Every finding on record at Aviata at Coral Bay

Based on record review and interview, the facility failed to document the resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers for 1 of 3 sampled residents, reviewed for pressure ulcers (Resident #1).The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Encephalopathy, Unspecified Respiratory Failure, Stage 4 Pressure Ulcer of the Sacral Region, Traumatic Brain Injury with loss of consciousness, Type 2 Diabetes and End Stage Renal Disease with dependence on Renal Dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], documented the resident's Brief Interview of Mental status (BIMS) was not attempted because the resident was unable to understand or communicate effectively. This MDS assessment documented the resident had one Stage 4 pressure ulcer that was present on admission. Resident #1 was dependent on the staff for all activities of daily living (ADLs). Review of the physician's orders dated 06/12/26 instructed for the resident's sacrum to be cleansed with wound cleanser or Normal Saline, pat dry, apply Honey Fiber to the wound bed, cover with silicone bordered dressing daily and as needed. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for June and July 2026 lacked any documentation of this wound care/dressing change provided for the resident. Review of the progress notes from 06/11/26 to 07/12/26 lacked any documentation of the wound care/dressing change provided for Resident #1. During an interview and side by side record review on 08/03/26 at 2:20 PM, Staff A, Licensed Practical Nurse/Wound Care Nurse in the presence of the Director of Nursing (DON) was asked about the process for wound care for residents with a pressure ulcer. Staff A stated a wound assessment was done on admission; the wound care orders and interventions were entered and the tasks completed. Each Friday, she made rounds with the wound care physician for an evaluation of the wounds. Staff A stated Resident #1 was admitted with a Stage 4 pressure ulcer to the sacrum; she did an assessment on 06/11/26 and the resident had 1 wound. On 07/10/26 the wound care physician's note documented the development of a new wound to the resident's lower left hip bone with a prognosis for poor healing due to the resident's multiple comorbidities. Staff A was asked where the wound care/dressing change provided for the resident was documented. She explained that when an order was placed, the task was reflected on the MAR/TAR documenting each encounter. The DON and Staff A reviewed the MAR/TAR and the progress notes for Resident #1 and stated there was no documentation of the wound care provided to the resident since admission on [DATE] to discharge on [DATE].

Based on record review and interview, the facility failed to notify the resident's representative of a change in the resident's physical status in 1 of 3 sampled residents, reviewed for change in condition (Resident #1).The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Encephalopathy, Unspecified Respiratory Failure, Stage 4 Pressure Ulcer of the Sacral Region, Traumatic Brain Injury with loss of consciousness, Type 2 Diabetes and End Stage Renal Disease with dependence on Renal Dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], documented the resident's Brief Interview of Mental status (BIMS) was not attempted because the resident was unable to understand or communicate effectively. This MDS assessment documented the resident was dependent on the staff for all activities of daily living (ADLs).Review of the physician's orders dated 06/29/26 indicated an order for a Chest Xray for a cough. The results indicated there was increased bilateral lung base opacity (hazy patches at the bottom of both lungs) due to atelectasis or pneumonia. It was documented this finding had worsened since the previous exam on 06/17/26.Review of the progress notes dated from 06/30/26 to 07/12/26 lacked documentation of any notification to the resident's representative of this change in condition. Further review of the record revealed the resident's son was the guardian.During an interview and side by side record review on 08/03/26 at 1:00 PM, the Director of Nursing (DON) was asked about the process when there was a change in the resident's condition. The DON explained that any change would be documented in the change of condition form or in the resident's progress note. This form would also have the date and time the resident's family was informed. She reviewed the records and confirmed there was not a change in condition form completed when the resident developed Pneumonia, and she was unable to find any supporting documentation in Resident #1's progress note.During an interview and side by side record review on 08/03/26 at 1:25 PM with Staff B, Registered Nurse (RN), also stated a change in condition would be documented on the form in the resident's electronic chart. Staff B reviewed the record and confirmed Resident #1's chest x-ray on 06/30/26 revealed Pneumonia but stated there was no documentation that this change was communicated to the resident's son.

Based on record review and interview, the facility failed to provide follow-up care for a surgical wound in a timely manner as evidenced by not attending to follow up surgical appointment and not informing the surgeon of the worsening condition of the resident's wound for 1 of 3 sampled residents (Resident #1).The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses included Diabetes, Chronic Kidney Disease, and Right Below the Knee Amputation, status post left foot toes amputation. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial/moderate assistance with activities of daily living. A review of Resident #1's care plan revealed the resident did not have a care plan for the left foot surgical wound. A review of Resident #1's orders revealed an order dated 03/10/25 for intravenous (IV) antibiotics for 25 days (until 04/05/25) , and an order dated 03/12/25 to follow up with the surgeon and infectious disease.A review of Resident #1's records did not reveal any documentation of the resident's left foot surgical wound's condition, or any treatment provided from admission on [DATE] until 03/17/25. Further review of Resident #1's orders revealed an order dated 03/17/25 for wound care to cleanse the foot surgical wound with Normal Saline and apply a dry dressing one time only. An order dated 03/19/25 documented for a dressing change to left foot to cleanse with Normal Saline, and apply a wound vacuum-assisted closure (vac) three times a week on Monday, Wednesday, and Fridays. A review of Resident #1's Treatment Administration Record (TAR) revealed that the dressing change and wound vac were applied on 03/21/25. However, there is no documentation indicating that the treatment was performed on 03/24/25 and 03/26/25. Additionally, no explanation was provided for the missed treatments on those dates.Record review revealed an order dated 03/20/25 for an appointment with the surgeon on 03/27/25 at 3:15 PM. An order dated 03/25/25 documented an appointment with infectious disease on 04/01/25 at 2:30 PM. A review of Resident #1's progress notes revealed a note dated 03/27/25 at 8:02 PM that documented Resident #1 went to a doctor visit for his wound today. No new orders received. Resident has a follow up appointment on 04/10/2025 at 2:30 PM. Plan of care ongoing.A review of a progress note dated 04/01/25 at 9:53 PM documented Resident #1 returned from a doctor's appointment. Orders received to continue IV antibiotics until 04/05/25, then remove IV line. A follow up with podiatrist (surgeon) will be necessary.Further record review did not reveal any documentation of the resident's left foot surgical wound's condition, or any treatment provided until 04/26/25. A progress note dated 04/26/25 at 3:32 PM documented Resident #1's left foot wound culture was positive for Pseudomonas, antibiotics were changed and the resident was to continue to follow up with the surgeon. Record review did not provide any evidence that Resident #1 went to his scheduled surgeon appointment on 04/10/25. Furthermore there was no evidence Resident #1's surgeon was notified of a change in the condition of the resident's wound.A review of Resident #1's progress notes dated 04/30/25 revealed the resident had an appointment with infectious disease, and an IV antibiotic was initiated. Again, there was no evidence that Resident #1's surgeon was notified of a change in the resident's wound.A review of a physician progress note dated 05/02/25 at 2:28 PM documented: Wound is reviewed with wound care nurse, wound vac was on place, after removed showed infected tissue, fetid (bad smelling), with bone exposure and discoloration and soft area of bone consistent with osteomyelitis, purulent discharge, foul smell, Meropenen (antibiotic) on IV BID (twice daily) X 10 days, follow up with ID (infectious disease) and foot surgeon will be arranged by nursing.Further record review revealed Resident #1 was transferred to the hospital on [DATE] for evaluation of the left foot wound. Resident #1 returned to the facility on [DATE]. There was no documentation of Resident #1's surgeon being notified of the change in the resident's wound.Record review revealed an order dated 05/05/25 for an appointment with resident #1's surgeon on 05/07/25 at 2:15 PM.A review of Resident #1's progress notes dated 05/07/25 at 3:55 PM documented Resident #1 returned back from the doctor's office with an order to send the resident to the hospital for evaluation.An interview was conducted with the Director of Nursing (DON) on 07/02/25 at 3:00 PM. The DON acknowledged the above.

Based on observations, interviews and policy review, the facility failed to maintain a dryer drum in a sanitary manner for 1 of 3 dryers observed in the laundry room, failed to provide a gown for sorting in the sorting area of the laundry room, failed to keep a broom and pan off of the floor in the laundry room; and failed to properly clean and disinfect a glucometer per facility policy. The findings included: 1. The facility's policy titled Cleaning and Disinfection the Meter with no date, revealed to disinfect: open the towelette container and pull out 1 towelette and close the lid. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other body fluids. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. This prevents disinfectant liquid from entering the meter. Properly dispose of the used towelette. Treated surface must remain wet for recommended contact time .do not wrap the meter in a wipe. Once contact time is complete, wipe meter dry. On 04/08/25 at 11:19 AM Staff A, a registered nurse, performed an accucheck on Resident # 109. The blood sugar was taken and no insulin coverage was necessary. After the accucheck was completed, Staff A returned to her medication cart to put away her supplies and clean and disinfect the glucometer. She took one Clorox wipe out of the container and wrapped the glucometer with the wipe. She did not wipe the entire surface of the glucometer horizontally and vertically. She stated she would let the glucometer sit wrapped for 3 minutes. When questioned, she said she will wipe it down after she let it sit for 3 minutes. Discussed with Director of Nurses and regional nurse consultant on 04/08/25 at 1:00 PM who agreed that the glucometer was not cleaned and disinfected properly. 2. An observation of the laundry room was conducted with the Director of Housekeeping on 04/10/25 at 9:29 AM. Walking into the dirty area of the laundry an observation was made of a broom with a pan on the floor. There was no gown for sorting in the dirty area. There are 3 washing machines. There are 3 dryers but 2 are working. Dryer #1 was observed with dry, hard residue stuck on the drum (photographic evidence obtained). An interview was conducted with the Director of Housekeeping who stated it is an old dryer and we want to get a new drum.

Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services in a manner to provide a safe, clean, home like environment. The findings included: 1). In the common area inside of the lobby/reception area, at the entrance to the courtyard, it was noted that there were 14 out of 16 lights that did not work and that another light was flashing off and on. 2). In the Main Dining Room on the second floor, the following were noted: A. There was an unidentified residue on the windows and the tint that was applied to the interior of the windows was peeling. B. there was an accumulation of dust in the air vent over the hand washing sink. C. The ceiling inside of the entrance to the second floor was unfinished and needed to be sanded and painted. 3). The frame and the door to the elevator by the Main Dining Room on the first and second floor was noted to have areas of peeling paint and linoleum on the floor in the elevator was peeling and damaged. 4). In the courtyard, the top of a canopy/shelter was torn and in disrepair and there was a screen that had fallen from one of the attached Assisted Living units that had fallen into the courtyard that was left for the duration of the survey. 5). On the second floor units, the following were noted: a. In room [ROOM NUMBER], there were scuff marks on the wall by the wall mounted air conditioning unit. Paint was missing from the corner of the wall exposing what appeared to be rust underneath by the window. The filters in the air conditioning unit were torn, and there was some residue on the left arm of the room chair. b. In room [ROOM NUMBER], there were brown spots on the wall to the left of the window and there was an accumulation of debris in the wall mounted air conditioning unit. c. In room [ROOM NUMBER], the privacy curtain between the beds was stained and the filters in the wall mounted air conditioning unit were dirty. There was a dried fluid on the top of the dresser of Bed A. d. In room [ROOM NUMBER], the over bed table for the B bed was held with a piece of tape and worn to a point that the particle board underneath was exposed. The hand sink in the shared bathroom was constantly running. e. In room [ROOM NUMBER], there was a hole in the door to the shared restroom and the wall to the left of the wall mounted air conditioning unit was damaged where the baseboard was not attached securely to the wall. f. In room [ROOM NUMBER], there were rub marks on the wall on both sides of the A bed dresser. g. In room [ROOM NUMBER], the floor tiles under the wall mounted air conditioning unit were separating and the adhesive was exposed, the exterior of the room entry door was noted to have scratches across the bottom, there was a hole in the exterior of the bathroom door. The baseboard and wall by the entrance to the room (in the corridor) to the right of the door was damaged in a manner that part of the baseboard was missing and there was a hole in the wall. During an environmental tour, on 04/10/25 at 8:14 AM, the Maintenance Director acknowledged the findings. While in the Main Dining Room on the second floor, the Maintenance Director placed his hand on the window and described the surface of the window as 'tacky'.

Based on interview and record review, the facility failed to provide restorative therapy as recommended by the Director of Physical Therapy for 2 of 2 sampled residents (Resident #62, and Resident #104.) The findings included: 1. Review of the record revealed Resident #62 was initially admitted on [DATE] with the admitting diagnosis of Paraplegia (the inability to voluntarily move the lower parts of the body.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 04/07/25 at 10:23 AM, when asked if he received any kind of therapy, Resident #62 stated he wasn't sure what kind of therapy he received but was pretty sure it was called restorative therapy. When asked how often he received it, he stated it wasn't that often because they don't have a lot of staff available to provide it; but when he received it, it helped. Review of the current orders did not reveal any kind of active therapy orders. During an interview on 04/09/25 at 2:05 PM, when asked if he knew what therapy orders Resident #62 had receivied, the Director of Physical Therapy stated he wasn't sure at the moment and would find out. During a follow up interview on 04/09/25 at 3:53 PM, the Director of Physical therapy, provided the surveyor a document titled Therapy Communication to Restorative Nursing Program (RNP) indicating the resident was part of the program. This document included Resident #62's functional status; problems/needs; and recommendations/approaches, photographic evidence obtained. When asked why there were no orders and what was done to keep track of when it was provided to the Resident, he stated that he was not sure how they kept track of it and that the Director of Nursing (DON) should be asked instead. During an interview on 04/09/25 at 4:24 PM, why Resident #62 did not have a RNP order, the DON stated the facility did not currently have a RNP since they only had one Restorative Certified Nursing Assistant (CNA), Staff C. The DON stated in order to have a program they would need a restorative nurse or an additional restorative CNA. When asked how many Residents were part of the RNP, the DON replied 10-15 residents. When asked how they kept track of what services were being provided to the Residents, the DON stated it should be documented in the electronic medical record. When the DON was made aware there was no documentation of Resident #62'S RNP services, she stated Staff C is supposed to be documenting in the electronic medical record but is aware she isn't documenting. She agreed on the importance of documenting work completed and that it should have been documented. It's a work in progress. she stated. During an interview on 04/10/25 at 09:29 AM, when asked to described Resident #62's RNP, Staff C stated, Leg exercises, all lower body, his upper body is okay. When asked how often he received the RNP and the last time he received it, she replied 3 times a week and Tuesday was the last time he received it, he would receive it later on that day. When asked how the dates are determined for the RNP days she stated she would pick the days she usually worked (Tuesday, Thursday, and Saturday.) Staff C provided the surveyor a list titled Restorative Nursing Program indicating all the current residents that were part of the program. Review of the list revealed 29 residents had current RNP recommendations, the most recent recommendation was on 03/28/25. During a side-by- side review of the list, Staff C was asked how she had time to see everyone, I try but it's hard, sometimes I have to spend less time with them. When asked to provide documentation of Resident #62's RNP services, Staff C stated she had not been documenting it. When asked why she hadn't been documenting, Staff C stated they had not set her up with a kiosk (computer CNAs document in) so she had not been able to put her documentation on it. They told me they would set one up for me but still haven't she stated. When asked if she wrote down what she did by hand, Staff C stated No, I don't write it down; I just keep it in my head and go from room to room. When asked if there was a reason she hadn't documented her work, she stated No, I'm just used to looking at my paper and doing it. She agreed that she should be documenting the work she is performing for the residents. 39026 2. Resident #104 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction and Atrial Fibrillation. His Brief Interview for Mental Status (BIMS) score was 14 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 03/08/25. This indicated the resident had intact cognition. Section O of this assessment revealed the resident had no restorative therapy minutes. On 04/07/25 at 10:19 AM an interview was conducted with Resident #104. The resident stated he was cut off by physical therapy because of documentation. He is only getting restorative some of the time. An interview was conducted with the Director of Nurses on 04/09/25 at 4:24 PM regarding the restorative program. She stated they don't currently have a restorative program in place ; to have a program they need two restorative aides and they currently only have Staff C available who works 3 times a week and provides these services to the residents when she works. They used to have a restorative program in the past. On 04/10/25 at 9:29 AM an interview was conducted with Staff C, identified as the restorative aide. She stated she had 29 residents on restorative therapy but has no documentation on the residents. She is the only one who does restorative. On 04/10/25 at 12:46 PM an interview was conducted with the Director of Physical Therapy regarding Resident #104. The Director stated the resident was discharged from therapy because of insurance coverage. He appealed and he was denied. Therefore, he referred him to restorative on 01/28/25 for 3 times a week restorative therapy. Discussed with Director of Physical Therapy why is he referring residents to restorative when he is aware that the facility does not have a restorative program. He stated that they are working on it.

Based on observation, interviews, record and policy review, the facility failed to provide a well-balanced diet that meets nutritional needs and honors residents' preferences for 2 of 5 residents sampled for food preferences (Resident #16 and Resident #51). The findings included: The facility's policy titled Dining and Food Preferences which originated 05/2015 and revised and 10/2022 revealed The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents/patients that do not consume certain foods or food groups. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, and Pneumonia. A Brief Interview for Mental Status (BIMS) was done on the Admission Minimum Data Set with an assessment reference date of 03/19/25. The BIMS score was 15 which indicated the resident had intact cognition. On 04/07/25 at 9:36 AM an interview was conducted with Resident #51. The resident stated he was given potato chips for supper last night (04/06/25) and a couple of sides but the main dish was chips. He further stated he was a vegetarian and thinks the kitchen does not know what to give him. On 04/07/25 at 12:05 PM an observation of the lunch meal revealed the resident was given fruit and cottage cheese. Record review revealed the resident was on a Regular diet, Regular texture, Regular/Thin Liquids consistency. A review of the resident's meal ticket for 04/06/25 for dinner revealed cottage cheese and fruit plate, 1/2 cup of potato wedges, 1/2 cup of coleslaw, a dinner roll, 8 ounces of milk, 6 ounces of tea of choice and a chocolate chip cookie. Review of the resident's meal ticket for breakfast on 04/09/25 revealed 1 biscuit, 6 ounces of hot cereal, 8 ounces of milk, 6 ounces of coffee or hot tea and 4 ounces of apple or cranberry juice. Review of the resident's meal ticket for lunch on 04/09/25 revealed a cottage cheese and fruit plate, 1/2 cup of parsley noodles, 1/2 cup of honey roasted carrots, 1 dinner roll, 1 slice of brown sugar glazed angel food cake and 6 ounces of tea. Review of the resident's meal ticket for dinner on 04/09/25 revealed cottage cheese and fruit plate, 1/2 cup tater tots, 1/2 cup braised cabbage, 1 dinner roll, 8 ounces of milk, 6 ounces of tea and 1/2 cup of sliced pears. A review of the resident's food preference assessment did not indicate that he was vegetarian. A review of the resident's nutrition assessment form dated 03/19/25 did not reveal he was vegetarian. On 04/10/25 at 11:00 AM an interview was conducted with Staff E, a registered dietitian. Staff E was asked if he was aware that Resident #51 was a vegetarian. He stated he was not aware. He then stated he would make sure his protein needs were met. The surveyor and Staff E then went to Resident #51's room together to interview him. The resident stated he had been a vegetarian since the 1970's. He likes rice, beans and fish. He is enjoying the cottage cheese, yogurt and fruit that is being provided for lunch and dinner but would also like a little variety. He stated last Sunday night he was provided a plate of potato chips for dinner and he was so hungry he ate them all. Staff E stated he would add fish to his diet and bean patties and veggie burgers. The resident was pleased. On 04/10/25 at 2:20 PM an interview was conducted with the kitchen manager who stated there is no diet for Lacto-ovo-vegetarian but she knew his preferences. They do preferences every 3 months of all of the residents but she had been to see him three times already for his preferences. The surveyor informed the kitchen manager that the dietitian was not aware that the resident was a vegetarian until surveyor intervention. 51137 2. Review of the record revealed Resident #16 was admitted on [DATE] with the admitting diagnosis of Intervertebral Disc Displacement, Lumbar Region (a condition where the discs in the lower back push through the tougher outer ring.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current orders revealed Resident #16 had a Carbohydrate Controlled Diet (CCD) with No Added Salt (NAS), (a dietary approach that focuses on managing carbohydrate intake and limiting sodium.) During an interview on 04/07/25 at 11:12 AM, when asked how the food was, he stated all his food was overcooked and burnt all the time. He described the servings of chicken as stringy and dry. Resident #16 showed the surveyor several pictures of the meals he was upset about. The food is often not edible, I ask myself; how can you send food out of the kitchen that looks like this, Resident #16 stated. When asked If he had told anyone about the concerns, he stated that he had addressed this with the Certified Dietary Manager, (CDM) but they were never fixed. The Resident stated Sunday night he was only served potato chips as an entree, photographic evidence obtained. He voiced he does not eat pork due to religious reasons and the main entree included a pork product that night. The Resident was not given an alternative entree option, leaving him without protein for dinner. Resident #16 was visibly upset during the interview, The food is unacceptable, he stated. During a dining observation on 04/07/25 at 1:06 PM, when asked how lunch was, Resident #16 stated his chicken was moist and cooked right; the Resident compared his meal to restaurant style quality. This is the first time in over a year it is cooked right, its only because you guys are here. Resident #16 stated that it usually never tasted that good and it was upsetting to him because it shows how much potential the kitchen had to put out a good meal. During a follow up dining observation on 04/08/25 at 1:25 PM, when asked how lunch was, Resident #16 stated he had quiche and a bread roll for lunch. I ate the bread because I was still hungry, he voiced. The Resident stated he couldn't eat the brussels sprouts on his meal tray because they were burnt, (photographic evidence obtained.) He stated, How can someone send out food that looks like this. During an interview on 04/10/25 at 09:03 AM, when asked if she was aware of Resident #16's food concerns, the CDM stated the Resident was at the last resident council meeting and he had spoke to her regarding his concerns of burnt food and she had addressed it at that moment. The CDM was shown pictures of Resident #16's meals he was upset about including the picture of the Resident's meal tray with only potato chips as an entree, the CDM acknowledged the findings. She stated that he should have been given another alternative that did not include pork but the meal ticket system did not capture that. During an interview with Resident #16 and the CDM on 04/10/25 at 09:57 AM, the CDM stated to the Resident We talked the last time you came to resident council meeting and had concerns about the food being burnt, have you seen any kind of improvement since? Resident #16 replied, No, it is getting worse. The cooks are putting out food that is poor quality; most of the time the food is not edible. The chicken is so dry and stringy; the noodles are rubbery; some food comes out so greasy and mostly everything else is always burnt. The Resident told the CDM that Monday's lunch was restaurant quality and it was upsetting to him because it showed him the potential the kitchen had to put out a good meal. Resident #16 addressed Sunday night's dinner that included only potato chips as an entree, the CDM acknowledged his concerns and stated he should not have only been provided potato chips. She stated the Resident should have received an alternative entree that did not include pork but the meal ticket system did not capture that. The CDM apologized to the Resident for all the concerns he had experienced.

Based on policy review, observation, record review, and interview, the facility failed to follow proper procedure for providing side rails as evidenced by failure to do an evaluation and get a consent signed prior to installing side rails for 1 of 24 residents observed (Resident #422). The findings included: Review of the policy titled Side Rail/Bed Rail dated 04/19/2018, documented, in part, Procedure: Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. Review the risk and benefits with the resident or representative. Obtain consent from the resident or resident representative. Obtain physician order for side rail/bed rail. Update the care plan and kardex. An observation on 04/09/25 at 1:52 PM, revealed bilateral one quarter side rails on Resident #422's bed. During an interview on 04/09/25 at 1:58 PM, when asked when he got the side rails, Resident #422 stated, They put them on this afternoon. The sister of Resident # 422 stated, They put them on today. I requested them, because he keeps falling out of bed and I'm afraid he is going to hurt himself. He had another fall last night. Record review on 04/09/25 and on 04/10/25 at 9:06 AM revealed that there was no documentation of a completed evaluation, prior to the side rails being installed for Resident #422. During an interview on 04/10/25 at 10:10 AM, when asked when the side rails were installed for Resident #422, the DON stated On yesterday because the mother requested them. When asked if the mother signed a consent, the DON stated It's a verbal consent with the mother and it should be in his record. When asked if an assessment was done prior to the side rails being installed for Resident #422, the DON stated, It was done by therapy I will get a copy for you. During an interview on 04/10/25 at 1:10 PM, when asked why she provided a copy of the therapy admission evaluation dated 04/03/25, the DON stated, I thought that's what you needed. When asked if nursing is responsible for doing an assessment as well, the DON stated, I didn't know nursing had to do one when the side rails are requested by the family. The DON then provided a copy of a side rail evaluation that she had completed with the date of 04/10/25 at 10:17AM.

Based on observations, record reviews, policy review, and an interview, the facility failed to provide respiratory care in accordance with Professional Standards of Practice for 2 Residents (Residents #61, #54) of 2 residents reviewed for respiratory care. The findings included: According to a review of the Policy and Procedures for Oxygen Therapy, the procedure for oxygen therapy included to start the oxygen flow rate at the prescribed liter flow. 1. Resident #54 was admitted to the facility on [DATE]. Her diagnoses included Heart Failure, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. A review of the Minimum Data Set (MDS) quarterly assessment completed on 02/16/25 revealed that Resident #54 had a Brief Interview for Mental Status score of 14, this indicated that she was cognitively intact. The focus of Resident #54's care plan last revised 02/06/24 said that the resident had respiratory issues related to shortness of breath, and that the resident received oxygen therapy secondary to Congestive Heart Failure. A record review showed Resident #54's care plan had a goal that stated the resident will have no signs and symptoms of poor oxygen absorption through the review date. This care plan was last revised on 08/29/24. An intervention listed said that the oxygen settings should provide oxygen per the (doctor's) order. Resident #54 had a doctor's order dated 07/06/23 to provide oxygen as needed at 2 Liters per minute. During an observation on 04/08/25 at 10:42 AM, the surveyor checked the oxygen concentrator to view the concentration of the oxygen that was being delivered via nasal cannula. The oxygen was delivered at 3 Liters per minute. The directions in the doctor's order specified 2 Liters per minute. On 04/09/25 at 8:00 AM,04/09/25 at 10:45 AM, and 4/10/25 at 11:22 AM, the oxygen level was set at 3.5 Liters per minute. Photographic evidence obtained. During an interview with Staff G (a Licensed Practical Nurse), on 04/10/25 at 11:22 AM, when asked to describe the oxygen level that Resident #54's concentrator was set on, Staff G said it was more than 3. The surveyor asked if it was set at 3.5 Liters per minute, and Staff G agreed with this finding. 2. A record review of Resident #61 revealed that she was admitted to the facility on [DATE]. Her diagnoses included Morbid Obesity, Shortness of Breath, and Generalized Muscle Weakness. A review of the Minimum Data Set (MDS), admission assessment completed on 02/03/25, revealed that Resident #61 had a Brief Interview for Mental Status (BIMS) score of 12. This indicated that she was cognitively intact. A record review showed a doctor's order dated 03/21/25 for oxygen to be administered at 2 Liters per minute via nasal cannula as needed to maintain saturations above 92%. A nursing progress note on 04/07/25 stated that Resident #61 was on continuous oxygen at 2 Liters via nasal cannula. During the initial observation on 04/07/25 at 4:08 PM, Resident #61 was in bed receiving oxygen via nasal cannula. The oxygen concentrator was set between 1-1.5 Liters per minute. The concentrator should have been set on 2 Liters per minute per the doctor's order. Observations on 04/09/25 at 10:25 AM, 04/10/25 at 8:13 AM revealed oxygen levels at 1.5 L. Photographic evidence obtained. During an interview with Staff G (a Licensed Practical Nurse), at 04/10/25 at 11:35 AM, the surveyor viewed the level of oxygen on the concentrator at eye level. The level was set at 1.25 Liters per minute. When Staff G was asked what the level of oxygen was set at, she answered that it was set at less than 2 L. When Staff G was asked if it was set at 1.25 Liters per minute, Staff G agreed with this finding.

Based on observations, interviews and record reviews, the facility failed to provide supervision to prevent the elopement of 1 of 3 residents reviewed for wandering and elopement, Resident #81. The findings included: The facility's policy 'Elopement/Wandering Risk Guideline' with a reference date of 09/21/16 and a revision date of 08/01/20, provided by the facility did not address 1:1 supervision to prevent elopement. Record review for Resident #81 revealed that the resident was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #81 had a Brief Interview for Mental Status (BIMS) score of 01. Progress notes and Interviews with staff confirmed that the resident was alert and oriented and able to make his own decisions for day to day activities. The MDS documented that Resident #81 displayed wandering behaviors each day of the 7-day look back period. The assessment documented that the resident required 'Supervision or touching assistance' for bed mobility and ambulated with minimal assistance. Resident #81's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, , Hip fracture, Seizure disorder, Malnutrition, Anxiety disorder, Depression, Left hip pain, Muscle weakness, Need for assistance with personal care, Cognitive communication deficit, Mood (Affective) disorder, Dependence on renal dialysis. Resident #1's care plan for wandering/elopement, initiated on 05/03/24 and most recently revised on 03/14/25 (upon most recent elopement), documented, Resident is an elopement risk/wanderer related to history of attempts to leave facility unattended. Resident had an elopement 6/19/24 elopement x2 ,7/1/24 attempted to push door open to leave facility, 3/14/25 resident left building unattended and brought back safely. The goal of the care plan was documented as, The resident will not leave facility unattended through the review date. Date Initiated: 05/03/2024 Revision on: 02/25/2025 Target Date: 05/26/2025. Interventions to the care plan included: o (3/14/25): Patient room changed away from exit doors. Continue to monitor frequently his whereabouts Date Initiated: 03/13/2025 Revision on: 03/14/2025 o Assess for elopement risk. Date Initiated: 05/03/2024 Revision on: 10/04/2024 o Constant supervision for safety Date Initiated: 01/01/2025 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book per resident preference Date Initiated: 05/03/2024 Revision on: 10/04/2024 o Electronic monitoring device. Date Initiated: 06/20/2024 Revision on: 10/04/2024 o Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/03/2024 Revision on: 10/04/2024 o psych consult ordered Lab ordered Date Initiated: 06/19/2024 Resident #81's most recent Elopement Risk Evaluation, dated 01/15/25, documented that the resident was an elopement risk due to the following factors: Resident is cognitively impaired Resident is independently ambulatory Has poor decision making skills Has demonstrated exit seeking behaviors Wanders oblivious to safety needs Has a history of elopement Has the ability to exit the facility On 03/14/25 at approximately 4:15 AM, Resident #81 exited the facility through a door at the end of the 120 unit that was equipped with alarms and was located by facility staff and law enforcement at the entrance to the bus loop of the local high school and returned to the facility 54 minutes later. A progress note, dated 3/14/2025 at 06:56AM , documented, Note Text: Upon his return to the facility, writer conducted a comprehensive head-to-toe assessment on the resident, confirming no new skin impairment, and resident denied pain. During the assessment, writer took the opportunity to remind the resident on the potential dangers of leaving the facility unattended. The resident nodded his head in agreement, and stated, Are you guys ok? I didn't mean to get you guys in trouble, I just want to get to my house, my sister think that I don't have a house, but I do. Resident was seen and evaluated by ARNP, new orders received and implemented. Efforts to contact the resident's sister were made but unfortunately proved unsuccessful, all safety precautions, including 1:1 in place. As documented by the Director of Nursing (DON). During an interview, with Resident #81, on 04/07/25 at 11:53 AM, when asked about exiting the facility, Resident #81 replied, I was trying to go home in Pompano. I was going to take a bus to Dixie Highway (in Lake Worth Beach) and then another bus can take me to Pompano. Resident #81 confirmed that the alarm sounded when he attempted to open the door. Resident #81 further stated, I don't like this place. I would rather be home. I am on dialysis. Resident #81 confirmed he was located by the high school by local law enforcement and facility staff and returned to the facility. Resident #81 was noted with wander guard to left ankle. Review of the nursing assignments for the shift and time that Resident #81 exited the facility revealed documentation that there were supposed to be 4 CNAs on the shift and that one of the CNAs did not call in or show up for the shift. During an interview, on 04/08/15 at 11:57 AM, with Staff I, Assigned LPN, when asked about Resident #81 eloping from the facility, the LPN replied, Basically, the patient eloped and the alarm went off to alert us. When I responded from the hall that I was at - I was a little further down the hall - I saw the CNA sitting with the patient and I left to take care of another patient. While in another room, I heard an alarm go off and when I went out to answer the alarm, there was another resident, and I asked if he pushed the door open and he said 'No'. I noticed that the CNA that was sitting with him was not there and I thought that he might have been in the shower with the CNA or in the courtyard. When I could not find the patient, I used the overhead pager to alert staff and initiate a search. I was working with another nurse, and she went outside to search with another CNA and she found him by the bus loop at the high school. The [NAME] had also responded while they were with the resident after finding him. The LPN further stated, The CNAs were rotating 1:1 each hour and the CNA left to take care of another patient. During an interview, on 04/09/25 at 6:34 AM with Staff J, CNA, when asked about providing 1:1 supervision to Resident #81 and how the resident managed to exit the facility, Staff J replied, I was on his door, my time was up and another CNA relieved me. I went to my regular assignment, we had 19 residents each that night because of a CNA that no call/no showed for the shift, there were 3 when there should have been 4. They were trying to get someone. Everyone takes an hour at a time at the door. He was calm and I left him and his roommate sleeping when I left the door. When I relieved the CNA (referring to Staff J), he was awake and agitated at the beginning of my rotation. During an interview, on 04/09/25 at 6:40 AM, with Staff K, CNA, when asked about the 1:1 supervision provided to Resident #81 and how the resident managed to exit the facility, Staff K replied, I relieved her at 3:00 AM, at 4:00 I left the door, my time was up. The CNA (Referring to Staff L) that was supposed to relieve me was at the nursing station and I went back to my assignment. The nurse called me (referring to Staff I). When I went back to my assignment, I heard the alarm at the door. I went to the other side, and I checked the door to see if it could open. I went to the other door where staff enter and leave. During an interview, on 04/09/25 at 7:10 AM with the DON, when asked about the staff member that did not show and how it was accounted for, the DON replied, I was not notified, the nurse decided on the rotation that night. The CNA that was on rotation was at the nurse's station (Referring to Staff L) she assumed that she was heading there because she was at the nurse's station. If we knew about it, we would have called somebody in. We are in the process of terminating the CNA that did not showup for work. Before the 11-7 supervisor leaves, he is responsible for 1:1 with the resident, Staff J was at the door. When the CNA did not show up for work, Staff I decided to do the hourly rotation, and the CNAs agreed, and everyone was asleep. He (referring to Resident #81) gets up at 5AM every morning, he is aware, he won't try anything if he sees the Administrator or I. We have been trying to find placement for him, but it is hard because of the dialysis and he needs a secured unit. On 04/09/25 at 8:00 AM, a message was left with Staff L, CNA. There was no response from the CNA.

Based on observation, interviews and record review; the facility failed to provide Physician ordered wound care post dermatology procedure for 1 of 1 resident sampled for skin condition (Resident #104). The findings included: Resident #104 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, and Atrial Fibrillation. His Brief Interview for Mental Status (BIMS) score was 14 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 03/08/25. This indicated the resident had intact cognition. On 04/07/25 at 10:19 AM an interview was conducted with Resident #104. He stated he had a [NAME] procedure to his upper back. When he went back to the dermatologist for a follow up visit, the Physician told him he had an infection in the wound because wound care was not done. Record review revealed the resident had a [NAME] (a precise micrograpic surgery to remove skin cancer) procedure on 03/10/25 at a dermatologist's office. The resident returned to the facility with orders to wash biopsy area to upper back with soap and water, apply Vaseline or Mupirocin to the wound, apply Telfa and adhere with paper tape, if severe redness, oozing, pain, fever or chills call the office. This order was not seen on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) when reviewed. An interview was conducted with the Director of Nurses (DON) on 04/09/25 at 11:15 AM. The DON reviewed the resident's orders post [NAME] procedure. She stated the orders were put in the electronic health record but not directed to the MAR or TAR so the treatment was not done. Further record review revealed the resident returned to the dermatologist on 03/25/25 and received a new order to clean area with soap and water. Appy mupirocin once a day. The dermatologist then ordered an antibiotic-Cefadroxil 500mg (milligrams) 1 by mouth twice a day x 7 days, take with food.

Based on observations, record reviews, and interviews, the facility failed to maintain the call device within reach for 1 of 10 residents observed (Resident #83). The findings included: A record review revealed that Resident #83 was admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease, Emphysema. The Minimum Data Set assessment dated [DATE] showed Resident #83's BIMS was 00 which indicated that Resident #83 had significant cognitive impairment. During observations on 04/07/25 at 12:00 PM, 04/08/25 at 8:00 AM, 04/08/25 at 5:14 PM, and 04/09/25 at 8:05 AM, the call device was located on the floor beneath Resident #83's bed. The call bell was not within reach of Resident #83. During an interview with Resident #83 on 04/09/25 at 11:30 AM, the surveyor asked the resident if she knew what the white plastic covered piece, the call bell, was used for. The surveyor held it in the surveyor's hand to show it to the resident. The resident answered yes, that's the call bell. When asked if she knew what the call bell was used for Resident #83 answered yes. I press it when I want the nurse to come in. The surveyor asked the resident if she had used it before and the resident answered yes. Multiple interactions with Resident #83 demonstrated that Resident #83 was able to carry on a conversation, and she answered questions appropriately. When Resident #83 was asked if she was comfortable with the head of the bed in the elevated position of approximately 35 degrees, Resident #83 said she preferred it to be higher. When asked if she required assistance in repositioning the head of the bed, Resident #83 said no. She said that she could do it herself. Resident #83 picked up the control for the bed and she elevated the head to the position that she preferred.

Based on record review and interviews the facility failed to provide a PASRR (Preadmission Screening and Resident Review) Level 2 when the Level 1 screening indicated the need, for 1 of 24 sampled residents (Resident #57). The findings included: Record review revealed Resident #57 was readmitted to the facility on [DATE]. The current Minimum Data Set, dated dated dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 15, on a 0-15 scale, indicating no cognitive impairment. Review of Resident #57's medical diagnoses on 04/08/25 indicated that she had a history of anxiety disorder (excessive worry about situations) and bipolar disorder (mental illness that causes intense shift in mood). Review of a PASRR Level 1 for Resident #57 dated 05/26/22, did not indicate that Resident #57 had a diagnosis of anxiety disorder. Review of a psychotherapy note dated 08/14/23, documented Resident #57 had a history of depression associated with bipolar disorder due to loss of independence with declining health and functional ability. A second psychotherapy note dated 11/01/23, documented Resident #57 had a diagnosis of bipolar and anxiety. During an interview on 04/08/25 at 10:32 AM, when asked if there was a more current PASRR Level 1 done that indicated Resident #57's current mental disorder diagnosis, the Regional Social Worker stated, She should have a more current one. The Regional Social Worker went to Acentra Health (Florida's provider for PASRR) online and stated Yes, she had a more recent one dated 09/29/23, but it still does not include the bipolar diagnosis. It still indicated that she needed a PASRR Level 2 due to her other diagnosis and it wasn't done. Review of the PASSAR Level 1 for Resident #57 dated 09/29/23, revealed that signs of serious mental illness or a related condition was found and a PASRR Level 2 was needed.

Based on observation, interview, and record review, the facility failed to provide a pneumococcal vaccination to a resident who consented to receive the pneumococcal immunization for 1 of 5 residents sampled for immunizations (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included Dementia, Congestive Heart Failure, and Type 2 Diabetes Mellitus. His Brief Interview for Mental Status (BIMS) score was 2 on the quarterly minimum data set with an assessment reference date of 02/23/25. This indicated the resident had severe cognitive impairment. On 04/09/25 at 4:00 PM an interview was conducted with the Infection Preventionist and the Director of Nurses (DON). A record review was conducted of 5 residents for receiving flu and pneumonia vaccines. A consent to receive a pneumonia vaccine was signed on 09/05/24 for Resident #32. There was no record in the electronic health record (EHR) that this vaccine was administered. The DON and Infection Preventionist stated they would look to see if there was any documentation that it was given that was not entered into the EHR. Discussed with DON on 4/10/25 at 9:15 AM who said she would look into this further and provide further information if she could find it. On 04/10/25 at 2:40 PM the DON provided the surveyor with a new consent for the pneumonia vaccine dated 04/10/25 for Resident #32. She stated the vaccine was ordered and was given today. The DON acknowledged it was not given after the last consent was done.

Based on record review and interviews the facility failed to file a grievance in a timely manner for 1 of 8 sampled residents, as evidenced by Resident #55 who had been missing her clothing for almost a month. The findings included: Record review revealed Resident #55 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating no cognitive impairment. During an interview on 04/07/25 at 9:42 AM, when asked if she was getting everything she needed, Resident #55 stated, I have not gotten any of my clean clothes back in almost a month. When asked how long she had been at the facility, Resident #55 stated, I have been here a little over a month. During an interview on 04/08/25 at 9:51 AM, when Resident #55 was complimented on the dress she was wearing, she stated, It's not mine. I haven't had my laundry back in 3 to 4 weeks. During an interview on 04/08/25 at 10:32 AM, when asked if she knew that Resident #55 had missing clothes, the Regional Social Worker stated, I'm not aware, I will have to look into it and let you know. During an interview on 04/09/25 at 9:36 AM, when asked if she had spoken to Resident #55 about her missing clothes, the Regional Social Worker stated I spoke to the resident regarding her missing clothes. She was missing 5 pairs of pants and 5 shirts. The previous social worker documented that the resident didn't come here with any belongings. I spoke to the social worker, at the sister facility she came from, and she said the resident definitely left the facility with clothing. When asked if there was an inventory sheet done for the resident on admission, the Regional Social Worker stated, I'm not sure yet, that's part of my investigation, but I did start a grievance. During an interview on 04/09/25 at 9:48 AM, when asked where the inventory sheet was kept that is filled out for a resident on admission, the Nursing Supervisor stated, In the chart. Whose inventory sheet are you looking for? The Nursing Supervisor looked in the chart and stated, I don't see one for her, give me a moment. Review of a progress note on 04/09/25 at 10:09 AM, revealed documentation of a conversation dated 04/08/25, that the Regional Social Worker had with social service at Aspire at the Sea in Pompano, where the resident resided prior, indicated that the social service reported that he walked Resident #55 out to the car on the day she was discharged with all of her belongings and none of the resident's belongings were left at the facility. During an interview on 04/10/25 at 9:46 AM, when asked for an update on the grievance for Resident #55, the Regional Social Worker stated, Here is a copy of the grievance I started, but it's not completed as of yet. A copy of the grievance dated 04/8/25 for Resident #55 was provided by the Regional Social Worker.

Based on observation, interview, and record review the facility failed to accurately document narcotic administration for 2 of 6 residents reviewed (Resident #79 and Resident #377). The findings included: 1. Review of the record revealed Resident #377 was admitted on [DATE] with a diagnosis of Encephalopathy (a condition where there is brain disease, damage or malfunction). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #377 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the Resident had moderate cognitive impairment. Review of the current orders revealed Resident #377 had an active order for Lorazepam 0.5mg tablet one tablet by mouth every 8 hours as needed. 2. Review of the record revealed Resident #79 had an initial admission of 04/04/23 and re-entry on 08/15/24 with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side (a condition where there is paralysis and muscle weakness on one side of the body). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #79 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current orders revealed Resident #79 had an active order for Lacosamide 100mg tablet, one tablet by mouth twice daily for seizures. 3. During a medication storage observation on 04/09/25 at 12:30 PM, the medication cart for the 200 unit was checked with Staff H, Licensed Practice Nurse (LPN). The paper documentation form titled Medical Monitoring/Control Record (MMCR) was compared with the electronic Medication Administration Record (MAR) for Resident #79 and Resident #377, who were both receiving narcotics. There were discrepancies for both Residents. The documentation on the MMCR revealed that the Lorazepam for Resident #377 was administered on 04/01/25 at 9:55 AM but was not documented on the MAR. On 04/04/25, this same medication was logged in the MMCR at 20:30 and documented on the MAR at 21:04. The documentation on the MMCR revealed that the medication Lacosamide for Resident #79 was administered three times on 04/06/25 as follows: 9:09 AM, 10:13 AM, and 6:04 PM. and one time on 04/07/25 at 5:30 PM. Review of the MAR computerized documentation revealed two administrations of the medication Lacosamide on 04/06/25 and one administration on 04/07/25. An interview was conducted on 04/09/25 at 12:36 PM, with the Director of Nursing (DON). When asked for clarification on the narcotic discrepancy found for Resident #79, the DON reviewed the MAR and the MMCR for Lacosamide. She stated, The medication cannot be given three times due to it being a scheduled medication. The computer will not let her (the nurse). This has to be a mistake. The DON agreed that the documentation on the MMCR did not match what was documented in the MAR. The DON agreed it should have been documented accurately. When made aware of the 2 discrepancies regarding the Lorazepam documentation for Resident #377, she agreed to the findings and stated she would find the nurse to interview. During an interview on 04/09/25 at 12:56 PM an interview with Staff D, Registered Nurse (RN), the nurse who administered Lorazepam for Resident #377. When asked about the discrepancy, Staff D stated, I made a mistake on the documentation of the date, I wrote 04/01/25 but it was supposed to be 04/02/25. When asked about the time discrepancies on 04/04/25 between the MMCR and the MAR, she admitted the times were off and should have been the same. During a phone interview on 04/09/25 at 1:06 PM, when asked about the medication administration for Lacosamide for Resident #79 on 04/06/25, Staff B, Registered Nurse (RN) stated, I made a mistake on the date I documented on the paper narcotic log. I did not work on 04/06/25, it was suppose to be 04/07/25. The DON who was present for both nurse interviews agreed that the staff should know the importance of documenting accurately especially when it came to narcotics.

Based on clinical and administrative record review and interviews, the facility failed to ensure that the staff consistently implemented the system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications. Failed to ensure prompt identification of loss or potential diversion of controlled medications and the determination of the extent of loss or potential diversion of controlled medications for 3 of 3 residents (Residents #1, #2 and #3). The findings included: 1) Review of the clinical record for Resident # 1 physician prescriptions revealed that the physician prescribed on 08/08/24 Dilaudid Oral Tablet 8 mg (Hydromorphone HCL) Give 1 tablet by mouth every 8 hours as needed for pain per pain management, and Xtampza ER Oral Capsule ER 18 mg Give 1 capsule by mouth every 12 hours for pain. Review of the Medication Monitoring/Control Record and the corresponding Medication Administration Record (MAR) revealed that the nurses did not consistently document the administration of the Dilaudid/Hydromorphone tab 8 mg one tablet by month every 8 hours as needed for pain on the Medication Administration Record. Further review of the Medication Monitoring/Control Record for Dilaudid /Hydromorphone tab 8 mg 08/01/24 - 08/30/24 the nurses documented they removed 116 doses. However, the corresponding MAR for August revealed that the nurses failed to document 12 doses as follows: 1. 08/08/24 - three doses were not documented at 4:20 AM, 1:00 PM and 6:30 PM 2. 08/12/24 - one doses at 1:00 PM 3. 08/13/24 - two doses at 5:00 AM, 1:00 PM. Additionally another dose was documented as administered at 7:00 PM 6 hours from the last dose signed out as administered on the Control Record. This documentation failure permitted the every 8 hour as needed pain medication to be administered within 6 hours. The nurse at 7:00 PM documented that the resident's pain was at level 5 on a scale of 0-10 with ten being the most severe. 4. 08/14/24 - one dose at 1:00 PM 5. 08/15/24 - one dose at 2:00 PM. Additionally another dose was documented as administered at 7:00 PM, 5 hours from the last dose signed out as administered on the Control Record. Again this documentation failure permitted the every 8 hour as needed pain medication to be administered within 5 hours. The nurse at 7:00 PM documented that the resident's pain was at level 5. 6. 08/20/24 - one dose at 6:30 PM. Additionally another dose was documented as administered at 10:00 PM, 3 1/2 hours from the last dose signed out as administered on the Control Record. Again this documentation failure permitted the every 8 hour as needed pain medication to be administered within 3 1/2 hours. The nurse at 10:00 PM documented that the resident's pain was at level 8. 7. 08/21/24 - one dose at 2:50 PM. 8. 08/23/24 - one dose at 9:00 PM. 9. 08/28/24 - one dose at 1:00 PM. In September, there were 27 doses documented on the Control Record as being administered until 09/17/24. However, the corresponding MAR for September revealed that the nurses failed to document 6 doses as follows: 1. 09/02/24 - one dose at 7:50 AM. 2. 09/04/24 - two doses at 7:00 AM and 3:00 PM 3. 09/07/24 - one dose at 7:00 PM 4. 09/12/24 - one dose at 10:00 PM 5. 09/17/24 - one dose at 2:30 PM 2) Review of the clinical record for Resident #2 revealed that the physician prescribed for the resident to receive Tramadol HCL Oral tablet 50 mg, give 1 tablet by mouth every 12 hours as needed for chronic pain. Further review of the Medication Monitoring/Control Record and the corresponding Medication Administration Record (MAR) revealed that the nurses did not consistently document the administration of the Tramadol on the MAR. The August Control Record documented 61 doses removed. However, the August MAR failed to document seven doses as follows: 1. 08/03/24 - one dose at 10:45 PM 2. 08/04/24 - one dose at 9:00 PM 3. 08/17/24 - one dose at 10:00 PM 4. 08/19/24 - one dose at 10:00 AM 5. 08/20/24 - one dose at 11:00 PM 6. 08/21/24 - one dose at 10:00 PM 7. 08/23/24 - one dose at 10:00 PM The September Control Record documented 31 doses being removed from 09/01-09/17/24. However, the corresponding MAR failed to document five doses as follows: 1. 09/01/24 - one dose at 9:00 PM 2. 09/06/24 - one dose at 9:00 AM 3. 09/0724 - one dose at 10:00 PM 4. 09/08/24 - one dose at 10:00 PM 5.09/17/24 - one dose at 10:54 PM An interview was conducted on 09/19/24 at approximately 12:00 Noon with the Director of Nursing. The DON confirmed that the nurses are to document the removal of the medication on the Control Record and document the administration of the medication on the Medication Administration Record. The surveyor reviewed with her the multiple record discrepancies for Residents #1 and #2. There are discrepancies between the Control Record and the MAR and the nurses failed to consistently document the medication administration on the MAR. 3) Review of the clinical record for Resident #3 revealed that the physician prescribed for the resident to receive Oxycodone HCL Oral tablet 15 mg, give 1 tablet by mouth every 6 hours as needed for pain. The September Control Record documented that the nurses removed 22 doses of the Oxycodone from 09/01/24 - 09/19/24. However, the corresponding MAR for September revealed the nurse failed to document 12 doses on the MAR as follows: 1. 09/06/24 - one dose at 6:00 PM 2. 09/07/24 - one dose at 6:00 AM 3. 09/08/24 - two doses at 6:00 AM and 6:00 PM 4. 09/09/24 - one dose at 12:00 PM 5. 09/14/24 - two doses at 12:00 AM and 6:00 AM 6. 09/15/24 - one dose at 6:00 PM 7. 09/16/24 - one dose at 6:00 PM 8. 09/18/24 - two doses at 12:18 AM and 6:08 AM 9. 09/19/24 - one dose at 6:00 AM An interview was conducted on 09/19/24 at approximately 2:30 PM with the Director of Nursing. The surveyor reviewed with her the continued pattern of the nurses failing to document the administration of medication and the multiple discrepancies between the Control Record and the MAR. The nurses are failing to consistently document the medication administration on the MAR.

Based on record reviews and interviews, the facility failed to provide evidence that allegations for abuse and neglect were thoroughly investigated. This is evidenced by the facility's failure to provide evidence conducting thorough investigations for 2 of 3 sampled residents (Residents #1 and #2). The findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation & Misappropriation, Revision Date 11/16/22, documented regarding investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during any questioning of or interviewing of residents. Investigations will be accomplished in the following manner. Preliminary Investigation: Immediately upon investigation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a through nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. Investigation: The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. 1) There were two separate incidents alleging neglect involving Resident #2. One incident occurred on 09/01/24 with Staff A and Staff D, when the resident alleged that Staff A yelled at him and he also had to sit in a soiled brief from 4 PM to 6 PM. The second incident occurred on 09/03/24 on the 3-11 shift with Staff B, alleging no one answered his call light from 9 PM to 11 PM. The resident alleged that he put his light on at 9:00 PM and no one answered his call light and did not provide care to him. There remains multiple questions left unanswered and the investigations lacked pertinent interviews, statements and reviews. Review of the facility's investigation for the first incident revealed the following: a.The 09/01/24 statement from Staff A, the male CNA, documented at 4:30 PM, he went to put Resident # 2 back to bed. The resident was very agitated, refused to go back to bed, saying profanity words to him. The CNA stated he left the resident's room because of agitation. After a half hour, the CNA stated he went back to the room, in front of the nurse, resident kept saying profanity word again to him. He left the room. b.The 09/05/24 statement from Resident #4, the roommate for Resident # 2, documented that the male CNA, Staff A, stripped the bed and Resident # 2 asked for a blanket. Staff A raised his voice and pointed his fingers at the resident. Resident # 2 stated I am not a child. Staff A stated I am just doing you a favor by helping you. Review of the facility's investigation for the second incident revealed: c.The 09/05/24 statement from Staff C, female CNA 11-7, documented another CNA was giving her report on another resident, when this resident was restless and yelling. So they went into the room together and they changed this resident. She stated she went to the pantry for a cup of water for this resident and took it to the resident's room. She left the room and she heard a call light and she noted that it was the call light for the room of Resident # 2 was on. She wrote that she went to the room and the resident reported to her that his light was on since 9 o'clock and no one answered the call light or the CNA came in and he had a bowel movement. She stated she checked his diaper but he did not and he told her he has been easing his body and he felt as if he did. But regardless no one attended to him or answered the call light since 9 o'clock. d.The 09/04/24 statement from Staff B noted that she worked Tuesday 3-11 on 09/03/24. Staff B noted that the resident was sitting in his wheelchair when she made her rounds, the resident asked her to put him in the bed. She went to get the supplies to clean the resident and she put him in the bed. She warmed his food and gave it to the resident, gave him water in his special cup, and put his boots on his feet. Then she went and took care of other residents. At 9:45 PM she went on break. At 9:00 PM she stated she was on the fllor and there were no lights on. When she came on duty on 09/04/24, the DON informed her the resident reported he put his light on at 9 PM on 09/03/24. She restated that there were no lights in the resident's room. An interview was conducted on 09/18/24 at 2:00 PM with the Social Worker, she stated that Resident # 2 reported that Staff A disrespected him. The surveyor reviewed the statements and had multiple questions regarding the yelling incident and the care issues that Social Worker could not answer and the information was not documented in the facility's investigation folder. She stated that the Administrator is the Abuse Coordinator and they are in between Director of Nurses and the other DON would have investigated this. A telephone interview on 09/18/24 at approximately 3:00 PM with the previous DON. She stated that Resident # 2 and his mother came to talk with them on 09/04/24. She said that the resident reported that he didn't feel Staff A gave him respect. He was disrespected and that the staff yelled at him. The DON further stated that the resident didn't have a problem with care. However, the mother stated that if he did that, it may get worse and voiced that the CNA shouldn't care for him. The DON stated that the staff did yell and the resident used profanity. The nurse heard a commotion and the staff said he is cursing. The surveyor asked about the statement from the nurse because there was no statement from the nurse. She was unaware of a statement from the nurse. She further stated that the CNA, Staff A, was reassigned to the first floor and was provided an in-service. The surveyor also asked the DON about follow-up on the statement from the resident's roommate regarding the exchange between the CNA, Staff A, and the resident. She stated she was not aware of the statement from the roommate. The resident also reported a second incident from the following day of staff not providing care for him on 3-11 shift. She stated the aide (Staff B) gave him ice water around 5:30-6:00 PM. The nurse gave meds at 8:45 PM. The surveyor asked the DON, when was the last time the aide provided care to the resident. She was not sure. She further could not confirm if the resident received care or was checked from 9-11:30 PM. The resident reported that no one answered his call light when he put his light on at 9:00 PM. The 11-7 CNA, Staff C said she checked him after she came on at 11 PM. She stated that they suspended the CNA, Staff B, pending investigation and filed a report of neglect. The facility did not file a report regarding the verbal altercation with CNA Staff A. The surveyor asked about who was responsible for reviewing the investigations to ensure the investigation is complete. She stated she could not answer that. An interview was conducted on 09/18/24 at 3:22 PM with the Administrator. He is the person that should verify the investigation is complete. The surveyor asked him regarding the investigations for Resident # 2. He stated he didn't know why there wasn't an interview or statement from the nurse. He thought the nurse no longer worked for them. He stated he was not aware of the statement from the resident's roommate. An interview was conducted on 09/19/24 at 2:45 PM with Resident #2. He stated that Staff A, came in about 3:30-3:45 PM and put 2 blankets on the bed like pads. They had sent his blanket to the laundry. He said he needed a blanket to cover up and the aide said no more blankets. And a discussion between he and the aide and he was told don't touch the blanket and he said Staff A yelled at him. They continued to go back and forth so, he said, f--- you to the aide. The aide left and he said he had his roommate to take the blanket off the bed and put it aside. He said about 4:00 PM he had to go to the bathroom and he said he moved his bowels and had to stay in that BM until the nurse cleaned him up about 6:00 PM. An interview was conducted on 09/19/24 at approximately 2:50 PM with Resident #4. He said Staff A had stripped the bed and put 2 blankets on the bed. The resident had him to take one of the blankets off the bed and put it in the window. The aide came back and Resident # 2 and Staff A were going at it and he heard the aide say something about don't touch the blanket and heard Resident # 2 say I'm not a child and the aide left and said he wasn't doing him. The surveyor asked him did he see anything. He said he heard the commotion, so he got up to go toward Resident # 2 bed and he said the aide pointed his finger at the resident and yelled at him and then left the room. A telephone interview was conducted on 09/23/24 at 3:42 PM with the nurse on duty on 09/01/24, Staff D. She was walking by Resident # 2 room and the resident looked mad and he was talking to his roommate. The resident was ready to be put to bed. There were 2 blankets put on his bed as underpads. She said she would go get him a blanket and Staff A was going to get the Hoyer lift. When she came back with the blanket, They were going at it. Staff A said I'm not going to do him anymore. He said the resident said f--- you to him. The surveyor asked for clarification on her statement, they were going at it. She then stated she didn't hear what was specifically being said but she heard loud sounds of two different voices. Stop yelling and I knew it was about the blanket. She said she later approached Staff A about providing care for the resident and she would assist him but Staff A refused. She stated she had to clean up the resident. She stated she works 7 AM - 7 PM. So she said she reported to the oncoming shift that they needed to get another aide to care for the resident because Staff A refused to. 2) Review of the grievance log revealed a complaint/grievance filed by Resident #1 on 08/29/24, regarding a violation of rights. The resident alleged that the facility's administrator spoke to him in the therapy room about his living arrangements and his bill in front of two other residents and two therapists. A description of the concern noted by the Administrator documented, Resident stated that the Nursing Home Administrator spoke to him in therapy room. RE: resident bill. Event took place approximately 4:00 PM no other residents in room when discussion occurred just therapists. Findings of investigation: Spoke with the OT (Occupational Therapist) to confirm that no other resident was in therapy room at the same time that I spoke with Resident # 1. Results of action taken: Staff educated on giving resident privacy in private areas when speaking to them. The Investigation included a Witness statement from the Administrator and the Occupational Therapist as follows: a. On 08/29/24 approximately 3:45 PM, I approached Resident #1 in the therapy room. He was in the room with the therapist. I asked how he was feeling. Resident #1 complained of his constant pain. I acknowledged his opinion. As it was just us in the therapy room, I asked him about his outstanding balance due to the facility. The outstanding balance and his patient responsibility that we are entitled to under the law. He stated that he needed the money for other personal expenses. He threatened to get outside counsel involved. I said that he has choice and left the therapy room. I provided privacy and confidentiality by taking him into the therapy room. b. A statement by the Occupational Therapist dated 09/04/24 documented Resident #1 was approached in Rehab room by our administrator. They discussed Business. Myself and my COTA (Certified Occupational Therapy Assistant) was in the room only. I left for part of the conversation to get Hot Packs. An interview was conducted on 09/19/24 at 10:30 AM with the Social Worker and she was asked regarding the investigation. She confirmed she did not have statements from the COTA, who was also allegedly present when the above incident occurred. There is also no evidence that the SW followed up with Resident #1 to identify the residents he said were present in the therapy room and once identified, there is no evidence of follow-up with the identied residents.

Based on clinical and administrative record review and interviews, the facility failed to consistently provide effective pain management by failing to obtain pain medication refills in a timely manner to ensure 1 of 3 residents reviewed (Resident #1), did not have extended periods of time without pain medications. The findings included: Review of the clinical record for Resident # 1 revealed that the resident was admitted to the facility on [DATE] with pertinent diagnoses which included: Intervertebral disc displacement lumbar region, pain in left foot, pain in right foot, low back pain, pain in joints of right hand, opioid dependence with other opioid-induced disorder, idiopathic peripheral autonomic neuropathy, peripheral vascular disease, and Diabetes Mellitus with Diabetic Neuropathy. Review of the physician prescriptions revealed that the physician prescribed on 08/08/24 Dilaudid Oral Tablet 8 mg (Hydromorphone HCL) Give 1 tablet by mouth every 8 hours as needed for pain per pain management; and Xtampza ER Oral Capsule ER 18 mg Give 1 capsule by mouth every 12 hours for pain. Then on 08/28/24, the physician prescribed further clarification regarding the as needed medication and prescribed Dilaudid Oral tablet 8 mg (Hydromorphone HCL) Give 1 tablet by mouth every 8 hours as needed for Pain. DO NOT GIVE WITHIN 2 HOURS OF Xtampza 18 mg. Review of the Medication Monitoring/Control Record revealed a control sheet for Xtampza ER Cap 18 mg 1 capsule by mouth every 12 hours. The nurse signed on 08/09/24, 28 tablets was received. The sheet documented every 12 hours the administration of the 28 prescribed medication from 08/09/24 at 10:00 AM until 08/22/24 9:00 PM. The next sheet does not report the prescribed medication was administered until 08/25/24 at 9:00 AM (2 days later). There is no evidence that the resident received the routine every 12 hour medication on 08/23/24 and 08/24/24 (4 doses). Further review of the Medication Monitoring/Control Record for Dilaudid /Hydromorphone tab 8 mg one tablet by mouth every 8 hours as needed for pain revealed that the nurse signed that 30 tablets was received on 08/09/24. The staff documented administering the 30 tablets as needed medication from 08/14/24 at 5:00 AM to 08/24/24 at 5:00 AM. Further review of the distribution of the as needed medication, the resident consistently received three as needed doses everyday during this time period. There is no evidence that the resident received additional doses of the as needed pain medication until 08/26/24 at 04:55 AM. The controlled sheet documented that 25 tablets were received on 08/26/24. Again the resident did not receive pain management medication for two days, 08/24/24 and 08/25/24 (6 possible doses were not available to be administered for those two days). Review of some of the pain monitoring documentation during the above 2 day span, when the resident's pain management medication was unavailable, revealed that the nurses documented the following, on a scale of 1-10, 10 being the worst): 08/22/24 -10:00 PM -5 08/23/24 - 5:00 AM - 5 08/23/24 - 1:40 PM - 8 08/24/24 - 5:00 AM - 5 08/25/24 -1:02 PM - 6 08/26/24 -12:20 PM - 5 08/26/24 - 2:11 PM - 9 An interview was conducted with the Director of Nursing on 09/19/24 at approximately 12 noon, the surveyor reviewed with her, the Medication Monitoring/Control Records and Medication Administration Record discrepancies. She confirmed that the Xtampza is not in the facility's emergency medication kit. Thus, the resident would not have received those doses, despite the nurse signing the Medication Administration Record to document that the medication was administered. Although, the Dilaudid is medication that is available in the emergency medication kit, the nurse would have to contact pharmacy to get approval to take the medication out and complete a form to document this removal, the facility did not provide any evidence that this occurred. An interview was conducted on 09/19/24 at 3:15 PM with Resident #1, who reported that the last few weeks, the staff have run out of his medications. He further stated about 2-3 weeks ago, he went 32 hours without his extended pain medications and 42 hours without his other pain medication. The staff wait until the medication is out before reordering. He further stated he kept asking for pain medication and he was told it was being order, then he later found out that the nurse did not order. He stated he was in so much pain, he was crying and he stated he kept following up with the nurses, and he was told it was ordered. There is no sense of urgency in this building. He stated he is in pain all the time pointing to his legs and stated he also applies ice pack in the area to help try to ease the pain some. Further review of the Resident #1's Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 15 (on a scale of 0-15, 15 being alert and oriented and does not identify memory impairment). Pain Management the resident received scheduled pain medication regimen and received PRN (as needed) pain medication. The facility identified a concern on 02/07/24 and the care plan was revised on 03/07/24 as the resident is at risk for pain related to chronic illness, physical impairment. Interventions included Administer analgesia as per orders, notify the MD if pain management is not effective; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions per orders. Review for compliance, alleviating of symptoms, dosing schedules and resident and resident satisfaction with results, impact on functional ability and impact on cognition; Monitor/document for side effects of pain medication; Monitor/record/report to Nurse any s/s (sign and symptoms) of non-verbal pain; Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.

Based on record review and interview, the facility failed to provide supervision to prevent an elopement for 1 of 3 resident reviewed for elopement risk (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease, Diabetes, Generalized Anxiety Disorder, and Unspecified Mood Disorder. A comprehensive assessment dated [DATE] documented Resident #1 was cognitively intact and required partial/moderate assistance with activities of daily living. The resident was assessed and care planned for at risk for elopement on 05/03/24. The resident had interventions in place. On 06/19/24 at 11:00 AM, Resident #1 exited the facility. The resident was returned to the facility at 12:30 PM by law enforcement. Facility investigation revealed Resident #1 exited the facility at approximately 5:00 AM on 06/19/24. Resident #1 was returned to the facility at 5:15 AM by staff. No additional interventions were put in place. An interview was conducted with the Regional Nurse Consultant (RNC) on 07/08/24 at 1:00 PM. The RNC stated the Nursing Home Administrator and Director of Nursing should have been notified and Resident #1 should have been placed on 1:1 observation. This would have prevented the resident from eloping 6 hours later. Resident #1 will remain on 1:1 observation until the resident can be transferred to a secured unit. The resident was moved to a room closer to the nursing station.

Based on observation, interview, record and policy review, the facility failed to ensure care and services for tube feeding for 2 of 2 sampled residents for tube feeding resulting in significant weight loss (Resident #62), and failure to provide tube feeding as ordered (Resident # 287). The findings included: The facility's policy titled Enteral Feeding-Enteral Nutrition Pump effective 11/30/14, and revised 11/12/18, revealed Nurses administer enteral feeding when volume control is indicated and as ordered by physician. The facility's policy titled Weighing the Resident effective 11/30/14, and revised 10/04/21, revealed Residents will be weighed unless ordered otherwise by the physician: . Admission/re-admission x 3 days . Weekly x 4 weeks . Monthly thereafter . As needed Weights will be completed as indicated and documented in the clinical record .When there is a significant variance from the previously recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change, consult with the Director of Dietary Services and/or dietician, notify the Interdisciplinary Team in order to update the care plan. 1) Record review revealed Resident #62 was initially admitted to the facility on [DATE] with diagnoses that included post Cerebral Infarction, Dysphagia, and Aphasia. The admission assessment dated [DATE] revealed the resident was admitted with a PEG tube (Percutaneous Endoscopic Gastrostomy which is a tube that brings nutrition directly into the stomach). His admission weight dated 08/23/22 was 172 pounds, height was 5 foot 5 inches, and the order for his feeding was Jevity 1.5 CAL @ 65ml (milliliters (ml) per hour (hr) x 20 hours. Jevity is a therapeutic nutritional formula for tube feedings. On 05/11/23 a nutritional evaluation was done post hospitalization which revealed the resident was taking Jevity 1.5 @ 60ml/hr x 20 hours. His weight was 170 pounds. On 06/13/23 the resident was sent to the hospital for PEG tube reinsertion and returned the same day. On 06/15/23, post hospitalization , a nutritional evaluation was done. He was on Jevity 1.5 @75ml/hr x 20hrs; Start time: 2:00 PM and End time:10:00 AM or until total volume is administered (total volume 1500 ml/daily). Weight recorded on 06/09/23 was 171.1 pounds. Weight on 07/10/23 was 172 pounds. Weight on 08/04/23 was 172.3 pounds. Weight on 09/07/23 was 172.5 pounds. On 10/11/23 the resident was transferred to the hospital after pulling out his PEG tube and returned to the facility on [DATE] with orders for an abdominal binder every shift for prevention of PEG dislodgement. Nutritional evaluation dated 10/17/23 revealed the resident was recently readmitted after being discharged to hospital on 10/11/23 for pulling his PEG tube out, remains NPO (nothing by mouth) with PEG, is tolerating tube feedings, resident is confused, weight dated 09/07/23 is 172.5 pounds. Plan/recommendation-Weigh x4 weeks, Obtain weight per facility protocol. Next weight dated 10/23/23 was 152.4 pounds. On 11/03/23 the electronic health record (EHR) revealed a dietary note written by the Registered Dietitian (RD). Resident has experienced wt (weight) loss, is currently 152.4# (pounds) as of 10/23/23, BMI (Body Mass Index) is 25.4, re-weigh has been requested, continues to tolerate TF Rx (tube feed prescription), Jevity 1.5 @ 75 ml/hr x20 hours w/ 250 ml water flush Q shift (750ml) ~provides 2250 kcal (kilocalories), 96g PRO (protein), and 1840 ml H2O (water) which meets estimated nutritional needs outlined in the Nutrition Evaluation assessment dated [DATE], nutritional needs were estimated according to previous body weight of 171#, weight loss was not anticipated will increase TF rate to 80 ml/hr x20hrs and will decrease flush order to 200 ml every shift (600 ml). Next weight dated 11/07/23 was 146.6 pounds. RD note dated 11/10/23 revealed resident has experienced sig wt (significant weight) loss of 13.8 % in 180 days, is currently 146.6# as of 11/07/23 after being re-weighed to confirm accuracy of weight on 10/23/23 .will continue to have resident re-weighed. Review of the nutritional review dated 11/27/23 revealed Resident #62's UBW (usual body weight) was 170 pounds. Most recent weight dated 11/07/23 was 146.6 pounds. Will continue to have resident re-weighed. Weight for Resident #62 on 12/13/23 per surveyor request was 152.8 pounds. Resident #62 was unable to do the Brief Interview for Mental Status (BIMS) according to the quarterly Minimum Data Set with an assessment reference date of 11/25/23. Observation of Resident #62 on 12/11/23 at 8:32 AM revealed the resident to be sleeping in bed. The tube feeding bag was not set up in the room. The orders for the tube feeding were for the tube feeding to start at 2:00 PM and off at 10:00 AM or until total volume is administered which was 1600ml/daily. Observation of Resident #62 on 12/11/23 at 2:00 PM. Resident in bed with no tube feeding present. On 12/11/23 at 3:00 PM an observation was made of Staff A, a Registered Nurse (RN) preparing the tube feeding and hanging a 1000 milliliter bottle of Jevity 1.5 CAL. The bottle was dated 12/11/23 with no start time. Rate 80 ml/hr for 20 hours. Total volume to be infused 1600 ml/daily. Interview with Staff A at this time who stated she stopped the feeding around 8:00-8:30 AM this morning and there was about 200 ml of Jevity left in the bottle. An observation was conducted on 12/12/23 at 7:29 AM of Resident #62 lying in bed with eyes closed, upon closer observation the resident had a bottle of Jevity 1.5 tube feeding hanging labeled with a start date of 12/11/23 and no start time. The tube feeding was at the 400 mark out of a 1,000-milliliter capacity bottle. This indicated the resident only received 600 milliliters when the resident should have received 1,400 milliliters (photographic evidence obtained). A review of a nursing progress note dated 12/12/23 at 6:00 AM revealed the feeding was held secondary to elevated residual 140ml. MD notified no new order given. On 12/12/23 at 9:54 AM, an observation was made of Staff B, a Licensed Practical Nurse (LPN) taking down the tube feeding. The bottle was at the 250ml mark. In an interview at this time with Staff B she stated the night nurse held the feeding, but she does not know how long the feeding was held. She stated normally the bottle is almost finished and she usually has an empty bottle. The bottle is hung at 2:00 PM and it runs all night and when it is 10:00 AM she takes the bottle down whether or not it is finished. An interview was conducted via telephone on 12/12/23 at 3:44 PM with Staff C, RN, who worked the prior night shift with Resident #62. She stated the residual was high, so she stopped the feeding for 2 hours. She stated she usually hangs a new bottle during the night, but she did not last night. Observation of Jevity feeding for Resident #62 on 12/13/23 at 8:30 AM revealed the bottle had approximately 800 ml of Jevity left in the bottle and was hung on 12/13/23 at 4:30 AM. An Interview was conducted with RD on 12/13/23 at 4:00 PM. The RD stated that he is in the facility 2 days a week usually Monday and Fridays. He has worked in this facility since November, 2022. He enters the weights into the electronic health record (EHR) and if there is significant weight loss he has the restorative aide reweigh the resident. Significant weight loss is 3 % in one week, 7.5% in 90 days and 10% in 180 days. The restorative aide has the previous weights and would know if there was a weight loss so she should be able to re-weigh them. He notifies the Director of Nurses (DON) or the Administrator if he does not get a re-weight on a resident. The RD was asked where the re-weights and weekly weights on Resident #62 were. The RD stated that he requested reweights. He said on 10/23/23 he emailed the DON, ADON (Assistant Director of Nurses) and the Administrator asking for weekly weights for this resident. He stated the restorative aide was new and had challenges on getting the weights on the residents he was requesting. Stated it is his responsibility to know what the residents weigh. For the weight loss, he suspected the restorative aide did not correctly weigh the person. He did not watch this resident being weighed. The RD was asked if he observed the tube feedings when they were hung for accuracy, and he replied that he did not. The RD stated he asked for weekly weights x 4 on Resident #62. He sent an email to the ADON, the DON and the Administrator on 11/10/23 about no re-weights being done. The ADON assured him that it would be done. Neither the Administrator or RD produced any emails. He informed the nurse practitioner (NP), and the NP informed the doctor about the resident's weight loss. The RD stated he does not get together with the DON, ADON and Administrator to discuss weights as a group. On 12/13/23 at 4:42 PM, an interview was conducted with the DON, ADON and Administrator altogether. The Administrator stated in October she was told that if there is a discrepancy in a resident's weight a reweight should be done. The Administrator further stated that whenever the RD needs a reweight, they should be able to get it. She stated her, the DON and the ADON had a meeting about getting reweights in November and had the scales calibrated in November. An Interview was conducted with Staff D, restorative Certified Nursing Assistant (CNA) on 12/14/23 at 11:28 AM, regarding the weight process. She stated the new residents are weighed every week x 4 weeks and long-term residents are weighed every month. If there is a change in weight, the dietitian gives her a list of residents who need to be weighed. She stated not every week is she given a list for weekly weights. When she gets the list for re- weighs, she has no idea of what the person weighed the previous month, she only gets a list of names. She stated she does the weights and gives the weights to the dietitian when she sees him the next time he comes. She has no weights currently that have not been given to the dietitian. Staff D stated she has been with the facility for 10 months and the last 2 months she has been the restorative CNA. An additional interview was conducted with the RD on 12/14/23 at 12:57 PM. He stated he put an intervention in for Resident #62 on 11/03/23 because he was waiting for a re-weight but did not get it. He asked the ADON, DON and Administrator when the last time the scales were calibrated, and they said they would have a technician come out to do that. He stated what he should have done is put interventions in when he saw the weight loss of 10/23/23 instead of waiting for a re-weight. He did not expect the weight to be correct at that point since it was a huge drop. 41837 2) Record review for Resident #287 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on 12/06/23 with diagnoses that included: Parkinson's Disease, Type 2 Diabetes Mellitus, Dependence on Renal Dialysis, Gastrostomy Status, Dementia, and Mild Protein-Calorie Malnutrition. Review of the Minimum Data Set for Resident #287 dated 08/01/23 revealed a Brief Interview of Mental Status score of 4, indicating severe cognitive impairment. Review of Physician's orders for Resident #287 revealed an order dated 12/08/23 as follows: Nepro at 75ml/hr. x 18 hours, start time 2:00 PM, end time 8:00 AM or until total volume is administrated (total volume 1,350 ml daily). Review of Physician's orders for Resident #287 revealed an order dated 12/08/23 as follows: as needed may stop enteral feed to provide ADL care to the resident and resume care to the resident and resume enteral feeding after providing care. On 12/12/23 at 2:30 PM, an observation was made of Resident #287 lying in bed with eyes closed and a bottle of tube feeding Nepro 1.8 (Formulary Type) infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/12/23 at 2:00 PM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. On 12/13/23 at 7:50 AM, an observation was made of Resident #287 lying in bed receiving care by Staff E Certified Nursing Assistant (CNA). There was no tube feeding present. There was an empty bottle of tube feeding with tubing in the garbage. The empty tube feeding bottle in the garbage was labeled as started on 12/12/23 at 2:00 PM. There were no other empty bottles of tube feeding. This would indicate that the resident only received 1,000 milliliter of tube feeding, not the 1,350 milliliter that was ordered. On 12/13/23 at 2:30PM, an observation was made of Resident #287 of resident lying in bed with a bottle of tube feeding Nepro 1.8 infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/13/23 at 2:00 PM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. On 12/14/23 at 7:50 AM, an observation was made of Resident #287 in the dialysis room with a bottle of tube feeding Nepro 1.8 infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/14/23 at 7:00 AM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. This indicated that the resident had received just over 1,000 milliliters of tube feeding in 18 hours, rather than the 1350 ml ordered An interview conducted on 12/13/23 at 7:50 AM with Staff E, CNA who stated she has worked at the facility for [AGE] years. When asked how long she has been giving care to Resident #287 this morning, she said maybe about 15 minutes. When asked if the tube feeding was already disconnected before she started providing care to Resident #287, she stated there was no tube feeding hanging. During an interview conducted on 12/13/23 at 7:55 AM with Staff A, Registered Nurse (RN) who stated she has been a nurse for about 7 months. When asked what time her shift started today, she said she was here at 7:00 AM. When asked if the tube feeding was running for Resident #287 when she came on duty, she said no the resident gets bolus tube feeding. When asked if there were any tube feeding issues reported by the previous nurse for Resident #287, she said no. Staff A later approached the surveyor to clarify that the resident does not get bolus tube feeding, the resident receives continuous tube feeding from 2:00 PM to 8:00 AM. When asked was the tube feeding running this morning when she came on duty, she said no, the night shift nurse must have taken it down before she came on duty. During an interview conducted on 12/14/23 at 1:00 PM with the Registered Dietitian (RD) who stated he has been working with long term care residents as a RD for about 3 years. When asked when he would be expected to see a resident who was newly admitted or readmitted , he stated within 7 days. When asked if he observes a resident who is receiving tube feeding, he said yes. When asked how often he said when they are admitted /readmitted , have a significant weight loss, and quarterly. When asked if he checks on the tube feeding for the residents, he said he checks to make sure the rate is correct, and it is the right formula. When asked if he verifies the volume infuse, he said he does not. When asked if he checks with the nurse about the total volume of the feeding infused, he said no, he just assumes the total volume ordered is infused. The RD stated he does periodically ask the nurses if the residents are tolerating the tube feeding.

Based on interview, clinical and administrative record review, the facility failed to follow acceptable professional standards of practice to coordinate health care services to obtain the needed prescriptions for controlled drugs to treat pain to ensure residents did not go extended periods of time without the necessary pain medication for 2 of 3 sampled residents (Resident # 2 and # 3). The Florida Nurse Practice Act documents that the nurse is to: (e) Coordinate health care as necessary and appropriate and evaluate with the patient or client the effectiveness of care. The administration of medication and treatment as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The Findings included: 1) Review of the clinical record for Resident # 2 documented that the resident was admitted to the facility on [DATE]. The clinical record contained an incomplete initial nursing assessment. The assessment described the type of pain the resident experienced as an ache, throb, shooting and continuous pain located in his calf and feet. However, the assessment failed to document the level of the resident's pain. The assessment did not contain a numeric or facial qualifier to identify the intensity/severity associated with the pain the resident experienced. Further review of the clinical record disclosed that the physician prescribed on 12/28/2015 for the resident to receive Pregabalin ([MEDICATION NAME]) 25 mg one every day for pain. Upon further investigation it was determined that the nurses failed to provide evidence of coordinating the resident's health care to obtain the necessary prescription from the physician to forward to pharmacy for pharmacy to dispense the [MEDICATION NAME]. Thus the resident was not administered the pain medication, [MEDICATION NAME], for 7 days. However, review of the Medication Administration Record [REDACTED]. An interview was conducted on 01/05/2016 at 10:50 AM with Staff A, Registered Nurse assigned to the resident this date. The nurse stated that she contacted the physician on 01/04/2016 regarding the prescription for the [MEDICATION NAME] because the resident did not have the required medication available. The physician was present in the facility and wrote the prescription on 01/04/2016. She stated because the medication is a controlled medication it requires a hand written prescription from the physician. The actual prescription is then forwarded to pharmacy and upon receipt they will authorize the nurse to obtain medication from the emergency kit if the medication is needed prior to the actual delivery of the controlled medication. The nurse also contacted the pharmacy who verified that the resident did not have a prescription on file for the [MEDICATION NAME] prior to 01/04/2016. Thus the pharmacy did not authorize for the medication to be obtained out of the emergency kit nor did the pharmacy dispense the medication for administration. The nurse did not obtain a prescription signed by the physician until 01/04/2016. She further stated she didn't know what occurred prior to 01/04/2016 because she was not on duty. A subsequent interview was conducted on 01/05/2016 at 11:20 AM with the Interim Director of Nursing regarding the accuracy of the [MEDICATION NAME] administration. After researching the situation, the Interim DON stated that the resident did not receive the medication and those documented doses were medication errors. An attempt to interview the resident was unsuccessful. 2) An interview was conducted on 01/05/2016 at 2:50 PM with Resident # 3, who stated that they ran out of pain medication on day before yesterday and yesterday, 01/03 and 01/04, and I suffered all day in pain. Review of the clinical record for Resident #3 ' s physician orders [REDACTED]. The facility documents administration on a 6-12 schedule. Review of the Control Record for the [MEDICATION NAME] documents that the nurses removed doses on 01/03/2016 at 12 AM; 6 AM and 12 noon, which was the last tablet for this distribution of [MEDICATION NAME]. The nurses later obtained a new prescription for the resident on 01/04/2016 and was able to obtain medication from the emergency kit for 01/04/2016 at 12 Noon. However, prior to receipt of the new prescription, the resident did not receive three doses of his pain medication. The facility failed to provide evidence that the resident received the pain medication, [MEDICATION NAME] on 01/03/2016 at 6:00 PM and 01/04/2016 12:00 AM and 6:00 AM. Furthermore, again the nurses placed their initials in the appropriate box to suggest they administered the medication, when there is no evidence the nurses had authorization to administer the controlled medication.

Based on record review and interview, it was determined the facility failed to ensure plan of care was implemented for 2 of 3 sampled residents (Resident # 1 and # 2) as evidenced by failure to administer [MEDICATION NAME] treatment to Resident # 1 and failure to implement wound care recommendations for treatment for [REDACTED]. The findings included: 1) Clinical record review conducted on 12/14/15 revealed Resident # 1 was prescribed [MEDICATION NAME] soap once daily for seven days and then weekly for four weeks on 11/27/15. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record including nurses notes failed to indicate the resident had refused the prescribed treatment. Nurses Notes dated 12/01/15 documents Call placed to pharmacy concerning [MEDICATION NAME] soap ordered for resident. This nurse spoke to pharmacy who stated the pharmacy does not dispense this soap, it should be house stock .Follow up will be done with supply personnel in AM. Interview with the acting Director of Nursing (DON) conducted on 12/14/15 at 5:40 PM revealed the director reviewed Resident # 1's clinical record, and confirmed the treatment record for the [MEDICATION NAME] treatment was left blank on the identified days listed above. The DON was not able to locate documentation the resident had refused the treatments or why the treatment was not administered as ordered. 2) Clinical record review conducted on 12/14/15 revealed Resident # 2 was admitted to the facility on [DATE] with a stage III pressure ulcer. physician's orders [REDACTED]. Wound care consult dated 12/08/15 documents the resident was admitted with a stage III ulcer to the sacrum, measuring 9 cm in length, 8.1 cm in width and 0.2 cm in depth; the treatment noted Calcium Alginate. Further review of the record failed to provide evidence the recommended treatment has been implemented since 12/08/15. Interview with the acting Director of Nursing (DON) conducted on 12/14/15 at 3:41 PM revealed the wound care practitioner writes the recommendations and then writes an order for [REDACTED].