Every finding on record at Avante at Ocala, Inc

Based on interview and record review, the facility failed to ensure orders were in place and communicated to direct care staff for one (Resident #1) of three reviewed for therapy/mobility services.Findings include:Review of Resident #1's Physician Orders revealed there were no order for assistive devices/braces. Review of Resident #1's medical record revealed she was admitted on [DATE] with medical diagnoses that included fusion of spine, lumbar region (diagnosis a); muscle weakness (generalized); other reduced mobility; cognitive communication deficitReview of Resident #1's most recent MDS (Minimum Data Set) dated 7/15/2026 She was independent for toileting hygiene. She required substantial/maximal assistance for bathing/showering; supervision or touching assistance for upper and lower body dressing, and substantial/maximal assistance for putting on/taking off footwear. Her MDS assessment dated [DATE] documented her BIMS (Brief Inventory of Mental Status) Score as 5 out of 15 which indicated she was significantly cognitively impaired. She received physical and occupational therapy.Review of Resident #1's Care Plan revealed the following:Focus - [Resident #1] requires assistance with functional abilities r/t (related to) reduced mobility, FUSION OF SPINE, LUMBAR REGION, pain. Interventions included - Resident requires partial/moderate assistance from staff (less than half) for transfers. Staff to provide physical assistance but encourage resident to do as much for self as possible.There was no mention of assistive devices.Review of Resident #1's [Discharge] Summary Report read, She requires ongoing multidisciplinary skilled services (OT, PT, SLP (speech language pathology/speech therapy)), nursing oversight for medical comorbidities (diabetes management, anemia monitoring, recent UTI (urinary tract infection) treatment), and assistance with safety and sequencing (LOS orthosis, assistive devices) to progress toward safe community discharge. Post-hospital care requirements: LSO brace to be used OOB. Equipment and assistive devices: LSO (lumbar sacral orthosis) - wear when out of bed; patient requires training to don/doff (don means to put on an orthotic device (such as a brace, splint, or AFO) and doff means to take it off).Review of Resident #1's Progress Notes revealed an MD (Medical Doctor) History and Physical Note dated 7/13/2026 with the date of service documented as 7/10/2026 read, Lumbar CT (computerized tomography - a diagnostic imaging procedure) showed moderate-to-severe degenerative changes with scoliosis with moderate to severe degenerative disc disease with moderate canal stenosis L1 through L5 with neuroforaminal stenosis bilaterally at L5-S1 and on the left at L3-4 (Neuroforaminal stenosis means the small openings where nerve roots exit the spinal column have narrowed. Bilaterally at L5-S1 means narrowing on both the left and right sides at the lowest lumbar-sacral level, while on the left at L3-4 means narrowing on the left side higher up in the lower back). She underwent a right MIS hemilaminectomy and intervertebral fusion of L3-4 and L4-5 (removal of a small piece of bone to relieve nerve pressure at two lower spine levels and locks the L3, L4, and L5 vertebrae together with screws and cages to stop painful motion) on [date of her surgical procedure]. Postoperatively patient to wear an LSO brace (a medical back brace designed to support and stabilize the lower back and the sacrum at the base of the spine; it limits twisting and bending movements, reduces pressure on spinal discs, and aids healing after surgery) went {sp.} out of bed. Patient cleared to discharge to [name of the facility] for PT/OT (Physical Therapy/Occupational Therapy) and medical management.Review of Resident #1's Progress Notes revealed a Follow up [Provider] note dated 7/15/2026 with the date of service documented as 7/14/2026 read, Patient seen and examined. Patient reports she is participating in therapy. PT/OT: Fall and safety precautions. Assessment/Plan: LSO brace went {sp.} out of bedReview of Resident #1's Progress Notes revealed an Admission/readmission Note dated 7/08/2026 that read, The resident's primary admitting diagnosis is Lumbar Spinal Stenosis s/p L3-5. Laminectomy. Physician was notified and orders were confirmed on 7/8/2026. Physician orders were sent to pharmacy on 7/8/2026. Initial Data Intake: Functional Status:The resident requires setup or clean-up assistance with eating. The resident requires partial/moderate assistance with toileting hygiene. The resident requires partial/moderate assistance to move from a sitting to a lying position. The resident requires partial/moderate assistance to move from lying to sitting on side of bed. The resident requires partial/moderate assistance to move from sitting to standing. The resident requires partial/moderate assistance to transfer from a bed to a chair/wheelchair. The resident requires partial/moderate assistance to transfer on and off a toilet or commode. The resident requires partial/moderate assistance from staff for bathing. The resident requires partial/moderate assistance to complete personal hygiene. The resident is able to dress with partial/moderate assistance. Sensory/Communication:The resident is alert and oriented to person and place. The resident does not use a sensory aid. Neurological/Musculoskeletal: The resident has no neurological symptoms. The resident has weakness. There was no documentation regarding an assistive device/brace for use when out of bed.Review of Resident #1's miscellaneous documents revealed a Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form/AHCA Form 5000-3008 which documentation in section X - Comments, Spinal Precautions; LSO Brace - OOB (out of bed)Review of a printed copy of Resident #1's Physical Therapy Treatment Encounter Note dated 7/15/2026 read, Precautions: Precautions / Contraindications: fall risk, WBAT BLE (weight bearing as tolerated bilateral lower extremities), Spinal, LSO Review of a printed copy of Resident #1's Physical Therapy PT Discharge summary dated [DATE] read, Skilled Interventions: Skilled interventions provided: skilled treatment interventions included instructing and training patient in compensatory strategies, energy conservation techniques, proper battery mechanics, safe transfer techniques, safety precautions and use of assistive device in order to improve functional mobility.Review of a printed copy of Resident #1's Occupational Therapy Treatment Encounter Note dated 7/15/2026 read, Therapist observed and assisted patient with donning LSO with Mod A (moderate assistance)Review of Resident #1's Task List revealed no tasks or interventions pertaining to use of an assistive device or brace. During an interview at 12:45 PM Staff E, Administrator (ADM) stated that she believed residents who had orders for assistive or orthotic devices would have it listed in their care plan and the facility would have to assess whether the resident needed the deviceDuring an interview at 1:00 PM the Director of Therapy and Rehab stated, She [Resident #1] was seen by all disciplines for an evaluation [physical therapy, occupational therapy, and speech therapy]. She had spinal surgery. The therapist did instructions on donning the brace when getting out of bed. She did have an LSO here (in therapy). I don't know if she did not wear it elsewhere. Both OT and PT had documentation for training for donning the LSO.During an interview at 1:53 PM Staff A, CNA (Certified Nursing Assistant) stated, [Resident #1] was transferring herself from the bed to her [wheel]chair; she came back from the bathroom and transferred herself back to bed. I asked her to stand up and then she flopped down. I had worked with her a couple of times before. She was not wearing a back brace she didn't ever have a back brace. I don't recall seeing a back brace.During an interview at 1:49 PM Staff F, LPN (Licensed Practical Nurse) - Supervisor stated I was called down to the room. The Resident was on the floor. We assisted her. I don't recall seeing a back brace.During an interview at 2:34 PM Staff B, LPN - Unit Manager stated that they went over new admissions with assistive devices in the morning meeting, which included MDS [staff from the MDS department]. MDS put the assistive device on the care plan. In the morning huddle they communicated their (residents) ADL (activities of daily living) needs to the CNAs (certified nursing assistants), or it could be seen on the Task Area [of the medical record]. She had worked with [Resident #1]. On the day Resident #1's parent came in, the Resident was in the bathroom, Resident #1 had taken herself to the bathroom. Resident #1 needed assistance turning her wheelchair around in the bathroom. When Staff B, LPN assisted Resident #1, the Resident had on the back brace. Staff B, LPN stated that in the skin section of the admission Assessment the nurse should document any devices the resident had or was wearing.During an interview at 2:35 PM Staff C, LPN - Wound Care Nurse stated that when a patient came in for an admission, if they have an assistive device, it should be on their 3008 or their discharge summary. If it wasn't there, the nurse should call the hospital to follow up. Once she [the nurse] verified that the device was there, it went in as an order and on the Care Plan. She took off Resident #1's back brace to assess her skin, and she had to assist Resident #1 to put it back on.During an interview at 3:00 PM Staff D, CNA stated that she had worked in the facility for 4 weeks and had worked on each hallway. She was familiar with assistive devices for the residents. She would ask the resident about their tolerance of wearing the device. Information about braces and devices would be passed on in report from the CNAs and the nurses. It would also be on the Task List for documentation. She assisted residents to put on their back braces when they got out of bed.During an interview at 3:15 Staff E, ADM stated that there was not an order for Resident #1's LSO. She had checked with medical records who had a copy of the baseline care plan for Resident #1. There was documentation of a discussion regarding use of the LSO while OOB. They had been waiting for the comprehensive care plan to complete the information and upload it in the system, but she was only in the facility for 7 days. Review of the Policy and Procedure titled Positioning Devices, with an issue date of 5/27/2026 read, Policy: It is the policy of this facility that residents who require the use of positioning devices to maintain body alignment, pressure relief, or other measures will be managed accordingly as per current standards of practice. Compliance Guidelines: 5. Facility staff will provide appropriate assistance to ensure that the resident can use the positioning device(s) safely. This may include assessment, education or therapy sessions for training on the use of the device(s), set up assistance, supervision, or physical assistance as needed. 6. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding advice. Training will also include when to refer to other departments for changes in condition or problems with the device. 7. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, problems with the device, or changes resident condition necessitating changes to positioning devices will be documented in the medical record. Modifications to the plan of care will be made as needed with appropriate referrals being obtained. 8. Residents will be assessed to ensure that positioning devices are properly used and are not at an increased risk for complications (e.g., skin breakdown, contractures, breathing problems, pain, etc.).

Based on record review and interview, the facility failed to ensure 1 Resident (Resident #1) out of 3 Residents sampled receives necessary treatment and services for pressure sores consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.Findings include:During the record review of Resident #1 medical record the resident was admitted on [DATE] with diagnoses of fracture of superior rim of left pubis, fracture of left acetabulum, fracture of sacrum, and fracture of superior rim of right pubis. Review of the nursing admission assessment completed on the same day 3/16/2026 of admission noted that Resident #1 had a pressure ulcer on the sacrum and a skin tear on right forearm. Review of Resident #1's physician orders noted there were no orders for wound care on pressure ulcer or skin tear until 3/23/2026. Wound care order read clean sacrum with n/s (normal saline), pat dry and cover with dry dressing one time a day for pressure. This was discontinued on 3/24/2026. An order dated 3/25/2026 clean sacrum with wound cleanser, apply Xeroform, and cover with bordered dressing. One time a day for pressure. An order dated 3/23/2026 skin tear on right forearm cleanse with n/s, pat dry and cover with dry dressing. One time a day for skin tear. An order on 3/31/2026 Wound care: Sacrum- cleanse wound cleaner, pat dry, protect peri wound with skin prep, apply betadine-soaked gauze, cover with bordered gauze dressing as needed for soiled/displaced/wound rounds. An order on 3/31/2026 Wound care: Sacrum- cleanse wound cleaner, pat dry, protect peri wound with skin prep, apply betadine-soaked gauze, cover with bordered gauze dressing every evening shift every Tuesday, Thursday, Saturday for stage 4 pressure ulcer. An order dated 3/16/2026 for Wound Consult PRN (as needed). Review of the Wound Care consultation on 3/31/2026 wound assessment noted, Wound #1 sacral is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of not healed. Initial wound encounter measurements are 6 cm (centimeters) length x 6.5 cm width x 1.5 cm depth. During an interview on 6/3/2026 at 3:00 PM with the Director of Nursing stated, The staff did not get a wound care order when the pressure ulcer was identified on admission. What should have happened was the nurse should call the doctor to get an order for wound care. That order should have been in place at the time the wound care physician visit was made.

Based on observation, interview and record review the facility failed to keep 1 Resident (Resident #3) out of 3 Residents sampled receives the necessary services to maintain good grooming in keeping fingernails clean and trimmed. Findings include:During an observation on 6/3/2026 at 9:25 AM Resident #3 lying in bed with a left-hand contracture and right hand with very long dirty fingernails. Unable to observe the nail length of left-hand nail length due to contracture. The fingernails extend about 1/2 inch to 3/4 of an inch from fingertips and dirty (Photo evidence). Review of Resident #3's medical record showed they were admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, depressed mood, contracture left hand, contracture of left wrist and a history of traumatic brain injury. During an interview on 6/3/2026 at 9:25 AM Resident #3 stated, I don't like them, I want my nails cut and clean. It has been a while since they did my nails, I don't remember when the last time was. During an interview on 6/3/2026 at 9:30 AM Staff A Certified Nursing Assistant (CNA) stated, I don't know [Resident #3's Name]'s bath schedule, the nails are long. [Resident #3's Name] is not mine. During an interview on 6/3/2026 at 9:35 AM Staff B, Registered Nurse stated, Resident nails are important to hygiene and should be maintained. It is my responsibility to ensure that hygiene is maintained. No, I did not see [Resident #3's Name]'s nails. Yes, I see they are long. During an interview on 6/3/2026 at 9:40 AM Staff C, CNA stated, Yes, [Resident #3's Name] is mine. I did see his nails were long yesterday. Yes, I did work yesterday, and I did not have time to get to him, I was very busy. During an interview on 6/3/2026 at 10:00 AM the Administrator stated, They (residents) are here to be taken care of. We should be doing their ADL's (Activities of Daily Living). During an interview on 6/3/2026 at 10:35 AM the Director of Nursing stated, My expectation is for the resident's nails to trimmed and clean each time they are bathed. Review of facility's policy titled, Activities of Daily Living Maintain Abilities, dated 3/2/2019 show it reads, Policy, It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life and honor and support these principles for each resident and that the care and services provided and person centered and honor and support each resident's preferences and choices.

Based on observation, interview, and record review the facility failed to ensure the full implementation of the facility's developed performance improvement plans to correct the facility's identified quality deficiencies for wound management, medication administration, infection control, and preadmission screening.Findings include:During an interview on 3/26/2026 at 8:37 AM, the Administrator stated the facility had identified concerns regarding preadmission screening and resident review and initiated a performance improvement project on 1/12/2026, regarding wound management and pharmacy recommendations and initiated a performance improvement project on 2/1/2026, regarding infection control and initiated a performance improvement plan on 2/13/2026. A request was made to review the performance improvement plan [PIP] and all related documentation to verify the implementation of the performance improvement. Review of the documentation provided did not include a PIP for Preadmission Screening and Resident Review (PASRR). Documentation was requested; no documentation was provided.Review of the documentation provided documented dated 01/12/2026: Focus: Medication Administration: Completion of medication administration competencies with licensed nurse: five medication observations x 4 weeks, and monthly x 2 months. Audits weekly of the medication carts to ensure they are free of expired medications and medications are labeled and dated for 12 weeks. Education of the nursing staff in the 5 rights [a foundational safety checklist used by nurses and caregivers to prevent medication errors. The right patient, the right drug, the right dose, by the right route and at the right time]. The findings will be reviewed at the QAPI [Quality Assurance Performance Improvement] meeting monthly. The documentation did not provide for staff education in the five rights of medication administration. The documentation did not provide medication cart audits. The documentation provided for observations of the licensed nursing staff for a total of ten (10) observations. Dated 01/16/2026, 01/23/2026, 02/06/2026, 02/13/2026, 03/13/2026, and 03/20/2026 of Staff EE, Licensed Practical Nurse (LPN) for a total of six (6) observations of this nurse. Dated 1/30/2026, 2/20/206, and 3/6/2026 of Staff GG, LPN for a total of three (3) observations of this nurse. Dated 02/27/2026 of Staff DD, LPN for a total of one (1) observation. The findings of the PIP will be reviewed during the monthly QAPI meeting.Review of the documentation provided documented dated 02/012026: The facility will ensure residents have appropriate wound management and treatment. The DON [Director of Nursing]: On admission will verify wound orders are in place, consult the wound care nurse practitioner, and provide care for all wounds. Any resident wound care identified on admission, the physician will be called to get an order and/or talk to the wound care nurse regarding care. License nursing staff will complete education on wound care. Weekly audits of 5 resident wounds will be conducted. The findings of the PIP will be reviewed during the monthly QAPI meeting. The documentation provided did not contain education of the licensed nursing staff.Review of the documentation provided dated 02/13/2026: Infection Control: Education to staff on hand hygiene, PPE [personal protective equipment] usage, and transmission based precautions. Education: Handwashing Policy. Audits: 5 times per week for 4 weeks, weekly for two months. The findings of the PIP will be reviewed monthly during the QAPI meeting. The documentation provided did not contain weekly audits and the documentation for the education provided was for Hand Competency Education and did not document education in PPE usage and transmission based precautions. A request was made for copies of the PIPs to the [NAME] President of Regulatory none were provided, and the PIPs could only be reviewed in the presence of the [NAME] President of Regulatory.During an interview on 3/26/2026 at 11:15 AM the performance improvement plans were reviewed with the Director of Nursing who stated that during review of the performance improvement plan for medication administration dated 1/12/2026 regarding administering correct medication and medications in the medication carts being appropriately stored. This is missing the completion of the medication administration competencies with licensed nurses, education of the 5 rights, weekly audits for medication carts for 12 weeks, and 5 medication observations weekly for four weeks. The Wound Management performance plan dated 2/1/2026 focuses on ensuring residents have the appropriate wound management and treatment. It is missing education provided to the staff regarding wound care. The Infection Control performance improvement focuses on staff hand hygiene, personal protective equipment usage and transmission based precautions. The Plan does not have education on personal protective equipment usage and transmission-based precautions. The audits are missing. A request was made to review all of the related documentation for the performance improvement plans to verify they were fully implemented. No additional information was provided.During an interview on 3/25/2026 at 1:32 PM the Administrator stated, Staff and practitioners compliance with processes [are missing]. PIPs would be considered complete when ongoing audits reveal that there has been no non-compliance for a length of time appropriate for the individual area. Next, we will revisit areas for improvement with a root cause analysis and PDSA [plan-do-study-act] for each area with goal dates. Education and audits will be maintained by the QA [Quality Assurance] committee. Documentation was requested to verify the full implementation of the PIPs and copies of the PIPs were requested. No additional documentation was provided.During an interview on 3/25/2026 at 2:15 PM the [NAME] President of Regulatory stated, Education was not documented accurately. A request was made for all documentation related to the PIPs to verify full implementation and copies of the PIPs. No additional documentation was provided.Review of the facility policy and procedure titled Quality Assurance and Performance Improvement (QAPI) with a last review date of 2/24/2026 read, Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. C. Develop and implement appropriate plans of action to correct identified quality deficiencies. D. Regularly review and analyze date, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. E. The QAA [Quality Assessment and Assurance] committee must sign to verify approval of all plans of correction written.

Based on interview and record review, the facility failed to ensure the individual responsible for directing the dietary service met the required qualifications in accordance with regulatory requirements affecting all residents receiving dietary services by increasing the risk of inadequate nutritional management, improper food safety practices, and noncompliance with dietary regulations.Findings include:Review of the Dietary Manager's personnel file, the file did not contain documentation the staff member working as the Dietary Manager had the required qualifications. A request was made for the Dietary Manager's certification/education as a Certified Dietary Manager, Certified Service Manager, or similar national certification for food service management and safety from a national certifying body, or an associate's degree or higher for food service managers or dietary managers.During an interview on 3/25/2026 at 11:30 AM the Corporate Dietary Manager stated the Dietary Manager does not have the required qualifications in accordance with regulatory requirements.Review of the policy and procedure titled Food and Nutritional Services, with a last review date of 2/24/2026 read, The facility must designate a person to serve as the director of food and nutrition services who .i. A certified dietary manager; or, ii. A certified food service manager; or iii. Has a similar national certification for food service management and safety from a national certifying body; or iv. Has an associate's or higher degree in food service managers or dietary managers and receives frequently scheduled consultations from a qualified dietitian or other clinical qualified nutrition professional.

Based on interview, record review, and review of policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical wellbeing of each resident by failing to fully implement performance improvement plans for identified non-compliance related to Preadmission Screening and Resident Review, medication storage, medication administration errors, wound care, and infection control.Findings include:Review of the job description titled Nursing Home Administrator read, Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times. He sent on job functions colon's responsibilities include but are not limited to the following: a period administrative functions. Duties: create and maintain an atmosphere of warmth and personal interest, ensuring a positive, environment throughout the facility. Ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status, plan, develop, organize, implement, evaluate, maintain, monitor, supervise, and direct all facility departments and overall operations, including programs, activities, policies and procedures and implement changes as necessary. Plan, Develop and maintain an ongoing quality assurance program, identify problems and deficiencies and develop and implement appropriate plans of actions to correct deficienciesReview of job description titled Director of Nursing read Purpose: To plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards governing the facility, and as may be directed by the administrator, to ensure the highest degree of quality fair is maintained at all times. Essential job functions colon's responsibilities include but are not limited to the following: a period administrative functions: plan, develop, organize, implement, evaluate and direct the nursing services department its programs and activities and directly supervised nurse managers and assistant director of nursing, fulfill the role of nurse administrator. Telephone availability 24/7 unless delegated to assistive director of nursing. Implement plans of action to correct deficiencies, unless none received. Ensure that all indicator logs are completed and updated at least monthly and the information is accurate and complete. Assist in planning, developing, implementing and maintaining resident discharge procedures and plans. Implement a nursing services organizational structure. Review nurses notes to ensure proper documentation is maintained related to residence treatment comma medication and conditions. Round on all facility residents, units, utility rooms, dining room rounds and all residents' common areas at least once per shift, provide direct nursing care as necessary, assist in recruiting, interviewing, hiring, counseling, evaluating, disciplining and terminating nursing service personnel document and coordinate personal personnel actions with the personnel manager or administrator. Care plans and assessment function ensure that all nursing service personnel are aware of the care plan and the care plans are used in providing daily services to the residents, review nurses notes and monitor residents to determine if the care plans being followed and if each resident needs are being met.Review of job description titled Assistant Director of Nursing read, Purpose: to assist the director of nursing and planning, organizing, developing and directing the day-to-day functions of the nursing department and to direct the in service education programs in accordance with current federal, state and local standards governing the facility, and as may be directed by the administrator, to ensure that the highest level quality of care is maintained at all times. 5. Participate in developing, implementing and maintaining the quality assurance program 7. Assist in developing and implementing a nursing service organizational structure, B. Nursing care Functions. 3. Review nurses notes to ensure proper documentation is maintained related to residence treatment, medications and condition. 4. Ensure proper record keeping by physicians. 5. Report problem areas to the director of nursing and assist in developing and implementing corrective actions. 6. Provide direct nursing care as necessary. 9. Round on all facility residents, nursing units, and common areas utility and medication rooms etcetera at least twice per day and all residents' common areas to include resident dining rooms each meal that he or she works during. And comprehensive resident care resident rooms round once a day at a minimum.10. Monitor residence treatment and medications to ensure residents are receiving proper care. Personnel function.1. Scheduling nursing services personnel for all ships may be delegated based on individual facility factors. Delegate administrative authority, responsibility and accountability to nursing services personnel as deemed necessary to perform assigned duties, ensure that all nursing service personnel have valid and current license and are performing duties in accordance with acceptable nursing standards. Oversee the scheduling and implementation of the general orientation program for all employees, Resident rights functions. 4. Monitor nursing services to ensure that resident rights and needs are met. Review nurses' notes and monitor residents to determine if the care plans are being followed and if each resident needs are being met.'During an interview on 3/26/2026 at 8:37 AM with the Administrator stated the facility had identified concerns regarding preadmission screening and resident review and initiated a performance improvement project on 1/12/2026, and regarding wound management on 2/1/2026, regarding infection control and initiated a performance improvement project on 2/13/2026. A request was made to review the performance improvement plan and all related documentation to verify the implementation of the performance improvement. During an interview on 3/26/2026 at 11:15 AM with the Director of Nursing stated, we identified problems with medication administration on 1/12/2026 regarding correct medication and the storage of medication in the medication carts. We did a plan for wound management on 2/1/2026 to ensure the residents have appropriate wound management and treatment and we did one for infection control for hand hygiene, personal protective equipment usage, and transmission based precautions.Review of the performance improvement plan documentation provided for medication administration dated 1/12/2026 regarding the administering of the correct medication and the medication in the medication carts being appropriately stored the documentation did not have the completion of the medication administration competencies with the licensed nurses, did not have education on the five rights of medication administration, weekly audits of the medication carts, there were ten observations of medication administration dated 1/16/2026, 1/23/2026, 1/30/2026, 2/6/2026, 2/13/2026, 2/20/2027, 2/27/2026, 3/6/2026, 3/13/2026, and 3/20/2026. The observations were conducted of a total of three nurses on different days.Review of the wound management performance plan documentation provided dated 2/1/2026 did not have education provided to the staff regarding wound care.Review of the infection control performance improvement documentation provided did not have education on personal protective equipment usage, hand hygiene, and transmission-based precautions. There were no audits. A request was made to review the missing documentation to verify performance improvement plans and implementation. No additional documentation was provided.During an interview on 3/25/2026 at 2:15 PM the [NAME] President of Regulatory stated, Education was not documented accurately. No other supporting documents were provided.During an observation on 03/23/2026 at 05:30 AM, there were three vehicles in the facility parking lot. Upon entry into the facility an observation was made of minimal staff presence, and one call light was persistently ringing in room [ROOM NUMBER].During the initial tour on 03/23/2026 at 5:35 AM of the North, South, and East Wings, several residents were observed awake. Discrepancies were identified on staffing communication boards, staffing assignment sheets, and actual clinical staff present in the facility. Total midnight census for residents was 129, included in the total were two residents ordered for one-on-one sitter observation, Residents #101 and #144. There were four registered nurses (RN) and five Certified Nursing Assistances physically present in the building. During an observation on 3/23/2026 at 05:50 AM of the North Wing communication board it documented the board was last updated on 03/19/2026. The documented names did not match the staffing sheet. (Photograph evidence obtained). During an observation on 3/23/2026 at 06:10 AM the South Wing communication board was in the process of being updated for the on-coming 7a-7p shift for 3/23/2026. The communication board did not match the staffing assignment sheet. The census was 53 residents. (Photograph evidence obtained).Review of the daily nursing assignment sheet for the South Wing (Rooms 101-129) documented Staff I, Licensed Practice Nurse (LPN), Staff M, Certified Nursing Assistant (CNA), Staff P, CNA, Staff J, CNA, and Staff Q, CNA, the census was 53 residents. (Photographic evidence obtained). The staffing for the South Wing consisted of one LPN and four CNAs for the census of 53 residents, included in this total were two residents, Residents #144 and #101 who were ordered for 1:1 supervision.During an observation conducted on 3/23/2026 at approximately 6:10 AM to verify the staffing schedule. Staff P, CNA was not located. A request was made to meet Staff P, CNA. When requested staff stated Staff P, CNA was not known to them. This resulted in one LPN and three CNAs to provide care and assistance for the resident census of 53 with two of the residents have physician ordered 1:1 supervision. During an observation on 3/23/2026 at 06:15 AM Resident #144 was lying in bed. There was no staff in the room providing the physician ordered 1:1 supervision.During an observation on 03/23/2026 at 6:16 AM of Resident #101, Staff J, CNA was providing 1:1 supervision for the resident which prevented Staff J from providing assistance to other residents.Review of Resident #144's physician orders dated 2/26/2026 read, 1:1 supervision. There was no documentation in the resident's record, no physician order, or communication with the physician to discontinue 1:1 supervision for Resident #144.Review of Resident # 101's physician orders dated 3/19/2026 read, Place resident on 1:1 observation due to fall risk until further notice, every shift. Review of the assignment sheets did not contain documentation for a 1:1 scheduled sitter for Resident #144 on 11p-7a for 3/4/2026, 3/10/2026, 3/16/2026, 3/18/2026, and 3/22/2026 through 3/25/2026.Review of the assignment sheets did not contain documentation for a 1:1 scheduled sitter for Resident #101 on the 11p-7a shift for 3/23/2026, 3/24/2026, and 3/25/26.During an interview on 03/23/2026 at 05:58 AM, Staff I, LPN stated she was responsible for 53 residents with three CNAs, one assigned to 1:1 observation. She reported ongoing staffing issues, including repeated no call/no show staff and inability to reach on-call staff, stating, You can never get in touch with the on-call because they leave the phone here at the facility. During an interview on 03/23/2026 at 06:15 AM, Staff J, CNA stated that when assigned as a 1:1 sitter, she does not assist other residents, including responding to call lights. She further reported that even with typical assignments of 18-19 residents, there is a delay in response times, we have to make the residents wait.During an interview on 3/23/2026 at 06:27 AM with Staff K, RN float stated, The facility tries to staff but there are too many call outs, and the staff can't get replaced. There is no assistance from the ADON (Assistant Director of Nursing) or DON (Director of Nursing). There are normally only four nurses on at night and one of those nurses is a float and has to move from North wing to South wing to take residents. There is no supervisor on for nights. During an interview on 03/23/2026 at 06:40 AM, Staff L, LPN stated, There has been occasions where he had only one CNA assigned to 26 residents, resulting in delays in providing care, including delayed assistance with incontinence care that results in complaints of not providing care timely.During an interview on 3/23/2026 at 07:22 AM with Staff M, CNA who works 11p-7a and 3p-11p shifts stated, I was assigned 22 residents last night because [Staff I, LPN's name] took all the independent residents, or I would have had a lot more.During an interview on 03/23/2026 at 07:31 AM, Staff N, CNA reported being assigned to 28 residents alone on a prior shift and stated she was unable to provide care timely, with residents frequently complaining about unanswered call lights. We have to initiate morning care as early as 4:00 AM to compensate for staffing shortages, we have delays in obtaining assistance for two-person transfers and are frequently prioritizing tasks due to the heavy workload.During an interview on 3/23/2026 at 10:40 AM Resident #83 stated, There is a delay on all shifts for staff to assist. I have actually had to wait for four hours for my call light to be answered, and the staff would finally come in but they tell me that they are short staffed. When they knew you were coming in they started cleaning up around my bed. This machine [pointed at the cpap - continuous positive airway pressure machine] is supposed to be cleaned weekly but I have to clean it or my sister cleans it. The food is terrible and they only give you a very small portion. Some of the nurses and staff are good; they care but others just don't care. Finally, I got my appointments that I needed but it took forever. During an interview on 3/23/20256 at 12:18 PM Resident #98 stated, One night I had to wait several hours to be changed [incontinent care]. I asked multiple times for help, but they told me that they did not have time because they were short staffed. I did complain to someone in administration. I don't remember who I talked to.During an interview on 3/23/2026 at 12:42 PM Resident #77 stated, the staff are slow to help her, I think they avoid me I've had multiple nights that I have not received my medications. I've told the nurses. During an interview on 3/23/2026 at 1:18 PM Resident #11 stated that she has had a couple of nights that she has not received her medications, and she has told the nurses that she did not get her medications on night shift.During an interview on 03/24/2026 at 3:10 PM, Staff G, LPN, stated, I worked a double on March 4th going into the 5th 3-11 and 11-7, and March 10th and March 15, I worked 16-hour shifts coming in at 3 PM and working until 7 AM. They were very short of staff during that time, and I was working about six days per week. There have been occasions where I have had the whole floor, 56 patients. It happened right before you all came in, early March or late February. I have noticed that a lot of times there are names on the schedule, but the nurse never shows up. We no longer have an on-call person, the on-call phone stays in the facility. They have been short staffed the whole time. I think the new staff they hire see there are no supplies, and no support and they leave. There have been three nights I have had to come in and take 56 patients. I cannot remember the dates.During a telephone interview on 3/28/2026 at 7:45 PM Staff Y, LPN stated, The leadership would leave at the end of the day around 4 - 5 o'clock PM knowing that we are short staffed and at times with only three nurses for the building. The DON and ADON were aware of the shortages but did not care and did not stay. Corporate came in about a month ago because of staffing but there was no change. I no longer work at the facility, it [the facility] is unsafe. During an interview on 03/25/2026 at 3:00 PM, the Staffing Coordinator stated staffing is scheduled based on acuity and planned staffing includes multiple CNAs per unit. We do have ongoing call-offs and I have had a few scheduling inaccuracies. I've placed the dates in wrong for the weeks and the staff show up on the wrong dates, and they are not really scheduled. That is what happened to 3/22/2026 on Sunday night. I had entered the wrong week. So, she [Staff P, CNA] showed on the schedule but she really was not supposed to work. I was not aware of this until Monday [3/23/2026] when I came into work. I have reported staffing concerns to the ADON and DON. Also, I've informed them that the on-call phone had been left in the facility, limiting access to after-hours staffing support. We met yesterday and discussed options on how staff could get in touch with the on-call person.During an interview on 03/25/2026 at 3:30 PM, the Assistant Director of Nursing (ADON) confirmed staffing is based on established ratios; however, staff are expected to redistribute workloads when shortages occur. The staff may need to float between units. The nurses will need to make this decision and reassign as needed. We do not have a night supervisor at this time. The on-call staff may not respond immediately but will respond when they can. The South Wing assignment of 53 residents [on Sunday night 3/22/26 going into 3/23/26 AM] was not consistent with expected staffing but CNA's and nurses from other areas are expected to float and assist as needed. The white boards [assignment boards] should be updated with each shift that is part of my rounds, but we get busy and I didn't catch that the boards were not up to date. The ADON verified the communication board for the North wing had not been updated since 3/19/2026. (Photographic evidence obtained). During an interview on 3/25/2026 at 4:00 PM, Staff G, Licensed Practical Nurse (LPN), stated, She [Resident #11] received all her meds. I gave all the residents their medications but forgot to go back and document that the medication was given on the 10th and 15th of March. I have so many residents at times that I just give the medications and don't document until the end of my shift. I probably got so tired that I could not stay any longer and did not document. I know that I have a problem with not documenting timely, but I'm working on my documentation.During an interview on 03/25/2026 at 4:07 PM, the Director of Nursing (DON) stated staff are expected to contact leadership when staffing issues arise and redistribute assignments; however, I was not notified of the staffing shortage on the night of the observation [3/23/2026].During an interview with the Administrator on 3/26/2026 at 2:30 PM the Administrator stated that she is ultimately responsible for the facility and oversees the DON. She was not aware of the staffing issues on 3/23/26 because AHCA [Agency for Health Care Administration] had arrived and normal processes and meetings came to a stop but normally she is informed during the AM meetings of any issues related to staffing. There is no Process Improvement in process related to short staffing. Review of the policy and procedure titled Staffing dated 2/24/2026 read, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.During an observation on 3/25/2026 at 8:50 AM, Staff AA, Licensed Practical Nurse (LPN), exited a resident's room and walked to the medication cart, and poured medications for Resident #142 without performing hand hygiene. Staff AA entered Resident #142's room, did not perform hand hygiene, handed the resident his medication and handed the resident a Styrofoam cup to drink water, touching the straw. Staff AA exited Resident #142's room without performing hand hygiene. Staff AA began to pour Resident #76's medication. Staff AA walked to Resident #76's room without performing hand hygiene. Resident #76 was in the restroom. Staff AA returned to the medication cart and performed hand hygiene.During an interview on 3/25/2026 at 9:25 AM, Staff AA, LPN, stated, I should have performed hand hygiene in between residents.Review of the facility policy and procedure titled Hand Hygiene with the last review date of 2/24/2026 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards or practice. Hand Hygiene Table: Between resident contacts. Before preparing, or handling medications.During an observation on 3/25/2026 at 9:35 AM, Staff Z, LPN, entered Resident #87's room and administered medication via gastrostomy tube. Staff Z did not rinse the flush syringe after finishing the medication administration and stored the syringe in a plastic package.During an interview on 3/25/2026 at 9:53 AM, Staff Z, LPN, stated, I should have rinsed the syringe after I was finished.During an interview on 3/25/2026 at 1:39 PM, the Assistant Director of Nursing stated, Staff should make sure that they are washing between each resident. Gastric tube flush syringe should be rinsed after they are used.During an interview on 3/26/2026 at 9:11 AM, the Director of Nursing stated, The syringe should be washed and dried before being placed back into the packaging after being used.Review of the facility policy and procedure titled Medication Administration via Enteral Tube with the last review date of 2/24/2026 read, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practices guidelines.During an observation on 3/23/2026 at 9:30 AM, the laundry facility door was unsecured while walking down the service hall to the kitchen. The door heading into the washing machine and dryer area was propped open. The door into the soiled linens area was propped open, and there were linen bins with items hanging out within the service hallway area.During an observation on 3/25/2026 at 6:04 AM, Staff CC, Laundry Technician, was exiting the laundry room with a cart. The soiled room door was propped open into the washer room area.During an observation on 3/25/2026 at 12:43 PM with the Housekeeping Supervisor, the soiled linen room's door was propped open with a black air mover blower fan. The room opened into the clean area of the laundry room.During an interview on 3/25/2026 at 12:47 PM, the Housekeeping Supervisor confirmed the soiled linen room door was open and stated, The door should not be open. We need to keep it closed.During an interview on 3/26/2026 at 9:11 AM, the Director of Nursing stated, The soiled room door should remain closed and not propped open. It serves as a barrier from the dirty to the clean area.Review of the facility policy and procedure titled Laundry with the last review date of 2/24/2026 read, Policy: The facility launders linens and clothing in accordance with current CDC [Centers for Disease Control and Prevention] guidelines to prevent transmission of pathogens.During an interview on 3/25/2026 at 8:45 AM, Staff S, LPN Unit Manager, stated, They moved [Resident #49's name] to [room number] for isolation. The NP [Nurse Practitioner] saw him yesterday and diagnosed him with shingles.During an observation on 3/25/2026 at 9:56 AM, Staff B, CNA (Certified Nursing Assistant), was adjusting Resident #49's pillows and blankets while the resident was lying in bed. Staff B was not wearing a gown.During an interview on 3/25/2026 at 9:59 AM, Staff B, CNA, stated, They told me in report he [Resident #49] has shingles, so they basically said to be careful with that. I was not wearing a gown. I should have had a gown on.Review of Resident #49's physician order dated 3/24/2026 read, Resident on contact isolation for shingles every shift until 04/01/2026 23:59 [11:59 PM]. Order Status: Active.During an interview on 3/25/2026 at 4:26 PM, the Director of Nursing stated, Residents with shingles should be on contact precautions, which requires a gown, mask and gloves. The CNA should have worn a gown when in the room and providing care for [Resident #49's name].Review of the policy and procedure titled Infection Control-Standard and Transmission-Based Precautions with the last review date of 2/24/2026 read, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines. 14. Contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such a multi-drug resistant organism (MDRO). a. Staff are to put on gowns and gloves upon room entry and remove gowns and gloves upon exit of resident room.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen environment, increasing the risk of contamination, foodborne illness, and infection.Findings include:During an observation on 3/23/2026 beginning at 9:32 AM in the kitchen there was food debris and residue present under the food prep tables, missing floor tiles in multiple areas around the kitchen exposing holes in the walls, and a live roach crawling on the wall.During an observation on 03/25/2026 at 11:30 AM in the kitchen there was food debris and residue present under the food preparation tables, grease residue present on the kitchen walls, dried food splatter on kitchen walls and ceiling, holes present in the kitchen walls and baseboard areas, large areas of missing floor tiles exposing concrete surfaces, a live roach observed crawling on the wall above the dishwashing area, multiple live roaches observed crawling from behind a metal plate affixed to the wall near the dishwashing area, food debris present on a cart used for food preparation, and an accumulation of food debris and residue near the kitchen doorways. (Photographic evidence obtained)During an interview on 03/25/2026 at 3:14 PM, the Regional Dietary Manager stated that the kitchen condition was unsanitary and not in accordance with corporate standards.Review of the facility policy and procedure titled Food and Nutritional Services, with a last review date of 02/24/2026, read, The facility will store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for resident access to accommodate room lighting on 3 of 3 hallways and failed to ensure all telephones and window blind mechanisms were in working order.Findings include: 1) During an observation on 3/23/2026 at 9:40 AM there was a light fixture on the wall behind the resident's bed. There was no cord attached to the light fixture that would enable the resident to engage the light. The light was off behind Resident #127's bed. During an interview on 3/23/2026 at 9:40 AM Resident #127 stated, There is no cord on the light for me to turn the light on or off. During observations on 3/24/2025 beginning at 12:00 PM of the 100 and 200 hall a total of eight residents on the 100 hall, Residents #127, #59, #1, #100, #132, #121, #72, and #16; and nine residents on the 200 hall, Residents #54, #49, #6, #26, #104, #85, #105, #139 and #25 did not have a pull cord attached to the light to enable the residents to turn the light on and off that was located behind their beds. During observations on 3/24/2026 beginning at 1:20 PM of the 300 hallway with the Director of Plant Operations and the Administrator residents' rooms for Residents #67, #96, #159, #106, and #110, did not have a pull cords to enable the residents to turn on the light attached to the wall behind the bed. During an interview on 3/24/2026 at 1:34 PM the Director of Plant Operations and the Administrator confirmed the light cords behind the residents' beds were not accessible for the residents. During an interview on 3/24/2026 at 1:35 PM the Director of Plant Operations stated, The light cords need to be fixed. Review of facility policy and procedures titled, Preventative Maintenance Program with a last review date 2/24/2026, read, Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for resident, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining scheduled maintenance services to ensure that buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in Maintenance Director's office. 2) During an observation on March 23, 2026, at 10:40 AM, in Residents #48's room, the window blind draw strings on either side of the blinds were broken. The blinds could not be raised properly by the staff or the resident. The phone line cable was hanging out of the wall, the wall plate outlet box did not have a cover over it, and when the phone was plugged in there was no dial tone. (Photographic evidence obtained). During an interview on March 23, 2026, at 10:40 AM, Resident #48 commented she was unhappy because her room phone was not working and the blinds did not work right. The staff was told about these problems before, but nothing was fixed. Review of the work order log documented two requests for phone repairs and one request for blind repairs for Resident #48's room. The first phone request was made on December 14, 2025, and closed on January 2, 2026. The second phone request was made on February 9, 2026, and closed on February 17, 2026. The blind request was made on February 7, 2026, and closed on March 4, 2026. During an interview on March 24, 2026, at 12:30 PM, Staff D, Director of Plant Operations, said parts for the phone jack had to be ordered from [name of the business] in Pompano Beach. The technician comes from [NAME] to fix the phone lines. The work orders are closed after the phone line is fixed. The resident pulled on the phone cord, which caused the phone to stop working. Staff D stated he was not aware the phone wall plate came off the wall and the phone cord was hanging. The blinds are ordered through a company called [name of the company]. I wait until two or three blinds need to be replaced before placing an order because each one costs $80. Review was conducted on March 24, 2026, and documented an order for window blinds was completed on March 24, 2026. (Photographic evidence obtained) During an interview on March 24, 2026, at 12:58 PM Staff D, Director of Plant Operations stated, the order for three new blinds was placed at 12:56 PM today. Review of emails documented a date of March 24, 2026, requesting an update related to the phone repair for Resident #48's room. An email from the Chief Information Officer stated the phone issue was escalated to a Priority 1 and currently under review with the facility's Information Technology Department. The email stated an anticipated correction within 30 days or less. (Photographic evidence obtained). 3) During an observation on 03/25/2026 at 10:35 AM, the wall located along the baseboard area below the air conditioning unit in Resident #86's room was noted to be in disrepair. The baseboard covering was detached and the lower portion of the wall had visibly damaged wallboard with sections of missing and crumbling material. An electrical cord was observed running through the damaged area. (Photographic evidence obtained) During an interview on 03/25/2026 at 10:40 AM, Staff D, Director of Plant Operations stated, I did not know the baseboard was broken, [Resident #86's room].

Based on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurate for 3 of 4 residents, Residents #2, #11, and #28, assessed for accuracy of PASRR.Findings Include: 1) Review of Resident #11's clinical record documented the resident was admitted on [DATE] with a diagnosis to include adjustment disorder with depressed mood. Review of Resident #1's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) dated 10/22/2025 did not document any mental illness. Review of Resident #11's physician orders dated 10/23/2025 read Trazodone HCL oral tablet 50 mg give 1 tablet by mouth at bedtime for depression Record review of Resident #11's Psychiatry Subsequent Note by (Name of the Psychiatry service) dated 12/2/2025 read, Trazodone HCL oral tablet 50 mg give 1 tablet by mouth at bedtime for depression. The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks During an interview on 3/25/2026 at 10:00 AM the Director of Nursing stated, The PASARR should have been redone with the diagnosis of depression listed In the history. 2) Review of Resident #2's Psychiatric Subsequent Note dated 12/11/2025 documented diagnosis to include depression, anxiety and dementia and read, MDD (Major Depressive Disorder), recurrent: the history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use of organic brain pathology. During an interview on 3/24/2026 at 4:00 PM the Regional Nurse Consultant stated, The PASRR is incorrect and should have included all of the residents mental illness including depression. 3) Review of Resident #28's Psychiatric Subsequent Note dated 11/25/2025 documented diagnosis to include depression and anxiety and read, MDD, recurrent: the history suggest that the patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use or organic brain pathology. Review of Resident #28's PASRR dated 3/31/2023 revealed in Section I, PASRR Screen Decision Making, subsection A: MI (mental illness) or suspected MI (check all that apply) the resident does not have any suspected or known MI noted. During an interview on 3/24/2026 at 4:00 PM the Regional Nurse Consultant, stated the PASRR was incorrect and should have included all of the residents mental illness including depression and anxiety. Review of the facility policy and procedure titled Resident Assessment-Coordination with PASARR Program with a last approval date of 2/24/2026 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or related condition receives the care and services in the most integrated setting appropriate to their needs.

Based on record review, observation, and staff interviews, the facility failed to ensure sufficient nursing staff and an effective staffing system was in place to meet resident needs. Findings include:During an observation on 03/23/2026 at 05:30 AM, there were three vehicles in the facility parking lot. Upon entry into the facility an observation was made of minimal staff presence and one call light was persistently ringing in room [ROOM NUMBER].During the initial tour on 03/23/2026 at 5:35 AM of the North, South, and East Wings, several residents were observed awake. Discrepancies were identified on staffing communication boards, staffing assignment sheets, and actual clinical staff present in the facility. Total midnight census for residents was 129, included in the total were two residents ordered for one-on-one sitter observation, Residents #101 and #144. There were four registered nurses (RN) and five Certified Nursing Assistances physically present in the building. During an observation on 3/23/2026 at 05:50 AM of the North Wing communication board it documented the board was last updated on 03/19/2026. The documented names did not match the staffing sheet. (Photograph evidence obtained). During an observation on 3/23/2026 at 06:10 AM the South Wing communication board was in the process of being updated for the on-coming 7a-7p shift for 3/23/2026. The communication board did not match the staffing assignment sheet. The census was 53 residents. (Photograph evidence obtained).Review of the daily nursing assignment sheet for the South Wing (Rooms 101-129) documented Staff I, Licensed Practice Nurse (LPN), Staff M, Certified Nursing Assistant (CNA), Staff P, CNA, Staff J, CNA, and Staff Q, CNA, the census was 53 residents. (Photographic evidence obtained). The staffing for the South Wing consisted of one LPN and four CNAs for the census of 53 residents, included in this total were two residents, Residents #144 and #101 who were ordered for 1:1 supervision.During an observation conducted on 3/23/2026 at approximately 6:10 AM to verify the staffing schedule. Staff P, CNA was not located. A request was made to meet Staff P, CNA. When requested staff stated Staff P, CNA was not known to them. This resulted in one LPN and three CNAs to provide care and assistance for the resident census of 53 with two of the residents have physician ordered 1:1 supervision. During an observation on 3/23/2026 at 06:15 AM Resident #144 was lying in bed. There was no staff in the room providing the physician ordered 1:1 supervision.During an observation on 03/23/2026 at 6:16 AM of Resident #101, Staff J, CNA was providing 1:1 supervision for the resident which prevented Staff J from providing assistance to other residents.Review of Resident #144's physician orders dated 2/26/2026 read, 1:1 supervision. There was no documentation in the resident's record, no physician order, or communication with the physician to discontinue 1:1 supervision for Resident #144.Review of Resident # 101's physician orders dated 3/19/2026 read, Place resident on 1:1 observation due to fall risk until further notice, every shift. Review of the assignment sheets did not contain documentation for a 1:1 scheduled sitter for Resident #144 on 11p-7a for 3/4/2026, 3/10/2026, 3/16/2026, 3/18/2026, and 3/22/2026 through 3/25/2026.Review of the assignment sheets did not contain documentation for a 1:1 scheduled sitter for Resident #101 on the 11p-7a shift for 3/23/2026, 3/24/2026, and 3/25/26.During an interview on 03/23/2026 at 05:58 AM, Staff I, LPN stated she was responsible for 53 residents with three CNAs, one assigned to 1:1 observation. She reported ongoing staffing issues, including repeated no call/no show staff and inability to reach on-call staff, stating, You can never get in touch with the on-call because they leave the phone here at the facility. During an interview on 03/23/2026 at 06:15 AM, Staff J, CNA stated that when assigned as a 1:1 sitter, she does not assist other residents, including responding to call lights. She further reported that even with typical assignments of 18-19 residents, there is a delay in response times, we have to make the residents wait.During an interview on 3/23/2026 at 06:27 AM with Staff K, RN float stated, The facility tries to staff but there are too many call outs, and the staff can't get replaced. There is no assistance from the ADON (Assistant Director of Nursing) or DON (Director of Nursing). There are normally only four nurses on at night and one of those nurses is a float and has to move from North wing to South wing to take residents. There is no supervisor on for nights. During an interview on 03/23/2026 at 06:40 AM, Staff L, LPN stated, There has been occasions where he had only one CNA assigned to 26 residents, resulting in delays in providing care, including delayed assistance with incontinence care that results in complaints of not providing care timely.During an interview on 3/23/2026 at 07:22 AM with Staff M, CNA who works 11p-7a and 3p-11p shifts stated, I was assigned 22 residents last night because [Staff I, LPN's name] took all the independent residents, or I would have had a lot more.During an interview on 03/23/2026 at 07:31 AM, Staff N, CNA reported being assigned to 28 residents alone on a prior shift and stated she was unable to provide care timely, with residents frequently complaining about unanswered call lights. We have to initiate morning care as early as 4:00 AM to compensate for staffing shortages, we have delays in obtaining assistance for two-person transfers and are frequently prioritizing tasks due to the heavy workload.During an interview on 3/23/2026 at 10:40 AM Resident #83 stated, There is a delay on all shifts for staff to assist. I have actually had to wait for four hours for my call light to be answered, and the staff would finally come in but they tell me that they are short staffed. When they knew you were coming in they started cleaning up around my bed. This machine [pointed at the cpap - continuous positive airway pressure machine] is supposed to be cleaned weekly but I have to clean it or my sister cleans it. The food is terrible and they only give you a very small portion. Some of the nurses and staff are good; they care but others just don't care. Finally, I got my appointments that I needed but it took forever. During an interview on 3/23/20256 at 12:18 PM Resident #98 stated, One night I had to wait several hours to be changed [incontinent care]. I asked multiple times for help, but they told me that they did not have time because they were short staffed. I did complain to someone in administration. I don't remember who I talked to.During an interview on 3/23/2026 at 12:42 PM Resident #77 stated, the staff are slow to help her, I think they avoid me I've had multiple nights that I have not received my medications. I've told the nurses. During an interview on 3/23/2026 at 1:18 PM Resident #11 stated that she has had a couple of nights that she has not received her medications, and she has told the nurses that she did not get her medications on night shift.During an interview on 03/24/2026 at 3:10 PM, Staff G, LPN, stated, I worked a double on March 4th going into the 5th 3-11 and 11-7, and March 10th and March 15, I worked 16-hour shifts coming in at 3 PM and working until 7 AM. They were very short of staff during that time, and I was working about six days per week. There have been occasions where I have had the whole floor, 56 patients. It happened right before you all came in, early March or late February. I have noticed that a lot of times there are names on the schedule, but the nurse never shows up. We no longer have an on-call person, the on-call phone stays in the facility. They have been short staffed the whole time. I think the new staff they hire see there are no supplies, and no support and they leave. There have been three nights I have had to come in and take 56 patients. I cannot remember the dates.During an interview on 3/25/2026 at 4:00 PM, Staff G, Licensed Practical Nurse (LPN), stated, She [Resident #11] received all her meds. I gave all the residents their medications, but forgot to go back and document that the medication was given on the 10th and 15th of March. I have so many residents at times that I just give the medications and don't document until the end of my shift. I probably got so tired that I could not stay any longer and did not document. I know that I have a problem with not documenting timely, but I'm working on my documentation.During a telephone interview on 3/28/2026 at 7:45 PM Staff Y, LPN stated, The leadership would leave at the end of the day around 4 - 5 o'clock PM knowing that we are short staffed and at times with only three nurses for the building. The DON and ADON were aware of the shortages but did not care and did not stay. Corporate came in about a month ago because of staffing but there was no change. I no longer work at the facility, it [the facility] is unsafe. During an interview on 03/25/2026 at 3:00 PM, the Staffing Coordinator stated staffing is scheduled based on acuity and planned staffing includes multiple CNAs per unit. We do have ongoing call-offs and I have had a few scheduling inaccuracies. I've placed the dates in wrong for the weeks and the staff show up on the wrong dates, and they are not really scheduled. That is what happened to 3/22/2026 on Sunday night. I had entered the wrong week. So, she [Staff P, CNA] showed on the schedule but she really was not supposed to work. I was not aware of this until Monday [3/23/2026] when I came into work. I have reported staffing concerns to the ADON and DON. Also, I've informed them that the on-call phone had been left in the facility, limiting access to after-hours staffing support. We met yesterday and discussed options on how staff could get in touch with the on-call person.During an interview on 03/25/2026 at 3:30 PM, the Assistant Director of Nursing (ADON) confirmed staffing is based on established ratios; however, staff are expected to redistribute workloads when shortages occur. The staff may need to float between units. The nurses will need to make this decision and reassign as needed. We do not have a night supervisor at this time. The on-call staff may not respond immediately but will respond when they can. The South Wing assignment of 53 residents [on Sunday night 3/22/26 going into 3/23/26 AM] was not consistent with expected staffing but CNA's and nurses from other areas are expected to float and assist as needed. The white boards [assignment boards] should be updated with each shift that is part of my rounds, but we get busy and I didn't catch that the boards were not up to date. The ADON verified the communication board for the North wing had not been updated since 3/19/2026. (Photographic evidence obtained). During an interview on 03/25/2026 at 4:07 PM, the Director of Nursing (DON) stated staff are expected to contact leadership when staffing issues arise and redistribute assignments; however, I was not notified of the staffing shortage on the night of the observation [3/23/2026].During an interview with the Administrator on 3/26/2026 at 2:30 PM the Administrator stated that she is ultimately responsible for the facility and oversees the DON. She was not aware of the staffing issues on 3/23/26 because AHCA [Agency for Health Care Administration] had arrived and normal processes and meetings came to a stop but normally she is informed during the AM meetings of any issues related to staffing. There is no Process Improvement in process related to short staffing. Review of the policy and procedure titled Staffing dated 2/24/2026 read, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, failed to ensure staff sanitized enteral medication flush syringe, failed to ensure an infection control barrier was provided in the laundry room, and failed to ensure staff used appropriate PPE (Personal Protective Equipment) for the residents on transmission based precautions to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 3/25/2026 at 8:50 AM, Staff AA, Licensed Practical Nurse (LPN), exited a resident's room and walked to the medication cart, and poured medications for Resident #142 without performing hand hygiene. Staff AA entered Resident #142's room, did not perform hand hygiene, handed the resident his medication and handed the resident a Styrofoam cup to drink water, touching the straw. Staff AA exited Resident #142's room without performing hand hygiene. Staff AA began to pour Resident #76's medication. Staff AA walked to Resident #76's room without performing hand hygiene. Resident #76 was in the restroom. Staff AA returned to the medication cart and performed hand hygiene. During an interview on 3/25/2026 at 9:25 AM, Staff AA, LPN, stated, I should have performed hand hygiene in between residents. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 2/24/2026 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards or practice. Hand Hygiene Table: Between resident contacts. Before preparing, or handling medications. 2) During an observation on 3/25/2026 at 9:35 AM, Staff Z, LPN, entered Resident #87's room and administered medication via gastrostomy tube. Staff Z did not rinse the flush syringe after finishing the medication administration and stored the syringe in a plastic package. During an interview on 3/25/2026 at 9:53 AM, Staff Z, LPN, stated, I should have rinsed the syringe after I was finished. During an interview on 3/25/2026 at 1:39 PM, the Assistant Director of Nursing stated, Staff should make sure that they are washing between each resident. Gastric tube flush syringe should be rinsed after they are used. During an interview on 3/26/2026 at 9:11 AM, the Director of Nursing stated, The syringe should be washed and dried before being placed back into the packaging after being used. Review of the facility policy and procedure titled Medication Administration via Enteral Tube with the last review date of 2/24/2026 read, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practices guidelines. 3) During an observation on 3/23/2026 at 9:30 AM, the laundry facility door was unsecured while walking down the service hall to the kitchen. The door heading into the washing machine and dryer area was propped open. The door into the soiled linens area was propped open, and there were linen bins with items hanging out within the service hallway area. During an observation on 3/25/2026 at 6:04 AM, Staff CC, Laundry Technician, was exiting the laundry room with a cart. The soiled room door was propped open into the washer room area. During an observation on 3/25/2026 at 12:43 PM with the Housekeeping Supervisor, the soiled linen room's door was propped open with a black air mover blower fan. The room opened into the clean area of the laundry room. During an interview on 3/25/2026 at 12:47 PM, the Housekeeping Supervisor confirmed the soiled linen room door was open and stated, The door should not be open. We need to keep it closed. During an interview on 3/26/2026 at 9:11 AM, the Director of Nursing stated, The soiled room door should remain closed and not propped open. It serves as a barrier from the dirty to the clean area. Review of the facility policy and procedure titled Laundry with the last review date of 2/24/2026 read, Policy: The facility launders linens and clothing in accordance with current CDC [Centers for Disease Control and Prevention] guidelines to prevent transmission of pathogens. 4) During an interview on 3/25/2026 at 8:45 AM, Staff S, LPN Unit Manager, stated, They moved [Resident #49's name] to [room number] for isolation. The NP [Nurse Practitioner] saw him yesterday and diagnosed him with shingles. During an observation on 3/25/2026 at 9:56 AM, Staff B, CNA (Certified Nursing Assistant), was adjusting Resident #49's pillows and blankets while the resident was lying in bed. Staff B was not wearing a gown. During an interview on 3/25/2026 at 9:59 AM, Staff B, CNA, stated, They told me in report he [Resident #49] has shingles, so they basically said to be careful with that. I was not wearing a gown. I should have had a gown on. Review of Resident #49's physician order dated 3/24/2026 read, Resident on contact isolation for shingles every shift until 04/01/2026 23:59 [11:59 PM]. Order Status: Active. During an interview on 3/25/2026 at 4:26 PM, the Director of Nursing stated, Residents with shingles should be on contact precautions, which requires a gown, mask and gloves. The CNA should have worn a gown when in the room and providing care for [Resident #49's name]. Review of the policy and procedure titled Infection Control- Standard and Transmission-Based Precautions with the last review date of 2/24/2026 read, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines. 14. Contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such a multi-drug resistant organism (MDRO). a. Staff are to put on gowns and gloves upon room entry and remove gowns and gloves upon exit of resident room.

Based on interview and record review the facility failed to encode and transmit the resident discharge assessment for 1 of 3 residents, Resident #136, reviewed for minimum data set [MDS] completion. Findings include:Review of Resident #136's medical record documented the resident was discharged on 11/11/2025.Review of Resident #136's Minimum Data Set (MDS) did not document a Discharge MDS Assessment. During an interview on 3/24/2026 at 3:08 PM Staff C, Licensed Practical Nurse Lead MDS Coordinator, stated, [Resident #136's name] discharge assessment was never done. We would have had to do the assessment so it can register.Review of the facility policy and procedure titled Resident assessment Instrument with a last approval date of 2/24/2026 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. This 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. Procedure: 6. Quarterly assessments are also done for residents every 3 months, at least every 92 days following a comprehensive assessment. Annual, entry, discharge, and re-entry assessments are completed following the guidelines indicated in the Final Rule and the RAI [Resident Assessment Instrument] MDS Version 3.0 Guidelines.

Based on observation, interview and record review, the facility failed to ensure resident assessments were accurate and reflected the resident's current status for 3 of 12 residents, Residents #17, #50, and #152, reviewed for Minimum Data Set (MDS) accuracy.Findings include: 1) During an observation on March 23, 2026, at 11:53 AM of Resident #50, the resident had no teeth. Review of the Modification of Annual Minimum Data Set, dated [DATE], documented under Section L for Oral/Dental Status subsection B which asks does the resident have no natural teeth or tooth fragments, it was marked No. During an interview on March 25, 2026, at 10:23 AM, Staff C, LPN stated the entry of no for No natural teeth or tooth fragments was marked incorrectly. Review of the resident's denture appointment documentation from [name of local dental service] dated September 19, 2025, indicated Resident #50 had no teeth. 2) Record review of occupational therapy Discharge summary dated [DATE] for Resident #17 documented a past medical history to include transient ischemic attack (TIA), bilateral foot drop and left hemiparesis. Review of the significant change MDS dated [DATE] documented under Section: GG functional abilities, subsection B, Functional Limitation in Range of Motion, was coded as 0 - no impairment for lower extremities. Documented under Section I, Active Diagnoses, subsection Neurological, did not include coding for TIA or hemiplegia. During an interview on 3/25/2026 at 3:08 PM with Staff C, LPN stated that Section GG, subsection functional limitation in range of motion was coded incorrectly and should be coded for impairment on both sides of lower extremity. She also stated that Section I active diagnosis, subsection neurological should have both TIA and hemiplegia coded, which it was not. 3) Review of Resident #152's clinical record documented an admission date of 1/29/2026 with medical diagnosis to include history of falls, muscle weakness, and adult failure to thrive. Review of Resident #152's Minimum Data Set (MDS) dated [DATE] documented Discharge returns not anticipated. Documented section A2105-01. Home community. During an interview on 3/24/2026 at 12:50 PM with Staff E, Social Services stated, The resident and family requested for her [ Resident #152] to be transferred to [a local skilled nursing facility's name]. During an interview on 3/23/2026 at 1:10 PM the Director of Social Services stated, She [Resident #152] was transfer to [name of local skilled nursing facility]. During an interview on 3/23/2026 at 1:36 PM Staff F, License Practical Nurse (LPN) MDS stated that section A-2105 Discharge status was coded 01. Home/community in error and the correct discharge status should have been 02. Skilled nursing facility. Review of the facility policy and procedure titled Resident assessment Instrument with a last approval date of 2/24/2026 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. This 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. Procedure: 6. The assessment will accurately reflect the resident's status.

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive, person-centered care plan for 3 of 12 residents, Residents #8, #17, and #28, reviewed for comprehensive, person-centered care plans. Findings Include: 1) During an observation on 3/23/2026 at 9:30 AM Resident #8 was sleeping and did respond to being addressed by name. Resident was dressed and lying in bed covered with a blanket. The head of the bed was elevated. During an interview on 3/23/2026 at 4:30 PM the Director of Nursing (DON) stated, She [Resident #8] is on hospice. A request was made to review Resident #8's care plan for hospice. The DON said the resident stated she did not want hospice and then wanted hospice. [Resident #8's name] should have an order for hospice and have a care plan for hospice. During an interview on 3/24/2026 at 8:20 AM Business Office Manager (BOM) provided a Change in [NAME] form for Resident #8 and stated, Here is the hospice information about the Resident. Review of the Long Term Care Facility-Change in [NAME] form for Resident #8 read, This is to advise that effective, 02/18/2026 the resident named above [Resident #8's name] is admitted to [Name of Hospice]. Box checked Medicaid/Cal (Facility bills [Name of Hospice]) at their daily room and board rate. Facility does not bill Medicaid/care for Room and Board. The form was signed by the Business Office Manager and the hospice representative on 2/19/2026. Review of (Name of Hospice) Medicare Hospice Benefit Election documented the resident signed the form on 2/18/2026 at 10:28 AM During an interview on 3/24/2026 at 9:22 AM BOM stated [NAME] was changed on the day that the Resident signed the paperwork with hospice. Review of Resident #8's care plan did not document the resident was under the care of hospice and hospice services. During an interview on 3/25/2026 at 4:10 PM the MDS (Minimum Data Set assessment) Coordinator, Licensed Practical Nurse (LPN) said the care plan had not been updated when the resident was put under the care of hospice. 2) During an observation on 03/23/2026 at 11:47 AM, Resident #17 was observed to have limited expressive communication, consisting primarily of yes/no or single-word responses with delayed response time. Review of Resident #17's medical record documented diagnoses to include other symptoms and signs involving cognitive functions and awareness, personal history of transient ischemic attack (TIA), unspecified voice and resonance disorder, dysphagia (oropharyngeal phase), primary progressive multiple sclerosis, and cognitive communication deficit. Review of Resident #17's comprehensive care plan did not have documentation of focus, goals, or interventions addressing the resident's communication deficit. During an interview on 03/25/2026 at 3:08 PM, Staff C, MDS stated the resident's care plan did not include a focus related to the communication deficit and acknowledged that it should have been included. 3) Review of Resident #28's physician order dated 06/07/2023 documented Chromium GTF [glucose tolerance factor] Oral Tablet, give 1 capsule by mouth one time a day for supplement, unsupervised self-administration. Dated 10/06/2025 Nattokinase Oral Capsule 100 mg, give 1 capsule by mouth one time a day for supplement, unsupervised self-administration. Review of Resident #28's Medication Administration Record (MAR) for March 2026 documented self-administration (SA) for Nattokinase and Chromium from 03/01/2026 through 03/24/2026. Review of Resident #28's comprehensive care plan did not document focus, goals, or interventions addressing the resident's ability to safely self-administer medications. During an interview on 03/24/2026 at 2:50 PM, Staff C, MDS stated the resident should have been care planned for self-administration of medications. Review of the policy and procedure titled, Care Planning-Interdisciplinary Team, with a last approval date of 2/24/2026, read Policy: The purpose of this policy is to outline the responsibility of the facility's Care Planning/Interdisciplinary Team in developing an individualized, comprehensive care plan for each resident. Policy Explanation and Compliance Guidelines: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment The care plan is based on the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which include, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Nurse Assessment Coordinator/MDS Coordinator; c. The Registered Nurse who is responsibility for the resident; d. The Manager/Dietitian e. The Social Services Worker responsible for the resident; f. The Activity Director/Coordinator; g. Therapist (speech, occupational, recreational, etc.), as applicable; h. Consultants (as appropriate); i. The Director of Nursing (as applicable); j. The Licensed Nurse responsible for resident care k. Nursing Assistants responsible for the resident's care; and l. Others as appropriate or necessary to meet the needs of the resident.

Based on interview, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 6 residents, Resident #86, reviewed for ADL care. Findings includeDuring an interview on 03/23/2026 at 2:04 PM Resident Representative for Resident #86 stated, They don't cut her [Resident #86's] nails, and her nails were digging into her palm the last time I saw her. During an observation on 03/24/2026 at 9:18 AM Resident #86's right hand was contracted into a closed position. The Resident's fingernails extended beyond her fingertips, touching the palm of her right hand.During an observation on 03/25/2026 at 8:53 AM, Resident #86 had a brace on her right arm and a washcloth in her right hand. The Resident's fingernails were approximately 1-1.5 inches long on her right thumb, right second finger, right third finger and right fourth finger. During an interview on 03/25/2026 at 10:31 AM, Staff A, CNA (Certified Nursing Assistant) stated, I'm planning on giving her a bath in a little while. Her nails are too long right now. The CNA who gave her a bath last time should have cut her nails.Review of Resident #86's care plan dated 01/29/2026 read, Focus: [Resident #86's name] requires assist w/adls [activities of daily living] d/t [due to] weakness, decreased mobility. Interventions: Resident is not able to assist and is totally dependent on staff for personal hygiene.Review of the policy and procedure titled, Activities of Daily Living (ADLS) Maintain Abilities review date 02/24/2026 read, It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shift and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene-bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to obtain the medication dosage prior to administration for 1 of 3 residents, Resident #84, and failed to ensure wound care treatment orders and wound care for 1 of 3 residents, Resident #157, observed for wounds. Findings include: Review of Resident #84's physician order dated 3/10/2026 read, Voltaren external gel 1% diclofenac sodium topical. Apply to knees topically before meals and at bedtime for pain. The required dosage for application is not documented. Review of Resident #84's Medication Administration Record for the period of 03/01/2026 to 03/25/2026 documented the Voltaren gel was administered. During an interview on 3/25/2026 at 1:46 PM, the Director of Nursing (DON) stated, The Voltaren order does not have a dosage. Review of my.clevelandclinic.org read, Voltaren Gel is a type of nonsteroidal anti-inflammatory drug (NSAID). This medication can cause serious bleeding, ulcers, or tears in the stomach. These problems can occur at any time and with no warning signs. They are more common with long-term use. Talk to your care team right away if you have stomach pain, bloody or black, tar-like stools, or vomit blood that is red or looks like coffee grounds. This medication increases the risk of blood clots, heart attack, and stroke. These events can occur at any time. They are more common with long-term use and in those who have heart disease. If you take aspirin to prevent a heart attack or stroke, talk to your care team. They can help you find an option that works for you. This medication may cause serious skin reactions. They can happen weeks to months after starting the medication. Talk to your care team right away if you have fevers or flu-like symptoms with a rash. The rash may be red or purple and then turn into blisters or peeling of the skin. Or you might notice a red rash with swelling of the face, lips, or lymph nodes in your neck or under your arms. Non-Steroidal Anti-Inflammatory Medicines (NSAIDs) disease or those risk factors. Heart problems caused by NSAIDs can happen within the first weeks of use, and may happen more frequently with higher doses or with long-term use. Do not take aspirin or other NSAIDs, such as ibuprofen or naproxen, while you are taking this medication. Review of the facility policy and procedure titled Medication Administration dated 2/24/2026 read Medications are administered by licensed nurses, 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. 10. Ensure that the six rights of medication administration are followed c. right dosage. Review of Resident #157's medical record documented diagnosis to include: fracture of superior rim of left pubis, non-displaced fracture of the anterior column of the left acetabulum, fracture of sacrum, cirrhosis of the liver, type 2 diabetes mellitus. During an observation on 3/23/2026 at 10:00 AM Resident #157 had dressing applied to the right forearm that was dated 3/16/2026. Review of Resident #157's physician orders did not document an order for a right forearm wound dressing. During an interview on 3/23/2025 at 10:50 AM the 100 hall Unit Coordinator stated I am not sure why the dressing is there and dated 3/16/2026. I will check to see if there is a note in the record or an order. There should be an order for a dressing, and the nurse should follow the physician order. Review of Resident #157's progress notes did not contain documentation relating to the right forearm injury.

Based on observation, interview and record review the facility staff failed to ensure that nebulizer mask stored after use consistent with professional standards of practice for 2 residents( Resident # 84 and Resident #121) of 6 Residents reviewed for respiratory care. Findings include:Findings include: 1) Review of Resident #84's clinical record documented the resident was admitted on [DATE] with diagnosis to include osteomyelitis (infection in the bone), acute respiratory failure, and pneumonia. During an observation on 3/23/2026 at 10:50 AM of Resident #84's room, the resident's nebulizer mask was lying across the nebulizer machine on the bedside table open to air and not in a bag. During an interview on 3/23/2026 at 10:50 AM Resident 84 stated, I take breathing treatments two times a day. I had the treatment this morning around 8 AM. During an observation on 3/23/2026 at 3:30 PM of Resident #84's room, the resident's nebulizer mask was lying across the nebulizer machine on the bedside table, open to air and not in a bag. Review of Resident #84's physician order dated 3/11/2026 read, Arformoterol tartrate inhalation nebulization solution 12 mcg [microgram]/2 ml [milliliters] (Arformoterol Tartrate) 2 milliliter inhale orally via nebulizer two times a day for sob [shortness of breath]. Review of Resident #84's physician orders dated 3/11/2026 read, Budesonide inhalation suspension 0.5mg/2ml (Budesonide (inhalation) 2 milliliter inhale orally two times a day for sob rinse with water after use to reduce aftertaste ad incidence of candidiasis do not swallow. Review of Resident #84's Medication Administration Record (MAR) documented arformoterol tartrate inhalation nebulization solution 15mcg/2 milliliters inhaled orally via nebulizer was administered 3/23/2026 morning dose. Review of Resident #84's MAR documented Budesonide inhalation suspension 0.5mg/2ml inhaled orally was administered 3/23/2026, morning dose. During an interview on 3/24/2026 at 2:58 Staff H, License Practical Nurse (LPN) stated, The nebulizer mask should be placed in a bag and covered after treatment. During an interview on 3/24/2026 at 3:35 PM the Director of Nursing stated, The nebulizer masks need to be placed in a bag and covered after each use. 2) Review of Resident #121's medical record documented the resident was admitted [DATE] with diagnosis of chronic pulmonary obstructive disease, type 2 diabetes mellitus. During an observation on 3/23/2026 at 9:44 AM of Resident #121's room, the oxygen mask for inhalation of medications was on the top of the resident's bed. (Photographic evidence obtained) During an observation on 3/23/2026 at 3:45 PM of Resident #121's room, the oxygen mask for inhalation was on the top of the resident's bed. During an interview on 3/23/2026 at 3:45 PM the Unit Coordinator stated, The mask should not be kept on the bed. It should be placed in a storage bag. Review of the policy and procedures titled Oxygen Administration with a last review date of 2/24/2026 read, Infection control measures included; keep delivery devices covered when not in use. 6. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 37 observations. The facility had a medication error rate of 5.41%.Findings include:During an observation on 3/25/2026 at 8:29 AM Staff BB, Licensed Practical Nurse (LPN) was preparing medications for Resident #100. Staff BB placed an 81 milligram (mg) chewable aspirin into the medication cup along with other prescribed medications. Prior to Staff BB entering Resident #100's room, the surveyor requested verification of the order for the 81 mg aspirin. During an interview on 3/25/2026 at 8:34 AM with Staff BB, LPN stated, [Resident #100's name] has an order for Aspirin 81 milligrams delayed release. I cannot interchange the two different Aspirins. I will have to go look for the medication in the medication room.Review of Resident #100's physician order dated 10/7/2025 read, Aspirin 81 Tablet Delayed Release 81 mg [milligram] (Aspirin) give 1 tablet by mouth one time a day for heart health.During an observation on 3/25/2026 at 8:50 AM Staff AA, LPN was preparing medications for Resident #142. Staff AA read the pre-record vitals on a sheet of paper on top of the medication cart of 108/61. Staff AA stated she would hold the Midodrine due to Resident #142's blood pressure. Prior to Staff entering Resident #142's room, surveyor requested verification of the order for the Midodrine.During an interview on 3/25/2026 at 9:20 AM Staff AA, LPN stated, [Resident #142's name] systolic blood pressure is 108 and the Midodrine order is to hold if systolic blood pressure is greater than 130. The Midodrine should not be held and should be given. I was nervous and got confused by the greater than symbol.Review of Resident #142's physician order dated 3/5/2026 read, Midodrine HCI [Hydrochloride] Oral Tablet 5 mg (Midodrine HCI) give 1 tablet by mouth three times a day for hypotension hold for SBP > [systolic blood pressure greater than] 130.During an interview on 3/26/2026 at 9:11 AM the Director of Nursing stated, First staff should check central supply and check if the medication is there. They should not give a chewable Aspirin if the order is for delayed release the staff should call the physician and get the order changed. The nurse should give medication as order if not call the physician. The nurse should follow the parameters provided in the order and not hold medication if it's with the parameters.Review of the facility policy and procedure titled Medication Administration with a review date of 2/24/2026 read, Policy: Medications are administered by licensed nurses, 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. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 10. Ensure that the six rights of medication administration are followed: c. Right dosage.Review of the facility policy and procedure titled Pharmacy Services with a review date of 2/24/2026 read, Policy: It is the policy of the facility to provide Pharmacy Services in accordance to State and Federal regulations. Procedure: 9. The facility will ensure that it is free of medication error rates of 5 percent or greater and that residents are free of any significant medication errors.

Based on observation, interview, and record review, the facility failed to ensure drugs were secured and/or not expired in accordance with professional standards for 2 of 3 units, for Residents #28, #155, #156, residents observed with unsecured and/or expired medications, not securing medications when unattended for 1 of 5 medication carts, and expired medications for 2 of 5 medication carts.Findings include: 1) During an observation on 3/23/2026 at 10:20 AM of Resident #155's room one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid were on Resident #155's bedside table unsecured. (Photograph evidence obtained). During an observation on 3/23/2026 at 2:54 PM of Resident #155's room there was one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid on Resident #155's bedside table unsecured. During an observation on 3/24/2026 at 2:58 PM with the Clinical Staff one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid were on Resident #155's bedside table unsecured. 2) During an observation on 3/23/2026 at 10:58 AM of Resident # 156's room three unidentified pills in a plastic medication cup were observed on the bedside table unsecured. (Photograph evidence obtained). During an observation on 3/23/2026 at 12:55 PM of Resident #156's room there were three unidentified pills in a plastic medication cup observed on the bedside table unsecured. During an interview on 3/24/2026 at 2:58 Staff H, License Practical Nurse (LPN) stated, Medications can't be at the bedside unsecured. During an interview on 3/24/2026 at 3:35 PM the Director of Nursing stated, Medications cannot be at the bedside unless they are self-administration and the medication still needs to be secure During an observation on 3/24/2026 at 12:12 PM of Resident #28's medication lockbox revealed the box was not locked and inside of the box were the following medications: Ubiquinol 100 mg (milligrams) per softgel, expiration date: 02/2025, Wobenzym N expiration date: 10/2024, Black Cumin Seed Oil, expiration date: 7/2025, B12 Methycobalamin, expiration date: 02/2025 and Probulin Probiotic, expiration date: 8/2025. During an interview on 03/24/2026 at 12:12 PM, Resident #28 stated, I should take the medication more regularly so they don't expire. The resident further stated staff do not routinely check the medications in the box. During an interview on 3/24/2026 at 1:45 PM, the DON, stated that her expectation would be that the nurses regularly check the medication box for appropriate storage, approved medication, and expiration dates. Review of the facility policy titled Self-Administration of Medication Program, dated 02/24/2026, revealed, a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective .10. The nursing staff is responsible for proper rotation of bedside stock and removal of expired medications. 3) During an observation on 3/24/2026 at 3:19 PM with Staff W, Licensed Practical Nurse of the Medication Cart North 1 there was an expired Wixela Inhaler with an open date of 2/9/2026 and one glucometer strip container that was not dated. During an interview on 3/24/2026 at 3:23 PM Staff W, LPN, stated, The inhaler is expired. It expires after 30 days of being opened. Any expired medication should be placed in the medication room and returned to the pharmacy or discarded. The glucometer strips should be dated once opened. During an observation on 3/24/2026 at 3:24 PM with Staff W, LPN of Medication Cart North 2 there were two containers of glucometer strips that were not dated. During an interview on 3/24/2026 at 3:27 PM with Staff W, LPN, stated, The glucometer strips should be dated once they are opened. During an interview on 3/26/2026 at 9:11 AM with the Director of Nursing stated, Expired medication should not be stored in the medication cart. They should be destroyed or returned to the pharmacy. The glucometer strip container should be dated once it is opened. 4) During an observation on 03/25/2026 at 5:50 AM Staff X, Licensed Practical Nurse was standing in front of her medication cart. There was a medication cup with three oral medications inside the cup was labeled [Resident #138's room number] in black marker. Another cup with medication inside the cup labeled [Resident #65's room number and last name] and an empty medication cup labeled [Resident #65's room number and last name]. Staff X was asked if she was doing another medication pass and answered yes she needed to do Resident #65's blood sugar and administer her morning medications. Staff X entered Resident #65's room without securing the medication in the medication cup labeled for Resident #138. Staff X took Resident #65's blood sugar and administered the medications that had been pre poured in the cup. Staff X returned to the medication cart to retrieve a needle to administer insulin to Resident #65. The medication cup labeled for Resident #138 was left unattended on top of the medication cart. During an interview on 3/25/2026 at 6:00 AM Staff X, LPN stated, I do resident's medication two at a time [Resident #138's name] refused and did not want her medication. I held on to them to be able to document the refusal. The medication should not be left on top of the cart. During an interview on 3/26/2026 at 9:11 AM the Director of Nursing stated, Medication should be pull only for the resident you are giving the medication to. One resident at a time. The medication should never be left unattended. Review of the facility policy and procedure titled Medication Storage with a last review date of 2/24/2026 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of the facility policy and procedure titled Pharmacy Services with a last review date of 2/24/2026 read, Policy: It is the policy of the facility to provide Pharmacy Services in accordance to State and Federal regulations. Procedure: 9. Drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Review of the facility policy and procedure titled Medication Administration with a last review date of 2/24/2026 read, Policy Explanation and Compliance Guidelines: 13. Identify expiration date. If expired, notify nurse manager.

Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 5 of 8 residents, Residents #11, #12, #14, #49, and #77, reviewed for medical records.Findings include: 1) Review of Resident #11's physician order dated 12/3/2025 read, Atorvastatin Calcium Oral Tablet 40 mg [milligrams], Give 1 tablet by mouth one time a day for HPLD [hyperlipidemia]. Review of Resident #11's Medication Administration Record (MAR) for March 2026 revealed no documentation for administration of Atorvastatin Calcium Tablet 40 mg on 3/10/2026 and 3/15/2026. Review of Resident #11's physician order dated 12/3/2025 read, Potassium Chloride ER [Extended Release] 10 meq [milliequivalent], Give 1 tablet by mouth one time a day for hypokalemia. Review of Resident #11's MAR for March 2026 revealed no documentation for administration of Potassium Chloride ER 10 meq on 3/10/2026, and 3/15/2026. Review of Resident #11's physician order dated 10/3/2025 read, Apixaban Oral Tablet 2.5 mg, Give 1 tablet by mouth two times a day for DVT [Deep Vein Thrombosis] prevention. Review of Resident #11's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Apixaban Oral Tablet 2.5 mg on 3/10/2026, and 3/15/2026. Review of Resident #11's physician order dated 10/3/2025 read, Calorically dense oral supplement two times a day for promote nutritional status. Review of Resident #11's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Calorically dense oral supplement on 3/10/2026, and 3/15/2026. Review of Resident #11's physician order dated 10/3/2025 read, Docusate Sodium Capsule 100 mg, Give 2 capsules by mouth two times a day for constipation. Review of Resident #11's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Docusate Sodium Capsule 100 mg on 3/10/2026, and 3/15/2026. During an interview on 3/25/2026 at 4:00 PM, Staff G, Licensed Practical Nurse (LPN), stated, She [Resident #11] received all her meds. I gave all the residents their medications, but forgot to go back and document that the medication was given on the 10th and 15th of March. I have so many residents at times that I just give the medications and don't document until the end of my shift. I probably got so tired that I could not stay any longer and did not document. I know that I have a problem with not documenting timely, but I'm working on my documentation. 2) Review of Resident #77's physician order dated 9/17/2025 read, Atorvastatin Calcium Oral Tablet 80 mg, Give 1 tablet by mouth one time a day for HPLD. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of Atorvastatin Calcium Tablet 80 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 3/23/2026 read, Melatonin Oral Tablet 3 mg, Give 3 tablets by mouth one time a day for insomnia. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of Melatonin Oral Tablet 3 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 10/9/2025 read, Plavix Tablet 75 mg, Give 1 tablet by mouth one time a day for blood thinner. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of Plavix tablet 75 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 12/6/2025 read, Depakote Oral Tablet Delayed Release 240 mg, Give 3 tablets by mouth two time a day for bi polar. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Depakote oral tablet delayed release 250 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 2/18/2026 read, Insulin Glargine YFGN U100 VL [vial] (10 ml [milliliter]), Inject 30 unit subcutaneously two times a day related to diabetes mellitus. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Insulin Glargine on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 10/8/2025 read, Metformin HCl [hydrochloride] Oral Tablet 1000 mg, Give 1 tablet by mouth two time a day for DM [Diabetes Mellitus]. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Metformin oral tablet 1000 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 10/8/2025 read, Metoprolol Tartrate Tablet 25 mg, Give 1 tablet by mouth two time a day for hypertension. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Metoprolol Tartrate tablet 25 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 10/8/2025 read, Potassium Oral Tablet, Give 20 mEq by mouth two time a day for hypokalemia. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Potassium oral tablet on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 1/26/2026 read, Baclofen Tablet 10 mg, Give two tablets by mouth every 8 hours for spasms. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Baclofen Tablet 10 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 1/26/2026 read, Lyrica Capsule 100 mg, Give 100 mg by mouth every 8 hours for radiculopathy. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Lyrica Capsule 100 mg on 3/10/2026, and 3/15/2026. Review of Resident #77's physician order dated 11/18/2025 read, Trazodone HCl Oral Tablet 100 mg, Give 1 tablet by mouth three times a day for depression. Review of Resident #77's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Trazodone HCl oral tablet 100 mg on 3/10/2026, and 3/15/2026. 3) Review of Resident #14's physician order dated 10/6/2025 read, Finasteride Oral Tablet 5 mg, Give 1 tablet by mouth one time a day for benign prostatic hyperplasia. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of Finasteride oral tablet 5 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Ropinirole HCl Oral Tablet 0.25 mg, Give 0.25 mg by mouth one time a day for restless legs. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of Ropinirole HCl oral tablet 0.25 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Secuado Transdermal Patch 24-hour 5.7 mg/ 24 hr [hour], Apply 1 patch transdermal one time a day for schizophrenia. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of Secuado transdermal patch 24-hour 5.7 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Trazodone HCl Oral Tablet 100 mg, Give 1 tablet by mouth one time a day for MDD [Major Depressive Disorder]. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of Trazodone HCL oral tablet 100 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Metformin HCl Oral Tablet 1000 mg, Give 1 tablet by mouth two times type 2 Diabetes Mellitus. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Metformin HCl oral tablet 1000 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Risperdal Oral Tablet, Give 0.25 mg by mouth two times a day for schizoaffective disorder. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Risperdal oral tablet on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Sotalol HCl Oral Tablet 120 mg, Give 1 tablet by mouth two times a day for HTN [hypertension]. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Sotalol HCl oral tablet 120 mg on 3/10/2026, and 3/15/2026. Review of Resident #14's physician order dated 10/6/2025 read, Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg, Give 2 capsules by mouth three times a day for mood disorder. Review of Resident #14's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Divalproex Sodium oral capsule on 3/10/2026, and 3/15/2026. During an interview on 3/25/2026 at 10:00 AM, the Director of Nursing stated, My expectation is that the medications are charted after they are administered. 4) Review of Resident #12's physician order dated 12/26/2025 read, Senna Oral Tablet 8.6 mg (Sennosides), Give 2 tablet by mouth one time a day for constipation. Order Status: Active. Start Date: 12/27/2025. Review of Resident #12's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Senna Oral Tablet 8.6 mg on 03/15/2026. Review of Resident #12's physician order dated 10/10/2025 read, Trazodone HCl Oral Tablet 100 mg (Trazodone HCl), Give 1 tablet by mouth one time a day for depression. Order Status: Active. Start Date: 10/10/2025. Review of Resident #12's MAR for March 2026 revealed no documentation for administration of the bedtime dose of Trazodone HCl Oral Tablet 100 mg on 3/15/2026. Review of Resident #12's physician order dated 12/26/2025 read, Colace Oral Capsule 100 mg (Docusate Sodium), Give 1 capsule by mouth two times a day for constipation. Order Status: Active. Start Date: 12/27/2025. Review of Resident #12's MAR for March 2026 revealed no documentation for administration of the evening dose of Colace Oral Capsule 100 mg on 3/15/2026. Review of Resident #12's physician order dated 11/13/2025 read, Memantine HCl Oral Tablet 10 mg (Memantine HCl), Give 1 tablet by mouth two times a day for dementia. Order Status: Active. Start Date: 11/22/2025. Review of Resident #12's MAR for March 2026 revealed no documentation for administration of the evening dose of Memantine HCl Oral Tablet 10 mg was on 3/15/2026. Review of Resident #12's physician order dated 10/17/2025 read, Seroquel Oral Tablet 50 mg (Quetiapine Fumarate), Give 2 tablet by mouth two times a day for brief psychosis. Order Status: Active. Start Date: 10/19/2025. Review of Resident #12's MAR for March 2026 revealed no documentation for administration of the 9:00 PM dose of Seroquel Oral Tablet 50 mg on 3/15/2026. During an interview on 3/25/2026 at 3:10 PM, Staff G, LPN, stated, I was working on the North Unit on March 15th. I was the nurse for [Resident #12's name]. I usually pass my meds and then I check them off after. On March15th, all of my residents got their meds. I was doing back-to-back shifts, and was tired and went home before I documented that the meds were given. I was planning to document them when I came back the next day, but I must have forgotten to document. 5) Review of Resident #49's physician order dated 12/19/2025 read, Claritin Oral Tablet (Loratadine), Give 1 tablet by mouth one time a day for allergies. Order Status: Active. Start Date: 12/19/2025. Review of Resident #49's MAR for March 2026 revealed no documentation for administration of Claritin oral tablet at 6:00 AM on 3/5/2026. Review of Resident #49's physician order dated 10/7/2026 read, Protonix Tablet Delayed Release 40 mg (Pantoprazole Sodium), Give 1 tablet by mouth one time a day for GERD [Gastro-Esophageal Reflux Disease]. Order Status: Active. Start Date: 10/08/2025. Review of Resident #49's MAR for March 2026 revealed no documentation for administration of the Protonix Tablet Delayed Release 40 mg tablet on 3/5/2026. Review of Resident #49's physician order dated 1/1/2026 read, Lantus Solostar 100 Unit/ML (3 ML), Inject 45 unit subcutaneously every 12 hours for DM. Order Status: Active. Start Date: 01/01/2026. Review of Resident #49's MAR for March 2026 revealed no documentation for administration of Lantus Solostar 100 unit/ml (3 ML) 45 unit subcutaneously at 6:00 AM on 3/5/2026. Review of Resident #49's physician order dated 10/9/2025 read, Novolin R FlexPen Injection Solution Pen-Injector 100 Unit/ML (Insulin Regular (Human)), Inject as per sliding scale: if 150-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units; 401+ [higher] if < [below] 60 or more than > 400 notify MD [medical doctor], subcutaneously four times a day for diabetic management. Order Status: Active. Start Date: 10/10/2025. Review of Resident #49's MAR for March 2026 revealed no documentation for administration of Novolin R sliding scale insulin at 6:00 AM on 3/5/2026. During an interview on 3/25/2026 at 3:10 PM, Staff G, LPN, stated, I was working on the North Unit on March 5th. I was the nurse for [Resident #49's name]. All of my residents got their meds. I must have forgotten to document. I should have documented that the medications were given. Review of the facility policy and procedure titled Documentation with the last review date of 2/24/2026 read, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. e. Record date and time of entry. f. Sign each entry with name and credentials of the person making the entry.

Based on observation, interview, and record review the facility failed to ensure all residents received adequate supervision to prevent possible accident hazards when 1 of 2 residents, Resident #1, eloped from the facility across the parking lot to a stop sign that was approximately 10 feet from a busy road. Staff within the facility were not aware that the resident was not in the facility. Findings included: Review of Resident #1's medical record documented Resident #1 was [AGE] years old and he was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] (a sudden, uncontrolled electrical disturbance in the brain), hypertension (high blood pressure), [CONDITION(S)] [CONDITION(S)], subdural hematoma (a buildup of blood on the brain), dementia (a loss of memory, language, problem solving and other thinking abilities that interfere with daily life), and [CONDITION(S)] (gradual loss of kidney function). Review of Resident #1's Minimum Data Set (MDS) annual assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severe cognitive impairment). Review of the last quarterly assessment conducted on October 9, 2021 revealed a BIMS score of 5 out of 15. Review of the physician progress note dated 2/2/2022 read: .I am following up with him for dementia, memory impairment, he is still refusing his BP [blood pressure] and [CONDITION(S)] medication, blood pressure within normal range, no recent [CONDITION(S)] activity, lung clear no cough and fever, no body ache and headache, vital sign normal. Neuro: AAO [awake, alert, and oriented] x 1 [self], no focal deficit. Assessment: Dementia, continue with supportive care, subdural hematoma, post hematoma evacuation, non-focal neuro exam pt [patient] consider fall risk, fall precaution. During an interview conducted on 3/10/2022 at 6:15 AM, when asked if the facility had an incident of elopement, the Administrator stated, Well there was one possible elopement on Sunday I was coming to the facility to check on things and I found [Resident #1's name] in the parking lot next to the road and I brought him back inside. There were no staff present outside. Maybe someone was sitting on the bench, but I don't know who it was. I did not do an investigation into what happened or how he was able to get outside, I do not know if a staff, or a visitor let him go outside. I did not interview staff related to what happened and I did not report this to anyone. He was still on our property, but he was right next to the road. I really have no idea what his cognitive abilities are. I should have done an investigation. I wasn't thinking I was just upset that I found him outside with no one with him. During an interview conducted on 3/10/2022 at 6:25 AM, the Director of Nursing (DON) stated, I did not investigate the elopement, [Resident #1's name] was found in the parking lot by the Administrator and he told me he was always in his line of sight. So, I didn't think about doing an investigation into this. I guess we really should have now that I know he was not in his line of sight the entire time. I really have no idea if he has done this before. We did not investigate to determine how or why this occurred. I cannot tell you who was on that evening taking care of him. I don't know what he is like cognitively. I don't know if he is confused. I don't think they completed a new elopement risk because I didn't think he eloped until now. We don't really know, and I thought that he was still on our property. The Administrator told me he found him in the parking lot. I really thought that he was still on our premises, so it's not really an elopement. But no, we did not complete any type of investigation, so we can't say that we have done anything to determine if it was an elopement or not. During an interview conducted on 3/10/2022 at 7:15 AM Resident #1 stated, I don't know maybe it is August. I think it's the weekend. I did go out to the garden a few days ago. I don't know how I got outside. It was sunny out and it felt good to be out of here. I was just sitting at the edge of the garden. During an interview on 3/10/2022 at 9:15 AM Staff D, LPN stated, I have worked here for about 9 months, and I am always on this end. I know [Resident #1's name] very well. He is always confused, and I think it has gotten worse since I have been here. He used to be like just a sun [NAME] and now he is always confused. I have never seen him try to get out any of the doors. I wouldn't consider him an elopement risk because I have never seen him try to leave; try to get out any doors. I did not know that he was found outside this weekend. If a resident is found outside, we would report this to the DON and make sure the resident was safe. I think we would need to do a new elopement risk. It just kind of shocks me that he even tried to get out. He is very sweet. He usually uses a wheelchair, but he is able to walk too. He will sometimes refuse to take medications or get care like showers. During an interview conducted on 3/10/22 at 9:40 AM, Staff A, Patient Care Assistant (PCA) stated, I was working on 3-11 on Sunday and I was taking a resident outside because I was walking outside. No one was at the front desk at the time. I don't know if I had to put a code in the door, I can't remember. There is usually someone at the desk every day. The door is usually locked, and we have to enter a code. But I can't remember. I don't know the last time I saw [Resident #1's name] on the unit before I saw the Administrator bringing him back inside. The Administrator was already walking the resident back inside when I saw them. I never saw the resident [Resident #1] outside or near the road and wasn't outside watching any residents at all. During an interview conducted on 3/10/22 at 11:55 AM, Staff B, Licensed Practical Nurse (LPN) stated, I was working on 3-11 on Sunday. I usually work 3-11. I don't remember it being a rough day. We had staff that day. I was working on the north end on Cart #1 that day. I remember that [Administrator's name] came over told me [Resident #1's name] he was not in the room. He told me they found him outside. I didn't know how he got outside. I don't know how long he was gone and how he got out. I was not his nurse that day, but I worked on that end. During a telephone interview on 3/10/22 at 12:21 PM, Staff C, LPN stated, I know that I worked on Sunday the day shift and I'm not sure, but I may have stayed over extra that day. I can check and get back to you when I get home. But if it said I Administered medications at 4:12 I must have. I don't really remember a lot. I did know he was in the parking lot. I did not assess him for any injuries, I was not told to do anything by the Administrator. During an interview conducted on 3/10/2022 at 1:35 PM, Resident #1 stated, I don't understand why everyone is upset. I was just waiting for my friend [NAME] to pick me up so I could get to a job. Everyone is making a fuss about this. During a telephone interview on 3/10/2022 at 6:10 PM Staff C, LPN stated, I did work over that day but don't really remember much. I recall the Administrator telling me he was outside. I work agency and don't always work the same cart every time. I don't know him that well. I don't know if he has dementia. On 3/11/2022 at 7:05 AM during an observation with the Administrator, he walked to the exact area Resident #1 was found on 3/6/2022 by him. The Administrator verified that the resident was found near the stop sign less than 10 feet from a well-traveled road and less than 300 feet from a major highway. During an interview conducted on 3/11/2022 at 07:05 AM, the Administrator stated, This is very close to the road, he was almost out to the road. I did consider this unsafe for the resident, that is why I was so upset when I saw him. I don't remember if he was just sitting in his wheelchair or still moving toward the road. He was sitting there all alone and there was not any staff with him. It wasn't dark when I found him it was exactly at 5:49 PM when I saw him. It wasn't raining or anything. No one knew he was out there, and no one knew how he got out. On 3/11/2022 at 7:25 AM during an observation with the DON, the DON went to the area Resident #1 was found. She stated, Oh I had no idea that it was so close to the road. I thought he was only on the sidewalk. I did not realize how far he had gotten. This is not good, not good at all. This road is very busy, anything could have happened. I would consider this an unsafe situation. During an interview conducted on 3/11/2022 (Friday) at 8:05 AM Resident #1 stated, It's Monday morning and I'm just about to get up and go to my job today. Oh, I can't tell you what the month is, it's spring. When asked if the Resident knew what year it was, he stated, Of course I know what year it is, its 1972. I do some odd jobs with my friend to get out of the house. I don't know, maybe the president is [NAME], I don't know I really am not political. Now my father would know exactly who the president is. My father isn't here, he lives in the south side. He's probably at work right now. I'm just waiting for my friend and I'm getting ready to go. I use the chair to get out there, but I can walk just fine. Review of Resident #1's Care Plans noted: Has ADL [Activities of Daily Living] self-care performance deficit related to weakness, dementia, ADL care fluctuations at times: assist with all ADL and mobility tasks as needed to ensure successful completion daily Limited physical mobility related to weakness: Ambulation: the resident is supervision (sup) x 1 assist as needed. Locomotion: The resident is sup x 1 assist as needed, observe, document, and report PRN (pro re nata or as needed) any s/sx (sign/symptoms) of immobility contractures forming or worsening, thrombus formation, skin breakdown, fall related injury, Physical Therapy (PT), Occupational Therapy (OT) referrals. At risk for impaired cognitive function/impaired thought processes related to dementia. Interventions include administer medications as ordered, monitor for side effects and effectiveness, ask yes/no questions to determine needs, observe and report PRN any changes in cognitive function (specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status), review medications and record possible causes of cognitive deficit (new medication or dosage increases, anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in doses of benzodiazepines drug interactions, errors or adverse drug reactions, drug toxicity), use task segmentation to support short term memory deficits and break tasks into one step at a time. At risk for falls related to weakness, dementia, medication use. Interventions include staff to remind resident to lock wheelchair prior to transferring, be sure residents call light is within reach and encourage the resident to use it, call for assistance as needed, the resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair as needed, PT to evaluate and treat as ordered or PRN. Review of the policy and procedure titled Free of Accident's hazards/supervision/devices, date issued 3/2/19, read: Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preference, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Procedure: 1. The facility must ensure that: a. The resident environment remains as free of accidents, hazards as is possible, and b. Each resident receives adequate supervision and assistance devices to prevent accidents. Review of the policy and procedure titled, Reporting accidents and Incidents, date issued 3/2/19, read: Policy: It is the policy of the facility to report accidents and incidents in accordance to State and Federal regulations. Procedure: 8. The facility will ensure that: a. The resident environment remains as free from accidents and hazards as is possible: and b. Each resident receives adequate supervision and assistive devices to prevent accidents. 9. The facility will provide an environment that is free of accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. This includes a. Identifying hazard(s) and risk(s). b. Evaluating an analyzing hazard(s) and risk(s). c. implementing interventions to reduce hazard(s) and risk(s): and d. Monitoring for effectiveness and modifying interventions when necessary. 10. The facility will identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent accidents.11. The facility will ensure each resident receives adequate supervision and assistance devices to prevent accidents.14. The facility will develop and implement written policies and procedures that: The policies and procedures must include but are not limited to the following elements: j. Resident elopement, if the elopement places the resident at risk of harm or injury.

Based on observation, interview, and record review the facility failed to ensure a resident was free from neglect when the resident eloped from the facility into the parking lot to a stop sign approximately 10 feet from a busy road; staff was not aware the resident was not in the facility, for 1 of 2 residents sampled for elopement, Resident #1. (Photographic evidence obtained). Findings included: On 3/10/2022 at 4:00 AM, the front door was locked upon entrance, facility staff entered a code to allow surveyor access to the building. The key pad was at an accessible height for wheelchair access. During an interview conducted on 3/10/2022 at 06:15 AM when asked if the facility had an incident of elopement the Administrator stated, Well there was one possible elopement on Sunday I was coming to the facility to check on things and I found [Resident #1's name] in the parking lot next to the road and I brought him back inside. There were no staff present outside. Maybe someone was sitting on the bench, but I don't know who it was. I did not do an investigation into what happened or how he was able to get outside, I do not know if a staff, or a visitor let him go outside. I did not interview staff related to what happened and I did not report this to anyone. He was still on our property, but he was right next to the road. I really have no idea what his cognitive abilities are. I should have done an investigation. I wasn't thinking I was just upset that I found him outside with no one with him. During an interview conducted on 3/10/2022 at 6:25 AM, the Director of Nursing (DON) stated, I did not investigate the elopement, [Resident #1's name] was found in the parking lot by the Administrator and he told me he was always in his line of sight. So, I didn't think about doing an investigation into this. I guess we really should have now that I know he was not in his line of sight the entire time. I really have no idea if he has done this before. We did not investigate to determine how or why this occurred. I cannot tell you who was on that evening taking care of him. I don't know what he is like cognitively. I don't know if he is confused. I don't think they completed a new elopement risk because I didn't think he eloped until now. We don't really know, and I thought that he was still on our property. The Administrator told me he found him in the parking lot. I really thought that he was still on our premises, so it's not really an elopement. But no, we did not complete any type of investigation, so we can't say that we have done anything to determine if it was an elopement or not. During an interview conducted on 3/10/2022 at 8:35 AM the Administrator stated, I was coming in to check on some things and make sure everyone was doing okay. When I drove up, I saw a resident [Resident #1] in a wheelchair by the stop sign, still in the parking lot. I parked and got the resident, I brought him up to the front and saw a staff member coming out of the facility. There was not any staff with him when I found him. I brought him back inside and told a nurse. I can't tell you how this happened. I have no idea how he got out of the building. Review of Resident #1's medical record documented Resident #1 was [AGE] years old and was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Annual assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severe cognitive impairment). Review of the last quarterly assessment conducted on October 9, 2021, revealed a BIMS score of 5 out of 15. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Neuro: AAO [awake, alert, and oriented) x 1 [self], no focal deficit. Assessment: Dementia, continue with supportive care, subdural hematoma, post hematoma evacuation, non-focal neuro exam pt [patient] consider fall risk, fall precaution. During an interview conducted on 3/10/2022 at 7:15 AM Resident #1 stated, I don't know maybe it is August. I think it's the weekend. I did go out to the garden a few days ago. I don't know how I got outside. It was sunny out and it felt good to be out of here. I was just sitting at the edge of the garden. During an interview on 3/10/2022 at 9:15 AM, Staff D, Licensed Practical Nurse (LPN) stated, I have worked here for about 9 months, and I am always on this end. I know [Resident #1's name] very well. He is always confused, and I think it has gotten worse since I have been here. He used to be like just a sun [NAME] and now he is always confused. I have never seen him try to get out any of the doors. I wouldn't consider him an elopement risk because I have never seen him try to leave; try to get out any doors. I did not know that he was found outside this weekend. If a resident is found outside, we would report this to the DON and make sure the resident was safe. I think we would need to do a new elopement risk. It just kind of shocks me that he even tried to get out. He is very sweet. He usually uses a wheelchair, but he is able to walk too. He will sometimes refuse to take medications or get care like showers. During an interview conducted on 3/10/22 at 9:40 AM, Staff A, Patient Care Assistant (PCA) stated, I was working on 3-11 on Sunday and I was taking a resident outside because I was walking outside. No one was at the front desk at the time. I don't know if I had to put a code in the door, I can't remember. There is usually someone at the desk every day. The door is usually locked, and we have to enter a code. But I can't remember. I don't know the last time I saw [Resident #1's name] on the unit before I saw the Administrator bringing him back inside. The Administrator was already walking the resident back inside when I saw them. I never saw the resident [Resident #1] outside or near the road and wasn't outside watching any residents at all. During an interview conducted on 3/10/22 at 11:55 AM, Staff B, LPN stated, I was working on 3-11 on Sunday. I usually work 3-11. I don't remember it being a rough day. We had staff that day. I was working on the north end on Cart #1 that day. I remember that [Administrator's name] came over and told me [Resident #1's name] he was not in the room. He told me they found him outside. I didn't know how he got outside. I don't know how long he was gone and how he got out. I was not his nurse that day, but I worked on that end. During a telephone interview on 3/10/22 at 12:21 PM, Staff C, LPN stated, I know that I worked on Sunday the day shift and I'm not sure, but I may have stayed over extra that day. I can check and get back to you when I get home. But if it said I administered medications at 4:12 I must have. I don't really remember a lot. I did know he was in the parking lot. I did not assess him for any injuries, I was not told to do anything by the Administrator. During an interview conducted on 3/10/2022 at 1:35 PM, Resident #1 stated, I don't understand why everyone is upset. I was just waiting for my friend [NAME] to pick me up so I could get to a job. Everyone is making a fuss about this. During a telephone interview on 3/10/2022 at 6:10 PM Staff C, LPN stated, I did work over that day but don't really remember much. I recall the Administrator telling me he was outside. I work agency and don't always work the same cart every time. I don't know him that well. I don't know if he has dementia. On 3/11/2022 at 7:05 AM during an observation with the Administrator, he walked to the exact area Resident #1 was found on 3/6/2022 by him. The Administrator verified that the resident was found near the stop sign less than 10 feet from a well-traveled road and less than 300 feet from a major highway. During an interview conducted on 3/11/2022 at 07:05 AM the Administrator stated, This is very close to the road, he was almost out to the road. I did consider this unsafe for the resident, that is why I was so upset when I saw him. I don't remember if he was just sitting in his wheelchair or still moving toward the road. I don't know why I didn't investigate. I can't explain to you why I didn't start the investigation and our policies to see if other residents were affected. I was very upset when I found him there. I was coming in to check on some things in the facility that day that I found him. He was sitting there all alone and there was not any staff with him. It wasn't dark when I found him it was exactly at 5:49 PM when I saw him. It wasn't raining or anything. No one knew he was out there, and no one knew how he got out. On 3/11/2022 at 7:25 AM during an observation with the DON, the DON went to the area Resident #1 was found. She stated, Oh I had no idea that it was so close to the road. I thought he was only on the sidewalk. I did not realize how far he had gotten. This is not good, not good at all. This road is very busy, anything could have happened. I would consider this an unsafe situation. During an interview conducted on 3/11/2022 (Friday) at 8:05 AM Resident #1 stated, It's Monday morning and I'm just about to get up and go to my job today. Oh, I can't tell you what the month is, it's spring. When asked if the Resident knew what year it was, he stated, Of course I know what year it is, its 1972. I do some odd jobs with my friend to get out of the house. I don't know, maybe the president is [NAME], I don't know I really am not political. Now my father would know exactly who the president is. My father isn't here, he lives in the south side. He's probably at work right now. I'm just waiting for my friend and I'm getting ready to go. I use the chair to get out there, but I can walk just fine. Review of Resident #1's Care Plans noted: Has ADL [Activities of Daily Living] self-care performance deficit related to weakness, dementia, ADL care fluctuations at times: assist with all ADL and mobility tasks as needed to ensure successful completion daily Limited physical mobility related to weakness: Ambulation: the resident is supervision (sup) x 1 assist as needed. Locomotion: The resident is sup x 1 assist as needed, observe, document, and report PRN (pro re nata or as needed) any s/sx (sign/symptoms) of immobility contractures forming or worsening, thrombus formation, skin breakdown, fall related injury, Physical Therapy (PT), Occupational Therapy (OT) referrals At risk for impaired cognitive function/impaired thought processes related to dementia. Interventions include administer medications as ordered, monitor for side effects and effectiveness, ask yes/no questions to determine needs, observe and report PRN any changes in cognitive function (specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status), review medications and record possible causes of cognitive deficit (new medication or dosage increases, anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in doses of benzodiazepines drug interactions, errors or adverse drug reactions, drug toxicity), use task segmentation to support short term memory deficits and break tasks into one step at a time. At risk for falls related to weakness, dementia, medication use. Interventions include staff to remind resident to lock wheelchair prior to transferring, be sure residents call light is within reach and encourage the resident to use it, call for assistance as needed, the resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair as needed, PT to evaluate and treat as ordered or PRN. Review of the facility policy titled Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment, Misappropriate of Property and Injury of Unknown Source Prevention (ANEMMI) revised 3/2/2019 reads Policy. The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress Residents of this facility shall be protected form occurrences of abuse, exploitation, misappropriation of property, mistreatment or neglect.

Based on observation, interview and record review the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process when the administrative staff failed to investigate an elopement, failed to develop and implement appropriate plans of correction, and failed to identify and correct quality deficiencies for 1 of 2 residents reviewed for elopement, Resident #1. Resident #1 was found in the parking lot alone at a stop sign approximately 10 feet from a busy road. Facility staff were not aware of the resident's whereabouts. Findings Include: During an interview conducted on 3/10/2022 at 6:15 AM, when asked if the facility had an incident of elopement, the Administrator stated, Well there was one possible elopement on Sunday. I was coming to the facility to check on things and I found [Resident #1's name] in the parking lot next to the road and I brought him back inside. There were no staff present outside. Maybe someone was sitting on the bench, but I don't know who it was. I did not do an investigation into what happened or how he was able to get outside, I do not know if a staff, or a visitor let him go outside. I did not interview staff related to what happened and I did not report this to anyone. He was still on our property, but he was right next to the road. I really have no idea what his cognitive abilities are. I should have done an investigation. I wasn't thinking I was just upset that I found him outside with no one with him. During an interview conducted on 3/10/2022 at 6:25 AM, the Director of Nursing (DON) stated, I did not investigate the elopement, [Resident #1's name] was found in the parking lot by the Administrator and he told me he was always in his line of sight. So, I didn't think about doing an investigation into this. I guess we really should have now that I know he was not in his line of sight the entire time. I really have no idea if he has done this before. We did not investigate to determine how or why this occurred. I cannot tell you who was on that evening taking care of him. I don't know what he is like cognitively. I don't know if he is confused. I don't think they completed a new elopement risk because I didn't think he eloped until now. We don't really know, and I thought that he was still on our property. The Administrator told me he found him in the parking lot. I really thought that he was still on our premises, so it's not really an elopement. But no, we did not complete any type of investigation, so we can't say that we have done anything to determine if it was an elopement or not. During an interview conducted on 3/10/2022 at 8:35 AM, the Administrator stated, I was coming in to check on some things and make sure everyone was doing okay. When I drove up, I saw a resident (Resident #1) in a wheelchair by the stop sign, still in the parking lot at 5:59 PM. I parked and got the resident, I brought him up to the front and saw a staff member coming out of the facility. There was not any staff with him when I found him. I brought him back inside and told a nurse. I can't tell you how this happened. I have no idea how he got out of the building. I really didn't consider this an elopement so there is no reporting and no investigation into it. I can't tell you how this happened. I have no idea how he got out of the building. I really can't say why I didn't start an investigation. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Annual assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severe cognitive impairment). Review of the last quarterly assessment conducted on October 9, 2021, revealed a BIMS score of 5 out of 15. On 3/10/22, a review of the nursing progress notes revealed no documentation of the event, no documentation of a resident assessment following the event, no documentation of physician notification, and no documentation of resident representative notification. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Neuro: AAO [awake, alert, and oriented) x 1 [self], no focal deficit. Assessment: Dementia, continue with supportive care, subdural hematoma, post hematoma evacuation, non-focal neuro exam pt [patient] consider fall risk, fall precaution. Review of Resident #1's assessments indicated the last elopement risk assessment was completed on 4/29/2021 and he was assessed as not at risk for elopement at that time. No additional elopement risk assessments are contained within Resident #1's medical record. Review of the QAA (Quality Assurance and Assessment) Committee Policy dated 3/2/2019 reads Policy. These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement which will lead to improvement in the lives of Nursing home residents through continuous attention to quality care, quality of life and resident safety. Procedure: The quality assessment and assurance committee reports to the facilities governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program. The committee will: 1. Develop and implement appropriate plans of action to correct identified quality deficiencies.

Based on observation, interview, and record review, the facility administration failed to investigate a serious adverse event when a resident was not safely and adequately supervised and found unsupervised in the parking lot approximately 10 feet from a busy road by the facility administrator for 1 of 2 residents (Resident #1). Findings included: Review of the job description titled Nursing Home Administrator reads: Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state, and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times. Administrative Functions: Duties: Create and maintain an atmosphere of warmth and personal interest, ensuring a positive, calm environment throughout the facility; ensure each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status; plan, develop, organize, implement, evaluate, maintain, monitor, supervise and direct all facility departments and overall operations, including programs, activities, policies and procedures and implement changes as necessary; assist department directors in developing and using department policies and procedures and establish rapport among all departments; interpret and ensure compliance with all facility policies and procedures by all employees, residents, families, visitors, government agencies and the general public; represent the facility at and participate in top level meetings and contacts with facility's governing boards, the medical community, outside support agencies, ancillary providers and private and governmental agencies; plan, develop and maintain an ongoing quality assurance program; identify problems and deficiencies and develop and implement appropriate plans of action to correct deficiencies; and implement and maintain effective marketing and public relations programs. Safety and Sanitation Functions: Duties: Ensure that all personnel, residents and visitors follow established policies and procedures, including safety regulations, fire protections and prevention polices, smoking regulations, infection and control procedures, and waste and disposal procedures, ensure that the facility and surrounding grounds are maintained in good repair; review accident and incident reports and establish effective accident prevention programs; and, ensure that all personnel attend and participate in Hazardous Communication and Universal Precautions training programs prior to reporting for work assignments. Review of the job description titled Director of Nursing reads: Purpose: To plan, organize, develop, and direct the overall operation of the Nursing Services Department in accordance with current federal, state, and local standards governing the facility, and as may be directed by the Administrator, to ensure that the highest degree of quality of care is maintained at all times. Essential Job Functions: Administrative Functions: Implement plans of action to correct deficiencies unless none received. Make reports and recommendations to the Administrator concerning operations of the department. Monitors all facility incidental accident reports providing assurance that they are complete and followed through accordingly. Implement corrective or remedial action when indicated. Ability to work in a constant state of alertness and in a safe manner at all times. Residents' Rights Functions: Monitor nursing services to ensure that residents' rights and needs are met. Review of the job description titled Assistant Director of Nursing reads Purpose: To assist the Director of Nursing in planning, organizing, developing, and directing the day-to-day functions of the Nursing Department and to direct the in-service educational programs in accordance with current federal, state, and local standards governing the facility, and as may be directed by the Administrator, to ensure that the highest level of quality care is maintained at all times. Administrative Functions: 5. Participate in developing, implementing, and maintaining a quality assurance program. Nursing Care Functions: 5. Report problem areas to the Director of Nursing and assist in developing and implementing corrective actions. Review of the Medical Director Agreement dated 6/26/2022 read Exhibit A. Medical Director shall review all new incident and accident reports to identify clinical risk and safety hazards and use the most recent grievance logs for any complaints or concerns related to clinical reasons. Review of Resident #1's medical record documented Resident #1 was [AGE] years old and was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Annual assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severe cognitive impairment). Review of the last quarterly assessment conducted on October 9, 2021, revealed a BIMS score of 5 out of 15. On 3/10/22, a review of the nursing progress notes revealed no documentation of the event, no documentation of a resident assessment following the event, no documentation of physician notification, and no documentation of resident representative notification. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Neuro: AAO [awake, alert, and oriented) x 1 [self], no focal deficit. Assessment: Dementia, continue with supportive care, subdural hematoma, post hematoma evacuation, non-focal neuro exam pt [patient] consider fall risk, fall precaution. During an interview conducted on 3/10/2022 at 6:25 AM, the Director of Nursing (DON) stated, I did not investigate the elopement, [Resident #1's name] was found in the parking lot by the Administrator and he told me he was always in his line of sight. So, I didn't think about doing an investigation into this. I guess we really should have now that I know he was not in his line of sight the entire time. I really have no idea if he has done this before. We did not investigate to determine how or why this occurred. I cannot tell you who was on that evening taking care of him. I don't know what he is like cognitively. I don't know if he is confused. I don't think they completed a new elopement risk because I didn't think he eloped until now. We don't really know, and I thought that he was still on our property. The Administrator told me he found him in the parking lot. I really thought that he was still on our premises, so it's not really an elopement. But no, we did not complete any type of investigation, so we can't say that we have done anything to determine if it was an elopement or not. During an interview conducted on 3/10/2022 at 06:15 AM the Administrator stated, Well there was one possible elopement on Sunday I was coming to the facility to check on things and I found [Resident #1 name] in the parking lot next to the road and I brought him back inside. There were no staff present outside. Maybe someone was sitting on the bench, but I don't know who it was. I do not know if a staff, or visitor let him go outside. I did not do an investigation into what happened or how he was able to get outside, I do not know if a staff, or visitor let him go outside. I did not interview staff related to what happened and I did not report this to anyone. He was still on our property, but he was right next to the road. I really have no idea what his cognitive abilities are. I should have done an investigation. I wasn't thinking I was just upset that I found him outside with no one with him. During an interview conducted on 3/10/2022 at 8:35 AM, the Administrator stated, I was coming in to check on some things and make sure everyone was doing okay. When I drove up, I saw a resident (Resident #1) in a wheelchair by the stop sign, still in the parking lot at 5:49 PM. I parked and got the resident, I brought him up to the front and saw a staff member coming out of the facility. There was not any staff with him when I found him. I brought him back inside and told a nurse. I can't tell you how this happened. I have no idea how he got out of the building. I really didn't consider this an elopement so there is no reporting and no investigation into it. I can't tell you how this happened. I have no idea how he got out of the building. I really can't say why I didn't start an investigation. On 3/11/2022 at 7:05 AM during an observation with the Administrator, he walked to the exact area Resident #1 was found on 3/6/2022 by him. The Administrator verified that the resident was found near the stop sign less than 10 feet from a well-traveled road and less than 300 feet from a major highway. During an interview on 3/11/2022 at 07:05 AM the Administrator stated, This is very close to the road, he was almost out to the road. I did consider this unsafe for the resident, that is why I was so upset when I saw him. I don't remember if he was just sitting in his wheelchair or still moving toward the road. I don't know why I didn't investigate. I can't explain to you why I didn't start the investigation and our policies to see if other residents were affected. I was very upset when I found him there. I was coming in to check on some things in the facility that day that I found him. He was sitting there all alone and there was not any staff with him. It wasn't dark when I found him it was exactly at 5:49 PM when I saw him. It wasn't raining or anything. No one knew he was out there, and no one knew how he got there. We do have an elopement policy and procedure. I should have used it. I wasn't sure this was an elopement, so that is why I didn't follow the policy. I think I asked staff to make sure all the residents were in the building, I think I asked them to do that. I did not tell the nurse, I don't even know the nurses name that was taking care of him, to check him for injuries. I did not tell them to do anything but see if all the other residents were accounted for. We did not change the code to enter and exit the facility. I just didn't do it. I was just so upset that he was so close to the road, and we didn't know he was there. No one knew he was out, and no one knew how he got out. I should have investigated this. On 3/11/2022 at 7:25 AM during an observation with the DON, the DON went to the area Resident #1 was found. She stated, Oh I had no idea that it was so close to the road. I thought he was only on the sidewalk. I did not realize how far he had gotten. This is not good, not good at all. This road is very busy, anything could have happened. I would consider this an unsafe situation. Review of the policy and procedure titled Free of Accident's hazards/supervision/devices date issued 3/2/19 read: Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preference, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Procedure: 1. The facility must ensure that: a. The resident environment remains as free of accidents, hazards as is possible, and b. Each resident receives adequate supervision and assistance devices to prevent accidents. Review of the policy and procedure titled Reporting accidents and Incidents date issued 3/2/19 read: Policy: It is the policy of the facility to report accidents and incidents in accordance to State and Federal regulations. Procedure: 8. The facility will ensure that: a. The resident environment remains as free from accidents and hazards as is possible: and b. Each resident receives adequate supervision and assistive devices to prevent accidents. 9. The facility will provide an environment that is free of accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. This includes a. Identifying hazard(s) and risk(s). b. Evaluating an analyzing hazard(s) and risk(s). c, implementing interventions to reduce hazard(s) and risk(s): and d. Monitoring for effectiveness and modifying interventions when necessary.10. The facility will identify each resident at risk f0r accidents and/or falls and adequately plan care and implement procedures to prevent accidents.11. The facility will ensure each resident receives adequate supervision and assistance devices to prevent accidents.14. The facility will develop and implement written policies and procedures that: The policies and procedures must include but are not limited to the following elements: j. Resident elopement, if the elopement places the resident at risk of harm or injury.

Based on record review and interview the facility failed to permit 1 of 3 residents to return to the facility after a hospitalization . Failure to return the resident to the same facility resulted in a loss of resident rights due to an extended hospitalization and subsequent transfer to a facility located a significant distance from the original area. (Resident #1). Findings: Review of Resident #1's closed record revealed an admission date of [DATE] and with a discharge on 1/4/19. Resident #1 's record revealed a list of [DIAGNOSES REDACTED]. The Resident resided in a regular unit. There was no secured unit in this facility. A review of the Nursing Progress Notes since 11/14/18 revealed no attempts of wandering, violence or self-injurious behaviors. Review of the Nursing Notes dated 1/4/19, at 16:01, revealed the Assistant Director of Nursing wrote was walking through the unit when looking side to side, I witnessed the resident attempting to do something with his door knob. As I approached the resident, it was noted, the resident, was attempting to wrap the string of his gym shorts around the door knob while having the other string around his neck. I immediately intervened by pulling the string off the door knob and putting my fingers between the string and his neck. I called out for help and when the other nurse arrived, scissors were used to cut the string from his neck. We wheeled him out of the area and had someone sit with him, began one on one, until doctor arrived to begin Baker Act paperwork. The Progress Notes dated 1/4/19 and timed 16:06, noted there were no injuries to the resident after a Body Check was completed. Further review of the Progress notes revealed the floor Licensed Practical Nurse/ Staff A wrote on 1/2/19 at 14:12 per Psychologist, new rx, 30 min spot checks & when daughter comes in & pt persists with ideations of dying, pt to be baker acted. At 13:32, Staff A wrote med compliant w/o distress, appetite good visiting with other residents & stated I want to die, life no good- spoke with pt & he stated my life no good, I do want to die, notified daughter, myself & pt spoke with her and she requested psych consult & will be at facility around 1900- Doctor in facility at this time & spoke with pt. There were no other noted issues regarding suicide ideations or behavioral issues. Further review of Resident #1's record revealed a Certificate of Involuntary Examination dated 1/4/19 at 4:10 PM, transported by Law Enforcement. The Clinical Psychologist signed the form writing Person has made repeated threats to harm himself by way of strangulation.is reported to have made an attempt at self harm on current day utilizing method verbalized in recent threats during past 48 hours. The Discharge /Bed Hold Authorization attached was completed and dated 1/4/19. Resident #1's Care Plan was revised on 11/22/18 with the following Objectives: Readmission from recent hospital visit for chest pain- requires extensive assist with ADLs Psychosocial - Depression, [MEDICAL CONDITION], feelings of sadness anxiousness, worried (Removal of harmful objects -1/4/19) [MEDICAL CONDITION] and Hypnotic medications Changes in mood- Medications, monitor, Behavioral Health consults, any changes in mood reported Spanish speaking -knows a little English Review of the physician's orders [REDACTED]. Review of Minimum (MDS) data set [DATE] revealed Resident #1 had a Cognition score of 4, which is determined to be limited understanding. A review of the chronological timeline, written by the Director of Nursing (DON), revealed the Administrator called the Hospital staff on 4/11/19 leaving a message for them to return his calls for discussion of Resident #1. It notes he made (hospital staff) aware the last two visits resulted in concerns they could not provide the care the resident needed. He wrote she stated understanding and we hung up. The facility wrote on their timeline dated 4/5/19, we asked her to ask him if he still wanted to hurt himself and he replied yes, We also asked her to ask him if he had the chance to hurt himself would he and he replied yes, we met with the Case Manager who stated they were not able to find placement anywhere else due to no one accepting any LTC patients. We told them regardless, if he said no to wanting to hurt himself again, he was still being restrained and had a sitter. The Case Manager stated she would remove the sitter. There was no documentation regarding any steps the facility attempted to accommodate Resident #1's return to the facility. There was no information provided the facility documented specific needs it could not meet or attempts the facility made to meet those needs. Nor was there any discussion of the services available at the receiving facility to meet the needs of the Resident. There was no policy provided describing the process for residents returning to the facility from the hospital. Review of Resident #1's Hospital record with an admission date of [DATE] revealed [MEDICATION NAME] and [MEDICATION NAME], was added to the psychoactive medications, [MEDICATION NAME] and Bupropian, the resident was previously ordered. On page 2 of the Final Report of the hospital record the Case Manager wrote on 4/11/19, Patient is here due to placement issues - could not be discharged yesterday for again placement issues. No further information was provided. Review of Resident #1's Hospital record revealed a summary by the Licensed Clinical Social Worker dated 3/12/19. She wrote he had no history of psychiatric hospitalization s/Baker Acts. The patient was at risk for harm to self . His primary [DIAGNOSES REDACTED]. He required a surrogate. He exhibited actions or behaviors that made or may have made him a danger to self or others. He had no psychiatric treatment more intensive than outpatient but did have a significant disruption to his normal living situation. There was no description of the significant disruption. Her note on 1/25/19 included the [DIAGNOSES REDACTED]. She wrote on 2/22/19, the patient was noted to be cooperative with normal mood. She wrote on 2/25/19 he was noted to be confused and was not accepted back to his skilled nursing facility. She wrote on 3/4/19, he was fairly cooperative but noted to be loud and yelling out on the unit. She wrote no specialized services deemed necessary does not appear to be in need of acute patient psychiatric care at this time. There was no further information provided. Further review of Resident #1's Hospital record revealed a Health assessment form 1823, signed by a Physician on 4/10/19. The Physician wrote one comment under Conditions, can't walk without assistance. During an interview with the Administrator/Executive Director (ED) on 5/20/19 at 9:15 AM he stated they scheduled a meeting with the hospital Case Manager to discuss the needs of the Resident's discharge readiness, but the hospital cancelled without rescheduling. He denied refusing to readmit the Resident but no plans were made for the transfer back to the facility. He referred to the Timeline section dated 4/9/19 in which it was written the ED let the Case Manager know he needed to review the documentation provided to him on (Resident #1) and discuss it with the Director of Nursing Services before he could make a decision. He stated the Manager of Case Management at the hospital did not cooperate with his facility when she did not continue to meet with them. During an interview with the Director of Nursing (DON) on 5/20/19 beginning at 8:45 AM, he stated they visited Resident #1 on 2 occasions while he was in the hospital. He stated the first time the resident had full siderails, ate from Styrofoam tableware with no fork or knife, the hospital staff cut his food for him and he had a 1 :1 sitter in the hospital. He stated the hospital told him anytime a patient put their feet over the siderails they assign a 1:1 sitter. The DON stated they asked a Spanish speaking Housekeeper who was present during their visit to interpret for him. He stated the Resident stated yes when he was asked if would try to kill himself again. The DON stated when they arrived for the second visit the hospital Nurse and Resident #1 were ready for an interview, including an interpreter. The DON stated the Resident denied he would try to kill himself again. The DON stated he observed, on the second visit, the resident still had full siderails on his bed, he was still eating without a fork or knife and using Styrofoam tableware. There was no 1:1 at that visit. He stated the hospital sent the Resident to an Assisted Living Facility but they returned him to the hospital because he was not ambulatory. During an interview with the Hospital Manager of Case Management, on 5/20/19 at approximately 5:00 PM she stated the hospital removed the 1:1 sitter from Resident #1 per the request of the skilled nursing facility. She stated they refused to cooperate with a plan to devise and implement the transfer. She stated they objected to the full siderails, lack of use of regular tableware along with the observation of the Resident attempting to put his feet over the edge of the bed to try to get out of bed on 4/5/19. She stated they were refusing readmission, because the Resident continued to state he would try to hurt himself again. She stated the Resident was in the hospital for 97 days. During an interview with Resident #1's daughter on 5/20/19 at approximately 3:30 PM and 6/7/19 at 8:40 AM. She stated her father transferred back to the hospital after a placement of about 2 days in an Assisted Living Facility on 4/12/19. She reported she was told he transferred back to the hospital because the facility did not understand he was not ambulatory. She stated her father was transferred from the hospital to another skilled nursing facility about 2 hours from her home. She stated her father was residing in a secured unit in that facility. She stated the only significant disruption for her father was having to move to the nursing home, when he became too difficult for her to handle physically at home. She stated she was upset the hospital placed her father about 2 hours from her home.