Every finding on record at Avante at Leesburg, Inc

Based on observation, interview, and record review, the facility failed to maintain food service equipment and food storage areas in a clean and sanitary condition by failing to ensure the kitchen ice machine and 2 of 2 nourishment room refrigerators and freezers were maintained free of debris and contamination. During an observation of the main kitchen on 07/19/2026 at 9:17 AM, the ice machine was observed with a significant amount of black substance and brown colored substance on the dispensing spout where ice falls into the storage bin. (Photographic evidence was obtained.)During observations of the facility nourishment rooms on 07/19/2026, the refrigerators and freezers in both rooms were observed to contain food debris and spilled liquid on interior surfaces.On 07/19/2026 at 10:13 AM, the Administrator and Director of Nursing confirmed the condition of the ice machine.During an interview on 07/21/2026 at 9:33 AM, the Dietary Manager stated that, based on the photographs taken on 07/19/2026, he could not say the ice machine had been cleaned properly on 07/17/2026 and acknowledged it could have been cleaned better. He stated maintenance staff were responsible for cleaning the ice machine and confirmed they were expected to follow the facility's Ice Machine Cleaning and Maintenance - Weekly procedure.During an interview on 07/21/2026 at 2:35 PM, the Maintenance Director stated he received the task to clean the ice machine but believed the kitchen staff were responsible for cleaning of the machine.Review of a [Third Party Food Service Company] invoice dated 07/20/2026 revealed the technician documented, The kitchen ice machine was in poor condition, heavily impacted with dirt and debris, preventing completion of preventive maintenance in its existing condition.Review of the facility's policy Ice Machine Cleaning and Maintenance - Weekly, last reviewed on 1/28/26 instructed staff to wipe the exterior, underside of the ice maker, dispensing spout, and ice bin with a clean cloth and appropriate cleaner. Review of the Ice Machine Cleaning and Maintenance - Quarterly procedure instructed staff to remove all ice, clean and sanitize the ice-making components, and scrub the interior of the ice bin, spouts, drain board, and surrounding components before rinsing with warm water.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 7 residents reviewed (Residents #2 and #73). Findings include: 1.) Review of Resident #2's physician orders dated 05/30/2026 revealed orders for Keppra Solution 100 mg/mL, 10 mL via G-tube (gastrostomy tube) twice daily, and Lacosamide Oral Solution 10 mg/mL, 10 mL via G-tube twice daily, for seizure disorder. Review of Resident #2's physician orders dated 05/31/2026 revealed an order to maintain an indwelling urinary catheter for urinary retention and a Stage 3 sacral wound. Review of Resident #2's physician orders dated 06/08/2026 revealed an order to reinsert an 18 French Foley catheter as needed for obstructive uropathy. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section I (Active Diagnoses) did not identify obstructive uropathy or seizure disorder as active diagnoses. During an interview on 7/21/2026 at 11:38 AM with the MDS Register Nurse Lead stated, [Resident #2's name] does have a diagnosis of seizure disorder and obstructive uropathy, the MDS section will need to be corrected. 2.) Review of Resident #73's physician order dated 6/2/2026 read, COPD [Chronic Obstructive Pulmonary Disease] /Asthma: HOB [head of bed] elevated, r/t SOB [related to shortness of breath] when lying flat or avoid lying flat due to SOB. every shift. Review of Resident #73's physician order dated 6/2/2026 read, Oxygen continuous at 3L [liters] via NC [nasal cannula] Medical DX [Diagnosis]: COPD every shift related to Acute Respiratory Failure, Unspecified whether with hypoxia or hypercapnia. Review of Resident #73's Minimum Data Set (MDS) titled Quarterly dated 7/5/2026 Section I Active Diagnoses did not document Asthma (COPD) as an active diagnosis. During an interview on 7/21/2026 at 11:38 AM with the MDS Register Nurse Lead stated, [Resident #73's name] does have a diagnosis of COPD, the MDS section will need to be corrected. Review of the facility policy and procedure tiled Resident Assessment Instrument (RAI) with a last review date of 1/28/2026 read, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. The assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development.

Based on record review and interview, the facility failed to ensure residents with newly evident or known diagnosis of serious mental disorders have a coordinated Preadmission Screening and Resident Review (PASRR) for 3 of 7 residents, Residents #4, #11, #36 reviewed for PASRR. Findings include: Review of Resident #11's admission record documented an initial admission date of 7/26/22 and a most recent admission date of 3/6/26 with diagnosis of Specified Persistent Mood Disorders dated 4/22/2025. Review of Resident #11's Preadmission Screening Resident Review (PASRR) dated 7/24/2023 did not have a diagnosis of Specified Persistent Mood Disorders documented. Review of Resident #11's Minimum Data Set Section I notes dated 6/1/2026 documented DX [diagnosis]: F34.89 Other Specified Persistent Mood Disorders. Review Of Resident #11's Palliative Care Note dated 3/12/2026 documented [diagnose]: Other Specified Persistent Mood Disorders. Review of Residents #11's Medication Administration Record dated 7/2026 documented: trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Depression -Start Date 07/05/2026. During an interview on 7/21/2026 at 10:25 AM, Director of Nursing stated, Any new diagnosis should be updated to the PASRR, and it is not the policy of the facility to not update PASRR's. 2.) Review of Resident #4's admission record, date of original admission 7/25/2019, revealed Resident #4 had been assigned a diagnosis of adjustment disorder with anxiety on 1/9/2024. Review of Resident #4's preadmission screening and resident review (PASRR), completed 5/12/2025, showed anxiety disorder, bipolar disorder, depressive disorder and insomnia entered as MI [mental illness] or suspected MI [mental illness] in Section I: PASRR Screen Decision-Making. Resident #4's PASRR had not been updated to include her diagnosis of adjustment disorder with anxiety. During an interview on 7/21/2026 at 11:08 AM, the Director of Nursing stated, Resident's Level I PASRRs should include all residents' mental health diagnoses. She stated she did not know how Resident #4's diagnosis of adjustment disorder with anxiety was overlooked. 3.) Review of Resident #36's admission record, date of original admission 3/5/2026, revealed Resident #36 had been assigned a diagnosis of Brief Psychotic Disorder or 3/5/2026. Review of Resident #36's preadmission screening and resident review (PASRR), completed 3/4/2026, showed schizophrenia and mood disorder entered as MI [mental illness] or suspected MI [mental illness] in Section I: PASRR Screen Decision-Making. Resident #36's PASRR had not been updated to include his diagnosis of Brief Psychotic Disorder following his admission to the facility. During an interview on 7/21/2026 at 11:08 AM, the Director of Nursing agreed residents' Level I PASRRs should include all residents' mental health diagnoses. She stated she did not know how Resident #36's diagnosis of brief psychotic disorder was overlooked. Review of the policy titled Coordination Pre-admission Screening and Resident Review (PASRR) Program, last reviewed 1/28/2026, read 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.

Based on record review and interview, the facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) prior to admission for a resident's serious mental disorder for 1 of 7 residents, Resident #107, reviewed for PASRR.Findings include:Review of Resident #107's admission record resident was admitted on [DATE] with a diagnosis including but not limited to depression [onset date 5/5/2026].Review of Resident #107's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASSR) dated 5/1/2026 did not document depressive disorder.Review of Resident #107's Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 read, Chief Complaint: Depression.During an interview on 7/22/2026 at 8:24 AM the Director of Nursing stated, [Resident #107's name] PASSR upon admission was not corrected; it should have been reviewed, and depressive disorder should have been included.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents, Resident #3 reviewed for diabetes management. Findings include:Review of Resident #3's admission record revealed an admission date of 04/10/26 with diagnoses including but not limited to Diabetes Mellitus Type II.Review of Resident #3's care plan dated 04/11/26 did not contain a focus area for Diabetes Mellitus Type II.During an interview on 07/21/26 at 02:27 PM, the MDS Coordinator stated that diabetes should have been added to Resident #3's care plan and needed to be corrected.During an interview on 07/21/26 at 03:22 PM, the Director of Nursing stated that residents with a diagnosis of Diabetes Mellitus Type II should be included in that resident's care plan. She stated that Resident #3's care plan should have been changed to include a focus for diabetes.Review of the facility's Comprehensive Care Plans policy dated 10/19/22 read, The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate.

Based on observation, interview and record review the facility failed to administered pain medication based on parameters for 1 of 6 residents, Resident #107, reviewed for medication management and failed to provide dressing changes for 1 of 3 residents, Resident #3, reviewed for skin conditions. Findings include: Review of Resident #107's physician order dated 5/8/2026 read, Tylenol Oral Tablet 325 MG [milligram] (Acetaminophen) give 2 tablet by mouth every 6 hours as needed for pain pain scale 1-4 Do Not Exceed 3000mg/24hr [hour]. Review of Resident #107's physician order dated 6/1/2026 read, Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) *Controlled Drug* give 1 tablet by mouth every 6 hours as needed for nonacute pain. Hold for Lethargy pain scale 6-10 Do not exceed 3000mg/24 hr. Review of Resident #107's Medication Administration Record for the Month of July 2026 Percocet 5-325MG was administered on 7/13/2026 at 0900 [9:00AM] pain level of 4. Review of Resident #107's Medication Administration Record for the Month of July 2026 Tylenol 325MG was given on 7/1/2026 at 1028 [10:28 AM] with a pain level of 5 and on 7/17/2026 at 1337 [1:37PM] with a pain level of 5. Review of Resident #107's Medication Administration Record for the Month of June 2026 Percocet 5-325MG was administered on 6/4/2026 at 1858 [6:58 PM] with a pain level of 5, on 6/13/2026 at 1137 [11:37AM] pain level of 0, 6/15/2026 at 1338 [1:38PM] pain level of 5, on 6/18/2026 at 0130 [1:30 AM] with a pain level 4, and on 6/27/2026 at 0348 [3:48AM] with a pain level 5. Review of Resident #107's Medication Administration Record for the Month of June 2026 Tylenol 325MG was given on 6/14/2026 at 0025 [12:25 AM] with a pain level of 9. Review of Resident #107's Medication Administration Record for the Month of May 2026 for Tylenol 325MG was given on 5/24/2026 at 2100 [9:00 PM] with a pain level of 7. During an interview on 7/21/2026 at 2:15 PM Staff D Licensed Practical Nurse (LPN), I cannot recall. A check mark means that the medication was given. Normally, I read the order and follow the parameters. During an interview on 7/21/2026 at 2:55 PM Staff E LPN stated, I don't recall why the medication was given out of parameters. During an interview on 7/21/2026 at 4:45 PM Staff F Registered Nurse (RN), stated, I think that [Resident #107's name] was telling me 4, 4.5 or 5 and I did not know which one to document, and I think I put a 5. I don't remember. If he has greater pain he studders or guards himself. During an interview on 7/22/2026 at 8:24 AM with the Director of Nursing stated, Staff are to follow physician orders unless it is a request from the resident, then the nurse should call the provider and get clarification. This should be documented in the record. If the resident has no preference, then orders should be followed. Review of the facility policy and procedure titled Medication Administration with a last review date 1/28/2026 read, Policy: Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 2.) During an observation on 07/21/26 at 09:05 AM, Resident #3 was observed in his bedroom, sitting upright in bed. There was a wound covered by a dressing dated 07/17 on his right forearm. [photographic evidence obtained]. During an interview on 07/21/26 at 09:08 AM, Resident #3 stated that his dressing was not changed yesterday. Review of Resident #3's physician's orders revealed an order dated 07/02/26 that read skin tear (2) to right lower arm. Cleanse with NS [normal saline], pat dry. Apply xeroform and cover with DSD [dry sterile dressing] every three days and prn if becomes soiled or dislodged until resolved; every evening shift every 3 day(s) for skin integrity AND as needed for skin integrity. Review of Resident #3's Treatment Administration Records for 07/20/26 revealed the order, skin tear (2) to right lower arm. Cleanse with NS [normal saline], pat dry. Apply xeroform and cover with DSD [dry sterile dressing] every three days and prn if becomes soiled or dislodged until resolved; every evening shift every 3 day(s) for skin integrity AND as needed for skin integrity, was not documented as completed on 07/20/26. During an interview on 07/21/26 at 03:03 PM, Staff I, Licensed Practical Nurse [LPN], confirmed that Resident #3's dressing was not changed as ordered. During an interview on 07/21/26 at 03:05 PM, Staff I, LPN, confirmed that the Treatment Administration Record for 07/20/26 indicated that the dressing change was not completed as ordered. She stated that all nurses are instructed to check off orders as scheduled when they are complete, and if the nurse can't complete a scheduled order, there must be a note. During an interview on 07/21/26 at 03:43 PM, the Director of Nursing stated that Resident #3's dressing was not changed on 07/20/26 as ordered. Review of the facility's policy titled, Clean Dressing Change, last reviewed on 1/28/26 shows it read, Verify and review physician's order for procedure; apply clean dressing as ordered and ensure the dressing is dated; document the completion of the dressing change on the treatment record.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 21 residents currently residing in the facility's Memory Care Unit. During an observation on 07/19/26 at 09:35 AM, an uncapped safety razor was observed at Resident #43's bedside on the nightstand [photographic evidence obtained]. Resident #43 resides in the Memory Care Unit, and the bedroom door was not secure from the outside.During an interview on 07/19/26 11:38 AM, Staff F, Registered Nurse, stated that residents should not keep safety razors in their rooms. [Resident #43's Name] is supervised while shaving because he has the functional ability to do so, but it must have been left with him. She stated, That's not supposed to be there.During an interview on 07/21/26 at 03:22 PM, the Director of Nursing said, I wouldn't expect there to be safety razors on the floor, that would be a safety concern. She explained that CNAs [Certified Nursing Assistants] are in charge of shaving the residents, and the CNA responsible for shaving Resident #43 should have removed the razor when finished.A policy on accident hazards was requested on 07/21/26 at 04:35 PM and was not provided by the facility.

Based on observation, interview, and record review the facility failed to provide oxygen at the prescribed rate for 1 Resident (Resident #33) and store oxygen supplies appropriately when not in use for 3 of 6 residents, Residents #2, #28, and #33, reviewed for respiratory services. Findings include: During an observation on 07/19/2026 at 9:35 AM Resident #28 was lying in bed resting calmly, with eyes closed. Resident #28's oxygen concentrator was off and the nasal cannula not bagged. The bag was dated 7/12 [2026]. [photographic evidence obtained] During an observation on 7/20/2026 at 8:01 AM Resident #28 was lying in bed. The oxygen concentrator was not in use. The nasal cannula dated 7/12 was not bagged. During an interview on 7/20/2026 at 8:01 AM Resident #28 stated, I am supposed to use oxygen at night. Review of Resident #28's physician order dated 6/30/2026 read, 6/30/2026 Oxygen continuous at [Blank] liters/ min via [Blank].Medical DX: [Blank]. every shift. Review of Resident #28's physician order dated 6/30/2026 read, Change Oxygen Set Up And Bag Weekly And As Needed every night shift every Sat. (Saturday) Place in labeled O2 bag and tie to handle of O2 concentrator. During an interview on 7/20/2026 at 12:45 PM Staff B, Licensed Practical Nurse (LPN) stated tubing should be bagged when not in use. [Resident #28's Name] oxygen order is not completed. It reads continuous, but there is no flow rate. I would have to find out if it is prn or continuous. During an interview on 7/20/2026 at 12:50 PM Staff B, LPN confirmed Resident #28's oxygen tubing was not bagged, the bag was dated 7/12 and the oxygen was off at time of interview. Staff B, LPN, stated, The bag is no good, it should have been changed with the tubing. She [Resident #28] states she uses at nighttime only. During an interview on 7/21/2026 at approximately at 11:00 AM, the Director of Nursing stated, Oxygen tubing should be bagged when not in use. The tubing is changed once a week usually during the night shift on Saturday from 11:00PM to 7:00 AM. Order should include the accurate documentation of how many liters and if it is as needed or continuous. The nurses should have called to clarify the order. 2.) During an observation on 7/22/2026 at 5:58 AM with Staff C, LPN, Resident #33 was lying in bed. Oxygen was running at 4 liters via tracheostomy mask, Staff C readjusted the oxygen concentrator to 5 liters. During an interview on 7/22/2026 at 5:58 AM Staff C, LPN confirmed Resident #33's oxygen was running at 4 liters per minute and stated, [Resident #33's Name]'s oxygen is supposed to be at 5 liters. Review of Resident #33's physician order dated 7/20/2026 read, Continuos [sic] O2 [oxygen] at 5L/min [liters per minute]. via trach [tracheostomy]. During an interview on 7/22/2026 at 6:30 AM with the Director of Nursing stated, The nurses should check the oxygen flow rate every shift to make sure it is running at the prescribe rate. Review of the facility policy and procedure titled Oxygen Administration with a last review date 1/28/2026 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 3.) During an observation on 07/20/2026 at 8:49 AM, Resident #2's nebulizer cup and tubing was observed lying directly on the resident's bed following a respiratory treatment. The nebulizer equipment was not stored in a clean, protected manner and remained in contact with the resident's bed linens.

Based on interview and record review the facility failed to collect laboratory exams ordered by the physician for 1 of 2 residents, Resident #15 reviewed for laboratory services. Findings include:Review of Resident #15 physician's order dated 06/17/26 read, BMP in 10 days.Review of Resident #15 results did not document lab results for 06/27/26.Review of Resident #15's Treatment Administration Record for June 2026 revealed that labs were not drawn according to the physician's order dated 06/17/26 that read, BMP in 10 days.During an interview on 07/21/26 at 10:35 AM, Staff I, Licensed Practical Nurse (LPN), explained that when labs are ordered, the receiving nurse is supposed to enter the order in the facility's online system and set the appropriate date to be completed. She stated that the evening nurse would be responsible for collecting Resident #15's lab sample.During an interview on 07/21/26 at 03:43 PM, the Director of Nursing explained that the physician's order dated 06/17/26 that read, BMP in 10 days, was not entered into the system with the correct collection date. She stated that the lab sample was not collected as ordered.Review of the facility's Diagnostic Services policy dated 03/02/19 read, it is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that the results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource.

Based on record review and interview, the facility failed to maintain complete and accurate clinical records for 13 (Resident #2, 6, 11, 17, 18, 25, 29, 39, 45, 56, 59, 66 and 104) out of 19 Residents, reviewed for medication orders and administration documentation. Findings include: 1.) Review of the Resident #2's physician's orders revealed an order dated 06/01/2026 to flush the resident's G-tube with 340 mL of water four times daily while tube feeding was infusing for a total of 1,360 mL of free water daily. Review of Resident #2's physician's orders dated 06/03/2026 revealed an additional order to administer 235 mL of water via G-tube every four hours for hydration. Review of the July 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed nursing staff documented administration of both active free-water flush orders. Review of the Registered Dietitian's comprehensive nutrition evaluation dated 06/01/2026 recommended administration of 340 mL water flushes four times daily for a total of 1,360 mL of free water each day. During an interview on 07/21/2026 at 9:47 AM, the Registered Dietitian reviewed the physician's orders and acknowledged two active free-water flush orders were present in the resident's medical record. During an interview on 07/22/2026 at 8:50 AM, the Director of Nursing (DON) stated the expectation was for nursing staff to obtain clarification when conflicting physician orders were identified to ensure the resident received the correct free-water flush regimen and the medical record accurately reflected the intended treatment. 2) During an observation on 7/21/2026 at 10:15 AM Staff G Licensed Practical Nurse (LPN) was preparing medication for Resident #29. Staff G stated Resident #29 had refused Novolog insulin that was scheduled to be administered at 8:00AM. Staff G prepared medication for Resident #29 and administered the medications. Staff G checked Resident #29 blood sugar which was 341. Staff G returned to the computer verified she was supposed to give 6 units of insulin aspart and administered the insulin subcutaneously. Staff G return to the computer and checked off all the medications for Resident #29. Review of Resident #29's Medication Administration Record for the month of July 2026 documented Novolog solution 100 UNIT/ML (Insulin Aspart) was administered at 0800 [8:00 AM] on 7/21/2026. Review of Resident #29's Medication Administration Record for the month of July 2026 documented on 7/21/2026 Insulin Aspart at 11:30 AM blood sugar level was 308. During an interview on 7/22/2026 at 11:24 AM, the Director of Nursing stated, I spoke to [Staff G's Name] and she does not know why the blood sugar shows as 308 she thinks she might have forgotten to hit save. For the Novolog it was a documentation mistake. [Resident #29's name] refused, but it self-populated what previously had been saved. During an observation on 7/21/2026 beginning at 10:15 AM of Staff G's computer screen, the electronic medication administration record had a total of 11 residents [Resident #6, #11, #17, #18, #39, #25, #46, #56, #59, #66, #104] names highlighted in red. During an interview on 7/21/2026 at approximately 10:45 AM with Staff G LPN stated, Residents in red mean that medications would still be pending. I already gave them all their medications, but I did not check them off. I give them (Residents) the medication and then will go back into the system later and check off I gave them the medication. During an observation on 7/21/2026 at 10:55 AM the Director of Nursing confirmed a total of 11 residents were showing in the system in red color as if medications had not been given. During an interview on 7/21/2026 at 10:55 AM, the Director of Nursing stated, I would expect staff to check off medication as given when the medication is given and completed. During an interview on 7/21/2026 at 12:49 PM with Resident #11 stated, The nurse gave me my medication early this morning. During an interview on 7/21/2026 at 12:51 PM with Resident #104 stated, The nurse gave me my medication this morning. It was on time. Review of the facility policy and procedure titled Documentation in Medical Record with a review date of 1/28/2026 read, Policy: Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview and record review the facility failed to follow prevent the spread of potential infectious diseases by not performing hand hygiene and following sterile procedure for 1 of 3 residents, Resident #33, reviewed for tracheostomy care, failed to follow enhanced barrier precautions in 1 of 3 units , and failed to contain soiled linen in the soiled utility room in the laundry room.Findings include:During an observation on 7/20/2026 at 2:01 PM with Staff B, Licensed Practical Nurse (LPN) entered Resident #33's room, donned a gown and performed hand hygiene. Staff B don surgical gloves and removed the old tracheostomy dressing. Staff B proceeded to remove her gloves and wash her hands. Staff B then open the tracheostomy care kit, donned sterile gloves and a bottle of normal saline from the kit was opened. Gauze was moistened with the normal saline, and the area beneath one side of the tracheostomy flange was cleaned. Staff B dispose of the gauze and used another moisten gauze to clean the opposite side of the flange. After completing the stoma care, Staff B removed the disposable inner cannula and discarded it. Without changing the gloves that had been used to clean around the stoma and tracheostomy flange, Staff B inserted a new sterile inner cannula. Staff B then removed the gloves, performed hand hygiene, and donned new pair of surgical gloves. While preparing for suctioning, Staff B searched through the bedside drawer, removed old suction tubing from the suction machine, discarded it, and retrieved a new suction catheter package, placed it on the bedside table, and removed her surgical gloves. Staff B then touched her personal eyeglasses. Staff B did not perform hand hygiene after touching the glasses. Staff B then opened the suction catheter. package, donned sterile gloves, opened the normal saline connected the suction catheter to the suction tubing and perform tracheal suctioning.During an interview on 7/20/2026 2:26 PM with Staff B, LPN, stated, I should have kept sterility more throughout the procedure.Review of Resident #33 physician order dated 6/21/2026 read, Trach-Provide trach care every day and PRN [as needed]. Change trach ties daily and PRN. as needed for Trach Care.During an interview on 7/21/2026 at 1:35 PM with the Director of Nursing stated, The dirty first and then move onto the clean. At least clean gloves. The nurse should not go from dirty to clean. Hand hygiene should have been performed in between. I would not consider change of gloves to be hand hygiene.Review of the facility Validation Checklist Tracheostomy Care read, Procedure Observed. 22. Maintained clean/sterile technique and observed any isolation precautions.Review of the facility policy and procedure titled Respiratory/Tracheostomy Care and Suctioning with a last review date of 1/28/2026 read, Policy: 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 plan and resident goals and preferences.2.) During an observation on 7/20/2026 at approximately 2:10 PM Staff A, CNA entered Resident #57's room and stated she would help the resident transfer from her wheelchair to her bed. Staff A closed the door behind her. When surveyor knocked on the door Staff A stated, patient care. Staff A was wearing gloves, but no gown and was assisting Resident #57 to get out of the wheelchair with her hands holding Resident #57.Review of Resident # 57's physician's order dated 2/16/2026 read, Enhanced Barrier Precautions: Chronic Wound. For wound every shift for multiple drug-resistant organism precautions.During an interview on 7/21/2026 at 1:28 PM the Director of Nursing stated, Staff are supposed to wear gown and gloves if they are going to actually come in contact with a patient with enhanced barrier precautions. Gown, gloves. They should be wearing both. They should wear a gown when transferring a patient.During an observation on 7/22/2026 at 5:58 AM, Staff C Licensed Practical Nurse (LPN)entered Resident #33's room, performed hand hygiene and donned a pair of gloves. Staff C did not don a gown. Staff C checked for placement and residual and began to administered medications to Resident #33 via her gastric tube.During an interview on 7/22/2026 at 6:24 AM with Staff C, LPN stated I forgot to put on a gown.During an interview won 7/22/2026 at 6:30 AM with the Director of Nursing stated, Staff should wear a gown and gloves when coming into contact with a resident's gastric tube.Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 1/28/2026 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 3. Implementation of Enhance Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: c. transferring, f. changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes.3) During an observation on 7/21/2026 at 3:20PM with the EVS Director of the laundry room the soiled utility room/laundry room, multiple soiled linen carts were noted to be overfilled, with linen extending above the rim of the carts. Linen visibly contained with dark substance was observed exposed rather than fully contained within the carts.During an interview on 7/21/2026 at 3:25 PM with the EVS Director stated soiled clothing should be covered.During an interview on 7/22/2026 at 11:24 AM with the Director of Nursing stated, Linen should be contained.Review of the facility policy and procedure titled Infection Control-Linen Management with a last review date of 1/28/2026 read, Policy: It is the policy of the facility to ensure linens are handlining in a way to prevent cross-contamination and the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure: 6. Dirty linens are contained in a closed container or bag.

Based on observation, record review, and interview, the facility failed to implement its smoking policies and procedures to ensure smoking materials were maintained by nursing staff for 1 of 3 residents reviewed for smoking safety (Resident #74). Findings include:During an observation on 07/21/2026 at 11:42 AM, Resident #74 was observed carrying a lighter and cigarettes in his vest pocket. The resident removed the items from his pocket.During an interview on 07/21/2026 at 11:43 AM, Resident #74 stated he kept them on his person because residents and staff took cigarettes and lighters from the designated smoking box. During an interview on 07/21/2026 at 11:45 AM, Staff H, housekeeper stated residents were expected to place their cigarettes and lighters in the designated smoking box after smoking. She stated there had been frequent issues with cigarettes and lighters being taken from the smoking box, resulting in residents keeping the items on their person.During an interview on 07/22/2026 at 8:50 AM, the Director of Nursing (DON) stated her expectation was that facility staff would follow the facility's smoking policy by maintaining residents' smoking materials in the designated smoking box.Review of the facility's policy and procedure titled Resident Smoking and Smokeless Tobacco Use, last reviewed 01/28/2026, revealed, All smoking and smokeless tobacco materials of residents who use them will be maintained by nursing staff.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents in 2 of 3 units for 5 residents, Residents #2, #4, #8, #9, and #10, reviewed for homelike environment.Findings includeDuring an observation on 06/22/2026 at 9:31 AM, Resident #8 was sitting up in bed. The drywall on the wall to the left side the bed was in disrepair. There were debris and a small plastic object observed in the air conditioning vent. (Photographic evidence obtained).During an interview on 06/22/2026 at 9:31 AM, Resident #8 stated, The wall is gouged. I would prefer if the wall was in better condition.During an interview on 06/22/2026 at 11:06 AM, the Director of Environmental Services/Interim Maintenance Director stated, I am responsible for maintenance now. Housekeeping cleans the AC [air conditioner] filters daily and should be pulling them out and wiping them down. Maintenance is responsible for removing the PTAC [packaged terminal air conditioner] cover and cleaning underneath it monthly.Review of Work History Report provided by the Director of Environmental Services/Interim Maintenance Director, read, Timeframe: Last 6 months. 04/30/2026 HVAC [heating, ventilation and air conditioning] (PTAC): Clean air filters. Marked done on time on 4/24/2026. 01/21/2026 HVAC (PTAC): Clean air filters. Marked done on time on 01/29/2026.Review of the work history reports provided by the Director of Environmental Services documented the last time the air conditioning units were cleaned was on 04/24/2026.Review of the policy and procedure titled, HVAC System reviewed 01/28/2026 read, Policy: The facility maintains HVAC systems in a manner that protects resident health and safety from fire and extreme temperatures. b. The Maintenance Director is responsible for notifying the service agency of needed repairs, servicing or maintenance. 6. Documentation of all inspections, tests, and maintenance shall be maintained by the Maintenance Director.During an observation on 06/22/2026 at 10:00 AM, Resident #9 was laying in bed with the head of bed raised approximately 30 degrees. The light fixture on the wall behind the resident's bed had a broken pull cord. The light fixture above the sink was not secured to the wall. (Photographic evidence obtained).During an interview on 06/22/2026 at 10:00 AM, Resident #9 stated, I'm waiting for a pull cord for my light. I can't turn it on or off. I've been here for three months, I have told multiple people about it, and it still hasn't been fixed.During an interview on 06/22/2026 at 11:15 AM, the Housekeeping Director/Interim Maintenance Director viewed the light fixture above the sink in Resident #9's room and stated, I wasn't aware of these issues. That shouldn't be like that.During an observation on 06/22/2026 at 10:15 AM, Resident #10 was sitting up in bed. The dresser on the right side of the bed was in disrepair, with the resident's belongings visible inside of the dresser. (Photographic evidence obtained).During an interview on 06/22/2026 at 10:15 AM, Resident #10 stated, I've been here for two years. My dresser has been broken, and it really bothers me. I want to know if they can switch it out for the one on the other side of the room, since no one is in there right now.During an interview on 06/22/2026 at 11:10 AM, The Housekeeping Director/Interim Maintenance Director viewed Resident #10's dresser and stated, I see the dresser is broken.During an observation on 06/22/2026 at 9:30 AM, Resident #4 was observed sitting up in bed. The Resident was adequately groomed with no adverse odors. The dry wall behind Resident #4's bed was in disrepair and there was a white, powdery substance on the floor. There was a thick, gray substance under the air intake cover of Resident #4's air conditioner.During an interview on 06/23/2026 at 9:25 AM, Resident #4 stated, The wall behind the bed is filthy and ugly and I wish they would do something about it.During an observation on 06/22/2026 at 9:45 AM, Resident #2 was lying in bed on her left side with her eyes closed. The drywall on the wall behind the resident's bed was in disrepair. (Photographic evidence obtained).During an interview on 06/22/2026 at 11:08 AM, the Director of Housekeeping Services/Interim Maintenance Director viewed the damaged drywall in Resident #2's room and the damaged drywall and white powdery substance on the floor of Resident #4's room and stated, That drywall should have been cleaned up.Review of the policy and procedure titled, Resident Right-Safe/Clean/Comfortable/Homelike Environment last reviewed 01/28/2026 read, Policy: It is the policy of the facility to provide a safe, clean, comfortable homelike environment such a manner to acknowledge and respect resident rights. Procedure: 1. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 2. The facility must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on interview and record review, the facility failed to ensure the provider was notified when a resident left the facility against medical advice for 1 of 3 residents, Resident #3, reviewed for change in condition. Findings include:Review of Resident #3's medical record documented the resident was admitted in to the facility on [DATE] and discharged on 05/06/2026. Review of Resident #3's nursing note dated 05/07/2026 read, Resident left against medical advice.Review of the medical record revealed the record did not have documentation Resident #3's physician was notified when Resident #3 left the facility against medical advice.During an interview on 06/22/2026 at 2:50 PM Staff A, LPN (Licensed Practical Nurse) stated, When [Resident #3's name] came in, transport brought him to Unit 1. We realized he was supposed to be in Unit 2, so we brought him to the correct room. The air conditioning was broken in the room, and he became very agitated. He asked for a urinal, but I couldn't find one. Apparently, they were in a big box in central supply, but they had recently rearranged the room, so I couldn't find one. I asked a CNA [Certified Nursing Assistant], and she couldn't find one either. I brought him a plastic cylinder. I don't know if he was okay with that solution or not because he left shortly after that. His daughter arrived around 11:00 PM to pick him up. He left AMA [against medical advice]. I called and notified my manager that she [Resident #3's daughter] was taking him home.During an interview on 06/23/2026 at 10:40 AM, the Director of Nursing stated, [Resident #3's name] came in and he refused to stay. Transport brought him to the wrong unit. We had to move him, and that made him mad and he didn't want to stay. When a situation like that happens, the staff need to do an AMA form, notify the physician, the DON [Director of Nursing] and the Administrator. I see the nursing note that says that the resident left AMA. It doesn't say whether the doctor was notified or not.Review of Resident #3's AMA form dated 05/06/2026 revealed the AMA form was not signed by the physician. During an interview on 06/23/2026 at 1:22 PM Staff A, LPN stated, I didn't call the doctor after [Resident #3's name] left AMA.Review of the policy and procedure titled, Change in Condition Process last reviewed 01/28/2026 read, Policy: 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: 4. A decision to transfer or discharge the resident from the facility.Review of the policy and procedure titled, Notice Requirements Before Transfer/Discharge (Including AMA) last reviewed 01/28/2026 read, Policy: It is the policy of the facility to notify the resident and or their legal guardian before transfer and/or discharge according to state and federal regulations. Discharge Against Medical Advice (AMA) b. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. c. May involve physician of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. d. Documentation of this notification should be entered in the nurses' notes by the nursing department.

Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 (Resident #195, #82, and #36) of 6 residents reviewed for oxygen therapy and respiratory treatments. Findings include: 1) During an observation on 4/14/25 at 10:17 AM, Resident 195's oxygen (O2) setting was on 4.5 liter (ltr), the O2 tubing is dated 4/6/25. (photographic evidence obtained) During an observation on 4/15/25 at 9:02 AM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. During an observation on 4/15/25 at 3:36 PM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. During an observation on 4/16/25 at 9:05 AM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. Review of Resident 195's admission record documented an original admitted [DATE] and a readmitted [DATE] with diagnosis that included COPD (Chronic Obstructive Pulmonary Disease), asthma and severe protein malnutrition. Review of Resident 195's physician's order dated 3/8/25, reads, change oxygen set up and bag weekly and as needed. every night shift on Saturday. Review of Resident 195's physician's order dated 3/3/25, reads, Oxygen at 3 liters/min (minute) via nasal canula for SOB (shortness of breath). 2) During an observation on 4/14/25 at 1:35 PM, Resident #82's oxygen (O2) tubing date appears to be written over and with multiple numbers overlapping. It is unclear as to what the date actually is. During an interview on 4/14/25 at 1:35 PM, Resident #82 stated, I watch the staff change the date on oxygen tubing without actually changing the tubing. You can see they tried to put another date on top of the previous date, if you look at my roommate she did the same thing to his. I don't know her name, it was at night, they shouldn't do that. That is wrong. (Photographic evidence obtained) During an observation on 4/15/25 at 3:15 PM, Resident #82's O2 tubing was marked with multiple numbers overlapping, same as yesterday (4/14/25). During an interview on 4/15/25 at 3:15 PM, Resident #82 stated, it is still the same, no one has changed it. During an interview on 4/16/25 at 9:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, The oxygen tubing should be changed weekly. I see the date; that should not be. During an interview on 4/16/25 at 9:15 AM, Resident #82 stated, I watch the staff change the date, the nurse did it right in front of me. During an interview on 4/16/25 at 10:00 AM, the Director of Nursing (DON) stated, that is unacceptable [changing date and not tubing], it is nursing 101; it is nursing standards of practice. Review of the policy and procedure titled, Tracheostomy Care and Suctioning/Oxygen, last reviewed on 2/19/25, reads, Policy: 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 goal and preferences. Procedures. 2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by physician, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 4. Based upon the residents assessment, attending physician's order's, 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. 46523 3) During an observation on 4/15/25 at 10:10 AM, Resident #36 was lying in bed. On top of bedside table there was a nebulizer mouthpiece not bagged and tubing that was not dated. (photographic evidence obtained) During an observation on 4/16/25 at 9:30 AM, Resident #36 was lying in bed. On top of bedside table there was a nebulizer mouthpiece not bagged and tubing that was not dated. Review of Resident #36's physician's orders documented no orders for respiratory therapy tubing changes. Review of Resident #36's physician's order dated 3/25/25 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. During an observation on 4/16/25 at 11:37 AM with Staff D, Registered Nurse, Unit Manager (RN UM), Resident #36 was lying in bed. A nebulizer mouthpiece was lying on top of the resident's nightstand without a bag and tubing was not dated. During an interview on 4/16/25 at 11:37 AM, Staff D, RN UM, stated, The nebulizer mouth piece should be bagged when not in use and the tubing should be dated and changed every 7 days. During an interview on 4/16/25 at 11:57 AM, the Director of Nursing (DON) stated, After use, the nebulizer mouthpiece should be stored in a bag. The tubing should be dated and changed every 7 days.

Based on observations, interviews, and record review, the facility failed to ensure food was safely stored, dated in a manner that preserves the nutritional value, and sanitation was maintained in the kitchen. Findings include: A walk-through tour of the kitchen was conducted on 4/14/25 at 9:35 AM with the facility Certified Dietary Manager (CDM). During the tour observations revealed a window above the 3-compartment sink with dishes stored on sill that were not inverted with a variety of plastic containers and lids. The sill appeared to have a ledge that had black stains and cracks. Directly across the ice machine a mop, broom, dustpan alongside of 2 carts that had buildup of dirt on the top and hand bar used to transport food. The deep fryer was full of very dark dirty oil and a buildup of food particles on the deep fryer top, edges, sides and the floor underneath the fryer had a buildup of thick black/brownish substance. The cooking range had a buildup of black food particles, black buildup on stainless steel backsplash and the front of the oven had buildup on the edges. There was a stainless steel bin with a serving utensil with burnt handle sitting on top of stove. The dry pantry had a number of small, lidded bowls in a large gray bin with initials and no dates on bowls were observed. The walk in freezer had ice that dripped down the entire front, top to bottom, of the shelves. The ice was encrusted on bags and boxes. There were 2 bags of unlabeled and undated food product that was frozen solid and unable to identify the contents of blue bag. (photographic evidence) A follow-up visit to the kitchen was made on 4/15/25 at 11:00 AM. The CDM was observed 3 times grabbing paper towels to close the water faucet valve and then, proceeded to dry hands with the same paper towel that was used to close the water faucet valve. During an interview on 4/14/25 at approximately 10:00 AM, the CDM stated there should be no storage on windowsill and when stored the dishes should be inverted, mops and brooms are not supposed to be there [across from ice machine]. The deep fryer and range was last cleaned several weeks ago. The CDM further acknowledged the number of small, lidded bowls in a large gray bin were set up for tomorrows breakfast and the initials stood for the contents of cereal; however they were not dated and should be. CDM stated he had not noticed the freezer had ice dripped on shelves and food product. An interview was conducted with the Regional Dietary Manager on 4/16/25 at 8:00 AM related to expectations for the kitchen and dietary services. The Regional Dietary Manager stated that it is his expectation that the dietary manager and dietary staff follow the policies storage and labeling of food and cleaning of equipment with good sanitation practices. CDM should not be drying his hands with the same paper towel used to shut off faucet. We know we have a problem with the kitchen. The CDM is brand new. Review of the policy titled Sanitation Inspection, revised 1/1/25 and last reviewed on 2/19/25, read, Policy: It is the policy of the facility as part of the department sanitation program, to conduct inspection to ensure food service areas are clean, sanitary in compliance with applicable State and Federal regulations. Policy Explanation and Compliance Guidelines. 1. All food service areas will be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. Review of the policy titled Dietary Services - Food and Drink, revised 3/2/19 and last reviewed on 2/19/25, read, Policy: It is the policy of the facility to assure that the nutritive value of food is not compromised and destroyed because of prolonged; food storage, light and air exposure; or cooking of foods in a large volume of water; or holding on steam table.

Based on record reviews and interviews, the facility failed to ensure resident assessment accurately reflects the resident's status for 2 (Resident #2, #14) of 7 residents reviewed for nutrition and dialysis. Findings include: 1) During an observation on 4/15/2025 at 8:30 AM, Resident #2 was eating in his room independently. On the meal tray there were two boiled eggs, coffee, grits, and ground meat. Meal ticket read fortified foods and double portions. During an observation on 4/15/2025 at 12:14 PM, Resident #2 was eating independently in his room. Meal tray included cooked carrots, mashed potatoes, ground meat, dessert, frozen treat, nutrition shake, and coffee. Meal ticket read fortified foods and double portions. Review of Resident #2's physician order dated 11/27/2024, read, Regular diet mechanical soft, texture thin consistency, large portions; fortified foods. Review of Resident #2's physician order dated 10/22/2024, read, Calorically dense oral supplement three times a day 120ml (milliliters). Review of Resident #2's physician orders dated 10/22/2024, Health shake two times a day with lunch and dinner. Review of Resident #2's Minimum Data Set titled Modified of Quarterly dated 2/21/2025,,documented resident was not receiving a therapeutic diet. During an interview on 4/17/2025 at 11:08 AM, the Minimum Data Set Regional Specialist stated, [Resident #2 Name] needed to be coded as therapeutic diet due to his fortified foods order. During an interview 4/17/2025 at 11:55 AM, the Register Dietitian stated, [Resident #2 Name] has had weight loss, for him (Resident #2) fortified foods and any additional supplements are considered therapeutic due to the weight loss. Review of the policy and procedure titled Resident Assessment Instrument (RAI), last review date of 2/19/2025 read, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Date Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. The assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. 49656 2) Review of the admission record for Resident #17 documented the resident was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease and type 2 diabetes mellitus. Review of Minimum Data Set (MDS) admission assessment, dated 4/6/2025, documented that Resident #14 was receiving dialysis services while a resident at the facility. Review of physician orders for Resident #14 documented no orders for dialysis. During an interview on 4/14/2025 at 9:24 AM, Resident #14 stated, I am not on dialysis. During an interview on 4/17/2025 at 1:15 PM, the Travel MDS Coordinator stated, We review the physician orders, hospital discharge documents, assessments and progress notes when completing the MDS. I was not here at this time. During an interview on 4/17/2025 at 2:20 PM, the Director of Nursing (DON), stated, It is expected that the MDS is updated immediately upon change of situation/condition. That reflects any and all changes regarding residents.

Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 3 (Resident #55, #66, #70, ) of 7 residents reviewed for mood and behavior Findings include: 1)Review of Resident #70 Stated of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 3/8/2024 did not document depressive disorder. Review of Resident #70 admission record resident was admitted on [DATE] with diagnosis included but not limited to anxiety disorder, depression, low back pain, and auditory hallucinations. Review of Resident #70 physician order dated 12/12/2024 Sertraline HCI Oral Tablet 50mg (milligrams) give 50mg by mouth one time a day for depression. During an interview on 4/16/2025 at 5:15 PM with [NAME] President of Clinical Operations stated , [Resident #70's name] depressive disorder should have be included in the level one before admission to the facility. Social Services reviews the PASRR and checks for accuracy and if they need to correct anything they will tell a nurse to correct it. During an interview on 4/16/2025 at 5:43 PM with the Director of Nursing stated, [Resident #70 name] PASRR was missed it should have been updated when she [Resident #70] came in from the hospital, but it was missed. Review of the facility policy and procedure titled Coordination-Pre-Admission Screening and Resident Review (PASRR) Program with a last review date 2/19/2025 read, Policy: It is the policy of the facility to assure that all residents admitted to the facility received a Pre-Admission Screening and Resident Review in accordance with State and Federal Regulation. 51447 2.) Review of Preadmission Screening and Resident Review (PASRR) dated 10/19/2022 read that Resident #55 did not have or was not suspected of having any mental illness. Review of physician order dated 9/18/2024 for Resident #55 read, Fluoxetine HCL Oral Capsule 20 mg (milligram), give 40 mg by mouth one time a day related to Major Depressive Disorder, Recurrent, Moderate. Review of physician order dated 1/24/2025 for Resident #55 read, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 2 capsules by mouth every 8 hours related to unspecified Dementia, unspecified severity, with other behavioral disturbances. Review of physician order dated 3/25/2025 for Resident #55 read, Trazodone HCL Oral Tablet 100 mg, give 0.5 tablet by mouth one time a day for depression related to Major Depressive Disorder, single episode, moderate. Review of psychiatry subsequent note dated 3/25/2025 for Resident #55 read, This is a [AGE] year-old patient with a past psychiatric history of depression, anxiety, dementia, insomnia and bipolar disorder .Today, I saw the patient as it was reported to me that the patient is unstable requiring psychiatric assessment. Review of psychiatry subsequent note dated 4/1/2025 for Resident #55 read, Today, I saw the patient to assess tolerability and effectiveness after recent medication changes .As per the collected information and interview, it appears that the patient is doing well overall. During an interview on 4/17/2025 at 11:30 AM with the DON, she stated, The PASRR is incorrect, and a new one should have been completed. 3.) Review of Preadmission Screening and Resident Review (PASRR) dated 10/25/2023 read that Resident #66 did not have or was not suspected of having any mental illness. Review of physician order dated 2/21/2024 for Resident#66 read, Escitalopram Oxalate Oral Tablet 10 mg (milligram), give 1 tablet by mouth one time a day for depression related to major depressive disorder, single episode, mild. Review of physician order dated 7/2/2024, Depakote Sprinkles Capsule Sprinkle 125mg, give 2 capsules by mouth two time a day for mood disorder. Review of psychiatry subsequent note dated 3/25/2025 for Resident #66 read, This is a [AGE] year-old patient with a past psychiatric history of depression, anxiety, dementia, mood disorder .Today, I saw the patient to initiate gradual dose reduction (GDR). Review of psychiatry subsequent note dated 4/1/2025 for Resident #66 read, Today, I saw the patient to assess tolerability and effectiveness after recent medication changes .As per the collected information and interview, it appears that the patient is doing well overall. During an interview on 4/17/2025 at 11:30 AM with the DON, she stated, The PASRR is incorrect, and a new one should have been completed.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive care plan for 1 (Resident #70) of 6 resident reviewed for medication management and 1 (Resident #42) of 6 residents reviewed for Hospice. Findings include: Review of Resident #70's physician order dated 12/12/2024, read, Sertraline HCI Oral Tablet 50mg (milligrams) give 50mg by mouth one time a day for depression. Review of Resident #70's Psychiatry Subsequent Note dated 4/8/2025 read, Chief complaint: Depression, anxiety, mood disorder and schizophrenia . Review of Resident #70's comprehensive resident centered care plan did not document a focus for depression. During an interview on 4/17/2025 at 10:50 AM, the Regional MDS (Minimum Data Set) Specialist stated, [Resident #70' s Name] antidepressant focus was resolved and had to be included again in the resident's care plan. Review of the policy and procedure titled Comprehensive Care Plans with a last review date of 2/19/2025 read, Policy: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidence by documentation from admission through discharge for each resident .The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the residents strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident.

Based on observations, interviews, and record reviews, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for 2 (Resident #84, #395) of 8 residents reviewed for central venous access devices and skin conditions. Findings include: 1) During an observation on 4/14/2025 at 9:39 AM, Resident #84 was lying in bed, there was a dressing on Resident #84 left upper and forearm dated 4/10/2025. There was a pink gentle border dressing on Resident #84 upper right arm with no date or initials. (photographic evidence obtained) During an interview on 4/14/2025 at 9:39 AM, Resident #84 stated, I had a fall, and I got a few skin tears. During an observation on 4/16/2025 at 8:21 AM, Resident #84 was sitting up in bed eating breakfast. Resident #84's left upper and forearm had a dressing dated 4/10/2024. There was a pink gentle border dressing on Resident #84's upper right arm with no date or initials. Review of Resident #84's physician orders resident did not have wound care orders for skin tear prior to 4/11/2025. Review of Resident #84's physician order dated 4/11/2025 read, Clean skin tears with NS (normal saline), xeroform, gauze bandage. Review of Resident #84's physician order dated 4/14/2025 read, Clean skin tears with wound cleanser, pat dry, apply xeroform to skin tear, wrap with rolled gauze 3 x week (3 times a week) and prn (as needed) every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for skin tear. Review of Resident #84's Weekly Skin Observation dated 3/25/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front). Review of Resident #84 Weekly Skin Observation dated 4/4/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front) skin tear. Review of Resident #84 Weekly Skin Observation dated 4/10/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front) skin tear. During an interview on 4/16/2025 at 11:13 AM with Staff B, Wound Care, License Practical Nurse (LPN), stated, I was the one who put those dressing in place [left upper and forearm dressing] on 4/10/2024. [Resident #84's Name] wound care is done three times a week. Maybe the nurse did not know he would not be seen by the wound care doctor since they are skin tears. I am not sure why he has a dressing on his upper right arm. During an interview on 4/16/2025 at 11:57 AM, the Director of Nursing stated, Nursing staff should perform wound care as per doctor's orders and document appropriately and accurately the services provided to the residents. Review of the policy and procedure titled Wound Management, with a last review date of 2/19/2025, read, Policy: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment and prevention of pressure as well as, non-pressure related wounds. Procedure: 1 .The admitting nurse/nurse identifying a skin integrity issue, will then be responsible for initiating the appropriate intervention such as ensuring treatment order(s) are in place . 2) During an observation on 4/14/2025 at 9:40 AM, Resident #395 was lying in bed; there was a single lumen picc (peripherally inserted central catheter) line on resident's right arm with a transparent dressing dated 4/1/2025. (photographic evidence obtained) Review of Resident #395's physician order dated 3/31/2025, read, PICC/MID line: Change dressing to insertion site (insert site) every 7 days and prn (as needed) using sterile technique. as needed. Review of Resident #395's physician order dated 3/31/2025, read, PICC/MID Line: RIGHT ARM) Dressing change 24 hours after insertion one time only for 24 hours after insertion for 1 day change dressing. During an interview on 4/16/2025 at 12:31 PM, the Director of Nursing stated, Intravenous dressing changes should be done weekly and as needed. Review of the policy and procedure titled PICC/Midline/CVAD (central venous access device) Dressing Change, with a last review date of 2/19/2025, read, Policy: It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type pf dressing and frequency of changes.

Based on observations and interview, the facility failed to ensure residents' dignity for 2 ( #96, #124) of 2 resident's interviewed about staff treatment and random observations during meals. For resident #96, who had to wait over an hour for assistance after an episode of bowel incontinence, she expressed embarrassment and began crying when explaining what happened. Moreover, resident # 124 expressed a lack of treatment to ensure dignity as staff refuse to honor the resident's request to wear an incontinence brief at night to prevent her from wetting the bed that causes her embarrassment. Findings: 1. Observations on 7/27/11 at 9:35 am revealed that the call light was on for Resident #96's room. A housekeeper came out of the room and walked over to a certified nursing assistant (C.N.A.) and informed her that the resident needed assistance. The C.N.A. entered the room and turned the light off. At 10:00 am, the call light was on again for Resident #96's room. A C.N.A. was observed entering the room and turning the call light off. At 10:15 am, the surveyor entered the room as the licensed practical nurse (LPN) was leaving. During the interview with the resident on 7/27/11 at 10:30 am, she stated that she had a bowel movement in her pants and she has been waiting over an hour for her aide to come and help her. She stated two CNAs told her that her aide was busy giving a shower and she would have to wait, they had turned off her light, but did not assist her. The resident stated that she had never had an incident like this before and she was so embarrassed and started crying. During the interview with the resident's assigned C.N.A. on 7/27/11 at 10:40 am, she stated that she has been busy with 2 other residents and no one told her that Resident #96 needed assistance. 2. During the interview with Resident #124 on 7/27/11 starting at 9:00 am, she stated that some of the C.N.A.s will take up to an hour to answer the call bell. The resident stated that she has asked 2 C.N.A.s to put a diaper on her at night because she feels that she will wet the bed. Both C.N.A.s have declined to do so. The resident stated that she wears the Depends during the day, but that she needs a diaper at night. She stated that she feels that it is to ensure her dignity and prevent embarrassment in case she has an accident. However, staff still refuse to honor her request. 3. On 7/26/11, observations during the noon meal revealed a resident was sitting at the dining room table watching her tablemate eat her lunch. The resident asked a staff for her plate and the response was it is coming. The then staff went to a room and asked a resident was she coming to the dining room for lunch. The resident responded "yes". The staff then placed her tray at the table, where the other resident was waiting, and walked away before the resident entered the dining area. The resident that was waiting to be served pulled the tray over to her section and attempted to eat the food. When the other resident came into the dining room, staff began to look for her tray as the resident's tray had been placed at the wrong table. Staff was then observed to have to take the tray away from the first resident. 4. A dining observation was conducted of the 100 hall unit dining room on 7/26/2011 beginning at 11:45 AM. Residents were served their trays from a tall tray delivery cart with the food items removed from the tray at tableside and placed on the table in front of each resident. The trays were then stacked off to the side for use later or to be returned to the kitchen. It was observed that tables were stripped by the CNA staff while residents continued to dine at the tables beginning at 12:32 PM. Three residents had been seated at the table when the CNA approached the table with a tray in hand. The tray was placed onto the top of the table while the remaining 2 residents continued to dine. The dishes, silverware, and glasses were removed from the table, placed onto the tray in front of the other residents and then taken to the cart which was off to the side of the dining area. The remaining residents were not rushed; however, one of the tablemate's did wheel his chair out of the dining room. The same staff person went to another table and started to place the tray on the table while she picked up dishes and placed all on the table to include the glasses and dessert. It was unclear whether she had asked the resident if she wanted everything picked up. Interview with this staff person at 12:44 PM revealed she had asked the resident about the removal of the items; however, it was still unclear whether or not the resident confirmed she wanted everything removed or just the main plate. At this time, another CNA was observed to walk over to a table, place the tray on the table and began to place the dishes from another resident on the tray while a resident was still dining. The Unit Manager was in the dining room at this time and was asked to observe what another CNA was in the process of doing, as she was now stripping a table while residents continued to sit at the table. All items, once again to include filled beverage glasses, food remaining on plates and dessert dishes, were removed and placed onto the tray which had been placed on the dining table. While the Unit Manager was observing, another CNA approached a 4th table and began to strip all items from it while residents continued to sit at the table. It was confirmed with the Unit Manager that placing a tray on top of the table while residents were still dining was inappropriate. It was confirmed that even though they may have asked if a resident had finished the meal, the mere act of stripping dishes from the table while other residents continued to eat was not acceptable and was considered a dignity issue.