Every finding on record at Aviata at Bradenton

Based on record review and interviews, the facility failed to ensure documentation was complete and accurate related to physician orders for catheter care for one (Resident #1) out of five residents reviewed. Findings included: A review of Resident #1's admission record revealed an original admission date of 9/23/25 and re-admission date of 2/28/26, with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, personal history of urinary (tract) infections, encounter for fitting and adjustment of urinary device, and other neuromuscular dysfunction of bladder. A review of Resident #1's active, completed and discontinued physician orders from 1/2026 to 3/2026 revealed the following: BEHAVIORS - MONITOR FOR THE FOLLOWING: . Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. every shift, with a start date of 3/1/26. Catheter Care as Needed as needed, with a start date of 3/1/26. Catheter Care as Needed every shift, with a start date of 3/1/26. CHANGE FOLEY one time only until 1/29/26 23:59 [11:58 p.m.], with a start and end date of 1/29/26. EMPTY FOLEY BAG RECORD OUTPUT every shift, with a start date of 3/3/26. Foley Catheter (16F [French] 10CC [cubic centimeter] BALLOON), with an order date of 2/28/26. A review of Resident #1's care plan revealed the following: [Resident #1] has Indwelling Catheter: Neurogenic bladder Date Initiated: 10/06/2025, with interventions to include, CATHETER: Cath [catheter] care as ordered. CATHETER: The resident has (foley Catheter). Monitor for s/sx [signs and symptoms] of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD [medical doctor] for s/sx UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp [temperature], Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A review of Resident #1's medication administration record (MAR) revealed the following:January 2026 the following order was documented, Change Foley Catheter 16F/10cc [cubic centimeter] on 15th of every month and as needed every night shift starting on the 15th and ending on the 15th every month for Catheter Care -Start Date- 01/15/2026 1900 [7:00 p.m.]-D/C [discontinue] Date- 02/27/2026 1122. Further review of the MAR revealed a blank space on 1/15/26 for this order. February 2026, under behavior monitoring documentation, entries on all days were marked as, No, except for 2/4/26 and 2/11/26 were marked as, Yes. A review of the progress notes on the days marked, No, for behaviors did not indicate the behavior Resident #1 was having. Further review of the MAR in February 2026 showed on 2/15/26, Staff B, Licensed Practical Nurse (LPN) changed Resident #1's catheter after it was changed on 2/12/26 by Staff A, LPN, which was also marked on the MAR.March 2026, the order for, EMPTY FOLEY BAG RECORD OUTPUT every shift showed, y was documented on 3/6/26 (day shift), 3/7/26 (night shift), and 3/9/26 (night shift). Further review of the order showed on 3/18/26 it was blank for the day shift and, NA, [not applicable] was documented for the night shift. A review of Resident #1's progress notes showed the following:1/29/26, Resident Foley catheter was changed and tolerated well the insertion. clear light yellow urine output noted.2/12/26, Change Foley Catheter 16F/10cc on 15th of every month and as needed as needed for catheter care.2/13/26, Change Foley Catheter 16F/10cc on 15th of every month and as needed as needed for catheter care PRN [as needed] Administration was: Effective. A review of Resident #1's progress notes dated 1/15/26 showed no documentation related to changing Resident #1's catheter. The resident had orders to change the catheter every 15th of the month and as needed. Further review of Resident #1's progress showed no documentation related to the rationale for changing the catheter on 2/12/26, then changed again on 2/15/26. On 3/23/26 at 1:10 p.m., an interview was conducted with the Director of Nursing (DON). He said the facility staff did not previously document a resident's input and output. He stated, There was an incident with [Resident #1], and the nursing staff are supposed to document the urine output based on the physician order. He confirmed there is a physician order, and the output should be documented in the MAR. On 3/23/26 at 1:20 p.m., a telephone interview was conducted with Staff A, LPN. She said catheter care included documenting the resident's output on a daily. Staff A, LPN confirmed she had changed Resident #1's catheter but could not recall the date of when she changed it or the reason why it was changed. She said she did not have the computer in front of her and could not confirm the information asked. On 3/23/26 at 1:31 p.m., a telephone interview was conducted with Staff B, LPN. She initially said she did not change Resident #1's catheter as it was not on her shift assignment. A review of the MAR in 2/2026 was conducted while on the telephone with Staff B, LPN, who then said she recalled changing it. Staff B, LPN said another nurse was present as the resident required two staff members to assist with care. She said she could not recall why Resident #1's catheter was changed on 2/12/26, then again on 2/15/26. On 3/23/26 at 3:37 p.m., a follow-up interview was conducted with the DON. He confirmed in the MAR on 3/6/26, 3/7/26, and 3/9/26, the y that was documented was incorrect. He stated the order is, Asking for amount of cc, not if it was emptied. He said if the output was not documented in the MAR or Treatment Administration Record (TAR), he expected it would be documented in a progress note. A review of the progress notes with the DON revealed there was no documentation on those dates. The DON said he was not sure what, NA, meant but it should not be documented. He stated the Order is pretty clear, and asked for urine output in ccs. He said staff were educated about what to document in the MAR. The DON confirmed Resident #1's catheter should have been changed on 1/15/26 if the order was for the 15th of every month. He said if it was not changed on 1/15/26, there should have been documentation, as to why not. He said he did not know why it was not changed on 1/15/26 and confirmed he reviewed the documentation which showed Resident #1's catheter was changed on 1/29/26. The DON said he knew it was changed on 1/29/26 from the progress note, but the documentation did not provide a reason for why it was completed that day. The DON stated on 2/15/26 he, Figured they followed the order. He stated he, Did not speculate on that. He confirmed the catheter was changed on 2/12/26 then changed again on 2/15/26 based on the MAR. He stated, If the nurse did not dig into why, or did not receive information in the nurse-to-nurse report, the nurse would not have known it was changed on 2/12/26. The DON said there had been confusion about the behavior monitoring order and staff would need to be re-educated. He said the order showed to indicate, Yes, if the resident had no behaviors and, No, if they had behaviors and the specific behavior should be documented in a progress note. He said under the previous company/ownership, the order allowed the staff to choose the behavior observed. He said he thought that was why staff continued to document, No, for behaviors. A review of the facility's policy titled Catheter Care, Urinary, with a revised date of 9/5/17, revealed the following, Procedure:Identify resident.Provide privacy and explain procedure.Assemble the following:Towel and wash clothSoapBasin of warm waterDisposable gloves Perform hand hygiene.Put on gloves.Remove catheter securement device while maintaining connection with drainage tube.Wash perineal area with soap and water from front to back.Rinse well and dry.Clean Catheter tubing with soap and water, starting close to urinary meatus, cleaning in circular motion along its length for about 4 inches, moving away from the body. Rinse well using the same motion.May use incontinent wipes in place of soap and water.Reattach catheter securement device.Return equipment to proper place. Perform hand hygiene. A review of the facility's policy titled Physician Orders, with a revised date of 3/3/21, revealed the following, ROUTINE ORDERS: . The order is transcribed to all appropriate areas of the electronic health record (eMar/eTAR) [electronic treatment administration record]. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record.

Based on observations, record review, interviews, and policy review, the facility failed to ensure kitchen sanitation requirements were met, due to kitchen walls had non-cleanable surfaces, and failed to ensure items in the kitchen pantry and walk-in refrigerator were dated, for one out of one walk-in refrigerators and one of one kitchen pantries.Findings Included:On 01/12/2026 at 10:15 AM, a kitchen tour was conducted with the District Manager of Dining, (DMD). The kitchen dishwasher was observed soiled with debris, build-up and corrosion on the motor and overhead hood of the dishwasher. The motor was observed with brown colored corrosion expanding from the base of the dishwasher motor. A white powdered material and white build-up was observed on the motor in various areas. The motor was observed with smudges. The metal counter next to the dishwasher was observed with corrosion on the legs of the counter. [NAME] pipes to the left of the dishwasher under the metal counter were observed with brown buildup near where one of the pipes entered a hole in the floor and surrounding areas. The floor under the dishwasher was observed with black, white, gray, and tan debris and build-up on in multiple locations. A small black tub was observed under the metal counter about half-way full of a transparent liquid. The wall behind the metal counter was observed in disrepair with holes in three locations.On 01/12/2026 at 10:20 AM, during a tour with the DMD of the kitchen chemical room, the outside wall of the chemical room was observed with a square hole in the bottom left corner where the wall met the floor, approximately 4 inches in size. The drywall of the hole was observed crumbling and the tile was missing and broken. The inside of the wall was visible. The chemical room revealed a faucet above a floor sink, closed, that actively leaked water. Live flying insects were observed in chemical room. The floor sink was observed discolored with tan and brown stains on the inside of the sink. The floor sink was observed with black streaks and build-up on, around, and in the floor sink.On 01/12/2026 at 10:38 AM, during a tour with the DMD of the kitchen freezer, a beige and light brown cake covered half of a cardboard plate it was on. The cake was wrapped in a plastic bag undated. The DMD confirmed the cake was undated.On 01/14/2026 at 12:03 PM, during a tour with the DMD of the kitchen pantry, a bag of brown sugar was observed wrapped in plastic and undated. About half of the contents remained. A clear bottle of a yellow food coloring was observed opened and undated. About half of the contents remained. The DMD confirmed the bag of brown sugar and the bottle of yellow food coloring had been opened and undated.On 01/14/2026 at 12:34 PM, during a tour with the DMD of the South Wing nourishment pantry, the refrigerator was observed with two thermometers that showed the refrigerator temperature was over 50 degrees. The temperature was confirmed by the DMD. In the refrigerator, there were unknown food items labeled with no resident names or room numbers. The DMD confirmed the unknown food items belonged to residents.During an interview on 01/12/2026 at 10:15 AM, the DMD stated having saw corrosion on the dishwasher's hood vent. The DMD stated having seen a hole in the lower left corner of the chemical room outside wall. The DMD attempted to turn off a faucet in the chemical room and stated the faucet had a leak and was unable to shut off the valve. The DMD stated not knowing the cleaning schedule of the kitchen. The DMD stated not knowing when and how often the kitchen had been cleaned. The DMD was unable to provide cleaning logs for the kitchen. The DMD stated the kitchen should have been cleaned and did not know the last time a deep cleaning had been performed on the kitchen.During an interview on 01/14/2026 at 11:35 AM the DMD stated the kitchen staff was responsible to ensure the kitchen was cleaned. The DMD stated there were undated food items in the walk-in refrigerator and freezer. The DMD stated not knowing why the refrigerator temperature in the South nourishment pantry room, was at 55 degrees. The DMD stated the food in the nourishment room refrigerator belonged to residents.During an interview on 01/14/2026 at 02:00 PM, Staff H Registered Nurse (RN), Unit Manager (UM) of the South wing, stated she was responsible for temperature log monitoring of the South wing nourishment room pantry refrigerator. Staff H stated not being aware of the refrigerator not working properly.During an interview on 01/15/2026 at 06:47 PM, the Nursing Home Administrator (NHA) and Regional [NAME] President (RVP), stated there were expectations for weekly and daily cleaning. The NHA stated the kitchen walls should not be in disrepair. The NHA stated drains should be cleaned, corroded items replaced, and general expectations for areas of the kitchen were to be clean.Record review of the facility's policy titled, Environment, dated 06/2025, showed:Environment Policy StatementAll food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces.4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.5. All dining areas will be cleaned and sanitized after each use, including tables, chairs, and floors. Photographic evidence obtained.

Based on observations and interviews, the facility failed to ensure the kitchen was free from pest in one out of three pantries observed.Findings include: On 01/12/2026 at 10:15 AM, a tour of the facility kitchen was conducted with the District Manager of Dining (DMD). During the tour, live insects were observed flying in the dishwasher room.On 01/14/2026 at 11:35 AM, during a tour of the facility the DMD moved an equipment cart in the kitchen near the eye washing station and a swarm of live insects flew up from the cart. A small clear plastic organizer the DMD referred to as a caddy was observed in the kitchen pantry with honey-like sticky substances, yellow in color. The yellow substances were observed in multiple areas of the caddy, including plastic drawers. The drawers and face of the caddy were observed with black, red, and tan debris. Live insects were observed flying and resting on shelves in the kitchen pantry. The DMD stated we should not have flies in the kitchen pantry. During an interview on 01/14/2026 at 02:26 PM, the DMD stated not knowing if the kitchen had ongoing pest control and monitoring. A request for a pest policy was made and not provided.Record review of the facility's vendor pest control logs revealed for the months of 11/2025 and 12/2025, the facility did not treat for flies.During an interview on 01/15/2026 at 06:47 PM, with the Regional [NAME] President (RVP) the Nursing Home Administrator (NHA), stated not knowing live flying insects were in the kitchen. The NHA stated having expectations of no pest in the kitchen. The RVP stated there was no pest control policy.Photographic evidence obtained.

Based on observations, interview and record review, the facility failed to ensure resident equipment was maintained and sanitary to include resident room air conditioner unit filters in two of two nursing units. Findings included: On 1/12/2026 at 10:30 a.m., 1/13/2026 at 9:45 a.m. and on 1/14/2026 at 8:50 a.m. during resident room tour, the following resident room wall mounted Packaged Terminal Air Conditioner (PTAC) units were observed for maintenance and cleanliness. It was found the air filters were heavily caked with dust and debris in resident rooms; 201, 204, 206, 207, 209, 210, 211, 212, 213, 214, 302, 303, 304, 306, 311, 104, 106, 109, 110, 115, 119, 121, 122, 127, 131. On 1/15/2026 at 8:45 a.m. an interview with the housekeeping director revealed she and the staff are responsible for cleaning resident spaces to include floors, walls, beds, bathrooms, trash, and windows. Rooms are also deep cleaned per a schedule. The housekeeping director confirmed resident rooms had Air Conditioning units, but the staff are not responsible for the cleaning and maintaining of the air filters. She revealed if the department observed something wrong with the unit, or saw that it needed maintenance, the issue would be brought to the attention of the Maintenance Director either verbally or by way of work order. She has not observed any air conditioning unit air filters and didn't know where they were located on the units. On 1/15/2026 at 10:45 a.m. an interview with the Maintenance Director (DOM) occurred. The DOM said each resident room has a wall mounted Package Terminal Air Conditioner (PTAC) air conditioning/heating unit. He said residents and/or staff could adjust the room temperature by way of the unit. The DOM said each unit has two air filters that should be cleaned and maintained. He said the routine maintenance and cleaning of the filters for each unit should be within a one-month timeframe. The DOM said the electronic maintenance system has a longer timeframe, but he and the staff try to conduct cleaning of air filters monthly. He said his staff had cleaned some filters yesterday but was unsure which ones were cleaned. At 10:57 a.m. the DOM provided the last three months (1/2026, 12/2025, and 11/2025) monthly PTAC unit maintenance and air filter cleaning sheets for review. The documentation only revealed the month the filters were cleaned and not the specific date. The Maintenance Director was provided with photographic evidence of the soiled filters that were noted on 1/12/2026, 1/13/2026, and 1/14/2026. He confirmed the filters should have been cleaned more frequently. On 1/15/2026 at 4:00 p.m. the Nursing Home Administrator provided the Maintenance policy and procedure, with a last revision date 12/20/2023 for review. The policy revealed; Policy - The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair. Procedure - The Director of Environmental Services will follow all polices regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the planet is free from hazards and in proper physical condition. Photographic Evidence Obtained

Based on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) Level I screening was completed prior to admission for four (#10, 21, 41, and 91) of the five residents reviewed.Findings include: Review of the admission record showed Resident #10 was admitted to the facility on [DATE], diagnoses including major depressive disorder, anxiety disorder, and schizoaffective disorder of the bipolar type. The resident was also diagnosed with Parkinsonism on 7/26/2024. Review of a level I PASRR for Resident #10 dated 11/21/2024 revealed qualifying diagnoses for Serious Mental Illness (SMI) and/or Mental Illness (MI), and a level II was not submitted for consideration. Review of the admission record showed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinsonism, mood disorder, psychotic disorder, dementia, anxiety, depression, and neurocognitive disorder with Lewy Bodies. Review of level I PASRR for Resident #21 dated 2/26/25 revealed qualifying diagnoses for SMI/MI, and a level II was not submitted for consideration. Review of the admission record showed Resident #91 was admitted to the facility on [DATE] diagnoses including bipolar disorder, anxiety and depression. Review of level I PASRR for Resident #91 dated 11/20/24 revealed qualifying diagnoses for SMI/MI, and a level II was not submitted for consideration. Review of the admission record showed Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including dementia, major depressive and mood disorder. Review of level I PASRR for Resident #41 dated 1/13/26 revealed, the primary diagnosis of dementia is not checked. The review showed the Level I PASRR is inaccurate and a level II was not submitted for consideration with the qualifying diagnoses. During an interview on 1/14/26 at 9:28 a.m. with Staff F, Registered Nurse (RN)/ Minimum Data Set (MDS) nurse and Staff G, Licensed Practical Nurse (LPN)/MDS nurse. Staff F, RN, MDS she was instructed if the resident is not having symptoms, submission for a Level II PASRR is not needed. Review of the facility's policy titled, Subject: Preadmission Screening and Resident Review (PASRR), revised: 11/08/2021 showed the following: Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: I. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level Il, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 2. If an individual is declared exempt from a PASRR screening, the Center should make sure that appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include: a. Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. b. Those who are certified by a physician as to be terminally ill with a 6-month prognosis, and are not a danger to self or others. c. Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's Disease, Huntington's Disease, Amyotrophic Lateral Sclerosis, CHF or COPD. d. Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASRR Level Il screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's record.

Based on observations, interviews, and record review, the facility failed to maintain an effective infection prevention program related to offering hand hygiene prior to eating for one of one dining room observed and proper storage for respiratory items for eight (#1, #16, #27, #50, #64, #72, #102, and #117) of eight residents sampled.Findings include: An observation of Resident #117's room on 1/12/2026 at 9:30 A.M. revealed an oxygen mask on the floor. A record review of Resident #117's record dated 1/15/2026 resident has no orders for oxygen or nebulizer. During an interview on 1/12/2026 at 10:00 A.M. the Staff D, Unit Manager (UM) stated she was unsure how the mask was on the floor of Resident #117 room but said sometimes the resident gets visitors from other residents with oxygen. An observation of Resident #27 on 1/12/2026 at 9:57 A.M. revealed a nebulizer mask uncovered. Review of Resident #27 admission record revealed a diagnosis of dependence on supplemental oxygen onset date of 2/12/2025. A Review of Resident #27 record of Order Summary Report dated 1/15/2026 at 5:53 P.M. showed an active order start date of 7/31/2025 for nebulizer. An order from the pharmacy dated 8/22/2025 for Budesonide Inhalation Suspension one vial inhale orally via nebulizer two times a day and an order dated 7/12/2025 for Ipratropium-Albuterol for quantity of one vial inhale orally two times a day. An observation of Resident #102 room on 1/12/2026 at 10:02 A.M. revealed a nebulizer mask left at the bedside uncovered. Review of Resident #102 admission record revealed a diagnosis of dependence on supplemental oxygen onset date of 05/21/2025. Review of Resident #102 Order Summary Report dated 1/15/2026 revealed an order that started on 8/06/2025 that said to change O2 tubing weekly when in use and an order for nebulizer use that started on 5/22/2025. Review of Pharmacy orders showed Resident #102 had an active order that started on 6/13/2025 for Albuterol to be administered with use of nebulizer for treatment. Review of the facility policy titled Oxygen Masks, Partial Rebreathing, dated 11/30/2014 revealed labeled tubing with date and time. Photographic evidence obtained. 2. On 1/12/2026 at 12:45 P.M. during observation of the lunch meal service in the 100 unit, observed staff started passing trays to the residents. The residents were not offered assistance with hand hygiene. An interview was conducted with Staff Q, Certified Nursing Assistant (CNA) on 1/12/2026 at 12:55 p.m. Staff Q stated that the staff do not usually offer to wash the residents' hands or offer any type of hand hygiene. An interview was conducted with the Director of Nursing (DON) on 1/12/2026 at 12:59 P.M. The DON stated that the facility used to have hand wipes but does not know of any now. The DON stated hand hygiene should be offered to the residents prior to meals. An interview was conducted with the Infection Preventionist (IP) on 1/15/26 at 9:08 A.M. The IP stated she was aware hand hygiene was not being provided to residents before meals are served. The IP said the facility has started providing mini hand sanitizers to each staff so that they can offer hand hygiene to the residents. On 1/12/2026 at10:02 A.M., Resident #16's nebulizer tubing on the floor, dated 1/4/2026. Photographic evidence taken of the nebulizer equipment and nasal cannula tubing date. An interview was conducted with the DON on 1/14/2026 at 10:40 A.M. The DON stated the facility changes oxygen tubing every Sunday. He stated the oxygen tubing date was not charted correctly. Review of admission Records showed Resident #16 was admitted to the facility on [DATE] with diagnoses including but are not limited to acute on chronic diastolic heart failure, generalized muscle weakness, chronic respiratory failure with hypercapnia, need for assistance with personal care, and other abnormalities of gait and mobility. 3. During an observation and interview on 1/12/25 at 9:29 A.M., Resident #50's wheelchair was stored in a shared bathroom with an uncovered nasal canula tubing with cream-colored prongs was wrapped around the wheelchair push bar. A review of Resident #51's admission record revealed initial admission on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence supplemental oxygen. During an observation and interview on 1/12/25 at 9:29 A.M., Resident #72 had an uncovered nebulizer mask on top of the bedside table. Review of Resident #72's admission record revealed admission to the facility on 1/29/25 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic bronchitis and obstructive sleep apnea. During a medication administration observation on 1/12/25 at 8:24 A.M., with Staff M, Respiratory Therapist (RT) Resident #1 was sitting on the side of her bed. There were uncovered nebulizer and Continuous Positive Airway Pressure (CPAP) masks on top of the bedside table. Staff M, RT stated the items should be bagged and covered when not in use. A review of Resident #1's admission record revealed initial admission on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and obstructive sleep apnea. (Photographic Evidence Obtained). During an interview on 1/13/26 at 10:52 A.M. Staff U, Certified Nursing Assistant (CNA), said she places oxygen supplies in a bag for infection control and does not know why the items were not in bags. A review of facility policy and procedure titled, Infection Control, revised October 2018 revealed the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and die regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: 2a.Prevent, detect, investigate, and control infections in the facility; 2b. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how find and use pertinent procedures and related infection control. The depth of employee training shall be to the degree of direct resident contact and job responsibilities. A review of a facility policy and procedure titled, Nebulizer (small volume nebulizer), revision on 3/20/2028 revealed the following: Note-Small volume nebulizers are used to deliver medication aerosols to the respiratory tract to relieve bronchospasm, to deliver medications, to improve the effectiveness of the cough and to relieve mucosa edema. Small volume nebulizers create a mist from a liquid medication solution that can be inhaled into the bronchial tree. Droplets of mist are delivered through a facemask or mouthpiece and absorbed into the bloodstream through alveoli within lung tissue. Procedures: Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place entire unit in a bag to be maintained in the resident's room.

Based on record review and interviews, the facility failed to develop care plans with problem areas and interventions related to discharge planning for one (#8. of three sampled residents. Findings included: On 1/12/2026 at 11:15 a.m. Resident #8's room was visited and he was noted seated on side of bed and was dressed for the day. Resident #8 revealed he was at the facility for either long term care services or rehabilitation services. He further commented he believed he was at the facility for short term, but nobody has spoken to him about any type of discharge planning. He revealed his desire was to complete rehabilitation services and possibly move into an Assisted Living Facility, but did know when that would happen. He could not remember anyone speaking to him with relation to discharge planning. Review of Resident #8's medical record revealed he was admitted to the facility on [DATE] for Rehabilitation short term care. Review of the advance directives revealed Resident #8 was his own responsible party. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score - 15 of 15); (ADL - Independent with most to all ADL tasks). Review of the current care plans with a next review date 4/13/2026 revealed no problem areas with goals and interventions to include discharge planning. There were no care plan problem areas related to discharge planning. It was determined Resident #8 was admitted to the facility for almost four months and there was no documentation in the chart related to discharge planning, nor was there any care plans speaking of discharge planning. On 1/15/2026 at 8:50 a.m. both the MDS Coordinator and Care Plan Coordinator were interviewed related to Resident #8.The MDS Coordinator and Care Plan Coordinator revealed Resident #8 was admitted to the facility on [DATE] for short term care initially. The MDS Coordinator and Care Plan Coordinator further revealed he was looking to at some point discharge to an Assisted Living Facility, per his plan. The MDS Coordinator and Care Plan Coordinator both confirmed there was not a current care plan problem area to identify his discharge planning with interventions. The Care Plan Coordinator revealed there are different departments that handle some care plan problem areas and believed Social Services handled the discharge planning care plan.The Care Plan Coordinator and MDS Coordinator both confirmed there should have been a care plan problem area to reflect the resident's discharge planning. On 1/15/2026 at 9:35 a.m. an interview with the Social Service Director revealed she was knowledgeable of Resident #8 and that he initially was admitted for short term therapy on 9/26/2026. She further revealed he had some payor source changes since his admission and his ultimate goal it to finish rehabilitation services and discharge to a nearby Assisted Living Facility. The Social Service Director confirmed there should have been a care plan to reflect his discharge planning and with interventions and her department (Social Services), is the department that usually develops that. The Social Service Director revealed the Care Plan to reflect discharge planning must have been overlooked. On 1/15/2026 at 4:00 p.m. the Nursing Home Administrator (NHA) provided the Plans of Care) policy and procedure with a last revision date of 9/26/2025 for review. The policy revealed;Policy - An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements.Plans of care is to be maintained as part of the final medical record. Procedure:Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Develops and implements an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, the participation of the resident and resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS).

Based on observation, interview and record review, the facility did not ensure Activities of Daily Living (ADL) care was provided for three residents (#12, 16, 57) of four residents sampled. Findings include: On 1/12/2026 at 9:28 a.m., Resident #12 was interviewed and observed with long, soiled fingernails and said, they don't help you here, when asked about the condition of his nails. On 1/15/2026 at 9:24 a.m., Resident #12 was observed with fingernails still long and soiled. Review of Resident #12's tasks report for 12/17/2025 to 1/15/2026 revealed the residents shower schedule is Saturday, Monday, and Thursday. The resident had a shower or bath for six days (12/17/2025, 12/19/2025, 12/24/2025, 1/5/2025, 1/6/2025) in the 30-day period of 12/17/2025 to 1/15/2026. Many of the days on the task sheet were checked as Not Applicable. Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including but are not limited to cerebrovascular disease, heart failure, abnormalities of gait and mobility, need for assistance with personal care, and cognitive communication deficit. Review of Resident #12's Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of four. This BIMS score indicated they have severe cognitive impairment. Functional Abilities revealed a code four for personal hygiene, which means the resident needs supervision or touching assistance. Shower/bathe revealed the resident would need substantial or maximal assistance. Review of Resident #12's Care Plan dated 12/16/2025 revealed a focus of alteration in usual functional performance in mobility or transfer status. This is related to muscle weakness and impaired mobility. Interventions showed functional status may vary on a day-to-day basis, staff are to provide support as needed. The resident requires partial to moderate assistance with one staff assist for tub/shower transfers. Supervision or touching assistance with one staff assist is required for personal hygiene. On 1/12/2026 at 10:02 a.m., an interview and observation occurred of Resident #16. Resident #16 stated not happy with their care at the facility. Resident #16 stated the staff have never assisted with or cared for her fingernails and toenails. Resident #16 stated their nails were long and they did not want them that way. Observed the fingernails to extend beyond the fingertip, with visible jagged edges and with a soiled appearance. An interview with Resident #16 was conducted on 1/15/2026 at 1:24 p.m. Resident #16 stated not receiving showers on scheduled shower days, including on 1/13/2026. Review of admission Records showed Resident #16 was admitted to the facility on [DATE] with diagnoses including but are not limited to acute on chronic diastolic heart failure, generalized muscle weakness, chronic respiratory failure with hypercapnia, need for assistance with personal care, and other abnormalities of gait and mobility. Review of Resident #16's MDS, dated [DATE], showed a BIMS score of 14. This BIMS score indicated they are cognitively intact. Functional Abilities revealed level 2 for self-care, which means the resident needs partial assistance from another person to complete any activities. Shower/bathe showed the resident would need the helper to support all of the effort. The assistance of two or more helpers is required to complete the activity. Review of Resident #16's Care Plan revealed a focus of alteration in usual functional performance in self-care related to muscle weakness and impaired weakness, respiratory failure. The intervention listed personal hygiene as supervision or touch assist with one staff assist. Shower and bathing are listed as dependent with one staff assist. Tub and shower transfers require partial/moderate assistance with one staff assistance. An interview was conducted with Resident #57's family member on 1/12/2026 at 11:14 a.m. The family member stated the facility staff do not shower the resident as scheduled therefore they come into complete the task. The family member stated the family cuts the resident's fingernails, as the facility had failed to assist. Review of the resident task report revealed the residents shower schedule is Monday, Wednesday, and Friday. No shower was recorded on 1/12/2026. Review of admission Records showed Resident #57 was admitted to the facility on [DATE] with diagnoses including but are not limited to Parkingson's Disease without dyskinesia, Unspecified dementia, major depressive disorder, encephalopathy, and blindness in the left eye (category 5). Review of Resident #57's MDS, dated [DATE], BIMS score of 0. This BIMS score indicated they have severe cognitive impairment. Functional Abilities revealed a level 1 for personal hygiene, which is substantial or maximal assistance. Review of Resident #57's Care Plan revealed a focus of alteration in usual functional performance in mobility/transfer status related to muscle weakness and impaired mobility due to resident's diagnoses. The residents' intervention include tub/shower transfers are dependent with two staff assist. The resident's personal hygiene is dependent on one staff assist. Shower/bathing is dependent on one staff assist. An interview was conducted with Staff P, Certified Nursing Assistant (CNA) on 1/14/2026 at 11:00 a.m. Staff P, CNA stated the CNAs perform shaving, nail care, showers, mouthcare, and other basic ADL care. She said she will introduce herself to the resident and tell them today is shower day. She lets them know if they refuse their shower, then she may not be able to get back to them. She will document the care in the electronic medical record. She stated there are not individual sections for nail care on the CNA shower sheets. Staff P stated the Activities Department will occasionally manicure resident's nails. An interview was conducted with Staff H, Registered Nurse (RN) and Unit Manager (UM) on 1/15/2026 at 9:10 a.m. Staff H, RN/UM stated that on the shower sheet, the CNA would write if the resident needs fingernails cut in the area on the sheet that asks about toenails. If they mark yes on the toenails, the podiatrist would be scheduled. Staff H stated the Social Services Director has the podiatry list. If the resident is not diabetic or has any other risk factors, then the nurses can cut the toenails. Staff H could not find a shower sheet for Resident #16 for Tuesday 1/13/26. Staff H was able to find the shower sheet for Resident #16 around 30 minutes later. Resident #16's shower sheet, dated 1/13/2026 was checked as the resident needing toenails cut, but not fingernail information. Resident #57's shower sheet, dated 1/12/2026 revealed the resident need their toenails cut. Resident #12's shower sheet had no notes describing fingernails or check marks in the toenail area on 1/13/2026. Review of the facility podiatry list revealed that Resident # 16 and Resident #57 were not on the podiatry list for needing care. An interview was conducted with the Resident Council President on 1/15/2026 at 1:15 p.m. They stated that one of the CNAs told the residents they do not cut nails. The resident stated the CNAs told them they will file them and straighten them but not cut them. They stated Podiatry comes in to take care of our feet, but it depends on the person and their feet. Review of the facility policy titled Care of Nails, with a revision date of 9/1/2017 revealed the facility procedure does include trimming fingernails and cleaning the nails. Review of the facility policy titled Bathing/Showering, with a revision date of 9/1/2027, revealed assistance with showering and bathing will be provided at least twice a week and PRN to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing. Their preference for bathing will be reviewed at least quarterly during the care conference.

Based on interview and record review the facility failed to ensure a resident's hearing aid was consistently available and utilized as needed to maintain communication, dignity, and quality of life for one (#72) of one resident reviewed.Findings include:On 1/12/26 at 9:51 a.m. during an observation and interview of Resident #72, a friend of the resident reported the facility staff failed to properly manage the resident's hearing aids, resulting in the devices being lost. The visitor stated facility staff did not remove the hearing aids at night. As a result, the resident has been without hearing aids for a while.A review of Resident # 72's admission record revealed admission to the facility on 1/29/25.A review of Resident #72's Admit/Readmit Screener dated 1/29/25 revealed right and left ear hearing aids present.A review of Resident # 72's health status note, dated 2/4/25 revealed .I placed her hearing aids in before breakfast .A review of Resident # 72's health status note, dated 2/14/25 revealed .her left hearing aid is in this am and staff cannot find the right hearing aid .A review of Resident # 72's health status note, dated 2/17/25 revealed .I placed both hearing aids in the [morning before] breakfast .A review of a grievance regarding Resident #72, dated 8/29/25 revealed the following:Concern: Family expresses that resident is missing her hearing aids.-Findings of investigation: After a search was done, hearing aids could not be located.-Plan to resolve complaint/grievance: Explained to family that hearing aids were not added to inventory sheet when brought in.-Expected results of actions taken: Also not order for hearing aids in system. Explained that resident can be enrolled to see audiologist in order to get new hearing aids .-Post investigation follow-up: Family satisfied with outcome . dated 8/29/25.A review of an email from the facility to their audiology services vendor dated, 10/21/25 revealed could you please add [Resident #72] to this upcoming visit .She had lost her hearing aids and has been needing a new pair for a while now .During a telephone interview on 1/14/2026 at 11:03 a.m. with Resident #72's representative said in August, the facility acknowledged the loss of the resident's hearing aids but stated they would not replace them. The facility told her if the resident enrolls in audiology services and obtained a new pair of hearing aids, the facility will assume responsibility for replacement should the devices be lost in the future.During an interview on 1/14/26 at 4:24 p.m. with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Regional [NAME] President of Operations (RVPO). The RVPO said Resident #72's family was initially concerned about the resident's cognitive ability to keep up with her hearing aids. A review of the facility policy and procedure titled, personal property- loss or theft, revised on 7/24/2017 revealed the following-Policy: The Center has processes to minimize the risk of loss or theft of resident's personal property revealed- Process: 1. At admission resident's belongings will be identified and recorded.A review of the facility policy and procedure titled, care of hearing aid, revised 9/1/17 revealed the following- Procedure: . Place hearing aid in appropriate container when not in use and store in safe place .

The facility failed to follow the clinical standard of practice to ensure adequate monitoring of behaviors and medication side effects for a resident prescribed psychotropic medication. This failure affected one (#41) of five residents reviewed.Findings included: A review of admission record revealed Resident #41's was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis' including but not limited to dementia, major depressive and mood disorder. A review of resident #41's care plans revealed: Focus: [Resident #41] uses antidepressant medication, initiated on 10/07/2025 Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift . A Review of Resident #41's psychiatry care plan note, dated 11/5/25 revealed In addition to monitoring for the occurrence of potential adverse effects from medications, we are also monitoring the following: any drug-drug, drug-disease interactions, the impact of any adverse effects on the patient's ability to perform activities of daily living or to interact with others; withdrawal from or decline in usual social patterns; decreased engagement in activities; and diminished ability to think or concentrate . A review of Resident #41's psychiatry subsequent note dated 1/7/26 revealed .mood swings are severe requiring monitoring .monitoring for the occurrence of potential adverse effects from medications . A review of order summary report dated 1/15/26 revealed Resident #41 had orders for the following medications. Depakote 500 mg give 1 tablet orally two times a day for mood disorder-1/8/26, Depakote 500 mg give 1 tablet orally give 2 tablets orally at bedtime for mood disorder-12/24/25, Donepezil HCl 10 mg give 1 tablet orally at bedtime related to unspecified dementia, unspecified severity, with other behavioral disturbance-7/8/25, Lorazepam 0.25 ml injection every 4 hours as needed for anxiety/restlessness-1/14/26, Paroxetine 10 mg orally give 1/2 tablet daily for major depressive disorder-1/9/26, and Zunveyl 10 mg orally two times daily-1/14/25. Discontinued medications Paxil 10 mg orally daily for depression-7/3/25 and Seroquel 25 mg 1/2 tablet orally twice daily for depression-7/2/25. During an interview on 1/25/26 at 8:45 a.m. Staff V, Registered Nurse (RN), said behavior monitoring is documented in the Medication Administration Record (MAR). If a resident is exhibiting behaviors, staff document the behavior, notify the provider, administer PRN medications as ordered, and may request an order for psychiatric consult. During an interview and record review on 1/15/26 at 8:59 a.m. with Staff H, RN, Unit Manager (UM) said the facility have standing orders to monitor residents who are prescribed psychotropic medications. She said behavior monitoring is documented on a behavior flow sheet in the electronic health record (EHR). Staff H, RN/UM was unable to show Resident #41's behavior monitoring documentation. She referred to asking the Director of Nursing (DON) to print the behavior monitoring documentation. During an interview on 1/15/26 at 9:10 a.m. the Director of Nursing (DON) said behavior monitoring is documented on the Medication Administration record (MAR). He opened Resident #41's EHR and revealed an order dated 1/14/26 for behavior monitoring. When asked to provide documentation of behavior monitoring for November 2025, December 2025 and January 2026, he stated that it is documented in the resident's progress notes. He was asked to provide documentation of behavior monitoring for the past three months, as recommended by psychiatry. During a follow-up interview on 1/15/26 at 12:20 p.m., the DON said no documentation of behavior monitoring was found for Resident #41 and acknowledged that behaviors were not documented daily. During a telephone interview on 1/15/26 at 1:30 p.m. Resident #41's Psychiatric Mental Health Nurse Practitioner (PMHNP) said he expects Resident #41's behaviors are monitored every shift; the resident is very confused.

Based on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Twenty-six medication administration opportunities were observed, and ten errors identified for two (#93 and #1) of five residents observed. These errors constituted a 38.46% medication error rate.Findings include:On 1/13/25 at 8:24 a.m. an observation of medication administration with Staff M, Respiratory Therapist (RT) was conducted with Resident #1. Staff M, RT picked up a nebulizer mask stored uncovered on top of the bedside table, poured the prescribed amount of Budesonide inhalation solution into the nebulizer cup. She connected the nebulizer cup to the nebulizer mask and turned on the nebulizer machine [A nebulizer is an electric machine that turns liquid medication into a fine mist that is inhaled into the patient's lungs by a facemask]. Staff M, RT handed the mask to Resident#1 and the resident positioned the mask and immediately began to inhale the medication. Staff M, RT used a stethoscope to listen to the Resident #1's lungs. Review of Resident #1 medication orders revealed the following orders:-Budesonide (Inhalation) 0.5 milligram (mg)/2 milliliter (ml) inhale orally two times a day for Shortness of breath(SOB) Respiratory: Check lung sounds, heart rate and respirations Pre and Post-Nebulizer administration. Record Minutes of nebulizer treatment.- Ipratropium-Albuterol 1 vial inhale orally four times a day for Shortness of breath(SOB) Respiratory: Check lung sounds, heart rate and respirations Pre and Post-Nebulizer administration. Record Minutes of nebulizer treatment.During an interview immediately after the medication was administered, Staff M, RT shrugged her shoulders when asked why the physician's orders to check Resident #1's lungs before beginning Budesonide inhalation solution administration was not followed. On 1/13/25 at 10:21 a.m. an observation of medication administration with Staff K, Licensed Practical Nurse (LPN) was conducted with Resident # 93.A review of Resident #93's order summary report dated 1/15/26, showed orders for the following medications:-Rivaroxaban Tablet 15 milligrams (mg) tablet orally-Amiodarone HCl Tablet 200 mg tablet orally-Polyethylene Glycol 3350 17 gram (gm) orally- Ascorbic Acid Tablet 500 mg tablet orally- Bimatoprost Ophthalmic Solution daily- Levothyroxine Sodium 75 microgram (mcg) oral tablet- Cyanocobalamin 1000 mcg intramuscularly- Isosorbide Dinitrate 5mg tablet orally- Donepezil Hydrochloride 10 mg tablet orally- Coenzyme Q10 30 mg capsule orally- Biotin 1000 mcg tablet orally- Sennosides Tablet 8.6 mg tablet orally- Docusate Sodium 1 capsule orally- Pantoprazole Sodium 40 mg tablet orally- Famotidine 20 mg tablet orally- Loratadine 10 mg tablet orally- Lactobacillus 1 capsule orallyStaff K, LPN administered the following oral medications:-Lactobacillus scheduled for 9:00a.m. was given at 10:21 a.m.-Docusate Sodium scheduled for 9:00a.m. was given at 10:21 a.m.-Coenzyme Q10 scheduled for 9:00a.m. was given at 10:21 a.m.-Ascorbic Acid scheduled for 9:00a.m. was given at 10:21 a.m.-Biotin scheduled for 9:00a.m. was given at 10:21 a.m.-Amiodarone scheduled for 9:00a.m. was given at 10:21 a.m.-Isosorbide Dinitrate scheduled for 9:00a.m. was given at 10:21 a.m.-Sennosides scheduled for 9:00a.m. was given at 10:21 a.m.Polyethylene Glycol scheduled for 9:00a.m. was given at 10:21 a.m.During an interview immediately after the medications were administered Staff K, LPN said Resident #93's medications were given late because she had to complete discharge paperwork for another resident.A review of a facility policy titled, administering medications, revised April 2019 revealed the following:Policy Statement-Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation: .2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions . 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).A review of a facility policy titled, nebulizer (small volume nebulizer), revised on 3/20/2018 revealed the following: Note-Small volume nebulizers are used to deliver medication aerosols to the respiratory tract to relieve bronchospasm, to deliver medications, to improve the effectiveness of the cough and to relieve mucosa edema. Small volume nebulizers create a mist from a liquid medication solution that can be inhaled into the bronchial tree. Droplets of mist are delivered through a facemask or mouth piece and absorbed into the bloodstream through alveoli within lung tissue.Procedure:Review physician's orderGather necessary equipment.Identify resident and explain the treatment.Perform hand hygiene.Position the resident in an upright position.Evaluate the resident. Establish baseline respiratory rate, pulse, oxygen saturation and breathe sounds.-Assemble nebulizer equipment.-Instill the prescribed medication into nebulization cup.-If using handheld nebulizer, instruct the resident to hold the mouth piece between the lips. If using mask for delivery, --place the mask on the resident.-Instruct the resident to take slow deep breathes and exhale slowly.-Administer treatment until medication is depleted-Evaluate the resident's response and effectiveness of treatment by evaluating breath sounds, pulse rate, oxygen saturation and respiratory rate.-Disassemble device and rinse the mouthpiece and nebulizer cup with water and air Place entire unit in a bag to be maintained in the resident's room.-Perform hand hygiene-Document treatment in the resident's medical record.

Based on observations, interviews and record review, the facility did not ensure medications were not accessible to unauthorized staff, residents, and visitors for one resident (#64) of 53 sampled residents.Findings include:On 01/12/2026 at 9:30 a.m. an observation was made of Resident #64 sitting on his bed. A breakfast tray was observed at bedside. On the meal tray was a plastic medication cup with what Resident #64 referred to as morning medications. The resident stated the nurse left the medications there a while ago. Resident #64 confirmed those were his morning medications mixed in pudding. Resident #64 stated, The meds are lumpy. I cannot swallow them. Resident #64 stated having trouble swallowing solids and was on a liquefied diet.An interview was conducted on 01/12/2026 at 10:32 a.m. with Staff S, Registered Nurse (RN). Staff S confirmed leaving the medications unattended at resident #64's bedside table. Staff S walked into the room and observed the plastic cup full of medications still at bedside. She stated she had crushed the medications and left them in the room for the resident. She stated the resident has trouble swallowing solids. She said everything had to be in liquid for this resident and that he normally took his time when taking them. Staff S stated she told Resident #64 to, let the medications melt first, and she would be right back. Staff S stated she should have supervised the resident during medication administration.On 01/14/2026 at 1:08 p.m. an interview was conducted with Staff H Registered Nurse (RN) Unit Manager. The unit manager stated for a medication pass to be considered proper, the nurse should verify the correct route ordered. Staff H said, At no time should a resident be left alone with medications. The nurse gives the patient the pills then they stay in the room and verifies that the medication is given correctly and taken. Staff H confirmed the nurse must watch the medication administration. She said, They are to stay while the meds are taken.An interview was conducted on 01/14/2026 at 10:07 a.m. with the Director of Nursing (DON) stated that no medications should be left unattended at a resident's bedside.Review of a facility policy titled, Administering Medications, revised April 2019, showed a policy statement - Medications are administered in a safe and timely manner, as prescribed. 4. Medications are administered in accordance with prescriber orders, including timeframes. 27. Residents may self-administer their own medications only if the Attending physician, in conjunction with the Interdisciplinary care Planning Team, has determined that they have the decision-making capacity to do so safely.Review of an undated facility policy titled, Medication Storage, revealed a policy - Medications will be stored in a manner that maintains integrity of the product and ensures the safety of the residents and is in accordance with FL (Florida) Department of health guidelines. Procedure A. 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.

Based on observations, record reviews and interviews, the facility failed to honor one (#64) of eight sampled residents with meals that were in the form of the resident's choice and dietary recommendation.Findings include: On 1/12/2026 at 9:31 a.m. Resident #64 breakfast tray was observed to have four bowls. One bowl was observed to have a yellow solid pulpy mass, the second bowl containing brown food item in the form of a scooped unidentifiable food substance, the third bowl contained white disk shaped unidentifiable solid food substance, and the fourth bowl appeared to be an applesauce texture substance. The meal ticket was observed beside the food tray which read all foods in bowls, all foods liquified. The statement on the meal ticket was highlighted in yellow. On 1/13/2026 at 9:00 a.m. Resident #64 breakfast tray was observed to have two uncovered bowls and one covered bowl. The uncovered bowl contained a yellow solid pulpy mass, and the other bowl appeared to be an applesauce texture substance. The meal ticket revealed, all foods in bowls, all foods liquified and that statement on the meal ticket was highlighted in yellow. During an interview on 1/13/2026 at 9:55 a.m., Resident #64 said, If the eggs were spread out with liquid, I could eat them but not in this lump. During an interview on 1/14/2026 at 7:35 a.m. with Staff B, Dietary Aide, who was handling the meal tickets and reviewing them, said he will review the meal tickets for diet type, diet consistency, allergies, likes/dislikes and any other special dietary orders. Staff B said the highlighting was to ensure they [the kitchen staff] follow the special instructions and will verbally call it out to the cook. Staff B said the tickets, and plated food is reviewed by at least three staff on the tray line to include himself, the cook, and the aide that takes the plated food/tray and places it in the tray cart. During an interview on 1/14/2026 at 7:45 a.m. the Regional Dietary Manager stated at least three staff members in the kitchen verify the meal tickets and ensured the orders/choices are followed/honored prior to going out to the residents. During an observation and interview on 1/14/2026 at 7:46 a.m. Staff B, Dietary Aide (DA) placed Resident #64's meal ticket on a plastic meal tray and sent the tray down the line. The meal ticket was then reviewed by the Staff A, [NAME] and he plated the resident's food items to include a bowl of scrambled (puree) eggs, a bowl of dark brown food (item biscuits for biscuits and gravy), Staff A then placed clear plastic wrap on both of the bowls and gave the entire meal tray to the last aide on the tray line. Observations revealed the bowl of puree eggs, and the bowl of puree sausage biscuit had not been liquified, per the meal ticket order. The bowls were shown to Staff A and he looked at the bowls and said, Oh I must have just missed that. Staff A explained that the eggs and the sausage and biscuit needed to be liquid with water and mixed/emulsified. During an interview on 1/14/2026 at 8:00 a.m. with the Regional Dietary Manager (RDM) confirmed the meal ticket for Resident #64 was not followed and stated Resident #64 was the only resident that had this specialized diet. The RDM reviewed the ticket and confirmed the texture was not correct. Durning an interview on 01/14/2026 at 11:45 a.m. with Staff T, Speech Language Pathologist (SLP) stated Resident #64 has trouble swallowing and the assessment and recommendations made were to liquidize Resident #64's food. Staff T said Resident #64 complains he has not been able to chew the food without adding liquid. Staff T, SLP was shown the photo of the meals from 1/12, 1/13, and 1/14, that Resident #64 had received and confirmed no liquid was added to the food. During an interview on 01/14/2026 at 2:53 p.m. Staff C, DA was shown photos of the meals Resident #64 received and Staff C confirmed that no liquid was added as it should have been as it was on the meal ticket. Staff C said the staff was expected to review resident choice and diet order on the meal ticket and highlight it on the meal ticket to make it easy for the cook to prepare the meal. Staff C explained that once it's on the food ticket It's expected we follow through with what is on the food ticket. Review of Resident #64's quarterly assessment Minimum Data Set (MDS) dated [DATE] showed an admission date of 11/20/2024 with diagnoses to include type two diabetes mellitus with unspecified diabetic retinopathy without macular edema, iron deficiency anemias, muscle weakness, dysphagia oropharyngeal, protein-calorie malnutrition, and other diagnoses. Review of the Order Summary Report dated as active orders as of 01/15/2026 the diet order read Dysphagia puree texture, regular/thin consistency, all food in bowls and liquified per resident request. Review of Resident #64's Progress notes entered and signed on 11/21/2025 at 9:24 a.m. by Staff T, SLP revealed diet to regular liquids continue puree/liquidized solids. Review of the facility's policy and procedure titled, Dining and Food Preferences, dated October 2022, revealed that individual dining, food, and beverage preferences are identified for all residents/patients. Procedure number four listed in the policy statement indicated that food and fluid preferences will be entered into the resident profile in the menu management software system. Procedure number seven states the individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order. and preferences.

Based on interview and record review the facility failed to ensure documentation was complete and accurate for one (#57) of one resident reviewed timely medication administration documentation. Findings include: An interview was conducted with Resident #57's family member on 1/12/2026 at 11:14 a.m. The family member stated they are concerned that the facility staff are not giving medication to Resident #57 timely. The family member stated Resident #57 reports to her the facility only gave the medications twice in one day although ordered for three times per day, but the nurse said it had been administered three. Review of the admission Records showed Resident #57 was admitted to the facility on [DATE] with diagnoses including but are not limited to Parkingson's Disease without dyskinesia, Unspecified dementia, major depressive disorder, encephalopathy, and blindness in the left eye (category 5). Review of Resident #57's Minimum Data Set (MDS), dated [DATE], showed Brief Interview for Mental Status (BIMS) score of 0. This BIMS score indicated they have severe cognitive impairment. Review of Resident #57's Care Plan, dated 12/15/2025, revealed a focus of Parkinson's disease, with a risk for neurological problems. An intervention listed states to give medications as ordered by the physician, then to monitor/document the side effects and effectiveness. Review of the Medication Audit report revealed Entacapone oral Tablet 200 mg, scheduled for 0900, 1300, and 1700 were administered at the same time in the Medication Administration Report (MAR) records in the afternoons on the following dates: 1/10/2025, 1/5/2026, 12/31/2025, 12/22/2025, 12/17/2025, 12/2/2025 Review of the Medication Audit report revealed Carbidopa-Levodopa Oral Tablet 25-100 mg with admissions scheduled for 0900, 1300, and 1700 were administered at the same time in the MAR records in the afternoons on the following dates: 1/10/2025, 1/5/2026, 12/31/2025, 12/22/2025, 12/17/2025, 12/2/2025 An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 1/14/2026 at 10:17 a.m. Staff L, LPN stated that she administers the medications at the right time, but she doesn't get a chance to chart until later. She said that the facility may have a policy, but sometimes it is impossible to chart the medications on time. She does not feel like they are short staffed. Staff L stated, things come up. Staff L confirmed not updating the progress notes on the days the medications are charted late. Staff L stated the electronic medication administration system does have an option to click see progress notes. An interview was conducted with the Director of Nursing (DON) on 1/15/2026 at 10:51 a.m. The DON stated just because the audit showed the medication was entered into the system at one time, that does not mean the medication was given at those times. He stated he would investigate the family's allegation of missed medications. The DON said there is no way to determine time medications are given if not documented at the time of administration. An interview was conducted with the DON on 1/15/2026 at 12:20 p.m. The DON stated the staff cannot combine documentation for medications. He said there is no policy on the documentation of medication administration. The DON said the expectation is medications are documented when given, to ensure accurately recorded. At no time should the nurse administer medication and record administration several hours later. If medication must be administered after the time allotted for administration, the medical doctor must be notified with the reason for the late administration. The nurse must also notify the family. Review of the facility policy titled Administering Medications, with an effective date of April 2019, revealed the policy statement of Medications are administered in a safe and timely manner, and as prescribed. Section 7 showed medications are administered within one hour of their prescribed time, unless otherwise specified.

Based on observation, record review, and interviews, the facility failed to ensure timely and consistent incontinence services were provided for three residents (#3, #4, and #2) of four residents sampled for incontinence care. Findings included: 1.Review of Resident #3's admission Record revealed an admission date of 10/2022 with diagnoses to include Chronic kidney disease, Stage 3 unspecified, overactive bladder, unspecified dementia, muscle weakness (generalized) and essential (primary) hypertension. A review of a social services progress note dated 12/17/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.A review of Resident #3's Care Plan, documented a focus area for ADL (Activity of Daily Living) self-care deficits, . Decline from prior level of functioning, needs assistance with self-performance, bed mobility, transfers, dressing, eating, toilet use, personal hygiene, oral hygiene, and bathing, initiated 04/15/2022. The interventions included: Toilet Use - I require extensive assist by one staff for toileting. Transfer - I require supervision with transfers.A review of Resident #3's progress notes revealed the following:On 07/24/2025 at 9:15 a.m., Staff A, Registered Nurse, (RN) documented a skin note: Skin observation complete and new MASD (moisture-associated skin damage) noted to Inner Buttocks crease. (Medical Doctor) notified and new order received for skin TX (treatment).On 07/25/2025 at 5:07 p.m., Staff A, RN documented, Resident started on PO (by mouth) ABT (antibiotic) for abnormal urine results.On 07/27/2025, a note documented by the Nurse Practitioner showed, The patient has been seen at the bedside. The patient was lying in bed. Staff noticed an open area on the right gluteal fold, during the skin checks. On assessment the (sic) is an open area on the right gluteal fold (a horizontal crease on the inferior aspect of the buttocks and the posterior upper thigh) noted, has no drainage or odor noted it is consistent with moisture-associated skin damage (MASD). New order was initiated for zinc oxide cream application with every brief change and as needed. The patient is to be repositioned every two hours as tolerated to aid in prevention of further skin breakdown.A review of Resident #3's ADL documentation for Toileting Hygiene for the dates of 07/18/2025, through 07/27/2025, a ten-day period, reflected the following documented assistance for Toileting Hygiene:Three of the 10 days, 07/19, 07/21, and 07/24, staff documented providing toileting services once during the 24-hour period.Three of the 10 days, 07/18, 07/20, and 07/22, staff documented providing toileting services two times during the 24-hour period.The other 4 dates, 07/23, 07/25, 07/26, and 07/27, staff documented providing toileting services three times during the 24-hour period.On 08/12/2025 at 1:51 p.m., an interview was conducted with Assistant Director of Nursing (ADON) regarding Resident #3's ADL documentation for toileting/ hygiene. During the review, she stated she could provide better documentation, she stated she was not familiar with the presented documentation. She confirmed it looked like documentation was lacking. On 08/12/2025 at 2:50 p.m., an interview was conducted with the Nursing Home Administrator (NHA), she stated she wanted to clarify what was needed for the ADL documentation. A review of the Toileting Hygiene documentation provided for Resident #3 was conducted with her. She stated, I know the care is being provided, the staff are not documenting. Subsequently, at approximately 3:20 p.m., the NHA, she provided a 2nd set of ADL paperwork. She could not decipher the code; she said, Let me get the unit manager; they review the documentation.On 08/12/2025 at 3:51 p.m. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) with the NHA in the room. She reviewed the ADL documentation. She stated, you should see documentation every shift. She stated her monitoring of the ADL documentation was, she would receive an alert if the resident had not had a bowel movement or urinated within three days, Nothing further. Staff B stated she had been familiar with Resident #3, the resident was not on her unit but would come over and need to be redirected to the other side; Staff B stated she would have an incontinent episode. You could see the urine/ damp clothes and staff would have to change her frequently.On 08/12/2025 at 5:00 p.m., the NHA returned with the Minimum Data Set Coordinator (MDS), RN. She provided additional forms for ADL assistance; The forms were reviewed with both of them and reflected no additional information. The MDS/RN stated there was an issue with documentation.2. A review of Resident #4's admission Record documented admission in 06/2021 with diagnoses including but not limited to; muscle weakness, Chronic Obstructive Pulmonary disease, chronic kidney disease, and unspecified dementia.A review of a social services progress note dated 11/04/2024 revealed Resident #4 had a BIMS score of 4, which indicated severe cognitive impairment.A review of Resident #4's care plan revealed a focus area for the resident being at risk for urinary incontinence due to overactive bladder and BPH (Benign Prostatic Hyperplasia) with an intervention: Clean peri-area with each incontinence episode.In addition, Resident #4 had a focus area for the resident being at risk of ADL self-care performance deficit due to impaired balance and history of stroke with an intervention for toilet use: extensive assist X 2 (two) staff. A review of Resident #4's progress notes dated 07/04/2025 revealed, skin issues: Moisture associated skin damage (MASD). Skin issue location: back and neck.A review of a Nutrition/ Dietary note, dated 07/29/2025, . Resident has MASD to his back/ neck; skin is otherwise intact.A review of Resident #4's ADL documentation for Toileting Hygiene for the dates of 08/01/2025, through 08/11/2025, an eleven-day period, reflected the following documented assistance for Toileting Hygiene:08/01, 11:02, Dependent08/01, 2208, Dependent08/02, 11:48, Dependent08/02, 21:52, Dependent08/03, 14:59, Dependent08/03, 21:42, Dependent08/04, 22:39, Dependent08/05, 10:43, Dependent08/05, 19:22, Dependent08/06, 6:59, Dependent08/06, 14:03, Dependent08/06, 22:16, Dependent08/07, 13:20, Dependent08/07, 2250, Dependent08/08=No documented services.08/09, 0400, Dependent08/09, 16:15, Dependent08/10, 14:59, Dependent08/10, 16:21, Dependent08/10, 23:36, Dependent08/11, 14:59, Dependent08/11, 22:12, DependentThe review showed seven of the 11 days, 08/01, 08/02, 08/03, 08/05, 08/07, 08/09, 08/11, staff documented providing toileting services two times during the 24-hour period. One of the 11 days, 08/04, staff documented providing toileting services one time during the 24-hour period. One of the 11 days, 08/08, no documentation of providing toileting services during the 24-hour period. Two of the 11 days, 08/06, 08/10, staff documented providing toileting services three times during the 24-hour period.On 08/12/2025 at 9:51 a.m. an interview was conducted with Resident #4's family member and Resident #4 who was sitting in a wheelchair at bedside, observed to be dressed in seasonally appropriate clothing. The family member stated it was hard to get (Resident #4) to respond. The family member stated she would come to the facility five days a week. For (Resident #4's) incontinence care, she would visit during the day, it was ok; for the 3pm-11pm shift, they will check him. For the 11pm-7am shift it is bad. I have come in early and found him so wet up past his neck. The smell: it is like old urine, like ammonia. I brought it up at the family council meeting. They said they were educating. It is not working. 3. A review of Resident #2's admission record, documented an admission date of 05/2024. The diagnosis list included but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side and muscle weakness.A review of Resident #2's care plan, documented a focus area, (Resident) was incontinent of bowel and at risk for impaired bowel elimination such as constipation and or diarrhea, effective 06/30/2021. Interventions included: Provide incontinence care after incontinence episodes, PRN (as needed).An interview and observation was conducted on 08/12/2025 at 11:15 a.m., with the Social Service Director (SSD). Resident #2's room was observed, the red light above the door was flashing and sounding. Resident #2 was in the room, in his wheelchair, he stated the call bell light had been going off for about a month and a half. The resident stated, they gave me a bell. Sometimes they do not hear it. It can take a while. Bells were observed at Resident #2's bedside and the roommate's bedside, and one on the back of the commode in the bathroom. At this time, the SSD said it was a shock to her; the residents had bells; she thought maintenance was fixing the call lights. A telephone interview was conducted on 08/12/2025 at 3:40 p.m. with Resident #2's family member, who stated he will visit (Resident #2) all the time, and he will come in at various times. The family member stated, the call bell light has been going off continuously for weeks. The family member said, I could understand if it were a couple to a few days, but it has been a month. They should have fixed. (Resident #2) has to wait for help. They had given him a bell to ring. Sometimes the staff do not hear it. (Resident #2) will have to go into the hall to ring the bell for them to hear it. I do his laundry; (Resident #2's) clothing is soiled. They are not getting to him quickly enough. I talked to maintenance; I talked to the NHA.The facility did not provide a policy.

Based on observation, record review, and interviews, the facility failed to ensure a functioning grievance process for one resident (#2) of four residents reviewed for grievances.Findings included: A review of Resident #2's admission record revealed an admission date of 05/2024 with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side and muscle weakness. On 08/12/2025 at 9:49 a.m., an observation was conducted of Resident #2's room. The light in the hallway above the door was sounding repeatedly with a flashing red light blinking. At 10: 50 a.m., an observation was conducted of Resident #2's room, the light above the door was still flashing and sounding. No residents were in the room at the time of observation. An interview was conducted on 08/12/2025 at 11:01 a.m. with the Social Service Director (SSD). A grievance from Resident #2 was reviewed, dated as received on 07/21/2025: Resident stated his call light was not answered timely on 3pm-11pm shift on 07/18/2025. The findings documented: Explained to resident that call light is malfunctioning and maintenance team are working on getting it fixed. Resident provided with a bell to ring in the meantime. The grievance was documented to have been resolved on 07/22/2025. The form documented the outcome was verbally communicated the outcome of the investigation and the resident was satisfied. During the interview with the SSD, she stated, his call light was dysfunctional. It was staying on continuously. We could not get it to cut off. We gave the residents (in the room) bells to ring during that period. They like to keep them, even though the light is fixed. We offered room changes until that got resolved; and we offered them staff to round more frequently in that room. During the interview on 08/12/2025 at 11:15 a.m., the SSD and the surveyor observed Resident #2's room, the red light above the door was flashing and sounding. Resident #2 was in the room, in his wheelchair, he stated the call bell light had been going off for about a month and a half. he said, They gave me a bell. Sometimes they do not hear it. It can take a while. Bells were observed at Resident #2's bedside and the roommate's bedside, and one on the back of the commode in the bathroom. At this time, the SSD said it was a shock to her; the residents had bells; she thought maintenance was fixing the call lights. On 08/12/2025 at 12:08 p.m., the Maintenance Director was interviewed. He stated for Resident #2's room, We changed the box in the wall, he (the resident) purposely pulled at the box; I have seen him bang it. I could be wrong. I used all the spare parts. For the grievance, there was a whole new box installed in the bathroom at the time the grievance was done. The Maintenance Director reported the continuous sounding of the light in the hall stopped at that time, it worked for about a week and then started up again. He stated he was waiting for a technician from an electric company to come to the facility to bring spare parts. When asked how long it took for the electric company to respond to a request from him, he stated, It takes about a week, sometime 2-3 days. When asked if he had any documentation to support the effort by the facility to resolve the resident's concern regarding the continuous call bell light, he did not respond. He stated he would call today. On 08/12/2025 at 3:40 p.m. a telephone interview was conducted with Resident #2's family member. He stated he would visit the resident all the time. He worked around the corner from the facility and will come in at various times. He stated the call bell light has been going off continuously for weeks. The family member said, I could understand if it were a couple to a few days, but it had been a month. They should have fixed it. The family member stated the resident has to wait for help. They had given him a bell to ring. The family member stated sometimes the staff do not hear it and reported having to go into the hall to ring the bell for them to hear it. The family member stated, I do his laundry; his clothing is soiled. They are not getting to him quick enough. I talked to Maintenance and the Nursing Home Administrator. A review of the facility's policies and procedures for Complaint/ Grievance, N-1042, last revised 10/24/2022, documented the policy: The Center will support each resident's right to vice a complaint/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint; Grievance and informed (sic) the resident of progress towards resolution.The procedure included: .4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days.

Based on observation, record review, and interview, the facility failed to ensure a timely repair of a call bell light for one resident (#2) of five sampled residents. Findings included: On 08/12/2025 at 9:49 a.m., an observation was conducted of Resident #2's room. The light in the hallway above the door was sounding repeatedly with a flashing red light blinking. At 10: 50 a.m., the light above Resident #2's door was observed still flashing and sounding. No residents were in the room at the time of observation. Resident #2's call bell light was identified to blink and sound continuously on 07/21/2025 and the light was still malfunctioning as of 08/12/2025.On 08/12/2025 at 11:01 a.m. a grievance from Resident #2 was reviewed with the Social Service Director (SSD). Resident #2's grievance was dated as received on 07/21/2025 with a resolution date of 07/22/2025. The concern in the grievance, Resident stated his call light was not answered timely on 3 p.m.-11 p.m. shift on 07/18/2025. The findings documented: Explained to resident that call light is malfunctioning and maintenance team are working on getting it fixed. Resident provided with a bell to ring in the meantime. During the interview with the SSD, she stated, his call light was dysfunctional. It was staying on continuously. We could not get it to cut off. We gave the residents (in the room) bells to ring during that period. They like to keep them, even though the light is fixed. We offered room changes until that got resolved; and we offered them staff to round more frequently in that room.On 08/12/2025 at 11:15 a.m., Resident #2's room was observed with the SSD present. The red light above the door was flashing and sounding. Resident #2 was in the room, in his wheelchair, he stated the call bell light had been going off for about a month and a half. Resident #2 stated, They gave me a bell. Sometimes they do not hear it. It can take a while. Bells were observed at Resident #2's bedside and the roommate's bedside, and one on the back of the commode in the bathroom. At this time, the SSD said it was a shock to her; the residents had bells; she stated she thought maintenance was fixing it. On 08/12/2025 at 3:40 p.m. a telephone interview was conducted with Resident #2's family member. He stated he would visit (Resident #2) all the time. He worked around the corner from the facility and will come in at various times. He stated the call bell light had been going off continuously for weeks. The family member said, I could understand if it were a couple to a few days, but it had been a month. They should have fixed it. He stated my (Resident #2) has to wait for help. They had given him a bell to ring. Sometimes the staff do not hear it. (Resident #2) will have to go into the hall to ring the bell for them to hear it. I do his laundry; (Resident #2's) clothing is soiled. They are not getting to him quick enough. I talked to Maintenance; I talked to the Nursing Home Administrator. On 08/12/2025 at 12:08 p.m., the Maintenance Director was interviewed. He stated for Resident #2's room, We changed the box in the wall, he (the resident) purposely pulled at the box; I have seen him bang it. I could be wrong. I used all the spare parts. For the grievance, there was a whole new box installed in the bathroom at the time the grievance was done. The Maintenance Director reported the continuous sounding of the light in the hall stopped at that time, and it worked for about a week and then started up again. He stated he was waiting for a technician from an electric company to come to the facility to bring spare parts. When asked how long it took for the electric company to respond to a request from him, he stated, It takes about a week, sometime 2-3 days. When asked if he had any documentation to support the effort by the facility to resolve the resident's concern regarding the continuous call bell light, he did not respond. He stated he would call today.On 08/12/2025 at 1:15 p.m., an interview was conducted with the Maintenance Director who stated he had two methods of receiving work orders from the staff, the (electronic work order) system and a binder at the nurses' station. He stated there was no order in either places for (Resident #2's) call bell light not functioning. The Maintenance Director said, I just walk by and fix it.

Based on interviews and record review, the facility failed to ensure a grievance was investigated and tracked through to a conclusion for one resident (#1) out of five sampled residents. Findings included: On 9/18/2023 at 8:55 a.m. an interview was conducted with Resident #1's family member via telephone. Resident #1's family member stated she was not Resident #1's responsible party, and the responsibility was with another family member. Resident #1's family member stated she visited Resident #1 regularly and when she visits, she routinely finds care concerns. Resident #1's family member stated she had been in contact with many staff members to include floor nurses, the Social Service Director, the Director of Nursing, and the Nursing Home Administrator related to the care concerns. She stated staffing at the facility changes often. She stated she has voiced her concerns with care to the facility. She stated her concerns with care have been related to staff not assisting Resident #1 with checking and changing, not providing sufficient hydration, and lying in bed nude with only wearing an adult brief. She stated she has mentioned these concerns on more than one occasion to management and feels the concerns have not been investigated. She stated there has been no communication from the facility about the concerns or any type of resolution. Resident #1's family member stated she had verbalized these complaints to the Administrator, the Social Service Director, and the Director of Nursing. On 9/18/2023 at 10:00 a.m. the Nursing Home Administrator (NHA) and the Social Service Director (SSD) provided the last nine months of the facility's Complaint/Grievance log for review. A review of the log for the months of 1/2023, 2/2023, 3/2023, 4/2023, 5/2023, 6/2023, 7/2023, 8/2023, and 9/2023 revealed the following complaints related to Resident #1: 1. The Grievance log dated 1/7/2023 revealed Resident #1's family member lodged a complaint related to care and services, which was investigated and confirmed with resolution on the same date. The Grievance log revealed Resident #1's family member was communicated back with investigation results. 2. The Grievance log dated 6/12/2023 revealed Resident #1's family member lodged a complaint related to a missing phone, which was investigated and confirmed with resolution on the same date. The Grievance log revealed Resident #1's family member was communicated back with investigation results. On 9/19/2023 an interview with the SSD was conducted. She stated Resident #1's family member's complaints were investigated, and timely resolution and communication to the family member was completed. A review of the medical record for Resident #1 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. The Advance Directives revealed the resident had a Power of Attorney in place to make his medical and financial decisions. The diagnosis sheet revealed diagnoses to include but not limited to, Parkinson's Disease, abnormal posture, depression, anxiety, and a history of falls. A review of the Progress Notes revealed the following: 7/16/2023 10:59 p.m. Nurse writer entered the room same time as resident's [family member] found resident naked on bed. Resident denied taking off his clothes. [Family member] got upset about resident left without clothes. Nurse writer started to get resident dressed up, and his [family member] began to take picture of resident and nurse. Writer asked [family member] nicely to stop taking her picture without authorization. [Family member] told nurse to stop putting clothes on resident if she continued to take picture. Writer reminds [family member] this is a HIPAA [Health Insurance Portability and Accountability Act] violation, so she has to stop. A review of the current Minimum Data Set (MDS) Annual assessment dated [DATE] revealed the following: Brief Interview Mental Score (BIMS) score of 5, indicating severe cognitive impairment. Activities of Daily Living (ADL) functional capacity listed as, Extensive assist with two person assist to include Bed Mobility, Transfers, Dressing, Toileting, Bathing. Supervision with Eating with one person. On 9/18/2023 at 12:03 p.m. an interview with the SSD revealed she was aware of Resident #1 and also aware of his Power of Attorney (POA). She revealed the POA was another family member. She stated a family member visits routinely but is not the POA. She stated the resident was a pleasant man and needed assistance with most of his ADL's and sometimes goes out to activities. She stated the resident has lower cognitive function but was able to speak with relation to his day. The SSD stated if a complaint is brought up to a staff member, the staff member must follow through with getting the complaint either on the written complaint form, or passing it along to the Unit Manager, and then the complaint is brought to her department's (Social Services) attention. The Social Service Director stated once she receives the complaint, she logs it and starts the investigation by way of communicating with the complainant, and passing the concern to the DON, the Administrator, and respective department related to the complaint. She stated the grievance should be identified and then addressed in a timely manner with investigation and communication back to the person who made the complaint. She stated the facility addressed a complaint from a family member of Resident #1 on 6/12/2023 and 1/7/2023. She stated the complaints were related to a missing phone and nursing care and both were investigated and resolved within the same day they were lodged. The Social Service Director stated there were no other voiced or written grievances for Resident #1 6/12/2023. The Social Service Director reviewed the resident's medical record to include a nurse progress note, dated 7/16/2023. She confirmed the note revealed the resident's family member had concerns with him lying naked on the bed and this concern was not addressed. The SSD stated the information was never forwarded to her in order for her to investigate it. She stated she was not sure of the nurse who wrote the note, but the staff member should have forwarded the concern to the Social Service Department. On 9/19/2023 at 1:00 p.m. an interview was conducted with the NHA and the DON. They stated Resident #1's family member routinely speaks with them regarding her concerns with care and services. They stated they felt all areas of concern had been sufficiently identified and investigated. They stated they were not aware of the concern that occurred on 7/16/2023. They confirmed the nurse note dated 7/16/2023 did explain Resident #1's family member voiced concerns, but stated the concern was not forwarded to them or the Social Service Director to investigate. The DON stated management is responsible for reading daily progress notes and are to report any concerns during daily meetings. On 9/18/2023 the Nursing Home Administrator provided the Resident and Family Concerns and Grievances policy and procedure with an implementation date of 11/28/2017 for review. The policy revealed the following: Policy: To comply with federal regulation, the facility has implemented the policy to support and facilitate each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Definitions section of the policy revealed; Prompt efforts resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. The Policy Explanation and Compliance Guideline section revealed; 1. The Administrator has appointed the facility Grievance Official to be the Social Service Director and his/her designee. Revised 9/7/2022. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. 4. Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, and phone number. 5. Grievances may be voiced in the follow forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Customer Service Line (if applicable). 6. Procedure: a. The staff member recording the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. (i) Take any immediate actions needed to prevent further potential violations of any resident right. (ii) Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. b. Forward the grievance form to the Grievance Official as soon as practicable. c. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. (i) Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. (ii) All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance. (iii) All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to concerns/grievances and will share them only with those who have a need to know. d. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. e. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum. (i) The date the grievance was received. (ii) The steps taken to investigate the grievance. (iii) A summary of pertinent findings or conclusions regarding the resident's concern(s). (iv) A statement as to whether the grievance was confirmed or not confirmed. (v) Any corrective actions taken or to be taken by the facility as a result of the grievance. (vi) The date the written decision was issued. f. For investigations regarding allegations of neglect, abuse, injuries of unknown source, and or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State law, within five business days of the incident. 7. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 8. The facility will make prompt efforts to resolve grievances. 9. The concern/grievance will be logged after it's resolved by the resident and/or responsible party.

Based on observations, interviews, and medical record review, the facility failed to ensure the care plan interventions were implemented according to orders for two residents at risk for elopement (#3 and #4) related to use of a Roam Alert bracelets out of five sampled residents. Findings included: On 9/18/2023 at 1:35 p.m. Resident #4 was observed in her room lying in bed. Her arms were exposed, and a yellow Roam Alert bracelet was observed on her right wrist. An interview was unable to be conducted. On 9/19/2023 at 7:27 a.m. Resident #4 was observed in her bed and lying flat with head on the pillow. Resident #4 had a Roam Alert bracelet on her right wrist. An interview was conducted on 9/18/2023 at 2:00 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E confirmed Resident #4 was an elopement risk and should wear a Roam Alert bracelet on her arm. Staff E stated the Roam Alert bracelet would sound off a door alarm should the resident get near the alarm system at any of the exit doors. The LPN stated Resident #4 had not had any exit seeking behaviors but utilized the Roam Alert bracelet due to her cognition and diagnosis of dementia. The LPN stated she and the other Unit Managers update the Roam Alert books to reflect who is an elopement risk throughout the facility and will keep the books at the nurse stations as well as the front lobby desk. She stated she and the other unit managers ensure all staff are knowledgeable of where the book is and how to identify if a resident is an elopement risk. Review of the North Wing Roam Alert book revealed a blank floor plan with room numbers, an elopement policy and procedure, and photos with names of residents who were elopement risks. Further review of the book revealed a sheet of paper that indicated; Roam Alert Log North Unit. Resident #4 was identified as an elopement risk and revealed she is to wear a Roam Alert bracelet on her right wrist. The book also revealed a face sheet with Resident #4's photograph. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Review of the Advance Directives revealed the resident had a Power of Attorney who made her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to dementia, altered mental status, and history of falls. Review of the current Physician's Order Sheet dated for the month 9/2023 revealed the following: Roam Alert for Safety. Check placement and function every shift. Place on Right Wrist and check skin for integrity; original order date 8/17/2023. Review of the most current Minimum Data Set (MDS) assessment Medicare 5 day dated 8/13/2023 revealed: Cognition/Brief Interview Mental Status Score (BIMS) of 8, indicating severe cognitive impairment. Activities of Daily Living (ADL) revealed Supervision as one person assistance with most ADLs. However, requires limited assistance with dressing; Behaviors revealed no behaviors exhibited with relation to wandering. Review of the most recent Elopement Risk assessment dated [DATE], revealed; Not wandering/seeking to find spouse and/family, and checked as not at risk for elopement. Review of the current care plans with a next review date 11/19/2023, revealed the following: 1. ADL self-care performance deficit related to metabolic encephalopathy, Hypertension, Dementia, Syncope, Altered Mental Status, History of falling, with interventions in place as reviewed and observed. 2. High risk for fall and related injury related to: Disease process/condition, Functional problem, Hypertension Dementia, Syncope, Altered Mental Status, History of falling, Medication usage and unavoidable decline. Use of assistive device to include wheelchair, fall risk factors present as determined by fall risk screen, with interventions in place as reviewed and observed. 3. Tend to wander aimlessly due to impaired cognitive function. However, is not actively seeking an exit at this time, and with interventions in place to include but not limited to: Check for proper functioning of the audible alarm system every shift and as need. On 9/19/2023 at 9:36 a.m. both MDS/Care Plan Coordinators Staff Band C revealed they were aware of Resident #4 and her being an Elopement risk. They stated the resident utilized a Roam Alert bracelet per the order and care plan. They reviewed the current care plans, and confirmed there was not any specific direction related to the use and maintenance of this Roam Alert band. Staff B and C both confirmed the intervention was not as descriptive with use and maintenance of this device, and confirmed other residents who have the same device are care planned specifically with the maintenance and us. On 9/202023 at 1:00 p.m. the Nursing Home Administrator provided the Comprehensive Care Plans, with an implementation date of 11/28/2017, for review. The Policy revealed the following; It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet at resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Definitions section of the policy revealed; Person-centered-care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The Policy Explanation and Compliance Guideline section of the policy revealed; 1. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. The resident's goals for admission, desired outcomes, and preferences for future discharge. 2. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 3. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 39866 Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His medical diagnoses include but are not limited to; fracture of the left acetabulum, history of falling, muscle weakness, Alzheimer's disease, adjustment disorder with anxiety, and cognitive communication deficit. Review of Resident #3's Minimum Data Set (MDS) dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of Resident #3's Elopement Risk evaluations dated 8/8/23 and 9/6/23 revealed the resident was at risk for elopement. An interview was conducted on 9/18/23 at 12:50 p.m. with Resident #3. The resident was observed to be sitting in his wheelchair, in the therapy gym. The resident was observed to be pleasantly confused and unable to describe past events with accuracy. An observation was made on 9/18/23 at 12:52 p.m. there was no wandering device observed on the resident or his wheelchair. An interview was conducted on 9/19/23 at 12:52 p.m. with Staff F, Occupational Therapy Assistant (OTA) she felt the residents' wrists and observed his ankles and observed his entire wheelchair and she confirmed there was no wandering device on the resident or his wheelchair. An interview was conducted on 9/18/23 at 12:54 p.m. with Staff D, Licensed Practical Nurse (LPN), she stated she was Resident #3's nurse. She stated the resident was supposed to have a wandering device on. She stated she had not checked for it yet. She reviewed the Physician orders and confirmed the resident was ordered to have a wandering device attached to the back of his wheelchair on the left side. An interview was conducted on 9/18/23 at 12:55 p.m. with Staff E, LPN, Unit Coordinator she confirmed the resident only had one wheelchair. An interview was conducted on 9/18/23 at 1:10 p.m. with the Director of Nursing (DON) he stated the location of the resident's wandering device is located in the elopement books and wouldn't necessarily be on the Physician orders. He located an elopement book and confirmed Resident #3's wandering device should be on the left side of his wheelchair. Resident #3 was observed being propelled down the hall by Staff F, OTA and the DON observed the resident's wheelchair and confirmed there was no wandering device on the resident or the wheelchair. Staff F, OTA stated Resident #3 received a new wheelchair last week sometime. She stated she was not the one who changed the wheelchair, but he got a new one because it was too low for him. She stated his old wheelchair would be in the therapy storage area in the therapy room. On 9/18/23 at 1:14 p.m. Staff G, Occupational Therapist (OT) stated she did not change his wheelchair Staff F, OTA did. The DON said Staff F, OTA said she didn't change it. Staff G, OT went to the computer to see what therapist changed the wheelchair and confirmed there was no documentation related to changing his wheelchair. Staff H, Physical Therapist Assistant (PTA) was in the therapy room, and she said she changed the chair on Wednesday of last week (9/13/23). She said his other chair was way too small for him. She said she does not remember there being a wandering device on his old chair because she would have seen it. She entered the therapy storage area, and she said, I believe this was his wheelchair and there was no wandering device on it. She stated she did not remember ever seeing it on the wheelchair. The wheelchair was observed not to have a wandering device on it. On 9/18/23 at 1:18 p.m. the DON said when the wheelchairs get changed the wandering device stays with the resident no matter what. Review of Resident #3's Physician orders revealed an order with a start date of 9/12/23 and no end date as; Roam alert for safety. Check placement and function every shift. Review of Resident #3's Treatment Administration Record (TAR) revealed a physician's order to start on 9/12/23 and was discontinued on 9/18/23 as; Ensure [wandering device] is in place every shift back of w/c (wheelchair) left side. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift on 9/12/23 through the night shift on 9/17/23. Further physician orders review on the TAR revealed; Roam alert for safety. Check for placement and function every shift with a start date of 9/12/23 and no end date. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift of 9/12/23 through the night shift on 9/18/23.

Based on observations, interviews, and record review the facility failed to ensure a wandering device was placed on one resident (#3) out of 5 residents reviewed to be at risk for elopement. Findings included: Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His medical diagnoses include but are not limited to; fracture of the left acetabulum, history of falling, muscle weakness, Alzheimer's disease, adjustment disorder with anxiety, and cognitive communication deficit. Review of Resident #3's Minimum Data Set (MDS) dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of Resident #3's Elopement Risk evaluations dated 8/8/23 and 9/6/23 revealed the resident was at risk for elopement. An interview was conducted on 9/18/23 at 12:50 p.m. with Resident #3. The resident was observed to be sitting in his wheelchair, in the therapy gym. The resident was observed to be pleasantly confused and unable to describe past events with accuracy. An observation was made on 9/18/23 at 12:52 p.m. there was no wandering device observed on the resident or his wheelchair. An interview was conducted on 9/19/23 at 12:52 p.m. with Staff F, Occupational Therapy Assistant (OTA) she felt the residents' wrists and observed his ankles and observed his entire wheelchair and she confirmed there was no wandering device on the resident or his wheelchair. An interview was conducted on 9/18/23 at 12:54 p.m. with Staff D, Licensed Practical Nurse (LPN), she stated she was Resident #3's nurse. She stated the resident was supposed to have a wandering device on. She stated she had not checked for it yet. She reviewed the Physician orders and confirmed the resident was ordered to have a wandering device attached to the back of his wheelchair on the left side. An interview was conducted on 9/18/23 at 12:55 p.m. with Staff E, LPN, Unit Coordinator she confirmed the resident only had one wheelchair. An interview was conducted on 9/18/23 at 1:10 p.m. with the Director of Nursing (DON) he stated the location of the resident's wandering device is located in the elopement books and wouldn't necessarily be on the Physician orders. He located an elopement book and confirmed Resident #3's wandering device should be on the left side of his wheelchair. Resident #3 was observed being propelled down the hall by Staff F, OTA and the DON observed the resident's wheelchair and confirmed there was no wandering device on the resident or the wheelchair. Staff F, OTA stated Resident #3 received a new wheelchair last week sometime. She stated she was not the one who changed the wheelchair, but he got a new one because it was too low for him. She stated his old wheelchair would be in the therapy storage area in the therapy room. On 9/18/23 at 1:14 p.m. Staff G, Occupational Therapist (OT) stated she did not change his wheelchair Staff F, OTA did. The DON said Staff F, OTA said she didn't change it. Staff G, OT went to the computer to see what therapist changed the wheelchair and confirmed there was no documentation related to changing his wheelchair. Staff H, Physical Therapist Assistant (PTA) was in the therapy room, and she said she changed the chair on Wednesday of last week (9/13/23). She said his other chair was way too small for him. She said she does not remember there being a wandering device on his old chair because she would have seen it. She entered the therapy storage area, and she said, I believe this was his wheelchair and there was no wandering device on it. She stated she did not remember ever seeing it on the wheelchair. The wheelchair was observed not to have a wandering device on it. On 9/18/23 at 1:18 p.m. the DON said when the wheelchairs get changed the wandering device stays with the resident no matter what. Review of Resident #3's Physician orders revealed an order with a start date of 9/12/23 and no end date as; Roam alert for safety. Check placement and function every shift. Review of Resident #3's Treatment Administration Record (TAR) revealed a physician's order to start on 9/12/23 and was discontinued on 9/18/23 as; Ensure [wandering device] is in place every shift back of w/c (wheelchair) left side. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift on 9/12/23 through the night shift on 9/17/23. Further physician orders review on the TAR revealed; Roam alert for safety. Check for placement and function every shift with a start date of 9/12/23 and no end date. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift of 9/12/23 through the night shift on 9/18/23. Review of Resident #3's care plan with an initiated date of 8/8/23 revealed I am an elopement risk/wanderer r/t [related to] History [sic] of attempts to leave facility unattended the goal included I rely upon staff to monitor my location to decrease my ability to elope from the facility through interventions as provided. The interventions included but are not limited to apply roam alert- Check for working condition, placement and skin integrity as ordered. Review of the facility's Elopements and Wandering Residents policy with an implementation date of 11/28/2017 revealed Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: .3. The facility is equipped with door locks/alarms to help avoid elopements. 4. alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. the facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .

Based on medical record and facility policy review, interviews with nursing staff members, the Director of Nursing (DON), the Physical Therapy Director, and the Advanced Registered Nurse Practitioner (ARNP) the facility failed to follow the comprehensive care plan interventions, related to fall risk, for one resident (#3) of twenty-four sampled residents. Due to the resident's history of falls and instability she was to be transferred by two staff members using a lift. The resident was transferred from the wheelchair to the bed by one staff member, without use of a lift. The resident was transferred to a sitting position on the side of the bed and left sitting there while the staff member left the immediate area. The resident fell face first onto the floor, sustained fractures to the nose and neck and required hospitalization . Findings included: A review of the Comprehensive Care Plan for Resident #3 revealed a focus area, goals and interventions as follows: Focus: (Resident #3) is at high risk for falls related to history of falls, [DIAGNOSES REDACTED]. The focus area was initiated on 10/04/2018. Goal: Will minimize the risk for fall related injuries thru next review. The target date was 12/30/2020. Interventions: ¼ side rails for turning and repositioning and assist with transfers Bed in lowest position Encourage to use call light and wait for assistance Encourage/assist resident to participate in meaningful activity Encourage/assist resident with non-skid socks/shoes when out of bed as allowed by resident Ensure call light is within reach Floor mat to door side of bed (Mechanical) lift and assist of two staff for transfers Keep a clutter free environment Keep personal items within reach Parameter mattress Reacher to assist with items Wheelchair with anti-tippers The medical record review revealed Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. A review of the current active physician order set for Resident #3 indicated: Patient to use (Mechanical) Lift for transfers with a 2 person assist, dated 11/05/2019, Floor mat to door side of bed DX (diagnosis): Decreased Safety Awareness - Fall, dated 5/21/2019, and Patient to have Left Hemi Tray on Wheelchair to Reduce Left Trunk Lean and Anterior Trunk Leaning to Enable Upright Sitting Posture, dated 7/26/2019, and Parameter Mattress, dated 5/30/2020. A review of the Minimum Data Set assessment dated [DATE] for Resident #3 indicated in Section B Hearing/Speech/Vision, the resident's vision was severely impaired. Section C Cognitive Patterns, of the assessment revealed a Brief Interview of Mental Status (BIMS) score was 5, indicating severe cognitive impairment. Section G Functional Status of the assessment indicated the resident required total assistance by two persons for transfers and balance during transfer from surface to surface was not steady and only able to stabilize with staff assistance. A review of the Fall Risk Evaluation form utilized by the facility revealed on 9/23/20 an evaluation was completed for Resident #3 and a score of 22 was obtained which indicated Resident #3 was at high risk for falls. A review of the CNA Care Tool form utilized by the facility revealed an updated tool on 10/26/20 which indicated Resident #3 was blind, utilized a wheelchair, transfer by two persons, and utilized a (Mechanical) lift which required two-person assist. The document also indicated Fall Alert program and a perimeter specialty mattress. A review of the progress notes for Resident #3 revealed a handwritten note dated 12/6/20 which stated, CNA (Certified Nurse Assistant) was calling for help. When enter the room Resident was observed on the floor lying on the R (right) side by the bed. Upon assessment BP (Blood Pressure) 157/94, 72, 20, 97.4, 97. Resident was bleeding pressure applied to affected area contusion about 2 x 2 cm (centimeters). PRN (as needed) Tylenol administered 325 x 2 for headache. MD (medical doctor) made aware order received to send resident out for eval and tx (treatment). Neuro check initiated. Also, skin tear to LL (left lower) leg. Family notified. Resident left facility 1:55 p.m. to hospital. An electronic note dated 12/7/2020 at 12:20 p.m. indicated Resident #3 was discharged to hospital on [DATE] with expected return. An SBAR (situation, background, appearance, review) form was completed for Resident #3 at the time of the incident (12/6/20). The form indicated a change of condition due to a fall with a contusion to forehead and a skin tear to the left lower leg. The primary care clinician was notified, and orders received to send resident out for evaluation. A review of the emergency room medical records for Resident #3 revealed a history and physical dated 12/07/2020 at 11:00 a.m. as follows: Chief Complaint: per ems (emergency medical services) pt (patient) from nursing home rolled out of bed getting into wheelchair, hitting face on floor, no loc (loss of consciousness), no blood thinner, no complaints of pain, hematoma to forehead bandaged by ems. Alert and oriented to person and place only. History of Present Illness: [AGE] year old admitted through emergency room after a ground level fall fell out of bed with a loss of consciousness sustained facial forehead trauma complain of neck pain found to have c-spine fractures admitted for further care and evaluation she is now in the ICU (Intensive Care Unit) no distress patient being seen for internal medicine consultation. Assessment/Plan/Diagnosis: [REDACTED]. Fracture C2 vertebra closed Facial laceration Fall Fracture C1 vertebra closed [MEDICAL CONDITION] History of dementia Advanced Age [MEDICAL CONDITION] disc disease LS spine On 3/4/21 at 11:28 a.m. an interview was conducted with the Social Services Director (SSD). She stated Resident #3 had been in the facility for quite a while and when she first came, she had frequent falls. She stated the resident was able to move around the facility in a wheelchair on her own and was known to be impulsive. On 3/4/21 at 12:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated he was notified of the event involving Resident #3 on 12/6/20 right after the event occurred by the nurse assigned to the resident. He indicated the nurse was Staff A, Licensed Practical Nurse (LPN) and the aide caring for the resident at the time was Staff B, Certified Nursing Assistant (CNA). The DON stated Staff B, CNA was the only staff member in the room at the time of the fall. The DON stated Resident #3 was a two-person (Mechanical) lift assist for transfers. The DON stated he conducted an interview with Staff B to determine what occurred. Staff B told him she was getting Resident #3 back into bed from the wheelchair after lunch when she noticed a skin tear to her leg after putting her on the bed so she went to go get supplies in the bathroom to clean up the resident's leg. The DON stated Staff B did not witness the fall. The DON stated Staff B came out of the bathroom and saw Resident #3 on the floor. The DON stated Staff B called for help and the nurse came to assess the resident. The DON stated he did not consider the incident an adverse event and did not file an immediate report despite knowing the resident had sustained multiple fractures. The DON stated he had consulted with the Administrator at the time and was told the resident was safe in the bed at the time so it was not considered an adverse event issue and he did not have to file an adverse event report. The DON was told the bed was in a low position and a mat was on the floor by Staff B, CNA. The DON reported Staff B was reeducated on safe transfers and how to read the care plan for the residents. A review of all residents' transfer method was completed according to the DON, but no evidence of the audit was available. The DON stated he interviewed the nurse at the time of the incident, but no statement was available for review. The DON stated Staff B told him the resident was laying down in the bed at the time of the incident and a review of the statement document did not reveal a position of the resident. The document just indicated the resident placed in bed. On 3/4/21 at 1:22 p.m. an interview was conducted with Staff A, LPN. Staff A indicated she was working on the day of the event. She stated the nurse caring for Resident #3 was Staff C, LPN. Staff A stated she was called to the room to assist Staff C, LPN with Resident #3. She stated they assessed the resident and decided she needed to go to the hospital for evaluation. Staff A, LPN stated Resident #3 was lying on the floor by the door bed with her face down on the floor. Staff A stated she went to go get paperwork and items for vitals and assessments and called the DON, the resident family, and the provider. Staff A indicated she had cared for Resident #3 in the past and was aware of the fall risk and frequent falls in the past. Staff A, LPN stated Resident #3 usually fell out of the wheelchair not the bed. Staff A, LPN stated she did not recall any major injuries in the past involving Resident #3. Staff A, LPN stated the bed was in the low position and the resident was bleeding, able to talk with them and stated her head hurt. Staff A, LPN stated she was never interviewed by anyone about the incident and no one ever took a statement from her. Staff A, LPN stated she knew Staff C, LPN did a report and completed all the nursing notes and documentation. On 3/4/21 at 2:33 p.m. an interview was conducted with the MDS Coordinator. She stated Resident #3 had six falls listed between February and April of 2019 on the care plan with new interventions put into place after each fall. The MDS Coordinator stated she believed a perimeter mattress was on the bed at the time of the incident on 12/6/20. On 3/4/21 at 3:20 p.m. an interview was conducted with Staff D, LPN Unit Coordinator (UC). Staff D, LPN UC stated he knew the resident well. He confirmed the resident had a history of [REDACTED]. Staff D stated several interventions were in place for Resident #3 and each fall was reviewed at the time of the events. Staff D stated he recalled Resident #3 would fall trying to transfer by herself from the wheelchair and the bed. Staff D confirmed Resident #3 required a (Mechanical) Lift transfer by two staff members for all transfers. Staff D stated all transfers using a Sara or (Mechanical) lift is required to have two staff members by policy. On 3/4/21 at 3:40 p.m. an interview was conducted with Staff B, CNA via telephone. Staff B confirmed she was caring for Resident #3 on the day of the incident 12/6/20. She stated she took her in the wheelchair to her room for the afternoon nap. Staff B stated she noticed a skin tear on the resident's leg that she sustained from the wheelchair during the transfer. She stated she left the resident sitting in an upright position on the side of the bed with her legs hanging off the bed and her hand on the bed rail. She went to the bathroom to get something to wipe up the skin tear and she had the water running. She stated she did not hear anything but when she came out of the bathroom, she saw the resident lying on the floor face down toward the wall and the overbed table. She stated the resident had fallen off the bed face first to the floor. Staff B stated no one else from the staff was in the room with her. Staff B stated she looked at the care plan for the resident and saw that it was a one-person transfer. Staff B stated the bed was in the low position and a fall mat was on the floor. She confirmed she called for help and the nurses came in right away to assess the resident and proceeded to call 911 and send the resident to the hospital. Staff B stated Resident #3 did not have a loss of consciousness. Staff B, CNA stated after the incident she gave a statement to the DON and was educated one on one about always using two people and reviewing the care plan prior to transfers. She stated she was not aware Resident #3 was a high risk for falls due to being newly hired back to the facility in November, she explained she had worked at the facility previously in 2018. Staff B stated she felt very bad about the incident and she still thinks about it and it bothers her. On 3/4/21 at 4:10 p.m. an interview was conducted with the MDS Coordinator. She confirmed the nursing aides are all educated on how to find the information about transfers in the C.N.A. Care Document that is kept for each resident on the floor. She stated the aides are to refer to the document and it is reviewed with them during orientation. She stated she teaches them specifically how to interpret the document for care. The Coordinator provided the education documents for Staff B, CNA for review. A review of the documents provided revealed Staff B, CNA was oriented to back safety and transfer techniques, fall and safety prevention on 11/24/20. Staff B was oriented to Sara and (Mechanical) lift transfers and completed a post test on 11/24/20. Staff B signed a lifting release form indicating staff are not to lift any patients, visitors, guests, or employees on the facility premises without first obtaining assistance on 11/24/20 during the orientation training. On 3/4/21 at 4:32 p.m. an interview was conducted with the Director of Rehabilitation. The Director indicated she knew Resident #3 well and the department had provided therapy services for the resident many times. She stated the resident had [MEDICAL CONDITION] and standing was always a challenge. The Director stated Resident #3 had been a frequent faller and interventions were put in place for positioning in her chair or sitting because she was impaired in trying to maintain an upright position. She stated Resident #3 had poor sitting balance which means she needs assistance with static, but if she tried to move, she would lose balance. The Director stated Resident #3 was on the therapy case load and received treatment for [REDACTED]. The resident had been seen seven times leading up to the fall and hospitalization . Resident #3 had been referred to therapy due to instable balance and decline while sitting. The Director explained the resident had a fall in May of 2019 and had a femoral neck fracture and from that point on all her abilities declined. The Director stated Resident #3 was considered a (Mechanical) lift for all transfers after May of 2019. The Director provided the treatment records for Resident #3. A review of the physical therapy plan of care date 11/20/20 to 12/08/20 listed the reason for referral of Resident #3 as Physical Therapy to evaluate and treat due to decline in bed mobility, weakness with decrease trunk control. Precautions were listed a poor safety awareness, high fall risk, visual impairment, history of [MEDICAL CONDITION]; (Mechanical) transfers; toileting program; floor mat door side bed; light weight hemi height wheelchair with posterior frame tilt, pressure reducing seat cushion, non-skid matting under seat cushion, and as of 7/26/19 left hemi arm tray, as of 9/17/19 full weight bearing lower extremities as tolerated. On 3/4/21 at 4:55 p.m. an interview was conducted over the telephone with Staff C, LPN. Staff C, LPN confirmed she was caring for Resident #3 on the day of the incident 12/6/20. She stated it was a Sunday afternoon around 2 p.m. Staff C stated she was passing medications when she heard the aide call out for help and she went right away to the room and saw the resident on the floor. She stated she called for the other nurse to come and help, and they assessed the resident and placed some pressure on her face because the resident was bleeding. Staff C stated the resident was lying on the floor on her side when she came in the room. She stated the resident was able to speak and the other nurse went to call 911. Staff C stated the ambulance came right away and transferred the resident to the hospital for evaluation. Staff C confirmed the bed was in a low position and the floor mat was under the resident. Staff C stated the aide told her she put her on the bed and went to the bathroom to get something to clean up the resident's leg and the resident fell . Staff C, LPN stated she filed all the paperwork and notified the DON about the incident. On 3/5/21 at 10:40 a.m. an interview was conducted with the Advanced Registered Nurse Practitioner (ARNP). The ARNP verified he had been providing care for Resident #3 since 2018 and was familiar with the resident. He stated she was wheelchair bound and was a high risk for falls. The ARNP stated a lot of interventions had been put in place to prevent falls. He stated she had a fall with major injury prior to the event in December 2020 when she had a fracture to a hip. He stated the resident also had a fall in July of 2019 in the shower but there was no major injury. The ARNP stated Resident #3 was doing very well but she was impulsive, and she would try to do things she could not do. He stated he was informed of the fall, and hospitalization of Resident #3. He stated he did not know the details. The ARNP stated Resident #3 was doing well leading up the event. He stated she was a feisty little thing and then he heard about the incident and he was surprised. The ARNP stated he was not part of an investigation or any root cause analysis to identify what happened. He stated the resident had some hypertension and was on some blood thinners due to a previous stroke, but she was doing fine. A review of the facility policy entitled 'Safe patient handling and mobility' with an implementation date of 10/8/2020 and a revised date of 10/8/2020 revealed the following: Purpose: To enhance the safety of the work environment for patient care providers and promote a safe and more comfortable environment for patients/residents who require total or partial moving or transfer assistance Application/Scope: Employees are expected to use safe patient handling and mobility techniques and equipment according to the rules of this policy. During planned patient/resident handling activities employees will not perform patient/resident transfers/complex lifts without mechanical assistive devices except in a an emergency. 1 Training: All facility employees involved in direct patient care are trained in safe patient handling and mobility using the appropriate equipment. They are trained upon hire, annually and as needed thereafter. All training done at the departmental level will be specific to the tasks and equipment used in the department. If employees/workers need retraining in order to use the equipment properly, they will be expected to participate fully. A review of the facility policy entitled Comprehensive Care Plans implemented on 11/28/2017 and revised on 12/31/2019 revealed the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed.

Based on record review and interviews with staff, the facility failed to ensure adequate supervision and intervention to prevent an elopement after a door alarm sounded for one (#4) of three residents reviewed for elopement. Findings included: A review of the facility's log for State and Federal reporting revealed that three residents had eloped from the facility since 04/24/20. The document revealed that Resident #4 was the most recent elopement on 01/07/21. On 01/20/21 at 4:49 p.m., the Director of Nursing (DON) verified that the date on the reporting log was incorrect, and the incident happened on 12/26/20. The DON reported that Resident #4 was not initially identified as an elopement risk. The incident happened around 12 noon on 12/26/20. She went out of the door that separated the assisted living facility (ALF) from the nursing home. The resident held on to the bar attached to the door in order to open the door. The door alarmed at the nursing station and at the receptionist desk up front. They were vacuuming at the time, so the receptionist did not hear the alarm. The resident entered the ALF side, exited through the door on the left-hand side of the ALF, and went out to the front parking lot. Staff checked the units after the alarm sounded instead of checking the exit doors. Resident #4 exited the facility and went outside. Staff B, Staffing Coordinator, and Staff C, Certified Nursing Assistant (CNA), saw Resident #4 outside and Staff B went out to get her. Staff B and Staff C met in the middle and brought her back into the facility. Resident #4 had a Brief Interview of Mental Status (BIMS) score of 4 (indicating severe cognitive impairment). A head to toe assessment was completed with no injuries. Interviews during the investigation revealed that the resident was observed sitting in the wheelchair in her room [ROOM NUMBER] minutes prior to the event. She was identified initially on admission as a wanderer, but was no longer displaying that behavior, and the care plan was updated. On 01/20/21 at 5:12 p.m., Staff B reported that she was asked to sit up front while the receptionist took a break on 12/26/20. The phone rang and she saw somebody roll by the window. Resident #4 was wheeling through the parking lot. Another CNA was walking by and they went to get her. Staff B stated that Resident #4 said she needed to call her son, and no one would let her call him. Staff B asked where she came from and the resident pointed to the door she came out of which was the ALF door. Staff B reported that the alarm on the door between the nursing home and the ALF was still going off at the time. The door between the nursing home and the ALF was unlocked. The door should always be locked stated Staff B. Staff B reported that she went to get her key to lock the door and reset the alarm. This all occurred during lunch time. Staff B reported that dietary used the door to deliver trays from the nursing home side to the ALF side. Staff B stated that dietary should have a key to lock the door back. Staff B reported that when dietary passes trays to the ALF side, they use that door and once it releases, you have to lock it back with the key. On 01/20/21 at 5:36 p.m., the DON confirmed that in order to turn the alarm off, you have to reset it with a key. The DON reported that nursing supervisors, direct supervisors, the staffing coordinator, and dietary had a key. Dietary knows to ensure the door was locked. Dietary was the only ones that used the doors. On 01/20/21 at 5:46 p.m., the Certified Dietary Manager (CDM) reported that she had a key along with the nursing supervisors, direct supervisors, and the staffing coordinator. The CDM stated that the ALF team had a code to come open the door during meal service. The CDM reported that she never had a code for the door leading to the ALF side. On 01/20/21 at 4:09 p.m., the Maintenance Director reported that the door connecting the ALF and nursing home would alarm and alert the staff. The door alarms after 15 seconds of pushing on the door and then the door unlocks. On 01/20/21 at 6:25 p.m., the DON reported that the alarm sounds at the nurses' station and there was also a panel with a light indicator that depicts which door was alarming. On 01/20/21 at 6:31 p.m., the DON reported that the Human Resources Director's office and a nursing station for the ALF side was on the other side of the door Resident #4 exited. The alarm sounded at the nursing station in the ALF as well. An investigation was started on the day the event happened. Staff started looking for Resident #4 on the unit instead of checking the door that was alarming. He reported that he did not know why staff did not come down to the door when they saw it alarming. They heard the alarm but were looking on the unit. On 01/21/21 at 10:50 a.m., the Administrator reported that the door to the ALF was unlocked from the inside and locked on the outside in which the resident could not come back into the facility if she wanted to. On 01/21/21 at 11:12 a.m., Staff A, Registered Nurse (RN), reported that she remembered Resident #4 and was the nurse on duty at the time of the event. She recalled that the resident got out of the door to the ALF and was wheeling down the parking lot. Staff A stated, She won't listen. Staff A reported that they said the alarm was going off, but she did not hear the alarm. They were making arrangements for the resident's phone to be connected so that she could talk to her son. Staff A reported that she had been in-serviced before this event to not ignore the alarms and run to wherever we hear it says it is going off. Prior to the incident, education was completed with staff on 08/13/20-08/14/20 related to exit door procedures on timers, alarms, and resetting the alarms. A review of Resident #4's Admission Record revealed she was admitted to the facility in September of 2019 with [DIAGNOSES REDACTED]. A review of the tele-med visit with the physician dated 06/18/20 indicated that the resident had a [DIAGNOSES REDACTED]. The resident was coded as independent for locomotion on and off the unit and the resident used a walker and wheelchair for mobility. A review of Resident #4's Wander Data Collection Tool dated 06/24/20, 09/14/20, 12/19/20 prior to the incident indicated that the resident was not at risk for elopement. The Wander Data Collection Tool completed on 12/26/20, after the elopement, indicated that Resident #4 was at risk for wandering. The form indicated that the patient was exit seeking wanting to go meet her son. A review of the Physician order [REDACTED]. A review of the nurse's note dated 12/26/20 revealed an elopement occurred at 12:00 PM on this shift through the ALF building to the parking lot. Resident was redirected to self and room by staff and a head to toe assessment was completed. Roam alert was applied. A review of the facility's report dated 12/26/20 revealed that Resident #4 eloped to the outside area and was believed to have pushed the doors open to the ALF. The investigation of the event by the DON included three staff member statements: The 1st stated: I was notified Resident #4 was outside by C.N.A. at 12:00 on 12/26/20. The 2nd stated: Staff member was on her break during episode of Resident #4 being outside. The 3rd stated: Resident #4 was outside sitting in wheelchair by smoking section. The SBAR Communication Form dated 12/26/20 revealed that Resident #4 stated the elopement occurred at 12 p.m. Resident wanted to talk to her son. A review of the policy titled Accidents and Supervision implemented on 11/28/17 and most recently reviewed and revised 01/03/2021 revealed the following: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Photographic evidence was obtained.

Based on interview and record review, the facility failed to provide one (Resident #54) of one resident receiving outside wound care, with physician ordered antibiotics for seven days after wound debridement and bone biopsy for a toe infection, resulting in a hospitalization for [MEDICAL CONDITION] directly from the wound care physician's office. Findings included: During an interview, on 10/14/19, at 10:15 a.m. with staff member J, LPN, she confirmed Resident #54 received wound care outside the facility and was sent to the hospital during the appointment on 10/10/19. During an interview with staff member G, LPN, unit manager, on 10/14/19 at 10:20 a.m., the unit manager confirmed Resident #54 was sent to the hospital during his appointment. They had not heard any updates. The chart was filed in medical records. During an interview on 10/15/19 at 2:34 p.m. with staff member C, RN, she stated she worked with Resident #54 on 10/10/19 before his wound care appointment and stated she did not change his dressing that day due to his appointment. During an interview. on 10/15/19 at 3:45 p.m with the Director of Nursing (DON), she stated the resident went to wound care for a debridement on 10/3/19 and had a follow up on 10/10/19. The DON asked staff member G, unit manager, to join the interview, and he confirmed Resident #54 went to wound care on 10/10/19 after debridement on 10/3/19 and stated they may be amputating the right second toe. Review of the wound care physician notes, dated 10/3/19, reflected: wound #32 right toe second treated with topical [MEDICATION NAME] 4% to wound bed prior to debridement. Change dressing every other day. Primary dressing - apply [MEDICATION NAME] or [MEDICATION NAME] touch over sutures. Secondary dressing wound #32 Right toe second gauze - fold 4x4 in half lengthwise and cover toe from base to to toe over the top of toe. (Do how was done at wound care center when dressing changes is done). [MEDICAL CONDITION] control, wound #32 right toe second, [MEDICATION NAME] Fx1, taped over toe area to form sock. If questions call wound care center. Bacteria identified in wound by culture - bone culture right second toe. Bone biopsy right second toe Medications [MEDICATION NAME] HCI 300 mg capsule - one capsule four times a day for ten days. Review of the transcribed physician order, dated 10/4/19, for wound #32 right 2nd toe reflected to discontinue current treatment. Start cleanse right 2nd toe with normal saline, pat dry and apply [MEDICATION NAME] to suture line wrap with kerlix, secure with [MEDICATION NAME] and change every other day and as needed for surgical wound. Review of the transcribed physician order, dated 10/4/19, reflected monitor suture to right second toe during wound care treatment for [REDACTED]. There was no evidence of the physician's orders [REDACTED]. being transcribed on the medication administration record. During an interview, on 10/15/19 at 4:34 p.m., with staff member G, LPN unit manger, confirmed he spoke to the nurse that documented the nursing progress note dated 10/6/19, and stated he told the nurse he did not agree that the resident had a change in condition after debridement and stated the resident's toe would have been swollen and warm after the debridement. The 10/6/19 nursing note reflected dressing change per order, second toe, slightly discolored, warmer than adjacent tissue/toes, color purplish, positive sensation, pre medicated prior to treatment. Resident has 4 intact sutures, toe nail intact, flap like separation, sutures in place, no drainage during dressing change but previous dressing serosanginous. New dressing applied, feet up, off heal. [MEDICATION NAME] effective, will continue to observe, toe does appear swollen. Vital signs stable and signed by Registered Nurse. Staff member G, LPN unit manager confirmed the nurses progress note, dated 10/4/19, reflected the toe without signs or symptoms of infection noted. Staff member G, LPN unit manager, reviewed the wound care note dated 10/3/19 which reflected Resident #54 with a bone culture and bone biopsy to the right second toe, positive for bacteria with [MEDICATION NAME] HCI 300 mg, one capsule four times a day for ten days. After reviewing the Medication administration sheets, staff member G, LPN unit manager, confirmed that the antibiotic should have been ordered and started on 10/3/19 and confirmed Resident #54 did not receive the antibiotics from 10/3/19 to 10/10/19 and confirmed the physician was not notified of the 10/6/19 documented changes. During an interview, on 10/15/19 at 4:52 p.m., with staff member K, LPN unit manager, stated, when a resident goes out to an appointment, the nurse would update the information and go over the information with the unit manager to confirm the information was changed and up to date. During a phone interview, on 10/16/19 at 09:53 a.m., with the wound care center, the nurse case manager stated, on 10/3/19 the resident came in for a bone biopsy and culture which showed multi organism growth and she called the facility on 10/9/19 to alert the staff. She confirmed she was transferred twice and did not know who she ended up speaking with, but it was a nurse that knew Resident #54 and she alerted the female nurse the resident was positive [MEDICAL CONDITION] and two strains of proteus. The nurse confirmed the [MEDICATION NAME] should have been started on 10/3/19, at latest 10/4/19, and she was not informed, as of 10/16/19, that the facility never ordered the medication. The nurse stated a concern she observed was the dressing would be changed the day of the appointment or the day before, which was not always correct, due to the dressing change ordered. The nurse described the right second toe as: blown up, angry, red and significantly inflamed. The nurse confirmed the goal was to order IV medication on 10/10/19 when the resident came to the wound appointment but, due to the changes observed, the resident was sent to the emergency room and had been in the hospital six days currently receiving IV medication for [MEDICAL CONDITION]. During an interview, on 10/16/19 at 12:45 p.m., with the Advanced Registered Nurse Practitioner (ARNP), he stated that he was not made aware of any changes with Resident #54 and confirmed the facility should have either sent a physician order [REDACTED]. The ARNP stated the unit managers get so busy with reports and meetings that they don't have time to assure the charts are correct. The ARNP stated he was not contacted about the wound or changes, and confirmed he reviews the entire record every month but does not go page to page. The ARNP stated he wanted to make sure the residents receive continuity of care, but does not dig through the notes with each visit. The ARNP stated the resident required total assistance and has been observed with urine soaked dressings on his legs in the past. The ARNP stated the resident relies on the staff to change his briefs and has discussed amputation in the past with the resident, but he refused and has been treated for [REDACTED]. During an interview, on 10/16/19 at 11:54 a.m., with the DON, she stated that she was made aware of the medication error for Resident #54 on 10/15/19 in the afternoon, after the unit manager was reviewing the record with the surveyor. The DON stated that inservices and trainings were started last night and a medication error investigation was started with the nurse that documented on 10/6/19. However, that nurse is out of state and unavailable. The DON stated that they did not contact the wound center to let them know that the resident did not receive his antibiotic for seven days. The DON confirmed that when a resident goes out to a wound center and comes back the unit manager, nurse manager and nurse on duty should look at the new information and call the facility physician to get an order from the consult doctor, and should have called the wound care center when the change in condition was noticed for the resident. The DON confirmed that the facility physician was notified last night, 10/15/19. The DON stated if the wound care center called the facility, the nurse or person at the desk should have documented the new information in the resident record. The DON stated the nurse that signed off on the TAR (Treatment Administration Record) was new. During an interview, on 10/16/19 at 3:10 p.m., with the DON and Staff member C, RN, confirmed staff member C was the nurse on duty that day. Staff member C, RN, stated the initials were hers and confirmed the initials did not look the same as her initials on other days. Staff member C, RN, confirmed she changed the dressing on 10/10/19 before sending the resident to wound care, but did not document on the wound and could not remember what the wound looked like. The DON stated that his toe looked the same from the debridement on 10/3/19 and confirmed the chart did not reflect any documentation from 10/3/19 after the wound care appointment, and wound progress notes were missing from 10/8/19 and 10/10/19. Staff member C, RN, confirmed she documented on the wounds before, but did not document on the 8th or 10th. The DON stated, we chart by exception and we completed 24 hour chart checks. The chart record did not have a 24 hour chart check sheet. Review of the nursing progress notes dated 10/7/19 from staff member G, LPN unit manager, reflected the resident had a wound care follow up appointment on 10/3/19 at the wound care center. There was a excisional skin/subcutaneous tissue/muscle/bone debridement with a total of 1.1 sq cm performed to the right 2nd toe per the wound care center, pain was managed and controlled using [MEDICATION NAME] 2% injectable. Patient tolerated 4 intact sutures. Return to facility treatment wash with normal saline [MEDICATION NAME] to suture line changed every other day. No signs or symptoms or complaints of pain. Facility physician and contact updated on current wound progression and changes. Review of the hospital medical record, dated 10/17/19, reflected Resident #54 currently receiving pipercillin-tazobactam/D5W 3.375 gm 50 ml IV piggyback every 6 hour every intervals and [MEDICATION NAME] plus [MEDICATION NAME] 5% in water 500 ml 1.75 gm 35 ml IV piggyback every 36 hours for [MEDICAL CONDITION]. Review of the wound care center progress notes, dated 9/26/19, reflected Resident #54 with follow up to wound #32 right toe second, debrided, change dressing every other day. Dress wound with calcium alginate with silver- cut to fit the size of wound bed, non boarder foam, medfix tape, use foam to cover wound and tip of toe. [MEDICATION NAME] F x 1, taped over toe to form sock. If questions call wound care center. Additional orders, patient to be toileted and changed every two hours to prevent urine into wound dressing and contaminating. Please document. Review of the wound care center progress notes, dated 9/12/19, did not reflect a wound #32 right toe second. Review of the medication administration form reflected Resident #54 not documented on 10/4/19 or 10/10/19 as receiving [MEDICATION NAME] HCL 50 mg one tablet by mouth 30 minutes prior to dressing change daily as needed for pain. Review of the treatment administration form for Resident #54 documented on 10/4/19, 10/6/19, 10/8/19, 10/10/19 and 10/12/19 as receiving a dressing change. Further review of the treatment administration form found, monitor sutures to right 2nd toe during wound care treatment for [REDACTED]. The 10/4/19 to 10/10/19 dates were blank. Review of the physician order, dated 10/10/19, reflected the resident direct admit to the emergency room at 3:00 p.m. Review of the wound care progress note. dated 10/10/19 at 2:00 p.m reflected Resident #54 was sent to the emergency room . Review of the care plan reflected resident with vascular ulcer of the right second toe related [MEDICAL CONDITION], dated 9/27/19, with a goal to have no signs or symptoms of infection through the review date. Interventions include wound care center to treat, monitor, document, report as needed for signs and symptoms of infection including redness and swelling, red lines coming from the wound. Supplements as ordered to promote wound healing. Treatment as ordered. Review of Resident #54's record reflected the resident with recent re-admission on 7/24/19 with a [DIAGNOSES REDACTED]. Review of facility policy for physician orders [REDACTED]. Specific procedures for medication orders [REDACTED]. Physician orders [REDACTED]. Review of facility policy for Documentation in Medical Record, revised on 3/6/19, 1 page, reflected: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The facility will document at minimum daily for all skilled residents and monthly for long term residents not limited to episodic events. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Review of the policy for Notification of Changes, revised on 3/26/19, 2 pages, reflected: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notify, consistent with his or her authority, resident's representative when there is a change requiring notification.