Every finding on record at Aviata at Arbor Springs

Based on record review, interview, and policy and procedure review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate (DNR) for 1 of 3 reviewed residents, Resident #6, when found unresponsive and absent of life. This has the potential to affect 42 residents with advance directives of Do Not Resuscitate.Findings include:Review of Resident #6's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include acute embolism and thrombosis of right subclavian vein, acute embolism and thrombosis of right internal jugular vein, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, generalized muscle weakness, dyspnea, unsteadiness on feet, recurrent mild major depressive disorder, generalized anxiety disorder, anemia, hyperlipidemia, essential (primary) hypertension, paroxysmal atrial fibrillation, unspecified diastolic (congestive) heart failure, occlusion and stenosis of unspecified carotid artery, stage 3 chronic kidney disease, dependence on renal dialysis, presence of automatic (implantable) cardiac defibrillator, and acute respiratory failure with hypoxia.Review of Resident #6's State of Florida Do Not Resuscitate Order read, Being informed of my right to refuse cardiopulmonary resuscitation (CPR), including artificial ventilation, cardiac compression, endotracheal intubation, and defibrillation, direct that CPR be withheld or withdrawn from me. The form was signed by Resident #6 and Staff P, Advanced Practice Registered Nurse (APRN) on [DATE].Review of Resident #6's physician order dated [DATE] read, Order Type: Advanced Directive. Order Summary: Do NOT Resuscitate.Review of Resident #6's nursing progress note authored by Staff A, Licensed Practical Nurse (LPN), dated [DATE] at 8:31 AM read, Resident returned on the unit from HD [hemodialysis] at approximately 8:30 am via transport. Upon arrival, resident was awake, alert, and noted to be conversing appropriately with the CNA's [certified nursing assistants] during transport back to her room. Resident continued speaking with staff members throughout the transfer from the transport chair to bed. Transfer was completed without incident, and resident tolerated transfer well.Review of Resident #6's nursing progress note authored by Staff A, LPN, dated [DATE] at 8:50 AM read, Late Entry. Note Text: Resident noted unresponsive at 8:40 am. At 8:40 am [Staff F, Registered Nurse (RN)'s name] initiated chest compressions, EMS [Emergency Medical Service] arrived at 8:45 am and assumed resident care. Time of Death 8:50 am.Review of Resident #6's nursing progress note authored by the Director of Nursing on [DATE] at 8:54 AM read, Resident time of death called at 08:50 am by EMS. MD [Medical Doctor] notified and order received to release resident remains to funeral home of family choosing. Daughter arrived at facility at 09:10 am. Resident daughter was informed that CPR was performed. Daughter was ok with this information and went to stay with her mom until the funeral home arrived.Review of the witness statement authored by Staff A, LPN, dated [DATE] read, Around 8:40 AM this writer was called by two CNA's to [Resident #6's room number] resident noted unresponsive upon entering the room, myself and another nurse [Staff F, RN's initials] assessed resident and asked the primary nurse [Staff E, LPN's first initial] resident code status. Informed full code, so code blue was called and initiated.Review of the witness statement authored by Staff A, LPN, dated [DATE] read, [Staff F, RN's name] and another nurse did CPR. AED was applied and no shock applied. I left the room and checked resident's chart for her code status red chart noted resident's name and DNR gold paper inside. I returned back to the room and informed the nurses that the resident is a DNR. I overheard someone saying that since 911 was called we have to continue CPR until they arrive, which we did.Review of the witness statement authored by Staff A, LPN, dated [DATE] read, I was standing by the nurses station around 8:35 AM, 2 CNAs came to the nurses station saying [Resident #6's name] is unresponsive right after we transferred her to bed. I dropped what I was doing and ran to [Resident #6's room number]. [Staff F, RN's name] was already in [Resident #6's room number] assessing [Resident #6's name]. Resident had shallow breathing during assessment, no pulse or respirations noted. Primary nurse [Staff E, LPN's name] what is resident code status, [Staff E, LPN's name] said full code and walked out of the room. When we heard full code, I said out loud this is a code blue. Someone overhead paged and [Staff F, RN's name] and all of the nurses came with the crash cart.Review of the witness statement authored by Staff E, LPN, dated [DATE] read, On request I went to verify the resident's code sheet after reviewing the resident's record I confirmed that the resident's code status was a DNR and immediately communicated the information. That time I instructed another nurse to accompany me or follow me to verify the code status. After I communicated the resident's DNR status, I observed that CPR was subsequently performed despite my communication. Also another nurse stated that the resident was DNR and I say that because compressions had already been started they had to continue on.Review of the witness statement authored by Staff F, RN, dated [DATE] read, Code blue was called and I jumped into action after I heard full code. We started performing CPR until EMS arrived. The nurse stated that the patient was a full code, code blue was activated and we nursing staff started to perform CPR.Review of the witness statement authored by Staff F, RN, dated [DATE] read, I was cleaning the wound cart when [Staff D, CNA's name] called my name and [Staff A, LPN's name] to check on the patient because she was unresponsive. [Staff A, LPN's name] got there first and I assisted her with my pulse oximeter. Initially while the sternal rub was on going sats [oxygen saturation] were at 72% with a pulse of 150's. As soon as the sternal rub was stopped the pulse dropped to 30's to 40's. The nurse [Staff E, LPN's name] who was with [Staff D, CNA's name] headed out to check the patient code status and came back and stated full code. Compressions were started after the attestation performed by [Staff A, LPN's name] requested in that the patient has no sign of life, no pulse, no respirations. Next thing I saw was [Staff A, LPN's name] calling code blue. Some staff came to the room with the crash cart and [Staff A, LPN's name] was putting the resident on CPR board. When [Staff A, LPN's name] finished putting the patient, she called to start compressions. As I did the first round, while [Staff A, LPN's name] used Ambu bag and placed patches for the AED. AED started, then we all stepped back. Another nurse took over compressions and [Staff G, LPN's name] the Ambu bag. I stepped back then the nurses started compressions, along with [Staff G, LPN's name]. They completed the round and switched positions. I headed to the hall and when I looked back, [Staff E, LPN's name] and [Staff K, LPN's name] were next to the patient and [Staff L, CNA's name] was writing on the board everything that happened. I was next to the door when EMS arrived. EMS took over, some staff stopped next to the room and I headed back to the nurses' station.Review of the witness statement authored by Staff C, CNA, dated [DATE] read, Upon getting resident from dialysis she was alert. We talked to her all the way to her room before connecting her to the [brand name of the mechanical lift device]. She stated she hates this part because of her pain. She was moaning and groaning and complaining until we were lowering her onto her bed. Once she was lowered onto bed, [Staff B, CNA's name] noticed she wasn't responding after multiple attempts calling her name. She asked me to go get the nurse. The nurse responded also alerted [Staff F, RN's name] also responded. I then stayed out of the room. [Staff A, LPN's name] came up. I told her the resident was unresponsive; she responded and headed to the room.Review of the witness statement authored by Staff B, CNA, dated [DATE] read, Bringing the resident back up from dialysis she was alert, we was having conversation with her before we put her on the [brand name of the mechanical lift device]. Once I got her in the bed I noticed she was not responding, so I told my aide I was with to go let the nurse know and once the nurse was in the room with 2 other nurses, I walked out of the room as the nurse walked in the room. She did say she was a DNR.Review of the witness statement authored by Staff I, LPN, dated [DATE] read, I was in the bathroom when the code was called. After I finished going to the bathroom, I walked up the subacute. When I arrived, EMS also arrived. I heard screaming that the resident is a DNR and saw nurse [Staff E, LPN's name] doing compressions. I called my DON and started education.Review of the witness statement authored by Staff L, CNA, dated [DATE] read, When I walked to the 600 hall, I made sure the crash cart was in the room. Once I saw the crash cart was there, I exited the room and waited in the hall for further instructions. I witnessed [Staff F, RN's name], [Staff A, LPN's name] and [Staff E, LPN's name] in the resident's room. [Staff F, RN's name] was doing compressions.Review of the witness statement authored by Staff G, LPN, dated [DATE] read, I was down 500 hall and heard a code called. When I got to the room, [Staff A, LPN's name] told me to get the O2 [oxygen] tank and [Staff E, LPN's name] to get the Ambu bag. [Staff A, LPN's name] helped me set up the Ambu bag. [Staff F, RN's name] was giving compressions, then switched out with [Staff H, LPN's name] or [Staff E, LPN's name]. [Staff A, LPN's name] walked away for a second and came back telling [Staff E, LPN's name] they had to talk after. She stepped away again, came back and stated the resident was a DNR but we had to continue compressions until EMS got there.Review of the witness statement authored by Staff H, LPN, dated [DATE] read, A code was called, I responded to room [ROOM NUMBER]. Compressions were being given by [Staff F, RN's name]. [Staff E, LPN's name] took over, then myself. [Staff A, LPN's name] went out of the room, came back and said stop she is a DNR. She then repeated to keep going as 911 was already called. CPR was continued until EMS arrived.Review of the witness statement authored by Staff V, LPN, dated [DATE] read, On Saturday 7/11 [[DATE]] I showed up for my shift at approximately 0700 [7:00 AM]. I informed supervisors [Staff A, LPN's name] I was not feeling well. I was instructed to go to the ER [emergency room] and I left at approximately 0745 [7:45 AM]. I returned to the building some time after 1000 [10:00 AM] and was informed of the incident before leaving to go home.Review of the witness statement authored by Staff D, CNA, dated [DATE] read, CNA [Staff C, CNA's name] and [Staff B, CNA's name] were putting pt [patient] to bed. I walked in to help and noticed pt looked different and something was not right. I asked [Staff C, CNA's name] to get the nurse [Staff A, LPN's name]. I got her nurse, [Staff E, LPN's name] as [Staff E, LPN's name] was coming to the room. She stated that pt was a DNR and went to the bedside with the BP [blood pressure] cuff. As I was walking out [Staff A, LPN's name] came in the room. Next thing I know was [Staff A, LPN's name] was saying call code blue.Review of the witness statement authored by Staff K, LPN, dated [DATE] read, On Saturday [DATE]th, 2026 I was on north front with [Staff M, LPN's name] to train on my first day. We were doing medication pass and then meet her there. When I entered 603 I stood back watching until the supervisor and another nurse told me to start helping with doing compressions. It was then said that she was a DNR but that compressions had to continue until EMS arrived,Review of the witness statement authored by Staff M, LPN, dated [DATE] read, This nurse responded to the resident incident and was asked to allow a newer nurse to take the lead in assisting with resident care to provide additional clinical experience. This nurse remained available to provide support as needed. This nurse left the incident post, 911 arrival.Review of the witness statement authored by Staff N, LPN, dated [DATE] read, On Saturday, [DATE] I was creating an additional assessment for MDS [Minimum Data Set] department as a new admission on the 500 hall. While visiting the patient I heard an overhead announcement for code blue on 600 hall. I observed licensed staff running towards 600 hall with crash cart. After leaving the patient room I went to the nurses station and asked a CNA who had coded. They provided their room number and stated that the staff needed the face sheet and patient DNR. I stated that I would retrieve the paperwork after logging into [name of medical documentation software] and pulling up the patient profile, I noticed she was a DNR. I immediately went to the room and observed staff who were providing chest compressions. At that time the AED was instructing staff to move away while it analyzed the patient's rhythm. I informed staff to remove the AED. EMS arrived and requested a copy of the patients DNR. I provided this from the red chart located at the nurses station. I did not perform CPR or touch the patient.During an interview on [DATE] at 1:15 PM, the Director of Nursing (DON) stated, The patient was talking to the CNAs on the way back from the dialysis clinic [A separately licensed End Stage Renal Disease facility, located in the same building]. The patient's blood pressure was low. The dialysis nurse had called [Staff A, LPN's name] and requested Midodrine [a medication used to treat low blood pressure] to be brought down to the dialysis room. They were going to do the Midodrine, but when [Staff A, LPN's name] went down to dialysis to bring the midodrine down there, and she saw the CNAs already pushing the resident back to her room. They let the resident leave unstable. The resident went unresponsive in the bed immediately after the CNAs transferred her into the bed.During an interview on [DATE] at 2:00 PM, Staff P, APRN, stated, I saw [Resident #6's name] a couple of weeks before she died. [Physician 1's name] was her primary doctor. During CPR, ribs can be broken, if the person is resuscitated, they can have pain, and the person can also be brought back to life against their wishes.During an interview on [DATE] at 2:15 PM, Staff A, LPN, stated, When she [Resident #6] returned from dialysis, she was talking and verbalizing with the CNAs. When they assisted her back to bed, she became unresponsive. Nurse [Staff E, LPN's name] told me she was a full code. After she said that to me, another nurse was in there assessing the patient with me. Once she said she was a full code, we activated CPR. Normally we check the computer to find out the code status. Fifteen minutes before they brought her back to the unit, the dialysis nurse called me and said her BP [blood pressure] was low. I checked the order and went to bring the Midodrine down and I saw the CNAs were already bringing her back. I was the supervisor at the time for the whole building. This happened on a Saturday. CPR was stopped when EMS arrived. While CPR was being done, I went and got the code book and found the DNR order. I was informed that after CPR is activated and 911 is called, CPR has to continue until EMS arrives.During an interview on [DATE] at 2:52 PM, Staff B, CNA, stated, I was [Resident #6's name]'s CNA. I went and got her from dialysis. When we brought her back to the room, she was talking to us. She was responding while she was in the [brand name of the mechanical lift device]. Once we lowered her down, that's when we saw she went unresponsive. [Staff C, CNA's name] went out and got the nurse. [Staff E, LPN's name] came in, she was the nurse that was on the cart that day. When [Staff E, LPN's name] walked in, I was walking out and [Staff A, LPN's name] was walking in. I don't know what happened after that.During an interview on [DATE] at 2:56 PM, Staff D, CNA, stated, I was walking past, and saw [Resident #6's name] on the [brand name of the mechanical lift device] lift. I walked into the room and asked if they needed help. As they were putting her down on the bed, I noticed [Resident #6's name] didn't look right. She was not responding. I said [Staff B, CNA's name], [Resident #6's name] don't look good. I went and got the nurse, [Staff E, LPN's name]. I heard [Staff E, LPN's name] say she was a DNR when she walked in the room with the blood pressure cuffs. I left the room after that.During an interview on [DATE] at 3:05 PM, Staff C, CNA, stated, We went and picked up [Resident #6's name] from dialysis. It was earlier than usual. They had her already sitting by the door when we got there. The nurse knew we were taking her. We passed [Staff A, LPN's name] in the hallway coming up 500 hall she was headed to dialysis because she said they had called her and asked for some medication for her. We got her hooked up in the [brand name of the mechanical lift device], lifted and put her over the bed. As we were lowering her, she let out a deep sigh and then became unresponsive while the [brand name of the mechanical lift device] pad was still under her. [Staff B, CNA's name] was calling her name, she wasn't responding, and [Staff B, CNA's name] told me to get the nurse. I looked for [Staff A, LPN's name], she was the supervisor. I saw [Staff E, LPN's name] on the med cart and told her [Resident #6's name] was unresponsive. [Staff E, LPN's name] got the vital sign equipment and headed to the room. I saw [Staff F, LPN's name] behind the nurses' station at 600 hall. I told him that she was unresponsive and he headed toward the room. I saw [Staff A, LPN's name] coming up the 500 hall, and I let [Staff A, LPN's name] know the patient was unresponsive and she headed toward the room. I did not go back into the room after that, I left.During an interview on [DATE] at 4:15 PM, the Director of Nursing stated, I was not here the day [Resident #6's name] coded. It was a Saturday. Around 9 AM, my phone started blowing up. The unit manager called me, [Staff A, LPN's name] called me, and the wound care nurse [Staff I, LPN's name] called me. They were telling me the resident was coming back from dialysis, they were putting her back to bed and she became unresponsive and they did CPR and that she had a DNR. At that point, I knew there was an error.During an interview on [DATE] at 5:08 PM, Staff I, LPN, stated, I saw [Staff E, LPN's name] doing chest compressions. EMS arrived and took over care of the patient. CPR was stopped. I notified the DON and asked what education I needed to start on.During an interview on [DATE] at 9:16 AM, Staff L, CNA, stated, We were down in the wound care area and heard the code over the intercom. I went up there. I peeked in the room and made sure they had the crash cart in the room. They did. I saw [Staff F, RN's name], [Staff A, LPN's name], and [Staff E, LPN's name]. [Staff F, RN's name] was doing compressions. Once I saw everyone was in there, I stood in the hallway and waited for EMS to arrive. It was not very long before EMS got there.During an interview on [DATE] at 9:31 AM, Staff O, Assistant Director of Nursing (ADON), stated, I was not here the day of [Resident #6's name]'s code. The information I have is that she came from dialysis, CNAs were putting her back to bed. She did not look right. I believe nurse [Staff E, LPN's name] came in, they asked what the code status was. They were told she was a full code, so they started CPR. After CPR was initiated, they were made aware she was a DNR. They thought that once you start CPR, you cannot stop until EMS gets there. As far as I knew at the time, once you initiate CPR, you can't stop until EMS gets there. If a patient is found unresponsive, the first thing you do after you assess is to check the code status in the red charts. Two nurses must verify the code status before CPR is initiated.During an interview on [DATE] at 9:47 AM, Staff F, RN, stated, I remember I was cleaning the wound care cart. One of the CNAs called my name. [Staff A, LPN's name] and [Staff E, LPN's name] went to the room. We took vitals on the patient. They called code blue and we all went back in the room. [Staff A, LPN's name] put her on the CPR board. Nurse [Staff E, LPN's name] said she was code blue. I did the first round of CPR, then new nurses we doing CPR until EMS arrived.During an interview on [DATE] at 9:53 AM, Staff H, LPN, stated, I know they came over and called code blue. I was on 700 hall passing meds. I went to the 600 hall for the code. When I got down there, [Staff F, RN's name] was already doing CPR on the patient. [Staff E, LPN's name] took over for [Staff F, RN's name], then I took over for [Staff E, LPN's name], then [Staff A, LPN's name] instructed us that the patient was a DNR. I was doing CPR at that point and I stopped. [Staff A, LPN's name] told me I had to keep going until EMS gets there. We have gotten education almost daily, and we were taught if patient is a DNR, not to continue doing if CPR was already started. If they are a full code, you keep going until EMS arrives. We have been doing mock codes, which is where we have a mannequin and they call a code, and we all report. Two nurses check the red book for DNR or code status. If it is a full code, the CNAs report to it also.During an interview on [DATE] at 10:00 AM, Staff N, LPN, stated, I went by the code blue when [Resident #6's name] coded. I came out of a patient room. I heard them running with the crash cart. I went up to the desk on South Unit and asked the CNAs what was going on. They told me the room number, and I went and checked the orders, and I saw she was a DNR. I came out with her medication list. I went down to the room and noticed a bunch of nurses. I told [Staff A, LPN's name] that the resident was a DNR and told her to take the AED [Automated External Defibrillator] off of her. I saw them start removing the AED. They were doing CPR when I walked down there. I don't remember who it was. I gave the DNR to the paramedics when they arrived after they went into the room and saw that staff were doing CPR. The head paramedic was upset and came out asking for the DNR. The red book was on the counter. I pulled the DNR out and gave it to him. I started talking to [Staff E, LPN's name]. She was upset saying she told them the patient was a DNR. [Staff A, LPN's name] said she didn't hear [Staff E, LPN's name], and she didn't check herself to verify the code status. The way it used to be is they would call a code blue, everyone would run. We would check code status with MDS [minimum data set].During an interview on [DATE] at 10:10 AM, Staff M, LPN, stated, I remember a code blue being called and going to the room. When I got there, they were working on her. I don't remember who all was in the room. I saw the nurses surrounding [Resident #6's name] and working on her. Then EMS came in, did an assessment and then they left. I was working on North Unit, 100 hall.During an interview on [DATE] at 12:37 PM, the Medical Director stated, I expect staff to alert someone if they find a person unresponsive. There is a process that the facility has, when a resident is in that state, we have book for code status and we use the computer. I was notified by [Administrator's name] shortly after the incident with [Resident #6's name] happened. If CPR is done appropriately, the sternum can be fractured, in the elderly population, one of the biggest things that can happen is that the ribs or the sternum can break.During an interview on [DATE] at 1:20 PM, the Director of Nursing stated, Once the DNR was discovered, staff should have stopped CPR. The staff had previously been educated that once CPR is started, you could not stop unless the resident wakes up, EMS arrives, or they have a doctor's order. That is what the staff thought. We educated them that if a DNR is found, CPR should be stopped.During an interview on [DATE] at 1:24 PM, Physician #1 stated, The staff notified my nurse practitioner that CPR was done on [Resident #6's name]. I am aware that she had a DNR. I can't say whether CPR should have been done or not, because I was not there, and people can change their minds. Complications of CPR can include bleeding and broken bones.During an interview on [DATE] at 5:02 PM, Staff E, LPN, stated One of the CNAs came out and told me the patient was unresponsive. I went in there and the nurse [Staff F, RN's name] and the supervisor were in there. They asked about the code status. I went out and checked and told them she was a DNR. Afterwards, [Staff A, LPN's name] told [Staff F, RN's name] to start CPR. Then a little while later, she walked out and walked back in and told us she was a DNR, but that we couldn't stop CPR until EMS got there. Afterwards [Staff A, LPN's name] pulled me to the side and said she didn't hear that I said the resident was DNR.During an interview on [DATE] at 3:45 PM, Staff G, LPN, stated, At the time of the code, I was passing meds. I ran to the room, [Staff H, LPN's name] went to the room and [Staff E, LPN's name] was in the room. [Staff F, RN's name] was giving compressions and [Staff A, LPN's name] was in there. I grabbed the oxygen tank and [Staff E, LPN's name] grabbed the Ambu bag. [Staff A, LPN's name] showed me how to hook up with Ambu bag. [Staff H, LPN's name] relieved [Staff F, RN's name] and began doing chest compressions. After she was finished, I was doing the Ambu bag. [Staff E, LPN's name] left the room, and then came back. Everyone came in and someone hooked up the AED. After that, [Staff E, LPN's name] left and came back in, then [Staff A, LPN's name] left and came back in and said she needed to speak to [Staff E, LPN's name] when we were finished. Then she said the resident was a DNR, but we have to keep running the code until EMS came.Review of the facility policy and procedure titled Advanced Directives with the last review date of [DATE] read, Policy: The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative.Review of the facility policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) with the last review date of [DATE] read, Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: Resident identification. Fully executed Florida Do Not Resuscitate order (DH1896), located in the advanced directive section of the medical record.The Immediate Jeopardy (IJ) was removed on [DATE]. The facility administration initiated an investigation regarding the incident On [DATE] and completed the investigation on [DATE]. On [DATE], the facility held an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and conducted a root cause analysis to develop a performance improvement plan. Root cause analysis identified as failure of staff to follow facility policy on verification of code status. On [DATE], 85% of licensed nurses and CNAs completed education on advance directives, resident rights, CPR/DNR, and abuse and neglect. On [DATE], 85% of licensed nurses and CNAs participated in code blue drills that was initiated on [DATE] for every 12 hours. On [DATE], 85% of licensed nurses competency for CPR/DNR were validated and verified through post testing.During interviews conducted on [DATE] through [DATE], 25 CNAs, 12 LPNs, 3 RNs, the Maintenance Director, the Appointment Scheduler, the Director of Patient Experience, and the Director of Central Supply stated that they had received training for abuse, neglect, and exploitation, resident rights, verification of advance directives with two nurses, and code blue training. All interviewed staff members confirmed their understanding of the training, how to verify code status with two nurses, and the location of advanced directives. All interviewed staff members stated that they have participated in code blue drills.The facility corrected the non-compliance as of [DATE]. The facility conducted 100% audit of all current residents' code status for accuracy. All licensed nurses and CNAs completed education on advance directives, resident rights, CPR/DNR, and abuse and neglect, participated in code blue drills, and completed competency verification by [DATE]. The facility conducted weekly audits of all newly admitted residents to ensure accuracy of advance directive status and to verify the nurse competency on advance directives. The facility conducted Ad Hoc QAPI meetings on [DATE], [DATE] and [DATE] to review the effectiveness of the corrective action plan.

Based on interview and record review, the facility failed to ensure a resident' concern regarding false statement by a staff member was filed as a grievance and investigated for 1 of 3 reviewed residents (Resident #8).Findings include:During an interview on 7/28/2026 at 9:50 AM, Resident #8 stated that he went to Social Services Director and reported that he had assisted his roommate following a fall and that a Certified Nursing Assistant (CNA) subsequently stated that the resident had not assisted her. The CNA's statement was false and that no one investigated his allegation and after speaking with Social Services Director, the Social Services Director approached him and asked whether he wanted to transfer because he was unhappy with the facility. The resident stated that he did not want to transfer and wanted to remain at the facility.Review of the facility's grievance log showed a grievance filed by Resident #8 on 4/8/2026 concerning inconsistent care. There was no grievance related to staff member's false statement.During an interview on 7/27/2026 at 1:55 PM, the Assistant Director of Nursing (ADON) stated, I don't know why a grievance was not filed. It should have been. The ADON further stated that she spoke with Resident #8 and removed the CNA from providing care to the resident.During an interview on 7/27/2026 at 11:32 AM, the Social Services Director stated that she was not aware of a grievance being filed by Resident #8 other than the grievance dated 4/8/2026. She stated that Resident #8 came to her office and reported that he had assisted his roommate after the roommate fell and that he had shoulder pain and he was unhappy with how the staff was treating him. The Social Services Director further stated that since Resident #8 had previously (January 2026) expressed a desire to be closer to his wife and because the resident was unhappy with the services at the facility, she asked whether he still wanted her to attempt to transfer him closer to his wife. The social services director stated, I did not fill out a grievance. That is not how grievances work.During an interview on 7/28/2026 at 2:25 PM, the Director of Nursing stated, A grievance should have been filed, investigated, and followed up in writing.Review of the facility policy and procedure titled Complaint/grievance dated 1/15/2026 read, The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Procedure: 1. An employee receiving a complaint/grievance from a resident family member and/or visitor will initiate a complaint/grievance form. 2. Original grievance forms are then submitted to the grievance officer/designee for further action. 3. The grievance officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the complaint/grievance form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance official will log complaints/grievances in monthly grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on interview and record review, the facility failed to ensure the provided services met professional standards of quality by allowing a resident to self-administer medications without a physician's order and without assessing the resident's ability to safely self-administer medications for 1 of 3 residents reviewed for medication administration (Resident #5). Findings include:During an interview on 7/27/2026 at 10:00 AM, Resident #5 stated, I do dialysis here every Tuesday, Thursday and Saturday. I have been here for about two weeks. They have not had my binders until today. They didn't have the binders, so I had to get permission to bring my binders in from home and take those.Review of Resident #5's admission record showed the resident was admitted on [DATE] with diagnoses to include other specified complication of vascular prosthetic devices, implants, and grafts; end stage renal disease; dependence on renal dialysis; acquired arteriovenous fistula; type 2 diabetes mellitus; muscle weakness; hypertensive chronic kidney disease; chronic atrial fibrillation; other disorders of phosphorus metabolism; gastroesophageal reflux disease; and gout.Review of Resident #5's physician order dated 7/1/2026 read, Calcium Acetate Oral Tablet 667 MG [milligram] (Calcium Acetate (Phosphate Binder)), Give 2 tablet by mouth three times a day every Mon [Monday], Wed [Wednesday], Fri [Friday], Sun [Sunday] for phosphate binder.Review of Resident #5's physician orders showed no order for self-administration of medications.Review of Resident #5's care plan showed no care plan focus or interventions for self-administering medications.During an interview on 7/30/2026 at 9:44 AM, Staff Q, Registered Dietician, stated, Some of the medications come bundled from the dialysis center, depending on their insurance. The dialysis dietician started last month. I believe the resident wasn't supposed to be here for a long time. I remember there was some issue with his binders, and the dialysis RD [Registered Dietician], the DON [Director of Nursing], and I spoke about it. But I do not remember the exact situation.During an interview on 7/30/2026 at 10:18 AM, the Director of Nursing stated, I was not aware that [Resident #5's name] was taking his home medication. He does not have orders to self-administer medications and was not care planned for self-administration of medications. He did not get permission from me. I am not sure who would have given permission for that. There is a process we have to do before that can happen. The process is that if a resident wants to self-administer, we do an assessment, if the assessment says they are cognitively able to do it, and able to verbalize their medication treatment times and everything about the medication. If they are able to do that, we have to create a journal or log for the resident to document in when they take their medications. We also have to get a locked box to keep the medications in. Then we have to care plan them for self-administration, and there needs to be an order.Review of the facility policy and procedure titled Self-Administration of Medication at Bedside reviewed on 1/15/2026 read, Policy: The resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedure: Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medications Evaluation. The Interdisciplinary Team will review the evaluation and will document Section III. Approval granted must be checked yes or no. Interdisciplinary team member signs the evaluation section. If approval is not granted, a statement must be written as to reason for denial. Complete the Care Plan for approved self-administered drugs. The MAR [Medication Administration Record] must identify meds that are self-administered and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer.

Based on record review and interview, the facility failed to ensure residents were provided sufficient orientation for safe and orderly transfer/discharge, failed to ensure an effective discharge plan was developed and implemented, and failed to ensure attempts to meet the specific resident needs at the facility as the basis for transfer for 1 of 3 residents reviewed for discharge (Resident #2). The facility discharged Resident #2 to a receiving facility located at a significant distance from the resident's family members and identified support system, resulting in Resident #2 experiencing emotional distress, increased social isolation, and decreased access to family support.Findings include: Review of Resident #2's admission record showed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder, brief psychotic disorder, other specified persistent mood disorders, and generalized anxiety disorder.Review of Resident #2's Nursing Home Transfer and Discharge Notice showed the resident was transferred to the receiving skilled nursing facility, located in Dunedin, Florida, 115 miles away from the facility, on 2/20/2026. The notice was provided to the resident on 2/19/2026 with an effective date of 2/20/2026. The notice documented the reason for transfer as Transferred to [the receiving skilled nursing facility's name] due to more frequent/lenient smoking times. The form was signed by the Director of Nursing, Staff A, Advanced Practice Nurse Practitioner (APRN) on 2/20/2026. The form had Resident #2's name printed and the resident signature line was blank.Review of Resident #2's records revealed no evidence of involvement of the resident and/or the resident representative in the discharge decision-making process or consideration of the resident's preferences and psychosocial needs.During an interview on 4/14/2026 at 11:42 AM, Staff B, Licensed Practical Nurse (LPN) Unit Manager, stated, I am not sure why [Resident #2's name] was discharged . That is not my area. I think it might have been related to smoking times. [Resident #2's name] was told the day before that he was being discharged . He was fine with it, and he was okay until he got into the transport van and found out he couldn't ride in the front seat. He had a very short temper and flew off the handle at the driver. He said he was being treated like an animal, because he had to ride in the back of the van.During an interview on 4/14/2026 at 1:06 PM, the Director of Nursing (DON) stated, [Resident #2's name] was transferred to [the receiving skilled nursing facility's name] in Dunedin, because they have more lenient smoking times. The day he transferred to the other facility, he was the only resident on that day.Review of Resident #2's smoking assessment dated [DATE] read, Does the resident currently smoke? A. Yes. Does the resident wish to quit smoking? No.Review of Resident #2's care plan showed the resident had no care plan focus for smoking or interventions to include smoking times.Review of Resident #2's progress notes showed no documentation that the resident being not in compliance with the smoking policy while residing in the facility.Review of Resident #2's records failed to demonstrate that alternative, closer placement options were explored or offered, and also failed to show resident met any of the requirements for an appropriate discharge due to the facility's inability to meet the resident's needs.During an interview on 4/15/2026 at 9:16 AM, the Director of Social Services stated, I was not involved with the discharge of [Resident #2's name]. I did not start working at this facility until February 17th. Sometimes sister facilities have more lenient smoking times. If a resident is being transferred to another facility, they would need to consent to the transfer and sign the discharge notice.During an interview on 4/15/2026 at 9:42 AM, Resident #2 stated, [the Director of Nursing's name] lied and said I'm closer to my family, but I am not. I woke up, ate breakfast, went to bed and the nurse told me, Pack your [s.], you're leaving. I was put in a minivan and drove here. I have not been able to see my family in Ocala. I am not even allowed to go outside of this facility. My daughter, my grandchildren and my fiance all live in Ocala. There is nothing to do and I can't see my family. I feel so sad and depressed. I never signed any forms, but somebody signed my discharge form, and it was not my signature. I think this is retaliation because I complained to [the Director of Nursing's name] about the CNAs [Certified Nursing Assistants] sleeping. During an interview on 4/15/2026 at 11:12 AM, the Administrator stated, We have timed and supervised smoking. We discharged some smokers to a sister facility due to there being more lenient smoking options. They were all fine with going. [Resident #2's name] signed the discharge notice. During an interview on 4/15/2026 at 11:20 AM, the Assistant Director of Nursing stated, [Resident #2's name] was given notice. [The Director of Nursing's name] gave him notice before he left. When he was here, he never had any visitors. [Resident #2's name] was a smoker, he would go out 5-10 times a day to smoke and would also leave to go to the store to buy cigarettes. He knew of the discharge. I didn't speak with him personally, but the information I got was that he was fine with it. He has a history of behavioral issues and being manipulative.During an interview on 4/15/2026 at 11:58 AM, Staff A, APRN stated, I was there the day before [Resident #2's name] discharged , and I heard a staff member speaking to him about how the policy of the other facility was more lenient for smoking. He said ok. [Resident #2's name] was a smoker. For discharges, I rely on social services and therapy, to help me determine if they are ready to discharge, and I sign the discharge notices. I believe they would need to have an order for transfer.Review of Resident #2's physician orders showed no order for discharge.During an interview on 4/15/2026 at 12:58 PM, the Assistant Director of Nursing stated, I don't see any discharge or transfer orders for [Resident #2's name].During an interview on 4/15/2026 at 2:16 PM, the Administrator stated, We have scheduled supervised smoking times. They have not changed in the past year. We were not able to meet that residents' needs because we don't have open smoking. In other words you can't smoke when you want. We added safety mag locks to the doors of the smoking area on February 10, 2026, so that residents could no longer go outside whenever they want. Social services talked with him [Resident #2] and nursing talked with him. The new facility offers more smoking times. We do serve smoking residents, and we go over the policies at admission. If the resident is agreeable to go somewhere else, discharge notice can be given on the same day. There should be a doctor's order for transfer. [The Medical Director's name] gave a verbal order to [the Director of Nursing's name] for the discharge.During an interview on 4/15/2026 at 2:18 PM, the Administrator stated, I do not know whether [the receiving skilled nursing facility's name] has an open smoking policy or what the scheduled smoking times are at [the receiving skilled nursing facility's name].Review of the schedule provided by the facility titled Smoking Times read, 7:15 AM-7:45 AM, 8:30 AM-9:00 AM, 9:45 AM-10:15 AM, 10:45 AM-11:15 AM, 1:00 PM-1:30 PM, 3:30 PM- 4:00 PM, 6:00 PM-6:30 PM, 7:45 PM-8:15 PM, 9:00 PM-9:30 PM, 10:00 PM-10:30 PM. Closed during all meals.During an interview on 4/15/2026 at 2:37 PM, the Medical Director stated, I gave verbal orders to transfer [Resident #2's name] to the other facility. Sometimes they will call me for discharge orders if, for example, they have transport arranged and have not been able to get a hold of the primary to get the order. I'm not sure about why [Resident #2's name] was transferred. I believe their needs could not be met because of smoking restrictions. Arbor Springs is a non-smoking facility. I am not sure if they have liberal smoking at the other facility. I don't know if other interventions were tried, I am not involved in their day-to-day care, you would need to check with their primary doctor.During an interview on 4/16/2026 at 11:17 AM, Staff C, APRN, stated, [Resident #2's name] was transferred because he wanted to be closer to his family and more lenient times as far as smoking goes, which I found strange because he didn't smoke. He wanted to be able to go out to the smoking patio whenever he wanted. I don't know how much notice they gave him before moving. That is not something I am involved with. I think moving someone with little notice could make them upset. I know [Resident #2's name] was being followed by psych. I think that if someone is moved to another facility, it could have some effects on them, but I don't believe they would be permanent effects. It could cause a temporary exacerbation of their underlying anxiety or depression.Review of the facility policy and procedure titled Interdisciplinary Discharge Planning revised on 4/28/2025 read, Policy: The facility will develop an interdisciplinary discharge plan based on the resident/resident representative's needs and goals. Procedure: 1. The resident/resident representative's discharge needs and goals and estimated length of stay will be developed upon admission. This goal is based upon clinical findings, availability of community and family resources, and resident/resident representative goals. 2. The interdisciplinary team monitors progress towards discharge goals throughout the resident's stay. Discharge plans are reviewed and revised as appropriate. 3. Prior to discharge, the discharge plan including the proposed discharge date will be reviewed with the resident/resident representative.

Based on record review and interview, the facility failed to ensure residents were provided with written notice of transfer/discharge at least 30 days in advance for 2 of 3 residents reviewed for discharge (Residents #2 and #11). Findings include:1) Review of Resident #2's Nursing Home Transfer and Discharge Notice showed the resident was transferred to the receiving skilled nursing facility, located in Dunedin, Florida, on 2/20/2026. The notice was provided to the resident on 2/19/2026 with an effective date of 2/20/2026. The form was signed by the Director of Nursing, Staff A, Advanced Practice Nurse Practitioner (APRN) on 2/20/2026. The form had Resident #2's name printed and the resident signature line was blank.During an interview on 4/15/2026 at 9:42 AM, Resident #2 stated, [The Director of Nursing's name] lied and said I'm closer to my family, but I am not. I woke up, ate breakfast, went to bed and the nurse told me Pack your [s.], you're leaving. I never signed any forms, but somebody signed my discharge form and it was not my signature.During an interview on 4/15/2026 at 9:16 AM, the Director of Social Services stated, If a resident is being transferred to another facility, they would need to consent to the transfer and sign the discharge notice.Review of Resident #2's physician orders showed no order for discharge.During an interview on 4/15/2026 at 12:58 PM, the Assistant Director of Nursing stated, I don't see any discharge or transfer orders for [Resident #2's name].2) During an interview on 4/16/2026 at 11:05 AM, Resident #11's Daughter/Power of Attorney stated, I had no advanced notice before they transferred my mom. When they called me, it wasn't confirmed. They said it may be an option to transfer her. I told them I would consider it and speak to my mother about it. No one ever called me back. I called back several times, and she was already on the bus being transferred. A lot of her belongings did not go with her. I have left several messages about her clothing and have not heard back. She was not prepared to be transferred. I let them know I wanted to discuss things with her first before she was moved, and they did not give me a chance to discuss it with her. It all happened so fast. There was no communication from the director of nursing. We did want her somewhere closer. Ocala is 2.5 hours from me and [the receiving skilled nursing facility's name] is 1 hour from me. But I just felt like it was very rushed. We were not given an opportunity to look at the other facility first. I felt like they were just trying to get rid of her because she is not very agreeable. She was very confused because she didn't realize she was being moved permanently and did not get to say goodbye to some of her friends and the staff. The night she was transferred I spoke with the social worker at [the receiving skilled facility's name]. I asked about the belongings and he told me that all of the residents belongings were in one box.Review of Resident #11's Nursing Home Transfer and Discharge Notice showed the resident was transferred to the receiving skilled nursing facility, located in Dunedin, Florida, on 2/2/2026. The notice was provided to the resident on 2/2/2026 with an effective date of 2/2/2026. The notice documented the reason for transfer as Moving closer to daughter who lives in [name of the city].During an interview on 4/15/2026 at 2:16 PM, the Administrator stated, If the resident is agreeable to go somewhere else, discharge notice can be given on the same day. There should be a doctor's order for transfer. [The Medical Director's name] gave a verbal order to [the Director of Nursing's name] for the discharge.Review of the facility policy and procedure titled Interdisciplinary Discharge Planning revised on 4/28/2025 read, Policy: The facility will develop an interdisciplinary discharge plan based on the resident/resident representative's needs and goals. Procedure: 1. The resident/resident representative's discharge needs and goals and estimated length of stay will be developed upon admission. This goal is based upon clinical findings, availability of community and family resources, and resident/resident representative goals. 2. The interdisciplinary team monitors progress towards discharge goals throughout the resident's stay. Discharge plans are reviewed and revised as appropriate. 3. Prior to discharge, the discharge plan including the proposed discharge date will be reviewed with the resident/resident representative.

Based on observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards, including proper refrigeration and expiration dates for six of seven medication carts observed for medication labeling and storage.Findings include: During an observation of medication cart #1 on [DATE] at 8:25 AM with Staff A, Registered Nurse (RN), there was an unlabeled medication cup with 12 pink tablets, and an unlabeled medication cup with 2 white tablets. There was one opened Lispro Insulin with no date opened or expiration date, one Novolog insulin with expiration date of [DATE], one opened Lantus insulin with no date opened or expiration date, one unopened Novolog insulin with pharmacy instruction to refrigerate until opened, and one unopened Novolog insulin with pharmacy instructions to refrigerate until opened. During an interview on [DATE] at 8:25 AM, Staff A, RN, stated, There should not be any medication that aren't labeled. If it says to keep in the refrigerator we should do that. I should not pre pour medications and keep them in the cart. That insulin is expired; I should not have that on the cart. During an observation of medication cart #2 on [DATE] at 8:45 AM with Staff B, Licensed Practical Nurse (LPN), there was one unopened Lispro insulin with pharmacy instructions to refrigerate until opened, two opened Latanoprost ophthalmic solutions with no date opened or expiration date, one Latanoprost ophthalmic solution with an open date of [DATE], and one Timolol ophthalmic solution with no date opened or expiration date. During an interview on [DATE] at 8:47 AM, Staff B, LPN, stated, All medicines should either be in the refrigerator, have a date they have been opened, and if they are expired they should not be on the cart. The eye drops are expired. During an observation of medication cart #4 with Staff F, LPN, on [DATE] at 10:50 AM, there was one Lantus insulin with no date opened or expiration date, one Novolin insulin with no date opened or expiration date, and one unopened Lantus insulin with pharmacy instructions to refrigerate until opened. During an interview on [DATE] at 10:55 AM, Staff F, LPN, stated, All medication should have either the date they were opened or an expiration date. All medications should stay in the refrigerator until we need them. During an observation of medication cart #5 with Staff E, LPN, on [DATE] at 10:58 AM, there was one unopened Admelog insulin with pharmacy instruction to refrigerate until opened, one opened Lantus insulin without pharmacy packaging or resident identification and no date opened or expiration date, two unopened Basalgar insulins with pharmacy instruction to refrigerate until opened, one opened Aspart insulin with no date opened or expiration dates, one unopened Lantus insulin with pharmacy instructions to refrigerate until opened, one expired Lantus insulin with an open date of [DATE], and one expired Novolog insulin with an opened date of [DATE]. During an interview on [DATE] at 11:03 AM, Staff E, LPN, stated, There shouldn't be any expired medicines on the cart. We should have then labeled with either the date they get opened or when they expire and if we aren't using insulin it should stay in the refrigerator until we open them. During an observation of medication cart #6 with Staff G, LPN, on [DATE] at 11:05 AM, there was one unopened Aspart insulin with pharmacy instructions to refrigerate until opened, one unopened Lantus insulin with pharmacy instructions to refrigerate until opened, and one opened Lispro insulin with no date opened or expiration date. During an interview on [DATE] at 11:09 AM, Staff G, LPN, stated, Every insulin should have the date they get opened or expire. We should not have any insulin on the cart if we aren't using it. It should stay in the refrigerator. During an observation of medication cart #7 with Staff D, LPN, on [DATE] at 11:40 AM, there was one expired Lispro insulin with an open date of [DATE], one unopened Glargine insulin with pharmacy instructions to refrigerate until opened, one unopened Humulin insulin with pharmacy instructions to refrigerate until opened, and one opened Novolin insulin with no date opened or expiration date. During an interview on [DATE] at 11:42 AM, Staff D, LPN, stated, We need to make sure every insulin has expiration dates and they should not be on the cart when they aren't opened, they should stay in the refrigerator. Review of the policy and procedure titled, Medication and Medication supply storage and disposal, last approval date of [DATE] reads, Policy: Central storage of medications is required for prescription, prescribed over-the-counter medications and CAM (Complementary and alternative Medicine) will be kept in locked area, in their original labeled container and may not be removed more than 2 hours prior to scheduled administration. Procedure: 6. Medication will be stored in an organized manner under proper conditions and in accordance with manufacturer's instructions. 8. The original container for prescription medications must be labeled with pharmacy label that includes the following: residents name, name of the medication, date the prescription was issued, prescribed dosage and instructions for administration, name and title of the prescriber. Review of the policy and procedure titled, Medication Storage, last approval date of [DATE] reads, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures safety of the residents and is in accordance with FL Department of Health guidelines. Procedure: E. Medications will be stored in the original, labeled containers received from the pharmacy. F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. G. Medications will be stored at appropriate temperature in accordance with pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following: 3. Cold place: 2-8 degrees Celsius(36-46 degrees F(Fahrenheit). H. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius ( 36-46 degrees F).

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when failing to perform hand hygiene during medication administration in 6 of 9 observation of medication administration.Findings include: During an observation of medication administration for Resident #9 on 3/6/2026 at 8:25 AM, Staff A, Registered Nurse (RN), was observed approaching the medication cart without performing hand hygiene, unlocked the medication cart, activated and typed on computer and prepared Resident #9's medications. Staff A, RN, was observed to pop the medication out of the blister pack directly into their hand and place the medications into the medication cup each time for 13 medications. Staff A, RN, entered Resident #9's room without performing hand hygiene, touching the overbed table and bed controls, donned gloves without performing hand hygiene took the residents blood pressure, and administered the medications. During an observation of medication administration for Resident #11 on 3/6/2026 at 8:35 AM, Staff A, RN, returned to the medication cart, unlocked the medication, touched and activated the computer and removed medications, popping the medications directly into her hand, touching her hair between medications for 3 medications and placing the medications into a medication cup. Staff A,RN, entered Resident #11's room without performing hand hygiene, touched the resident's arm, overbed table and bed controls, donned gloves without performing hand hygiene. Staff A, RN, took residents blood pressure, and administered medications, doffed gloves and performed hand hygiene.During an observation of medication administration for Resident #10 on 3/6/2026 at 8:41 AM Staff A, RN, returned to the medication cart, unlocked the cart, touched and activated the computer, and removed medications, popping the medication directly into their hand and placing the medication in the medication cup for 4 medications. Staff A, RN, entered Resident #10's room without performing hand hygiene, touching the bed controls and overbed table, donned gloves without performing hand hygiene, checked Resident #10's blood pressure and administered the medications.During an interview on 3/6/2026 at 8:43 AM Staff A, RN, stated, I guess I should have not touched the medicine and just put it in the medication cup. I should have used the hand sanitizer more frequently.During an observation of medication administration for Resident #7 on 3/6/2026 at 8:51 AM, Staff C, Licensed Practical Nurse (LPN), was observed returning to the medication cart, unlocking the medication cart, activating and typing on the computer, and preparing the medications without performing hand hygiene. Staff C, LPN, entered Resident #7's room without performing hand hygiene, touching the overbed table and bed controls, obtained a blood pressure and administered Resident #7's medications without performing hand hygiene. Staff C, LPN, exited the room and returned to the medication cart to prepare medications for another resident without performing hand hygiene.During an observation of medication administration for Resident #6 on 3/6/2026 at 8:55 AM, Staff C, LPN, returned to the medication cart, unlocked the medication cart, activated and typed on the computer without performing hand hygiene, prepared Resident #6's medications, and entered the residents room without performing hand hygiene. Staff C, LPN, obtained Resident #6's blood pressure and administered medications touching the overbed table during the observation. Staff C, LPN, exited the room without performing hand hygiene and returned to the medication cart and began preparing medications for another resident. During an observation of medication administration for Resident #8 on 3/6/2026 at 9:02 AM, Staff C, LPN, returned to the medication cart, unlocked the cart, activated and typed on the computer, prepared all medications without performing hand hygiene. Staff C, LPN, entered Resident #8's room without performing hand hygiene, touched the overbed table and resident. Staff C, LPN, checked Resident #8's blood pressure, and administered all medications without performing hand hygiene. Staff C, LPN, exited the residents room and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident.During an interview on 3/6/2026 at 9:06 AM, Staff C, LPN, stated, Oh, I should have done that. I should have used the hand sanitizer that is why it's right here on the cart.Review of the policy and procedure titled Hand Hygiene last approval date of 1/15/2026 reads, Overview: The CDC defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel). Purpose: To reduce the spread of germs in the healthcare setting. Process: Hand hygiene should be performed: Before and after patient care, After contact with inanimate objects (including medical equipment) in the immediate patient vicinity.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean and homelike environment related to broken and damaged wall tiles in the resident shower room. During an interview on 03/06/2026 at 9:05 AM, Resident #14 stated that there was a missing shower tile in the shower room, and she caught her toe on it in January. During an observation on 03/06/2026 at 9:29 AM, there were seven broken wall tiles in the 400's hall shower room on the wall adjacent to the door. Two tiles were chipped with sharp edges exposed, leaving an uneven surface with deteriorating grout. During an interview on 03/06/2026 at 11:47 AM, the Maintenance Assistant stated, Those tiles are in disrepair. I tour the shower rooms daily, but I was not able to come through this one yet. Review of policy and procedure titled, Maintenance last approval date of 01/15/2026 read, The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition.

Based on record review and interview the facility failed to notify the resident and the resident's representative of the transfer and the reasons for the move in writing in a language and manner they understand for 3 of 3 residents, Residents #1, #4, and #5, reviewed for discharge and/or transfer. Findings include: Review of Resident #1's clinical record contained a document titled SNF/NF [skilled nursing Facility/Nursing Facility] to hospital Transfer Form that read, Sent to [name of hospital] 11/13/2025 00:30 [12:30 AM]. Review of Resident #1's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/13/2025 transferred to [name of hospital]. Review of Resident #1's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. Review of Resident # 4's clinical record contained a document titled SNF/NF to hospital Transfer Form that read, Sent to [name of hospital]. Dated 11/11/2025 11:00 [AM]. Review of Resident #4's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/11/2025 transferred to [name of hospital]. Review of Resident #4's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. Review of Resident #5's clinical record contained a document titled SNF/NF to hospital Transfer Form that read, Sent to [name of hospital. Dated 11/14/2025 14:29 [2:29 PM]. Review of Resident #5's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/14/2025 transferred to [name of hospital]. Review of Resident #5's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. During an interview on 12/10/2025 at 1:55 PM Staff D, LPN [Licensed Practical Nurse] Unit Manager stated, All the transfer documents are put in a packet and given to EMS [Emergency Medical Services]. Nothing is given in writing to the residents, just a verbal on why they are being sent out. During an interview on 12/10/2025 at 3:24 PM E, LPN stated, We do a change in condition and transfer out to the hospital. We complete it with a transfer form. We call the ER [Emergency Room] on why we are sending the patient. We provide a transfer summary, face sheet, orders to EMS so that they have medication and orders. Nothing is given to the patient, we tell them exactly why they are going out, who ordered for the transfer and where they are going. We try to ask if they have a preferred hospital. During an interview on 12/10/2025 at 3:35 PM Staff C, LPN stated, I would talk to the resident to see if they wanted to go to the hospital. We do not hold them. I will let them go and send them to the hospital. I would send the face sheet, medication list and DNR [Do Not Resuscitate] yellow form. I would give the transfer forms to EMS, complete a change of condition in the computer, and the resident gets the bed hold that they sign everything else goes to EMS. I tell them [the resident] who is sending them and why they are going and what hospital they are going to. During an interview on 12/10/2025 at 4:23 PM Staff B, LPN stated, The transfer papers are given to EMS, all the paperwork, which includes the transfer summary, face sheet, doctor orders and medications. I never give the paper to the residents at the time of transfer it's always given to EMS. During an interview on 12/10/2025 at 4:27 PM the Director of Nursing stated, We have always completed a transfer summary, change of condition, and provided EMS with the transfer summary, face sheet, physician orders and tell the resident why they are going out and who sent them to the hospital. We cannot tell them the exact hospital because we do not know where they are going because EMS determines based on availability. We do not hand the papers for transfer to the resident because it would get lost. EMS gives the papers to the hospital. We do not give anything to the residents. Review of the policy and procedure titled Discharge and Transfer with an effective date of 11/30/2014 read, The Company will ensure that transfer or discharge is safe, orderly and is appropriate to meet the needs of the resident.

Based on observation, record review, and interview, the facility failed to ensure staff followed infection control standards for transmission-based precautions to prevent the possible spread of infection and communicable diseases for 1 of 3 residents reviewed for infection prevention and control practices, Resident #2.Findings include: Review of the clinical record for Resident #2 documented the resident was admitted into the facility on [DATE] with a diagnosis of pseudomonas aeruginosa (a bacteria that is considered to be a multi-drug-resistant organism) a urinary tract infection (UTI). Review of Resident #2's physician orders dated 12/10/2025 read Contact isolation for pseudomonas aeruginosa in urine (UTI). Review of the Isolation precaution signage posted on the PPE (personal protective equipment) rack read Stop - Contact precautions everyone must: clean their hands, including before entering and when leaving the room, with soap and water. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. During an observation on 12/10/2025 at 09:30 AM Staff A, Certified Nursing Assistant (CNA) entered Resident #2's room without wearing PPE, (gown/gloves). The Resident's room had (PPE) stored and readily available in a rack hanging on the door from outside. The isolation precaution signage was posted on the rack. (Photograph evidence obtained). Staff A, CNA entered the room with no PPE donned and proceeded to move Resident #2's personal belongings around on top of the bedside table. Staff A, CNA then left the room. During an interview on 12/10/2025 at 09:3 5AM Staff A, CNA stated, I wound only put on the gown, gloves, or a mask if I was doing something for the patient. I don't have to wear gown or anything if I am not touching the resident. During an interview on 12/10/2025 at 09:39 AM Staff B, License Practical Nurse (LPN) Supervisor stated, [Resident #2's room number] is on contact isolation and the staff should be coming and asking if they do not understand what they should be wearing. Anyone entering a contact isolation room should wear a gown, mask and gloves. During an interview on 12/10/2025 AT 4:27 PM the Director of Nursing stated, [Resident #2's name] is on contact precautions and staff should be finding out what type of PPE is required by asking the nurse, if they do not know what to wear. With contact precautions I expect the staff to wear a gown, gloves and mask when entering the room. Review of the policy and procedure titled Isolation - Categories of Transmission - Based Precautions read, Contact precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with a resident or indirect contact with environmental surfaces or resident care items in the residence environment. 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident staff will change gloves after having contact with infective materials, for example fecal material and wound drainage. B. Gloves will be removed and hand hygiene performed before leaving the room. C. Staff will avoid touching potentially contaminated environmental surfaces or items in the residence room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on record review and interview, the facility failed to maintain complete and accurately documented medical records for wound care for 1 of 3 residents reviewed for wound care (Resident #107), for 2 of 4 residents intravenous (IV) therapy (Residents #178 and #183), and for 3 of 9 residents reviewed for medication management (Residents #15, #120 and #187). Findings include: 1) Review of Resident #107's physician order dated 7/15/2025 read, Wound: Right heel Cleanse with normal saline, pat dry, skin prep and LOA [Leave Open to Air] daily and PRN [as needed] every day shift for Wound care. Review of Resident #107's Treatment Administration Record (TAR) for August 2025 for right heel wound care showed no entries documented on 8/9/2025. Review of Resident #107's physician order with the start date of 7/3/2025 and discontinuation date of 7/15/2025 read, Wound Care (Coccyx): Cleanse with wound cleanser, pat dry, apply cmc [carboxymethylcellulose] fiber and medical grade honey to wound bed, cover with silicone bordered super absorbent dressing daily and as needed every day shift for wound care. Review of Resident #107's TAR for July 2025 for coccyx wound care showed no entries documented on 7/3/2025, 7/4/2025, 7/10/2025, 7/11/2025, 7/12/2025, 7/13/2025, 7/14/2025. Review of Resident #107's physician order dated 8/1/2025 read, Wound Care (Coccyx): Cleanse with wound cleanser, pat dry, collagen particles and med honey to wound bed, cover with silicone bordered super absorbent dressing daily and as needed every day shift for wound care. Review of Resident #107's TAR for August 2025 for coccyx wound care showed no entries documented on 8/9/2025. During an interview on 8/20/2025 at 12:08 PM, Staff G, Registered Nurse (RN), stated, [Resident #107's name] wound care was ordered for night shift, but on those days, I completed it during the day. I let the night shift nurse know that it was already completed, but I guess the night shift nurse just forgot to document it. During an interview on 8/20/2025 at 2:25 PM, Staff E, RN, stated, I float between units. I changed [Resident 107's name] dressings on August 9th (8/9/2025) for her coccyx and her heel. I forgot to document that I did the wound care. During an interview on 8/21/2025 at 9:20 AM, the Director of Nursing (DON) stated, I expect the nurse that completes the wound care to document that it was completed. The dressing change should have been documented by [Staff G's name]. Review of the facility policy and procedure titled Dressing Change with the last review date of 2/18/2025 read, Policy: A clean dressing will [be] applied by a nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure. Document in medical record. 2) During an observation on 8/18/2025 at 10:30 AM, Resident #178 was sitting up in bed. There was a Peripherally Inserted Central Catheter (PICC) line on the resident's left upper arm, with a transparent dressing dated 8/10/2025 at 11:00 AM (Photographic evidence obtained). During an interview on 8/18/2025 at 10:30 AM, Resident #178 stated, No one has changed the dressing on my PICC line since I've been here. Review of Resident #178's physician order dated 8/12/2025 read, Change Left Arm Double Lumen PICC line catheter site dressing every week with transparent dressing. Change needleless access device every day shift every Fri [Friday]. Review of Resident #178's Medication Administration Record (MAR) for August 2025 showed PICC line dressing was changed on 8/15/2025 by Staff B, Licensed Practical Nurse (LPN). During an interview on 8/21/2025 at 9:33 AM, Staff B, LPN, stated, I changed [Resident #178's name] PICC line dressing on August 15th. We change the dressings every 7 days. 3) During an observation on 8/18/2025 at 10:39 AM, Resident #183 was lying in bed. There was a double lumen PICC line on the resident's left upper arm with a transparent dressing dated 8/8/2025, with dry black matter (Photographic evidence obtained). During an interview on 8/18/2025 at 10:39 AM, Resident #183 stated, My IV dressing was last changed on the 8th [8/8/2025] during my hospital stay. Review of Resident #183's physician order dated 8/14/2025 read, Change midline catheter site dressing every week with transparent dressing. Change needleless access device every day shift every Fri. Review of Resident #183's TAR for August 2025 showed PICC line dressing was changed on 8/15/2025. During an interview on 8/22/2025 at 8:10 AM, with the DON stated, I expect nurses to document accurately the services provided. During an interview on 8/22/2025 at 9:26 AM, Staff L, RN, stated, I don't recall that day. Maybe she was sleeping and I checked it off. Normally when she is sleeping, I don't disturb her and come back. I might have forgotten to come back and do the dressing change. 4) Review of Resident #187's physician order dated 6/30/2025 read, Cefazolin Sodium Injection Solution Reconstituted 3 GM [gram] (Cefazolin Sodium), Use 3 gram intravenously every 8 hours for hand infection until 07/18/2025 23:59 [11:59 PM]. Review of Resident #187's MAR for July 2025 for administration of Cefazolin Sodium showed coded 9 (other/see progress notes) was documented on 7/5/2025 at 6:00 AM, 7/6/2025 at 2:00 PM, 7/13/2025 at 2:00 PM, and 7/13/2025 at 6:00 AM. No entries was documented on 7/13/2025 at 6:00 AM. Review of Resident #187's progress notes showed no note regarding Cefazolin on 7/5/2025, 7/6/2025 and 7/13/2025. Review of Resident #187's physician order dated 6/27/2025 read, Tramadol HCl Oral Tablet 50 MG [milligram] (Tramadol HCl) Give 1 tablet by mouth every 8 hours for pain for 3 days. Review of Resident #187's MAR for June 2025 showed code 9 was documented on 6/26/2025 at 5:00 PM, and on 6/28/2025 at 1:00 AM. Review of Resident #187's progress notes showed no notes regarding Tramadol on 6/26/2025 and 6/28/2025. Review of Resident #187's MAR for July 2025 for administration of Tramadol showed the following were documented: no entry on 7/2/2025 at 6:00 AM and 10:00 PM; code 9 on 7/6/2025 at 10:00 PM, code 9 on 7/7/2025 at 6:00 AM, no entry on 7/13/2025 at 6:00 AM, and code 9 at 2:00 PM. Review of Resident #187's progress notes showed no notes regarding Tramadol on 7/6/2025 and 7/7/2025 and 7/13/2025. During an interview on 8/22/2025 at 11:45 AM, Staff L, RN, stated, Normally I will use a the code of 9 if the medication was not available, but I don't recall. During an interview on 8/22/2025 at 2:16 PM, Staff M, LPN, stated, I would leave the entry blank only if medication is not available in pyxis. I would make a note that I contacted the provider and pharmacy. During an interview on 8/22/2025 at 2:19 PM, Staff N, LPN, stated, I don't recall why I would have a blank entry. Normally I would document if the medication is not available and would notify the provider. During an interview on 8/22/2025 at 2:27 PM, Staff O, LPN, stated, I don't recall. I would write a note and contact the pharmacy and provider. During an interview on 8/22/2025 at 2:33 PM, the Medical Doctor #1 stated, I cannot recall the resident. The staff will normally call me and notify me when the medication is not available. I have no concerns that staff are giving medication appropriately. During an interview on 8/22/2025 at 2:39 PM, the DON stated, Staff are supposed to write an explanation when using the code 9 and document accurately did show not leave any entry blank. 5) Review of Resident #120's physician order dated 9/13/2024 read, Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate), Give 1 tablet by mouth one time a day for HTN [hypertension]. Review of Resident #120's MAR for August 2025 for administration of Amlodipine Besylate 5 MG showed code 4 (Vitals outside of parameters for administration) was documented on 8/2/2025, 8/6/2025 and 8/16/2025. Review of Resident #120's progress notes for August 2025 showed no notes associated with the administration of Amlodipine on 8/2/2025, 8/6/2025, 8/16/2025. 6) Review of Resident #15's physician order dated 5/15/2024 read, Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate), Give 5 mg by mouth one time a day related to essential (primary) hypertension. Review of Resident #15's MAR for August 2025 for administration of Amlodipine Besylate Oral Tablet 5 MG showed code 4 was documented on 8/6/2025 and 8/16/2025. Review of Resident #15's progress notes for August 2025 showed no notes associated with the administration of Amlodipine on 8/6/2025, 8/16/2025 During an interview on 8/22/2025 at 11:40 AM, Staff F, LPN, stated that on 8/2/2025, 8/6/2025, 8/16/2025, when she documented code 4 for the reason the resident's Amlodipine was not administered, she spoke to either the doctor or nurse practitioner, but forgot to document it. During an interview on 8/22/2025 at 1:55 PM, the DON stated that her expectations about documentation by the nursing staff would be accurate, timely and complete documentation.

Based on observation, interview, and record review, the facility failed to follow infection control practices for tracheostomy care for 1 of 3 residents reviewed for respiratory services (Resident #116) and failed to ensure staff performed hand hygiene and followed Enhanced Barrier Precautions (EBP) instructions to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 8/21/2025 at 1:30 PM, Staff B, Licensed Practical Nurse (LPN), entered Resident #116's room. Staff B donned personal protective equipment (PPE), set the sterile field to provide tracheostomy care, placed sterile gloves in the field, performed hand hygiene, donned sterile gloves, removed and disposed of the inner cannula, did not clean the site, and inserted a new cannula. Staff B doffed the gloves, performed hand hygiene, donned sterile gloves, and cleansed the outside area of the tracheostomy. Staff B removed the gloves, did not perform hand hygiene, and donned new pair of gloves and cleansed the wound near the tracheostomy. Staff B did not remove her gloves, did not perform hand hygiene, patted the wound dry, and applied the wound treatment with gauze. During an interview on 8/21/2025 at 2:05 PM, Staff B, LPN, stated, I am not sure if I would have done anything different. I should have performed hand hygiene and cleaned the site before inserting the new inner cannula. I did use sterile gloves. My mind just went another direction. Review of Resident #116's physician order dated 8/14/2025 read, Wound care-trach site Daily, and PRN [as needed], Clean Wound with: Cleanse with normal saline primary treatment: calcium alginate other dressings: leave open to air every day shift for wound care. During an interview on 8/21/2025 at 4:00 PM, the Infection Preventionist stated, Nurses should keep it [tracheostomy care] sterile and wash hands and change gloves when cleaning a wound. During an interview on 8/22/2025 at 8:10 AM, the Director of Nursing (DON) stated, Tracheostomy care should be a sterile procedure: Clean the area before inserting the new inner cannula. Change gloves and perform hand hygiene in between the steps of wound care. Review of the facility policy and procedures titled Tracheostomy Care with the last review date of 2/18/2025 read, Procedure. Aseptically don sterile gloves (Gown, and goggles, as necessary). For tracheostomy with disposable inner cannula: Remove and dispose of the soiled inner cannula. Clean around stoma site with sterile water or saline with cotton tipped applicators and/or sterile 4x4 [4 inch by 4 inch gauze], dry with sterile gauze if needed. Insert new disposable inner cannula and lock into place. Review of the facility policy and procedure titled Dressing Change with the last review date of 2/18/2025 read, Policy: A clean dressing will [be] applied by nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure. Cleanse wound as ordered, dispose of gauze; Remove gloves and perform hand hygiene; Apply treatment as order [Sic.] and clean dressing. 2) During an observation on 8/20/2025 at 8:51 AM, Staff A, Registered Nurse (RN), washed her hands and applied gloves prior to initiating the administration of Piperacillin 4.5 grams, an intravenous (IV) antibiotic infusion, for Resident #68. Staff A did not don a gown. Staff A cleaned the hub of the IV line with alcohol and flushed it with normal saline. Staff A then left the hub open to air while priming the IV tubing with the medication. Staff A did not clean the hub of the IV again before connecting the IV tubing and beginning the infusion. Review of Resident #68's physician orders did not show an order for Enhanced Barrier Precautions. During an observation on 8/20/2025 at 9:12 AM, Staff B, LPN, performed hand hygiene, donned gloves, did not don a gown, and proceeded to disconnect the IV tubing that had been administering an infusion of Daptomycin from Resident #178 to flush the IV line. During an interview on 8/20/2025 at 4:27 PM, Staff B, LPN, stated, For residents on EBP, the Infection Preventionist tells the staff which residents are on EBP, why they are on EBP and what PPE to wear and when to wear it. The Infection Preventionist goes over with the staff the details and puts a sign on the door. When asked, Staff B did not provide what conditions would require the use of EBP or need for donning PPE. Staff B stated she would wear and when she would wear it according to the sign on the door or by checking the resident's chart. Review of Resident #178's physician orders did not show an order for Enhanced Barrier Precautions. 3) During an observation on 8/20/2025 at 9:40 AM, Staff A, RN, washed her hands and donned gloves, but did not don a gown. Staff A cleansed the tip of Resident #94's IV with alcohol and flushed the IV with normal saline. After priming the IV tubing, Staff A wiped the tip of the IV catheter with alcohol and connected the IV tubing and began the infusion of Ceftazidime 2000 MG (milligrams) Injection. During an observation on 8/21/2025 at 8:37 AM, Staff E, RN, entered Resident #180's room, administered three oral medications to Resident #180 and left the room. Staff E did not perform hand hygiene and prepared medications for another resident. At 8:47 AM, Staff E entered Resident #100's room, administered six oral medications to the resident. Staff E did not perform hand hygiene and exited the room. During an observation on 8/21/2025 at 9:43 AM, Staff E, RN, crushed Ascorbic Acid 500 mg for Resident #75. Staff E donned gloves, but did not perform hand hygiene or don a gown. Staff E flushed the resident's G-tube (gastrostomy tube) with water, instilled the medication, and then flushed with water, removed and discarded his gloves. During an interview on 8/21/2025 at 11:10 AM, Staff E, RN, stated that Enhanced Barrier Precautions were for residents with things such as wounds, G-tubes, trachs [tracheostomies], or who were immunocompromised. For those residents he would make sure he had cleaned hands and wore gloves. He would wear a gown if he were doing wound care for an open wound, or if there was a possibility of drainage. He may even wear double gloves. If he were doing trach care, he would wear a face shield. He would wash his hands between every room. If he were hanging [initiating] and IVG [infusion], he would check the dressing for the proper date and be sure it was clean. He would wear gloves and be sure that all of the medication infused before he disconnected the line. During an interview on 8/21/2025 at 11:30 AM, the DON stated, Enhanced Barrier Precautions were for any resident with a hole they weren't born with, an insertion site of any kind, wounds, IVs, supra-pubic catheters, G-tubes, anything of that nature. Staff providing patient care in the 'splash zone' would wear all of the PPE (mask, gown, and gloves), but not if they were just delivering a food tray. They would wear the appropriate PPE if they were assisting a resident with eating and there was the potential for drainage, such as with a trach. When disconnecting IV tubing for an IV, staff needs to wear a gown and gloves, maybe a mask, if there was a potential for splashing. For administering medications through a G-tube, the nurse needed to wear all PPE, because they would be in the splash zone. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 2/18/2025 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) . 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Review of the facility policy and procedure titled Medication Preparation for Administering with the last review date of 2/18/2025 read, Policy: All medications will be prepared . and administered in a manner consistent with the general requirements outlined in this policy. Procedure: A. Prior to preparing or administering medications, follow the facility's infection control policies (e.g., hand washing).

Based on observation, interview, and record review, the facility failed to ensure medications were labeled, failed to ensure medications were secured in 3 of 7 halls, failed to label and remove expired medication in 3 of 7 medication carts, and failed to keep refrigerator logs updated in 1 of 3 medication rooms.Findings include: 1) During an observation on [DATE] at 10:42 AM, Resident #183 was lying in bed. There was one bag of Daptomycin 650 MG [milligram]/50 ML [milliliter] antibiotic medication. The infusion bag or the intravenous line were not dated. During an interview on [DATE] at 9:28 AM, the Director of Nursing (DON) stated, The IV tubing should be dated. During an interview on [DATE] at 1:20 PM, the DON stated, We do not have any policy for dating intravenous lines. 2) During an observation on [DATE] at 10:10 AM, Resident #50 was sitting on the side of her bed. There were two inhalers and one medicine cup containing white cream on the overbed table (Photographic evidence obtained). During an interview on [DATE] at 10:10 AM, Resident #50 stated, These are my inhalers. I take them to help my breathing whenever I need them. I am not sure what the cream is. During an interview on [DATE] at 11:34 AM, the DON stated, Medication should be stored in the med cart, not at the bedside. [Resident #50's name] is not allowed to self-administer meds [medications]. She should not have had the inhalers and cream at her bedside. Review of Resident #50's physician order dated [DATE] read, Albuterol Sulfate HFA 108 (90 Base) MCG/ACT [Micrograms/Actuation] Aerosol, solution Give 2 puff by mouth every 6 hours for Bronchitis. Review of Resident #50's physician order dated [DATE] read, Albuterol-Budesonide Inhalation Aerosol 90-80 MCG /ACT (Albuterol-Budesonide) 2 puff inhale orally every 6 hours for Bronchitis. The order was discontinued [DATE]. 3) During an observation on [DATE] at approximately 11:30 AM, there were two tubes of hydrocortisone acetate 1% cream and one tube of Permethrin cream on the bedside table of Resident #153. The creams were not labeled with orders for the resident (Photographic evidence obtained). During an observation on [DATE] at approximately 3:40 PM, there were two tubes of hydrocortisone acetate 1% cream and one tube of Permethrin cream on the bedside table of Resident #153. Review of Resident #153's physician order dated [DATE] read, Permethrin External Cream 5% (Permethrin), Apply to back/chest/arms/leg topically one time only for itching for 1 day leave on for 14 hours, repeat in 14 days. The order status showed Completed. During an interview on [DATE] at 3:48 PM, Staff H, Licensed Practical Nurse (LPN), stated, They [the residents] should not have any medications at bedside unless they have a self-administration order. During an interview on [DATE] at 3:55 PM, Staff J, LPN, stated, I didn't give it [the creams] to her [Resident #153]. I haven't been on this hall in three weeks. I gave her medications at lunch, and I didn't see the creams there. 4) During an observation on [DATE] at 11:05 AM, there was a purple discus inhaler on the bedside table of Resident #20. The inhaler was not labeled with orders for the resident. During an observation on [DATE] at 11:20 AM, Resident #20 retrieved a purple discus inhaler from his unlocked drawer. Review of Resident #20's physician order dated [DATE] read, Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG [micrograms]/DOSE, 1 inhalation inhale orally every 12 hours for COPD [Chronic Obstructive Pulmonary Disease] rinse mouth and expectorate after use. During an interview on [DATE] at 11:25 AM, Staff J, LPN, stated, I didn't know he had that [the inhaler]. I didn't give it to him. During an interview on [DATE] at 11:30 AM, Staff H, LPN, confirmed the Resident #20 did not have a self-administration order and stated, He [Resident #20] should not have that [the inhaler] in his room. 5) During an observation on [DATE] at approximately 2:30 PM, there was one box containing two vials of glucose control solution in 600 Hall Medication Cart. One vial had an expiration date of [DATE] and the other was dated [DATE]. The top of the box for the control solutions had an expiration date stamped on it, which read, Exp: [DATE]. (Photographic evidence obtained). During an interview on [DATE] at approximately 2:35 PM, Staff C, LPN, confirmed the expiration date on the box of glucose control solutions was [DATE]. 6) During an observation on [DATE] at 3:07 PM, there was one open box containing an Adviar diskus (a prescription medication used to treat asthma and chronic obstructive pulmonary disease (COPD)) that was dated [DATE] in 400 Hall Medication Cart. There was a pharmacy label on the box that read, Throw away 30 days after opening the foil pouch, or when the dose counter reaches 0, whichever comes first. There was also one plastic bag containing an open box with a bottle of Latanoprost (a medication primarily used to treat glaucoma). Neither the box nor the bottle was dated with the date they were opened. On the plastic bag were labels from the pharmacy. One label was dated [DATE], and another label read, After opening, may store at room temperature. Throw away any drug left after 6 weeks (Photographic evidence obtained). During an interview on [DATE] at 3:10 PM, Staff D, LPN, confirmed that both Advair diskus and Latanoprost were active medications for the residents named on the prescription labels. 7) During an observation on [DATE] at 3:35 PM, there was one box of glucose control solutions, which were both expired in North Hall Medication Cart. One vial was dated [DATE] and one vial was dated [DATE]. There was also one open unlabeled box containing Fluticasone Diskus (medication available as an inhalation powder, primarily used to prevent and control asthma symptoms). The box had a pharmacy label with the date [DATE]. There was also a label that read, Throw away 30 days after opening the foil pouch, or when the dose counter reaches 0, whichever comes first. There was also one open unlabeled vial of insulin (Photographic evidence obtained). During an interview on [DATE] at 3:40 PM, Staff F, LPN, confirmed that all items/medications were actively being used. During an interview on [DATE] at 11:30 AM, the DON stated, In the medication rooms, the refrigerator temperatures are to be checked and recorded daily. On the day shift, it is the unit manager's responsibility. On the weekends, I expect the nurses to check the temperatures. Review of the facility policy and procedure titled Medication Storage with the last review date of [DATE] read, Policy: Mediations will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. C. Medications will be stored in an orderly, organized manner, in a clean area. F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

Based on record review and interview, the facility failed to ensure the residents' right to formulate advance directives was honored for 1 of 7 residents reviewed (Resident #143).Findings include: During an interview on [DATE] at 4:20 PM, Resident #143 stated, I have requested to be a DNR (Do Not Resuscitate).Review of Resident #143's Advance Directives Discussion Document dated [DATE] showed the resident's wish to withhold cardiopulmonary resuscitation.Review of Resident #143's Do Not Resuscitate (DNR) Order form signed by the resident on [DATE] documented the resident refused cardiopulmonary resuscitation (CPR) and directed that CPR be withheld or withdrawn from him. The form was not signed by the physician.Review of Resident #143's progress note dated [DATE] read, HPI [History of Present Illness]. Discussed advance care planning with patient. Patient would like to be a DNR. Patient is alert and oriented x 4 . Deemed it is perfectly capable of making decisions of a [Sic] being a DNR. Patient will be changed from full code to DNR.During an interview on [DATE] at 9:48 AM, the Director of Nursing stated, Normally, what I like to do is have a 2-3 day turn around just in case something happens with the DNR forms. It [Do Not Resuscitate Order] was sitting in Social Services Office, so the doctor could not sign it. The ARNP [Advance Registered Nurse Practitioner] is new and did not know he had autonomy and could sign the form. The doctor comes in on Saturdays and Social Services Office is closed and if no one knows he would not be given the form to sign. It would not be accessible to the doctor to sign. During an interview on [DATE] at 1:25 PM, the Social Services Director stated, When residents first come in, we fill out the discussion form and if they want to be DNR, we have them sign the DNR order form and when the doctor comes in, we have then sign the form.Review of the facility policy and procedure titled Advance Directives with the last review date of [DATE] read, Policy: The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development Coordinator/designee will. 4. Upon completion of Advance Directives Discussion Document, Social Services or nurse will notify the Physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record.

Based on record review and interview, the facility failed to ensure residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) within the required time frame for 1 of 3 residents reviewed for beneficiary notification (Resident #191).Findings include:Review of Resident #191's SNF Beneficiary Notification Review read, Medicare Part A Skilled Services Episode Start Date: 3/7//25, Last covered day of Part A Service: 6/12/25. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.Review of Resident #191's Notice of Medicare Non-Coverage (NOMNC) notice showed the resident's Medicare coverage for current skilled services would end on 6/12/2025. The resident acknowledged the receipt of the notice and signed it on 6/11/2025.During an interview on 8/19/2025 at 11:20 AM, the Social Services Director stated, My assistant and I are responsible for the SNF ABN and NOMNC review with the residents and/or representatives, their signing the forms, and filing the signed forms appropriately in their medical record. The NOMNCs should be given to residents 48 hours before last day of coverage or 72 hours prior, which would be best practice.During an interview on 8/19/2025 at 1:48 PM, the Director of Social Services stated, The NOMNC and ABN were signed on 6/11/2025 by the resident. The last covered day is 6/12/2025. It wasn't a Resident initiated discharge.Review of the facility policy and procedure titled SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage with the last review date of 2/28/2025 read, Policy. SNFs must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no later than two days (48) hours before the effective date of the end of the coverage that their Medicare coverage will be ending.

Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed and failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for 1 of 2 residents reviewed for behavioral diagnosis (Resident #22).Findings include: Review of Resident #22's admission record showed the resident was admitted on [DATE] with diagnosis including but not limited to generalized anxiety (onset date of 7/15/2025), major depressive disorder (onset date of 8/20/2025), and bipolar disorder (onset date of 8/20/2025). Review of Resident #22's PASRR dated 7/15/2025 showed no mental illness to include depression disorder, anxiety disorder, or bipolar disorder under Section I. PASRR Screen Decision Making.Review of Resident #22's physician order dated 7/15/2025 read, Clonazepam Oral Tablet 1 MG [milligram] (Clonazepam), Give 1 tablet by mouth every 12 hours for Anxiety.Review of Resident #22's physician order dated 7/15/2025 read, Aripiprazole Oral Tablet 10 MG (Aripiprazole), Give 1 tablet by mouth one time a day for Psychotics.Review of Resident #22's physician order dated 7/15/2025 read, Amitriptyline HCl Oral Tablet 25 MG (Amitriptyline HCl), Give 1 tablet by mouth at bedtime for Depression.Review of Resident #22's psychology evaluation note dated 7/16/2025 read, Chief complaint: Depression.Review of Resident #22's psychiatry evaluation note dated 8/6/2025 read, Chief Complaint: Depression, anxiety, bipolar disorder and nicotine dependence. History of Present Illness: This is a [AGE] year old patient with past psychiatric history of depression, anxiety, bipolar disorder and nicotine dependence. Patient was evaluated for underlying psychiatric conditions and treatment. Facility requested consult.During an interview on 8/21/2025 at 9:23 AM, the Director of Nursing stated [Resident #22's name] PASRR should have been revised upon admission.During an interview on 8/22/2025 at 1:25 PM, the Social Services Director stated, Nurses or admissions will take a look at the PASSR and bring it to me if they need one or the one they have needs to be updated.Review of the facility policy and procedure titled Preadmission Screening and Resident Review (PASRR) with the last review date of 2/28/2025 read, Policy: The Center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled resident receive appropriate pre-admission screening according to Federal/State guidelines.

Based on observation, interview, and record review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) dressings were changed as ordered for 2 of 10 residents reviewed for intravenous (IV) therapy (Residents #178 and #183) and failed to ensure residents received blood pressure medications as ordered for 1 of 7 residents reviewed for medication management (Resident #101). Findings include: 1) During an observation on 8/18/2025 at 10:39 AM, Resident #183 was lying in bed. There was a double lumen PICC line on the resident's left upper arm with a transparent dressing dated 8/8/2025, with dry black matter (Photographic evidence obtained). During an interview on 8/18/2025 at 10:39 AM, Resident #183 stated, My IV dressing was last changed on the 8th [8/8/2025] during my hospital stay. During an observation on 8/19/2025 at 8:30 AM, Resident #183 was lying in bed. There was a transparent dressing with gauze under the dressing dated 8/18/2025. During an observation on 8/21/2025 at 8:02 AM, Resident #183 was lying in bed. There was an IV transparent dressing with gauze and dry dark matter under the dressing dated 8/18/2025 (Photographic evidence obtained). Review of Resident #183's physician order dated 8/14/2025 read, Change midline catheter site dressing every week with transparent dressing. Change needleless access device every day shift every Fri [Friday]. During an interview on 8/21/2025 at 9:27 AM, Staff K, Licensed Practical Nurse (LPN), stated, IV dressings should be changed every 7 days. The dressing should not have a gauze under the dressing. [Resident #183's name] dressing needs to be redressed. During an interview on 8/21/2025 at 9:28 AM, the Director of Nursing (DON) stated, IV dressings should be changed every week. There should not be gauze under the dressing. If there is gauze, then the dressing needs to be change from 24-48 hours. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes with the last review date of 2/28/2025 read, Policy: Central venous catheter dressing will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines: 1. Dressing must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change transparent semi-permeable membrane (TSM) dressing at least every 5-7 days and PRN [as needed] (when wet, soiled, or not intact). 3. If gauze is used, it must be changed ever 2 days. 2) During an observation on 8/18/2025 at 10:30 AM, Resident #178 was sitting up in bed. There was a PICC line on the resident's left upper arm, with a transparent dressing dated 8/10/2025 at 11:00 AM (Photographic evidence obtained). During an interview on 8/18/2025 at 10:30 AM, Resident #178 stated, No one has changed the dressing on my PICC line since I've been here. Review of Resident #178's physician order dated 8/12/2025 read, Change Left Arm Double Lumen PICC line catheter site dressing every week with transparent dressing. Change needleless access device every day shift every Fri. During an interview on 8/21/2025 at 9:33 AM, Staff B, LPN, stated, I changed [Resident #178's name] PICC line dressing on August 15th. We change the dressings every 7 days. During an interview on 8/21/2025 at 9:25 AM, the DON stated, [Resident #178's name] dressing should have been changed. PICC dressing changes should be done every seven days. 3) Review of Resident #101's physician order dated 7/12/2025 read, Diltiazem HCl Oral Tablet 60 MG [milligram] (Diltiazem HCl), Give 1 tablet by mouth every 8 hours for HTN [hypertension] Hold for SBP [systolic blood pressure] Less Than 110, HR [Heart Rate] Less Than 60. Review of Resident #101's Medication Administration Record (MAR) for July 2025 for administration of Diltiazem HCl 60 MG showed the following was documented: on 7/23/2025 at 10:00 PM, X for BP (blood pressure) and pulse and code 5 (hold/see progress notes); and on 7/26/2025 at 6:00 AM, 7/28/2025 at 6:00 AM, and 7/31/2025 at 6:00 AM, X for BP and pulse and code 4 (Vitals outside of parameters for administration). Review of Resident #101's MAR for August 2025 for administration of Diltiazem HCl 60 MG showed the following was documented: on 8/1/2025 at 10:00 PM, X for BP and pulse and code 4; on 8/2/2025 at 6:00 AM, X for BP and pulse and code 4, and at 10:00 PM, X for BP and pulse and code 5; on 8/3/2025 at 10:00 PM, X for BP and pulse and code 5; on 8/4/2025 at 6:00 AM, X for BP and pulse and code 5; on 8/5/2025 at 2:00 PM, X for BP and pulse and code 4; on 8/7/2025 and 8/8/2025 at 2:00 PM, X for BP and pulse and code 4; on 8/13/2025 at 6:00 AM, no entries; on 8/18/2025 at 2:00 PM, 114/50 for BP and X for pulse and code 4. Review of Resident #101's physician order dated 7/12/2025 read, Metoprolol Tartrate Oral Tablet 75 MG (Metoprolol Tartrate), Give 1 tablet by mouth every 12 hours for HTN (hypertension) Hold for SBP Less Than 110. Review of Resident #101's MAR for July 2025 for administration of Metoprolol Tartrate 75 MG showed the following was documented: on 7/23/2025 at 9:00 PM, 146/81 for BP and code 5; on 7/26/2025 at 9:00 PM, X for BP and code 4; and on 7/27/2025 X for BP and code 4. Review of Resident #101's MAR for August 2025 for administration of Metoprolol Tartrate 75 MG showed the following was documented: on 8/2/2025 and 8/3/2025 at 9:00 PM, X for BP and code 5; on 8/12/2025 at 9:00 AM, 111/58 for BP and code 4; and on 8/14/2025 at 9:00 AM, 112/40 for BP and code 4. Review of Resident #101's physician order dated 7/12/2025 read, Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN Hold for SBP Less Than 110. Review of Resident #101's MAR for July 2025 for administration of Lisinopril 20 MG showed X for BP and code 4 was documented on 7/27/2025 at 9:00 AM. Review of Resident #101's MAR for August 2025 for administration of Lisinopril 20 MG showed the following was documented: on 8/12/2025 at 9:00 AM, 111/58 for BP and code 4; and on 8/14/2025 at 9:00 AM, 112/40 for BP and code 5. During an interview on 8/20/2025 at approximately 3:00 PM, the DON stated, I spoke to the nurse who worked with [Resident #101's name]. The nurse charted vital signs for only one of the medications ordered and not each one. My expectation is that if there is a parameter in the order for a medication, the appropriate vital signs are to be documented for each medication. If a medication is held, I expect the nurse to document why the medication was held. During an interview on 8/22/2025 at 9:40 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, I was no notified of any low blood pressure or low pulse readings for [Resident #101's name] or any of her medications being held. My expectation is that the nurses administer medications as ordered or contact me if they are holding the medications.

Based on observation, interview, and record review, the facility failed to administer oxygen at the ordered flow rate for 2 of 3 residents reviewed for respiratory services (Residents #8 and #184).Findings include:1) During an observation on 8/18/2025 at 10:48 AM, Resident #184 was lying in bed, being administered oxygen at 2 liters per minute via nasal cannula.During an observation on 8/19/2025 at 10:39 AM, Resident #184 was lying in bed, with oxygen being administered at 2 liters per minute via nasal cannula.Review of Resident #184's physician order dated 8/12/2025 read, Oxygen at 3 liters/min [minute] via Nasal Cannula continuous every shift.During an observation on 8/20/2025 at 2:54 PM with Staff K, Licensed Practical Nurse (LPN), Resident #184 was being administered oxygen at 3 liters per minute.During an interview on 8/20/2025 at 2:54 PM, Staff K, LPN, stated, [Resident #184's name] has orders for oxygen to be administered at 3 liters per minute. I had to readjust his oxygen. Nurses are supposed to check every shift the residents' oxygen flow rate.During an interview on 8/21/2025 at 9:28 AM, the Director of Nursing (DON) stated, Nurses are to check the flow rate during their shift and every time they walk into the resident's room.2) During an observation on 8/18/2025 at 10:27 AM, Resident #8 was being administered oxygen at 3 liters per minute via nasal cannula.During an observation on 8/19/2025 at 8:20 AM, Resident #8 was lying bed, with oxygen being administered at 3 liters per minute via nasal cannula (Photographic evidence obtained).Review of Resident #8's physician order dated 5/22/2025 read, Oxygen via nasal cannula at 4 L/min [liters per minute] continuous, Humidification: Yes, every shift for SOB [Shortness of breath].During an interview on 8/22/2025 at 11:40 AM, the DON stated, [Resident #8's name] oxygen should not be at 3 liters. His flow rate would need to be corrected.Review of the facility policy and procedure titled Oxygen Therapy with the last review date of 2/28/2025 read, Procedure. Review physician's order . Start O2 [oxygen] flowrate at the prescribed liter flow or appropriate flow for administration device.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services according to professional standards of practice for 2 of 6 residents reviewed for IV (Intravenous) therapy, Residents #6 and #3. Findings include: 1) During an observation on 5/8/2025 at 5:40 AM, Resident #6 was sleeping. The resident had a single lumen midline catheter to her left upper arm, infusing IV fluids. The transparent dressing over the midline insertion site was lifting up at the edges. Under the transparent dressing, there was a gauze that had dried blood on it; occluding the view of the insertion site. The dressing was dated 4/29/2025. Review of Resident #6's physician order dated 4/29/2025 read, Insert midline: May use 1% Lidocaine for IV insertion one time only for IV hydration for one day. Review of Resident #6's physician order dated 5/1/2025, with discontinued date of 5/2/2025 read, Change Left arm midline catheter dressing every week with transparent dressing. Review of Resident #6's medication administration record (MAR) for May 2025 showed no midline catheter dressing changes documented. During an interview on 5/8/2025 at 6:02 AM, Staff E, Registered Nurse (RN), stated, The dressing should have been changed already. I'm not sure why it wasn't. The date on it is 4/29/2025. There is blood and gauze under the dressing that makes it needed to be changed. I'm not sure why it wasn't. During an interview on 5/8/2025 at 7:30 AM, Resident #6 stated, That [the dressing] hasn't been changed at all since I got it put in. It's had blood under that since it was put in. It was bleeding a little when they put it in. I needed to get these IV fluids because my kidneys weren't working so good. During an observation on 5/8/2025 at 10:50 AM, Resident #6 was resting quietly in bed with a left midline with IV fluids infusing. The dressing was dated 4/29/2025 and was pulling up from the skin. There was a 2x2 gauze covered with dried blood under the transparent dressing. During an interview on 5/8/2025 at 12:55 PM, the Director of Nursing (DON) stated, All central line dressings need to be changed every 7 days. If there is gauze under a dressing, it should be changed every 2 days. Review of the facility policy and procedure titled Catheter Insertion and Care read, Midline dressing changes: Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way . 4. Use a sterile, transparent, semi- permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM dressing and change the dressing every 48 hours. 46523 2) During an interview on 5/8/2025 at 6:28 AM, Resident #3 stated, The staff inserted a midline in my arm by mistake. I did not need the midline for the medication that was prescribed. I even took a picture of the midline. Then the staff had to remove the midline from my arm when they realized the medication was an injection. Review of Resident #3's physician order dated 3/27/2025 read, Ceftriaxone Sodium Intravenous Solution Reconstitued 1 GM [gram] (Ceftriaxone Sodium), Use 1 gram intravenously every 24 hours for infection/abscess for 7 days dilute with 2.1 ml [milliliters] of 1% lidocaine solution. Review of Resident #3's physician order dated 3/27/2025 read, Insert midline IV for Ceftriaxone Sodium Intravenous Solution Reconstituted 1 GM, may us 1% lidocaine STAT for antibiotic use. Review of Resident #3's physician order dated 3/27/2025 read, Ceftriaxone Sodium Solution Reconstitueted 1 GM, Inject 1 gram intramuscularly every 24 hours for infection/abscess for 7 Days Dilute with 2.1 mL of 1% lidocaine solution. Review of Resident #3's Medication Administration Record (MAR) for March 2025 showed midline was inserted on 3/27/2025 at 11:00 PM. Review of Resident #3's MAR for March 2025 showed Ceftriaxone Sodium Injection Solution was administered intramuscularly from 3/28/2025 through 3/31/2025. Review of Resident #3's MAR for April 2025 showed Ceftriaxone Sodium Injection Solution was administered intramuscularly from 4/1/2025 through 4/3/2025. Review of Resident #3 progress note dated 3/27/2025 read, resident need iv (intravenous) access for antibiotics. Review of Resident #3's progress note dated 3/28/2025 read, Received orders to remove pt [patient] midline. Old dressing was removed, site was cleansed with chlorhexidine solution, and allowed to air dry. Midline catheter was gently removed, applying pressure to the insertion site. Catheter tip was inspected for integrity, tip intact. Insertion site held with sterile gauze and hemostasis achieved within expected timeframe. Pressure bandage was applied to site. Pt was educated on dressing care and signs and symptoms to report to nurse. Review of Resident #3's progress note dated 4/3/2025 read, Plan . Abscess labia, Ceftriaxone 1 gram IM [intramuscular] daily for 3 days for a total of 10 days of therapy. During an interview on 5/8/2025 at 8:30 AM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, stated, [Resident #3's name] midline was inserted accidently and it had to be removed. [Staff B, LPN's name] was the nurse who put in the order for the intravenous medication. During an interview on 5/8/2025 at 8:44 AM, Staff B, LPN, stated, I don't recall much. I do think [the Advance Registered Nurse Practitioner #1's name] called and requested a midline to be inserted. During an interview on 5/8/2025 at 8:52 AM, the Director of Nursing stated, I spoke to [Staff A's name] and he said it [inserting a midline] was a mistake and a nurse caught the mistake and they removed the midline and corrected the order. I am not sure if the doctor was notified. During an interview on 5/8/2025 at 8:54 AM, the Advance Registered Nurse Practitioner #1 stated, [Resident #3's name] Ceftriaxone was never meant to be given intravenously. [Resident #3's name] was never meant to get a midline inserted. I never gave an order to insert a midline. This was a mistake from a nurse. I was there the following day and caught the mistake and the order was corrected. [Resident #3's name] received all her doses of the mediation intramuscularly. I was not aware the midline was actually put in. I would have then not had it [the midline] removed and just change the route of the medication to intravenous. The risk was minimal for the resident. There is always risk for infection, but very minimal if any. A midline is pretty benign. During an interview on 5/9/2025 at 8:39 AM, Staff C, LPN, stated, Originally what happened was I came on shift the nurse from the prior shift told me she [Resident #3] needed a PICC [Peripherally Inserted Central Catheter] line. When they [the organization that provides intravenious catheter insertions] came in they stated it would be best for a midline. I told my supervisor, and he said to change it [the physician's order] to a midline. I believe the midline was not used [for Resident #3]. When I came back the next time, she [Resident #3] no longer had a midline. The nurse who told me she [Resident #3] needed the PICC line was [Staff B's name]. Review of the facility policy and procedure titled Insertion of Peripheral Midline or Peripherally Inserted Central Catheters revised on 1/17/2019 read, General Guidelines . 4. Placing a midline or PICC requires a provider order and a written consent from resident or legal guardian.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected each resident's status for 1 of 3 residents reviewed for nutrition, Resident #3. Findings include: Review of Resident #3's annual Minimum Data Set (MDS) dated [DATE] showed the resident was not on a therapeutic diet while a resident at the facility under Section K- Swallowing/Nutritional Status. Review of Resident #3's physician order dated 11/18/2024 read, Regular diet Regular texture, regular/thin consistency, CCD NAS (Controlled Carbohydrate Diet No Added Salt) diet. During an interview on 5/8/2025 at 10:13 AM, the MDS Coordinator stated, [Resident #3's name] MDS will have to be modified to reflect she was on a controlled carbohydrate diet back in November. During an interview on 5/8/2025 at 10:48 AM, the Director of Nursing stated, The MDS should be accurate, reflecting the correct information pertaining to the resident.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection by not isolating 2 of 7 residents under investigation for COVID-19 (Coronavirus Disease 2019) in 600 Hallway, Residents #2 and #3, failed to follow CDC (Centers for Disease Control) guidelines and facility policy and procedures related to droplet precautions, for 4 of 7 residents under investigation for COVID-19 in 300 Hallway and 600 Hallway, Residents #1, #4, #14 and #15, failed to ensure staff contain PPE (Personal Protective Equipment) used for the residents under investigation for COVID-19 in trash receptacles to prevent environmental exposure, failed to ensure staff performed hand hygiene before and after resident care and during tray delivery and pickup, and cleaned/sanitized blood pressure cuffs and thermometers between resident use for 10 of 16 sampled residents, Residents #2, #3, #5, #9, #10, #11, #12, #13, #15, and #16. As a result of this deficient practice, 135 out of the 135 residents are at risk for developing a communicable disease (COVID-19). Findings include: 1. On 05/07/2020 at 8:20 AM, during a tour of 600 Hallway, Resident #2 room was observed having no isolation signage and no PPE (Personal Protective Equipment) supply drawer outside the room. On 05/07/2020 at 8:39 AM, Staff A, CNA (Certified Nursing Assistant), was observed entering Resident #2's room with a mask on and without gown and gloves and face shield or sanitizing her hands. Staff A obtained the resident's vital signs and exited the room. Staff A did not sanitize her hands or the blood pressure cuff and thermometer. Review of the physician order [REDACTED]. Laboratory: Order Summary: . [MEDICAL CONDITION] panel, COVID-19 Testing. Other: Order Summary: Infection Precautions - Droplet, Contact. During an interview with Staff A, CNA, on 05/07/2020 at 10:45 AM, she stated, I did not know that the resident (Resident #2) should have been on isolation, I would have put on PPE when I went into the rooms. I also should have worn gloves. I was just rushing, and I shouldn't have done that. During an interview with Staff B, RN, on 05/07/2020 at 10:30 AM, she stated, I didn't know the other residents (Resident #2 and Resident #3) were supposed to be in isolation, no one told me in report that they were suspected COVID-19. When we have residents that are suspected COVID-19, we place them in standard, contact and droplet isolation until the test results come back. 2. On 05/07/2020 at 8:20 AM, during a tour of 600 Hallway, Resident #3's room was observed having no isolation signage and no PPE (Personal Protective Equipment) supply drawer outside the rooms. On 05/07/2020 at 8:42 AM, Staff A, CNA, was observed entering Resident #3's room without sanitizing her hands or the blood pressure cuff and thermometer and without donning PPE. Staff A obtained the resident's vital signs and exited the room. She did not sanitize blood pressure cuff and thermometer or sanitize her hands. Review of the physician order [REDACTED].#3 read as follows: Diagnostic: Order Summary: Chest X-ray 2 views AP/LAT due to cough . Laboratory: Order Summary: . [MEDICAL CONDITION] panel, COVID-19 Testing. During an interview with Staff A, CNA, on 05/07/2020 at 10:45 AM, she stated, I did not know that the resident (Resident #3) should have been on isolation, I would have put on PPE when I went into the rooms. I also should have worn gloves. I was just rushing, and I shouldn't have done that. During an interview with Staff B, RN, on 05/07/2020 at 10:30 AM, she stated, I didn't know the other residents (Resident #2 and Resident #3) were supposed to be in isolation, no one told me in report that they were suspected COVID-19. When we have residents that are suspected COVID-19, we place them in standard, contact and droplet isolation until the test results come back. 3. On 05/07/2020 at approximately 9:15 AM, Staff C, CNA, was observed entering Resident #14's room without donning PPE or performing hand hygiene when she exited the room and placed the tray on the cart. Review of physician order [REDACTED].#14 read as follows: Diagnostic: Order Summary: Chest X-ray 2 views AP/LAT. DX (Diagnosis): cough/congestion . Other: Order Summary: . [MEDICAL CONDITION] panel, COVID Testing . Infection Precautions - Droplet, Contact. During an interview with Staff C, CNA, on 05/07/2020 at 9:22 AM, she stated, I didn't realize that I wasn't using hand sanitizer, I guess I was so busy I didn't think about it. I did remove the tray from (Resident #14's room). I did not put on any PPE. I was just picking up the tray, so I don't have to. When we go into an isolation room, we put on gowns gloves, we already have on a mask and goggles, when we are going to do care. We change our mask and clean our goggles after leaving an isolation room. I did not clean my goggles. We have to use hand sanitizer before and after all resident care and when we pick up meal trays. 4. On 05/07/2020 at 1:00 PM, Staff F, LPN (Licensed Practice Nurse), was observed in Resident #7's room. After exiting the room, Staff F did not sanitize the blood pressure cuff or thermometer. She was then observed to enter Resident #15's room. Staff F did not perform hand hygiene and donned gloves and gowns, then obtained Resident #15's vital signs. Review of physician order [REDACTED].#15 read as follows: Diagnostic: Order Summary: 2 views AP/LAT Chest X ray for cough and congestion . Laboratory: Order Summary: COVID-19, [MEDICAL CONDITION] Panel . Other: Order Summary: Infection Precautions - Contact. During an interview with Staff F, LPN, on 05/07/2020 at 1:10 PM, she stated, I did not clean the thermometer and blood pressure machine, I was in a hurry and forgot to. I should have done it and I should have cleaned my hands before putting on my gloves. If residents have any fever, cough, wheezing shortness of breath, any gastrointestinal problems we let the doctor know and place the resident on contact and droplet precautions. I don't know if it's wrong to put the trash can outside of an isolation room. 5. On 05/07/2020 at 8:20 AM, during a tour of Hallway 600, Resident #1's room had isolation signage on the doors, reading Stop. Contact Precautions. The room door was open. Red trash receptacles containing used PPE were observed outside Resident#1's room. On 05/07/2020 at 8:20 AM, Staff B, Registered Nurse (RN), was observed in front of Resident #1's room, which was identified by signage as an isolation room. The resident room was open during observation. She was observed doffing her gown and gloves outside of the resident's room and placing it in a red trash receptacle in the hallway. Staff B removed her gloves, did not perform hand hygiene, and returned to the medication cart. She opened the computer and began typing and opened the medication cart and began pouring medications. Review of the physician order [REDACTED].#1 read as follows: Diagnostic: Order Summary: CXR (Chest X-Ray) . Laboratory: Order Summary: . COVID-19, Flu, [MEDICAL CONDITION] Panel. Review of Resident #1's Interactive Change of Condition form dated 05/05/2020 at 2:39 AM read as follows: Situation: The change in condition, symptoms or signs observed is/are: short of breath, with chest congestion, wheezing and low oxygen saturation. Temperature was documented as 99.1. Resident noted to be having some difficulty breathing, noted pursed lip and using accessory muscles, complained of (shortness of breath), noted wheezing and chest congestion. O2 (oxygen) Sat (saturation) was 87%, on 2 liters O2. Review of COVID-19 Screening dated 05/05/2020 for Resident #1 revealed: COVID indicators present. Temperature 99.1, chest congestion, cough, increased shortness of breath, O2 sat decreased by 3% or greater since last taken. During an interview with Staff B, RN, on 05/07/2020 at 10:30 AM, she stated, I did remove my personal protective equipment in the hallway, that is where the trash can was, but they came around and fixed that and put the other residents on isolation. I did not sanitize my goggles after I left the isolation room, I should have. I just forgot to. 6. On 05/07/2020 at 8:20 AM, during a tour of Hallway 600, Resident #4's room had isolation signage on the door reading Stop. Contact Precautions. The room door was open. Red trash receptacles containing used PPE were observed outside Resident #4's room. Review of physician order [REDACTED].#4 read as follows: Order Summary: . COVID-19 Swab Test . Other: Order Summary: Infection Precautions- droplet COVID-19 Testing. Review of Resident #4's Interactive Change of Condition dated 05/05/2020 at 2:30 AM read as follows: Fever, shortness of breath, at 1 AM, resident c/o (complained of) not feeling well, noted shivering, flushed in the face, c/o (shortness of breath), lungs clear, no cough noted, denies pain, Temp 101.8 orally, O2 Sat 89% on room air, 2 liters O2 administered at 1:20 AM HOB (Head of Bed) elevated O2 sat 98% on 2 liters. 7. On 05/07/2020 at 8:32 AM, Staff A, CNA, was observed in 600 Hallway, entering Resident #9's room, obtaining the resident's vital signs in Bed A. At 8:34 AM, Staff A was observed obtaining vital signs for Resident #10 in bed B. Staff A did not sanitize the blood pressure cuff or thermometer between the residents. Staff A did not perform hand hygiene or sanitize the used equipment before she exited the room. At 8:35 AM, Staff A entered Resident #11's room and laid the blood pressure cuff and thermometer on the resident's bed. Staff A did not perform hand hygiene assisted the resident to reposition in bed. She exited the room without performing hand hygiene and did not clean the blood pressure cuff or thermometer. At 8:39, Staff A entered Resident #2's room without donning PPE, did not perform hand hygiene and obtained the resident's vital signs. Staff A exited the room without performing hand hygiene or sanitizing the used equipment. During an interview with Staff A, CNA, on 05/07/2020 at 10:45 AM, she stated: I should have sanitized my equipment between residents and between rooms and I should have used hand sanitizer. I also should have worn gloves. I was just rushing, and I shouldn't have done that. 8. On 05/07/2020 at 8:56 AM, Staff D, CNA, was observed entering Residents #12 and #13's room. The CNA did not perform hand hygiene and obtained vital signs for Residents #12 in Bed B. The CNA did not sanitize the blood pressure cuff or thermometer, did not perform hand hygiene and obtained the vitals for Resident #13 in Bed A. Staff D did not sanitize the equipment, did not perform hand hygiene and exited the room. On 05/07/2020 at 8:59 AM, Staff D, CNA, was observed entering Resident #16's room. The CNA did not perform hand hygiene and obtained the resident's vital signs. Staff D did not perform hand hygiene did not sanitize the blood pressure cuff or thermometer when she exited the room. During an interview with Staff D, CNA, on 05/07/2020 at 9:03 AM, she stated, I should have used hand sanitizer when I left (Residents #12 and #13' and Resident #16's room). We should have gloves on when we are taking care of residents. I don't know why I didn't, I guess I was in a hurry. I should have cleaned the equipment after each use between residents and used hand sanitizer. 9. On 05/07/2020 at 9:28 AM, Staff E, CNA, was observed in Resident #5's room, Bed B, handling a urinal with her ungloved hands. She returned to the resident's bedside, pulled gloves out of her pocket, put them on and assisted the resident with getting back into bed. Staff E then was observed going to Bed A, removing the linens and placing clean linens on the bed. The CNA did not remove her gloves, perform hand hygiene, or don a clean pair of gloves prior to applying clean linen to the bed. During interview with Staff E, CNA, on 05/07/2020 at 9:46 AM, she stated, I did touch that urinal without gloves. I put gloves on as soon as I realized I did that. I helped the resident and went to change the other bed in the room. I should have removed my gloves and washed my hands. We should always have gloves on when we are giving residents care. 10. On 05/08/2020 at 7:45 AM, Staff J, CNA, was observed going to the soiled utility room with gloves, a gown, a mask and goggles on. When he exited the soiled utility room at 7:55 AM, he had gloves, gown, mask and goggles on and proceeded to enter Resident #3's room. During an interview with Staff J, CNA, on 05/08/2020 at 8:30 AM, he stated, I left room (Resident #11's room), that is an isolation room, after I helped him position in bed and gave him his tray. I had to empty some garbage and so I went to the dirty utility room, I did not take off my gown, gloves, mask or goggles. I should have done that. I did go into Resident #3's room after that to answer the light. We are supposed to clean our goggles after being in a resident's room. We should take off our gown and gloves and wash our hands before we leave an isolation room. 11. On 05/07/2020 at 8:50 AM, Staff E, CNA, was observed removing meal trays in 500 Hallway. Staff E did not sanitize her hands between three rooms she entered. During an interview with Staff E, CNA, on 05/07/2020 at 8:53 AM, she stated, I should have sanitized my hands after I brought each tray to the cart. Our policy is that we sanitize with the hand sanitizer, I just forgot to. 12. On 05/07/2020 at 9:05 AM, Staff G, CNA, and Staff C, CNA, were observed collecting breakfast trays in all rooms in 300 Hallway. Staff C and Staff G did not perform hand hygiene before or after collecting the trays. During an interview with Staff G, CNA on 05/07/2020 at 9:18 AM, she stated, I know that I should have used hand sanitizer after I picked up each tray. I don't know why I didn't, I just forgot to. We have to wear gloves when we are taking care of residents, we should wash our hands, put on gloves before any resident care. During an interview with Staff C, CNA, on 5/7/2020 at 9:22 AM, she stated, I didn't realize that I wasn't using hand sanitizer, I guess I was so busy I didn't think about it. I did remove the tray from (Resident #14's room). I did not put on any PPE. I was just picking up the tray, so I don't have to. When we go into an isolation room, we put on gowns gloves, we already have on a mask and goggles, when we are going to do care. We change our mask and clean our goggles after leaving an isolation room. I did not clean my goggles. We have to use hand sanitizer before and after all resident care and when we pick up meal trays. During an interview with the Medical Director on 05/07/2020 at 10:00 AM, he stated, We have a protocol for determining when a resident goes into isolation for COVID-19. If the residents have a fever, cough, shortness of breath, a drop in oxygen saturation, any congestion, sore throat or generalized malaise, we place the resident in isolation of standard, contact, and droplet precautions. If we find that there is another reason for the symptoms, then we lower the isolation to what is ideal for the specific causative agent. All residents on contact/droplet precautions that have been symptomatic and tested for COVID-19 are required to be in isolation with a closed door and all staff are expected to adhere to that until it is proven that the resident does not have COVID-19. We have worked together to determine what directions to go during this time following CDC guidelines and recommendations. Staff have been required to wear face masks and goggles while on duty at all times. My role, when we find issues to work on, is to be active in the fix and to be informed about how they are correcting it and offering any assistance that I can. I think that it has been difficult for nursing homes because they have functioned with a different expectation when it comes to isolation and maintaining the necessary home like environment and the resident's rights. It has been a challenge to retrain staff in the new expectations that COVID-19 has created, but I am committed to assist this facility in any possible way. During an interview with the Director of Nursing on 05/07/2020 at 11:00 AM, she stated, All staff have been educated about the expectations to perform hand hygiene, they are expected to perform hand hygiene before entering a room to provide any care and upon exiting the room. Staff also are expected to clean all equipment between each resident whether they are in the same room or they are moving to a different room. All residents on the 600 Hallway should have had their red trash cans for PPE in the room and not out in the hallway. I do not know why the residents in rooms [ROOM NUMBERS] did not have isolation signs and isolation supplies or why the staff was unaware that they were on isolation. It is my expectation that all staff adhere to our facilities policies and procedures for standard, droplet and contact precautions. We audit and monitor staff compliance with these. All staff had been educated in March regarding COVID-19, donning and doffing PPE and hand hygiene. We place all admissions or residents returning to the facility in a 14-day isolation. Any symptomatic residents are considered possibly having COVID-19 and under suspicion and would be tested for COVID-19 and placed in both contact and standard precautions until they are found to be negative for COVID-19. During an interview with Staff M, RN, Staff Educator, on 05/08/2020 at 8:45 AM, she stated, I have been educating staff that during meal tray passes they can use the same gown between COVID-19 suspected residents because they aren't positive. When asked if that followed CDC guidelines or the facility policy and procedure on contact precautions, she stated, That is the guidance that has been provided by our corporate staff and I just am teaching the information that is provided. I don't think there are any CDC recommendations for passing meals to suspected COVID-19 residents. I guess it does not follow our policy and procedure for contact precautions. During an interview with the Executive Director on 05/08/2020 at 2:29 PM, she stated, I expect that all facility staff follow through with the CDC guidelines for isolation as well as our own policies and procedures on suspected COVID-19 patients, hand hygiene during resident care and meal tray delivery and pick up and proper use of personal protective equipment use and placement of trash receptacles for any isolation resident. Review of the facility's infection control policy and procedures titled IC405 COVID-19 effective 03/27/2020 read as follows: Policy: In addition to standard precautions, contact and droplet precautions will be implemented for patients with suspected or confirmed to have Covid-19 based on the Centers for Disease Control and Prevention (CDC) guidelines. Follow local public health and state regulations when applicable. Practice Standards: 1. Active screening of employees, visitors and other health care workers will be done upon entry into the Center. Follow the visitation restriction, active screening of visitors and employees and return to work for employees- Close contact, confirmed or suspected COVID-19 guidelines . 7. For patients with an undiagnosed respiratory infection, staff follow standard, contact and droplet precautions (i.e. facemask, gloves and isolation gown) with eye protection when caring for the patient. When [DIAGNOSES REDACTED]. Review of the CDC guidelines titled Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes read as follows: Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness. This interim guidance focuses on the following priorities: Keep unrecognized COVID-19 from entering the facility, identify infections early and take actions to prevent spread; Assess current supply of personal protective equipment (PPE) and initiate measures to optimize supply, quickly recognize and manage severe illness; Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to this location while undergoing evaluate. All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of the facility's protocol titled Notification about Suspected or Confirmed Patient with COVID-19 read as follows: Does the suspected patient have any of the following? -Fever greater than 100.0, -Cough, -Shortness of breath, -Oxygen desaturation great than 3%, -Minor respiratory symptoms (stuffy nose, sore throat, nasal or chest congestion or chest pressure), -General malaise (Headache, feeling rundown, achy), New onset or worsening of confusion; If yes: Complete Nursing Change of Condition assessment, Notify provider, Complete testing as ordered (i.e. Rapid flu, respiratory [MEDICAL CONDITION] panel, Implement droplet and contact precautions with door closed, Begin log of persons entering the room. Was COVID-19 testing ordered? Yes: Complete test for COVID-19, Implement suspected COVID-19 checklist. No: Continue to monitor for undiagnosed respiratory illness: Droplet and contact until [DIAGNOSES REDACTED]. Review of the facility's policy and procedure titled IC303 Droplet Precautions and Respiratory Hygiene/Cough Etiquette effective date 9/1/04, review date 11/15/19, revision date 6/15/19 read as follows: Policy: Droplet precautions will be followed in addition to standard precautions when caring for a patient who has known or suspected infection by microorganisms that are transmitted by droplets (Large particles droplets, for example influenza. Purpose: To prevent transmission of infectious agents by droplet. Process: . 2. Post a Stop. Please see nurse before entering room sign on door. 4.2 Change personal protective equipment and perform hand hygiene between contact with patients in the same room. 4.3 Before exiting room, remove and bag PPE and wash hands . 6.0 Dedicate personal care equipment (thermometer, blood pressure cuff, stethoscope, etc.) or use disposable equipment when available. 6.1 If use of common equipment is unavoidable, clean and disinfect item before use on another patient. Review of the facility's policy and procedure titled IC301 Contact Precautions effective date 2/15/01, review date 11/15/19 revision date 6/15/19 read as follows: Policy: In addition to standard precautions, contact precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment. Purpose To reduce risk of transmission of epidemiological microorganisms by direct and indirect contact. 4. Staff must use barrier precautions when entering the room. 4.1 Wear gowns and gloves. 4.2 Wear eye protection if splashing of infectious material is likely . 4.4 Change gowns and gloves and perform hand hygiene before providing care to the other resident in the room. 4.5 Before exiting the room, remove and bag gown and gloves and wash hands upon exiting the room. Review of the facility's policy titled IC203 Hand Hygiene effective date 2/15/01, review date 11/15/2019, revised dare 11/28/17 read as follows: Policy: Adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled and after exposure to known or suspected [MEDICAL CONDITION] or infectious diarrhea (i.e. Norovirus and the use of alcohol-based hand rubs for routine decontamination in clinical situations. Per the Centers for disease control and prevention (CDC) when hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. Process: 1. Perform hand hygiene: Before patient care, 1.2 before an aseptic procedure, 1.3 after any contact with blood or body fluids, even if gloves are worn, After patient care, After contact with the patient's environment. Review of the facility's policy titled IC201 Cleaning and Disinfecting dated 09/04/2020 read as follows: Policy: Cleaning and disinfecting patient care items and environment will be conducted based on risk of infection involved. Practice Standards: 1. Clean and disinfect items/environment according to risk of infection category . 1.2. Semi-critical items or objects that come in contact with mucus membranes and non-intact skin. These items require a high level disinfection . 1.3. Non-critical items are objects that do not come in contact with mucus membranes but do come in contact with intact skins (i.e. blood pressure cuff and stethoscope). These items require cleaning between patient use . 5. Perform routine disinfection of the items used in daily care practices with environmental protection agency registered disinfectant . 5.2. Multi-patient equipment must also be cleaned after patient use.

Based on observation, interview, and record review, Administration failed to ensure the management of the facility was conducted in a manner to ensure resident safety was maintained, Quality Assurance protocols and standards were implemented for the safe provision of food served to 6 of 13 residents identified with food allergies [REDACTED]. On 04/23/19, Resident #21 experienced an acute allergic reaction after consuming a food containing a food allergen. The resident was transferred to the hospital emergency department for emergent treatment. The resident recovered. However, the facility continued to serve this resident, as well as other residents, foods with allergens they must avoid, due to improper preparation and monitoring of the food service trays, and the lack of therapeutic diet menus. Thirteen residents were identified to have food allergies [REDACTED]. The Immediate Jeopardy began on (MONTH) 23, 2019. The Administrator was informed of the Immediate Jeopardy on 07/10/2019 at 6:27 PM. The Immediate Jeopardy was on going. Cross reference to F600, F692, F806, and F865. The findings included: An interview was conducted with the facility Administrator on 07/08/2019 beginning at 2:50 p.m. The incident involving Resident #21 was discussed to include corrective action taken post the event on 4/23/2019. He verified a Root Cause Analysis (RCA) was not conducted related to the identification of serving a a documented food allergy to a resident on 4/23/2019 and consumed by Resident #21, resulting in an emergent transfer to a higher level of care. A review of the Event Summary Report provided by the facility included, Patient (#21) exited room and notified staff she was allergic to fish and had consumed half of the fish filet that was sent to her by the kitchen. Patient states, My throat will close. Call placed to (Resident's Physician/Medical Director), ARNP (Advanced Registered Nurse Practitioner) ordered patient to be sent to Emergency Department (ED) for evaluation. Resident #s 32, 33, 34, 35 and 38 were discussed with the Administrator during an interview on 07/10/2019 at approximately 9:00 a.m. regarding the residents having received food delivered from the kitchen of documented allergens. The allergens were identified for the residents on the meal tray delivery slips, nutritional assessments, their allergy lists, and residents' medical records. The Administrator stated the concerns were brought up at the Quality Assurance meeting in (MONTH) 2019 (the first meeting, post the event) and reviewed. Review of the (MONTH) 2019 Quality Assurance data provided by the Administrator revealed no notations or indication of any kind referencing the event involving Resident #21 or the establishment of any monitoring mechanisms for both kitchen and tray delivery nursing staff. Review of the Facility assessment dated [DATE] of the specialized care and services provided to the residents in the facility was conducted. The Facility Assessment failed to identify residents with food allergies [REDACTED]. There were 13 residents of 158 identified with food allergies [REDACTED].>During an interview on 07/08/2019 at 2:58 p.m. with the Administrator he stated the Facility Assessment was completed on 12/20/2018. Review of the Job Responsibilities/Job Description, revised 10/04/16 for the Position Title: Medical Director under Position Summary read: The Medical Director works with the Senior Vice President of Medical Affairs to ensure that delivery of clinical services fulfills the mission of achieving the highest levels of clinical quality, efficiency, and outcomes. Essential Functions: Ensures Clinical Quality at the Center, Clinical Quality and Safety, Partner with the Center Executive Director, and the Center Nurse Executive, to optimize Center performance across key clinical measures and objectives. Clinical Policies and Protocols. Implement and promote Center wide adherence to clinical policies and protocols. Review of the Job Description: Centers Position Title: Center Executive Director, Effective Date: 01/01/16, Position Summary read: Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and [MEDICATION NAME] to patients, residents, and families. Responsible for assuring that the center operates in full compliance with Federal and State regulations while Doing the Right Things, which will result in high levels of performance in each of the focus areas. The Center Executive Director is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Center Executive Director administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. In the state of Florida the Center Executive Director serves as the center's Risk Manager.

Based on observation, interview, medical record review and facility documentation, the facility failed to prevent neglect for 6 of 13 sampled residents (Residents #21, 32, 33, 34, 35 and 38) with identified food allergies and served food with allergens. On 04/23/2019, Resident #21 experienced an acute allergic reaction after consuming a food containing a food allergen. The resident was transferred to a hospital emergency department for emergent treatment. The resident recovered. However, the facility continued to serve this resident, as well as other residents, food with allergens they must avoid. Thirteen residents were identified to have food allergies. This resulted in immediate jeopardy. The Immediate Jeopardy began on (MONTH) 23, 2019. The Administrator was informed of the Immediate Jeopardy on 07/10/2019 at 6:27 PM. The Immediate Jeopardy was on going. Cross reference to F692, F806, F835, and F865. The findings included: 1. During an interview on 06/04/2019, at 3:05 PM, Resident #21 reported weeks ago, she was served an entrée that contained fish. The resident stated she is highly allergic to seafood and strawberries. She had to be transported to the hospital via ambulance due to the allergic reaction she had to the fish. The resident also stated since her return after that incident, on 06/03/2019 she was served strawberries mixed with lettuce. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. The resident's nutritional assessment, completed on 08/01/2018, lists the resident's allergies, which included seafood, shell fish, and strawberries. The Progress note dated 04/23/2019 at 8:01 PM indicated the resident became nauseous and complained of difficulty breathing after consuming some fish that had been sent to her by the kitchen. The resident was sent to the local hospital emergency department for evaluation and treatment. The hospital Discharge Summary dated 04/23/2019 confirmed, acute allergic reaction. Hospital records indicated Solu [MEDICATION NAME] 125 mg, IV (intravenously) push once (used to treat inflammation, severe allergies, flares of chronic illnesses), [MEDICATION NAME] 20 mg IV push once and [MEDICATION NAME] 50 mg IV push once was administered. Follow up care with facility physician 1 2 days. The discharging [DIAGNOSES REDACTED]. During an interview on 06/06/2019, at 10:05 AM, the Dietary Manager confirmed two kitchen staff are supposed to read the residents' tray cards and verify each meal before it goes out for service. The Dietary Manager confirmed Resident #21 was served strawberries on 06/03/2019. During an interview on 06/06/2019, at 10:05 AM, the Registered Dietitian confirmed Resident #21 was served fish on 04/23/2019. The Dietary Manager provided a copy of the computer record of Resident #21's tray card for 04/23/2019 (the actual tray card for 4/23 was not available.) The computer record does not list the menu items for the meals; however, it does include a list of Resident #21's allergies, including seafood, shellfish, and strawberries. The Dietary Manager provided a copy of Resident #21's tray card for 06/03/2019. The card listed a Seasonal Fruit Platter for the lunch and dinner menus. During an interview on 07/08/2019, at 11:37 AM, Resident #21 advised that she had received food containing strawberries from the facility kitchen since the incidents in (MONTH) and June. Approximately two weeks ago, she received strawberry mousse at her dinner meal. She did not eat the mousse and informed her nurse, who went with her to the kitchen. The kitchen staff told them that it was strawberry mousse. The resident stated approximately one week ago, she received a brownie with a strawberry mousse topping. The resident stated she and the nurse involved in the previous incident returned the brownie to the kitchen. The kitchen staff told them that the topping on the brownie was strawberry mousse. During an interview on 07/08/2019, at 03:47 PM, Staff SS, Licensed Practical Nurse (LPN) confirmed that two or three weeks ago, he was alerted by Resident #21 that she had been served a brownie with a strawberry topping. Staff SS stated he accompanied the resident to the kitchen. Staff SS confirmed that the kitchen staff told him the topping on the brownie was a strawberry topping. The facility's dietary records revealed Resident #21's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Strawberries. The resident's care plan, revised on 05/08/2019, included a focus area and intervention that states, (The resident) is allergic to seafood and strawberries; Staff to verify that meals served do not contain seafood or strawberries, as (the resident) reports seafood and strawberry allergies (not allergic to tuna). 2. During an interview with Resident #32 on 07/08/2019 at 12:25 PM, the resident reported that he is allergic to shellfish and regular fish. Approximately three months ago, he was served dinner that included fish. The resident stated that he ate some of the fish before he realized what it was, causing him to vomit. Approximately two weeks later, he was served fish for dinner again. He thought it was chicken and took a bite, but he then realized that it was fish and spit it out. The resident did not become ill during the second incident. Resident #32's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 06/21/2019. The nutritional assessment documented the resident has a food allergy to shellfish. The Resident's care plan, initiated on 10/15/2018, included the resident's food allergies. The facility's dietary records revealed Resident #32's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Shellfish. 3. During an interview on 07/08/2019 at 1:25 PM, Resident #33 reported she is allergic to fish. Approximately one week ago, she was served fish by the facility kitchen for either lunch or dinner. She recognized that it was fish, so she did not eat it and she sent it back to the kitchen. The resident stated, This happens all the time. Resident #33's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 04/16/2019. The nutritional assessment lists the resident's food allergies which included fish, but not shellfish, and tuna. The resident's care plan, initiated on 08/29/2017, listed the resident's allergies, including fish, shellfish, and tuna. Review of the facility's dietary records revealed that Resident #33's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Tuna. 4. During an interview on 07/08/2019 at 01:05 PM, Staff MM, Certified Nursing Assistant (CNA) stated Resident #34 was served shrimp and rice for dinner on 07/07/2019. The resident's food allergies are listed on her tray card, and she noticed the resident is allergic to shellfish. Staff MM did not serve the shrimp to the Resident and took it back to the kitchen. During an interview on 07/09/2019, at 9:55 AM, Resident #34 stated she is allergic to fish and shellfish. The resident confirmed she received shrimp from the facility kitchen. She also stated she received a fish filet at her next meal. Resident #34's medical record documented the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 06/26/2019. The nutritional assessment lists the resident's allergies as shellfish, but it does not include fish and seafood. The resident's care plan, initiated on 06/25/2019, listed the resident's allergies, including fish, seafood, and shellfish. Review of the facility's dietary records revealed that Resident #34's tray ticket for the date of 07/08/2019 documented the resident's food allergies as shellfish. 5. During an interview on 07/09/2019, at 10:20 AM, Resident #35 reported that she has many food allergies that include fish, dairy, tomatoes, and peanuts. She receives food she is allergic to almost daily. The resident stated that a couple of months ago she received a sandwich from the kitchen to take with her to her [MEDICAL TREATMENT] treatment. The sandwich was wrapped and labeled as turkey. When she unwrapped the sandwich, she discovered it was tuna fish. Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 04/30/2019. The nutritional assessment lists the resident's food allergies, which included nutmeg, seafood, berries, dairy, fish, melons, peanuts, tomatoes, eggs, mushrooms, Splenda, and watermelon concentrate. Review of the resident's food allergies indicated the allergy to Splenda (name brand) however the resident's tray delivery slip obtained from the Food Services Department on 07/08/2019 failed to acknowledge Splenda as an allergy. Review of the facility's dietary records revealed Resident #35's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Dairy Allergy, Egg Dishes, Fish/Seafood, Mushrooms, Peanuts, Strawberries, [NAME]atoes, Tuna, and Watermelon. 6. A kitchen tray line observation was conducted during the extended survey on 07/10/2019 beginning at 7:35 AM. The Food Services Director was observed behind the serving line plating food to be placed on the trays for delivery to the floor. The line was being observed for the kitchen process for monitoring or validating resident allergies during tray preparation. Nine (9) resident's trays of the 13 identified with allergies were observed. Resident #38 has identified allergies to cinnamon, eggs, nuts, peanuts, tomatoes, mandarin oranges. A large red dot was observed on her tray slip. The plate of raisin toast (4 half slices) was presented by the server, the front line staff took the plate, placed it on the hot plate, placed a dome over it and then placed it into the tray delivery cart at 8:29 AM. After two (2) additional trays had been completed and placed on the cart, the Director was asked if there was cinnamon in the raisin toast. He stated, No, there is no cinnamon, just plain raisin toast. The package of raisin toast was obtained with the label clearly identifying, Cinnamon Raisin bread. The tray had been removed from the cart and the toast was being removed with plain white toast being added. The plate was not changed out and this surveyor could not confirm if any of the cinnamon residue remained on the plate with the new slices of toast. An interview was conducted with the Certified Dietary Manager/Food Services Director (CDM/FSD) on 07/09/2019 beginning at 10:53 AM. He stated he's been employed at this facility for approximately 2 weeks. He was asked to describe the process the facility utilizes for ensuring resident's trays are prepared and served with the proper items and specifically those with identified allergies. He confirmed the allergies are communicated from nursing once identified to the Food Services Department. They are then included in the departmental computer system with the data added to each resident's tray delivery slip for each meal. He confirmed the allergies are identified in a black box on each slip. Once the tray ticket is prepared for service on the tray line, the first person on line, starter or expeditor, calls out items needed. The cook will prepare the plate given the identified food items. He confirmed if a food item is identified on the ticket as an allergy and that food is on the line to be served, the resident would receive an alternate of equal nutritional value. The checker then places the final items on the tray, verifies the correct items on the tray and then loads the tray on the cart. This surveyor asked the FSD how a resident could end up receiving an identified food allergen on their tray. He replied he could not answer that, he did not know. He confirmed the Food Services Department had no tracking mechanism for checking trays regarding their accuracy when leaving the kitchen and no mechanism for identifying problems with residents receiving food that are identified as allergens prior to today. He confirmed once a problem is identified, he will go to the resident and speak with them about the issue, only when he is made aware of the concern. An observation of the tray line production service on 07/10/2019 beginning at 7:35 AM, no sign off sheet was observed being completed by the checker for tray accuracy. The only monitoring observed is identifying the time on a form for when the truck leaves the kitchen. The Director of Nursing (DON) was interviewed on 07/09/2019 a 10:59 AM. Prior a request was made for documentation of in service information or training provided to the floor nursing and CNA staff regarding meal service and residents with allergens. The DON confirmed there was no previous training provided. The facility policy and procedure, revised 07/1/2019, titled Policy #OPS300 Abuse Prohibition. Neglect defined: The failure of the Center, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source and misappropriation of property for all residents. Process: The Center Executive Director or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation and misappropriation of property. 7. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Center Executive Director (CED) or designee will perform the following: Enter allegation into the Risk Management System (RMS). Report allegations involving neglect not later than two (2) hours after the allegation is made if the event results in serious bodily injury. An interview conducted on 6/08/2019 at approximately 2:00 p.m. the facility Center Executive Director confirmed they failed to report this incident of neglect to the State survey agency, according to the facility policy.

Based on observation, interview, medical record review and facility data, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and prioritized problems that reflect services provided to residents based on resident and staff input, and other information for 6 of 13 residents identified with food allergies [REDACTED]. On 04/23/19, Resident #21 experienced an acute allergic reaction after consuming a food containing a food allergen. The resident was transferred to the hospital emergency department for emergent treatment. The resident recovered. However, the facility continued to serve this resident, as well as other residents, foods with allergens they must avoid. This was due to improper preparation and monitoring of the food service trays; the lack of therapeutic diet menus; the failure of the facility to identify residents with food allergies [REDACTED]. Thirteen residents were identified to have food allergies [REDACTED]. The Immediate Jeopardy began on (MONTH) 23, 2019. The Administrator was informed of the Immediate Jeopardy on 07/10/2019 at 6:27 PM. The Immediate Jeopardy was on going. Cross reference to F600, F692, F806, and F835. The findings included: An interview was conducted with the facility Administrator on 07/08/2019 beginning at 2:50 p.m. The incident involving Resident #21 was discussed to include corrective action taken post the event on 4/23/2019. He verified a Root Cause Analysis (RCA) was not conducted related to the identification of serving a a documented food allergy to a resident on 4/23/2019 and consumed by Resident #21, resulting in an emergent transfer to a higher level of care. A review of the Event Summary Report provided by the facility included, Patient (#21) exited room and notified staff she was allergic to fish and had consumed half of the fish filet that was sent to her by the kitchen. Patient states, 'my throat will close.' Call placed to (Resident's Physician/Medical Director), ARNP (Advanced Registered Nurse Practitioner) ordered patient to be sent to Emergency Department (ED) for evaluation. Resident #s 32, 33, 34, 35 and 38 were discussed with the Administrator during an interview on 07/10/2019 at approximately 9:00 a.m. regarding the residents having received food delivered from the kitchen of documented allergens. The allergens were identified for the residents on the meal tray delivery slips, nutritional assessments, their allergy lists, and residents' medical records. The Administrator stated the concerns were brought up at the Quality Assurance meeting in (MONTH) 2019 (the first meeting post the event) and reviewed. Review of the (MONTH) 2019 Quality Assurance data provided by the Administrator revealed no notations or indication of any kind referencing the event involving Resident #21 or the establishment of any monitoring mechanisms for both kitchen and tray delivery nursing staff. Review of the Facility assessment dated [DATE] of the specialized care and services provided to the residents in the facility was conducted. The Facility Assessment failed residents with food allergies [REDACTED]. There were 13 residents of 158 identified with food allergies [REDACTED].>During an interview on 07/08/2019 at 2:58 p.m. with the Administrator he stated the Facility Assessment was completed on 12/20/2018. Review of Job Responsibilities/Job Description: Position Title: Medical Director - Medical Directors partner to achieve the highest levels of center performance in quality, safety, and efficiency. Essential Functions: Ensures Clinical Quality At The Center: Clinical Quality and Safety - Partner with the Center Executive Director (CED) and the Center Nurse Executive (CNE), to optimize Center performance across key clinical measures and objectives. Participate in monthly Quality Assurance/Performance Improvement meetings. Support nursing education. Review of Description: Position Title: Administration. The Center Executive Director is responsible for planning and is accountable for all activities and departments of the Center to assure the highest degree of quality of care is consistently provided to residents. Essential Functions: Business Excellence: 1. Assures that the QAPI (Quality Performance Improvement Program)Process is understood and utilized by all members of the Center Leadership Team to continually improve all aspects of the Center performance. Review of Job Description: Title: Registered Dietitian: Essential Functions Of The Job. Job Function: Administrative duties - Reviews and makes recommendations for an ongoing quality assurance program for the Dining Services Department.

Based on interview, observation, and record review, the facility failed to provide therapeutic diets to ensure 6 of 13 sampled residents (Residents #21, #32, #33, #34, #35 and #38) with identified food allergies, were not served foods with allergens they must avoid. On 04/23/19, Resident #21 experienced an acute allergic reaction after consuming a food containing a food allergen. The resident was transferred to the hospital emergency department for emergent treatment. The resident recovered. However, the facility continued to serve this resident, as well as other residents, foods with allergens they must avoid, due to the lack of therapeutic diet menus. Thirteen residents were identified to have food allergies. This resulted in immediate jeopardy. The Immediate Jeopardy began on (MONTH) 23, 2019. The Administrator was informed of the Immediate Jeopardy on 07/10/2019 at 6:27 PM. The Immediate Jeopardy was on going. Cross reference to F600, F806, F835, and F865. The findings included: 1. During an interview on 06/04/2019, at 3:05 PM, Resident #21 reported weeks ago, she was served an entrée that contained fish. The resident stated she is highly allergic to seafood and strawberries. She had to be transported to the hospital via ambulance due to the allergic reaction she had to the fish. The resident also stated since her return after that incident, on 06/03/2019 she was served strawberries mixed with lettuce. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. The resident's nutritional assessment, completed on 08/01/2018, lists the resident's allergies, which included seafood, shell fish, and strawberries. The Progress note dated 04/23/2019 at 8:01 PM indicated the resident became nauseous and complained of difficulty breathing after consuming some fish that had been sent to her by the kitchen. The resident was sent to the local hospital emergency department for evaluation and treatment. A review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. The resident's nutritional assessment, completed on 08/01/2018, lists the resident's allergies, which included seafood, shell fish, and strawberries. The resident's care plan, revised on 05/08/2019, includes a focus area and intervention that states, (The resident) is allergic to seafood and strawberries; Staff to verify that meals served do not contain seafood or strawberries, as (the resident) reports seafood and strawberry allergies (not allergic to tuna). The hospital Discharge Summary dated 4/23/2019 confirmed, acute allergic reaction. Hospital records indicated Solu [MEDICATION NAME] 125 mg, IV (intravenously) push once (used to treat inflammation, severe allergies, flares of chronic illnesses), [MEDICATION NAME] 20 mg IV push once and [MEDICATION NAME] 50 mg IV push once was administered. Follow up care with facility physician 1 2 days. The discharging [DIAGNOSES REDACTED]. During an interview on 06/06/2019, at 10:05 AM, the Dietary Manager confirmed two kitchen staff are supposed to read the residents' tray cards and verify each meal before it goes out for service. The Dietary Manager confirmed Resident #21 was served strawberries on 06/03/2019. During an interview on 06/06/2019, at 10:05 AM, the Registered Dietitian confirmed Resident #21 was served fish on 04/23/2019. The Dietary Manager provided a copy of the computer record of Resident #21's tray card for 04/23/2019 (the actual tray card for 4/23 was not available.) The computer record does not list the menu items for the meals; however, it does include a list of Resident #21's allergies, including seafood, shellfish, and strawberries. The Dietary Manager provided a copy of Resident #21's tray card for 06/03/2019. The card listed a Seasonal Fruit Platter for the lunch and dinner menus. During an interview on 07/08/2019, at 11:37 AM, Resident #21 advised that she had received food containing strawberries from the facility kitchen since the incidents in (MONTH) and June. Approximately two weeks ago, she received strawberry mousse at her dinner meal. She did not eat the mousse and informed her nurse, who went with her to the kitchen. The kitchen staff told them that it was strawberry mousse. The resident stated approximately one week ago, she received a brownie with a strawberry mousse topping. The resident stated she and the nurse involved in the previous incident returned the brownie to the kitchen. The kitchen staff told them that the topping on the brownie was strawberry mousse. During an interview on 07/08/2019, at 3:47 PM, Staff SS, Licensed Practical Nurse (LPN) confirmed that two or three weeks ago, he was alerted by Resident #21 that she had been served a brownie with a strawberry topping. Staff SS stated he accompanied the resident to the kitchen. Staff SS confirmed that the kitchen staff told him the topping on the brownie was a strawberry topping. The facility's dietary records revealed Resident #21's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Strawberries. 2. During an interview with Resident #32 on 07/08/2019 at 12:25 PM, the resident reported that he is allergic to shellfish and regular fish. Approximately three months ago, he was served dinner that included fish. The resident stated that he ate some of the fish before he realized what it was, causing him to vomit. Approximately two weeks later, he was served fish for dinner again. He thought it was chicken and took a bite, but he then realized that it was fish and spit it out. The resident did not become ill during the second incident. Resident #32's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 06/21/2019. The nutritional assessment documented the resident has a food allergy to shellfish. The Resident's care plan, initiated on 10/15/2018, included the resident's food allergies. The facility's dietary records revealed Resident #32's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Shellfish. 3. During an interview on 07/08/2019 at 1:25 PM, Resident #33 reported she is allergic to fish. Approximately one week ago, she was served fish by the facility kitchen for either lunch or dinner. She recognized that it was fish, so she did not eat it and she sent it back to the kitchen. The resident stated, This happens all the time. Resident #33's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 04/16/2019. The nutritional assessment lists the resident's food allergies which included fish, but not shellfish, and tuna. The resident's care plan, initiated on 08/29/2017 listed the resident's allergies, including fish, shellfish, and tuna. Review of the facility's dietary records revealed that Resident #33's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Tuna. 4. During an interview on 07/08/2019 at 01:05 PM, Staff MM, Certified Nursing Assistant (CNA) stated Resident #34 was served shrimp and rice for dinner on 07/07/2019. The resident's food allergies are listed on her tray card, and she noticed the resident is allergic to shellfish. Staff MM did not serve the shrimp to the Resident and took it back to the kitchen. During an interview on 07/09/2019, at 9:55 AM, Resident #34 stated she is allergic to fish and shellfish. The resident confirmed she received shrimp from the facility kitchen. She also stated she received a fish filet at her next meal. Resident #34's medical record documented the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 06/26/2019. The nutritional assessment lists the resident's allergies as shellfish, but it does not include fish and seafood. The resident's care plan, initiated on 06/25/2019, listed the resident's allergies, including fish, seafood, and shellfish. Review of the facility's dietary records revealed that Resident #34's tray ticket for the date of 07/08/2019 documented the resident's food allergies as shellfish. 5. During an interview on 07/09/2019, at 10:20 AM, Resident #35 reported that she has many food allergies that include fish, dairy, tomatoes, and peanuts. She receives food she is allergic to almost daily. The resident stated that a couple of months ago she received a sandwich from the kitchen to take with her to her [MEDICAL TREATMENT] treatment. The sandwich was wrapped and labeled as turkey. When she unwrapped the sandwich, she discovered it was tuna fish. Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 04/30/2019. The nutritional assessment lists the resident's food allergies, which included nutmeg, seafood, berries, dairy, fish, melons, peanuts, tomatoes, eggs, mushrooms, Splenda, and watermelon concentrate. Review of the resident's food allergies indicated the allergy to Splenda (name brand) however the resident's tray delivery slip obtained from the Food Services Department on 07/08/2019 failed to acknowledge Splenda as an allergy. Review of the facility's dietary records revealed Resident #35's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Dairy Allergy, Egg Dishes, Fish/Seafood, Mushrooms, Peanuts, Strawberries, [NAME]atoes, Tuna, and Watermelon. The resident's care plan, revised on 07/02/2019, documented 1. The resident has many reported food allergies that do not appear to be true allergies. Monitor for any signs or symptoms of an allergic reaction and alert physician as warranted. The resident has reported she is allergic to egg yolks, dairy products, shellfish, all fish, tuna, strawberries, watermelon, mushrooms, nutmeg, tomatoes, and artificial sweeteners most of these allergies are likely intolerances (if even that), and the resident voiced to center RD (Registered Dietician) on 1/17/2018 and 1/19/2018, (and many times thereafter) that she wishes to be able to receive some of these food items at times. 6. On 07/10/2019, at 7:35 AM, a kitchen observation for the breakfast meal was conducted. A meal tray was being prepared for Resident #38 that included four half slices of raisin toast. The kitchen staff completed the tray preparation, and the tray was placed on a tray cart for delivery to the resident. After observation of two (2) additional trays placed in the tray delivery cart, the surveyor asked the Dietary Manager if the raisin toast contained cinnamon. The Dietary Manager told the surveyor that there was no cinnamon in the raisin toast. The surveyor confirmed that the packaging of the raisin toast was labeled Cinnamon Raisin Bread. The kitchen staff removed the raisin toast from the resident's meal tray and replaced it with plain white bread toast. The plate was not changed out and this surveyor could not confirm if any of the cinnamon residue remained on the plate with the new slices of toast. A review of Resident #38's medical record revealed that the resident was admitted to the facility on [DATE]. The resident's medical record lists the following food allergies: cinnamon, tree nuts, citric acid, egg, and peanuts. The resident's care plan, revised on 05/13/2019, includes the relevant focus area and intervention listed below: 1. (The resident) is at nutritional risk, inadequate oral intake related to history of eating disorder as evidenced by needs for enteral feeding to meet nutritional needs. Avoid food allergies (the resident) reports she is allergic to tomatoes (because of the citric acid they contain), oranges (because of the citric acid they contain), peanuts, tree nuts, (whole) eggs (by themselves), and cinnamon. (The resident) can consume citric acid in some food items, and she can consume eggs that have been incorporated into other food items (e.g. baked goods.) A review of the facility menu for 07/10/2019 confirmed that raisin toast was on the breakfast menu. A review of the facility's dietary records revealed that Resident #38's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Cinnamon, Egg, Nuts, Peanuts, [NAME]atoes, and Mandarin Oranges. An interview was conducted on 07/08/2019 at 12:08 p.m., with the facility Registered Dietitian, (RD). Resident #21 was discussed. The RD stated Resident #21 became ill immediately after she'd been served food, she was allergic to and consumed. She was served fish that she should not have received. An interview was conducted with the Certified Dietary Manager/Food Services Director (CDM/FSD) on 7/09/2019 beginning at 10:53 AM. He stated he's been employed at this facility for approximately 2 weeks. He was asked to describe the process the facility utilizes for ensuring resident's trays are prepared and served with the proper items and specifically those with identified allergies. He confirmed the allergies are communicated from nursing once identified to the Food Services Department. They are then included in the departmental computer system with the data added to each resident's tray delivery slip for each meal. He confirmed the allergies are identified in a black box on each slip. Once the tray ticket is prepared for service on the tray line, the first person on line, starter or expeditor, calls out items needed. The cook will prepare the plate given the identified food items. He confirmed if a food item is identified on the ticket as an allergy and that food is on the line to be served, the resident would receive an alternate of equal nutritional value. The checker then places the final items on the tray, verifies the correct items on the tray and then loads the tray on the cart. This surveyor asked the FSD how a resident could end up receiving an identified food allergen on their tray. He replied he could not answer that, he did not know. He confirmed the Food Services Department had no tracking mechanism for checking trays regarding their accuracy when leaving the kitchen and no mechanism for identifying problems with residents receiving food that are identified as allergens prior to today. He confirmed once a problem is identified, he will go to the resident and speak with them about the issue, only when he is made aware of the concern. The Tray Line production line was observed on 07/10/2019 beginning at 7:35 AM. No sign off sheet was observed being completed by the checker for tray accuracy. The only monitoring observed was identifying the time on a form for when the truck leaves the kitchen. The Director of Nursing (DON) was interviewed on 07/09/2019 a 10:59 AM. Prior a request was made for documentation of in service information or training provided to the floor nursing and CNA staff regarding meal service and residents with allergens. The DON confirmed there was no previous training provided. Review of the food service policy and procedures, revised 9/2017, titled, Dining and Food Preferences #HCSG Policy 005 read: 1) The diet requisition form will notify the dining services department of food allergies upon admission and prior to any meals served. 4) Food allergies, food intolerance, food dislikes and food and fluid preferences will be entered into the resident profile in the menu management software system. Review of the Policy #HCSG 013, revised 9/2017, titled, Meal Distribution read: Meals are transported to the dining locations in a manner that ensures proper temperature, maintenance, protects against contamination and are delivered in a timely and accurate manner. 4) The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. Review of the Policy #NSG201, revised 03/01/2018, titled, Allergic/Adverse Reactions read: Centers establish a system to identify and communicate patient's allergies and or any adverse reactions. To prevent allergic/adverse reactions. 1) During admission assessment, determine if the patient has any known allergies/adverse reactions. Instruct/educate patient to report any allergies/adverse reaction to staff. 2) Record allergies/adverse reaction in the medical record. If the patient has a food allergy, notify Food and Nutrition Services. 3) Attach allergy or adverse reaction label to chart with specific allergy noted. 4) When obtaining new orders, review allergic/adverse reaction and inform physician/mid level provider as necessary. 5) Observe patient for s/s (signs and symptoms) of allergies/adverse reaction and report to physician and mid level provider and pharmacy.

Based on interview, observation, and record review, the facility failed to provide 6 of 13 sampled residents' (Residents #21, #32, #33, #34, #35 and #38) food to accommodate resident food allergies. On 04/23/19 Resident #21 experienced an acute allergic reaction after consuming a food containing a food allergen. The resident was transferred to a hospital emergency department for emergent treatment. The resident recovered. However, the facility continued to serve this resident, as well as other residents, foods with allergens they must avoid. Thirteen residents were identified to have food allergies. This resulted in immediate jeopardy. The Immediate Jeopardy began on (MONTH) 23, 2019. The Administrator was informed of the Immediate Jeopardy on 07/10/2019 at 6:27 PM. The Immediate Jeopardy was on going. Cross reference to F600, F692, F835, and F865. The findings included: 1. During an interview on 06/04/2019, at 3:05 PM, Resident #21 reported weeks ago, she was served an entrée that contained fish. The resident stated she is highly allergic to seafood and strawberries. She had to be transported to the hospital via ambulance due to the allergic reaction she had to the fish. The resident also stated since her return after that incident, on 06/03/2019 she was served strawberries mixed with lettuce. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. The resident's nutritional assessment, completed on 08/01/2018, lists the resident's allergies, which included seafood, shell fish, and strawberries. The Progress note dated 04/23/2019 at 8:01 PM indicated the resident became nauseous and complained of difficulty breathing after consuming some fish that had been sent to her by the kitchen. The resident was sent to the local hospital emergency department for evaluation and treatment. The resident's care plan, revised on 05/08/2019, includes a focus area and intervention that states, (The resident) is allergic to seafood and strawberries; Staff to verify that meals served do not contain seafood or strawberries, as (the resident) reports seafood and strawberry allergies (not allergic to tuna). The hospital Discharge Summary dated 4/23/2019 confirmed, acute allergic reaction. Hospital records indicated Solu [MEDICATION NAME] 125 mg, IV (intravenously) push once (used to treat inflammation, severe allergies, flares of chronic illnesses), [MEDICATION NAME] 20 mg IV push once and [MEDICATION NAME] 50 mg IV push once was administered. Follow up care with facility physician 1 2 days. The discharging [DIAGNOSES REDACTED]. During an interview on 06/06/2019, at 10:05 AM, the Dietary Manager confirmed two kitchen staff are supposed to read the residents' tray cards and verify each meal before it goes out for service. The Dietary Manager confirmed Resident #21 was served strawberries on 06/03/2019. During an interview on 06/06/2019, at 10:05 AM, the Registered Dietitian confirmed Resident #21 was served fish on 04/23/2019. The Dietary Manager provided a copy of the computer record of Resident #21's tray card for 04/23/2019 (the actual tray card for 4/23 was not available.) The computer record does not list the menu items for the meals; however, it does include a list of Resident #21's allergies, including seafood, shellfish, and strawberries. The Dietary Manager provided a copy of Resident #21's tray card for 06/03/2019. The card listed a Seasonal Fruit Platter for the lunch and dinner menus. During an interview on 07/08/2019, at 11:37 AM, Resident #21 advised that she had received food containing strawberries from the facility kitchen since the incidents in (MONTH) and June. Approximately two weeks ago, she received strawberry mousse at her dinner meal. She did not eat the mousse and informed her nurse, who went with her to the kitchen. The kitchen staff told them that it was strawberry mousse. The resident stated approximately one week ago, she received a brownie with a strawberry mousse topping. The resident stated she and the nurse involved in the previous incident returned the brownie to the kitchen. The kitchen staff told them that the topping on the brownie was strawberry mousse. During an interview on 07/08/2019, at 03:47 PM, Staff SS, Licensed Practical Nurse (LPN) confirmed that two or three weeks ago, he was alerted by Resident #21 that she had been served a brownie with a strawberry topping. Staff SS stated he accompanied the resident to the kitchen. Staff SS confirmed that the kitchen staff told him the topping on the brownie was a strawberry topping. The facility's dietary records revealed Resident #21's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Strawberries. 2. During an interview with Resident #32 on 07/08/2019 at 12:25 PM, the resident reported that he is allergic to shellfish and regular fish. Approximately three months ago, he was served dinner that included fish. The resident stated that he ate some of the fish before he realized what it was, causing him to vomit. Approximately two weeks later, he was served fish for dinner again. He thought it was chicken and took a bite, but he then realized that it was fish and spit it out. The resident did not become ill during the second incident. Resident #32's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 06/21/2019. The nutritional assessment documented the resident has a food allergy to shellfish. The Resident's care plan, initiated on 10/15/2018, the resident's food allergies are listed on the care plan. The facility's dietary records revealed Resident #32's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Shellfish. 3. During an interview on 07/08/2019 at 1:25 PM, Resident #33 reported she is allergic to fish. Approximately one week ago, she was served fish by the facility kitchen for either lunch or dinner. She recognized that it was fish, so she did not eat it and she sent it back to the kitchen. The resident stated, This happens all the time. Resident #33's medical record documented the resident was admitted to the facility on [DATE]. The Resident's most recent nutritional assessment was completed on 04/16/2019. The nutritional assessment lists the resident's food allergies which included fish, but not shellfish, and tuna. The resident's care plan, initiated on 08/29/2017 listed the resident's allergies, including fish, shellfish, and tuna. Review of the facility's dietary records revealed that Resident #33's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Fish/Seafood, Shellfish, and Tuna. 4. During an interview on 07/08/2019 at 01:05 PM, Staff MM, Certified Nursing Assistant (CNA) stated Resident #34 was served shrimp and rice for dinner on 07/07/2019. The resident's food allergies are listed on her tray card, and she noticed the resident is allergic to shellfish. Staff MM did not serve the shrimp to the Resident and took it back to the kitchen. During an interview on 07/09/2019, at 9:55 AM, Resident #34 stated she is allergic to fish and shellfish. The resident confirmed she received shrimp from the facility kitchen. She also stated she received a fish filet at her next meal. Resident #34's medical record documented the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 06/26/2019. The nutritional assessment lists the resident's allergies as shellfish, but it does not include fish and seafood. The resident's care plan, initiated on 06/25/2019, listed the resident's allergies, including fish, seafood, and shellfish. Review of the facility's dietary records revealed that Resident #34's tray ticket for the date of 07/08/2019 documented the resident's food allergies as shellfish. 5. During an interview on 07/09/2019, at 10:20 AM, Resident #35 reported that she has many food allergies that include fish, dairy, tomatoes, and peanuts. She receives food she is allergic to almost daily. The resident stated that a couple of months ago she received a sandwich from the kitchen to take with her to her [MEDICAL TREATMENT] treatment. The sandwich was wrapped and labeled as turkey. When she unwrapped the sandwich, she discovered it was tuna fish. Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. The resident's most recent nutritional assessment was completed on 04/30/2019. The nutritional assessment lists the resident's food allergies, which included nutmeg, seafood, berries, dairy, fish, melons, peanuts, tomatoes, eggs, mushrooms, Splenda, and watermelon concentrate. Review of the resident's food allergies indicated the allergy to Splenda (name brand) however the resident's tray delivery slip obtained from the Food Services Department on 07/08/2019 failed to acknowledge Splenda as an allergy. Review of the facility's dietary records revealed Resident #35's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Dairy Allergy, Egg Dishes, Fish/Seafood, Mushrooms, Peanuts, Strawberries, [NAME]atoes, Tuna, and Watermelon. 6. On 07/10/2019, at 07:35 AM, a kitchen observation for the breakfast meal was conducted. A meal tray was being prepared for Resident #38 that included four half slices of raisin toast. The kitchen staff completed the tray preparation, and the tray was placed on a tray cart for delivery to the resident. After observation of two (2) additional trays placed in the tray delivery cart, the surveyor asked the Dietary Manager if the raisin toast contained cinnamon. The Dietary Manager told the surveyor that there was no cinnamon in the raisin toast. The surveyor confirmed that the packaging of the raisin toast was labeled Cinnamon Raisin Bread. The kitchen staff removed the raisin toast from the resident's meal tray and replaced it with plain white bread toast. The plate was not changed out and this surveyor could not confirm if any of the cinnamon residue remained on the plate with the new slices of toast. A review of Resident #38's medical record revealed that the resident was admitted to the facility on [DATE]. The resident's medical record lists the following food allergies: cinnamon, tree nuts, citric acid, egg, and peanuts. The resident's care plan, revised on 05/13/2019, includes the relevant focus area and intervention listed below: 1. (The resident) is at nutritional risk, inadequate oral intake related to history of eating disorder as evidenced by needs for enteral feeding to meet nutritional needs. Avoid food allergies (the resident) reports she is allergic to tomatoes (because of the citric acid they contain), oranges (because of the citric acid they contain), peanuts, tree nuts, (whole) eggs (by themselves), and cinnamon. (The resident) can consume citric acid in some food items, and she can consume eggs that have been incorporated into other food items (e.g. baked goods.) A review of the facility menu for 07/10/2019 confirmed that raisin toast was on the breakfast menu. A review of the facility's dietary records revealed that Resident #38's tray ticket for the date of 07/08/2019 documented the residents' food allergies as: Cinnamon, Egg, Nuts, Peanuts, [NAME]atoes, and Mandarin Oranges. An interview was conducted on 07/08/2019 at 12:08 p.m., with the facility Registered Dietitian, (RD). Resident #21 was discussed. The RD stated Resident #21 became ill immediately after she'd been served food, she was allergic to and consumed. She was served fish that she should not have received. An interview was conducted with the Certified Dietary Manager/Food Services Director (CDM/FSD) on 7/09/2019 beginning at 10:53 AM. He stated he's been employed at this facility for approximately 2 weeks. He was asked to describe the process the facility utilizes for ensuring resident's trays are prepared and served with the proper items and specifically those with identified allergies. He confirmed the allergies are communicated from nursing once identified to the Food Services Department. They are then included in the departmental computer system with the data added to each resident's tray delivery slip for each meal. He confirmed the allergies are identified in a black box on each slip. Once the tray ticket is prepared for service on the tray line, the first person on line, starter or expeditor, calls out items needed. The cook will prepare the plate given the identified food items. He confirmed if a food item is identified on the ticket as an allergy and that food is on the line to be served, the resident would receive an alternate of equal nutritional value. The checker then places the final items on the tray, verifies the correct items on the tray and then loads the tray on the cart. This surveyor asked the FSD how a resident could end up receiving an identified food allergen on their tray. He confirmed that he could not answer that, he did not know. He confirmed the Food Services Department had no tracking mechanism for checking trays regarding their accuracy when leaving the kitchen and no mechanism for identifying problems with residents receiving food that are identified as allergens prior to today. He confirmed once a problem is identified, he will go to the resident and speak with them about the issue, only when he is made aware of the concern. The Tray Line production line was observed on 07/10/2019 beginning at 7:35 AM. No sign off sheet was observed being completed by the checker for tray accuracy. The only monitoring observed was identifying the time on a form for when the truck leaves the kitchen. The Director of Nursing (DON) was interviewed on 07/09/2019 a 10:59 AM. Prior a request was made for documentation of in service information or training provided to the floor nursing and CNA staff regarding meal service and residents with allergens. The DON confirmed there was no previous training provided. Review of the food service policy and procedures, revised 9/2017, titled, Dining and Food Preferences #HCSG Policy 005 read: 1.) The diet requisition form will notify the dining services department of food allergies upon admission and prior to any meals served. 4.) Food allergies, food intolerance, food dislikes and food and fluid preferences will be entered into the resident profile in the menu management software system. Review of the Policy #HCSG 013, revised 9/2017, titled, Meal Distribution read: Meals are transported to the dining locations in a manner that ensures proper temperature, maintenance, protects against contamination and are delivered in a timely and accurate manner. 4.) The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. Review of the Policy #NSG201, revised 03/01/2018, titled, Allergic/Adverse Reactions read: Centers establish a system to identify and communicate patient's allergies and or any adverse reactions. To prevent allergic/adverse reactions. 1.) During admission assessment, determine if the patient has any known allergies/adverse reactions. Instruct/educate patient to report any allergies/adverse reaction to staff. 2.) Record allergies/adverse reaction in the medical record. If the patient has a food allergy, notify Food and Nutrition Services. 3.) Attach allergy or adverse reaction label to chart with specific allergy noted. 4.) When obtaining new orders, review allergic/adverse reaction and inform physician/mid level provider as necessary. 5.) Observe patient for s/s of allergies/adverse reaction and report to physician and mid level provider and pharmacy.

Based on medical record review and interview, the facility failed ensure the completion of a 30 day discharge notice for 2 of 2 residents, Resident #17 and #19; and failed to allow a resident to return post Baker Act enforcement for 1 of 8 residents reviewed, Residents #17. The failure to allow the resident to return to the facility resulted in harm causing an 18 day hospitalization until alternate living arrangements could be made. The findings included: 1. Review of the facility nursing progress notes for Resident #17 dated 05/07/2019 at 10:02 p.m. documented Resident arrived at 7:30 p.m. via stretcher and EMS (Emergency Medical Services) was directed to North wing. Resident started yelling at the staff and using profanities upon arrival. I had a conversation with resident about new room and resident stated I'm not staying in here, take me back to my old room. Resident then tried to physical hit me in the face X2 (two times). Resident then picked up the wheelchair leg attachments and threw them at staff, Resident continued profanities. Resident then stated, it's hot in here, I can't breathe. Resident's nurse asked if she could put the oxygen on, resident stated, yeah, 'expletive'. Oxygen was placed within reach and resident put it on. Resident then proceeded to say I'm still not staying in here, I'll kill myself if I have to. Resident then took the oxygen tubing off and wrapped it around his neck twice and started to pull. Resident's nurse and myself both witnessed this attempt to inflict bodily harm. Oxygen cannula taken away from resident. Three attempts were made to notify the resident's daughter. Local Police notified; Physician informed of resident's behavior and suicidal threats. Physician ordered resident be sent out to the hospital. Police arrived and spoke to the resident. Resident stated I'll kill myself if I get a chance. Officer stated he was now going to Baker Act the resident and EMS was called, resident was transported via stretcher to the hospital. Review of the Census List for the resident documented the resident was admitted on [DATE] at 5:29 p.m. into a room located in the rehabilitation section, in a newer section of the facility. The room had the capacity to house two residents. Dated 02/22/2019 to 04/04/2019 the resident had two room changes which were also located in the rehabilitation section of the facility. Upon return to the facility on [DATE], the resident was placed in a room located in the older section of the facility which had the capacity to house three residents. Review of the Case Management records from the receiving hospital documented: dated 05/09/2019 at 9:58 a.m. Received consult Pt. (patient) has been cleared from BA (Baker Act) and clear to return to LTC (Long Term Care) facility (Oakhurst). At 11:09 Spoke with the Administrator of Oakhurst regarding Pt. (patient) d/c (discharge). The Administrator has refused to accept Pt. back stating he attacked one of the RNs (Registered Nurse). Empathized with the Administrator however explained statutes and laws governing kicking Pt.'s out of the LTC facility, explained Pt. was never admitted and has been d/ced (discharged ) medically so any social or behavioral issues with Pt. at the facility need to be addressed with Pt., his family and CMS/AHCA (Centers for Medicare and Medicaid, Agency for Health Care Administration) as the hospital is a crisis facility. The Administrator continues to refuse Pt. back despite knowledge of laws. Dated 05/10/2019 at 1:24 p.m. the daughter in law was attempting to make arrangements for the Pt. to discharge home. The daughter in law was not able to find in home care. He needs to make a second choice since Oakhurst will not take him back. Dated 5/10/2019 at 5:49 p.m. gave patient list of Rehab to make his choices. Dated 05/17/2019 at 12:15 p.m. Oakhurst confirmed Pt. has been declined by Oakhurst and they absolutely will not take Pt. back. Dated: 5/25/2019 at 2:11 Pt. is d/c today to a LTC facility. Review of the resident's facility medical record did not contain documentation of the needs of the resident that could not be met that would prevent the resident's return to the facility. A request was made to the Administrator on 06/05/2019 at 8:30 a.m. and on 06/06/2019 at approximately 8:30 a.m. with the DON for documentation of why the facility was not able to meet the resident's needs, and the efforts the facility made to assist with locating accommodations for the resident's placement. No documentation was provided. Review of the resident's facility profile dated 05/07/2019 revealed a [DIAGNOSES REDACTED]. An interview was conducted with the Case Manager of the recieving hospital on [DATE] at 10:29 AM. She confirmed the Baker Act was rescinded upon arrival at the hospital and evaluation in the Emergency Department. She confirmed the skilled nursing facility's refusal to allow the resident to return to the facility. She was unaware of any 30 day notification. The resident remained in the hospital without a transfer location from 5/07/2019 through 5/25/2019. Review of the resident's Nursing Home Transfer and Discharge Notice (30 day notice), (no date was documented) revealed the notice was incomplete. A request was made to the Administrator for a completed 30 day notice on 06/05/2019 at 8:30 a.m., and the DON on 06/06/2019 at approximately 8:30 a.m. The Administrator provided Page 2 of the document that contained signatures of the facility staff. Page 1 contained the Resident's last name, the name, address, telephone number, facility contact person, and telephone number. Reason for Discharge or Transfer was documented as: Your needs cannot be met in this facility. Brief explanation to support this action, (attach additional documentation if necessary): was left blank, no additional documentation was attached. The Date Notice is given: was blank. The Effective Date: was blank. The transfer or discharged location was blank. An interview was conducted with the facility Administrator on 6/06/2019 at 10:35 AM. The Administrator confirmed the facility documentation failed to reveal justification as to why the resident was not returned to his original room or wing. The resident was placed in a three bed room in the older portion of the facility, and not the two bed room in the rehabilitation section of the facility which is newer. The Administrator did not state why the resident had not been admitted back into his original room or wing. A request was made for documentation to show the resident's room prior to discharge to the hospital was not available on 05/07/2019, the date of his re-admission. No documentation was provided. 2. A review of the medical record for Resident #19 revealed the resident was discharged from the facility via Baker Act enforcement dated 4/09/2019. review of the resident's medical record revealed [REDACTED]. The Effective Date: was blank. An interview was conducted with the facility Administrator on 6/06/2019 at 10:40 AM. He confirmed the form was incomplete and did not provide the 30 day effective date of the notice.

Based on medical record review and interview, the facility failed to allow a resident to return to the facility in a comparative living environment (same room/wing) as when discharged under the Baker Act enforcement for 1 of 3 residents reviewed for readmission to the facility, Resident #17. The failure to allow the resident to return to his prior living arrangements (composite distinct part) resulted in harm, with his reaction causing the facility to discharge under a Baker Act enforcement. The findings included: Review of the facility medical record for Resident #17 revealed the resident had been discharged on [DATE], with readmission on 5/07/2019. He was then discharged the same day from the facility to an acute care hospital via Baker Act enforcement. Review of the facility nursing progress note dated 05/07/2019 at 10:02 p.m. documented Resident arrived at 7:30 p.m. via stretcher and EMS (Emergency Medical Services) was directed to North wing. Resident started yelling at the staff and using profanities upon arrival. I had a conversation with resident about new room and resident stated I'm not staying in here, take me back to my old room. Resident then tried to physical (sic) hit me in the face X2 (two times). Resident then picked up the wheelchair leg attachments and threw them at staff, Resident continued profanities. Resident then stated, it's hot in here, I can't breathe. Resident's nurse asked if she could put the oxygen on, resident stated, yeah, 'expletive'. Oxygen was placed within reach and resident put it on. Resident then proceeded to say 'I'm still not staying in here, I'll kill myself if I have to. Resident then took the oxygen tubing off and wrapped it around his neck twice and started to pull. Resident's nurse and myself both witnessed this attempt to inflict bodily harm. Oxygen cannula taken away from resident. Three attempts were made to notify the resident's daughter. Local Police notified; Physician informed of resident's behavior and suicidal threats. Physician ordered resident be sent out to the hospital. Police arrived and spoke to the resident. Resident stated I'll kill myself if I get a chance. Officer stated he was now going to Baker Act the resident and EMS was called, resident was transported via stretcher to the hospital. Review of the Census List for the resident documented the resident was admitted on [DATE] at 5:29 p.m. into a room located in the rehabilitation section, in a newer section of the facility. The room had the capacity to house two residents. Dated 02/22/2019 to 04/04/2019 the resident had two room changes which were also located in the rehabilitation section of the facility. Upon return to the facility on [DATE], the resident was placed in a room located in the older section of the facility which had the capacity to house three residents. A review of the resident's Care Plan initiated on 02/01/2019 revealed no indication of behavioral issues being identified prior to this event on 5/07/2019 when he returned from the hospital. The facility provided no justification as to what needs could not be met in the skilled nursing facility upon the resident's return, nor documented them on the transfer notice. Review of the resident's facility medical record did not contain documentation of the needs of the resident that could not be met that would prevent the resident's return to the facility. A request was made to the Administrator on 06/05/2019 at 8:30 a.m. and on 06/06/2019 at approximately 8:30 a.m. with the DON for documentation of why the facility was not able to meet the resident's needs, and the efforts the facility made to assist with locating accommodations for the resident's placement. No documentation was provided. An interview was conducted with the facility Administrator on 6/06/2019 at 10:35 AM. The Administrator confirmed the facility documentation failed to reveal justification as to why the resident was not returned to his original room or wing. The resident was placed in a three bed room in the older portion of the facility, and not the two bed room in the rehabilitation section of the facility which is newer. The Administrator did not state why the resident had not been admitted back into his original room or wing. A request was made for documentation to show the resident's room prior to discharge to the hospital was not available on 05/07/2019, the date of his re admission. No documentation was provided. An interview was conducted with the receiving hospital Case Manager on 6/5/2019 at 10:29 AM. She confirmed the Baker Act was rescinded upon arrival at the hospital and evaluation in the Emergency Department on 05/07/2019. She confirmed the skilled nursing facility's refusal to allow the resident to return to the facility. She was unaware of any 30-day notification. The resident remained in the hospital without a transfer location from 5/07/2019 through 5/25/2019. Review of Case Management records from the receiving hospital documented: dated 05/09/2019 at 9:58 a.m. Received consult Pt. (patient) has been cleared from BA (Baker Act) and clear to return to LTC (Long Term Care) facility (Oakhurst). At 11:09 Spoke with the Administrator of Oakhurst regarding Pt. d/c (discharge). The Administrator has refused to accept Pt. back stating he attacked one of the RNs (Registered Nurse). Empathized with the Administrator; however, explained statutes and laws governing kicking Pt.'s out of the LTC facility, explained Pt. was never admitted and has been d/ced medically so any social or behavioral issues with Pt. at the facility need to be addressed with Pt., his family and CMS/AHCA (Centers for Medicare and Medicaid, Agency for Health Care Administration) as the hospital is a crisis facility. The Administrator continues to refuse Pt. back despite knowledge of laws. Dated 05/10/2019 at 1:24 p.m. the daughter in law was attempting to make arrangements for the Pt. to discharge home. The daughter in law was not able to find in home care. He needs to make a second choice since Oakhurst will not take him back. Dated 5/10/2019 at 5:49 p.m. gave patient list of Rehab to make his choices. Dated 05/17/2019 at 12:15 p.m. Oakhurst confirmed Pt. has been declined by Oakhurst and they absolutely will not take Pt. back. Dated: 5/25/2019 at 2:11 Pt. is d/c today to a LTC facility. An interview was conducted with the facility Administrator on 6/06/2019 at 10:35 AM. The Administrator confirmed the facility documentation failed to reveal justification as to why the resident was not returned to his original room or wing. The resident was placed in a three-bed room in the older portion of the facility, and not the two-bed room in the rehabilitation section of the facility which is newer. The Administrator did not state why the resident had not been admitted back into his original room or wing. A request was made for documentation to show the resident's room prior to discharge to the hospital was not available on 05/07/2019, the date of his re-admission. No documentation was provided.

Based on record review, interview and review of facility policies and procedures and documentation, it was determined that the facility failed to ensure the advanced directives for 1 (#4) of 22 sampled residents were implemented. Resident #1 was identified to be a Full Code status according to the Social Service Assessment of [DATE], Physician order [REDACTED]. On [DATE], the facility nursing staff did not initiate CPR when resident #1 was found unresponsive. Nursing notes indicate that " found pt (patient) expired." The facility staff did not ensure that advance directives were initiated per physician order [REDACTED]. Failure of the the facility staff to implement Advanced Directives resulted in the finding of Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was found to be removed and the deficiency fully corrected on [DATE]. Findings: A review of the medical record revealed that resident #4 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The discharge date was identified as (deceased ) [DATE] Review of the Social Services/ Admission assessment from the original admission on [DATE] revealed the resident had a living will and was a full code. The authorization for emergency treatment was signed by resident on [DATE]. A review of the Social Services Assessment for readmitted d [DATE] revealed that the resident stated that she wanted to be full code. Review of the Physicians orders for [DATE] (dated [DATE]) and [DATE] identified, under the section advanced directive, CPR. Review of the Interdisciplinary Progress Notes dated [DATE] revealed a late entry was made at 1210 for [DATE]. The notes identified that an assessment was done, resident denied pain. The resident said she had a sore throat. Oral care was completed. Resident in Speech therapy. The patient had the nursing assistant wash her hair. Her sister was in the room visiting at 1430. The doctor was at the bedside at 1500. Sister at bedside and voiced she would be taking the patient to the follow up appointment for [MEDICAL CONDITION] on [DATE]. Review of the Interdisciplinary Progress Note dated [DATE], revealed the Licensed Practical Nurse (LPN) was called to the resident's room by the patient's family at 8:25 PM. She "found the patient had expired". Note documents that the nurse notified the physician at 8:30 PM and the family voiced relief that patient had passed on and was not longer suffering. The Funeral home arrived at 11:00PM to remove the body with the family at the bedside. On [DATE] at 1:23 PM, an interview with the Interim Director Of Nursing (DON) confirmed that resident #4 was a full code. The patient [MEDICAL CONDITION], but had expressed to staff she wanted to be a full code. The DON stated that in the care plan meeting ([DATE]) the resident again expressed she wanted to be a full code. Review of the Facility's Policy entitled Advanced Directives (policy Number CL-,[DATE]) reveals that under number 8 on page 3 of 6 it states: The Licensed Nurse ensures advanced directives are executed per physician's orders [REDACTED]. On [DATE] at 11:20 AM, an interview was conducted with the Interim DON. She stated that revealed on [DATE] at approximately 8:35 PM resident #4 was noted to be without vital signs by the registered nurse (RN) Supervisor and the Licensed Practical Nurse (LPN). The resident was assessed for vital signs by both nurses a this time. The resident had been observed leaving her bathroom and getting into bed about 15 minutes prior to the nurses being called to the room. The DON stated that both nurses failed to check the medical record for code status and failed to initiate CPR. The DON stated that the facility started an immediate investigation on [DATE]. During the investigation, the RN stated that she assumed resident #4 was a Do Not Resuscitate (DNR) because of [MEDICAL CONDITION]. The LPN stated she just " fell apart " . The investigation revealed that the LPN involved had entered the CPR status into the computer when the resident was admitted on [DATE]. Continued interview with the DON revealed both nurses were immediately suspended on [DATE] and fired for failing to initiate CPR on resident #4. The following Action Plan and Plan of Correction was put in place starting on [DATE] and ending on [DATE]. The Corrective Action continues to be monitored through the Facility's Quality Assurance Program. 1. Investigation started immediately on [DATE] by Director of Nursing. Statements obtained from Nurses and Certified Nursing Assistant (CNA). RN and LPN involved suspended immediately on [DATE] and terminated. Licenses of RN and LPN reported to State of Florida Board of Nursing. Federal Immediate report submitted to Agency for Health Care Administration (AHCA) as neglect on [DATE]. Florida Department of Children and Families- Adult Protective Services notified of neglect on [DATE]. 2. All Nursing staff (130 of 130 full time staff) in-serviced on the facility's policy and procedure for Advance Directives and Abuse/Neglect. Copy of inservice and sign in sheets obtained. 3. 100% audit of the facility's residents' advance directives was completed to ensure accuracy of code status. No problems identified with identification of code status. 4. Audit of all deceased residents' records for last 6 months conducted to ensure that code status was honored. No problems identified. 5. A Performance Improvement Committee Ad Hoc - CPR meeting held on [DATE] with department heads on corrective action which included review of the policies and procedures surrounding advanced directives to include Full Code and Do Not Resuscitate status. Location of status in medical record and how to identify. Review of difference between treating medical item i.e. broken hip and honoring Do Not Resuscitate order if in [MEDICAL CONDITION]. Identification of steps to take when patient appears to be in [MEDICAL CONDITION] i.e. identification of resident code status, calling 911 and physician. If starting CPR, continue to provide CPR until paramedics arrive. Facility will conduct mock codes/CPR drills every shift for three days and the every month for three months to identify opportunities for continued education. Facility will continue to review employee records with regard to CPR training to identify continued educational needs. Scheduled CPR classes for employees. Surveyor verified that CPR classes were scheduled. 6. Review of 22 medical records (residents #1 through #22 to include resident #4) revealed that the code status for each resident was accurate based on the advanced directives. 7. Mock Codes/CPR checks conducted on every shift for 3 days. Documentation provided and reviewed confirmed codes/drills for [DATE], [DATE] and [DATE]. Code/drill identified for [DATE] (as noted from Performance Improvement Committee Meeting of [DATE] to continue drills once a month for 3 additional months.) No problems noted. 8. Interview of staff (CNAs #1,#2, #3; LPNs #2, #3, #4) covering all shifts (7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts), revealed and confirmed that they had been in-serviced on the facility's policies and procedures for abuse/neglect and Advanced Directives, have sufficient knowledge of the need to honor a resident's Advance Directives; and are able to locate this information in the medical record. a) Interview on [DATE] at 11:10AM with LPN #4 revealed that she had been in-serviced and was able to verbalize the correct procedure for accurately identifying a advanced directives. She stated she was inserviced on abuse and neglect b) Interview on [DATE] at 2:20 PM with LPN #2, revealed that she was trained in advanced directives, where to identify code status in the chart and abuse/neglect. She stated she is a new employee and works with a mentor. She would report any problems to the supervisor immediately. c) Interview on [DATE] at 10:00AM LPN #3 revealed that she was in-serviced on abuse/neglect and advanced directives. She stated that she is aware of the location of the crash carts. She explained that for a code she would obtain a crash cart, and verify code status. She stated that the code status is located in the front of the chart and also there is a yellow paper stating DNR if resident is a DNR. (Interview consistent with facility policy) d.) Interview on [DATE] with CNA #1 revealed that she was able to identify where to locate code status in chart and that it is documented on CNA care card. She verified she was inserviced on abuse/neglect and advanced directives. e.) Interview on [DATE] at 9:15AM with CNA #3 revealed that she was able to verbalize which of her residents were full codes. However, she would check the residents' charts to verify code status. She verified that she was inserviced on abuse/neglect and advanced directives. f.) Interview on [DATE] at 10:15AM with CNA #2 revealed that the facility is conducting mock codes. She stated that she would call the nurse for help in an emergency. She stated that code status is noted on the front of the medical chart and the CNA care cards. She verified she was inserviced on abuse/neglect 9.) Staffing coordinator ensures a Nurse with current CPR is on every shift. 10) Interview on [DATE] at 9:50 AM with resident #3 revealed that she has Advanced Directives in place and that she is a Full code. Record review revealed that a Full Code status (to be resuscitated) was in place in medical record. 12.) Interview on [DATE] at 10:25 AM with resident #1 revealed that she requested CPR. Record review verified that the medical record documented Full code status. 13.) Interview on [DATE] at 10:30AM with resident #2 revealed that she wanted CPR. Review of the medical record verified documentation of full code status. 14.) interview with resident #22 revealed that she has advanced directives. Review of the medical record confirmed advanced directives were in place. 15.) Facility maintains an ongoing audit of deceased residents to ensure that code status is honored. 16.) Code status/advanced directives and CPR have been added to the Facility's Quality Assurance program for ongoing monitoring.

Based on record review, interview and review of facility policies and procedures and documentation, it was determined that the facility failed to implement thier policies and procedures to prevent neglect by failing to ensure that nursing staff implemented the advanced directives for 1 (#4) of 22 sampled residents. Resident #1 was identified to be a Full Code status according to the Social Service Assessment of [DATE], Physician order [REDACTED]. On [DATE], the facility nursing staff did not initiate CPR when resident #1 was found unresponsive. Nursing notes indicate that " found pt (patient) expired." The facility staff did not ensure that advance directives were initiated per physician order [REDACTED]. Failure of the the facility staff to implement policies and procedures to prevent neglect by failing to eusure Advanced Directives were followed resulted in the finding of Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was found to be removed and the deficiency fully corrected on [DATE]. Findings: A review of the medical record revealed that resident #4 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The discharge date was identified as (deceased ) [DATE] Review of the Social Services/ Admission assessment from the original admission on [DATE] revealed the resident had a living will and was a full code. The authorization for emergency treatment was signed by resident on [DATE]. A review of the Social Services Assessment for readmitted d [DATE] revealed that the resident stated that she wanted to be full code. Review of the Physicians orders for [DATE] (dated [DATE]) and [DATE] identified, under the section advanced directive, CPR. Review of the Interdisciplinary Progress Notes dated [DATE] revealed a late entry was made at 1210 for [DATE]. The notes identified that an assessment was done, resident denied pain. The resident said she had a sore throat. Oral care was completed. Resident in Speech therapy. The patient had the nursing assistant wash her hair. Her sister was in the room visiting at 1430. The doctor was at the bedside at 1500. Sister at bedside and voiced she would be taking the patient to the follow up appointment for [MEDICAL CONDITION] on [DATE]. Review of the Interdisciplinary Progress Note dated [DATE], revealed the Licensed Practical Nurse (LPN) was called to the resident's room by the patient's family at 8:25 PM. She "found the patient had expired". Note documents that the nurse notified the physician at 8:30 PM and the family voiced relief that patient had passed on and was not longer suffering. The Funeral home arrived at 11:00PM to remove the body with the family at the bedside. On [DATE] at 1:23 PM, an interview with the Interim Director Of Nursing (DON) confirmed that resident #4 was a full code. The patient [MEDICAL CONDITION], but had expressed to staff she wanted to be a full code. The DON stated that in the care plan meeting ([DATE]) the resident again expressed she wanted to be a full code. Review of the Facility's Policy entitled Advanced Directives (policy Number CL-,[DATE]) reveals that under number 8 on page 3 of 6 it states: The Licensed Nurse ensures advanced directives are executed per physician's orders [REDACTED]. Review of the facility's policy and procedure entitled Abuse & Neglect Prohibition Program dated Janaury 2008 defines neglect as "the withholding of goods and services that are necessary with resulting physicial harm or pain or mental anguish." Signs and symptoms listed in this document include, but are not limited to: Withholding care and Denial or delay in medical care. On [DATE] at 11:20 AM, an interview was conducted with the Interim DON. She stated that revealed on [DATE] at approximately 8:35 PM resident #4 was noted to be without vital signs by the registered nurse (RN) Supervisor and the Licensed Practical Nurse (LPN). The resident was assessed for vital signs by both nurses a this time. The resident had been observed leaving her bathroom and getting into bed about 15 minutes prior to the nurses being called to the room. The DON stated that both nurses failed to check the medical record for code status and failed to initiate CPR. The DON stated that the facility started an immediate investigation on [DATE]. During the investigation, the RN stated that she assumed resident #4 was a Do Not Resuscitate (DNR) because of [MEDICAL CONDITION]. The LPN stated she just " fell apart " . The investigation revealed that the LPN involved had entered the CPR status into the computer when the resident was admitted on [DATE]. Continued interview with the DON revealed both nurses were immediately suspended on [DATE] and fired for failing to initiate CPR on resident #4. The following Action Plan and Plan of Correction was put in place starting on [DATE] and ending on [DATE]. The Corrective Action continues to be monitored through the Facility's Quality Assurance Program. 1. Investigation started immediately on [DATE] by Director of Nursing. Statements obtained from Nurses and Certified Nursing Assistant (CNA). RN and LPN involved suspended immediately on [DATE] and terminated. Licenses of RN and LPN reported to State of Florida Board of Nursing. Federal Immediate report submitted to Agency for Health Care Administration (AHCA) as neglect on [DATE]. Florida Department of Children and Families- Adult Protective Services notified of neglect on [DATE]. 2. All Nursing staff (130 of 130 full time staff) in-serviced on the facility's policy and procedure for Advance Directives and Abuse/Neglect. Copy of inservice and sign in sheets obtained. 3. 100% audit of the facility's residents' advance directives was completed to ensure accuracy of code status. No problems identified with identification of code status. 4. Audit of all deceased residents' records for last 6 months conducted to ensure that code status was honored. No problems identified. 5. A Performance Improvement Committee Ad Hoc - CPR meeting held on [DATE] with department heads on corrective action which included review of the policies and procedures surrounding advanced directives to include Full Code and Do Not Resuscitate status. Location of status in medical record and how to identify. Review of difference between treating medical item i.e. broken hip and honoring Do Not Resuscitate order if in [MEDICAL CONDITION]. Identification of steps to take when patient appears to be in [MEDICAL CONDITION] i.e. identification of resident code status, calling 911 and physician. If starting CPR, continue to provide CPR until paramedics arrive. Facility will conduct mock codes/CPR drills every shift for three days and the every month for three months to identify opportunities for continued education. Facility will continue to review employee records with regard to CPR training to identify continued educational needs. Scheduled CPR classes for employees. Surveyor verified that CPR classes were scheduled. 6. Review of 22 medical records (residents #1 through #22 to include resident #4) revealed that the code status for each resident was accurate based on the advanced directives. 7. Mock Codes/CPR checks conducted on every shift for 3 days. Documentation provided and reviewed confirmed codes/drills for [DATE], [DATE] and [DATE]. Code/drill identified for [DATE] (as noted from Performance Improvement Committee Meeting of [DATE] to continue drills once a month for 3 additional months.) No problems noted. 8. Interview of staff (CNAs #1,#2, #3; LPNs #2, #3, #4) covering all shifts (7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts), revealed and confirmed that they had been in-serviced on the facility's policies and procedures for abuse/neglect and Advanced Directives, have sufficient knowledge of the need to honor a resident's Advance Directives; and are able to locate this information in the medical record. a) Interview on [DATE] at 11:10AM with LPN #4 revealed that she had been in-serviced and was able to verbalize the correct procedure for accurately identifying a advanced directives. She stated she was inserviced on abuse and neglect b) Interview on [DATE] at 2:20 PM with LPN #2, revealed that she was trained in advanced directives, where to identify code status in the chart and abuse/neglect. She stated she is a new employee and works with a mentor. She would report any problems to the supervisor immediately. c) Interview on [DATE] at 10:00AM LPN #3 revealed that she was in-serviced on abuse/neglect and advanced directives. She stated that she is aware of the location of the crash carts. She explained that for a code she would obtain a crash cart, and verify code status. She stated that the code status is located in the front of the chart and also there is a yellow paper stating DNR if resident is a DNR. (Interview consistent with facility policy) d.) Interview on [DATE] with CNA #1 revealed that she was able to identify where to locate code status in chart and that it is documented on CNA care card. She verified she was inserviced on abuse/neglect and advanced directives. e.) Interview on [DATE] at 9:15AM with CNA #3 revealed that she was able to verbalize which of her residents were full codes. However, she would check the residents' charts to verify code status. She verified that she was inserviced on abuse/neglect and advanced directives. f.) Interview on [DATE] at 10:15AM with CNA #2 revealed that the facility is conducting mock codes. She stated that she would call the nurse for help in an emergency. She stated that code status is noted on the front of the medical chart and the CNA care cards. She verified she was inserviced on abuse/neglect 9.) Staffing coordinator ensures a Nurse with current CPR is on every shift. 10) Interview on [DATE] at 9:50 AM with resident #3 revealed that she has Advanced Directives in place and that she is a Full code. Record review revealed that a Full Code status (to be resuscitated) was in place in medical record. 12.) Interview on [DATE] at 10:25 AM with resident #1 revealed that she requested CPR. Record review verified that the medical record documented Full code status. 13.) Interview on [DATE] at 10:30AM with resident #2 revealed that she wanted CPR. Review of the medical record verified documentation of full code status. 14.) interview with resident #22 revealed that she has advanced directives. Review of the medical record confirmed advanced directives were in place. 15.) Facility maintains an ongoing audit of deceased residents to ensure that code status is honored. 16.) Code status/advanced directives and CPR have been added to the Facility's Quality Assurance program for ongoing monitoring.

Based on interview and record review, facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with physicians' orders to provide antibiotic therapy for 1 (resident #1) of 4 residents sampled who entered the facility with [MEDICAL CONDITION]-Sensitive Staphylococcus Aureus (MSSA) bacteremia. The resident was without antibiotic therapy from 02/02/2012 until discharge to the hospital on [DATE] (26 days). FINDINGS: Record review for resident #1 revealed that he was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of hospital Discharge Plan dated 2/2/2012 for resident #1 revealed that left upper arm surgical incisions with staples and dry gauze dressing (wrapped with kerlix). Left upper arm wound appeared to be clean, dry, and intact. Physicians ' order noted on Discharge Plan dated 2/2/2012 appears as " [MEDICATION NAME] INJ [MEDICATION NAME] D5W 50ML 2 GM in [MEDICATION NAME] 5% IN WATER 50 ML INFUSE OVER 30 MINUTES MD DOES NOT WANT CONT INFUSION 2/2 IV ACCESS ISSUES IVPB (intravenous piggy back) Q4H " Hospital Discharge Plan dated 2/2/2012 revealed that resident #1 is status [REDACTED]. Resident #1 ' s old right tunneled catheter was removed on 1/27/2012, and a new left chest tunneled [MEDICAL TREATMENT] (HD) catheter was placed on 1/30/2012 since resident #1 is to undergo placement of a AV fistula on the right arm. A PICC line was inserted on 1/31/2012 for administration of continuous IV [MEDICATION NAME] infusion. Hospital Nurses' Note dated 1/26/2012 for resident #1 revealed that [MEDICATION NAME] was infusing at 21ml/hour which was a continuous infusion. Hospital list of Active Inpatient Medications dated 1/26/2012 for resident #1 included [MEDICATION NAME] 12 grams in normal saline 500ml at 21ml/hour (intravenous piggy back) IVPB. Hospital Internal Medicine Progress Note dated 1/26/2012 revealed that resident #1 presented to the hospital with infected old left upper extremity AV fistula and fistula was surgically excised on 1/26/2012 by Vascular Surgery. Resident #1 was on [MEDICATION NAME] initially, now switched to [MEDICATION NAME] after blood cultures speciated MSSA. Right tunneled [MEDICAL TREATMENT] (HD) catheter to be removed on 1/27/2012 after [MEDICAL TREATMENT]. Blood cultures were to be repeated and place new tunneled catheter once culture proven clear. Resident #1 was noted having difficulty maintaining peripheral IV access. WBC result was noted at 20.29k/cmm. [MEDICATION NAME] will be continued, but not as continuous infusion; instead, will start [MEDICATION NAME] 2g IVPB (intravenous piggyback) every 4 hours intermittent dosing, due to difficult peripheral venous access, and limited ability to administer other meds, blood products, etc., if needed, while a continuous infusion is running. Hospital Internal Medicine Attending Noted dated 1/28/2012 for resident #1 noted that [MEDICATION NAME] is being dosed intermittently (2gm every 4 hours) rather than as continuous infusion, due to difficult venous access, and limited ability to administer other meds, blood products, etc., if needed, while a continuous infusion is running. Noted that left upper extremity is wrapped in ace wrap, but wound appeared to be clean, dry, and intact per vascular surgeons note. Hospital Nurses' Note dated 1/30/2012 revealed that resident #1 had a left arm fistula that was removed. Area has dressing intact with Penrose drain. Right chest Tessio catheter was also removed and dry dressing is covering site. Hospital list of Active Inpatient Medications dated 1/31/2012 for resident #1 included [MEDICATION NAME] 2 grams in [MEDICATION NAME] 5% 50ml infuse over 30 minutes, MD does not want continuous infusion 2/2 IV access issues. Hospital Nephrology Note dated 1/31/2012 revealed that resident #1 grew MSSA from his [MEDICAL TREATMENT] catheter. As outlined by Infectious Disease service, resident #1 will need 4 weeks of [MEDICATION NAME] therapy from the last negative culture. Hospital lab results dated 1/27/2012 for resident #1 revealed white blood count (WBC) high at 13.35k/cmm. WBC low reference range of 4.6k/cmm and high of 10.8k/cmm. WBC results dated 1/31/2012 high at 12.38k/cmm. WBC results on day of hospital discharge date d 2/2/2012 noted at 8.90k/cmm. WBC results dated 2/6/2012 noted at 11.0k/cmm. Review for resident #1 of the nursing home's list of all physicians' orders dated 2/2/2012 and signed by the physician on 2/6/2012 revealed [MEDICATION NAME] Sodium 2 gm Solution Reconstituted Intravenous (IV) - Daily Everyday: infuse over 30 minutes. IVPB (intravenous piggyback) every 4 hours. MD does not want cont infusion 2/2 IV access issues. Other treatment orders dated 2/2/2012 notes AV fistula/graft location as left upper extremity. Monitor AV fistula/graft site for signs/symptoms (s/s) of infection. Notify physician if s/s of infection are observed. Orders Noted By: nurses ' signature is unreadable. Order not noted on Treatment Administration Record (TAR). Continued review of all physicians' orders for resident #1 dated 2/4/2012 and signed by physician on 2/6/2012 revealed an order to apply dry sterile dressing to left upper arm incision site daily until staples are removed. Facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility's History and Physical dated 2/6/2012 for resident #1 revealed that the physician noted [DIAGNOSES REDACTED]. Physicians' plan noted to continue admission orders [REDACTED] Review of the Nurse's Note dated 2/4/2012 revealed that the nurse completed a full body assessment for resident #1 and noted a surgical incision to left upper extremity with sutures, PICC site, [MEDICAL TREATMENT] port, and surgical incision to left neck region. No signs/symptoms (s/s) of infection were noted at this time. Continued review of the Nurse's Note dated 2/8/2012 revealed that resident #1 was back from [MEDICAL TREATMENT] and the nurse dressed wound per order. No s/s of infection noted. Nurses' Note dated 2/24/2012 revealed that resident #1 spent the day at [MEDICAL TREATMENT]. Nurse observed clear, odorless fluid leaking from left upper arm wound site. The note indicated the area appeared swollen, but not warm. Resident #1 denied pain in area. Nurse redressed the wound site and informed the night nurse. Nurses' Note dated 2/27/2012 revealed that resident #1 spent the day at [MEDICAL TREATMENT]. The nurse documented that she changed dressing to the left upper extremity and noticed a white thick fluid from upper arm wound. The wife stated she will have the VA hospital look at arm. No other interventions were noted. Nurses' Note dated 2/28/2012 revealed that resident #1 was taken to the VA hospital by wife and did not return to the facility. Review of the 24 Hour Chart Audit for resident #,1 placed in front of " Physician order [REDACTED]. Review of Physical Therapy Evaluation dated 2/3/2012 for resident #1 revealed therapy noted that the PICC line to the right upper extremity was for antibiotic therapy until 2/25/2012. The evaluation was signed by physician and dated 2/6/2012 certifying the need for these services furnished under this plan of treatment while under his care. Review of [MEDICAL TREATMENT] Communication forms for resident #1 revealed communication forms located in medical record for resident #1. The record included 2 forms undated and 2 forms for 2/13/2012 and 2/27/2012. The facility obtained communication forms from the [MEDICAL TREATMENT] center via fax dated 4/2/2012 for 2/20, 22, 24, 27/2012. No notation of s/s of infection were noted on the [MEDICAL TREATMENT] forms. During interview on 3/29/2012 at 1:45 PM, the Minimum Data Set (MDS) assessments for resident #1 were requested from the MDS Coordinator. She revealed that she completed 3 assessments for resident #1 which included a 5 day admission MDS dated [DATE], a 14day MDS dated [DATE], and a Discharge MDS. Review of Admission MDS assessment dated [DATE] revealed resident #1 coded as not having any unhealed pressure ulcers at Stage I or higher, no surgical wounds present and no surgical wound care needed. Resident #1 was coded as not having any other skin issues. Continued review of hospital Discharge Plan DCFS 3008 dated 2/2/2012, sent to the facility, revealed physicians' order for decubitus care for a perianal Stage II to apply Aloe-Vesta ([MEDICATION NAME]) four times a day as needed, irritations (rash) on bilateral buttocks excoriated with skin tears, and left upper arm surgical incisions with staples that required the facility to apply dry gauze dressing and wrap with kerlix. Review of Care Plan for resident #1 addressing [MEDICAL TREATMENT] dated 2/4/2012 with goal of no infection at access site revealed interventions to be inappropriate. Interventions were noted for use of arteriovenous (AV) fistula/graft. Per hospital documentation, left upper extremity AV fistula was surgically removed on 1/26/2012. Left chest area tunneled [MEDICAL TREATMENT] catheter was inserted on 1/30/2012 and used for [MEDICAL TREATMENT]. Review of the nursing home's Interdisciplinary Care Plan Problem List dated 2/16/2012 revealed a need/problem/concern related to Antibiotic Therapy. No care plan addressing Antibiotic Therapy was noted in resident #1's medical record. Review of Interdisciplinary Attendance Log dated 2/16/2012 for resident #1 revealed nursing, social services, activities, and family participated. Review of facility policies and procedures relating to intravenous medication administration and intravenous access device flushes were reviewed. Procedure addresses to verify physician order. Interview on 3/29/2012 at 2:00 PM with the Registered Nurse (RN), Weekend Supervisor revealed that he "cannot remember that particular situation " referring to being questioned by the family about the IV antibiotic order status. Interview on 4/9/2012 at 5:30 PM with the wife and daughter of resident #1 revealed that they both informed the weekend supervisor that resident #1 was supposed to be on antibiotics and were told that he would check with the doctor. Continued interview at this time with the wife and daughter of resident #1 revealed that wife requested that resident #1 be sent to the hospital on [DATE] because he was very listless, confused, and " there was something wrong, he was sick " . She was told by the nurse that she had to pay $100 before the resident could be be transported. She did not have the money and said she would be back in the morning and take her husband to the emergency room at the VA hospital in Gainesville. They did not know why the nurse would not call 911 to be taken by emergency medical services. Interview on 3/29/2012 at 2:20 PM with Director of Nursing (DON) and RN, Unit Manager for Sub-acute Unit, where resident #1 resided, revealed that they did not know if the doctor was called after nurse noted drainage on 2/24/2012. Continued review of the medical record revealed that resident #1 was discharged from the facility on 2/28/2012 to the VA hospital in Gainesville. Review of VA hospital records revealed that resident #1 was admitted to the hospital on [DATE] for lethargy and malaise which started 3-5 days prior to admission. Admission [DIAGNOSES REDACTED].#1 with mental status changes. Facility Interdisciplinary Health Education Record undated reveals that resident #1 was alert and verbal during stay in nursing home. That resident #1 was previously admitted to the same hospital and was found to have a bacteremia with MSSA. Resident #1 received antibiotic therapy during his previous stay and on discharge date [DATE] blood cultures results noted no bacteria growth in 5 days. Per hospital discharge summary on 2/2/2012, and notes during that stay, resident #1 was intended to continue antibiotic infusion through 2/25/ . Per hospital physician discussion with the nursing home, antibiotics were not administered. On 2/28/2012, hospital admission, cultures were drawn and revealed MSSA again. Antibiotic therapy was started and the plan was to continue for 6 weeks.

Based on interview and record review, facility failed to ensure that residents are free of any significant medication errors for 1 (resident #1) of 4 residents sampled. Resident #1 was not administered physician ordered antibiotic therapy for [MEDICAL CONDITION] Sensitive Staphylococcus Aureus (MSSA) bacteremia from 02/02/2012 until discharge to the hospital on [DATE] (26 days). FINDINGS: Record review for resident #1 revealed that he was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of hospital Discharge Plan dated 2/2/2012 for resident #1 revealed that left upper arm surgical incisions with staples and dry gauze dressing (wrapped with kerlix). Left upper arm wound appeared to be clean, dry, and intact. Physicians' order noted on Discharge Plan dated 2/2/2012 appears as " [MEDICATION NAME] INJ [MEDICATION NAME] D5W 50ML 2 GM in [MEDICATION NAME] 5% IN WATER 50 ML INFUSE OVER 30 MINUTES MD DOES NOT WANT CONT INFUSION 2/2 IV ACCESS ISSUES IVPB (intravenous piggy back) Q4H " Hospital Discharge Plan dated 2/2/2012 revealed that resident #1 is status [REDACTED]. Resident #1 ' s old right tunneled catheter was removed on 1/27/2012, and a new left chest tunneled [MEDICAL TREATMENT] (HD) catheter was placed on 1/30/2012 since resident #1 is to undergo placement of a AV fistula on the right arm. A PICC line was inserted on 1/31/2012 for administration of continuous IV [MEDICATION NAME] infusion. Hospital Internal Medicine Progress Note dated 1/26/2012 revealed that resident #1 presented to the hospital with infected old left upper extremity AV fistula and fistula was surgically excised on 1/26/2012 by Vascular Surgery. Resident #1 was on [MEDICATION NAME] initially, now switched to [MEDICATION NAME] after blood cultures speciated MSSA. Right tunneled [MEDICAL TREATMENT] (HD) catheter to be removed on 1/27/2012 after [MEDICAL TREATMENT]. Blood cultures were to be repeated and place new tunneled catheter once culture proven clear. Resident #1 was noted having difficulty maintaining peripheral IV access. WBC result was noted at 20.29k/cmm. [MEDICATION NAME] will be continued, but not as continuous infusion; instead, will start [MEDICATION NAME] 2g IVPB (intravenous piggyback) every 4 hours intermittent dosing, due to difficult peripheral venous access, and limited ability to administer other meds, blood products, etc., if needed, while a continuous infusion is running. Hospital Internal Medicine Attending Noted dated 1/28/2012 for resident #1 noted that [MEDICATION NAME] is being dosed intermittently (2gm every 4 hours) rather than as continuous infusion, due to difficult venous access, and limited ability to administer other meds, blood products, etc., if needed, while a continuous infusion is running. Noted that left upper extremity is wrapped in ace wrap, but wound appeared to be clean, dry, and intact per vascular surgeons note. Hospital Nurses' Note dated 1/30/2012 revealed that resident #1 had a left arm fistula that was removed. Area has dressing intact with Penrose drain. Right chest Tessio catheter was also removed and dry dressing is covering site. Hospital list of Active Inpatient Medications dated 1/31/2012 for resident #1 included [MEDICATION NAME] 2 grams in [MEDICATION NAME] 5% 50ml infuse over 30 minutes, MD does not want continuous infusion 2/2 IV access issues. Hospital Nephrology Note dated 1/31/2012 revealed that resident #1 grew MSSA from his [MEDICAL TREATMENT] catheter. As outlined by Infectious Disease service, resident #1 will need 4 weeks of [MEDICATION NAME] therapy from the last negative culture. Hospital lab results dated 1/27/2012 for resident #1 revealed white blood count (WBC) high at 13.35k/cmm. WBC low reference range of 4.6k/cmm and high of 10.8k/cmm. WBC results dated 1/31/2012 high at 12.38k/cmm. WBC results on day of hospital discharge date d 2/2/2012 noted at 8.90k/cmm. WBC results dated 2/6/2012 noted at 11.0k/cmm. Review for resident #1 of the nursing home's list of all physicians' orders dated 2/2/2012 and signed by the physician on 2/6/2012 revealed [MEDICATION NAME] Sodium 2 gm Solution Reconstituted Intravenous (IV) - Daily Everyday: infuse over 30 minutes. IVPB (intravenous piggyback) every 4 hours. MD does not want cont infusion 2/2 IV access issues. Other treatment orders dated 2/2/2012 notes AV fistula/graft location as left upper extremity. Monitor AV fistula/graft site for signs/symptoms (s/s) of infection. Notify physician if s/s of infection are observed. Orders Noted By: nurses ' signature is unreadable. Order not noted on Treatment Administration Record (TAR). Continued review of all physicians' orders for resident #1 dated 2/4/2012 and signed by physician on 2/6/2012 revealed an order to apply dry sterile dressing to left upper arm incision site daily until staples are removed. Facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility's History and Physical dated 2/6/2012 for resident #1 revealed that the physician noted [DIAGNOSES REDACTED]. Physicians' plan noted to continue admission orders [REDACTED] Review of the Nurse's Note dated 2/4/2012 revealed that the nurse completed a full body assessment for resident #1 and noted a surgical incision to left upper extremity with sutures, PICC site, [MEDICAL TREATMENT] port, and surgical incision to left neck region. No signs/symptoms (s/s) of infection were noted at this time. Review of Physical Therapy Evaluation dated 2/3/2012 for resident #1 revealed therapy noted that the PICC line to the right upper extremity was for antibiotic therapy until 2/25/2012. The evaluation was signed by physician and dated 2/6/2012 certifying the need for these services furnished under this plan of treatment while under his care. Review of the nursing home's Interdisciplinary Care Plan Problem List dated 2/16/2012 revealed a need/problem/concern related to Antibiotic Therapy. No care plan addressing Antibiotic Therapy was noted in resident #1's medical record. Review of Interdisciplinary Attendance Log dated 2/16/2012 for resident #1 revealed nursing, social services, activities, and family participated. Review of facility policies and procedures relating to intravenous medication administration and intravenous access device flushes were reviewed. Procedure addresses to verify physician order. Interview on 3/29/2012 at 2:00 PM with the Registered Nurse (RN), Weekend Supervisor revealed that he "cannot remember that particular situation " referring to being questioned by the family about the IV antibiotic order status. Interview on 4/9/2012 at 5:30 PM with the wife and daughter of resident #1 revealed that they both informed the weekend supervisor that resident #1 was supposed to be on antibiotics and were told that he would check with the doctor. Continued interview at this time with the wife and daughter of resident #1 revealed that wife requested that resident #1 be sent to the hospital on [DATE] because he was very listless, confused, and " there was something wrong, he was sick " . She was told by the nurse that she had to pay $100 before the resident could be be transported. She did not have the money and said she would be back in the morning and take her husband to the emergency room at the VA hospital in Gainesville. They did not know why the nurse would not call 911 to be taken by emergency medical services. Continued review of the medical record revealed that resident #1 was discharged from the facility on 2/28/2012 to the VA hospital in Gainesville. Review of VA hospital records revealed that resident #1 was admitted to the hospital on [DATE] for lethargy and malaise which started 3-5 days prior to admission. Admission [DIAGNOSES REDACTED].#1 with mental status changes. Facility Interdisciplinary Health Education Record undated reveals that resident #1 was alert and verbal during stay in nursing home. That resident #1 was previously admitted to the same hospital and was found to have a bacteremia with MSSA. Resident #1 received antibiotic therapy during his previous stay and on discharge date [DATE] blood cultures results noted no bacteria growth in 5 days. Per hospital discharge summary on 2/2/2012, and notes during that stay, resident #1 was intended to continue antibiotic infusion through 2/25/ . Per hospital physician discussion with the nursing home, antibiotics were not administered. On 2/28/2012, hospital admission, cultures were drawn and revealed MSSA again. Antibiotic therapy was started and the plan was to continue for 6 weeks.