures was requested on 09/03/25, and the above Therapeutic Leave policy was provided by the Administrator. When asked if the LOA policy and the Therapeutic Leave policy are the same, she stated yes, they do not have a policy specifically for LOA. Record review revealed Resident #1 was admitted to the facility on [DATE] with a re-admission on [DATE], with diagnoses that included Diabetes Mellitus due to Underlying Condition with Diabetic Neuropathy; Cognitive Communication Deficit, Dementia Unspecified Severity, Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Alcohol Abuse with Alcohol-Induced Psychotic Disorder, Polyneuropathy and Chronic Kidney Disease. Review of Section C of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had a BIMS (Brief Interview for Mental Status) score of 06/15, which indicated that she had severe cognitive impairment. Review of previous BIMS assessments revealed Resident #1 never scored a 15/15 (cognitively intact), prior to the elopement on 08/23/25. Prior BIMS scores included: on 06/15/21 it was 12/15 (moderate); on 06/10/22 it was 07/15 (severe); and on 02/24/25 it was 09/15 (moderate). Record review revealed on 08/24/25, the facility filed a Federal Report for Neglect, which documented on 08/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of 9, which indicated cognitive impairment, had not been assessed as an elopement risk, exited the facility and walked outside. Review of the facility's investigation report documented the following timeline of the event from 3:35 PM to 5:41 PM (over the 2 hours when the resident went missing): At 1535 (3:35 PM) Resident #1 walked out of the facility. Receptionist opened the door for the resident.At 1538 (3:38 PM) Man in yellow shirt walked into facility.At 1546 (3:46 PM) Man in yellow shirt comes back into facility.At 1548 (3:48 PM) Certified Nursing Assistant (CNA) comes to the lobby, leaves the facility and walks the neighborhood. Head count started.At 1552 (3:52 PM) CNA returns to the facility; no resident with her. She then states she did not see any elderly lady walking. She will go get her car keys to look.At 1559 (3:59 PM) CNA leaves facility with her car to look around the neighborhood; and returned.At Dinnertime (no exact time noted on the report), a CNA notifies the nurse that Resident #1 has not touched her dinner, and she is not in the room.At 1723 (5:23 PM) The nurse walks to the front of the facility after thoroughly searching the unit.At 1724 (5:24 PM) CNA and the nurse walk out the front door; CNA gets into her car and started driving around the neighborhood.At 1741 (5:41 PM) CNA walks in the facility with the resident; resident was placed on 1:1 supervision.Further review of the facility's investigation report revealed witness statements were collected from staff members involved in the incident. Review of Resident #1's electronic care plans on 09/02/25 revealed Resident #1's care plans included: Impaired cognitive function/dementia or impaired thought processes related to (r/t) Impaired decision making which was initiated on 02/23/24 and revised on 08/05/25; Resident is Spanish-speaking, able to understand and be understood in English, but may prefer to communicate in Spanish at times which was initiated on 08/25/25; and Resident #1 is at risk for further falls r/t Gait/balance problems, seizures, muscle weakness, poly neuropathy, psychotropic medications which was initiated on 07/29/21 and revised on 08/05/25. Further review of the electronic care plans revealed there was no care plan developed for elopement or that Resident #1 exited the facility without staff's knowledge on 08/23/25. Facility management did not acknowledged that Resident #1 eloped on 08/23/25. This is evidenced by interviews conducted with the Administrator and [NAME] President (VP) of Operations: On 09/02/25 at 10:35 AM the [NAME] President (VP) of Operations came into the conference room to ask the surveyor for details of the complaint. She stated that Resident #1 has a BIMS of 15 and capable of making her own decisions. She stated that they reported it (elopement) out of precaution, however, she does not feel that it should have been reported because the resident has a BIMS of 15 and therefore not an elopement. She then stated, actually, if we had not filed a report, you would not have known about Resident #1 taking a walk independently and returning safely to the facility. On 09/02/25 at 9:21 AM an interview was conducted with the Administrator to obtain her statement and understanding of what occurred on 08/23/25. She stated Resident #1 had a BIMS score of 09/15 and the resident went up to Staff A, weekend receptionist, and told her that she wanted to go for a walk. Staff A opened the front doors and allowed Resident #1 to exit. The Administrator stated after Resident #1 returned to the facility, a reassessment of her BIMS was conducted yielding a score of 15/15. She also stated the BIMS assessment was conducted in the resident's native language (Spanish) and Resident #1 had a BIMS of 15/15 again, indicating that she is cognitively intact and able to make her own decisions. The Administrator stated the resident was asked what happened, why she left without notifying staff and she responded, she went to visit her friend and since the resident has a BIMS of 15, it is not considered an elopement. The Administrator stated the resident was assessed and skin check was conducted with no injuries or concerns. She then explained she was unsure why Staff A did not contact management, perhaps because she was new to the facility; however, Staff A should have confirmed that Resident #1 was capable of walking outside on her own. The Administrator stated that the staff did not contact the police because the staff felt Resident #1 was around the neighborhood and not anywhere else. Review of the current Physician's orders for medications showed that Resident #1's medications included an order dated 10/13/23 for Depakote Delayed Release 250 milligrams (mg) tablet to be given by mouth three times a day for Seizures; an order dated 10/17/23 for Oxycodone HCl 10 mg tablet to be given by mouth every 8 hours for non-acute pain; Gabapentin 400 mg capsule to be given by mouth every 8 hours related to Diabetic Neuropathy dated 09/26/22. Further review of the Physician's orders for medications showed that Resident #1 had an order dated 07/21/25 for Farxiga 5 mg tablet to be given by mouth one time a day for Diabetes Mellitus Type 2; an order dated 08/15/25 for Cymbalta 60 mg capsule delayed release particles, given by mouth two times a day for Depression/Anxiety; an order dated 07/07/25 for Ropinirole HCL 0.25 mg tablet to be given by mouth two times a day for Restless Leg Syndrome. Record review on 09/02/25 revealed Resident #1 had no orders for Leave of Absence (LOA), or to be able to leave the facility unaccompanied. Record review of Resident #1's Cognitive Assessment Note dated 05/02/25 conducted by Staff F, Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed Resident #1 was seen due to the facility requiring a detailed cognitive assessment as Resident #1 is showing behaviors related to memory problems requiring recommendation on the care plan. Further review revealed Resident #1 had consequences on functional areas that included: Impairment in remembering names and numbers of relatives and friends; Impairment in traveling outside the neighborhood, driving, or arranging to take public transportation. In addition, Resident #1 was given The St. Louis University Mental Status (SLUMS) exam in which she scored a 6/30 which indicated severity-Dementia. Staff F documented that Resident #1 appears to have Major Cognitive Disorder of mixed etiology. Review of Resident #1's Psychiatry Subsequent Notes from 05/06/25, 07/01/25, 07/18/25, 07/25/25, 08/12/25, and 08/22/25, all documented the following: Thought Process-Somewhat disorganized; Thought Associations-Somewhat loose; Speech- Impaired; Insight and Judgement- Impaired; Orientation-Oriented x2; Recall/Short-term Memory-Impaired; Attention Span/Concentration-Impaired; Fund of Knowledge-Impaired. Review of the Psychiatry Subsequent Notes dated 08/25/25 (two days after the elopement event) documented Resident #1 was alert and oriented x 3 and calm during the interview; and a BIMS assessment was conducted (in English by Staff F, PMHNP) in which she scored a 15/15. Review of Resident #1's Psychiatry Subsequent Notes (Amended) created by Staff F, dated 08/26/25 documented Prior to the last visit, the patient had some confusion observed, possible related to a language barrier and facility instructions and assessment not being provided in the patient's native language, and the patient went out through the front door. Review of Resident #1's Physician Progress Notes created by the Physician Assistant (PA), dated 08/25/25 documented Resident #1 has a complex medical history and was seen today due to exiting the facility and was promptly returned without incident or harm. During time of review resident BIMS is a 15 per Social Worker (SW) when completed in her native language. Resident able to leave LOA with third party following facility LOA protocol. On 09/02/25 at 1:10 PM, Resident #1 was observed standing in the hallway near the Activity Director's office. She was dressed (shirt and pants), had sandals on and her hair was in a ponytail. She was asked (in English) her name, which she was able to state as well as her room number. At this time an interview was conducted with Resident #1, and she was able to respond to the questions correctly. However, she was slightly confused when she wanted to go back to her room and thought her room was in the same hallway (Resident #1's room was on the opposite side of the building). Then Staff B, Activity Director, who also speaks Spanish, assisted the resident back to her room and informed the surveyor that Resident #1 is sometimes confused. On 09/02/25 at 1:15 PM, an interview (in Spanish) was conducted with Resident #1 in her room and she was asked if she goes out for walks often. She stated she does go for walks by herself often because she wants to visit her friend and then she laughed (her friend lives at the facility and in the same hallway). She then stated she was tired and wanted to take a nap. On 09/03/25 at 11:16 AM, an interview (in Spanish) was conducted with Resident #1 regarding the incident that occurred on 08/23/25. She stated that she was going out for a walk to go to her friend's house (this friend is a resident in the facility) but could not recall the exact date or address. She mentioned that she was running to cross the street because it was raining and she was afraid she would get sick. Then, she stated a man in a gray car drove up and asked her if she needed a ride, and asked her where she wanted to go, she stated to her trailer home. Then she said the man told her that there was no trailer park in this area. She remembered the man's name, and he took her to his home and gave her coffee, cookies and yogurt. Resident #1 stated she met a female police officer at the man's house and then a staff from Avante picked her up. When asked if she would be able to come back to the facility on her own, without the staff or the police, she stated she probably could, laughed and then stated that she has been at the facility for 15 years (resident was admitted on [DATE]) and has done it before. She then stated she was not lost she was looking for her trailer home. An interview was conducted on 09/02/25 at 11:33 AM with Staff F, PMHNP, who stated he has been coming to facility for almost 2 years. He stated Resident #1 has Dementia and Bipolar disorder. She is usually cooperative; however, she gets agitated sometimes with her roommate. He stated Resident #1 understands English but prefers Spanish. He stated she had never mentioned to him that she wanted to leave or go out of the facility. He confirmed that Resident #1 has periods of confusion; however, when he spoke with her last week, at that time, she was cognitively intact and able to communicate any concerns. He stated that she spoke about wanting to go see a friend, however, was unable to tell where her friend lived. An interview was conducted on 09/02/25 at 3:35 PM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for almost 2 years. She stated that Resident #1 is a little confused, but pleasant and has never mentioned that she wanted to go out to visit a friend, at least not to her. Staff C recalled coming in for her shift around 3:25 pm on 08/23/25; and while doing rounds saw Resident #1 in her room drinking coffee and she spoke with her, however, Resident #1 never mentioned anything about going out or seeing a friend. Staff C then mentioned Resident #1 has a Spanish speaking friend in the same unit (Hibiscus) and they often talk to each other. She stated Resident #1 is active and walks around the facility. She stated that she did not hear the first overhead page and if there was a head count at that time no one let her know. During dinner, one of the aides mentioned to her that Resident #1 was not in her room and she said she would check in the Flamingo unit because Resident #1 is always there as well. However, she did not see Resident #1, then she returned to the Hibiscus unit and started the head count. Staff C stated she then walked to the front desk and asked the receptionist if she had seen Resident #1; the receptionist stated she didn't know who that was. At this time the staff started looking for Resident #1 everywhere and Staff D, Certified Nursing Assistant (CNA), took her car to look for Resident #1 around the neighborhood. When Resident #1 returned to the facility, Staff C stated she asked the resident what happened, Resident #1 didn't mention anything, she was confused, calm and laughing, but unable to say where she went. An interview was conducted on 09/02/25 at 3:59 PM with Staff D, CNA, who stated that she has worked at the facility for over 2 months and knows Resident #1, who had never mentioned wanting to go out for a walk. Staff D stated that Resident #1 does like to visit her friend on the same unit (Hibiscus). She stated that around 3 something PM, there was a page for a head count, she went outside, walked up the street and looked down and saw no one and returned to the facility. The dinner trays are usually at the unit by 4:30-5:00 PM, and at this time Staff C, RN asked her where Resident #1 was; she then grabbed her car keys and rode down to almost the streetlight, passing the park and seeing no one. Staff D then stated as she was heading back to the facility, she was passing a road and noticed a Sheriff's car, turned back around and went up the street, that's when she saw Resident #1 sitting in the garage with the police officer and the owner of the house. The police officer asked Resident #1 if she knew her (Staff D) and Resident #1 stated no at first, however, she then realized who she was. Staff D stated Resident #1 got in the car with her and the police officer followed them to the facility and spoke with the receptionist. Staff D stated she took Resident #1 back to her room and gave her water and her dinner. She stated she did not ask Resident #1 why she was at the man's house, but she overheard Resident #1 mention to another staff member she was going on vacation. Staff D then stated that she feels that Resident #1 is a little confused. A phone interview was conducted on 09/02/25 at 5:58 PM with Staff A, weekend receptionist, who stated she has worked at the facility for about 3 weeks and works every other weekend. She stated that this is her first job in a nursing home. She stated she did not recall seeing Resident #1 walking out of the facility on 08/23/25. She noted she had to watch the video to see what occurred. She confirmed that she never looked at Resident #1 and mistook her for a visitor trying to exit the building. Visitors are to sign in and out, but sometimes the visitors are in a hurry and do not sign out and do not stop by the front desk. Staff A stated that a neighbor came in, she could not recall the time and said that there's someone walking along the outer street, but she did not think it was affiliated with the facility. She then stated that another person came in stating, I think there is someone that is walking that might be from Avante, she has a blue striped dress, who looks lost and confused, and that the woman was walking kind of fast on the main street. She recalled thinking she had not seen anyone wearing a dress; however, she did an overhead page for a head count. Then Staff A said that a nurse came up to her and asked her why she is requesting a head count, and she explained that two people from the neighborhood came in with concerns. At this time, the nurse got in the car and a few minutes later returned and stated she did not find anyone. Staff A thought the nurses had done the head count and found no concerns. Then an hour later a nurse came up to her and asked if she saw Resident #1; and Staff A stated that she was thinking I hope that is not the person that was walking around the streets earlier. She stated she was unclear on the training or if she was going to receive more training, however she had not heard from the facility if they were going to let her go or if she still has a job, at this moment she has been suspended. During an interview conducted on 09/03/25 at 12:22 PM with Staff H, Licensed Practical Nurse (LPN), she stated she has worked at the facility for 4 years. She stated a head count means all residents that are supposed to be at the facility are accounted for. Staff H stated she knows Resident #1, she is a sweet lady, but she is confused. Staff H confirmed that Resident #1 never goes through the front doors, therefore she does feel that she might not know how to return to the facility. During an interview conducted on 09/03/25 at 4:50 PM with Staff I, RN, she stated she has worked at the facility for 9 years. She stated she knows Resident #1 well. Staff I noted that Resident #1 is very friendly, she speaks Spanish but can communicate with her in English with no problem. Resident #1 has some confusion, however, has never exited the facility or gone outside on her own. When asked if she feels Resident #1 would be able to return to the facility on her own. She stated no, someone should guide her back because it is a new environment. During an interview conducted on 09/03/25 at 4:58 PM with Staff J, CNA, who stated she has worked at the facility for 31 years. She stated Resident #1 is nice, she can communicate with her in English with no problem, and she is sometimes confused. Staff J stated Resident #1 has never mentioned to her about wanting to go outside. When asked if she felt that Resident #1 would be able to return to the facility if she went outside; Staff J stated no, she would not be able to come back on her own. On 09/04/25 at 10:18 AM an interview was conducted with Staff K, RN, nurse consultant. She stated that the company had realized that the BIMS assessments were being done incorrectly and they have put in place that only the psych NP will be conducting the BIMS assessments. When asked if she felt that Resident # 1, with a BIMS of 06, would be able to return to the facility on her own; she stated that the BIMS on the MDS were conducted by the previous social worker, and they were not accurate. On 09/04/25 at 11:42 AM, another interview was conducted with Staff F, PMHNP, who stated Resident #1 can walk around the facility independently; however, he could not say yes or no if she could find her way back if she were to exit the facility. He also stated that a resident with a BIMS of 06/15 would be able to go outside, and they may or may not find their way, this depends on the individual. He stated Resident 1 would have LOA rights depending on physician's order, however, someone with a diagnosis of Dementia might need someone to accompany them. He confirmed that even a resident with a BIMS of 15 can get lost in a new environment. He stated he does feel that she would be able to move out of the way if she saw a car coming, however Dementia is tricky, sometimes the resident is here sometimes not. A phone interview was conducted on 09/04/25 at 12:52 PM with the Chief Medical Officer. He stated that he has known Resident #1 for a long time and has been practicing Spanish with her. He stated that he believed that on the day of the incident, she might have panicked and could not remember where she was living, sometimes a change in surroundings can affect their cognitive response. He stated at this time that he will remove her LOA and reassess her mental status and redo her BIMS himself. He also added, if the resident wants to go out of the facility, she will be supervised until he determines the resident is safe to go out on her own. Review of the Chief Medical Officer letter statement received and signed on 09/04/25 at 3:31 PM included that Resident #1 is a long-term resident at the Lake Worth Facility, who is well known to him. The resident had resided in the facility for more than two years. She had consistently demonstrated the ability to safely enjoy time outdoors without supervision. Her baseline cognitive status had traditionally been that of someone safe to enjoy the outdoors independently. Recently, Resident #1 left the facility stating she was going for a walk. Upon arrival back to the facility, her cognitive status was promptly reassessed, with a BIMS score of 15 documented at this time. Review of the Florida Department of Children and Families (DCF) Adult Protection Investigator (API)'s report, opened on 08/25/2025, revealed the API interviewed Resident #1 on 08/25/2025 at 4:29 PM at the facility. The Adult Protection Investigator (API) showed the resident the form to be completed for LOA, Leave of Absence. The translator asked the resident if she has to fill out the form and she did not know what the translator was explaining to her and said she has Alzheimer's. The translator explained it again and Resident #1 stated oh she remembered now. The resident confirmed she left the facility to look for her friend [NAME] who lived down the hall, she got lost and went outside looking for her. Review of the Palm Beach County Sheriff's Office Offense Report dated 08/23/25 documented the following: On August 23rd, 2025, at approximately 16:36 hours, the Law Enforcement Officer (LEO) responded to a call regarding an elderly female, who was observed walking near 22nd and 8th [ A] Street. The complainant reported seeing the female walking in the area and expressed concern due to her disoriented behavior. He (complainant) stated that he initially checked with the Avante Nursing Home to determine if she was a resident, but staff there reported no missing person.Upon arrival the LEO engaged with the female, who identified herself as [Resident #1] and provided her date of birth . The resident stated she was from [P.R.] and mentioned living in a Trailer Park or an apartment complex near Forest Hill Boulevard. The female appeared confused and provided inconsistent information about her residence, alternating between stating she lived in a nursing home and with her cousin. She mentioned having a room in her name at a yellow building but was unable to provide a specific address.She was unable to recall the name of her nursing home or provide contact information for any relatives. Efforts were made to verify her identity and locate her residence. A search of her identifying information revealed no prior police reports or missing person records. Dispatch identified a possible address which was listed on her Florida driver's license. PBSO district 1 was dispatched to the location to make contact with any individuals familiar with the female. District 1 advised that [Resident #1] is unknown to them and they have resided there for the last 13 years.While waiting to obtain any other leads, a nurse from Avante Nursing Home arrived at the location and identified the female as a resident of their facility. The nurse stated that the female may have been diagnosed with Alzheimer's or Dementia but was unsure of her specific medical history. The nurse explained that the nursing home conducted a head count after being alerted by a neighbor about possible missing resident, however, the initial head count failed to identify the female as missing.The LEO then relocated to Avante Nursing Home to speak with the staff. The facility's staff acknowledged the need for improved security measures, including monitoring the main entrance and implementing enclosed secured outdoor areas for residents.

Based on observations and interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. This had the potential to affect 103 residents who were on oral diets. The findings included: On 05/27/25 at 8:45 am, an initial tour of the kitchen was conducted. The Dietary Manager was present, and the following observations were made: 1. The backsplash of the Vulcan stove top was ladened with dark black residue. 2. The Vulcan double oven had dried on white crusty sediment, and thick black residue in the area just beneath the hinge of the oven door. 3. The Dean fryer had light brown flaky sediment along the upper rim of the fryer. When the cook was asked if the fryer was used today, he said that it was not used today. It was last used yesterday at the dinner meal. 4. The American Dish Service dishwasher rinse cycle temperature was 114' F, not the required 120' F as stated on the metal tag affixed to the oven. The plastic crates used to place dishes into the dishwasher, and to carry clean dishes out of the dishwasher, had an accumulation of a thick, white, flaky debris. The DM took his fingernail to it and some of it broke up and flaked off. 5. A stack of sheet pans was ladened with black residue. 6. The hood over the ovens/cooking area had brown and white residue on it. 7. The floor under the shelves of the walk-in refrigerator had the following food items: a plastic bottle of T.G. [NAME] 8 oz milk, several individual use creamers, 2 pieces of green lettuce, plastic wrapping, 2 slices of deli meat, 1 yogurt, dried white residue, brown residue. The Dietary Manager agreed with these findings, and photographic evidence was obtained of the the above findings. A follow-up tour of the kitchen was conducted with the Regional Certified Dietary Manager on 05/27/25 at 3:45 PM. The following was observed: 8. The entrance to the walk in freezer had a build-up of ice near the door. When asked why there was a build-up of ice, the DM said that there was a problem with air leakage at the doorway and that a work order was put in. The temperature of the freezer was 0' F. The foods were frozen solid. There was a buildup of ice on the floor and an open space along the inside door that was not sealed. 9. The walk-in refrigerator was observed to have a loose gasket. The Regional Certified Dietary Manager agreed with these finding. Photographic evidence obtained.

Based on observations, interviews and record reviews, the facility failed to ensure the medications were timely administered for 2 of 6 residents observed for medication passes (Resident #80 and Residetn#409). The facility also failed to follow the physician ordered and prescribed medications for 3 of 38 sampled residents (Resident # 41, Resident #8, and Resident #68). The Findings included: A review of facility's policy titled, General Dose Preparation and Medication Administration, with a recent revision date of 11/15/24, it was revealed the following: to administer the medication within timeframes specified by facility policy or manufacturer's information (proc. 5.4; pg. 97); prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including confirming that the Medication Administration Record (MAR) reflects the most recent medication order (proc. 3- 3.4; pg. 97). 1). Resident #80 was admitted on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation, Essential Primary Hypertension, Aphasia following Cerebral Infarction, and Hemiplegia/ Hemiparesis following Cerebral Infarction. A review of admission Minimum Data Set (MDS) under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 5 indicating Resident #80 had severely impaired mental cognition. During a medication pass observation on 05/29/25 at 11:42 AM, with Staff B, a Licensed Practical Nurse (LPN), she stated that she is going to administer the 9:00 AM medication for the resident. She prepared the following medications: Aspirin 81 milligrams (mg), 1 tablet, with an expiration date of 11/26; Atorvastatin 80 mg tablet, 1 tablet, 1time a day, with an expiration date of 02/28/26; Carvedilol 12.5 mg, 1 tablet, 2 times a day, with an expiration date of 12/25; Lisinopril 40 mg, 1 tablet, 1 time a day with an expiration date of 12/31/25; and Zoloft 25 mg, 1 tablet, 1 time a day with an expiration date of 05/10/26. All these medications were administered after 12:00 PM. A review of Resident #80's MAR revealed all the above medications were administered at 9:00 AM. In an interview with Staff B, LPN, when she was asked what the documented administration time of the above medications for Resident #80 was, she responded, 9:00 AM. When asked why she did not document the accurate time of after 12:00 PM, she responded, I do not know how. 2). Resident #409 was admitted on [DATE] with diagnoses including Absence of Epileptic Syndrome Intractable without Status Epilepticus, Metabolic Encephalopathy, Hyperlipoidemia and Obstructive and Reflux Uropathy. A review of the admission Minimum Data Set (MDS) under Section C revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #409 had good mental cognition. During a medication pass observation using Flamingo Medication cart 1 with Staff E, a Registered Nurse (RN) on 05/28/25 10:45 AM, it was observed that her computer screen produced a pink color on the 9:00 AM medications for Resident #409. When Staff E , an RN was asked what the pink color meant, she responded, I am administering the medications later than the scheduled time. She added that medications must be administered one hour before and one hour after the scheduled time. She added, I think it is still ok. She administered the following medications: Cefuroxime 250 milligrams (mg), 1 tablet, 2 x a day with an expiration date of 04/08/26. This medication was taken by Resident #409 at 11:08 AM; Sertraline 25 mg, 1 tablet, once a day, with an expiration date of 04/30/26. This medication was taken by Resident #409 at 11:05 AM; Keppra 750 mg, 2 tablets by mouth, 1 time day, with an expiration date of 02/31/25. This medication was administered at 11:02 AM. A review of Resident #409's Medication Administration Record (MAR), it was revealed the above medications were documented administered at 9:00 AM, with check marks and 3 letter initials . 2)The findings included: Review of the record revealed Resident #8 was admitted to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE], documented that the resident had a Brief Interview Mental Status (BIMS) score of 13 on a 0 to 15 scale, indicating no cognitive impairment. During an Interview on 05/27/25 at 11:11 AM, with Resident #8, in his room, two tubes of cream in a zip lock bag were sitting on the bedside table. One of the tubes was dated as prescribed on 12/19/24 and the other tube, that had never been opened, was dated 4/24. When asked if the cream was being applied by the nurses the resident stated No. When asked are you capable of applying the ointment yourself, the resident stated No. When asked do you have a fungus on your feet, the resident stated Yes. (photographic evidence obtained) Record review revealed an order for Resident #8 dated 12/19/24, that instructed the staff to apply Ciclopirox Olamine External Cream 0.77 % (antifungal cream) to the bottom of both feet two times a day for fungus. Review of the Medication Administration Record for the month of May revealed that the staff had documented on record indicating that the treatment had been provided to Resident # 8. (photographic evidence obtained) During an interview on 05/28/25 at 11:34 AM, when asked was the cream applied to your feet today, the resident stated No. When asked has anyone on any shift asked you if you wanted the cream on your feet the resident stated No. There were 2 tubes on cream in a zip lock bag observed on Resident #8's bedside table. (photographic evidence obtained) During an interview on 05/29/25 at 1:06 PM, the Unit Manager was taken to Resident #8's room and two tubes of cream in a zip lock bag were observed sitting on the bedside table. When asked where the medication should be stored the Unit Manager stated, It should be on the medication cart. At this time, the Unit Manger was made aware that the cream had been observed on Resident #8's bedside table since 05/27/25 and the unit manager was told that the resident said that he had not been receiving the medication. At this time, the Unit Manager took the zip lock bag with the cream out of the resident's room. 3)The findings included: Record review revealed that Resident #41 was admitted to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 on 0 to 15 scale, indicating no cognitive impairment. During an interview 05/27/25 @ 11:28 AM, Resident # 41 stated I can't sit on my bottom because it hurts. When asked have you talked to the wound doctor regarding your wound, the resident stated Yes, but she says I'm diabetic and it will take time to heal. The doctor says it's not open anymore and the ridges on my buttocks will be there. I have a cream they put on the wound. When asked how often the cream is applied, the resident stated, Every time I get changed. Review of the care plan dated 05/07/2025 indicated that Resident #41 has impaired skin related to decreased bed mobility, obesity (overweight), diabetes (increase in blood sugar), Hemiplegia (paralyzed limbs), incontinence and generalized weakness. The areas: the left ischium (hip) shear, right ischium shear, left buttock shear, and right buttock shear, with a goal that the resident will have intact skin, free of redness, blisters or discoloration provided that the staff administer medications as ordered, observe and document side effects and effectiveness of medication, administer treatments as ordered and observe for effectiveness. During an interview on 05/28/25 at 10:25 AM, Staff O, (Certified Nursing Assistant (CNA) observed providing incontinent care for Resident #41. The skin on both buttocks and ischium area was observed to have ridges, excoriation and redness. When asked do you notice any drainage from the wounds on her buttock, Staff O, CNA stated No. There was some white cream observed in a plastic drinking cup with a tongue compressor sitting inside of it. When asked are you applying this cream on Resident # 41 buttocks Staff O, (CNA) stated, Yes. Review of an order dated 3/17/25 for Resident #41 instructed licensed nurse to cleanse left buttock shear and right ischium shear with wound cleanser, pat dry, apply Silver Sulfadiazine (antibiotic cream to treat and prevent wound infection in burns wounds) and leave open to air every day and evening shift for lesion/shear. During an interview on 05/28/25 at 11:52 PM, when asked are you familiar with Resident #41's wounds on her buttocks area, the Wound Care Nurse stated, Yes, but it's not a wound anymore because there's no depth. The resident was recently discharged from the wound care doctor seeing for her. Now, there is an order to apply Silvadene cream to the resident's buttocks area. When asked how often the cream is supposed to be applied, the Wound Care Nurse stated, I will have to look. It's twice a day. When asked who normally applied the cream, the Wound care nurse stated, I apply it in the daytime and on the other shift the evening nurse is to apply the cream. During an interview on 05/28/25 at 4:06 PM, when asked if she provided the wound care treatment for Resident #41, the Wound Care Nurse stated, I went to put the cream on the resident, but Staff N, Licensed Practical Nurse (LPN) said that she had just applied the cream 10 minutes prior after she cleaned the resident. Record review on 05/29/25 at 2:22 PM, revealed that the silver sulfadiazine cream was discontinued by the wound care nurse and a new order written dated 05/28/27 for zinc oxide. During an interview on 05/29/25 at 3:12 PM, when asked why the silver sulfadiazine cream was discontinued for Resident #41, the Wound Care Nurse stated, after having the conversation with you I decided to call the nurse practitioner in regard to changing the treatment since we have been using the silver sulfadiazine cream on Resident #41 for a long period of time. Also, the wound care doctor will evaluate her again on next Monday 4)The findings included: Record review revealed Resident #68 was admitted on to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating no cognitive impairment. During an interview on 05/27/25 at 10:42 AM, in Resident #68's room, a tube of ointment with a prescribed date of 12/19/24 was observed on the bedside table. When asked what the ointment was for, the resident stated It's for my feet. The nurse put it there and I put it on myself. This is the second tube I've had. When asked do you have a fungus on your feet, Resident #68 stated Yes, I put on gloves when I put it on my feet. When asked do the nurses ever applied the ointment, the resident stated No, I can do it myself. (photographic evidence obtained) Further review of the record revealed an for Resident #68, dated 12/19/24, that instructed the staff to apply Ciclopirox Olamine External Cream 0.77 % (antifungal cream) to the bottom of both feet every shift. Review of the Treatment Administration Record (TAR), on 05/27/29, for the month of May revealed that the staff had documented that the antifungal cream was administered for Resident #8 on every shift. (photographic evidence obtained) During review of the TAR, on 05/29/25 at 12:15 PM, Staff M, Registered Nurse (RN) had signed the record acknowledging that she administered the cream for Resident #68. During an interview on 05/29/25 at 12:19 PM, when asked what cream you applied for Resident #68's feet, Staff M, RN, went to the treatment cart to find the cream but was having difficulty finding the cream. After a couple of minutes of allowing Staff M, RN to look for the cream, the cream was pointed out to her. The cream was in a box which was dated as ordered on 05/27/25. During a brief interview on 05/29/25 at 12:23 PM, when asked if the nurse applied the cream to his feet, Resident # 68 stated No, not today. I do not want it today. During an interview on 05/29/25 at 1:07 PM, The Unit Manager was made aware of Resident #68 stating that he did not receive or want the antifungal cream on his feet today, but Staff M, RN documented and acknowledged during conversation that she administered the cream for Resident #68.

Based on observations, interview, and record review the facility failed to follow their Safe Smoking policy to reassessa resident quarterlyand after a change in condition and failed to update the smoking care plan for 1 of 1 resident reviewed for smoking (Resident #72). The findings included: Review of the facility's policy titled, Safe Smoking with a revised date of 01/11/19 included in part the following: Screening - A safe smoking screen is performed on admission for a resident who wishes to smoke. Reassessment of the resident occurs annually and/or after a significant change in condition. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part Generalized Anxiety Disorder. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the MDS for Resident #72 revealed Significant Change dated 08/22/24. The Care Plan for Resident #72 dated 09/19/23 with a focus on the resident is a smoker and is noncompliant with facility's smoking policy. The goal was for the resident to safely smoke at designated times , in designated areas with supervision of staff and have no smoking injuries or incidents x90 days. The interventions included in part the following: Smoking assessment to be completed on admission, quarterly and with any significant change in condition. Smoking will be supervised by staff members. Review of the Smoking Assessments for Resident #72 revealed the following: A Smoking assessment dated [DATE] documented May smoke but must be supervised by staff volunteer or family? answered Yes. A Smoking assessment dated [DATE] documented May smoke but must be supervised by staff volunteer or family? answered No. In summary there was no smoking reassessment performed after the resident had a significant change in condition on 08/22/24 and the facility failed to perform smoking assessment quarterly as documented in the intervention of the resident's care plan with a focus on smoking. On 05/27/25 at 4:30 PM an observation was made of Resident #72 smoking on the smoking patio. Staff member seen through the window observing/monitoring the residents who were on the smoking patio. During an interview conducted on 05/27/25 at 4:32 PM with Resident #72 who was asked if she has always smoked while at the facility, she said yes. The resident said the staff hold her cigarettes and lighter and they provide them to her when she comes to the smoking patio. The resident stated she comes several times a day to smoke on the patio. During an interview conducted on 05/29/25 at 10:30 AM with the Director of Nursing (DON) who was asked when smoking assessments are completed and by whom, the DON stated they are done by nursing on admission and then quarterly if the resident is a smoker. When asked about Resident #72, the DON acknowledged the resident was admitted to the facility on [DATE] and had only 2 smoking assessments (09/14/23 and 12/12/24). The DON stated the smoking assessment should have been done in March of 2025 and was overdue.

Based on interviews, record review, and policy review, the facility failed to investigate an allegation of abuse thoroughly for 1 of 35 sampled residents (Resident #307). The findings included: A review of the facility's policy on Abuse, Neglect, Exploitation and Injuries of Unknown Origin, effective 03/01/17, clarified that residents must not be abused by anyone, including facility staff, other residents, consultants, volunteers, family members, visitors, or other individuals. It stated that alleged violations involving mistreatment, neglect, or abuse must be immediately reported to the facility administrator and to other officials in accordance with state and federal law and through established procedures. The detailed investigation and reporting procedure for abuse mandated a thorough investigation, and a grievance form for an allegation of physical abuse without evidence of physical injury. [NAME] A review of the medical records for Resident #307 revealed that he was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of larynx, tracheostomy status, and muscle wasting. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed that Resident #307 had a Brief Interview for Mental Status score of 12, which indicated that he was cognitively intact. A review of the medical records of Resident #85 (he was the roommate of Resident #207) revealed he was admitted [DATE] with diagnoses including Schizophrenia, Brief Psychotic disorder, anxiety, and bipolar disorder. Per Minimum Data Set assessment dated [DATE], Resident #85's BIMS score was 5. This indicated severe cognitive impairment. Resident #85 had behavior problems. His care plan dated 04/03/25 noted that he yelled obscenities in facility hallways, and he hit another resident during a smoke break which was related to poor impulse control. During an initial screening interview with Resident #307, on 05/27/25 at 12:43 PM, when asked if he was ever abused at the facility, he described an incident when his roommate, Resident #85, threw a television remote control at him which hit him in the forehead. Resident #307 said that Resident #85 also lifted up the bottom of the privacy curtain that hung between the beds and threw it over the table. Resident #307 wrote on his communication board that the curtain hit him in the chest. Resident #307 had a trach in place with an exposed open area in between the trach and the surrounding skin (stoma). The surveyor asked him to show with his hands where the curtain hit him, and Resident #307 moved his hands from the bottom of his rib cage to his face while he mouthed the words from my chest to all over my face. When Resident #307 was asked if he reported it to anyone, he said that he told the nurse manager that he wanted Resident #85 arrested, but they only moved him down the hallway. He explained that Resident #85 used awful defamatory language towards nursing every day, and he still heard him from his room. He said they should have moved Resident #85 further away from his room. When Resident #307 was asked if Resident #85 came into his room and threw things at him after his room changed, Resident #307 answered no. Resident #307 mouthed words and wrote full sentences with a stylus on his communication board to communicate effectively. During an interview with the administrator in her office, on 05/27/25 at 1:48 PM, the surveyor reported the incident. The administrator told the surveyor that she knew about the incident that occurred with Resident #307 and his roommate. The surveyor requested all documents that related to that incident. A review of the Resident #307's medical record showed no documentation about the incident. On 05/27/25 at 2:52 PM, the administrator entered the conference room and explained that Staff D, an RN, observed the incident on Saturday. She said that Resident #85 had a diagnosis of tardive dyskinesia and that Resident #85 accidentally moved the curtain into Resident #307. The administrator said that the remote control fell off the table and landed on the resident. She said it was an accident and that Resident #307 agreed with that. On 05/27/25 at approximately 4:00 PM, the administrator provided the surveyor with a Witness Statement signed by Staff D. Staff D wrote that when she was doing rounds on May 24 (2025), at 9:00 AM, she went to the room of Resident #307 and asked the residents if they were ok. Resident #307 reported to her that his roommate hit him with the remote control. She wrote that she discussed the incident with both residents and we conclude(d) it was an accident. She wrote that the roommate tried to pick up his stuff from the floor and the curtain was wrapped around the table. She wrote that's how the remote fell on him. She ended the statement with a note about changing the room of the other resident to prevent more accidents. There was no mention of the name of the roommate in the Witness statement. There was no statement from Resident #307 provided to the surveyor. During an interview with Resident #307 on 05/29/25 at 8:29 AM, the resident said that the top nurse (who he reported the incident to) came to him and spoke about the incident. The surveyor asked Resident #307 if the nurse referred to it as an accident and he answered yes. When asked if he agreed with the nurse that it was an accident, Resident #307 answered: I told her that was bullshit. When Resident #307 was asked how the incident affected him, Resident #307 said that when he saw Resident #85 in the hallway he was horrified. Resident #307 said that the facility should have called the police right away. He said he should have been able to fill out a police report. Again, Resident #307 spoke about the awful defamatory language used by Resident 85 and he asked the surveyor if she heard it. In an interview with Staff D on 05/29/25 at approximately 12:30 PM, the nurse clarified that she did not observe the incident. She also said that the incident was a misunderstanding. An interview on 05/29/25 at 6:31 PM with the administrator, who also holds the position of risk manager, revealed that Staff D texted her on Saturday (05/24/25) to see if she thought it was abuse, neglect, exploitation, or misappropriation. The administrator was asked under what circumstances she interviewed residents herself. The administrator said that she interviewed residents when she was made aware of ongoing concerns. Per the administrator, there weren't any ongoing concerns mentioned. The administrator said she did not have any statements from Resident #307 or Resident #85. During an interview with the Administrator/Risk Manager on 05/30/25 at 9:31 AM, she said she spoke to Resident #307 last night, and that she reported the incident to the police and to the DCF. Per the administrator, DCF didn't accept the case, and the police came out and spoke to Resident #307. Resident #307 declined to press charges, and the police did not take the case. The administrator reported the incident to AHCA (the State Agency) on 05/29/25. This was 5 days after the incident occurred. An interview with Resident #307 on 05/30/25 at 10:39 AM confirmed that the police came to the facility and spoke with him on 05/29/25. When asked how he felt after the discussion with the police, Resident #307 said good. When Resident #307 was asked if Resident #85 came to his room after the incident, he answered no.

Based on policy review, observation, record review, and interview, the facility failed to assess for self-administration of medication for 1 of 35 sampled residents, as evidenced by no assessment was completed for Resident #68 to self-administer medication. The findings included: Review of the policy titled Self-Administration of Medication Program revised: 06/26/2024, documented in part, It is the policy of the facility to allow the resident the right to self -administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate .Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. Resident's preference will be documented on the appropriate assessment in the medical record. The results of the interdisciplinary team assessment are recorded in the resident's medical record. Record review revealed Resident #68 was admitted to the facility on [DATE]. The most recent comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating no cognitive impairment. During an interview on 05/27/25 at 10:42 AM, in Resident #68's room, a tube of ointment with a prescribed date of 12/19/24 was observed on the bedside table. When asked what the ointment was for, the resident stated It's for my feet. The nurse put it there and I put it on myself. This is the second tube I've had. When asked have the nurses ever applied the ointment, the resident stated No, I can do it myself. Photographic evidence obtained. Further review of the record revealed an order dated 12/19/24, that instructed the staff to apply Ciclopirox Olamine External Cream 0.77 % (antifungal cream) to the bottom of both of Resident #68's feet every shift. Review of the Treatment Administration Record (TAR), on 05/27/25, for the month of May, revealed that the staff had documented on every shift administration of the antifungal cream for Resident #68. During further review of the record, there was no documentation of an assessment completed by the interdisciplinary team for Resident #68 to self-administer medication.

Based on observations, interviews, and record reviews, the facility failed to provide a resident choice for showers, for 1 of 35 sampled residents (Resident #103). The Findings included: A review of facility's policy titled, Quality of Care, revised on 03/02/19, revealed facility ensures that each resident receives, and the facility provides the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations. Resident #103 was admitted on [DATE] with diagnoses that included Central Cord Syndrome, Quadriplegia,Neuromuscular Dysfunction of the Bladder and Major Depressive Disorder. A review of the Minimum Data Set (MDS) under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating Resident #103 had good cognitive function. Section GG revealed Resident #103 was dependent on the ability to bathe self, including washing, rinsing, and drying self. Record review of the Nursing care plan initiated on 04/24/25 revealed Resident #103 was dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility. One of the care plan goals for Resident # 103 was to improve the current level of function with the intervention to provide bath/ shower as necessary, since resident is totally dependent on showering, dressing, toilet use, and transfer. In an interview with Resident #103 on 05/28/25 at 10:15 AM and on 05/29/25 at 12:00 PM, she stated that she has been in the facility for 5 weeks. When asked about her stay, she responded, she was so uncomfortable with her bad smelling, dirty hair and neck. Resident #103 pointed to a cervical collar around her neck area. She added that she had been requesting showers since she arrived at the facility, but staff did not frequently provide her the choice of showers whenever she requested. She received 2 showers in the past 5 weeks. She added the staff stated they will come back and give her showers, but it happened only twice in the past 5 weeks. She told staff multiple times that she desperately needed assistance in showering and did not prefer bed baths. In an interview with Staff O, Certified Nursing Assistant, (CNA) on 05/28/25 at 11:00 AM, she stated she will put the shower schedule on the board for today. She added that the shower schedule must be posted as early as possible so staff can give showers per residents' requests. When asked about the usual time she provides shower to her assigned residents, she stated, It depends on when the resident likes to have one. When asked how many residents' showers she provides during her shift, she responded, It depends, sometimes 2 and 3. When asked if she documents the showers she provides residents, she responded, We have a shower log binder. In an interview with Staff C, a CNA on 05/30/25 10:00 AM, when asked how other staff would know that she already provided a shower to her assigned residents, she responded, We document them in the shower log. When asked if she documented the showers, she provided for Resident #103, she stated she never had this resident. When asked if she could provide a copy of the shower log of her assigned residents, she stated she would ask the Unit Manager. When asked if she could show this surveyor the shower log, she stated, It is at the Nursing station. During an inspection of a binder called the shower log found at the Nursing station, Staff C, a CNA verified that the shower log for residents was not updated. There were no residents' names and shower times documented. This Staff kept on turning pages, but she could not show the surveyor any showers provided to residents. When the Assistant Director of Nursing (ADON) was asked regarding a copy of a shower log for Resident #103 on 05/28/25 at 11:45 AM, she stated it would be provided. But until the last day of the survey no copy of the shower log was provided. In an interview with the Flamingo Unit Manager on 05/29/25 at 10:00 AM, when she was asked about shower schedule, she responded, Shower is scheduled every other day. Each member of the CNA staff is assigned to a resident. The CNA Staff provide residents' showers during day and afternoon, but not during the night shift. She stated any resident can ask for an extra shower but it must be scheduled by staff. When asked if she checks the shower log binder, she responded, Yes. When asked who is responsible for checking the shower log binder, she responded, It is the ADON. When asked to show the shower log for Resident #103, she stated I will print you a copy. Until the last day of survey, no shower log for Resident #103 was provided to the surveyor. In an interview with the Corporate Administrator on 05/29/25 at 11:24 AM, she was asked to print a shower log for Resident #103. She stated she would ask the Director of Nursing (DON) to print a copy. Until the last day of survey, no copy of the shower log for Resident #103 was provided to the surveyor.

Based on observations, interviews and record reviews, the facility failed to ensure a medication cart was secured for 1 of 5 medication carts (Flamingo unit). The facility also failed to ensure medications are secured at bedside for 2 of 35 samplef residents (Resident #68 and Resident #8). The findings included: A review of facility's policy titled, General Dose Preparation and Medication Administration with revision date of 11/15/24, revealed the following: the facility staff should not leave medications or chemicals unattended ; and the facility should ensure that medication carts are always locked when out of sight or unattended. 1). Resident #97 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, A review of Minimum Data Set under Section C revealed a Brief Interview of Mental Status (BIMS) score of 8 indicating impaired mental cognition. During a medication pass observation on 05/27/25 at 4:31 PM, Staff R, Registered Nurse, (RN), who stated he has been working in the facility for one year, and he will administer the scheduled medications for Resident #97. Staff R, RN unlocked Flamingo medication cart 1 and searched for the medication Cyclobenzaprine 10 mg (milligram), which he stated is scheduled for 3 times a day. After searching the medication drawers for a few minutes, Staff R, RN stated he could not find the medication. He added the medication has been ordered from the Pharmacy. On 05/27/25 at 4:31 PM, after checking Resident#97's blood sugar, Staff R RN stated he would go inside the storage room to check if the medication was delivered there. Staff R, RN left the Flamingo medication cart #1 unattended and unlocked. In an interview with the Director of Nursing (DON) on 05/27/25 at 4:41 PM, he was shown Flamingo medication cart #1 was left unattended and unsecured when the surveyor opened the first 2 top drawers. Staff R, RN came back from the storage room and the DON told him the medication cart was unlocked. 2) Record review revealed Resident #68 was admitted on to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating no cognitive impairment. During an interview on 05/27/25 at 10:42 AM, in Resident #68's room, a tube of ointment with a prescribed date of 12/19/24 was observed on the bedside table. When asked what the ointment was for, the resident stated It's for my feet. The nurse put it there and I put it on myself. This is the second tube I've had. Photographic evidence obtained. Further review of the record revealed an order dated 12/19/24, that instructed the staff apply Ciclopirox Olamine External Cream 0.77 % (antifungal cream) to the bottom of both of Resident #68 feet every shift. During an interview on 05/29/25 at 1:09 PM, the Unit Manager was made aware that a tube of Ciclopirox Olamine External Cream 0.77 % (antifungal cream) was observed at the Resident #68's bedside on 05/27/25 at 10:42 PM. 3)Review of the record revealed Resident #8 was admitted to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE], documented that the resident had a Brief Interview Mental Status (BIMS) score of 13 on a 0 to 15 scale, indicating no cognitive impairment. During an Interview on 05/27/25 at 11:11 AM, with Resident #8, in his room, two tubes of cream in a zip lock bag were sitting on the bedside table. One of the tubes were dated 12/19/24 and the other tube, that had never been opened, was dated 4/24. When asked if the ointment was being applied by the nurse the resident stated No. When asked are you able to apply the ointment yourself, the resident stated No. Photographic evidence obtained. Record review revealed an order for Resident #8 dated 12/19/24, that instructed the staff to apply Ciclopirox Olamine External Cream 0.77 % (antifungal cream) to the bottom of both feet two times a day for fungus. During an interview on 05/29/25 at 1:06 PM, the Unit Manager was taken to Resident #8's room and two tubes of cream in a zip lock bag were observed sitting on the bedside table. When asked where the medication should be stored the Unit Manager stated, It should be on the medication cart. At this time, the Unit Manger was made aware that the cream had been observed on Resident #8's bedside table since 05/27/25 and the unit manager was told that the resident said that he had not been receiving the medication. At this time, the Unit Manager took the zip lock bag with the cream out of the resident's room.

Based on observation, interview, and record review, the facility failed to ensure discontinued controlled medications were removed from the medication carts, and initials and time matched on the MAR and control sheet, for 3 of 10 residents reviewed for controlled medication storage (Residents #91, #20, #97). The findings included 1). Resident #91 was admitted on [DATE] with diagnoses including Primary Hypertension, Unspecified Mood Affective Disorder, Anxiety Disorder, Unspecified Dementia, and Behavioral Disturbances. A review of Minimum Data Set (MDS) dated [DATE], under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident #91 had severely impaired mental cognition. A review of Physician orders dated 11/06/24 revealed Lorazepam 0.5 mg, 1 tablet by mouth twice a day for 7 days. A review of Resident #91's Narcotic sheet revealed 12 counts of Lorazepam 0.5 mg tablets were received on 11/16/24. The medication is to be discontinued on 11/23/24 per physician order. A further review of Resident #91's narcotic sheet revealed that on 12/01/24 at 1:45 AM, 1 tablet was given. On 12/04/25, 1 tablet was administered at 02:05 AM. On 12/20/25, 1 tablet was given at 2 PM. A further record review revealed that Lorazepam 0.5 mg was given on 01/26/24 (typographical error for the year 2025) at 5 :00 PM. On 03/02/24 ( typographical error for 03/02/25), 1 tablet was given, but there was no documentation of the time it was given to Resident #91. A further review of Resident #91's narcotic sheet for Lorazepam 0.5 mg revealed there were 6 tablets left which was also the same number on the Bingo medication dispenser. In an interview with the Director of Nursing (DON) on 05/30/25 12:33 PM, he stated that he is responsible for checking that the discontinued medications are removed from the medication carts. He added that Nurses help to make sure unused and discontinued medications are removed from the medication carts, but the ultimate responsibility falls on him. In an interview with the visiting Regional Director on 05/30/25 at 12:30 PM, she stated that upon review of Resident # 91's records, she found that Lorazepam was administered even after it was ordered discontinued. She asked the DON to contact the resident's family and notify resident's attending physician. When was asked why it took 5 months to check Resident # 91's discontinued medication orders, she did not respond. When she was asked who is responsible for verifying discontinued medications are removed from the medication carts, she responded, The facility Nurses and the Director of Nursing. 2) Resident #20 was admitted on [DATE] with diagnoses including Gastro-Esophageal Reflux Disease Type 2 Diabetes Mellitus Anxiety disorder and Major Depressive disorder. A review of current Minimum Data Set (MDS) dated [DATE] under Section C of the Brief Interview of Mental Status (BIMS,) revealed a score of 5 indicating Resident #20 had severely impaired cognition. A record review of Physician orders dated 03/04/25 revealed Lorazepam 0.5 mg, 1 tablet every 24 hours as needed for anxiety for 14 days. A review of Resident #20's Narcotic sheet revealed 13 counts of Lorazepam 0.5 mg were received on 03/16/25 with the Nurse's signature. The medication was ordered to be discontinued on day 14 (03/30/25). A further review of Resident #20's Narcotic sheet, it revealed Lorazepam 0.5 mg, 1 tablet was given, and was removed from the Bingo dispenser card on 05/12/25 at 5:00 PM and at 10:00 PM, with the same Nurse's signature. In an interview with Staff A, an LPN on 05/29/25 at 3:50 PM, who was asked who received the medications and who signed out the medication from Resident #20's Narcotic sheet on 05/12/25 at 5:00 PM and at 10:00 PM, responded she does not know whose Nurse's signatures are on the Narcotic sheet. A record review of May 2025 MAR for Resident #20 revealed no documentation for Lorazepam 0.5 mg . 3) Resident #97 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, Dysphagia following Cerebral Infarction, and Chronic Kidney Disease. A review of the current Minimum Data Set (MDS) under Section C revealed a Brief Interview of Mental Status (BIMS) score of 8 indicating Resident #97 had impaired mental cognition. A review of physician orders revealed Oxycodone-Acetaminophen, 10-325 milligrams (mg), 1 tablet by mouth every 6 hours as needed for pain. A review of Medication Administration Record (MAR) dated 05/27/25, it revealed the Oxycodone-Acetaminophen 10-325 mg was administered at 11:34 AM by Staff B, Licensed Practical Nurse (LPN). When compared with Resident #97's narcotic sheet, it was revealed Oxycodone -Acetaminophen 10-325 mg, I tablet was administered at a different time from the documentation in MAR. The medication was administered at 4:34 PM on 05/27/25 with a squiggly m signature. Resident #97's narcotic sheet had documented 5 tablets were left and it was the same number left on the Bingo medication dispenser. In an interview with Staff A, LPN on 05/29/25 at 3:50 PM, who was asked who signed out the medication in the Narcotic sheet on 05/27/25 at 4:34 PM, responded she does not know whose Nurse's signatures are on the Narcotic sheet. When asked if that was the same nurse who documented in MAR, she did not respond.

Based on interviews and record review the facility failed to maintain completed dialysis communication records for 1 of 1 resident sampled for dialysis (Resident #90). The findings included: Review of the facility's policy titled, Dialysis with a revised date of 03/02/19 included in part the following: Nurses will educate the resident and/or family/resident representative on risks of non-compliance and document in the resident's clinical record as needed. The facility and the dialysis center should maintain regular communication and should a change in condition occur before or during dialysis treatment the sending facility should communicate the changes in needs to the receiving facility. Record review for Resident #90 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: End Stage Renal Disease, and Dependence on Renal Dialysis. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the Dialysis Communication Sheets (DCS) for Resident #90 from 05/07/25 to 05/23/25 documented in part the following: The DCS dated 05/07/25 was incomplete. The DCS dated 05/14/25 did not have the resident or the dialysis center name. The DCS dated 05/21/25 was incomplete The DCS with no date no resident or the dialysis center name. was incomplete Review of the progress notes for Resident #90 from 05/07/25 to 05/23/25 documented in part the following: There was no note dated 05/07/25 There was no note dated 05/14/25 There was no note dated 05/21/25 Review of the Physician's Orders for Resident #90 revealed an order dated 02/04/24 for Resident is a dialysis patient with a MWF schedule resident chair time is 1pm and is to report for dialysis. Review of the Care Plan for Resident #90 dated 02/11/25 with a focus on the resident needs hemodialysis related to renal failure Monday, Wednesday, Friday 1:00 PM chair time. Pickup at 12:00 PM. The goals were for the resident to have immediate intervention should any signs/symptoms of complications from dialysis occur and the resident will have no signs/symptoms of complications from dialysis through the review date. The interventions included in part the following: Encourage resident to go for the scheduled dialysis appointments on days the resident receives dialysis. An interview was conducted on 05/27/25 at 10:10 AM with Resident #90 who stated he goes out to dialysis Monday, Wednesday and Fridays. When asked how they give him the dialysis, he said it is through a port in his chest, when he pulled down his gown to show it to surveyor. during an interview conducted on 05/29/25 at 9:45 AM with Staff M Registered Nurse (RN) who was asked about the dialysis communication sheets she said they fill out the top of the form and send the form with the resident to dialysis, the dialysis center fills out their portion in the middle of the sheet and return it with the resident. When the resident returns to the facility they put the vital signs directly into the resident's electronic medical record and the dialysis communication form gets filed into the dialysis book for the specific resident.

Based on observations, interviews and record reviews, the facility failed to provide tracheostomy care and services consistent with the professional standards of practice for 1 of 1 sampled for tracheostomy care (Resident #64); failed to obtain oxygen orders for 2 of 6 residents (Resident #408, and Resident #308); and failed to follow orders for oxygen therapies for 3 of 11 residents receiving oxygen (Resident #7, Resident #23, and Resident #66). The Findings included: A review of facility's policy titled, Policies and Procedures: Respiratory/Tracheostomy Care and Suctioning, with a revision date of 03/26/21, revealed 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 person-centered care plan and resident goals and preferences; the facility, in collaboration with the attending practitioner, must perform a comprehensive assessment of the respiratory needs: and based upon the resident assessment, attending physician orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. 1). Resident # 64 was admitted on [DATE] with diagnoses that included Non-traumatic Subarachnoid Hemorrhage from Unspecified Intracranial Artery, Encephalopathy, Type 2 Diabetes Mellitus with Hyperglycemia, and Respiratory Failure. A review of the current Minimum Data Set (MDS) dated [DATE] revealed Section C was not completed due to severely impaired cognition. A record review of physician orders dated 01/03/25 revealed to provide tracheostomy care every day and as needed. Change tracheostomy tie daily and as needed, every evening and night shift for tracheostomy care. During an observation on 05/28/25 at 9:14 AM, 2 pink saline containers were at bedside table together with an open tracheostomy care kit. There was no tracheostomy obturator observed. During another observation on 05/28/25 at 12:07 PM, there was no tracheostomy obturator observed at bedside of Resident #64. During another observation on 05/29/25 at 2:47 PM, there was no tracheostomy obturator observed at Resident #64's bedside. During a tracheostomy care observation with the Assistant Director of Nursing (ADON) and Staff F, Licensed Practical Nurse (LPN), who were both asked about the inner cannula or tracheostomy obturator, both stated that they keep a box of extra tracheostomy tubes at bedside because the Respiratory Therapist used to change the tracheostomy tubes every day when needed. When they were asked if changing the tracheostomy tube is included in facility's tracheostomy care policy, the ADON responded, I will provide you a copy. They both did not show where the obturator is kept for Resident # 64. 2). Resident #408 was admitted on [DATE] with diagnoses that included Surgery of the Circulatory System, Presence of Cardiac Pacemaker, Hypertensive Heart Disease with Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). A review of Minimum Data Set (MDS) revealed it was not completed due to recent facility admission. During an observation on 05/27/25 at 2:00 PM, there was no oxygen signage on Resident #408's door. During the following days until the last day of the survey, oxygen signage was not observed on Resident #408's door. During an observation on 05/27/25 at 2:30 PM, Resident #408 was observed with a oxygen concentrator at bedside infusing through resident's nasal cannulae at 3 Liters (L) per minute (min). An additional observation on 05/28/25 at 12:13 PM revealed Resident #408 was wearing nasal cannulae on both nares infusing at 3 L/min. There was also an oxygen tank on a standing cart next to the door. A review of physician orders dated 05/27/25 and 05/28/25 revealed no oxygen orders for Resident #408. In an interview with Staffe E, Registered Nurse (RN), on 05/28/25 at 9:10 AM, when asked if Resident #64 is receiving oxygen, she responded, Yes A record review of physician orders revealed an order for oxygen, continuous at 3 L/min via nasal cannula, every shift related to COPD. It was dated 05/29/25 at 11:00 PM 3) Resident #308 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with Hypoxia, and Cardiac Pacemaker. This resident's Brief Interview for Mental Status (BIMS) score, assessed on 05/28/25 was 14. This indicated that Resident #308 was cognitively intact. His care plan for COPD dated 05/27/25 included an intervention that listed oxygen settings per MD order. During an observation on 05/27/25 at 5:22 PM, Resident #308 was sitting in a wheelchair in his room and a nasal cannula was situated to deliver oxygen into his nose. The oxygen concentrator was set at 4 liters per minute. There was no order for oxygen in the electronic medical records. During an observation on 05/28/25 at 5:24 PM, the resident was in his room and receiving oxygen at 4 liters per minute. On 05/29/25 at 11:55 AM, Resident #308 was sitting in the wheelchair in his room. He was receiving oxygen from the concentrator which was set at 3.5 liters per minute. During an interview with Staff G on 05/29/25 at 4:20 PM, the surveyor requested that the nurseto look for an oxygen order for Resident #308 and she didn't see an order. The surveyor and Staff G went to Resident #308's room. On 05/29/25 at 4:38 PM, the surveyor and Staff G observed that the resident received oxygen at 3.5 liters per minute. Staff G agreed with this finding. Staff G was asked if it's important to have an order for oxygen, and she responded, yes. Staff G said that the doctor's order is necessary to know what the resident needs. Staff G called the doctor to follow up accordingly. Photographic evidence obtained. 4). A record review revealed that Resident #23 was admitted to the facility on [DATE]. Her diagnoses included CVA, Tracheostomy status, Dementia, Aphasia, and Acute and Chronic Respiratory Failure. A significant change assessment dated [DATE] showed that Resident #23 had severe cognitive impairment. Her care plan for tracheostomy related to impaired breathing mechanics included an intervention to provide oxygen per MD orders. The doctor's order for oxygen dated 01/20/25 stated oxygen 28%/2 liters via trach collar. During observations on 05/28/25 at 10:55 AM, 05/28/25 at 5:35 PM, and 05/29/25 at 9:35 AM, Resident #23 was in bed receiving oxygen from the concentrator that was set on 4 liters per minute. During an interview with Staff G on 05/29/25 at approximately 4:45 PM, the surveyor and Staff G went to Resident #23's room. The surveyor and the nurse observed the oxygen concentrator, and it was set on zero. Staff G acknowledgedobservation The nurse left the room to get another concentrator, and she returned quickly with another oxygen concentrator. The nurse set the replacement concentrator on 2 liters per minute, per the doctor's order. Photographic evidence obtained. 5). A record review revealed that Resident #66 was admitted to the facility on [DATE]. His diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Tracheostomy Status. Per the Minimum Data Set (MDS) significant change assessment dated [DATE], the resident rarely understood and was rarely understood. He had memory problems. Resident #66's had a care plan dated 05/10/23, which focused on his tracheostomy that was related to impaired breathing mechanics, surgery, and respiratory failure. The intervention listed was to administer respiratory treatments as ordered. A record review of the doctor's order for oxygen for Resident #66 was dated 01/20/25. It stated: for Trach - Encourage and assist resident with use of humidified oxygen 28%/2 liters via trach collar every shift for Trach O2 (oxygen). An observation during the initial resident screening, on 05/27/25 at 5:52 PM, revealed Resident #66 lying down in his bed. He received oxygen via the trach collar, and the oxygen concentrator was set on 3 liters per minute. Observations on 05/28/25 at 5:32 PM, and on 05/29/25 at 9:30 AM revealed the oxygen concentrator was set on 3 liters per minute. During an interview with Staff G on 05/29/25 at approximately 4:36 PM, the surveyor and Staff G went to Resident #66's room. The surveyor and the nurse observed the oxygen concentrator, and it was set on 3 liters per minute. Staff G agreed with this finding, and she corrected the oxygen setting to follow the doctor's order to be set at 2 liters per minute. Photographic evidence obtained. 6). A record review revealed that Resident #7 was admitted to the facility on [DATE], and he was readmitted to the facility on [DATE]. His diagnoses included Malignant Neoplasm of the Colon, Morbid (Severe) Obesity, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, (COPD) and Pleural Effusion. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE] was 14. This indicated that Resident #7 was cognitively intact. A record review of Resident #7's care plan for COPD last revised on 11/06/23 listed the intervention for oxygen settings to be administered per MD order. The Doctor's order per the electronic medical record was dated 01/08/2025. It said to administer oxygen continuous at 4 liters per minute via nasal canula for the medical diagnosis of shortness of breath. During observations on 05/28/25 at 10:11 AM, 05/28/25 at 6:32 PM, and on 05/29/25 at 9:47 AM Resident #7 was in bed while he received oxygen via nasal canula. The oxygen concentrator was set on 7 milliliters per minute. On 05/29/25 at 9:58 AM, Resident #7 requested that Staff B fill the water bottle that provided humidification via oxygen concentrator. A few minutes later, Staff B and the ADON entered the room and they explained the process while they added water into the bottle. On 05/29/25 at 11:41 AM, the oxygen concentrator was set to 7 liters per minute. The nurses who added water to the bottle on the oxygen concentrator failed to change the oxygen setting to 4 liters as per the Doctor's order. During an interview with Staff G on 05/29/25 at 4:52 PM, the surveyor and Staff G went to Resident #7's room. The surveyor and Staff G observed that the resident received oxygen at 7 liters per minute. Staff G agreed with this finding. The surveyor asked Resident #7 if he changed the setting on the oxygen concentrator and he responded that he never adjusted the setting for the oxygen. When the nurse approached the concentrator to lower the volume of the oxygen administered to 4 liters per milliliter as per the Doctor's order, Resident #7 adamantly protested. Resident #7 explained that it's been that high for a very long time. He said he needed it that high because without it that high he feared he would get pneumonia. He told the nurse to leave it at 7 milliliters per minute. Staff G said she would speak to the Doctor. Photographic evidence obtained.

Based on observations, record reviews, interviews, policy review, and review of professional standards of practice, the facility failed to provide the appropriate treatment for enteral feeding to decrease the risk of complications including weight loss and dehydration, for 1 of 7 sampled residents on enteral feeding (Resident #92). The findings included: The facility's policies and procedure for Nutrition/Hydration Status Maintenance revised on 03/02/19 stated that a resident who is fed by enteral means must receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. A review of current professional standards of practice to promote the safe provision of enteral feeding recommends that the components of the feeding be included in the doctor's order. These include the following: the kind of feeding and its caloric value, the volume of the formula, the mechanism of administration (e.g., gravity or pump), and the volume and frequency of water flushes. Nurse driven enteral nutrition protocols for volume-based feedings are recommended. The reference for these protocols is the American Society for Parenteral and Enteral Nutrition (ASPEN) 2016: ASPEN Safe Practices for Enteral Nutrition Therapy. Current professional standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as slow and progressive weight loss. These standards of practice were summarized from the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. A record review of Resident #92's medical record revealed that he was admitted to the facility on [DATE]. He was hospitalized on [DATE] and then readmitted to the facility on [DATE]. Resident #92's diagnoses included: Dysphagia following Cerebral Infarction, Dysphagia Oropharyngeal Phase, Gastrostomy Status, Muscle Wasting and Atrophy. Resident #92 was dependent on enteral feeding to provide adequate nutrition, and there was a doctor's order to provide nothing by mouth. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE] was 10. This indicated that Resident #92 had cognitive impairment. A record review of Resident #92's weights revealed that his admission weight on 03/12/25 was 129 lbs. His Body Mass Index, (BMI) was 18.5 which indicated he was underweight for his age. The Nutrition admission assessment dated [DATE] noted that Resident #92 appeared cachectic. On 04/04/25, his weight was 118 lbs. There were no weekly weights recorded following his admission. Resident #92's weight decreased 11 pounds in 23 days. On 05/19/25 Resident #92's weight was 114 lbs. His BMI was 16.4. This indicated that he was severely underweight. A record review of a dietary progress note written on 05/27/25 said Resident #92's weight loss 11.6% since admission, was likely related to recent hospitalization. The resident was hospitalized on [DATE] when he weighed 111.6 lbs (04/21/25). His weight decreased 17.4 pounds, 13.4% prior to being sent out to the hospital. A record review of Resident #92's enteral feeding orders dated 05/01/25 were: two times a day Jevity 1.5 or Isosource 1.5 80ml/hr x20 hours via G-tube. On 2pm, off 10am. A review of the enteral feeding order revealed that the total amount of the formula of Isosouce 1.5 to be administered daily was not included in the order. In addition, a 20-hour feeding every day could not be administered two times per day. An observation of the Kangaroo Omni pump, that was used to administer the enteral feeding formula for Resident #92 on 05/29/25 at 5:30 PM, revealed that the pump was active. The rate of administration of the Isosource 1.5 formula was 80 milliliters per hour. This agreed with the doctor's order. The display on the monitor showed that 272 milliliters was administered since the 2:00 PM start of the feeding. Photographic evidence showed the 1000 ml bag of Isosource and the monitor. The plastic bag of Isosource was dated 05/29/25 with a black marker. Since the doctor's order was for 80 milliliters to be administered for 20 hours, the total volume of the Isosource formula to be administered was 1600 milliliters (per day). At approximately 2:30 AM, the 1000 milliliters bag of formula should have been used up, except for time off for activies of daily living, and second bag of formula was needed to complete the balance of 600 milliliters to complete the volume of the feeding. An observation of the Kangaroo Omni pump, that was used to administer the enteral feeding formula for Resident #92 on 05/30/25 at 8:25 AM revealed that the pump was inactive. Observation of the 1000 ml bag of Isosource 1.5 revealed that approximately 150 milliliters was administered since the start of the feeding. Photographic evidence shows the bag of Isosource was dated 05/30/25, and approximately 850 milliliters of formula remained in the bag. An observation of the Kangaroo Omni pump, that was used to administer the enteral feeding formula for Resident #92 on 05/30/25 at 9:04 AM, revealed that the pump was inactive. An observation of the Kangaroo Omni pump, that was used to administer the enteral feeding formula for Resident #92 on 05/30/25 at 9:48 AM, revealed that the pump was inactive. Observation of the 1000 ml bag of Isosource 1.5 revealed that approximately 150 milliliters was administered since the start of the second bag (dated 05/30/25) needed to complete the desired volume of the feeding. Photographic evidence shows the bag of Isosource had approximately 850 milliliters of formula in the bag. A complete feeding of 1600 milliliters from 2 bags of 1000 milliliters each, would have left 600 milliliters remaining, not 850 milliliters. During this feeding, the resident received 250 milliliters less Isosource 1.5 than the order specified (80 milliliters for 20 hours). A record review of Resident #92's medical record progress notes revealed no notes explaining the reason for the inactive pump from 8:25 AM through 10:00 AM. The scheduled time of administration was to administer the formula from 2:00 PM until 10:00 AM. During an interview with Staff D, on 05/30/25 at 10:05 AM, the surveyor requested that she view the enteral feeding pump for Resident #92. The surveyor made the nurse aware that the pump was observed inactive since 8:25 AM. When the nurse was asked how she managed the resident's enteral feedings, she answered that they follow a schedule. When asked how she knew if he received enough formula, the nurse answered that they weigh him monthly. When asked how much Isosource 1.5 formula he required daily, she said she needs to see the order. The surveyor and the nurse went to the cart and the nurse said that the order was for 80 milliliters per hour times the time of feeding. The surveyor asked the nurse to calculate the amount of each feeding, and the nurse calculated 1600 milliliters per day. The volume of the Isosource 1.5 formula to be administered daily was not included in the order. The surveyor and the nurse went back into Resident #92's room. The surveyor pointed to the bag of formula that showed approximately 150 milliliters of formula was administered. The nurse agreed with this finding. The surveyor asked the nurse if she could look at the history of administration on the pump's display monitor to see how much formula was administered. The nurse was unaware that this was a function of the pump. The surveyor explained how to view the history for the past 3 days, and Staff D pressed the history button and entered 3 days. The display monitor revealed that Resident #92 received 2938 milliliters in the past 3 days. At 10:00 AM, with1600 milliliters ordered per day, Resident #92 should have received 4800 milliliters; 2938 milliliters was 61.2% of the amount of formula that was prescribed. The facility administered less nutrition than was ordered. This put Resident #92 at an increased risk for complications related to enteral feeding such as weight loss and dehydration.

Based on observations, record reviews, interviews, policy review, and review of professional standards of practice, the facility failed to maintain acceptable parameters of nutrition status for 1 of 4 residents investigated for nutrition (Resident #307). The findings included: A review of the facility's policy on Weight Management last revised on 03/02/19 stated that residents were to be weighed on a monthly basis unless otherwise ordered by the physician or deemed necessary by the dietitian and or the interdisciplinary team. Current professional standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as slow and progressive weight loss. A review of the policy on modified consistency diets provided by the Dietary Manager (DM) described the mechanical soft diet as a diet used for patients/residents with limited chewing ability. The foods included on the mechanical soft diet included ground moist meats, poultry and fish (without bones), canned fruits and vegetables, well-cooked soft vegetables, finely chopped fresh fruits and vegetables as tolerated, soft breads, and desserts. The pureed diet consisted of pureed, homogenous, and cohesive foods. Foods were described as pudding like, with no coarse textured foods allowed. A review of the medical records for Resident #307 revealed that he was admitted to the facility on [DATE]. His diagnoses included Malignant Neoplasm of Larynx, Unspecified Protein-Calorie Malnutrition, and Muscle Wasting. A wound assessment performed on 05/12/25 documented that Resident #307 had a stage 4 pressure ulcer to his coccyx. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed that Resident #307 had a Brief Interview for Mental Status score of 12. This indicated that he was cognitively intact. During an initial resident screening interview on 05/27/25 at 12:43 PM, Resident #307 expressed his concern about weight loss. He said he used to weigh 180 pounds and now he weighed close to 130 lbs. The resident was wearing a hospital gown while lying down in bed. Severe muscle wasting to his clavicles was observed. Resident #307 ate the dessert and drank the 4 ounce carton of Mighty shake, which accompanied his lunch meal. He didn't eat any of the food on the meal plate which contained sweet potato, green beans, pureed chicken/gravy. He didn't eat the peanut butter and jelly sandwich that was served on the side. The resident said he didn't want the peanut butter and jelly (PB&J) sandwich because he was tired of it. He said they sent a PB&J sandwich to him three times a day. Resident #307 said that he asked for a tuna fish sandwich once since he was admitted and he never received it. A record review revealed that Resident #307's diet order since 05/08/25 was a diet with No Added Salt, Mechanical Soft (L3), Pureed Meat (L1) texture, with Thin consistency Fluids. The diet order included directions to provide a soft sandwich with lunch/dinner meals, and whole milk with all meals. During an observation of the dinner meal on 05/28/25 at approximately 5:30 PM, the resident's tray of food included a PB&J sandwich on the side. The tray of food rested on the tray table next to the resident's bed. Resident #307 was asleep. During an observation of Resident 307's breakfast meal on 05/29/25 at 8:47 AM, the surveyor saw that the resident did not eat any of the foods from his breakfast tray. The breakfast foods served to Resident #307 did not comply with the mechanical soft diet with pureed meat. The kitchen sent 1 slice of well-done toast with a piece of cheese on it, 1 slice of well-done toast with scrambled eggs, and ground ham. The crust of the toast was cooked to a brown/black color. Photographic evidence obtained. The bread was not soft as described in the policy for the mechanical soft diet, and the ham should have been pureed, not ground. Resident #307 was on a diet with pureed meat. He was served 2% reduced fat milk instead of the whole milk specified to be served with all meals per Resident #307's diet order. The PB&J sandwich from the night before remained on the resident's tray table. The sandwich had a small insect flying in between the sandwich and the plastic wrap that covered it. The sandwich was dated 05/28/25. Photographic evidence obtained. Resident #307 placed the wrapped sandwich under the plastic dome covering his breakfast and he said he didn't want anything. The surveyor offered to let the kitchen know that he didn't eat his breakfast, and that he would appreciate a soft sandwich. Resident #307 was receptive. The surveyor went to the kitchen and requested a tuna sandwich from the cook. The cook said that there was no tuna available at that time, and that he had some ready-made sandwiches available in the refrigerator. He offered PB&J or turkey/cheese sandwiches. The surveyor requested a turkey /cheese sandwich to be delivered to the resident. The Regional Certified Dietary Manager delivered 2 turkey and cheese sandwiches to Resident #307, and per the resident, he ate 1 sandwich. An observation of the lunch meal on 05/29/25 at 12:57 PM revealed that Resident #307 received a PB&J sandwich with his meal, and then he threw the PB&J out into the garbage. Photographic evidence obtained. During an interview on 05/30/25 at 7:06 AM, the Dietary Manager and the Regional Certified Dietary Manager were shown a photo of the breakfast meal with the identifying meal ticket on the tray that was served to Resident #307 on Thursday, 05/29/25. They agreed that the resident was served ground meat instead of the required pureed meat as specified in his diet order. A record review of Resident #307's medical records revealed that his weight on 05/09/25 was 126.2 lbs. There were no other recorded weights for Resident #307 at the start of the survey. Resident #307's Body Mass Index (BMI) was 15.8. This indicated that he was severely underweight. On 05/29/25 the surveyor requested a current weight for Resident #307. The surveyor observed the nurse zero the scale. Then she assisted Resident #307 to stand-up on the platform scale. On 05/29/25 at 3:44 PM, his weight was 118.4 lbs. His weight decreased 7.8 lbs (6.1%) in 20 days. This weight loss was significant. A record review of Resident #307's Nutrition comprehensive risk screen revealed that it was initiated on 05/13/25, and it was signed (locked) on 05/27/25. Concerns noted in the assessment included the diagnosis Severe Protein-Calorie Malnutrition, the resident appeared cachectic, he was on a mechanical soft diet with puree meat, and he had 4 skin wounds. The assessment included a list of skin impairments: a Coccyx stage 4 wound, a left buttock deep tissue injury, a right buttock stage 4 wound, and a right heel deep tissue injury. A high calorie supplement was recommended and initiated on 05/09/25 to provide additional nutrition support. A protein supplement was recommended and initiated on 05/13/25. The Nutrition assessment included a plan to monitor weights weekly for four weeks. During an interview with the Diet Tech Registered (DTR), when asked how many days to do the nutrition assessment, she said that the assessment was input within 5 days of the resident's admission, and she believed it needed to be completed within 7 days. The assessment was signed 19 days after Resident #307 was admitted . The DTR said that the assessments that she wrote were in collaboration with the RD. The nutrition assessment summary note included the signature of the RD with a note that the documentation was reviewed and approved; and that the RD will continue to collaborate on resident care with the DTR. When the DTR was asked how she decided who should be weighed weekly for 4 weeks, the DTR said that it was our plan for this resident based on his plan of care. The DTR and the surveyor searched Resident #307's medical records for a nutrition care plan and there was no care plan in place for nutrition. The surveyor asked the DTR why the Resident was not weighed weekly, and she said she didn't know and that she will have to look into that. The DTR recommended increases in the high calorie supplement and the protein supplement on 05/30/25 following her review of Resident's weight loss since admission. Interventions for weight loss could have been made sooner if the resident was weighed weekly for four weeks post admission as per recommended professional standards of practice, and per the recommendation of the DTR and RD in the Nutrition Risk assessment.

Based on policy review, record review, interview and observation, the facility failed to identify and notify of a change in condition for 1 of 35 sampled residents (Resident #91) as evidenced by no documentation of a change in condition in the medical record. The findings included: Review of the policy titled Change in Condition Process revised 3/2/19, documented in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Situations requiring notification include: an accident involving the resident which result in injury, potential to require physician intervention. Upon identification of a change in condition in a resident the nurse will complete an evaluation of the resident's status and document findings on the Change in Condition in the residents' electronic medical record Review of the record revealed Resident #91 was admitted to the facility 11/12/24. The quarterly assessment dated [DATE], documented the resident had a Brief Interview for Mental Status score of 03, on a scale of 0 to 15, indicating severe cognitive impairment. During an observation on 05/27/25 at 12:03 PM, Resident #91 was sitting in the Dolphin dining area being assisted with eating lunch, scratches were observed on her nose. The scratches had dried blood and scabs. Resident's fingernails appeared short and well groomed. During a brief interview on 05/27/25 at 12:05 PM, when asked if she was aware of how Resident #91 received the scratches on her nose Staff C, Certified Nursing Assistant, stated No, she had them when I came, so I'm not sure. During a interview on 05/27/25 at 12:30 PM, when asked if she was aware of how Resident #91 got scratches on her nose Staff A, Licensed Practical Nurse (LPN), stated No, maybe she scratched or picked at her own nose. Review of a Skin assessment completed on 05/27/25, documented Resident #91 had no new skin areas and there was no documentation of the scratches to the nose. During an interview with the Unit Manger on 05/28/25 at 9:59 AM, when asked if she was aware of the scratches to Resident #91's nose, the Unit Manager stated Yes, and the family and doctor was notified. The family said the resident had a habit of scratching herself. When asked if she documented the conversation she had with the family or doctor, the Unit Manager, stated No. When asked if the behavior of Resident #91 scratching herself was care planned, the Unit Manager stated No. Further record review did not reveal any documentation of progress notes of communication to the family or doctor regarding Resident #91's change in condition. There was no change in condition evaluation completed for the scratches on Resident #91. During an interview on 05/29/25 at 9:50 AM, when asked are you aware of how Resident #91 got the scratches on her nose, the Activities Assistant stated No, when I came a few days ago, I asked the same thing, and no one seems to know. During an interview on 05/29/25 at 9:58 AM, when asked what is your process when a resident sustains a new injury or has a change in condition, the Unit Manager stated, I usually call the family and notify the doctor. When asked did you document that you notified the family or doctor for Resident #91, the Unit Manager stated No, the family was actually here in the facility, and they saw the scratches on her nose. When asked who was the family that was here to visit, the Unit Manger stated, It was two people I'm not sure who they were, you can look on her face sheet. When asked did you do a change in condition assessment for Resident #91, the Unit Manager stated No. When asked does the facility have a change in condition assessment in the computer, the Unit Manager stated Yes. When asked why a progress note or assessment was not completed, the Unit Manager stated I don't know. I should have completed one. During an interview on 05/29/25 at 11:01 AM, when asked what do you do when you notice a resident has a new skin tear or condition, Staff A, Licensed Practical Nurse (LPN) stated, I would ask the nurse I'm relieving what happened and if there is any documentation. When asked what if the incident happened on your shift, Staff A, LPN stated, I would have the wound care nurse see the resident and I will do an incident report. When asked what was done when you noticed the scratches on Resident # 91's nose, Staff A, LPN stated, I asked other nurses what happened, and they said she scratched herself. During a telephone conversation on 05/30/25 at 11:45 AM, with Resident #91's son, when asked when did you last visit with your mother at the facility where she resides, the son stated, I was there about a week and half ago. When asked if he had a conversation with any staff regarding the scratches on his mother's nose, the son stated No, I did not have a conversation with anyone about the scratches on my mother's nose. I don't recall her having any scratches on her nose. The only conversation I had was regarding where the remote was, because she was just lying in the bed staring at the ceiling. When asked if there was anyone with you when you visited your mother the son stated, My wife was with me, she is the one who helped me take care of my mother before we put her in the facility. When asked, did you discuss with any staff about your mother having a habit of scratching herself, the son stated No, I'm not aware of her having a habit of scratching.

Based on record review and interview the facility failed to ensure a PRN (as needed) psychotropic medication was addressed in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications, as evidenced by an anti-anxiety medication prescribed to Resident #36 did not have a discontinue date. The findings included: Review of the record revealed Resident #36 was admitted to the facility on [DATE]. The comprehensive assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 03 on a 0 to15 scale, indicating severe cognitive impairment. Review of the record revealed an order for Resident #36, dated 03/26/25, for Lorazepam 0.5 milligrams (mg) every four hours as needed for anxiety (excessive worry) without a date to discontinue. Review of the April and May Medication Administration Record (MAR) for Resident #36, revealed administration of Lorazepam 0.5mg by staff. A pharmacy consultation report dated 04/16/25 and 5/12/25 for Resident #36, recommended that Lorazepam (anti-anxiety medication) be tapered down and discontinued or documentation of a specific diagnosis and indication with a rationale for use be provided, because it had been prescribed for greater than 14 days. The pharmacy consultation reports for 04/16/25 or 5/12/25 were not addressed or signed by the physician. During an interview conducted on 05/29/25 at 4:30 PM with Staff S, the Consultant Pharmacist (CP), she stated she had been working with the facility for years. When asked about Resident #36, Staff S, the Consultant Pharmacist stated, In April the resident was on Lorazepam PRN (as needed) with no stop date and the recommendation was to taper the dose as necessary and add a stop date. In May, the pharmacy recommendation for Resident #36 documented the resident had a PRN order for anxiety medication, which has been in place for greater than 14 days without a stop date, Lorazepam 0.5mg take 1 tablet by mouth every 4 hours as needed for anxiety. During an interview on 05/30/25 at 10:29 AM, the DON stated he had been working at the facility for almost 10 years. When asked if Lorazepam is considered a psychotropic medication, the DON stated, Lorazepam is for anxiety. When asked do you agree that Lorazepam is a psychotropic, the DON stated Yes. When asked how often the physician comes in the facility to review the pharmacy consult recommendation, the DON stated Usually monthly, but I did not know that the family did not want Resident #36 to be seen by psych doctor. I called hospice yesterday, regarding the Lorazepam. When asked who wrote the order for the PRN Lorazepam, the DON stated, It was probably from the hospital. When asked why the physician didn't sign the pharmacy recommendation, the DON stated, The assigned doctor didn't sign the recommendation, because the resident should have been seen by the psych doctor, but the family did not want the resident to be seen. When asked why the recommendation from April by pharmacy to get a stop date for the Lorazepam was not followed through, the DON stated, I've already told you, because the family didn't want the psych doctor to see the resident so that's why I called hospice to review, and they will be in today.

3). Resident #56 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, Alcohol Dependence with Alcohol-Induced persisting Dementia, Unspecified Psychosis, Major Depressive Disorder, and other Persistent Mood Disorders. A record review of Minimum Data Set (MDS) under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 7 indicating Resident #56 had impaired cognitive function. Section N revealed a yes response to antidepressant. A review of physician orders dated 03/05/25 revealed Trazodone Hydrochloride 50 milligram (mg), to give 0.5 tablet by mouth, two times a day for depression. An additional review of orders revealed the behavior code monitoring every shift as needed for behavior. An additional order revealed Memantine Hydrochloride 5 mg, to give 2 tablets by mouth, two times a day for Dementia. A review of psychiatry progress notes dated 05/08/25 revealed the following This resident struggled with alcohol use resulting in negative consequences on his life. The resident also suffers from psychotic symptoms that are long and lasting. Additional notes revealed to continue Memantine for dementia, Trazodone to treat depression, and Valproic Acid for mood disorder. During a record review of Level I PASARR (Preadmission Screening and Resident Review) dated 08/26/24 , it was found incomplete with no pages 2 and 4. There was no Level II PASARR found on Resident #56's electronic medical record under miscellaneous records. In an interview with the Director of Social Services on 05/30/25 at 2:45 PM, when asked why Resident #56's PASARR Level I was incomplete, she responded, I had been out for a while and was not able to check . When asked if Level II PASARR is indicated for Resident #56, she responded, I agree, but I never found a time to request for one since I had no help, and just came back from being off. Based on policy review, record review, and interviews, the facility failed to ensure that PASRR (Preadmission Screening and Resident Review) Level 1 was documented completely for 2 of 35 sampled residents as evidenced by the PASRR Level 1 for Resident #56 and Resident #91 was not completely filled out, and failure to ensure that the PASRR Level 2 was completed for 1 of 35 sampled residents, as evidenced by the results of the PASRR Level 1 screening for Resident #86. The findings Included: Review of the Policy titled Coordination-Preadmission Screening and Resident Review (PASSR) Program revised 3/2/19, documented in part It Is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal regulations. The facility will coordinate assessments with the pre-admission screening and resident review practicable to avoid duplicative testing effort. Incorporating the recommendations from the PASRR level 2 determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care. 1). Record review revealed Resident #86 was admitted to the facility on [DATE]. The quarterly assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 07 on a 0 to 15 scale indicating severe cognitive impairment. Review of Resident #86 medical diagnosis indicated that she had a history of dementia (impairment of mental function that affect daily function) with mood disturbance, major depressive disorder (persistent feelings of sadness), and schizophrenia (mental health condition where people experience a disconnect from reality). Review of the record revealed a PASRR Level 1 dated, 09/20/24 for Resident #86 with documentation in section four of the PASRR Level 1 that indicated that a Level 2 PASRR should have been requested due to her diagnosis of Serious Mental Illness. Review of the care plan dated 3/25/25 for Resident #86 documented the resident has impaired cognitive function/dementia or impaired thought processes related to impaired decision making, diagnosis of Schizophrenia with a goal that the resident will maintain current level of cognitive function through the review date and the resident has a communication problem related to schizophrenia with a goal that the resident will be able to make basic needs known on a daily basis through the review date. Review of a progress note dated 05/16/25, by staff documented that the patient was observed to be highly agitated and upset. Very restless, pacing the hallway and yelling incoherently. Patient reports seeing people in the room with her and in the hallway. Review of physician orders dated 04/25/25, revealed that Resident #86 is prescribed Seroquel (antipsychotic) 50 MG, 1 tablet by mouth at bedtime related to Schizophrenia. A second order dated 05/19/25 revealed that Resident #86 is prescribed Trazodone (antidepressant) 50 MG, 1 tablet by mouth at bedtime for depression related to major depressive disorder. During an interview on 05/28/25 at 8:21 AM, when asked what is your process for making sure the PASRR are filled out accurately, the Social Worker stated Unfortunately a lot of the residents are coming in without the PASRR filled out properly, so I'm having the psychiatrist to evaluate them and then I redo the PASRR after they are seen. I am trying to catch up. I know a lot of them are triggering for needing a PASRR Level 2. When asked if she was aware of Resident #86, the Social Worker stated, I will go and review hers right now. 2). Record review revealed Resident #91 was admitted to the facility on [DATE]. The quarterly assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 03 on a 0 to 15 scale indicating severe cognitive impairment. Review of Resident #91 medical diagnosis indicated that she had a history of bipolar (episodes of mood swings) disorder, dementia (impairment of mental function that affect daily function) with other behavioral disturbance, anxiety (excessive worry). Further record review revealed a PASRR Level 1 dated, 10/11/24 for Resident #91 that was not accurately filled out. The document failed to indicate the resident's mental illness diagnosis but indicated that dementia was the resident's primary diagnosis. Review of the care plan dated 3/5/25 for Resident #91 documented that the resident had self-care performance deficit related to confusion, psychosis and required assistance with activities of daily living with a goal that the resident will maintain current level of function in activities of daily living through the review date. During an interview on 05/28/25 at 8:21 AM, when asked what is your process for making sure the PASRR are filled out accurately, the Social Worker stated Unfortunately a lot of the residents are coming in without the PASRR filled out properly, so I'm having the psychiatrist to evaluate them and then I redo the PASRR after they are seen. I am trying to catch up. I know a lot of them are triggering for needing a PASRR Level 2. When asked if she was aware of Resident #91, the Social Worker stated, I will go and review hers right now.

Based on record review and interview, the facility failed to provide the necessary care and interventions for a new admission as evidenced by failure to reconcile the hospital discharge instructions for medications and treatments in order to provide continuity of care, resulting in a severe decline in the resident's health, for 1 of 3 sampled residents (Resident #3). Findings included: Review of the clinical record for Resident #3 revealed he was admitted to the facility on [DATE] from a hospital after a motor vehicle accident on [DATE]. The resident suffered a [CONDITION(S)], and cervical, spinal, skull, humerus, clavicle, and rib fractures during the accident. He had a [CONDITION(S)] and required supplemental oxygen for breathing. He was an insulin dependent diabetic with a feeding tube in his stomach as he was unable to eat or drink by mouth since the accident. He was alert and confused but able to talk and had only [CONDITION(S)]. He was admitted to this facility, in part, to receive rehabilitation therapy. Based on his 5-Day MDS (Minimum Data Set) assessment, dated [DATE], he was not comatose and had adequate hearing and vision. He could speak and understand to some extent. The assessment documented diabetes, spinal cord trauma, fractures, depression, and anxiety. It also noted no pressure injury or ulcer at all. The resident received speech, physical, occupational, and respiratory therapies while in the facility. His BIMS (Brief Interview for Mental Status) score was 3 of 15 as he was disoriented to time and unable to recall words indicating short term memory issues and significant cognitive decline. The resident's clinical record included hospital discharge instructions for medications, oxygen, contact precautions, and other orders from the attending physician in charge of his care, which were sent with the resident to the facility. Partial discharge orders from the hospital included, but were not limited to: Resume tube feeding Glucerna (tube feeding for diabetics) 1.5 bolus 220 milliliters (ml) every four hours via feeding tube; Continue to wear the cervical collar at all times for three months; Soak 2x2 gauze with Thera-honey, place on non-adhesive [MEDICATION(S)] over wound on the posterior scalp daily; and continue use of Incentive Spirometer a minimum of ten times per hour for two months. Medications included: Insulin [MEDICATION(S)] (Novolog) subcutaneous before meals and at bedtime for sliding scale. Upon arrival to the facility on [DATE], the admission assessment for Resident #3 was completed at 12:46 PM. His blood sugar at that time was 156 mg/dl. The Patient Transfer Form (form 3008) completed by the transferring facility and sent with discharge paperwork was completed on [DATE]. Review of the form indicated the resident was on contact precautions for [CONDITION(S)] in the nose; his last insulin dose was received [DATE] at 10:00 AM, tube feeding instructions of Glucerna 1.5, 220 milliliters (ml) bolus every four hours; resident had a pressure ulcer at the base of his skull under his cervical collar; he was alert and disoriented but could follow simple instructions. He was also oxygen dependent through his [CONDITION(S)] requiring 6 liters per minute of humidified oxygen. Review of the facility's dietary order showed [MEDICATION(S)] 1.5 at 65 ml per hour for 20 hours was ordered, for total of 1300 mls in 24 hours to begin at 2:00 PM and off at 10:00 AM. Ordered on [DATE] at 11:00 PM by Staff I, the dietician. Review of the clinical recored revealed the resident did not have orders for any insulin from admission on [DATE] at 12:46 PM until [DATE] at 11:35 PM and the first dose was not administered until the morning of [DATE] at 6:30 AM when the resident's blood sugar was 323. This was 42 hours after his admission and only the second time his blood sugar was checked. Review of the orders for blood sugar monitoring and sliding scale insulin showed the [DATE] order called for checking blood sugar four times daily at 6:30 AM, 11:30 AM, 4:30 PM and 10:00 PM. The resident's MAR (medication administration record) showed on [DATE] at 11:30 AM, [DATE] at 10:00 PM and [DATE] at 6:30 AM those blood sugar checks were not completed; therefore, no insulin could have been given. On [DATE] at 4:00 PM, Staff D, a Registered Nurse (RN) wrote a progress note, stating: Critical lab result received and reported to Physician's Assistant. Glucose noted 501. New orders received for [MEDICATION(S)] 10 units twice daily and give fast acting insulin, 15 units STAT, recheck in an hour and if blood sugar is >400 give another 10 units and recheck in an hour. Staff D entered an incomplete order of Inject 15 units subcutaneously one time only for abnormal lab for 1 Day at 4:15 PM. The 15 units of Insulin [MEDICATION(S)] (fast acting) Solution was documented as being given almost two hours later at 5:53 PM and a blood sugar of 503 was documented by Staff J, a Registered Nurse (RN) at 5:55 PM. There is no documentation or evidence showing the order was carried out as written in the progress notes. There is no evidence of the additional 10 units being given or any additional blood sugar checks. The next documented blood sugar check was by Staff J on [DATE] at 10:13 PM and it was 387. During an interview with Staff D on [DATE] at 1:35 PM, she said she verbalized the order with instructions to the oncoming evening supervisor (Staff J) before she left the building. The surveyor attempted to interview Staff J on [DATE] however she was not working that day. A voicemail message requesting a call back was left at the number provided by the facility on [DATE] at 4:20 PM and no call back had been received. The only chart entry by the facility dietician, Staff I, on [DATE] at 05:18 AM was incomplete but notes blood sugar of 390, weight of 247 pounds, and RD (Registered Dietician) to assess upon return to facility: admitted ,d+[DATE], discharged to hospital ,d+[DATE] will follow up as needed. The note was created on [DATE] at 4:24 AM as a late entry six days after his discharge to the hospital. On [DATE] at 3:14 PM during an interview with Staff I, the dietician, she said she covers several buildings, and she is in this facility ,d+[DATE] times a week. She was asked to explain their tube feeding and how she determines who gets which type of tube feeding formula. She said if they have been admitted she would review their orders or if they don't have any orders, she will see what the discharge instructions say. They usually have an established one (tube feed) to see if it meets their needs. She looks at height and weight and if it is an appropriate formula, she will agree or change it. She would then continuously review to make sure it is correct. She said she doesn't have to see a resident; she will go on what information she has. If the resident is not in the building yet she can log on to the system and see documentation before she orders the tube feeding. She stated, We typically have about three formulas that we use in the building. Diabetasource or [MEDICATION(S)] and maybe a renal (kidney) formula. [MEDICATION(S)] is only for diabetics whose blood sugar is controlled or those that have higher energy needs like if they are underweight or have a lot of wounds. Her explanation of a well-controlled diabetic would be one with a hemoglobin A1C around 5.8, like they don't really have it (diabetes). She then logged on to the in-house system and reviewed Resident #3's notes to determine why he was given [MEDICATION(S)] and not Diabetasource. She stated, After reviewing all I can say is I don't know what info I had at that time. She could not explain why she ordered [MEDICATION(S)] instead of Diabetasource for this diabetic resident who was 5' 6 and 247 pounds. On [DATE] at 2:38 PM during an interview with Staff C, Resident #3's clinical record, photo, and orders were reviewed. She was shown the order change to discontinue the [MEDICATION(S)] tube feed to Diabetasource tube feed on ,d+[DATE], four days after admission. She said she didn't remember the resident but said if he was diabetic, that's why it was changed. His blood sugar was probably sky high and it got changed to Diabetasource so his blood sugar could be controlled. She stated, We carry two of them, [MEDICATION(S)] if not diabetic and Diabetasource if they are diabetic. All tube feedings are off at 10am and [new hung] up at 2pm. If the tube feeding was off at ten and the blood sugar was in the 300s then something wasn't right. That's probably why I called the doctor. The resident's blood sugars were documented as follows: On [DATE] at 4:31 PM = 156. On [DATE] at 06:00 AM = 323 and 4:30 PM = 390. On [DATE] at 1:14 PM = 161, 5:55 PM = 503, and 10:13 PM = 387. On [DATE] at 4:17 AM = 389; 1:54 PM = 364, 4:30 PM = 359 and 10:00 PM = 215. On [DATE] at 7:36 AM = 256 and 11:44 AM = 346; the next blood sugar checks were during the family visit after 4:30 PM, which would only register high on the blood glucose monitor. According to the User Instruction Manual provided by Staff A, the Assistant Director of Nursing (ADON) on [DATE], this indicates the blood sugar is over 600. The regional nurse confirmed these are the same meters that were being used in March of this year (2021). During review of the resident's orders, an order to check his vital signs every shift was noted. It was ordered on admission to start [DATE] at 3:00 PM. Review of the resident's TAR (treatment administration record) showed his vital signs had not been assessed for six of the sixteen shifts he was in the facility. Of significant importance is that his vital signs were not taken at all for 34 hours, between [DATE] at 8:00 AM and the next day [DATE] just before 6:00 PM. At that time, his blood pressure was lower, he had a fever of 99.5 degrees, a heart rate of 107 beats per minute and his oxygen level was down to 95%. At the same time, his blood sugar was 503. The shift in vital signs and elevated blood sugar may have been an indication of [CONDITION(S)], a severe infection affecting the whole body. There is only documentation of physician notification of the high blood sugar (503), not the change in heart rate, fever, or oxygen level. Potentially, the infection would have been detected earlier had his vital signs been assessed as ordered and the results were reported to the physician in a timely manner. On [DATE] at 9:33 AM there was a late entry note charted for the previous day as effective on [DATE] at 9:03 AM: Pt has low grade fever today and is [CONDITION(S)]. Reviewed hospital records. Pt was on [MEDICATION(S)] (long-acting insulin) bid (twice daily) in hospital. Will add [MEDICATION(S)] (long-acting insulin) bid (twice daily). Will order CXR (chest Xray) for fever. Due to the delay, the chest Xray did not get ordered until [DATE] at 9:33 AM, a day later. Earlier that morning, at 5:51 AM, RT (Respiratory Therapy) began documenting removal of thick yellow secretions from the resident's airway during suctioning. The chest Xray was completed on [DATE] at 6:50 PM and the results reported to the facility the same evening at 7:03 PM. Xray results revealed Small patchy densities at the lung bases could be secondary to atelectasis, early stage of pneumonia (non-consolidated) or [CONDITION(S)]. On [DATE] at 11:30 PM, a progress note showed notification to the physician's answering service regarding the chest Xray results. Nursing was awaiting a return call from the doctor and the oncoming nurse was notified. There is no evidence/documentation of any return call from the physician, follow up by the nursing staff or orders to follow regarding the chest Xray results that showed a worsening respiratory condition. There was also no documented evidence of incentive spirometer use as ordered on discharge from the hospital. The lungs were a potential cause of infection/[CONDITION(S)]. Additionally, the 3008-form received from the hospital noted a pressure ulcer at the base of his skull under the cervical collar and wound care orders were on the discharge paperwork. There is no facility documentation acknowledging this wound or any wound care that was done since his admission. This also may have been a source of infection. This resident had also been on contact precautions for [CONDITION(S)] in his nose. There was no documentation in the record to indicate any acknowledgement of this infection control issue for the resident or the facility. No isolation or contact precautions had been followed at any time since his admission. Along with elevated blood sugar, this also may have been a source of infection. On [DATE] at 3:11 PM, Staff L made a late entry progress note for [DATE] at 5:50 PM: At 1520 (3:20 PM) the writer made the routine round and the patient was in bed resting. 1630 (4:30 PM) patient's wife and soon [son] arrived in the facility to visit, the patient was seen by the family. Patient's blood sugar was high and patient was weak. Upon patient's family request to send patient to hospital for monitoring sugar level, 911 was called by the nursing supervisor and paperwork prepared. 911 arrived at 1725 (5:25 PM) and patient left at 1730 (5:30 PM). The DON made aware and Primary physician. On [DATE] at 1:20 PM, Staff L, the nurse assigned to care for him on [DATE], was interviewed by telephone. She said he was awake during rounds earlier when she started her shift at 3:00 PM. He was talking in his room. We put him in the Geri-chair with the Hoyer Lift and pushed him out [front] for his visit with family. When she got him outside, he wasn't awake, and it happened really fast (that he became less responsive) so she checked his blood sugar. She confirmed the glucometer said high and the resident's son told her to send him to the hospital. She stated, They were talking to him, but he wasn't answering, and his eyes were open. She confirmed they have the same glucometers then as they have now. She said they checked the blood sugar one time and called 911. On [DATE] at 5:34 PM, Staff K charted: Patient is seen by the family, patient's wife and son. Patient's sugar was high and patient was weak. Upon patient's family request to send patient to hospital for monitoring sugar level. Primary nurse is aware. 911 is called by the writer and paper work prepared. 911 arrived at 1725 and patient left at 1730. Primary nurse will contact the on call MD and ER nurse for report. On [DATE] at 2:05 PM Staff K, a Registered Nurse who was the weekend supervisor on [DATE], was interviewed by phone. She said she helped to bring this resident to the front of the building to visit with his family. She said he wasn't unresponsive but he was really weak and sleepy. When she talked to him, he would close his eyes and maybe answer a little bit. She said she told the staff nurse assigned to care for him to check his blood sugar at the time of the visit. She said the glucose meter just said, high, so they sent him to hospital. Review of the fire rescue records from [DATE] after their arrival at the facility, showed the initial vitals assessment at 5:23 PM as: unresponsive, heart rate 125, respiratory rate 16, oxygen level of 97% on supplemental oxygen, blood pressure of ,d+[DATE], and a fever of 104 degrees. Review of the emergency room records from [DATE] showed the blood sugar at 6:08 PM was 737 (High), and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident coded in the ER and was pronounced deceased at 10:40 PM. On [DATE] at 3:39 PM, the findings were reviewed with the Regional Vice President of Operations and the Regional Nurse, at which time they acknowledged the findings. The following is a definition of [CONDITION(S)] on the CDC.gov website: [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening medical emergency. [CONDITION(S)] happens when an infection you already have triggers a chain reaction throughout your body. Without timely treatment, [CONDITION(S)] can rapidly lead to tissue damage, organ failure, and death. Almost any type of infection can lead to [CONDITION(S)]. Infections that lead to [CONDITION(S)] most often start in the lung, urinary tract, skin, or gastrointestinal tract.