Every finding on record at Aviata at Greenacres

Based on record review and interview the facility failed to provide copies of an itemized bill as requested for 1 of 3 sampled residents (Resident #4).The findings included:During a phone interview on 07/22/26 at 9:04 AM, Resident #4 explained after her discharge from the facility, and upon receiving statements from her insurance company, she had phoned the facility on four different occasions requesting an itemized bill of services. Resident #4 explained she had spoken to the receptionist on two occasions, and was transferred to the billing person once, who told her it would be available the next day. Resident #4 stated she phoned the next day and was told it wasn't ready but that a message would be given to the billing person. Resident #4 stated she never got the requested itemized bill from the facility.Review of the record revealed Resident #4 was admitted to the facility on [DATE] and was discharged on 02/06/26. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident 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 07/23/26 at 11:50 AM, when asked the process to provide a requested itemized bill, the Business Office Manager (BOM) stated she would just print it out and provide it to the resident. The BOM then clarified they do have a third-party billing system so she would request the itemized bill, would usually get it within a day or so, and would then print it out for the resident. When asked what she would do if a discharged resident called and requested an itemized bill, the BOM stated she would get the resident's email address and send it that way, or send it via mail. When asked if she kept any log or any documentation of requested items, the BOM stated she did not.During the continued interview, when asked if she provided an itemized bill to Resident #4, the BOM stated she recalled the resident requesting it and looked through her emails. The BOM located emails on her phone and stated the resident called on 05/04/26 and requested the itemized bill to discuss with her insurance company, and she in turn requested it from their third-party billing company that same day. The BOM stated she did not receive it so sent a follow-up request on 05/13/26 and received it on 06/08/26. The BOM looked through her emails and stated she had sent it directly to the resident's insurance company and further stated, Oh . that's on me. I never sent it to her (Resident #4). When asked if there was any reason she did not send it to Resident #4, the BOM stated, No. When asked if there was any written process or policy related to provision of requested item from the business office, the BOM stated she did not think so.

Based on interview and record review the facility failed to ensure a proper and timely discharge process for 2 of 3 sampled residents as evidenced by the failure to complete the Discharge Plan and Instructions for Residents #4 and #5, failure to ensure timely set-up and provision of Home Health Agency (HHA) services and Durable Medical Equipment (DME) for Resident #4, and failure to ensure a timely transfer or attempt to transfer Resident #5 as per family request.The findings included:Review of the policy Discharge of Resident to Home or Other Center, revised 03/24/25, documented in part, Procedure: 1. Upon determination by the interdisciplinary team that resident is appropriate for discharge, the Nurse will obtain a physician's order for discharge to include: a) Place of discharge, b) Community resources or referrals required, c) Status of medications on discharge (i.e. May discharge home with med). 2. Complete the Discharge Plan and Instructions. 5. Provide resident/resident representative a copy of the Discharge Plan and the pharmacy medication list. 6. Document final disposition in the resident's clinical record.Review of the policy Interdisciplinary Discharge Planning, revised 04/28/25, documented in part, Procedure: . 2. a. Social Services/designee is responsible for identifying and coordinating necessary outside services and document in the medical record. 3. Prior to discharge, the discharge plan including the proposed discharge date will be reviewed with the resident/resident representative.1) Review of the record revealed Resident #4 was admitted to the facility on [DATE] and was discharged on 02/06/26. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Resident #4 had been admitted to the facility after a car accident in which she sustained a broken right leg, broken left foot, broken left arm and hand, and neck strain.During a phone interview on 07/22/26 at 9:04 AM Resident #4 confirmed the above fractures and stated she was non-weight bearing throughout her stay at the facility and for a total of three months afterward, thus was esentially bed and wheelchair bound. The resident also explained during her stay at the facility she had out-patient surgery on her left wrist. When asked about the discharge process, the resident explained the social worker had told her they would set up home health services and equipment. On the day of her discharge someone informed her they were working on the discharge. The resident explained that she lived alone but found family that would take her into their home. Resident #4 stated she called the equipment company because her family member was going to pick up the wheelchair, but the equipment company did not have the orders so wouldn't have the wheelchair for her. The resident explained that someone finally got ahold of the social worker via phone, as she had gone home for the day, and the social worker allowed her to borrow the facility wheelchair. Resident #4 stated at about 5:30 PM a nurse said goodbye and left, without going over any discharge papers. The resident explained the next day she looked at the papers that were essentially blank and had to call her managed care company to find out what home health agency to use. The resident stated she did not get home health services for several days.Review of the progress notes lacked any documentation related to the discharge of Resident #4. A physician progress note dated 02/06/26, the day of her discharge, documented, Disposition: Continue skilled nursing care with multidisciplinary support.Further review of the record revealed the Discharge Plan and Instructions that had only seven of the eleven sections completed. This form completed by the Social Services Director (SSD) on 02/06/26 documented that Resident #4 was returning home with her spouse or family and that she would have home health services, with a referral made to the resident's managed care provider, and DME to include a 3 in 1 drop arm commode. A document titled Response to Fax Request from the resident's managed care provider, time-stamped 02/09/26 at 10:40 AM, three days after discharge, documented the resident would start home health services on 02/11/26, five days after discharge from the skilled nursing facility.During an interview on 07/23/26 at 12:02 PM when asked about the discharge process related to home health services and DME, the Social Services Director (SSD) explained the process depends upon the insurance company involved, but generally the day before discharge she will make the necessary arrangements for the resident. When asked specifically about Resident #4's discharge, the SSD stated she wasn't sure but would have sent out the referral to the management care provider and DME the day prior to her discharge. The SSD volunteered that she recalled the DME couldn't provide the wheelchair on the day of discharge, so she allowed the resident to borrow one from the facility. The SSD provided a text message that documented the initiation of DME on 02/06/26, the day of discharge. When shown the managed care provider faxed response indicating the home health services would not start until 02/11/26, five days after discharge from the facility, the SSD agreed with the findings and stated she would look for the faxed referral information.During a subsequent interview on 07/23/26 at 1:05 PM, the SSD provided the faxed referral packet with a handwritten date of 02/06/26 on the fax cover sheet. Further review of the packet revealed the Order Summary Report that included the medications was time-stamped 02/09/26, three days after discharge. When asked about the discrepancy the SSD had no explanation.2) Review of the record revealed Resident #5 was admitted to the facility on [DATE] and discharged on 06/01/26. The resident had suffered a traumatic brain injury after a car accident.Progress notes revealed the following:a) A progress note dated 07/30/25 documented a referral was sent to another nursing facility on 07/18/25 and the resident was denied admission.b) On 05/15/26 a referral was sent to another nursing facility and they were waiting approval.c) On 05/29/26 a referral was sent to a sister facility per family request to be closer to [NAME] County. The referral was accepted and the transfer date was set for 06/01/26.d) On 06/01/26 Resident #5 was transferred to their sister facility in [NAME] County.Review of the Discharge Plan and Instructions dated 06/01/26 revealed the document was not completed.During an interview on 07/23/26 at 12:15 PM, when asked about the transfer request by the family and transfer process for Resident #5, the SSD explained that at first her mother wanted her to live at home, but she lived in a two-story townhome that would not work for them. Then the family stated they wanted the resident to be closer to home so they could be more involved in her care. The SSD stated she told the mother it would not be easy to find a place due to her very young age and level of care and insurance. When shown the progress notes documenting the transfer process started the previous year on 07/18/25 with no follow-up until 05/15/26, the SSD agreed, again stating it was difficult to find a facility that would accept the resident, but had no evidence of any other attempts. When shown the Discharge Plan and Instructions document, the SSD agreed it had not been completed.

Based on record review and interview, the facility failed to ensure appropriate care and services related to seizures for 1 of 3 sampled residents as evidenced by the failure to monitor for seizure activity, failure to implement seizure precautions, and failure to assess and implement interventions during a seizure for Resident #2. The findings included:Review of the record revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of convulsions. Review of the hospital record for the stay just prior to admission, revealed the resident had a new onset seizure while in the hospital. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a diagnosis of seizure disorder. Review of the physician orders and Medication Administration Record (MAR) documented Resident #2 received Lacosamide (an anti-seizure medication) twice daily as of 04/27/26 and Keppra (an anti-seizure medication) as of 04/28/26. The record lacked any care plan related to care and services or interventions for seizures.Review of a physician progress note dated 05/23/26 with a date of service as 05/21/26 documented staff were to implement seizure precautions for Resident #2. This was documented again on 06/07/26 for the service date of 06/04/26.Review of a nurse practitioner progress note dated 05/15/26 documented nursing staff were instructed to continue monitoring for seizure activity. Additional progress notes dated 05/22/26, 05/25/26, 05/29/26, and 06/01/26 all documented to monitor for seizures.A nursing progress note dated 06/05/26 at 5:09 AM documented, Patient was sent to the hospital following a seizure episode around 0450 (4:50 AM). After several intervention we called 911. They take him to the hospital.A Change In Condition form dated 06/05/26 at 5:23 AM simply documented Resident #2 had a seizure with vitals that were obtained at 5:25 AM through 5:27 AM.The record lacked any evidence of either the implementation of any seizure precautions or seizure monitoring. The record also lacked any documentation as to the type of seizure or condition of the resident, the length of the seizure, and specifically what interventions were implemented.During an interview on 06/09/26 at 1:11 PM, when asked what seizure precautions were, Staff A, Registered Nurse (RN) stated having the bed in the lowest position, side rail pads, and possibly floor mats. When asked what should be done if a resident was having an active seizure, the RN stated she would put the resident on their side, complete an assessment with vitals, and if the resident became unresponsive, she would send them out to the hospital. The RN stated if the resident was on precautions she would have to monitor the resident. When asked how that would be documented, the RN stated it would be an order and she would document in the MAR.During an interview on 06/09/26 at 1:43 PM, when asked what seizure precautions were, the Assistant Director of Nursing (ADON) stated they would include having the bed in the low position and side rail pads if the side rails were being utilized. When asked what should be done if a resident was having a seizure, the ADON stated they should ensure the residents safety and a clear environment and ensure airway clearance after the seizure. When asked what the nursing staff should document after a resident had a seizure, the ADON stated she would expect to see a description of what happened, to include describing the seizure, and what the staff did for the resident. Staff nurses should also notify the physician and family, as appropriate. When asked if she was aware of the recent seizure activity for Resident #2, the ADON stated she was not. When shown the documentation by Staff A, RN, the ADON agreed it was not complete.During an interview on 06/09/26 at 2:10 PM, when asked what she expects her staff to do if a resident was having a seizure, the Director of Nursing (DON) stated she would expect the resident to be in a low bed, turn them to their side, ensure their safety, and time the seizure. The DON stated If the resident had any as needed medication for active seizures, she would expect staff to provide those meds. If the resident continued to seize, she would expect her staff to send the resident out via 911 services. When asked if she was aware of the recent seizure for Resident #2, the DON stated she was as she received a phone call from the night nurse about 5:30 AM, she believed. The DON volunteered she instructed the nurse to time the seizure and to document her observations. When asked about seizure precautions, the DON stated they don't do the padded side rail intervention and was unsure why. The DON also stated there should be an order to observe and monitor for seizures.

Based on record review, interview, and observation, the facility failed to treat a resident with dignity for 2 of 7 sampled residents (Resident #1 and Resident #7).The findings included: 1.Record review revealed Resident #1 was admitted to the facility on [DATE] post knee replacement surgery. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living.A phone interview was conducted with Resident #1 on 02/25/26 at 11:00 AM. Resident #1 stated while she was at the facility, they placed a bedside commode next to her bed. The resident stated while she was using the bedside commode, urine splashed on the floor as well as her body. Resident #1 stated it was humiliating. It appeared the bedside commode did not have the correct bottom/collection container on it.An interview was conducted with the Nursing Home Administrator (NHA) on 02/26/26 at 10:00 AM. The DON stated they did not currently have any residents who use a bedside commode. The NHA, after conferring with a staff member, stated the bedside commodes are kept in the shower room and supply closet.An observation of the supply closet revealed 3 bedside commodes covered with plastic. Further observation of the bedside commode revealed they did not have an attached bucket/drainage collection. An observation of the shower room revealed 3 bedside commodes without collection containers.An interview was conducted with the NHA on 02/26/26 at 10:30 AM. The NHA acknowledged the above.2. Resident #7 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented Resident #7 had mild cognitive impairment, and was dependent for activities of daily living.Resident #7 was observed sitting in a wheelchair next to the nursing station slouched over to the right side on 02/25/26 at 11:00 AM. Resident #7 was yelling Help! I need to be repositioned. The resident was observed handled roughly by 2 staff members trying to reposition/adjust the resident in the wheelchair in front of others watching. The NHA was made aware of the observation on 02/26/26 at 12:00 PM.

Based on observation, interview and record review the facility failed to respond to call lights in a timely manner due to nonfunctioning call system in 5 out of 32 rooms on the South unit affecting rooms 216, 224, 259, 273, 279; failed to provide care and services to meet the needs for wound care and catheter care for 1 of 1 resident reviewed for wound care and catheter care (Resident #5); and failed to administer medications as ordered for 2 of 4 residents reviewed for medications (Residents #1 and #3). The findings included:Review of the facility's policy titled, Call Bell System -Inoperable with a revised date of 08/22/17 included in part the following: Residents must have at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regular scheduled basis by Maintenance. If the call bell system is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Maintenance, the Executive Director of Clinical Services must be notified immediately. Hand bells or tap bells will be placed within reach of any resident affected by an inoperable call bell. Residents and staff will be educated on their usage. If a large number of resident are affected by inoperable call bells, a CNA or Licensed Nurse will be assigned to check on the residents affected every 15 minutes. They will sign a Round Sign Off form after each check as proof that residents were monitored closely. The Director o Maintenance and the Executive Director will focus on the repair of the inoperable call bell(s) which will be their priority until they are operable. Review of the facility's policy titled, Clinical Guideline Skin and Wound with an effective date of 04/01/17 included in part the following: On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Licensed Nurse to document presence of skin impairment/new skin impairment when observed and document weekly until resolved. Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. Develop individualized goals and interventions. Review of the facility's policy titled, Dressing Change with a revised date of 12/06/17 included in part the following: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Apply treatment as ordered and clean dressing. Review of the facility's policy titled, Catheter Care, Urinary with a revised date of 09/05/17 included in part the following: remove catheter securement device while maintaining connection with drainage tube. Reattach catheter securement device. Review of the facility's policy titled, Medication -Oral Administration of with a revised date of 08/15/19 included in part the following: Document the administration and acceptance or decline of all medications administered. When documenting in the EMR (Electronic Medical Record) the nurse will document immediately prior to administration and or immediately post administration based on preferred individual professional practice of the nurse. Should the resident decline or be unable to accept the medication this will need to be documented following standard protocol. Chart on nurse's notes. Pertinent observation after administration. 1. Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses that included in part the following: Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Cognitive Communication Deficit. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #5 revealed in part the following: An order dated 02/20/26 for catheter care every shift for catheter hygiene. An order dated 02/25/26 for Right hip: paint with betadine and allow to dry. Cover with 6x6 bordered dressing. Change three times a week, Monday, Wednesday, and Friday and as needed. There was no order to secure the catheter device. Review of the Treatment Administration Record for Resident #5 revealed no documentation of right hip wound care having been performed from 02/19/26 to 02/24/26. Review of the Nurse Progress Notes for Resident #5 entered as a late entry on 02/24/26 with an effective date of 02/20/26 included in part the following: Wound noted to right hip area measures 7 x 6.6 x 0. Wound bed covered 100% eschar, peri wound skin within normal limits, no drainage or sign/symptom of infection. Orders added for betadine to right hip three times week on Monday, Wednesday, and Friday. On 02/25/26 at 11:26 AM observation of Resident #5 lying in bed disheveled, long uncombed hair, long untrimmed beard who was wearing a gown that was secured around his neck but off of his body, the covers of the bed were only covering his feet, his body was exposed and he was wearing an intact white brief with see through sides with the right side exposed revealing an approximate 5 inch diameter darkened spot on his right hip under the see through part of the brief. The resident also was noted to have an indwelling urinary catheter in place that did not appear to be secured in place as the tubing was coming out of the back of the brief near the upper leg. The call light was on the floor and not within the reach of the resident. The Assistant Director of Nursing (ADON) came into the room and acknowledged the resident needed to be covered, she acknowledged he had a wound on the right hip that was not dressed in the intact brief. The nurse also acknowledged the drainage tubing for the indwelling urinary catheter was not secured in place. The nurse was asked about the wound not being covered, she said the resident must have taken the dressing off but could not locate the dressing and did acknowledge the brief was still secured. During an interview conducted on 02/26/26 at 2:00 PM with the Wound Care Nurse who was asked about the wound care for Resident #5, she said she had done it on 02/20/26 and did not do it on 02/23/26 because she was out that day. She acknowledged the wound care was not completed on 02/23/26. During an interview conducted on 02/26/26 at 3:11 PM with the Director of Nursing (DON) who was asked about Resident #5 she acknowledged he came back to the facility on [DATE] and had a right hip wound on admission. Wound care for right hip was provided on 02/20/26 and again on 02/25/26. She acknowledged the wound care orders were not entered into the resident's chart until 02/24/26 and there was no documentation of wound care provided to the right hip on 02/23/26. 2. Record review for Resident #3 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Discitis Unspecified Multiple sites in Spine, Type 2 Diabetes Mellitus and Heart Failure. MDS dated [DATE] Documented in Section C a BIMS score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #3 revealed in part the following: An order dated 01/31/26 for daily weight and record for Congestive Heart Failure one time a day. An order dated 02/19/26 for Bumex 0.5mg give 4 tablets by mouth daily. An order dated 02/03/26 for Micafungin Sodium Intravenous Solution use 100mg intravenously one time a day. An order dated 02/09/26 for Ozempic (0.25 or 0.5mg/dose) subcutaneous solution pen injector 2mg/3ml inject 1 pen needle subcutaneously ever Monday. An order dated 02/18/26 for Victoza subcutaneous solution pen injector 18mg/3ml inject 0.6mg subcutaneously daily. An order dated 01/26/26 to monitor vital signs every shift. An order dated 01/26/26 for PICC or MID line: Measure upper arm circumference and external catheter length on admission, with each dressing change and as needed every shift for maintenance until 02/11/26. An order dated 02/03/26 for Havrix Intramuscular Suspension prefilled Syringe 0.5ml (Hepatitis A Vaccine) inject 1 syringe intramuscularly one time only for prophylaxis for 30 days. An order dated 02/12/26 for Hepllsav-B intramuscular solution prefilled syringe 20mcg/0.5ml (Hepatitis B Vaccine) inject 1 syringe intramuscularly one time only for prophylaxis. Review of the Medication Administration Record for Resident #3 revealed in part the following: On 02/01/26 and 02/02/26 no weights or documentation of weights. On 02/23/26 no Bumex 0.5mg 4 tablets administered. On 02/07/26 no Micafungin Sodium Intravenous Solution 100mg administered. On 02/09/26 no Ozempic administered. On 02/22/26 no Victoza administrator. On 02/07/26 no monitoring of vital signs documented. On 02/07/26 no PICC or MID line: Measure upper arm circumference and external catheter length on admission, with each dressing change On 02/03/26, 02/04/36 and 02/05/26 Havrix Intramuscular Suspension prefilled Syringe 0.5ml Hepatitis A Vaccine was not administered. On 02/12/26 and 02/13/26 Hepatitis B Vaccine was not administered. During an interview conducted on 02/25/26 at 1:00 PM with Resident #3 who stated the Social Worker has been helping him to get transferred to two other facilities closer to his brother in [NAME] Beach, one does not accept Medicaid pending and the other does not have any long term beds available. During an interview conducted on 02/26/26 at 10:30 AM with Director of Nursing (DON) who was asked about the grievance for Resident #3 that she investigated regarding call light response and provided education to staff who worked on the day of the incident. In the grievance report she documented in part the following: Staff will respond to call lights promptly per facility policy. Improved monitoring during shift. Resident satisfied with response time. When asked for the facility call light policy, she said they have no policy, it is a protocol and she wrote policy when she should have put protocol. She was asked for a copy of the facility protocol on call lights. On 02/26/26 at 11:46 AM the DON stated they do not have any written policy or written protocol for answering call lights timely. During an interview conducted on 02/26/26 at 3:11 PM with the Director of Nursing (DON who was asked about Resident #3 she acknowledged the resident had several medications that were not given in the month of February. She acknowledged all medications had to be locked at all times. 3.During a tour of the South unit on 02/25/26 from 10:45 AM to 1:00 PM the following five observations were made: At 10:58 AM call lights were not functioning in room [ROOM NUMBER]. At 11:12 AM call lights were not functioning in room [ROOM NUMBER]. At 11:35 AM call lights were not functioning in room [ROOM NUMBER]. At 12:07 PM call lights were not functioning in room [ROOM NUMBER]. At 12:12 PM call lights were not functioning in room [ROOM NUMBER]. On 02/26/26 at 9:00 AM an interview was conducted with the Director of Maintenance, who was asked about the call lights not functioning. He said he was just made aware of the nonfunctioning call lights yesterday and he started working on it immediately. They have a vendor in the facility today to assist with the repair of the call light system. The vendor was observed by the surveyor in the facility on 02/26/26. 4. Record review revealed Resident #1 was admitted to the facility on [DATE] post knee replacement surgery. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. Resident #1 was care planned for pain medication therapy related to pain, recent surgery. An intervention included was to administer analgesic (pain) medications as ordered by physician. A review of Resident #1's orders revealed an order dated 12/10/25 for Naproxen (an ant inflammatory) one tablet every 6 hours as needed for pain. An order dated 12/10/25 was for Oxycodone one tablet every 4 hours as needed for moderate to severe pain level 5-10. A review of Resident #1's Medication Administration Record (MAR) revealed the resident was administered Naproxen on 12/10/25 at 2:00PM (pain level 6), on 12/11/25 at 10:00 AM (pain level 5), on 12/12/25 at 8:47 AM (pain level 5), and on 12/15/25 at 6:00 AM (pain level 6). Further review of Resident #1's record did not reveal why the ordered Oxycodone was not administered or offered for the resident's moderate to severe pain level, or if the administered medication was effective. An interview was conducted with the Director of Nursing (DON) on 02/26/26 at 12:00 PM. The DON acknowledged the above.

Based on interview and record review, the facility failed to ensure ordered home health was set up for a resident upon discharge for 1 of 7 sampled residents (Resident #1).The findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] post knee replacement surgery. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. A phone interview was conducted with Resident #1 on 02/25/26 at 11:00 AM. Resident #1 stated she was still waiting to receive home health treatment since discharge from the facility on 01/31/26.A review of Resident #1's orders revealed an order dated 01/30/26 to discharge home on [DATE] with occupational therapy (OT), physical therapy (PT), home health. DME (durable medical equipment) to include standard walker. An interview was conducted with the facility's Social Services Director (SSD) on 02/25/26 at 11:30 AM. The SSD stated Resident #1 was originally supposed to be discharged home on [DATE], but the ordered walker had not been delivered. SSD confirmed Resident #1 was discharged home without home health services being confirmed. The SSD stated she faxed orders to a home health agency on 01/29/26. The SSD stated she did not have documentation of confirmation of home health services. A review of Resident #1's records did not reveal any documentation related to the discharge of Resident #1's status with attempt to set up home health services.

Based on observations interviews and record review the facility failed to secure medications at the bedside for 1 of 6 sampled (Resident #7), and failed to secure medications at 2 of 2 nursing stations (North and South). The findings included: Review of the facility's policy titled, Medication Storage with no date included in part the following: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel as defined by facility policy. Record review for Resident #7 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Acute Respiratory Failure with Hypoxia, Quadriplegia C5-C5 Incomplete, and Dysphagia Unspecified. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment. 1.Record review for Resident #7 revealed no assessment or physician's order to self-administer medication. Review of the Physician's Orders for Resident #7 revealed in part the following:An order dated 01/5/26 for Allergy Cream 2-0.1 % (diphenhydramine-Zinc Acetate) apply to back/affected area topically every 12 hours as needed for Itching.An order dated 02/20/26 for Allergy Cream 2-0.1 % (diphenhydramine-Zinc Acetate) apply to neck, back and chest topically as needed for Itching.An order dated 02/2/26 Clobetasol Propionate E External Cream 0.05 % apply to bilateral upper arms topically two times a day for bullous pemphigoid apply to bilateral upper extremities topically every 12 hours for eczematous rash, bullous pemphigoid for 14 Days Clean bilateral upper extremities forearms with normal saline. Apply Clobetasol to wounds/blisters. Cover with abdominal pads and wrap with Kerlex twice daily and apply to affected areas topically every 12 hours as needed for Bullous pemphigoid, rash. On 02/25/26 at 11:07 AM an observation was made of Resident #7 of night stand top drawer open with hydrocortisone 2.5% cream and Clobetasol Propionate 0/05% cream. On 02/25/26 at 11:08 AM during an interview conducted with Staff C Registered Nurse (RN) who was asked if Resident #7 has any creams ordered, she stated he has an order dated 02/02/26 for Clobetasol Cream and Allergy Cream (diphenhydramine-Zinc Acetate). On 02/25/26 at 11:09 AM during a side-by-side observation with Staff C RN with Staff A CNA who both acknowledged the medications are kept at the bedside and they both said they are there so the CNA can put the creams on the patient when they provide care. 2.On 02/25/26 at 11:55 AM observation of 1 bottle of melatonin 3mg and 1 bottle of melatonin 5mg was on the nursing counter (200 unit) with no staff member in sight and 3 residents adjacent from the nursing station.During an interview conducted on 02/25/26 at 12:00 PM with the Assistant Director of Nursing (ADON), she acknowledged the medications were left at the nursing station but they were unopened. 3.On 02/26/26 at 11:09 AM an observation was made at the unsecured North Nursing station of an unsecured enema saline laxative with active ingredient Diabasic sodium phosphate 7gm and Monobasic sodium phosphate 19gm. There were no staff members at or near the nursing station, however there were 4 residents near the nursing station.During an interview conducted on 02/26/26 at 11:15 AM with Staff E Registered Nurse Unit Manager who was asked if medications should be secured at all times, she said yes. When asked about the enema saline solution, she said she had no idea who left it at the nursing station but removed it immediately.

Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 sampled residents with a mechanical soft ordered diet (Resident #4).The findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with a readmission date of 04/18/25. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required substantial/max assist with activities of daily living.Resident #4 was care planned for at risk of malnutrition related to need for therapeutic and mechanically altered diet. Interventions included explain and reinforce to the resident the importance of maintaining the diet ordered and monitor/document/report as needed and signs and symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling.A review of Resident #4's orders revealed an order dated 12/17/23 for a dysphagia mechanical soft diet.Resident #4 was observed sitting in the hallway next to the nursing station, coughing, on 02/25/26 at approximately 12:00 PM. Resident #4 was observed with something grasped in the hand and putting it to the mouth and coughing. Staff was observed passing by the resident not intervening. Surveyor inquired what was in the resident's hand. Resident #4 exposed what appeared to be a chewy granola bar. Surveyor asked Staff Z, a certified nurse assistant (CNA) where the resident got the granola bar and she said from his drawer, but it was the last one. An observation of Resident #4's room revealed no food in the resident's drawer but revealed a breakfast tray on the bedside table with another resident's name the ticket. The tray had remnants of scrambled hard eggs and hashbrowns with crispy/crunchy edges. Staff Z was assisting Resident #4's roommate. Staff Z shrugged her shoulders when questioned about the tray. An interview was conducted with the Speech Therapist (ST) and Registered Dietician (RD) on 02/25/26. They both agreed Resident #4 should not have had the chewy granola bar and the crispy hash browns.

Based on observation, interview and record review, the facility failed to ensure dignity with dining for 2 of 5 residents sampled for dignity (Resident #160 and Resident #161). The findings included:1.Resident #160 was admitted to the facility on [DATE] with diagnoses that included Encephalopathy, Adult Failure To Thrive, Dementia, and Anxiety. Her Brief Interview for Mental Status (BIMS) was 4 on the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/29/25. This indicated the resident was severely cognitively impaired. A review of the admission MDS also revealed the resident was dependent on eating. Her diet order was a consistent carbohydrate diet, renal diet, dysphagia puree texture, regular/thin liquids consistency. This indicated the resident had difficulty in swallowing.On 07/07/25 at 12:49 PM the surveyor observed Staff D, a certified nursing assistant (CNA) feeding the resident, who was in bed, while standing up. On 07/08/25 at 12:00 PM the surveyor observed Staff E, CNA, feeding the resident lunch standing up. The surveyor asked Staff E if she was aware that she should be sitting down and she stated she was aware. 2. Resident #161 was admitted to the facility on [DATE] with diagnoses that included Wedge Compression Fracture of Unspecified Lumbar Vertebra, Unspecified Injury of Spleen, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant side. His BIMS score was 11 on the Medicare 5-day MDS with an ARD of 07/01/25. This indicated he had mild cognitive impairment. The MDS also revealed that for eating, the resident had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. His diet was Regular, Dysphagia Puree texture with Honey Thickened fluids consistency.On 07/08/25 at 12:03 PM, the surveyor observed Staff F, CNA, feeding resident lunch while standing up. When the Staff F saw the surveyor, he picked up a chair that was across the room and sat down.On 07/09/25 at 2:30 PM an interview was conducted with the Director of Nursing (DON) to discuss the findings.

Based on observation, interview and record review the facility failed to provide fingernail care to dependent residents for 4 of 4 sampled residents, Residents #54, #75, #90, #91; failure to shave a resident (Resident #54) ; failure to provide oral hygiene to a resident (Resident #91).The findings included:1.Review of the record revealed Resident #54 was admitted to the facility 04/17/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #54 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact.Review of Resident #54's care plan dated 04/18/25 documented Alteration in Usual Functional Performance in self-care related to Deconditioning including an intervention that documented Personal Hygiene-Setup or clean-up assist with 1 assist.A review of Resident #54's task for personal hygiene documented Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) was reviewed on 07/09/25 and revealed that in a 30 day look back period it was documented as being completed. Observations were conducted on 07/07/25 at 10:43 AM, 07/08/25 at 10:03 AM, 07/09/25 at 10:00 AM and 07/10/25 at 9:57 AM; Resident #54 had long, dirty nails and long unkempt facial hair on all days. During an interview on 07/07/25 at 10:43 AM when asked how his care was, Resident #54 stated his electric shaver was not working and had been asking staff to help him shave his facial hair and had not received any assistance. When asked how often they cut and cleaned his fingernails he stated, they don't. Resident #54 looked at his fingernails and stated, they need to be cut.On 07/08/25 at 10:03 AM, Resident #54 was heard asking a staff member to help him shave and they acknowledged they would help him. Upon entering Resident #54 room he was noted to be visibly upset and frustrated. When asked if staff had taken care of his facial hair and fingernails yet, Resident #54 stated they have not shaved me or cut my nails, all I'm getting is words and no action. The Resident showed the surveyor his nails and stated see how jagged my nails are, I don't care if they charge me I'll pay for it I just want it done; everyone just gives me words but no action.During a follow up interview on 07/09/25 at 10:00 AM, Resident #54 stated that they still hadn't shaved his facial hair, again, he stated, my nails are still jagged and long, they don't take care of me, they don't do anything, all I get is words from everyone.During an interview on 07/10/25 at 10:05 AM when asked who was in charge of resident's nail care, shaving, and oral hygiene, Staff B, Certified Nursing Assistant (CNA) stated, we are, the CNAs. When asked how often each was done, Staff B stated: nail care was every other week, oral care was daily, shaving depended on if the beard was long and when the Resident requested they wanted it done.On 07/10/25 at 10:11 AM, Staff B came to Resident #54's room with the surveyor to address the Resident's concerns. When asked how the Resident's nails and facial hair looked like to Staff B, he acknowledged his nails were long and dirty and agreed his facial hair needed shaving. Resident #54 expressed his frustrations to Staff B and stated he was not getting any care and needed to be shaved.2. Review of the record revealed Resident #75 was admitted to the facility 10/01/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #75 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was moderately cognitively impaired.Review of Resident #75's care plan dated 04/15/25 documented Alteration in Usual Functional Performance in self-care related to deconditioning including an intervention that documented Personal Hygiene -Partial/moderate assistance with 1 staff assist.A review of Resident #75's task for personal hygiene documented Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) was reviewed on 07/09/25 and revealed that in a 30 day look back period it was documented as being completed.Observations were conducted on 07/07/25 at 2:48 PM, 07/08/25 at 10:09 AM, 07/09/25 at 9:00 AM and 07/10/25 at 9:59 AM; Resident #75 had long unkempt nails on all days.During an interview on 07/07/25 at 02:48 PM when asked if she received fingernail care, Resident #75 stated her nails were long and would like them cut.During an interview on 07/10/25 at 10:30 AM, when asked who was in charge of resident's nail care, Staff A, Certified Nursing Assistant (CNA) stated, the nails were cut by CNAs. When asked how often they were taken care of, she stated every month or when I see they are long I will cut them. Staff A was made aware Resident #75 had expressed she wanted her nails cut and came into the resident's room with the surveyor to observe the resident's fingernails. Upon entering, Staff A acknowledged the length of her nails and stated she would take care of them.3. Review of the record revealed Resident #90 was admitted to the facility 01/15/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #90 had a Brief Interview for Mental Status (BIMS) score of 7, on a 0 to 15 scale, indicating the resident was severely cognitively impaired.Review of Resident #90's care plan dated 01/16/25 documented Alteration in Usual Functional Performance in self-care related to right hemi/CVA (a right brain stroke that happens when blood supply to the right side of the brain is stopped and affects the left side of the body). including an intervention that documented Personal Hygiene - Dependent with 1 staff assist.A review of Resident #90's task for personal hygiene that documented Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) was reviewed on 07/09/25 and revealed that in a 30 day look back period it was documented as being completed.Observations were conducted on 07/07/25 at 9:59 AM, 07/08/25 at 9:20 AM, 07/09/25 at 12:32 PM and 07/10/25 at 10:02 AM; Resident #90 had long, unkempt nails with heavy dirt accumulation on all days.During an interview on 07/07/25 at 09:59 AM when asked if they clean and cut his fingernails, Resident #90 replied nope they don't. Resident #90 expressed the staff do not offer or provided nail care.During an interview on 07/10/25 at 10:05 AM when asked who was in charge of resident's nail care, Staff B, Certified Nursing Assistant (CNA) stated, we are, the CNAs. When asked how often it was done, Staff B stated nail care was done every other week. When asked, what happens if the Resident requested care more often, Staff B stated they would do it when they requested it.On 07/10/25 at 10:09 AM, Staff B came with the surveyor to observe Resident #90's nails with the surveyor and address the Resident's concerns. When asked how the Resident's nails looked like to Staff B, he acknowledged his nails were long and dirty but stated sometimes the resident would refuse. When asked where he documented Resident refusals of personal hygiene, Staff B stated in the electronic medical record and would let the nurse know. Review of the personal hygiene tasks for Resident #90 did not reveal any refusals.4. Review of the record revealed Resident #91 was admitted to the facility 01/17/25 with the diagnosis of aphasia (a language disorder that affects a person's ability to communicate) following a cerebral infarction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #91 had a Brief Interview for Mental Status (BIMS) score of 7, on a 0 to 15 scale, indicating the resident was severely cognitively impaired.Review of the active orders revealed a Nothing by Mouth diet, NPO texture, NPO consistency, a peg tube with enteral feeding order, and an order that stated Resident #91 was nonverbal.Review of Resident #91's care plan dated 05/09/25 documented Alteration in Usual Functional Performance in self-care related to Deconditioning including interventions that documented Oral Hygiene - Dependent with 1 staff assist and Personal Hygiene-Dependent with 1 staff assistA review of Resident #91's task for oral hygiene documented Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment was reviewed on 07/09/25 and revealed that in a 30 day look back period it was documented as being completed.A review of Resident #91's task for personal hygiene documented Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) was reviewed on 07/09/25 and revealed that in a 30 day look back period it was documented as being completed.Observations were conducted on 07/07/25 at 11:19 AM, 07/08/25 at 9:54 AM, 07/09/25 at 12:38 PM and 07/10/25 at 9:53 AM; Resident #91 had long, dirty nails and dry, chapped lips on all days. On 07/10/25 at 9:53 AM Resident #91's lips appeared cracked with spots of blood.During an interview on 07/07/25 at 11:19 AM an interview was conducted with Resident #91 where he was able to participate by nodding yes and no. When asked if he gets his nails cut and clean, the resident nodded no. When asked if he would of liked to receive nail care, he nodded yes.During a follow up interview on 07/09/25 at 12:38PM, Resident #91 was asked if he had been provided nail care yet and nodded no. When asked if he had received any kind of oral hygiene, Resident #91 nodded no. Resident #91's lips were noted to appear very dry and was asked if his lips hurt from being dry, he nodded yes.During an interview on 07/10/25 at 10:21 AM when asked who was in charge of resident's nail care, Staff C, Certified Nursing Assistant (CNA) stated, the CNAs. When asked how often it was done, Staff C stated daily or when they asked for it. Staff C came with the surveyor to observe Resident #91's nails and address his concerns. When asked how the Resident's nails looked like to Staff C, she acknowledged his nails were long and dirty. When asked how Resident 91's lips look to Staff C, she states dirty and dry. Staff C acknowledged the Resident had blood on his lips from them getting cracked.During an interview on 07/10/25 at 10:33 AM, when asked who was in charge of Activities of Daily Living (ADL) care provided to residents, the Director of Nursing (DON) stated overall she was responsible, but the CNAs would be in charge of the direct care with oversight of the nurses. When asked how often nail care, shaving, and oral hygiene should be provided, the DON stated: Nail Care should consist of weekly trimmings and daily cleanings ; Oral hygiene should be after meals, as needed, at least daily and with AM and PM care; shaving should be daily, as needed and per request or upon observations. The DON was made of the findings related to Residents #54, #75, #90, and #91 she agreed with all concerns and stated we need to treat residents the way we want our parents treated. The DON stated the staff that round on the residents should have focused on those things and observe the residents closer.

Based on observations, interview, and record review, the facility failed to implement interventions to monitor behaviors related to antidepressant and antipsychotic medication for 1 out of 5 residents reviewed for Unnecessary Medications (Resident # 58). The findings included: Record review for Resident # 58 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Dementia, a condition characterized by a progressive decline in affecting memory, thinking, language, and behavior, Parkinson's Disease and Bipolar Disorder. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident # 58 had a Brief Interview for Mental Status score of 12, which indicated that she was moderately cognitively impaired. Review of the Physician's Orders showed that Resident # 58 had an order for Zonegran Oral Capsule 100 milligrams (mg) 1 capsule by mouth two times a day for Agitation. She also had an order for Venlafaxine Oral Tablet 75 MG one time a day for Depression. There was an additional order for Venlafaxine Oral Tablet 37.5 MG. Give 1 tablet by mouth at bedtime related to Major Depressive Disorder. Resident #58 also had Physician orders for Nuplazid Oral Capsule 34 MG. Give 1 capsule by mouth one time a day for Hallucinations, and Mirtazapine Oral Tablet 15 MG. Give 1 tablet by mouth at bedtime for Major depressive disorder. Review of the Medication Administration Record (MAR) for Resident # 58, for July 2025, lacked documentation of behavior monitoring for antipsychotic and psychotropic medication.On 07/09/25 at 2:30 PM an interview was conducted with the Director of Nursing (DON). Discussed with the DON that there was no behavior monitoring for the antipsychotic or psychotropic medication for Resident #58. The DON stated they might have paper monitoring, or it could be on the MAR. AT 3:00 PM the DON stated behavior monitoring would be on the MAR but she did not see behavior monitoring for Resident #58.

Based on observation, interviews, and menu review, the facility failed to provide adequate portion size for the main lunch entree for Regular diets, with the potential to affect 46 residents on Regular diets. In addition, 3 of 10 sampled residents voiced food concerns regarding inadequate portions during survey ( Residents #3, #8 and #9). The findings included: 1. On 11/14/24 at 9:44 AM, an interview was conducted with Resident #3, he stated The facility doesn't give enough food; they need bigger portion. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnosis including diabetes. Review of the admission minimum data set assessment, reference date 10/30/24, recorded a brief interview for mental status score of score 15, which indicated Resident #3 was cognitively intact. Review of care plans evidenced Resident #3 had the potential of nutritional problem related to insulin dependent diabetes type 1, elevated blood sugar levels, and abnormal labs. Interventions included provide and serve diet as ordered (Regular diet). This care plan also documented Resident #3 had potential/actual impairment to skin integrity of fragile skin. Intervention included: encourage good nutrition and hydration in order to promote healthier skin. 2. On 11/14/24 at 11:38 AM, an interview was held with Resident #8. He stated he did have a problem with the portion of the food he received. He did not receive enough to eat. Review of clinical record for Resident #8 revealed, he was admitted to the facility on [DATE] with diagnosis including brain neoplasm (brain cancer). Review of the minimum data set assessment recorded a brief interview for mental status score of 15, which indicated Resident #8 was cognitively intact. Review of dietary care plan documented Resident #8 had nutritional problems or potential nutritional problems related to brain neoplasm. Interventions included: Provide and serve diet as ordered. 3. On 11/14/24 at 11:45 AM, an interview was conducted with Resident #9, he stated this place is costing him money because he must order out all the time. The facility did not give him enough food. The portions they give are for a child. He was always hungry, and he would like to have a snack at night. Clinical record review for Resident #9 revealed he was admitted to the facility on [DATE] with diagnosis that included cutaneous abscess. According to Resident #9's minimum data set assessment, reference date 11/01/24, it was recorded Resident #9 had a brief interview for mental status score of 14 which indicated Resident #9 was cognitively intact. Resident #9's care plans, revealed, he had potential for nutritional problem related to actual skin impairment of the left buttock pilonidal abscess. Intervention included: Encourage good nutrition and hydration. 4. Review of the day 6 menu cycle revealed the regular lunch for Friday 11/15/24 included: Shrimp & Sausage Jambalaya, 1 cup which is equal to 8 ounces was to be served to 46 residents. On 11/15/24 beginning at 11:42 AM, an observation of lunch tray line service was conducted in the kitchen accompanied with Staff A, who revealed she was the food service manager, however her badge read Account Manager. During the observation, Staff B, a dietary staff was plating the food and three other dietary staff were assisting putting the trays in the food cart. An observation was made of Staff B as she prepared a plate, she put six ounces of shrimp & sausage Jambalaya on the plate. However, according to the menu, she was supposed to put 8 ounces on the plate. The scoop she used read 6 ounces. An inquiry was made regarding the portion, Staff A looked at the scoop and agreed Staff B was not using the correct scoop. During that time, the surveyor requested to see the trays that were already prepared with the shrimp & sausage Jambalaya to ensure adequate portion was put on the plates. Staff C and Staff D removed 7 trays from the food carts. It was revealed that only 6 ounces of shrimp & sausage Jambalaya was on the plates,confirmed by Staff B, who revealed she used the 6 ounces scoop.

Based on interview, observation, and record review, the facility failed to provide appropriate supervision to prevent an elopement, which resulted in a resident who was able to leave the facility and travel along a busy roadway with a likelihood of being hurt, killed or lost, for 1 of 1 sampled resident reviewed for elopement risk (Resident #1). The deficient practice allowed Resident #1 to exit the facility from between 07/25/24 at 9:00 PM to 07/26/24 at 5:45 AM without supervision. Resident #1 walked approximately 3 miles away from the facility, before being stopped by staff. Resident #1 was transported back to the facility by the same staff. Census was 94 at the time of the survey. Seven residents were identified at risk of elopement or wandering. Resident #1 remains in the facility with one-to-one (1:1) supervision. The facility's Administrator was notified of Immediate Jeopardy and given the Immediate Jeopardy (IJ) Template on 08/14/24 at 3:30 PM. The Immediate Jeopardy was removed at the time of the facility exit on 08/16/24. The findings included: Review of the facility policy, titled, Elopement/Wandering Risk Guideline, Revision Date 08/01/20, documented in the section labeled Process, a bullet point that states Initiate individualized interventions based on Patient/Residents' risk. Record review revealed Resident #1 is vulnerable, adult male, who was admitted to the facility on [DATE]. Resident # 1 had his most recent Minimum Data Set (MDS) Quarterly Assessment on 07/10/24. At that time, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated a moderate cognitive deficit. Resident #1 was identified as a elopement risk upon his initial evaluation at admission on 04/02/24. On 06/27/24, Resident #1 was re-evaluated as an elopement risk when he began exhibiting signs of exit seeking. The resident's diagnoses included the following: Cardiomegaly (enlarged heart), generalized muscle weakness, anxiety disorder, acute kidney failure, insomnia, altered mental status, cognitive communication deficit and encephalopathy. The primary diagnosis for the admission was encephalopathy (damage or disease that affects the brain). From the facility's report, on 07/26/24 at 6:39 AM, the Director of Nursing (DON), who is no longer on staff at the facility, reported to the Administrator that Resident #1 was missing from the facility. Resident #1 was out of the facility for an unknown amount of time, he left either late at night or in the early morning, and walked 3 miles, before he was found. The distance was determined by Google Maps and verified by this writer, on 08/12/24, using his car's trip odometer. When Resident #1 was brought back to the facility, he was asked how he got out and he stated he loosened the screws in the window lock placed on the bottom inside track. He then was able to remove the device, open the window, remove the screen and climb out the window. On 08/12/24 at 1:13 PM, an interview with Staff A, a facility Housekeeper, was conducted. Staff A stated that she was off duty and on her way to a store when she saw Resident #1. Staff A stated that the time was around 7:30 AM. Staff A stated she saw Resident #1 as he was walking Northbound on a busy 6-lane divided roadway, with a 45 Mile Per Hour (MPH) speed limit, near the entrance ramp to the 4-lane Florida's Turnpike with a speed limit of 70 MPH. Staff A stated she made a U-turn, pulled over to the side of the road with her hazard lights on and spoke to Resident #1. Resident #1 told Staff A that he was going to his family. Staff A called the facility to inform them she found Resident #1 near the Turnpike ramp, and she was going to try to get Resident #1 into her car. Staff A stated she offered Resident #1 a ride, letting him believe she was taking him to his family, and he accepted the ride. Resident #1 was then returned to the facility by Staff A. Record review was conducted of a nurse's progress note dated 06/27/24 at 6:58 AM indicated Resident #1 informed the nurse that someone called him through the television, and he needed to be somewhere. The nurse documented that Resident #1 was monitored closely and the oncoming nurse was notified to continue. A progress note dated 06/27/24 at 7:15 AM indicated an order was received to place a wanderguard device on Resident #1. The nurse documented the wander guard was placed on Resident #1's right foot and the Staff monitored him closely. On 06/27/24 at 8:37 AM, Psychiatry was notified of the exit seeking behavior. The Resident was noted to have been standing at the front door and expressing he was leaving that morning. The same note stipulated that the Assistant Director of Nursing (ADON) told the nurse that Resident #1 was expressing he was going to another country. The nurse documented that Resident #1 had told the nurse the week prior that he, Resident #1, was going to Canada. The investigative report, dated 08/01/24, revealed that the resident was last seen by his primary nurse on 07/25/24 between 8 and 9 PM. The nurse stated she did not see Resident #1 at 5:45 AM, when she was passing medications. On 08/13/24 at approximately 2:15 PM, an interview conducted with the primary nurse, Staff L, who worked the 7:00 PM to 7:00 AM shift, starting on 07/25/24, on the North Wing. Staff L stated she did not remember when she last saw Resident #1, but she did notice he was missing at around 5:45 AM on 07/26/24. Staff L stated she reported the resident missing to Staff B (nurse on South Wing). At that time the elopement protocol was started. On 08/13/24 at 9:37 AM, an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C stated that she works the 11:00 PM - 7:00 AM shift. Staff C stated that when she first came on shift and looked in the resident's room, she noted the bed was made as if there was no one assigned to the bed. Staff C stated she did not see the resident, and she never laid eyes on him. Staff C stated she normally works the South Unit and Resident #1 was on the North unit. Staff C stated when she works the South unit, she is more familiar with the residents and would ask the nurse about a missing resident. Staff C stated she did not ask the nurse about the resident not being there. Staff C stated she just did not ask about the resident. Staff C stated that there is no communication between shifts. On 08/13/2024 at 8:24 AM, an interview was conducted with Staff B, Registered Nurse (RN), who worked on the South Wing from 7:00 PM to 7:00 AM on the day of the elopement. Staff B stated that she was the weekend supervisor for her shift. Resident #1's room was on the North Wing. Staff B stated that at approximately 6:00 AM the nurse who was primary for Resident #1 informed Staff B that Resident #1 was missing. Staff B stated she immediately initiated the elopement protocol and had the staff search the facility and grounds for Resident #1. Staff B stated she was present when Resident #1 was returned to the facility. Staff B stated Resident #1 appeared to be in good spirits and unharmed. Staff B remembered that the weather that morning was overcast but it was not raining at the time. Staff B stated Resident #1 was dressed in a T-shirt, either in long shorts or pants, and he had a jacket or sweater with a hood over his shoulder. On 08/13/24 at approximately 4:00 PM, an interview was conducted with Resident #1. Resident #1 explained that he got out by loosening the screws on the (window blocking) device, removed it, opened the window, pushed out the screen and climbed out the window. Resident #1 stated he put it all back together so no one would see. Resident #1 was unsure of the time he got out. **An onsite IJ Removal Plan verification was conducted on 08/16/24. The following is verification that the IJ Removal Plan was implemented and the Immediate Jeopardy had been removed: On 08/16/24 at 9:00 AM, the IJ Removal plan was reviewed with Administrator present. The criteria section 1 included items already reviewed during the initial investigation. The Elopement policy and procedure were not changed as no changes were thought to be necessary. Resident #1 remained in the facility with continuous 1:1 observation. The Executive Director led a Quality Assurance and Performance Improvement meeting on 07/26/24 with the Medical Director, Director of Clinical Services, Plant Operations, Dietary Supervisor, MDS Coordinator, Business Development Director, Business Office Manager and Assistant Director of Nursing. The Elopement Policy was reviewed, and the root cause of the elopement was discussed. The meeting included a Root Cause Analysis, which was reviewed with the Administrator. The facility determined Resident #1 strongly wanted to go home to his family. Resident #1 determined that the windows did not have alarms and that was probably the easiest way to escape the building without being noticed. Resident #1 was evaluated by the psychiatric services on 07/26/24 with recommendation for continued 1:1 observation and new orders for lab work. Interview, record review, and observation confirmed this to be true during the initial investigation. Lab orders were received from the attending physician. The results were obtained 07/27/24, 07/29/24 and 08/01/24 and reviewed by attending physician with no new orders. Record review confirmed these orders were received and acted upon. The lab results showed the resident had normal or near normal values. There were no indicators that would point to confusion, or a change of cognition as would be related to infection or other disease processes. Under criteria two, the following was reviewed: o On 07/26/24, a facility wide head count was conducted to verify all residents present in the facility. Documentation provided included a copy of the Midnight Census used to check the presence of all residents on both wings. o On 07/26/24, the Plant Operations Manager rounded in the facility to validate all exit door alarms were functioning properly and windows were secured. Documentation examples were provided to show the doors and windows were being checked daily. o On 07/26/24, the Director of Clinical Services and/or designee checked all residents with the wanderguard for functioning and placement. The wander guard checks were recorded in the Treatment Administration Record (TAR). The checks were done for each shift. The checks involved checking for placement and checking for functioning. Functioning checks were done with a device that has a green light that turns on if the device is good. If the green light does not go on, the wanderguard is replaced. On 07/26/24, the Director of Clinical Services and/or designee reviewed and updated all the elopement risk books. Elopement evaluation for 5 remaining elopement risk residents were reviewed. Elopement evaluation for 2 residents not at risk were reviewed. The evaluations matched to the documentation kept in the Elopement Binders, which were found at the two nurses' station and the front desk. On 07/26/24 daily window checks initiated. See above (Operations Manager). On 08/15/24, Maintenance director conducted a new inspection of all flip locks on windows to ensure locking mechanism is working and all windows were locked. No corrections needed. Observations were made of the window lock tests. The locks were checked to ensure they could unlock in an emergency. Under criteria three, the following were verified: Facility staff were educated by clinical leadership and executive director beginning 07/26/24 on missing persons, abuse/neglect, elopement, midnight census head count, accounting for residents on assignment, identifying residents on assignment, identifying residents with increase exit seeking behavior - implement 1:1 accordingly. Education was validated with post testing and elopement drill participation. Copies of sign-in sheets for all shifts were provided for the education provided. An Elopement drill was observed. The staff appeared competent in responding to the drill. As of 08/02/24 a total of 117 of 120 staff, including contracted staff members, had received elopement education, and participated in elopement drills. New hires will receive education in orientation. Certified letters were sent out to those staff members that were unable to attend the education. Staff include: Therapy Housekeeping laundry Dietary CNA Nurses All department heads and administrative staff. Newly hired staff will receive education in orientation. A list of employees with the date of the education provided was secured by the surveyor. Current facility nurses were educated by the Director of Clinical Services or designee, on the importance of providing thorough supervision for residents with signs and symptoms of wandering or exit seeking behaviors. This included how to monitor, and screen generalized statements and conversations even on admission for risk of elopement. Reinforced education included how to monitor and identify different residents for increased sign and symptoms of elopement risk in the SNF settings. Key components included how to search interior and exterior of rooms and corridors to increase the accuracy and effectiveness of elopement drills. As of 08/02/24, 35 out of 35 nurses had received education from the Director of Nursing/designee. One of the 35 nurses had not completed an elopement drill due to being out on maternity leave at this time. A certified letter has been sent to notify of ineligibility to work until elopement drills have been completed with posttest. Documentation was provided as part of the education documentation noted above. The Director of Nursing and/or designee conducted elopement drills on each shift daily starting on 07/26/24 continued daily through 08/07/2024 including post drill education based on response. On 08/07/24, Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held. After a review of the elopement drills revealed 100% compliance with responses every shift, the committee has determined the drills will be conducted 3 times a week for 4 weeks. Elopement risk evaluations on new admissions will be reviewed at the morning clinical meeting. On 08/14/24, the Director of Nursing initiated education to CNA and licensed nurses on nurse-to-nurse verbal report, nurse to CNA verbal report, and CNA to CNA verbal report. Interviews and record review conducted with no concerns noted. Under criteria 4, the following was noted: The Executive Director led an additional Quality Assurance and Performance Improvement meeting on 07/31/24 with the Medical Director, Director of Clinical Services (DCS), Social Services Director, Assistant Director of Nursing, Plant Operations, Activities, Dietary Supervisor, MDS Coordinator, Therapy Director. The Elopement Policy and Procedure was reviewed, and the root cause of elopement was discussed. DCS and/or designee will continue weekly quality reviews times 3 months of residents at risk for elopement to ensure policy and procedures in place. New admissions audited by DCS/designee to ensure accurate elopement risk identification, appropriate interventions in place as required and care plan in place as necessary. Oversight will be provided by the Regional Nurse Consultant. The Plant Operations Manager and/or designee will be responsible for conducting elopement drills weekly for 4 weeks and monthly for 3 months. The results will be reviewed during the Quality Assurance Committee meeting. The above points were covered with previous documentation review. On 08/16/24 at 2:50 PM, an interview was conducted with Staff F, RN, relating to reporting at change of shift. Staff F stated that communication between staff is important so the oncoming shift knows of any changes from the previous shift. Staff F also stated, if someone notices a resident is not where they should be, it gives the staff more time to follow the elopement policy to locate the resident. The nurse stated that communication is supposed to happen between the nurse going off and the nurse coming on, between the CNA going off and the CNA coming on and between the Nurse and CNA to make sure the team is involved. On 08/16/24 at 3:02 PM, an interview was conducted with Staff G, RN, who stated that when she gets report, she includes the CNA she is working with because she wants the CNA to know the resident in case there are changes in condition. On 08/16/2024 at 3:08 PM, an interview was conducted with Staff H, CNA, who stated when she first comes in, she and the off going CNA first do a head count to make sure no-one is missing. The off going CNA also informs the oncoming CNA if there have been changes to the residents. The nurse then tells the CNA if there are changes in the residents' status or other information the CNA needs to know. Staff H stated she usually cares for 10 to 12 residents on her shift. On 08/16/24 at 3:14 PM, an interview was conducted with Staff I, CNA, who stated if a resident who eloped is not on 1:1 or if the resident is at risk for elopement, then she and the other CNAs check on the resident every 30 minutes. The CNA stated that at the beginning of her shift she does rounds with the off going CNA to make sure the residents are present and to offer help if needed. Then Staff I would get report from the off going CNA. Staff I stated she also gets report from the nurse as well. She stated this is how she finds out if there are any changes or special instructions. On 08/16/24 at 4:02 PM, an interview was conducted with Staff J, CNA, who works the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts. Staff J explained that if there is a missing person then she would notify the nurse immediately. She stated then they are assigned to search inside and outside the facility to try and find the resident. Staff J stated that they (CNAs) round on the residents who are elopement risk every 30 minutes. Staff J stated that there is a sheet where they place a check mark and initials next to the time the resident check is performed. On 08/16/24 at 4:10 PM, an interview was conducted with Staff K, CNA, who works 3:00 PM to 11:00 PM. Staff K expressed that if a resident has an elopement, then the resident is placed on 1:1 observation. Staff K stated that when there is an elopement then the nurses tell the CNAs who to look for and if the CNA is to look outside or inside. Staff K stated that they do rounding with the CNA from the last shift to make sure there were no changes. Staff K state she also gets report from the nurse about anything new regarding the resident. The scope and severity of F689, was lowered to a (D) for no actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 08/16/24. The scope and severity were lowered because of the facility's corrective actions implemented. These corrective actions were verified by the surveyor through observations, interviews, and record review on 08/16/24.

Based on record review, the facility failed to appropriately care plan for monitoring of a resident as an elopement risk, for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. On 04/05/24, Resident #1 was identified as an elopement risk. A comprehensive care plan was initiated for that problem. The focus on the care plan stated the following: The resident is an elopement risk/wanderer r/t [related to] exit seeking. The goal states: The resident's safety will be maintained through the review date. Interventions included the following: Electronic monitoring device q [every] shift. 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. The above interventions were initiated on 04/05/24. When the resident was determined to be actively exit seeking on 06/27/24 the following interventions were put in place: Wanderguard Check Q [every] shift. Monitoring: Wanderguard - Expiration Date. Wanderguard - check for function each day. These revisions were initiated when Resident #1 was noted to have verbalized exit seeking behaviors. These verbalizations included expressing he was going to another country and expressing he was going to Canada on two separate occasions. These were documented in nurses' progress notes on 06/27/24. It was not until after the elopement of 7/26/24 that actively monitoring the resident every 30 minutes was added. On 08/01/24 the intervention of one-to-one (1:1) observation was added.

Based on interview, observation, and record review, the facility failed to provide appropriate supervision to prevent an elopement, which resulted in a who was able to leave the facility and travel along a busy roadway with a likelihood of being hurt, killed or lost, for 1 of 1 sampled resident reviewed for elopement risk (Resident #1). The deficient practice allowed Resident #1 to exit the facility on [DATE] between 8:12 PM and 8:18 PM. Resident #1 ran approximately 1.3 miles away from the facility, before being stopped by staff. Resident #1 was transported back to the facility by the same staff. There were eighty (80) residents in the facility at the time of the survey. Two residents were identified at risk of elopement or wandering after the elopement. Resident #1 was subsequently discharged to the care of his family on [DATE]. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Immediate Jeopardy Template on [DATE] at 5:31 PM. The Immediate Jeopardy was Ongoing at the time of the facility exit on [DATE]. The findings included: The facility policy titled Elopement/Wandering Risk Guideline, Revision Date: [DATE]. Under the section labeled Process: there is a bullet point that states Initiate individualized interventions based on Patient/Residents' risk. Resident #1 was admitted to the facility on [DATE]. Resident #1 had been evaluated as an elopement risk upon admission with an elopement bracelet placed on [DATE]. Resident #1's care plan was developed to include elopement risk as of [DATE]. Resident #1 had his admission comprehensive assessment on [DATE]. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated cognitive impairment. The resident had a Mood score (Section D) of 00, which indicates he had no issues with poor mood at the time of the assessment. Resident #1 had no behavior concerns indicated in Section E - Behaviors. Resident #1's diagnoses included the following: Malignant Neoplasm of the Head, Neck, and Face, Squamous Cell Carcinoma, Depression, Anxiety Disorder, and unspecified Protein-Calorie Malnutrition. On [DATE], a review of the facility's report revealed that on [DATE] at approximately 7:45 PM, Resident #1 was showing exit seeking behaviors at the back door on the South Wing. Staff B redirected the resident to his room, and informed Staff A to place the resident under observation. Staff A called the DON to inform her of the elopement attempt. When Staff A returned to the South Wing, she was unable to locate Resident #1. Staff A called the DON again, and called the police. Staff began a search. Two staff members went out with their cars and located Resident #1 about 1.3 miles north of the facility, and returned the resident to the facility at approximately 8:30 PM. On [DATE] at 10:55 AM, an interview was conducted with the Regional Nurse Consultant. A root cause analysis was conducted and determined the nurses failed to properly adhere to 1:1 eye contact on a resident who was actively exit seeking. On [DATE] at 10:11 AM, a telephone interview was conducted with Staff A-RN (Registered Nurse), who was the nurse assigned to care for Resident #1 on [DATE], which was the date of the elopement. Staff A-RN stated that she arrived at 8:00 PM on [DATE]. Staff A-RN stated that when she came in, she saw two staff members trying to contain Resident #1, and Resident #1 was very agitated. She stated the door alarm was ringing at the same time. The nurse stated she called the Director of Nursing (DON) at that time to report what was going on and to obtain the code to silence the alarm. The nurse stated the DON instructed her to get a C.N.A. (certified nursing assistant) to put Resident #1 on 1:1 observation. The nurse stated that when she went back to the hallway, she discovered Resident #1 was missing. Staff A-RN stated she asked a resident in the hall if he had seen Resident #1. The resident in the hall told Staff A-RN that Resident #1 went out the back door. The nurse was unable to recall the name of the resident she spoke to. Staff A-RN stated she called the DON at that time and was instructed to search the grounds and the facility. Staff A-RN stated at that time two other staff members went in their cars to find the missing resident. Staff A-RN stated she called 911 to get the police to assist with the search. Staff A-RN stated she called the police again when Resident #1 was returned to the facility. Staff A-RN stated Resident #1 was placed on 1:1 observation following his return. On [DATE] at 11:54 AM, a telephone interview was conducted with Staff B-RN. Staff B-RN stated on [DATE] she had finished her shift (7A to 7P) she heard the door alarm and saw other staff looking for Resident #1. The nurse stated she asked the other staff members if they had looked in the rooms, bathrooms, and closets and when they said yes, she said we need to get our cars and search. Staff B-RN stated she and Staff C-RN drove to the main road where she went north, and Staff C-RN went south. Staff B-RN stated she saw Resident #1 running up the sidewalk when she pulled over. She stated she called Staff C-RN to come back and help her. Staff B-RN stated she started to run after Resident #1 on foot. Staff B-RN stated Staff C-RN drove ahead of Resident #1, pulled over and approached Resident #1 on foot. Staff B-RN stated they were able to stop Resident #1 and convince him to come back to the facility with them. On [DATE] at 12:05 PM an interview was conducted with Staff D-CNA (Certified Nursing Assistant). Staff D-CNA stated that when Resident #1 was missing she searched inside and outside the building. Staff D-CNA stated she helped bring Resident #1 back to his room after he was found. Staff D-CNA stated they put him on 1:1 observation and the CNAs took turns watching him. Staff D-CNA stated they watched him until the next shift and then turned the duty over to the CNA for the ,d+[DATE] night shift. On [DATE] at 3:00 PM, an interview was conducted with Resident #2 who witnessed Resident #1's elopement. Resident #2 stated that Resident #1 was very angry and was first at the front door. Resident #2 stated Resident #1 was yelling where is my nurse. Resident #2 stated he pointed towards the south hallway and said She's down there [NAME]. Resident #2 stated Resident #1 then ran down the hall to the exit door, opened it, went out and climbed over the fence. When asked which side Resident #1 went to, Resident #2 said the left side. When asked, was that the side with gate, Resident #2 said yes. The gate was verified by this writer to be on the left side when facing the rear of the building. On [DATE] at 3:15 PM, an interview was conducted with Resident #3 regarding the elopement. Resident #3 stated he was wheeling himself around (the hallways) when he saw Resident #1 go out the back door. When asked what he saw, Resident #3 stated he saw a guy (Resident #1) go over the fence. When asked which side of the fence he said the left side. This confirmed what Resident #2 had stated as well. On [DATE] at 9:35 AM, a telephone interview was conducted with Staff C-RN, who confirmed that on [DATE], Resident #1 attempted to leave the facility by the rear exit of the south wing at approximately 7:45 PM. Staff C-RN indicated Resident #1 had been agitated and attempted to leave through the exit doors resulting in the alarm sounding. Staff C-RN stated he redirected Resident #1 back to his room. Staff C-RN stated he then informed Staff A-RN, Resident #1's assigned nurse, to place Resident #1 on 1:1 observation related to the elopement attempt. Based upon interviews and record review, on [DATE] at between 8:12 PM and 8:18 PM, Resident #1 left the facility by the backdoors of the South wing. Resident #1 then allegedly climbed the wooden, 6-foot-high fence into the back parking lot of the facility. Resident #1 was running north along a 6-lane main roadway adjacent to the facility with a 45-mph speed limit. Resident #1 was found 1.3 miles north of the facility near a traffic controlled intersection of the main roadway and an intersecting side street. While he was out of the facility Resident #1 passed multiple residential communities and crossed two intersections with traffic lights, indicating a need for traffic control. Resident #1 could have fallen, gotten lost, or gotten struck by a car, and suffered a serious injury or died . Photographic evidence obtained.

Based on record review and interview, the facility failed to keep complete and accurate records for 19 of 19 records reviewed (Residents #5, #13, #17, #18, #24, #27, #28, #32, #34, #40, #41, #50, #51, #60, #61, #62, #64, #68, and #222). The findings included: A review of #28's records revealed no physician notes since May 2023. An interview was conducted with the Nursing Home Administrator (NHA) on 03/13/24 at 10:00 AM. The NHA stated the physician progress notes should be in the resident's electronic records and done monthly. Surveyor requested the last 3 months of physician progress notes. The NHA stated she would get in touch with the physician to inquire about the physician notes. An interview was conducted with the NHA on 03/13/24 at 3:00 PM. The NHA produced 3 months of physician notes for 12/24, 01/24, and 02/24. The NHA could not answer why the physician notes were not part of the resident's records. The physician notes were handwritten and illegible. Surveyor requested the last 3 months of physician progress notes for the rest of the sampled residents (Residents #5, #13, #17, #18, #24, #27, #32, #34, #40, #41, #50, #51, #60, #61, #62, #64, #68, and #222). On 03/14/24, the NHA provided written physician progress notes for Residents #5, #13, #17, #18, #24, #27, #32, #34, #40, #41, #50, #51, #60, #61, #62, #64, #68, and #222. The written physician progress notes were illegible. An interview was conducted with the Medical Director/attending physician for the facility's residents on 03/14/24 at 10:00 AM. The Medical Director stated resident's physician progress notes were kept in his office. The Medical Director acknowledged the progress notes should be in the resident's records. The Medical Director stated, I'll do better. When questioned on the illegible written progress notes, the Medical Director stated he did not have access to the electronic medical records for documentation. 39026

Based on observations, interviews and record review, the facility failed to provide care in a manner to maintain a resident's dignity for 47 residents on the South unit, including Resident #18. The findings included: The facility's policies and procedures for Dignity did not address dignity during dining. 1). Resident #18 was admitted to the facility on [DATE]. According to the resident's most recent assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #18 had a Brief Interview fore Mental Status score of 02, indicating severe cognitive impairment. The MDS documented that the resident was dependent upon staff for eating. Resident #18's diagnoses at the time of the assessment included: Anemia, Diabetes, Cerebrovascular incident, Non-Alzheimer's Dementia, Hemiplegia, Seizure disorder, Malnutrition, Depression, Epilepsy, contracture of muscle left upper arm. Cognitive communication deficit, Dysphagia, Muscle weakness, Limitation of activities due to disability. During an observation of breakfast, on 03/12/24 08:43 AM, it was noted that Resident #18 had not been served breakfast. During an interview with Staff A, LPN, while standing directly outside of the resident's room, when asked about Resident #18 not being served breakfast, Staff A replied, She is a feeder, when the CNA (Certified Nurse's Assistant) is finished with another resident, she will feed her. 2). On 03/13/24 at 8:25 AM, Resident #18 was observed in bed with breakfast on over bed table and being fed by Staff B, LPN. It was noted that Staff B was standing at the resident's right side of bed to feed her. When asked about standing next to the resident Staff B acknowledged that she should have been seated to feed the resident, There wasn't a chair in the room, and I recognized that the food was getting cold. 3). During an observation of lunch being served to the residents in their rooms on the South Unit, on 03/13/24 at 11:58 AM, Staff C, CNA was instructed to go to the dining room by another staff member. Staff C replied by yelling out, I can't, I have feeders. At the time of the observation, Staff C was at the room at the end of the unit close to the emergency exit and could be heard by this Surveyor from the nurse's station, approximately 90 feet from away, according to the Regional Director of Plant Operations. During an interview with Staff C at the time of the observation, Staff C acknowledged that she had referred to the residents as feeders and understood the concerns. During an interview, on 03/13/24 at approximately 12:30 PM, the Administrator acknowledged understanding of the concerns and replied that the staff would be in-serviced. During an interview, on 03/14/24 at 3:00 PM, the Regional Nurse Consultant stated that the facility did not have a policy and procedure specific to dignity during dining.

Based on record review and interview, the facility failed to ensure that a complete and accurate Pre-Admission Screening and Resident Review (PASARR) was completed for 1 of 2 residents reviewed, Resident #60. The findings included: Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #10 had a Brief Interview for Mental Status score of 10, indicating that the resident was moderately cognitively impaired. In Section IA of the resident's PASARR, completed by the resident's Attending Physician on 05/11/23, the PASARR documented that Resident #60 had diagnoses that included: Anxiety Disorder, Depressive Disorder and Agoraphobia. Section 1B of the PASARR documented that Resident #60 had functional limitations in major life activities that included: Capacity for independent living, Self-care, and Self direction. Section I documented that the resident previously received services for Mental illness and had been referred for Mental Illness Services. The findings of the Level I PASARR was based on documented History, Behavioral Observations and Medications. Sectio II-2 of the PASARR documented that the resident had the following difficulties with: Interpersonal functioning, Concentration, persistence and pace, and Adaptation to change. Section II-3 of the PASARR documented, Due to the mental illness, the individual has experienced an episode of significant disruption to the normal living situation for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in interventions by housing or law enforcement. The PASARR instructs the person that is completing the assessment, A Level II PASARR evaluation must be completed prior to admission if any box in Section 1.A or 1.B is checked and there is a 'yes' checked in Section II.1, II.2 or 11.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Section IV of the PASARR was not completed to determine if Resident #60, 'may be admitted to an NF. During an interview, on 03/14/24 at 3:33 PM with the Social Services Director, when asked about Resident #60's PASARR not being completed, the Social Services Director stated, I submitted for a Level II and it was declined. The Social Services Director provided documentation of a response from the request for the Level II screening, dated 02/27/24, that documented: We can't complete the screening. This case is being closed due to an incomplete submission packet. The Social Services Director stated that she had not followed up on the response to the request being declined.

Based on observation, interview and record review, the facility failed to provide activities to meet the needs and interests for 1 of 2 residents reviewed for Activities, Resident #60. The findings included: Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent assessment, a Quarterly Minimum Data Set (MDS), date 12/27/23, Resident #60 had a Brief Interview for Mental Status score of 10, indicating that the resident was moderately cognitively impaired. The MDS documented that Resident #60 required substantial/maximal assistance for activities of daily living, except for eating. Resident #60's diagnoses at the time of the assessment included: Anxiety disorder, Depression, Psychotic disorder, Rheumatoid arthritis, Agoraphobia, Chronic pain. A care plan, dated 12/27/23, with a revision date of 03/11/24, documented, The resident experiences loneliness and or isolation. The goal of the care plan was documented as, The resident will express feelings around loneliness and isolation with a target date of 05/30/24. Interventions to the care plan included: Encourage resident to express feelings of loneliness and isolation. Further review of Resident #60's electronic health record revealed that there was no care plan for Activities. A 'Community Life Progress Review (Activities assessment), dated 01/03/24, documented that the resident 'Prefers to watch TV'. On 03/12/24 at 9:58 AM, Resident #60 was observed in bed in wearing a hospital gown. The resident's roommate stated that Resident #60 had not been out of bed during the previous 3 weeks. When Resident #60 was asked if the statement by her roommate was accurate, Resident #60 nodded agreement with the statement made by the roommate. The resident was informed by this Surveyor about the activity involving Baking Cookies that was scheduled for this day in the afternoon and resident was visually excited to attend. During the interview and observation, it was noted that the television was turned off and the remote control for the television was on the resident's overbed table that was not in the resident's reach. On 03/12/24 at 2:29 PM 8 residents were observed in the Activity room while cookies were being baked for the residents and the residents were being served beverages by the Activities staff. It was noted that Resident #60 was not among the 8 residents in attendance. Interview with resident - was asked if she wanted to attend the activity and nodded head up and down in a 'yes' manner. During an interview, on 03/12/24 at 2:34 PM Staff F CNA, when asked about Resident #60 being out of bed and participating in activities, Staff F replied, she just moved rooms. It is not normal for her to be in bed. Sometimes she gets up. I washed and put a clean gown on her. There was no clean clothes in the closet. On 03/12/24 at 2:40 PM, an observation of Resident #60's closet noted that there were 3 pairs of pants and several shirts. Resident #60 confirmed that the clothing was hers and was unsure of any missing clothing since being moved from another unit. During an interview, on 03/13/24 at 7:14 AM, with Staff G, LPN, when asked about Resident #60's participation in activities and being out of bed, Staff G replied, She has therapy get her out of bed, sometimes she wants to stay in bed and you cannot force them to get out of bed. The CNAs get them in the chair and the Activities come and get them. When asked of the most recent time that Resident #60 had been out of bed, Staff G replied, a couple of weeks ago before lunch. I think it was for activities. During an interview, on 03/13/24 at 7:27 AM, with Staff A, LPN, when asked about Resident #60 being out of bed and participating in activities, Staff A replied, yesterday was the first day that I worked with her for a while. Her roommate said that she didn't feel like getting up. After PT, she will go to activities. The Activities will come and ask them if they want to go. During an interview, on 03/13/24 at 10:15 AM, the Activities Director stated that she tries getting residents to do exercise, they don't want to, they just want to sit and drink coffee. Every once in a while a couple of them will, but this is what they want. On 03/13/24 at 4:55 PM, Resident #60 was observed in her wheelchair in her room, with the television turned off and the remote control for the television on the overbed table that was out of the resident's reach and no other source of stimulation noted. During an interview, on 03/13/24 at 5:39 PM, with The Therapy Director, when asked about Resident #60 participating in therapy, the Therapy Director replied, I just finished with her - 03/11/24 was my last day with her. Speech Therapy projected discharge is tomorrow (03/14/24). I usually work with her in the room. When asked about assisting the resident to Activities at the completion of therapy, the Therapy Director replied, more often than not she would rather sit in her room and watch TV. When asked about the resident's physical and cognitive ability to operate the television remote control, the Therapy Director replied, her cognition is not as good. She has her good days and her not so good days. If she had a good night, she is more engaging and alert. Her cognition varies. She has the physical capacity to use the remote, but not always the cognitive ability. On 03/14/24 at 10:15 AM, Resident #60 was observed in bed with television off and remote control on over bed table that was out of the resident's reach and no other source of stimulation noted. During an interview, on 03/14/24 at approximately 10:30 AM, with the Activities Director, the Activities Director stated that she had started a care plan for Activities for the resident this morning. The Activities Director further stated that the resident also enjoys books and 1:1 visits. During the observation and interview, Resident #60 was in bed with television off and remote control out of reach and books on her nightstand to the resident's right side of bed also out of reach.

Based on observation, interviews, policy and record review; the facility failed to provide care and services to prevent a potential decline in a resident's physical and/or psychosocial well-being for 1 of 5 sampled residents, reviewed for unnecessary medications (Resident #62). The findings included: The facility's policy titled, Medical Care/Standard of Practice with an effective date of 11/30/14 and revision date of 03/03/21, revealed The attending physician will complete a history and physical (H&P) on all residents as required by the applicable state law. In the event the admitting physician is new to the resident, the admitting physician shall complete an H&P on the resident within 48 hours of admission. Resident #62 was admitted to the facility on [DATE] post hospitalization for Personal history of traumatic brain injury, Pedestrian on foot injured in a motor vehicle accident and Traumatic subarachnoid hemorrhage with loss of consciousness. Resident #62 was unable to perform the Brief Interview for Mental Status (BIMS) and was unable to speak. In an interview with the resident on 03/11/24 at 10:15 AM the resident was able to nod her head to indicate that she understood the questions asked but could not respond except for nodding her head. Upon admission to the facility, the resident was on Enoxaparin Sodium (Lovenox) Injection Solution Prefilled Syringe 30 milligrams (mg) per 0.3 milliliter (ml). Instructions were to inject 30 mg intramuscularly two times a day for DVT (deep vein thrombosis). Enoxaparin sodium is an anticoagulant that helps to prevent formation of blood clots. A review of Enoxaparin sodium was done on the Food and Drug Administration (FDA) site. Lovenox (Enoxaparin sodium) must not be administered by intramuscular injection. Lovenox (enoxaparin sodium injection), is for subcutaneous and intravenous use. Thrombocytopenia can occur with the administration of Lovenox. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with Lovenox. A review of the medical chart revealed the H&P was done on 01/08/24. A review of the nursing progress notes and Medication Administration notes revealed on 03/08/24 at 9:35 AM the resident refused Enoxaparin Sodium. The note read she was crying MD (Medical Doctor) notified. On 03/08/24 a nursing progress note read Patient refused am Lovenox injection, crying saying No, no it hurts too much Dr notified, who said, noted. On 03/09/24 a medication administration note stated refused, MD notified. On 03/10/24 a medication administration note read I don't want it, it hurts. Dr . made aware. Attempted to call the nurse who wrote these notes on 03/13/24 at 3:53 PM but she did not answer the phone. An interview was conducted with Staff D, Regional Director of Clinical Services, on 03/14/24 at 4:45 PM who stated that the nurse had to be referring to the Enoxaparin since it was not given those three days and all other medications were given. Staff D also stated at this time that she had been trying to reach the Physician to have the Enoxaparin Sodium discontinued and after 4 attempts to reach him, he still did not answer her. An interview was conducted with Staff E, the Consultant Pharmacist, on 03/13/24 at 09:42 AM. She produced a pharmacy review dated 01/31/24 for a recommendation for a stop date for Enoxaparin. The recommendation for a person with an acute illness with decreased mobility was a FDA approved duration of up to 14 days 30 mg twice a day and up to 3 months with 40 mg daily. Resident #62 had been taking 30 mg twice a day since 12/28/23. The resident's last Complete Blood Count (CBC) was done 01/03/24 with an order for it to be repeated in 90 days. An interview was done with Resident #62's Physician on 03/14/24 at 12:06 PM. The Physician was asked why the H&P was late on Resident #62 and he had no response as to why. The Physician was asked how long should Resident #62 have been on Enoxaparin Sodium and he replied she should have been taking it for 2 weeks. When asked why he did not respond to the recommendation of the consultant pharmacist to provide a stop date on 01/31/24 he replied that he did not see the recommendation. He stated that he wanted Resident #62 to see a trauma doctor to regulate the Enoxaparin Sodium for which he told the Director of Nurses. When asked where the referral was for her to see a trauma doctor he stated he probably did not write one and he will do better next time. When asked where the progress notes were from his visits to Resident #62 in January 2024 and February 2024 he stated they were in his office and he will email them. On 03/14/24 at 4:00 PM the progress notes arrived to the facility. Reviewed the notes for January and February 2024. On 02/24/24 the Physician wrote under medications that the resident was receiving Lovenox indicating he was aware that she was still taking this medication. The Lovenox was discontinued on 03/13/24.