Every finding on record at Aviata at Harts Harbor

Based on observations, interviews, and record review, the facility failed to ensure residents' right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatment and supports for daily living safely for 14 (Residents #17, #22, #29, #75, #89, #59, #48, #23, #53, #1, #71, #34, #101 and #67) residents in 11 (Rooms #1, #2, #3, #4, #6, #8, #9, #10, #11, #15 and #21) of 65 resident rooms currently in use, and in both of the hallways (East and South) in the facility.The findings include: On 3/30/26 at 10:30 AM, a tour of the facility began. On 3/30/26 at 10:47 AM, room [ROOM NUMBER], occupied by Residents #17 and #22, was observed with a door frame that was missing multiple chucks of wood. In the bathroom, the floorboard behind the toilet was noted to be separated from the wall and was lying on the floor. Next to the sink, another floorboard was partially separated from the wall. Dark brown/black stains were observed throughout the tiles on bathroom floor. There were multiple holes, chips, and cracks along the top of the frame of the closet. Miscellaneous debris and brown flakes were covering the windowsill located next to Bed B. (Photographic evidence obtained) On 3/30/26 at 10:51 AM while conducting an interview with Resident #29 in room [ROOM NUMBER] Bed B, a live cockroach ran across the floor and behind a dresser in front of Bed A. Resident #29 stated she had seen roaches in the room before. She stated they were on her roommate's (Bed A's) side of the room. Other live roaches were observed on the floor and wall near the back of the dresser. (Photographic evidence obtained) On 3/30/26 at 11:03 AM, room [ROOM NUMBER], occupied by Residents #75 and #89, was observed with multiple red/brown stains on the floor. The windowsill contained debris, multiple miscellaneous items and insect carcasses. Red/brown stains were observed on the bottom of the window. Multiple red/brown stains were observed on the ceiling and the trim. The trim was noted to be cracked, stained, and separated from the ceiling. (Photographic evidence obtained) On 3/30/26 at 11:30 AM room [ROOM NUMBER], occupied by Residents #59 and #48, was observed. Upon entering the room, a foul odor was noted. A wheelchair that was tucked next to Bed A's closet had multiple items piled on top of it including incontinence padding, hygiene products, sterile medical supplies, a blanket, pads, washcloths and a pillow. A bottle of sterile water was observed on Bed A's TV stand. The contents were over half empty. There was no 'open date' on the bottle. A trashcan was observed next to Bed B with no liner in place. A rolled-up plastic glove and a plastic straw were observed on the floor next to the trashcan. Miscellaneous debris and brown flakes were covering the windowsill. Another plastic glove was observed next to the bedside table. The floorboards were cracked and had a brown substance covering them. There were multiple re/brown stains and several miscellaneous brown and black flakes and clumps on the floor. An oxygen mask was observed under Bed B, a trash bag filled with linen was sitting on the floor and another trash bag containing a purple cloth was stuffed behind the dresser. (Photographic evidence obtained) On 3/30/26 at 11:30 AM, an observation was made of room [ROOM NUMBER], occupied by Resident #23. [NAME] stains were observed on the floor next to the window. The wall under the windowsill had multiple cracks. The floorboard was covered with brown stains and debris. The windowsill contained debris, multiple miscellaneous items and insect carcasses. The bathroom had towels on the floor in the corner with a broom on top of them. There was a bedside commode in the bathroom with an unidentified green object inside of it. A laundry basket of hygiene products was observed under the commode. Chipped paint was observed behind the toilet next to the floorboard. (Photographic evidence obtained) On 3/30/26 at 11:34 AM, Resident #53 was interviewed in his room, room [ROOM NUMBER]. He stated he required minimal assistance from staff. He was able to perform all activities of daily living (ADLs) independently. During the interview, several environmental concerns were observed. There was miscellaneous debris and brown flakes covering the windowsill. The window blinds were bent and broken. Both call bells were on the floor and wrapped around two additional cords in between Bed A and Bed B. The bathroom light would not turn on. Resident #53 stated it had been like that for a while and the facility needed to put in a new lightbulb. A pink bin was observed on the floor in the bathroom in between the sink and the toilet. Multiple rags with brown stains were wadded in the sink. [NAME] stains following a splatter pattern were observed on the wall and the handrail next to the toilet. A pair of shoes was observed under Bed A next to a pool of brown liquid. (Photographic evidence obtained) On 3/30/26 at 2:50 PM, an observation was made of room [ROOM NUMBER], occupied by Residents #1 and #71. A urinal containing a yellow liquid was observed on the bedside table. Red/brown stains were noted on the wall in a splatter pattern. The windowsill contained debris, multiple miscellaneous items and insect carcasses. [NAME] and black flakes covered the room's air conditioning unit. A disposable razor was observed sitting on the resident's table. The call bell was on the floor. (Photographic evidence obtained) On 3/31/26 at 10:04 AM, multiple brown stains with splatter and streak patterns were observed under the window in room [ROOM NUMBER]. A collection of miscellaneous black and brown flakes was observed along the floor panel in the corner of the room next to the air conditioning unit, and on the air conditioning unit. Several large cracks were observed in the wall where the air conditioning unit met the windowsill. A section of the ceiling trim had dislodged from the ceiling and there were multiple large stains observed on the ceiling. A trash bag containing miscellaneous items was observed on the floor. (Photographic evidence obtained) Upon exiting room [ROOM NUMBER], exposed pipes were observed in the ceiling covered with a thick black substance. The pipes extended the length of the East Hall where rooms #1, #2, #3, #4, #5 and #6 were located. Cracked and peeling paint was observed throughout the ceiling. (Photographic evidence obtained) On 3/31/26 at 10:21 AM, an interview was conducted with Resident #34 in his room. During the interview multiple brown stains were observed on the wall and the floor under the windows on the far side of the room. An unidentified blue wrapper was observed on the floor under the window. A black electrical cable was found on the floor on the far side of the room. The end of the cable was loosely wrapped in a circle on the floor and did not connect to anything. (Photographic evidence obtained) An interview was conducted on 3/31/26 at 2:00 PM with Housekeeper C who stated she worked five days a week from 7:00 AM to 2:00 PM. She stated she got her daily assignment from the manager and that there were usually two housekeepers assigned to each hall. She stated she had the same daily routine. Each room was swept and mopped. The housekeepers cleaned the bed rails, the blinds, the toilets, sinks, paper towel holders, behind the toilet seats, and mopped the floor in every room every day. She stated the windowsills and A/C vents were to be cleaned daily. When she was asked to describe the protocol when pests were sighted, she stated it would be reported to the manager then reported electronically to maintenance. On 3/31/26 at 2:21PM, an interview was attempted with Resident #101 in his room, room [ROOM NUMBER]. The resident was nonverbal and unable to be interviewed. While in the resident's room several crawling insects were observed on the floor next to the resident's bed. Insects were also observed flying near the floor and the resident's bed. The resident's personal belongings were in cardboard boxes in a chair next to the bed. [NAME] stains were observed on the floor along the wall behind the bed. Several small ants were crawling near the call light box located behind the head of the resident's bed. The resident made nonverbal gestures and pointed. He was advised to press his call light for assistance. The call light was pressed but did not illuminate outside of the resident's doorway. An interview was conducted on 3/31/26 at 2:24 PM with the Maintenance Director. He was asked about the facility's pest control protocol and replied that the pest control company came to the facility every two weeks. He stated if there were sightings, staff should notify him or document the sightings in the book at the nurses' station. He stated he was not aware of any concerns. He was accompanied to Resident #101's room (room [ROOM NUMBER])and upon entering the room, he quickly acknowledged the pests crawling on the floor. He was directed to the pests on the wall. He stated he was not aware of this as there were no work orders/reports submitted. As the pests began to fly, he stated something needed to be done. He was advised that the resident's call light was not working properly. He stated staff were responsible for reporting things like this. During the interview, Certified Nursing Assistant (CNA) G entered the room. She stated the call light was going off at the nurses' station. She approached the resident asking what he needed and as she went to turn off the call light, she observed the insects crawling on the call light box on the wall and quickly withdrew her hand. She stated she had not seen them before. The Maintenance Director stated the resident needed to be relocated and that he would have to get with nursing management. CNA G stated she was not the assigned CNA for Resident #101; CNA F was assigned to Resident #101 today. An interview was conducted on 3/31/26 at 2:28 PM with CNA F who stated she had been employed at the facility for two years. She confirmed that she had received training in Abuse and Neglect, Resident Rights, and ADL care. She stated she was familiar with Resident #101. He was bed-bound and non-verbal. He pointed and used hand gestures to communicate. She was asked to explain the facility's protocol when pests were observed in a resident's room. She stated that should be reported to Maintenance. When asked if she had observed any pests in Resident #101's room, she replied that she had. She stated she observed gnats in the resident's room on the day of this interview. She said she wiped it up with soap and water and verbally notified Maintenance of her observation. On 3/31/26 at 2:40 PM, Resident #67 was observed lying in bed. The bed was in the lowest position. Two fall mats were resting against the wall next to the resident's bed, and a can of soda was on the floor next to the resident's bed. An over-bed table was observed across the room in a corner. The resident rolled over, raised his head, and motioned toward the can of soda on the floor. He then reached for the soda nearly falling off the bed. Licensed Practical Nurse (LPN) XX was summoned to assist the resident and she was accompanied to his room. An interview was conducted with LPN XX on 3/31/26 at 3:04 PM. She stated she was familiar with the resident. When asked how he transferred, she stated she was unsure and would have to check the Kardex. When she was asked whether the resident was at risk for falls, she replied that she was unsure. Her attention was directed to the bed in the lowest position. She stated that was an intervention for residents who were identified as at risk for falls. She stated if the resident was at risk for falls, he would also have had mats down on the floor. Her attention was then directed to the fall mats resting against the wall. She said, Oh. She was asked if/when they should be down. She stated the mats should be down whenever the resident was in bed as long as they were not a hazard to the resident. An interview was conducted on 3/31/26 at 4:35 PM with the Housekeeping Supervisor. She stated she had been working at the facility for five years. She was asked about the facility's housekeeping protocol. She stated housekeeping staff were to clean each room daily and then return to check each room two to three more times each day to ensure the room remained clean. The housekeeping staff were to clean any high-touch surfaces including bedside tables, bed rails, door handles, air conditioning units, windowsills, toilets, sinks, and paper towel dispensers. She explained that there was no checklist for staff to complete once they finished their daily cleaning. She said she inspected the rooms after they had been cleaned, as needed; however, she was unable to confirm how often she did this or provide any evidence that she was rounding to check resident rooms as stated. A tour of the facility was conducted with the Housekeeping Supervisor and the Maintenance Director. They were shown the identified environmental concerns. The Housekeeping Supervisor confirmed that these areas should have been cleaned but stated the insect concerns would have been reported to maintenance rather than housekeeping. The Maintenance Director confirmed that repairs were needed stating he would ensure they were done. A review of the facility's 5-Step Daily Room Cleaning procedure revealed: Empty Trash Collect trash from all rooms as a first priority. Replace liner as needed. Sanitize the trash can daily. Be aware of sharps or other potentially hazardous materials in trash. Horizontal Surfaces - disinfected Using a solution of properly diluted germicide, sanitize all horizontal surfaces (allowing for appropriate solution dwell time). As you enter the room, work clockwise around the room hitting all surfaces. Tabletops, headboards, windowsills, chairs - should all be done. 3. Spot Clean Walls Vertical surfaces are not completely wiped down daily - but must be spot-cleaned daily. Walls - especially by trash cans, light switches and door handles - will need special attention. 4. Dust Mop The entire floor must be dust mopped - especially behind dressers and beds. Employees should never damp mop a floor before it has been dust mopped. Move all furniture to dust mop. All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur 5. Damp Mop Remember - The procedure is to damp mop- not wet mop. The most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily.

Based on observations, interviews, and record review, the facility failed to provide an environment free from physical restraints for one (Resident #10) of one resident observed in a Geri Chair (reclining chair).The findings include:During an observation on 3/31/26 at 9:45 AM, Resident #10 was observed in a reclining chair (Geri-Chair) in the dining room on the south nursing unit. A review of the resident's medical record revealed no physician's order for a Geri-Chair.A review of the resident's active care plan revealed no care plan addressing the Geri-Chair.During an observation on 4/1/26 at 9:30 AM, Resident #10 was observed sitting in a Geri-Chair in the activity room, watching television.During an observation 4/1/26 at 11:40 AM, Resident #10 was observed sitting in a Geri-Chair in the activity room. The chair was pushed up to a table and the resident was watching television.During an interview on 4/1/26 at 11:00 AM, Certified Nursing Assistant (CNA) J stated She [Resident #10] loves her independence. I'm not sure why she got put in the chair, but it was probably about a month ago to keep her from falling.During an interview on 4/1/26 at 11:30 AM, CNA R stated, I had a weekend off and when I came back, I was told by the nurse that she was to be in the Geri-Chair. She said it was because of her falls. CNA R stated she was unable to recall which nurse gave her this information.During an interview on 4/1/26 at 1:30 PM, Occupational Therapist (OT) S stated, It was just a temporary thing to put her in the chair. I didn't document it. When he was asked more than once to explain why the reclining chair was being used, OT S did not provide a clear response.During an interview on 4/1/26 at 2:30 PM, Physical Therapist (PT) K stated, I don't know who put her in that chair. When asked to explain the clinical rationale for Resident #10 having been placed in a restrictive chair (Geri-Chair), PT K replied, I don't know.During an interview on 4/1/26 at 4:30 PM, PT K stated, I just did a complete re-evaluation on her [Resident #10] and she is okay for a standard wheelchair. When asked where the documentation was for her being placed in the reclining chair (Geri Chair) originally, PT K stated, I do not know where that is.During an interview on 4/2/26 at 11:00 AM, Minimum Data Set Registered Nurse (MDS RN) O stated, I wasn't aware of her being in a Geri-Chair so it wasn't care planned. We hold IDT (interdisciplinary team) reviews after every fall and a Geri-Chair was never mentioned as an intervention.During an interview on 4/2/26 at 9:58 AM, the Director of Clinical Services (DCS) stated, So, when I spoke to them (staff), it appears that when she first came in the regular wheelchair, I believe she couldn't sit up for a long period of time, and that was why they put her in the Geri-Chair. When asked where this was documented, the DCS replied, OT said they did it. When the DCS was advised that this was not documented anywhere in the Occupational Therapy note review, the DCS replied, I don't know where it is.A review of Resident #10's electronic health record revealed an admission date of 1/16/26 and the following pertinent diagnoses: dementia-severe, adult failure to thrive, diabetes mellitus, depression, and repeated falls. There was no physician's order for Resident #10 to be placed in a Geri-Chair. A review of the resident's active Care Plan revealed no interventions for the use of a Geri-Chair.A review of the facility's policy titled Physical Restraints (effective 11/30/14), revealed:Procedure: A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which indicate the need for a restraint. The interdisciplinary team may use restraint decision-making tools as needed to assist in determining restraint versus enabler versus restraint/enabler. The resident/responsible party will sign consent for the use of a safety device after review of risks/benefits. The nurse will obtain the physician's orders for the restraint. Restraint use is documented in the resident care plan and in the nurses' notes.

Based on observation, interviews and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #59) of five residents reviewed for accident hazards from a total survey sample of 21 residents. A staff member was observed transferring a dependent resident using a mechanical lift without the assistance of a second staff member. The resident was observed swinging from side to side in the lift as the staff member attempted to lower the resident onto a shower bed. This action could have resulted in serious harm to the resident.The findings include:On 3/30/26 at 11:15 AM, Resident #59 was observed in the hallway outside of his room. He was hanging from a Hoyer lift (mechanical lift) that was being operated solely by Certified Nursing Assistant (CNA) E. No other staff members were observed in the resident's room or in the hall. CNA E was observed moving Resident #59 into position over a shower bed constructed of PVC pipes and a waterproof mattress. CNA E lowered Resident #59 down toward the shower bed, pausing the Hoyer lift repeatedly during the process as the resident swung from side to side in mid-air. CNA E released a control attached to the Hoyer lift in an attempt to steady the resident and stop the swinging motion. Once the resident's movement was controlled, CNA E resumed operating the lift, unassisted, and lowered Resident #59 onto the shower bed. (Photographic evidence obtained)An interview was conducted on 3/30/26 at 11:21 AM with Licensed Practical Nurse (LPN)/Unit Manager A. She was advised of the observation of CNA E operating the Hoyer lift by herself. Unit Manager A walked hurriedly down the hall where Resident #59's room was located. As Unit Manager A approached the resident's room she observed CNA E as she continued to maneuver the Hoyer lift with Resident #59 suspended in mid-air above the shower bed. She asked CNA E what she was doing and where her help was. CNA E responded inaudibly as she shook her head and shrugged her shoulders. Unit Manager A repeatedly asked the resident if it was his preference to receive care in the hallway. The resident only shook his head and did not respond verbally. Unit Manager A continued, This is your preference to be in the hall, right? Resident #59 did not provide a verbal response.An interview was conducted on 3/30/26 at 11:36 AM with Unit Manager A. She was asked about the observation of CNA E operating the Hoyer lift by herself. Unit Manager A confirmed that CNA E should not have operated the Hoyer lift alone. She stated CNA E should have waited for another staff member to assist her.An interview was conducted on 3/31/26 at 10:15 AM with Resident #59. He was asked about the observation on 3/30/26 of his being transferred with the Hoyer lift operated solely by CNA E. Resident #59 stated he knew two staff members were required to operate the lift. He stated CNA E was unable to find another staff member to assist her and proceeded to operate the lift by herself.On 4/1/26 at 4:02 PM, an interview was conducted with CNA E. When asked about transferring Resident #59 via the Hoyer lift without assistance on 3/30/26, CNA E reported knowing that the Hoyer lift required two staff members to operate, but she could not find a second staff member. CNA E reported wanting to get Resident #59 to the shower, so she decided to transfer the resident without assistance. When asked, CNA E stated it was not normally difficult to find a second staff member to assist with transferring a resident via Hoyer lift.A review of Resident #59's medical record revealed an original admission date of 6/4/25 with his most previous admission on [DATE]. His diagnoses included paraplegia, assault by firearm, colostomy, and dysphagia.A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 2/17/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. There were no documented signs of psychosis, behavioral symptoms, or rejection of care. The MDS further revealed that Resident #59 had impairment of lower extremities with documented dependence for toileting and moving from lying to sitting position and substantial to maximum assistance for rolling left and right. Resident #59's active care plan was reviewed and revealed that the resident was at risk for skin integrity related to fragile skin. The goal was to ensure that he remained free from complications related to pressure injuries. The interventions included using a draw sheet or lifting device to move the resident and to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A review of the facility's policy and procedure titled Lifting and Moving Residents (effective 11/30/14), revealed: Procedure: 1. Assess the resident's condition and mobility. (Determine if resident has been designated as a 2 or 4 person lift.) 2. Get help if at all in doubt about your ability to move the resident alone. Use resident transfer equipment as required. (Do not attempt to lift any resident alone that has been designated as a 2 or 4 person lift.)

Based on observations, record review, interviews and on a review of the facility's policy titled Oxygen Therapy, the facility failed to ensure that a resident who required 0respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #74) of four residents reviewed for oxygen therapy from a total survey sample of 21 residents.The findings include:On 3/30/26 at 12:44 PM, Resident #74 was observed sitting up in bed with oxygen infusing at a flow rate of 3 liters per minute (LPM) via nasal cannula. (Photographic evidence obtained)On 3/31/26 at 10:48 AM, the resident was observed sitting in the dayroom watching television with oxygen infusing at 3 LPM via nasal cannula. (Photographic evidence obtained) On 3/31/26 at 10:40 AM, a review of the resident's active physician's orders revealed an order for oxygen to be delivered a 2 LPM continuously. The order was written with a start date of 10/5/25.On 3/31/26 at 10:52 AM, Licensed Practical Nurse (LPN) A was observed changing the flow rate setting on the oxygen concentrator from 3 LPM to 2 LPM. When she was asked why she changed the flow rate setting, she stated the oxygen flow rate was set at 3 LPM and it should have been set at 2 LPM according to the current order. She was asked how a nurse knew the appropriate oxygen flow rate a resident was supposed to receive. She stated the nurse should go by whatever the physician ordered. She was asked how often the nurse checked the resident's concentrator to ensure the flow rate setting was correct. She stated, They should check it every shift. LPN A confirmed she had received education for how to care for the resident receiving oxygen therapy. The resident was not observed attempting to change her oxygen flow rate setting during the survey. On 3/31/26 at 2:10 PM further review of Resident #74's medical record revealed an admission date of 10/2/25 and diagnoses including acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Progress notes from 12/29/25 through 3/31/26 were reviewed with only one entry regarding a resident-specific behavior of manipulation of the oxygen concentrator. This was documented during the survey after the surveyor observed the oxygen concentrator flow rate at the incorrect setting.A review of the physician's progress note dated 2/6/26 at 5:13 PM revealed a pulmonary follow-up for COPD and hypoxia.A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. There was no documented psychosis or behaviors, and she required substantial/maximal assistance with bed mobility and transfers. Shortness of breath with exertion and when lying flat was documented along with the need for oxygen therapy.On 4/1/26 at 3:11 PM, an interview was conducted with CNA T. She was asked to explain her role and responsibility when caring for a resident who received oxygen. She stated her responsibility was to ensure that the nasal cannula was in place in the resident's nose. She stated she was not tasked with adjusting the flow rate setting on a resident's oxygen concentrator, nor had she ever been instructed by a nurse to change the flow rate setting on an oxygen concentrator. On 4/2/26 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). He was asked what his expectations were regarding the care of residents who received oxygen therapy. He stated the facility had an Angel Rounds program that involved all managers who made routine rounds of each resident's room and documented any areas of concern; this included oxygen concentrator settings. He stated, The CNAs (certified nursing assistants) know not to touch or attempt to adjust the concentrators, but we have a system where we tag the concentrator with the number of liters the resident should have. This system allows any staff to be able to observe if the liters are incorrect whenever they encounter the resident and to report to the proper staff so the liters can be adjusted.A review of the facility's policy titled Oxygen Therapy (Document Name: RT-430, effective 11/30/14, revision on 8/28/17), revealed:Start O2 (oxygen) flow rate at the prescribed liter flow or appropriate flow for administration device.

Based on record review, interviews, and facility policy and procedure review, the facility failed to provide adequate supervision to prevent the elopement for one (Resident #1) of 12 residents identified as at risk for elopement and failed to provide staff training on the facility's Leave of Absences (LOA) process. Resident #1 was allowed to sign himself out of the facility despite being evaluated as an elopement risk. Review of the medical record for Resident #1 revealed an admission date of 3/17/23 and re- entry on 7/7/24. His diagnoses included metabolic encephalopathy, obesity, major depressive disorder, alcohol abuse, insomnia, tobacco use and anxiety disorder.Review of Resident #1's Care plan initiated on 11/15/23 indicated he may go out on LOA with meds and escort. Resident/family members must sign out every LOA. Resident was care planned as an elopement risk/wanderer related dementia and impaired safety awareness. The resident will not leave facility unattended. Interventions included to assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident prefers electronic monitoring device: a wander guard on right wrist needs to be changed 7/20/26.Further record review revealed that on 8/23/25, Resident #1, went to the receptionist and requested to sign out of the facility. The receptionist provided the resident the sign out book, which he signed and exited the facility through the main entrance.Review of Resident #1 current physician orders revealed the following:-Wander guard - Expiration Date 7/26.-Wander guard - Check for placement on Right wrist every shift for monitoring 5/30/24.- Wander guard - Check for function each day- every night shift for monitoring 7/20/23.- May go out with responsible party 3/18/23.- Document Resident behaviors every shift r/t exit seeking- every shift for patient safety - 8/24/25.Review of Behavior note dated 8/23/25 for Resident #1 revealed the on-call Team Health was notified regarding elopement.Review of Behavior note dated 8/24/25 for Resident #1 indicated that the resident continued to be 1:1 supervision, no changes noted at this time in the client or client condition, staff will continue to monitor the client.Review of Social Services note dated 8/25/25, revealed the Director of Social Services discussed the elopement that occurred with resident. Resident reported he does not remember signing himself out or trying to cross the street. Resident reported he is not trying to leave the facility and feels safe.During an interview with Employee A, Human Resource Coordinator (HRC) on 10/22/25 at 1:22 pm, she stated that on 8/23/25, she was the manager on duty. She explained that she was at the front desk when Resident #1 asked to sit on the porch. The receptionist asked if he could go out, and I told him he had to sign out. The HRC came back to the front and looked outside. She saw what appeared to be a man standing on the facility's lawn. She asked the receptionist if that was the resident who asked to go outside. She noticed his wheelchair was still in the facility. Resident #1 had walked to the neighbor across the street to ask for a ride to the store. The HRC then went outside and helped the resident back to the facility with the assistance of the neighbor across the street. When asked if the resident was wearing a wander guard, she stated she did not recall him having a wander guard on. When asked about the LOA process, she stated that she was not aware of the process and assumed the receptionist knew the process.During a phone interview on 10/22/25 at 1:45 pm, with Employee B, Receptionist, she stated that she has been working at the facility for almost a year. She stated that prior to the incident she had not participated in any type of drill. She explained that when a resident wants to go out, she checks to see if the resident is permitted to leave the facility with or without someone with them. When asked about Resident #1, she explained that she was not aware of the caution elopement book and had not been informed of it. She thought that if residents had a sheet on their sign out book they could go outside. She explained that the HRC asked her to sign the resident out. The resident had a wheelchair but got up and walked out of the facility and did not say where he was going. She confirmed that she had not received any training on LOA.On 10/22/25 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). He explained that the facility conducted elopement assessment upon admission, quarterly, on change on condition and any elopement incident. He mentioned elopement drills are conducted at least monthly and can be conducted more frequently. Drills are conducted by the maintenance department. However, when there is an incident all the department heads can assist. When asked about the LOA process, he explained that the resident must sign out with the nurse then the receptionist at the front. The receptionist verifies with the nurse that the resident has signed out at the nurse's station. If they are going out for an extended time the nurses coordinate with the pharmacy and physicians to make sure all the patient's orders are in place. When asked about the incident with Resident #1, he explained that on 8/23/25 the weekend supervisor informed him that the resident signed out the facility, which he should not have been able to do. When asked about Resident #1's wander guard, he explained that the daytime receptionist (Employee C) stated that resident had attempted to go out of the facility earlier during the day and she redirected him. Resident #1's hand wander guard activated the alarm during this time. The Resident removed his wander guard prior to the incident where he signed himself out. When asked for the elopement assessment, he stated that after the incident it was noted that assessments were not completed per the policy. The DON could also not produce the elopement drills conducted before the incident. After the incident he stated that ANE and elopement training/drill was conducted, however the process for LOA was not conducted. When asked how often the elopement binder was audited, he stated on admission and any changes on condition.Review of the facility's policy titled Leave of Absence Document Name N760 - Revision date 6/14/25 revealed the following:Process: A patient/resident is allowed a leave of absence (LOA) from the center in accordance with safe medical practice and state and federal regulations. During admission process patient/residents receive information regarding the Leave of Absence procedure. Procedure: 1. Obtain a physician's order for the patient/resident to leave the center.2. Obtain the signature of the patient/resident or resident representative indicating the date and time of departure on the Release of Responsibility for LOA form. a. Indicate by their signature that they are taking responsibility for the patient/resident and have notified the nursing staff of the anticipated departure and acknowledge release of responsibility to center, its personnel or the attending physician for a decline in condition or accident while the patient/resident is on LOA. Review of the facility's policy titled Elopement/wandering risk guideline Document Name N-1031 Revision Date 8/1/20 revealed the following:Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Patient/Residents' risk. Document individualized interventions in the patient/resident Care Plan and Kardex. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day.Maintain the Elopement Risk Alerts in an easily accessible location. Complete routine elopement drills monthly and review in QAPI meeting. QAPI: Review trends of elopement drills by the QAPI team.

Based on record review, interviews, and facility policy and procedure review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies related to elopement. Facility staff permitted Resident #1 who was an elopement risk to sign out of the facility without an escort. The facility did not implement the corrective action noted in their Performance Improvement Plan (PIP). There was a total of 12 residents at risk for elopement. Review of the medical record for Resident #1 revealed an admission date of 3/17/23 and re- entry on 7/7/24. His diagnoses included metabolic encephalopathy, obesity, major depressive disorder, alcohol abuse, insomnia, tobacco use and anxiety disorder.Review of Resident #1's Care plan initiated on 11/15/23 indicated he may go out on LOA with meds and escort. Resident/family members must sign out every LOA. Resident was care planned as an elopement risk/wanderer related dementia and impaired safety awareness. The resident will not leave facility unattended. Interventions included to assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident prefers electronic monitoring device: a wander guard on right wrist needs to be changed 7/20/26.Further record review revealed that on 8/23/25, Resident #1, went to the receptionist and requested to sign out of the facility. The receptionist provided the resident the sign out book, which he signed and exited the facility through the main entrance.Review of Resident #1 current physician orders revealed the following:-Wander guard - Expiration Date 7/26.-Wander guard - Check for placement on Right wrist every shift for monitoring 5/30/24.- Wander guard - Check for function each day- every night shift for monitoring 7/20/23.- May go out with responsible party 3/18/23.- Document Resident behaviors every shift r/t exit seeking- every shift for patient safety - 8/24/25.Review of Behavior note dated 8/23/25 for Resident #1 revealed the on-call Team Health was notified regarding elopement.Review of Behavior note dated 8/24/25 for Resident #1 indicated that the resident continued to be 1:1 supervision, no changes noted at this time in the client or client condition, staff will continue to monitor the client.Review of Social Services note dated 8/25/25, revealed the Director of Social Services discussed the elopement that occurred with resident. Resident reported he does not remember signing himself out or trying to cross the street. Resident reported he is not trying to leave the facility and feels safe.Resident #1 had only two Elopement assessment dated [DATE], 7/21/24 which indicated that the resident was at risk of elopement.During an interview with Employee A, Human Resource Coordinator (HRC) on 10/22/25 at 1:22 pm, she stated that on 8/23/25, she was the manager on duty. She explained that she was at the front desk when Resident #1 asked to sit on the porch. The receptionist asked if he could go out, and I told him he had to sign out. The HRC came back to the front and looked outside. She saw what appeared to be a man standing on the facility's lawn. She asked the receptionist if that was the resident who asked to go outside. She noticed his wheelchair was still in the facility. Resident #1 had walked to the neighbor across the street to ask for a ride to the store. The HRC then went outside and helped the resident back to the facility with the assistance of the neighbor across the street. When asked if the resident was wearing a wander guard, she stated she did not recall him having a wander guard on. When asked about the LOA process, she stated that she was not aware of the process and assumed the receptionist knew the process.During a phone interview on 10/22/25 at 1:45 pm, with Employee B, Receptionist, she stated that she has been working at the facility for almost a year. She stated that prior to the incident she had not participated in any type of drill. She explained that when a resident wants to go out, she checks to see if the resident is permitted to leave the facility with or without someone with them. When asked about Resident #1, she explained that she was not aware of the caution elopement book and had not been informed of it. She thought that if residents had a sheet on their sign out book they could go outside. She explained that the HRC asked her to sign the resident out. The resident had a wheelchair but got up and walked out of the facility and did not say where he was going. She confirmed that she had not received any training on LOA.On 10/22/25 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). He explained that the facility conducted elopement assessment upon admission, quarterly, on change on condition and any elopement incident. He mentioned elopement drills are conducted at least monthly and can be conducted more frequently. Drills are conducted by the maintenance department. However, when there is an incident all the department heads can assist. When asked about the LOA process, he explained that the resident must sign out with the nurse then the receptionist at the front. The receptionist verifies with the nurse that the resident has signed out at the nurse's station. If they are going out for an extended time the nurses coordinate with the pharmacy and physicians to make sure all the patient's orders are in place. When asked about the incident with Resident #1, he explained that on 8/23/25 the weekend supervisor informed him that the resident signed out the facility, which he should not have been able to do. When asked about Resident #1's wander guard, he explained that the daytime receptionist (Employee C) stated that resident had attempted to go out of the facility earlier during the day and she redirected him. Resident #1's hand wander guard activated the alarm during this time. The Resident removed his wander guard prior to the incident where he signed himself out. When asked for the elopement assessment, he stated that after the incident it was noted that assessments were not completed per the policy. The DON could also not produce the elopement drills conducted before the incident. After the incident he stated that ANE and elopement training/drill was conducted, however the process for LOA was not conducted. When asked how often the elopement binder was audited, he stated on admission and any changes on condition.Review of the facility Quality assurance projects revealed elopement Performance Improvement Plan dated 8/25/25. The root cause was identified as Receptionist should always verify the elopement binder. The plan included:1.Audit performed of current residents in house to determine at risk/Updated Elopement Risk Assessments as appropriate for all residents identified at risk/Orders and Care Plans Updated as appropriate for all residents identified at risk/Nursing Staff education initiated on identifying residents at risk for elopement & elopement risk assessments & elopement Policy and procedure.2. Education initiated with all-staff on abuse and neglect (ANE), elopement policy and procedure, elopement books, LOA books, and LOA process. Drills initiated every shift until all current employees have participated then drills per routine guidance. 3. Staff Education provided on door security, and responding: 1. Education provided to IDT team on updating resident assessments, plan of care, orders, elopement books, etc. as changes occur with resident status. Weekly audits of residents at risk for elopement & elopement books to be performed by DON/Designee. Review of the facility weekly audits of residents at risk for elopement and elopement books revealed there were only three audits.Further review of the elopement book there revealed there were 13 residents noted as at risk of elopement. Resident #2 who was noted as an elopement risk had been discharged on 10/5/25.Clinical record review for Resident #3 revealed that she was admitted to the facility on [DATE], her diagnoses included asthma, bipolar disorder, current episode mixed, severe, with psychotic features, major depressive disorder, recurrent, anxiety disorder, need for assistance with personal care.Review of elopement assessments dated 11/15/24, 8/24/25 indicated that the Resident #3 was not an elopement risk.Further review of the quarterly MDS with and ARD of 7/26/25, indicated that the resident had a brief interview of mental status score (BIMS) of 15 out of 15 indicating normal cognitive status. No wandering behaviors noted.Care plan revised on 1/19/22 indicated that Resident #3 is an elopement risk/wanderer- wander guard in place to right ankle. exp Feb. 2026.Quarterly MDS ARD 7/26/25 - BIMS 15 - No wandering (Care plan was not updated).During an interview with Employe C Certified Nurse Assistant (CNA) on 10/22/25 at 4:35 pm, she stated that she had worked in the facility for almost 20 years and was familiar with Resident #3. She stated that Resident #3 was independent with her care alert and oriented and able to make needs know. She stated that resident had no exit seeking behaviors.During interview with the Administrator on 10/22/25 at 5:29 pm, he stated that he coordinated QAPI. When asked how he ensured that the plan identified in the PIP was followed. He stated that PIP is discussed during clinical meeting conducted daily. He stated that the Elopement PIP was still ongoing and the facility was still conducing audits and training. When asked for the weekly audits of residents at risk for elopement & elopement books, he stated that the DON was responsible to conduct the audit he confirmed that there were only three audits (Copies obtained). He stated that he did not review the audits during the September QAPI.Reviewed facility policy and procedure titled Quality Assurance Performance Improvement Program (QAPI) Document Name: PI-215 revised 10/24/25, revealed the following:Page 6: Performance Improvement Projects: The center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the centers services and resources identified in the Facility Assessment. At a minimum, the center must conduct one performance improvement project annually. a. The PIP should focus on high-risk or problem prone areas, identified by the center.b. The team may consist of one or more team membersc. The team will complete the following functions: i. Collect and analyze data. ii. Determine Root Cause. iii. Determine steps for resolution.iv. Implement corrective action.v. Evaluate effectiveness of the actions.vi. Report progress to QAPI committee.

Based on observations, staff interviews, a staff cleaning schedule review, and facility policy and procedure review, the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable living environment, by keeping resident care equipment and rooms clean for four (Residents #109, #32, #10, and #46) of five residents who received enteral feedings, from 33 residents sampled for the survey, and a facility census of 117 residents. Failure to maintain a clean living environment can impact residents' enjoyment of their living space due to unsanitary and uncomfortable living conditions. It could also affect their ability to attain/maintain their highest practicable physical, mental, and social well-being. The findings include: During an observation of Residents #10 and #46's room, East #10A and 10B, on 06/24/2024 at 1:25 PM, the gastrostomy tube (g-tube - feeding tube) pole, the pump, the tubing, the floor, the walls, the bed frames, bed rails, privacy curtain, tray table, floor mat, and nightstand were splattered with enteral food product that had dried. The floor mats for Resident #10 had dirt and debris in the folds of the mats. Plastic disposable tubing caps were observed on the floor. (Photographic evidence obtained) During an observation of Resident #109's room, East 30B, on 06/24/2024 at 11:18 AM, the g-tube pole, the pump, the tubing, the floor, the walls, the bed frames, the oxygen concentrator, and the fall mats were splattered with enteral food product that had dried. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During an observation of Resident #32's room on 06/24/2024 at 11:10 AM, the g-tube pole, the pump, the tubing, the floor, the walls, the bed frame, the bed rail and nightstand were splattered with enteral food product that had dried. A light blue liquid that had been spilled was dried on the floor next to the bed and wall. Plastic disposable tubing caps and trash were observed on the floor, under the bed, next to the wall, and on the nightstand. (Photographic evidence obtained) During a second observation of Residents #10 and #46's room on 06/26/2024 at 10:18 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic evidence obtained) The floor mats for Resident #10 were observed with dirt and debris in the folds of the mat. Plastic disposable tubing caps were observed on the floor. (Photographic evidence obtained) During a second observation of Resident #109's room on 06/26/2024 at 11:46 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During a second observation of Resident #32's room on 06/26/2024 at 11:54 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic evidence obtained) The light blue liquid that was dried on the floor next to the bed was no longer there. Plastic disposable tubing caps and trash were observed on the floor under the bed, next to the wall, and on the nightstand. (Photographic evidence obtained) During a third observation of Residents #10 and #46's room on 06/27/2024 at 10:23 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Plastic disposable tubing caps were observed on the floor next to the wall and on the nightstand. (Photographic evidence obtained) During a third observation of Resident #109's room on 06/27/2024 at 10:28 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During a third observation of Resident #32's room on 06/27/2024 at 10:33 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Plastic disposable tubing caps and trash were observed on the floor under the bed, next to the wall and on the nightstand. (Photographic evidence obtained) During an interview with Housekeeper I on 06/25/2024 at 10:53 AM, she stated the housekeeping staff were responsible for cleaning the enteral feeding product off of the floors, walls, bed frames and other surfaces in the room. She confirmed that only the nurses could clean the enteral feeding pumps. She stated she was usually assigned to the East wing and had cleaned rooms 10A and 10B, 28A and 30B already today. During an interview with Unit Manager/Licensed Practical Nurse (LPN) E on 06/27/2024 at 11:05 AM, she confirmed that the nursing staff were the only staff that could clean the feeding pumps. She stated the housekeeping staff could clean the enteral feeding product off of all of the other surfaces in the resident's room. Nurses should wipe up the food product right away when it was spilled so it did not dry. During an interview with Director of Environmental Services H on 06/27/2024 at 4:32 PM, she stated the housekeepers should mop up the enteral food product as soon as possible. She wanted the nurses to inform the housekeepers if they were going to start a new enteral food bag, so if food was spilled it could be mopped up right away. If not, then the food product dried and was extremely hard to get up. The resident would have to be moved out of the room due to the strong chemicals in the cleaning products used to get the dried-on food product up. She stated she thought the rooms on the East Wing had been cleaned yesterday because she had been informed that they had enteral food splattered in them. A review of the updated facility housekeeping calendar for the month of June 2024 revealed that rooms [ROOM NUMBERS] had been deep cleaned on 06/13/2024 and 06/17/2024 respectively. room [ROOM NUMBER] had not been deep cleaned in the month of June. room [ROOM NUMBER] was on the original calendar to be deep cleaned on 06/20/2024 but was removed on the updated calendar. Privacy curtain audits had been conducted on the East wing during the week of 06/17/2024 through 06/21/2024. Baseboards had been cleaned every Tuesday and Thursday in the month of June. Fall mats were cleaned every Thursday in the month of June. (Copies obtained) A review of the housekeeping staff schedule revealed that Housekeeper I was scheduled from 06/24/2024 through 06/27/2024 from 7:00 AM to 3:00 PM. (Copy obtained) A review of the facility's policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment (revised 9/2022), revealed: Resident care equipment will be cleaned and disinfected according to CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. A. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue or the vascular system are considered critical items and must be sterile when used, based on acceptable sterilization procedures. B. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible (Note: Some items that may come in contact with non-intact skin for brief period of time are usually considered non-critical surfaces and are disinfected with intermediate-level disinfection). C. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical surfaces include bed rails, beside tables, etc. Non-critical items require cleaning followed by either low or intermediate level disinfection. a. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Low-level disinfection is generally appropriate for most non-critical equipment. b. Intermediate level disinfection is traditionally defined as destruction of all vegetative bacteria including tubercle bacilli, lipid and some nonlipid viruses, fungi, but not bacterial spores. A review of the facility's policy and procedure titled Five-Step Daily Room Cleaning (revised 10/25/2016) read: Purpose: To teach environmental services employees the proper cleaning method to sanitize a patient room or any area in the healthcare facility. 2. Horizontal surfaces - disinfected. Using a solution of properly diluted germicide, sanitize all horizontal surfaces (allowing for appropriate solution dwell time). As you enter the room, work clockwise around the room hitting all surfaces. Tabletops, headboards, window sills, chairs - should all be done. 3. Spot Clean Walls. Vertical surfaces are not completely wiped down daily - but must be spot-cleaned daily. Walls - especially trash cans, light switches and door handles - will need special attention. 4. Dust Mop. The entire floor must be dust mopped - especially behind dressers and beds. Move all furniture to dust mop. All corners and along baseboards must be dust mopped to prevent buildup. Damp mop. The most important area of a patient's room to disinfect is the floor. This is where all air-borne bacteria will settle and so it needs to be sanitized daily. As with dust mopping, start in the far corner of the room, move all furniture necessary and run the mop along the edges first. 6. Spot Clean Walls and/or Partitions. Wipe walls especially by trash containers, light switches and door handles. (Photographic evidence obtained) .

Based on record review, staff interview, and facility policy and procedure review, the facility failed to ensure Quarterly Minimum Data Set (MDS) Assessments were completed timely for seven (Residents #83, #105, #87, #76, #28, #59, and #60) of 33 residents sampled for the survey. The findings include: A 06/27/2024 review of the Minimum Data Set (MDS) viewer in the survey shell, revealed no evidence of Quarterly MDS assessments for Residents #83 or #105. An interview with MDS Nurse J on 06/27/2024 at 9:15 a.m., revealed that the last MDS assessment transmitted for Resident #83 was on 01/15/2024. She confirmed that a quarterly assessment was due on 04/16/2024 but was never opened. When she was asked about Resident #105, MDS Nurse J confirmed that the last MDS assessment transmitted for Resident #105 was on 02/15/2024, and a quarterly assessment should have been completed on 05/17/2024, but was not opened. MDS Nurse J was asked how the MDS quarterly assessments were being tracked. She replied they were tracked through the 30-day electronic MDS scheduler report she ran each month. A review of the facility's 30-Day MDS Scheduler Report revealed that Residents #83, #105, #87, #76, #28, #59, and #60 were all overdue for quarterly assessments. A review of the facility's MDS N-1025 policy (effective 11/30/2014 and revised 09/25/2017), read: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident.

Based on observations, staff interviews, clinical record review, and facility staff training curriculum and employee handbook review, the facility failed to provide reasonable accommodation of needs for one (Resident #109) of 33 residents sampled for the survey, by failing to ensure that residents capable of using the call light had access to the call light at all times. The findings include: On 06/24/2024 at 11:18 AM, Resident #109 was observed lying in bed on his right side facing the privacy curtain. His eye were closed. His call light was clipped against the wall under the call light wall plug and out of his reach. (Photographic evidence obtained) On 06/26/2024 at 11:46 AM, Resident #109 was observed lying in bed on his back with his eyes closed. The call light was clipped to the privacy curtain, out of his reach. (Photographic evidence obtained) On 06/27/2024 at 10:28 AM, the resident was observed lying in bed on his right side facing the privacy curtain. His call light was clipped against the wall under the call light wall plug and out of his reach. (Photographic evidence obtained) During an interview with the resident on 06/27/2024 at 10:28 AM, he nodded his head when asked if he knew what the call light was used for. He was asked if he wanted it clipped to his bed so he could reach it. He stated yes. He stated he was cold and wanted a blanket. During an interview with Licensed Practical Nurse (LPN) F on 06/27/2024 at 10:33 AM, she confirmed that Resident #109 could use his call light. She was made aware of the observations of the resident's call light having been out of reach. She stated she thought the night shift staff clipped the call light to the wall when they were providing incontinence care, and then forgot to clip it back on the bed for him. She confirmed that rounds were made in the mornings by the department head assigned to this wing of the facility. One of the things they checked for was the position of the call light. She was made aware that the resident asked for a blanket. She stated he had not asked her for a blanket or indicated that he felt cold. She agreed that he would not have been able to ask without the use of his call light. During an interview with East Wing Unit Manager/LPN E on 06/27/2024 at 11:05 AM, she confirmed that Resident #109 could use his call light and make his needs known. A review of the resident's medical record face sheet revealed that he was initially admitted on [DATE]. His diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), malnutrition, gastroparesis (condition preventing proper stomach emptying), anxiety, anemia (lower than normal amount of red blood cells), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD - stomach acid irritates the food pipe lining), and adult failure to thrive. (Copy obtained) A review of the care plan, dated 05/15/2024, revealed that the resident had an Activities of Daily Living (ADL)/Self-Care Performance Deficit related to limited mobility, difficulty walking, dementia, schizophrenia and autistic disorder. Goal: The resident will maintain current level of function through the review date. Interventions included: Encourage the resident to use bell to call for assistance. Initiated 02/06/2023 (Copy obtained). A review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed that the resident had no impairment in his upper or lower extremities. He used a wheelchair for mobility. He was dependent for eating (required tube feedings), the ability to come to a standing position from a sitting position, and walking 10 feet once standing. He required substantial/maximal assistance with toileting, putting on/taking off footwear, personal hygiene, moving from a sitting to a lying position and from a lying to sitting position, as well as transferring to and from his bed to a chair, for toilet transfers and wheeling 50 feet once seated in hiswheelchair. He required partial/moderate assistance with rolling from left and right. (Copy obtained) A review of the facility's Skills Competency Assessment: Positioning a Resident form used to assess certified nursing assistants' (CNAs) competency and job skills, revealed: 16. Leave resident in comfortable position with call light within reach. (Copy obtained) During an interview with the Administrator on 06/27/2024 at 5:30 PM, she stated the nursing staff were trained using the employee handbook, which covered customer service. They were assessed for their competency using the Skills Competency Assessment form that included ensuring that the call light was always within reach for the resident and staff to use. She was shown the photographic evidence and she confirmed that the call light was not within reach for Resident #109 on the occasions observed by this surveyor, but it should have been. She confirmed that the department heads were assigned to a specific hallway to make rounds each morning in an effort to ensure the residents had their call lights among other things.

Based on record review and interview, the facility failed to obtain a Level II Pre-Admission Screening and Resident Review (PASARR) preventing the ability of the facility to incorporate the recommendations from the PASARR Level II into the resident's assessment, care planning, and transitions of care for one (Resident #87) of three residents whose PASARRs were reviewed, from a total of 33 residents sampled for the survey. The findings include: A review of the medical record revealed that Resident #87 was admitted to the facility on [DATE] with diagnoses including anxiety, schizoaffective disorder, bipolar disorder, and major depressive disorder. Further review of the record revealed that a PASARR Level I was completed on 4/30/2021. Section I of that PASARR did not include the diagnoses of anxiety or schizoaffective disorder. There was no evidence that a Level II PASSAR was completed for Resident #87. Based on Section III of the Level I PASARR, Resident #87 was exempt from a Level II due to: The individual is being admitted under the 30-day hospital discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF (nursing facility) must notify the Level I screener on the 25th day of stay, and the Level II evaluation must be completed no later than the 40th day of admission, on or before (date): ______ (The date was left blank; however, the 25th day of stay would have been 5/25/2021 and the 40th day would have been 6/9/2021.) A review of the resident's active physician's orders included: Primidone (anticonvulsant) 50 mg every morning for tremor; Lithium (psychiatric medication) 150 mg twice a day for bipolar; Fluoxetine HCL (antidepressant) 20 mg Give 1 capsule by mouth one time a day for depression give with 10 mg for a total of 30 mg total, failed GDR (gradual dose reduction), not the source of patient tremors. Patient having relapse.; Lorazepam (sedative) 1 mg, 0.5mg three times a day for anxiety, and Olanzapine (antipsychotic) 2.5 mg every evening for psychosis. An interview was conducted with the Director of Nursing on 6/27/2024 at 4:32 p.m. He stated he and the Director of Social Services (DSS) were responsible for reviewing the PASARRs for accuracy upon resident admission. He further stated he determined whether or not the PASARR needed to be elevated to a Level II and/or whether the resident's diagnoses on the PASARR matched their admission diagnoses. He stated if the PASARR needed to be updated or called in for a PASARR level II, he or the DSS would contact the appropriate agency to request a screening. He stated he was familiar with Resident #87. He reviewed the Level I PASARR completed on 4/30/2021 and confirmed a Level II screening was required and had not been completed. A review of the facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR), Document Name: SS-402 (Effective Date: 11/8/2021, Revision Date: 11/8/2021), revealed the following: Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectual Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.

Based on observation, resident and staff interviews, medical record review, and facility policy and procedure review, the facility failed to revise the care plan for one (Resident #24) of one resident reviewed for dialysis treatment, out of two residents receiving dialysis, from a total of 33 residents sampled for the survey. Resident #24's dialysis port site was changed; however, his care plan was not revised to reflect the new port site. Failure to update the care plan timely could result in unmet resident needs and negatively impact the resident's health. The findings include: On 06/25/2024 at 10:35 AM, Resident #24 was observed lying in bed. He confirmed that he was receiving dialysis treatments off-site on Mondays, Wednesdays and Fridays. His left upper arm was observed with two puncture holes that had no dressing on them. He stated he no longer had a shunt in his arm; he now had a port in his chest for dialysis treatments. During an interview with Resident #24 on 06/27/2024 at 12:55 PM, he gave permission for observation of the port in his right upper chest wall. He pulled his shirt up and showed the port covered with a dressing. He stated he did not want the shunt in his left arm anymore and told them to put in a port. He could not remember when they did the surgery. He thought it had been a few months ago. During an interview with the East Wing Unit Manager/Licensed Practical Nurse (LPN) E on 06/27/2024 at 1:53 PM, she confirmed that Resident #24 had a port in his right upper chest wall for dialysis treatments. She was not aware that the care plan had not been revised. A review of the medical record face sheet revealed that he was admitted on [DATE] with a re-entry on 01/31/2024. His diagnoses included other mechanical complication of surgically created arteriovenous fistula, subsequent encounter, end-stage renal disease (ESRD). A review of the Nursing Progress Notes revealed a note dated 04/03/2024, which read: Resident returned from dialysis appointment AAOx3 (Awake, alert, and oriented to himself, his location, and the time). Port access to right upper chest intact with bruit and thrill noted. A review of the annual Minimum Data Set (MDS) assessment, dated 05/21/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. He was documented with diagnoses of renal insufficiency, renal failure and ESRD. He received renal dialysis on Mondays, Wednesdays, and Fridays. A review of the Care Plan, dated 06/04/2024, revealed the following Focus Area: Resident needs outpatient dialysis (hemo) related to End Stage Renal Disease (ESRD). He has a left arm arteriovenous (AV) fistula. Interventions: Cleanse left arm with normal saline, pat dry, apply Hydrafera blue foam, cover with dry dressing every day shift every T, Th and Sat. (Tuesdays, Thursday, and Saturdays) for wound management. May use alginate silver and foam until Hydrafera is available. The care plan did not indicate that the resident had a port in his chest. A review of the Physician's Orders revealed an order dated 06/05/2024, which read: Hemodialysis - Assess site right upper chest for bruising/bleeding/symptoms of infection every shift for monitoring. A review of the facility's policy and procedure titled Plans of Care N-1015 (effective 11/30/2014), revealed: An individualized person-centered plan of care will be established by the interdisciplinary team with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedures: Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of each resident and in response to current interventions after the completion of each MDS assessment and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (Residents #24 and #59) of three residents sampled for review of ADL care, from a total of 33 residents sampled for the survey. Failure to provide care and services to meet residents' ADL needs can potentially have a negative outcome to the residents' health. The findings include: 1. On 06/25/2024 at 10:35 AM, Resident #24's fingernails were observed to have grown approximately one half inch beyond the end of his fingers. The nails were unclean. The resident stated he did not get his nails trimmed, but he would like to have them trimmed. He thought a nurse had to do it because he was diabetic. During an interview with East Wing Unit Manager/Licensed Practical Nurse (LPN) E on 06/26/2024 at 10:10 AM, she stated the nurses trimmed the fingernails of the diabetic residents and a podiatrist trimmed their toenails. The certified nursing assistants (CNAs) were to conduct a full body skin assessment during shower/bathing time and inform the nurse if a resident's nails needed to be trimmed. If they communicated verbally to the nurse, the nurse might document it in the notes, but might not. It was not on the Treatment Administration Record (TAR). She stated she had the CNAs use a shower form to document any skin issues and concerns such as nails that needing trimming. If a resident was diabetic, the form was to go to the nurse so she could trim the resident's nails. A review of the shower documentation with LPN E revealed that Resident #24 was scheduled to have a shower/bath on Mondays, Wednesdays, and Fridays during the 3:00 PM to 11:00 PM shift. No shower sheets for Resident #24 were found in the binder at the nurses' station. LPN E was asked to produce the shower forms for Resident #24. She looked through the shower binder where the forms were stored and could not find any forms for Resident #24. She left the interview to go look in her office. At 1:15 PM, she returned and stated she could not find any shower forms for Resident #24. An interview was conducted with Resident #24 on 06/26/2024 at 1:49 PM in his room. He had just returned from dialysis. He stated no one had cut his nails since the last interview with this surveyor (06/25/2024 at 10:35 AM). He stated he was willing to allow the staff to cut his nails. He confirmed again that he wanted them cut. His fingernails remained approximately one half inch beyond the end of his fingers. They were unclean. He gave permission to take a photograph of his hand. (Photographic evidence obtained) He confirmed that he could not remember the last time his nails were trimmed. A review of the medical record face sheet for Resident #24 revealed he was admitted on [DATE] with a re-entry on 01/31/2024. His diagnoses included, but were not limited to: Unspecified protein-calorie malnutrition, type II diabetes with other diabetic kidney complication, dependence on renal dialysis, peripheral vascular disease, polyosteorarthritis, iron deficiency, polyneuropathy, and edema unspecified. A review of the annual Minimum Data Set (MDS) assessment, dated 05/21/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15 out 15 possible points, indicating intact cognition. He was documented with no mood disorder, no signs or symptoms of psychosis, and no impairment in his upper extremities. He was noted as dependent on staff for toileting and bathing with set-up assistance only for personal hygiene. He was documented with a diagnosis of type II diabetes. A review of the Care Plan, dated 06/04/2024, revealed the following Focus Areas: [Resident #24] has an ADL/Self-Care Performance Deficit related to activity intolerance, osteoarthritis, ESRD on dialysis, diabetes, chronic pain, cataracts, fatigue and impaired balance. Interventions included: Bathing/Showering: Check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. Focus area: Resident is resistive to care related to adjustment to nursing home, refuses medication, refuses showers, fluid restriction recommended but resident declines, diet restrictions and may refuse dialysis at times. Also refuse eyes drops. Interventions: Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Focus area: Resident has Diabetes Mellitus. Educate resident that nails should always be cut straight across, never cut corners. File rough edges with emery board. A review of the nursing progress notes dated from 03/28/2024 through 06/27/2024 revealed no documentation verifying that Resident #24 had refused ADL care. (Copies obtained) During an interview on 06/27/2024 at 1:53 PM with East Wing Unit Manager/Licensed Practical Nurse (LPN) E, she stated she would cut Resident #24's nails herself and left the interview. A review of the facility's policy and procedure titled Care of Nails N-117 (effective 11/30/2014, revised on 09/01/2017) revealed it did not include a policy statement. Procedures were: Perform hand hygiene, explain procedure to resident and bring the following equipment to resident's bedside: basin, towel, emery board, orange stick, nail clippers. Place towel beneath the area to be treated, may soak hand in basin half full of warm water if needed, trim nails, clean nails, apply body lotion to nail area if indicated, clean and return equipment to designated area, discard disposable equipment, perform hand hygiene. (Copy obtained) 2. On 6/25/2024 at 11:35 AM, Resident #59 was observed sitting up in bed. The resident stated he was blind. He was asked about his ADL care and he replied that he wasn't receiving showers. He stated the staff used to give him a bed bath which he was ok with; however, he hadn't received a bed bath in a month. He stated the staff were wiping him off. He preferred the bed bath and wasn't satisfied with being wiped off. He stated his nails had not been cleaned. He was told they would cut them down and it was never done. He showed both of his hands. His nails were jagged and uneven. Several of the nails had a substance, dark brown in color, underneath the tip of the nail. (Photographic evidence obtained) A record review revealed that Resident #59 was admitted to the facility on [DATE] with a readmission on 4/21/2022. His diagnoses included: Cerebral infarction due to inclusion; type 2 diabetes mellitus; acute kidney failure; legal blindness and peripheral vascular disease. A review of the annual MDS assessment, dated 3/6/2024, revealed that Resident #59 scored 15 out of 15 possible points on the brief interview for mental status (BIMS) assessment, indicating that he was cognitively intact. He had no impairment in his upper extremities and impairment on both sides of his lower extremities. He was assessed as being frequently incontinent of bladder and always incontinent of bowel. A review of the active Care Plan revealed a Focus Area for ADL/Self-Care Performance Deficit related to right below knee amputation. On 6/26/2024 at 1:54 PM, the resident was observed sitting up in bed. He stated he hadn't spoken to anyone else about the bed baths since his initial interview with this surveyor on 6/25/2024 at 11:35 AM. He further stated staff gave him bed baths regularly then they ended without notice. His fingernails remained jagged and uneven with a brown substance beneath the tips of several nails. (Photographic evidence obtained) Resident #59 was interviewed again on 6/27/2024 at 5:51 PM. He stated he had not received a bed bath yet. He further stated the certified nursing assistant (CNA) came into his room and asked to see his hands. He revealed them to her; however, she did not clip or clean his nails. (Photographic evidence obtained) An interview was conducted with CNA M on 6/27/2024 at 6:13 PM. She stated she was familiar with Resident #59. She said the resident did not like receiving showers. She gave the resident bed baths on Mondays, Wednesdays, and Fridays on the 3:00 PM to 11:00 PM shift. She was asked if she performed nail care when she gave the resident a bed bath. She replied, If he wants his nails cut I would cut them. She did not say when she last performed nail care for this resident. She was asked to provide documentation of the showers Resident #59 had received over the last month. She stated showers were documented in the shower book at the nurses' station. She provided the book for review. A review of the information provided revealed a shower sheet signed by CNA M, dated 6/3/2024, with bed bath handwritten under the resident's name. (Photographic evidence obtained) She was asked if there were any more shower sheets available from 5/1/2024 through 6/27/2024 for Resident #59. She looked through the shower book and confirmed she could not produce the documentation. She stated she gave the resident a bed bath on 6/24/2024 but did not document it. An interview was conducted with LPN N on 6/27/2024 at 6:19 PM. She stated all showers should be documented on a shower sheet and signed by a nurse.

Based on observations, medical record review, staff interviews and facility policy and procedure review, the facility failed to ensure that residents requiring respiratory care, received such care, consistent with professional standards of practice, by failing to follow physicians' orders for two (Residents #109 and #18) of three residents sampled for review of respiratory therapy, from a total of 33 residents sampled for the survey. Failure to provide needed respiratory care for residents could negatively impact their medical status and functional abilities. The findings include: 1. On 06/24/2024 at 11:18 AM, Resident #109 was observed lying in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. (Photographic evidence obtained) On 06/25/2024 at 9:56 AM, Resident #109 was observed in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. During an interview on 06/25/2024 at 11:25 AM with Licensed Practical Nurse (LPN) F, she confirmed that she was assigned to this resident. She stated she checked the oxygen concentrator levels when she made her first rounds in the morning. On 06/26/2024 at 11:46 AM, Resident #109 was observed in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. (Photographic evidence obtained). A review of the resident's physician's orders revealed an order dated 02/09/2024 for oxygen at a flow rate of 2 L/min every shift for monitoring. (Photographic evidence obtained) A review of the medical record face sheet revealed that Resident #109 was admitted on [DATE] with a re-entry on 02/09/2024. His diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and adult failure to thrive. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed the resident was assessed with the diagnoses adult failure to thrive and chronic respiratory failure. He presented with shortness of breath or trouble breathing when lying flat. Prognosis: Resident does not have a condition or chronic disease that may result in a life expectancy of less than six months. Oxygen therapy was marked no with the date of 05/02/2024. (Copy obtained) A review of the resident's Care Plan (dated 05/16/2024, and revised on 06/27/2024), revealed the resident had shortness of breath related to a chronic respiratory illness. He was to receive oxygen therapy and nebulizer treatments as needed. (Copy obtained) During an interview with Unit Manager/LPN E on 06/26/2024 at 2:24 PM, she stated the physician's orders for oxygen therapy should have been written for as needed only, but the Nurse Practitioner changed the order on 03/07/2024 to continuous oxygen therapy. LPN E stated she would adjust the resident's flow rate level to 2 L/min. On 06/27/2024 at 10:28 AM, Resident #109 was observed lying bed on his back. He was receiving oxygen via a nasal cannula. The oxygen concentrator flow rate was set between 1.5 L/min and 2 L/min. (Photographic evidence obtained) During an interview with MDS Coordinator/Registered Nurse (RN) G on 06/27/2024 at 4:20 PM, she was asked to review the Quarterly MDS assessment dated [DATE] for the use of oxygen therapy. In section J - Health Conditions, the resident was identified as having shortness of breath when lying flat. In section O - Special Treatments and Programs, oxygen therapy was not checked off as in use for this resident. She reviewed the electronic medical record and confirmed that the assessment was coded incorrectly. During an interview with the UM on 06/27/2024 at 11:05 AM she confirmed that she went to Resident #109's room on 06/26/2024 and adjusted his oxygen flow rate to 2 L/min. 2. On 06/24/2024 at 12:35 PM, Resident #18 was observed in bed with oxygen infusing at 2.5 liters per minute via nasal cannula. (Photographic evidence obtained) On 06/25/2024 at 11:22 AM, Resident #18 was observed in bed with oxygen infusing at 2.5 liters per minute via nasal cannula. (Photographic evidence obtained) On 06/27/2024 at 10:12 AM, Resident #18 was observed in bed with the oxygen infusing at 3 liters per minute via nasal cannula. (Photographic evidence obtained) A review of the medical record revealed that Resident #18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and Dementia. She had a brief interview for mental status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. She was receiving hospice services for end-of-life care and she required oxygen therapy. A review of the resident's physician's orders revealed an order dated 8/10/2020 for pulse oximetry, an order dated 8/11/2020: Oxygen saturation as needed, notify MD (physician) if less than 90%, an order dated 03/14/2022: Do Not Resuscitate, an order dated 08/31/2023: Oxygen at 2 liters per minute via nasal cannula (NC) as needed, and an active order for Vitas Hospice for COPD and heart failure. A review of the Care Plan revealed a Focus Area for Hospice related to end-stage CHF (initiated 8/31/2023, revised 12/28/2023), a Focus Area for Resident Dependent on Staff for meeting emotional, intellectual, physical, and social needs related to Dementia. (initiated 3/02/2022, revised 12/14/2022), a Focus Area for Resident has Congestive Heart Failure. (initiated 01/10/2019, revised 11/30/2021), a Focus Area for Impaired Cognitive Function/Dementia or impaired thought processes (initiated 01/10/2019, revised 11/30/2021), a Focus Area for Do Not Resuscitate (initiated 01/10/2019, revised 2/24/2022), and a Focus Area for Oxygen Therapy related to CHF. (initiated 01/10/2019, revised 11/30/2021). On 06/27/2024 at 10:12 AM, an interview was conducted with LPN C. She stated she was familiar with Resident #18. When she was asked to describe the resident's needs, LPN C stated, She receives hospice care, she is alert, and she receives oxygen. LPN C was asked to provide the resident's physician's order for oxygen. She checked the order in the electronic medical record and stated, She gets two liters. LPN C was accompanied to the resident's room to verify the oxygen flow rate the resident was receiving. LPN C looked at the flow meter and stated, She is getting three liters. The oxygen flow rate was set at 3 liters per minute. A review of the facility's policy and procedure for Oxygen Therapy (effective 11/30/2014, revision 8/27/2017), revealed: Physician's order for oxygen therapy shall include administration modality, FiO2 or liter flow, continuous or as needed (PRN), and PRN orders must include specific guidelines as to when the resident should use the oxygen. Review physician's order, Start (O2) oxygen flow rate at the prescribed liter flow or appropriate flow for the administration device. (Photographic evidence obtained)

Based on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (Resident #64) of a total of 33 residents sampled for the survey. The findings include: On 6/24/2024 at 10:40 AM, Resident #64 was observed sitting in his wheelchair in his room. The resident was asked if he had any concerns with his stay in the facility. He stated he wasn't being scheduled for and/or had missed several medical appointments, and he hadn't seen the cardiologist or the neurologist. Since his admission to the facility, he had lost his financial and insurance benefits. He stated he received a discharge notice for non-payment. He advised the facility that he was homeless and didn't have a safe place to discharge to. They offered to discharge him to a hotel for five days at their cost, and he advised them that he did not have any income. He made several requests of the Social Services Director and Business Office Manager for help in obtaining financial assistance. He stated he still had not received any assistance. He was told that his supplemental benefits ended because he owed child support and was in arrears. They were able to restore his insurance benefits and coverage to pay his monthly fee for residency in the facility. He showed the surveyor a copy of a notice dated 4/23/2024 from the Social Security Administration (SSA). Per the documentation, the resident did not qualify for Supplement Security Income (SSI) benefits. The Explanation stated We were unable to obtain additional information medical and non-medical reports from the following: [NAME] Harbor Healthcare Center. A review of Resident #64's medical record revealed an admitted [DATE]. His diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; alcoholic cirrhosis; epileptic seizure related to external causes; chronic combined systolic (congestive) and diastolic (congestive) heart failure; personal history of pulmonary embolism; essential (primary) hypertension; other specified cardiac arrhythmia; other chest pains; syncope and collapse; other pancytopenia; thrombocytopenia and chronic pain syndrome. A review of the annual Minimum Data Set (MDS) assessment, dated 4/10/2024, revealed a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. He was documented as feeling down, hopeless and/or depressed 7-11 days during the lookback period. No behaviors were documented. No impairment in upper/lower extremities was documented, and the resident was independent with activities of daily living and mobility. A review of the Nursing Home transfer and Discharge Notice (AHCA form 3120-0002, dated 5/1/2024), revealed that the location to which the resident was being discharged was 10520 Balmoral Circle [NAME], FL 32218. Reason for discharge or transfer: Your bill for services at this facility has not been paid due to reasonable and appropriate notice to pay. A review of the Fair Hearing Request for Transfer or Discharge from a Nursing Home (AHCA form 3120-0003, dated 5/1/2024), revealed: I disagree with the transfer or discharge for the following reason(s): Never had follow ups with neurology and cardiology from [acute-care hospital name] in two years and two months. A psychiatric consultation dated 5/29/2024 revealed: Resident reports improvements with depression however, he continues to have persistent symptoms. Patient needs more time with current regimen to see full beneficial effects, do not recommend any changes at this time. A physician's note dated 5/30/2024 revealed: Chief complaints: chronic disease management; Celiac; postural orthostatic tachycardia syndrome (POTS); resident also has diagnoses of seizure disorder and neuropathy. Celiac disease: Dietitian is following patient placed on low gluten diet, bowel regimen increase lactulose to twice daily and Miralax twice daily with effective results; Seizure-Keppra 500 mg (milligrams) twice daily, no breakthrough seizures; Neuropathy/chronic pain - gabapentin 400 mg three times daily, currently on oxycodone 15 mg four times daily in-house pain management is monitoring titration and prescribing; depression: Trazodone 100 mg at bedtime - patient is followed by psychiatry and psychology; anxiety: Lorazepam 0.5 mg four times daily - psychiatry is following titration medications and prescribing. An interview was conducted on 6/26/2024 at 2:56 PM with the Business Office Manager (BOM). She stated she applied for benefits for Resident #64 and he was not approved. Medicaid was covering his room and board; however, due to external financial obligations he did not get approved for financial benefits. She stated he did not have any income, therefore he was denied financial benefits from another state agency. She provided the notice dated 4/23/2024 from the Social Security Administration (SSA), which the resident had previously provided stating he was denied benefits. The BOM reviewed the letter with the surveyor. The documentation was reviewed. The surveyor directed her to the section titled: Explanation which stated We were unable to obtain additional information medical and non-medical reports from the following: [NAME] Harbor Healthcare Center. She stated she called the SSA and was advised there was no additional information needed from the facility. She could not provide any documentation to confirm this, nor could she state whom she spoke to and/or when the call was made. She then stated she was not aware that additional information was required or action that needed to be taken. She stated the resident was taken to the office of SSA after the letter was received. Again, she could not provide any information about when this occurred. She stated the resident got out of his wheelchair and walked into the SSA building. She then stated this was why he was denied financial benefits; he did not present himself as disabled. An interview was conducted on 6/27/2024 at 4:32 PM with the Director of Nursing (DON). He confirmed that the resident was issued a facility discharge notice. When asked why, he stated, The facility could not meet his financial needs. He stated Resident #64 had expressed in a care plan meeting that he could not meet his financial obligations to the facility due to external financial obligations. The facility felt the resident would do better in a more independent setting. After reviewing the discharge notice dated 5/1/2024 (Photographic evidence obtained), the DON confirmed the address to discharge to was a hotel. He was asked if that was a safe discharge location. He stated it was safe for Resident #64. He confirmed the resident did not have any income and added the resident may have had access to more financial assistance if he were in the community. He stated the resident was advised of the discharge and that he stressed concerns with being able to get to and from his medical appointments if he was discharged . He stated the resident had a meeting with the BOM and a SSA representative. He stated the facility transported the resident to an appointment and would not permit him to come inside with him adding that he [the resident] removed himself from his ambulatory device and walked into the office. He again confirmed the resident had no income at the time. He stated the appointment was on 4/1/2024. He denied knowledge of any additional information requested from SSA. He was asked when the resident had last seen a cardiologist. He stated the resident was followed by the facility cardiologist in house. He could not confirm the last time the resident had been seen by the cardiologist. He stated the resident had requested to see another physician for a second opinion. The resident requested to see his previous provider; however, he had not done so citing insurance coverage as a possible reason. The DON confirmed the resident had not seen a neurologist. He was asked if the resident had any diagnoses which would warrant him seeing a neurologist. He responded; He has the headaches and seizures. On 6/27/2024 at 5:38 PM, the DON advised the survey team that cardiology notes were not in the system for Resident #64. He provided documentation indicating the resident was seen by the cardiologist during the survey on 6/26/2024 at 5:39 PM. Additional information provided revealed the resident's visit prior to this was on 5/30/2023.

Based on observation, record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. There were 25 opportunities for error with two errors identified, resulting in an error rate of 8% and involving one (Resident #75) of six residents observed during medication administration, from a total of 33 residents sampled for the survey. The findings include: On 06/26/2024 at 9:48 AM, Licensed Practical Nurse (LPN) D was observed administering medications to Resident #75. She administered Torsemide 10 mg (1) tablet by mouth, and she administered Advair 100-50 mg (milligrams), 2 puffs, without providing the resident with water to rinse/spit following inhalation, or instructions to rinse his mouth well and spit following inhalation. A review of Resident #75's active physician's orders revealed an order for Torsemide as follows: Torsemide oral tablet, 10 mg, give three tablets by mouth one time a day for congestive heart failure (CHF), order dated 2/14/2024, start date 2/15/2024. Further review of Resident #75's activie physician's orders revealed and order for Advair as follows: Advair Diskus Inhalation Aerosol Powder breath Activated 100-50 MCG/ACT (micrograms per actuation) (Fluticasone-Salmeterol), 2 puff, inhale orally one time a day for COPD (chronic obstructive pulmonary disease), rinse mouth well and spit after each use. A review of the facility's policy and procedure for Administration of Medications (revised April 2019), revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on record review and interview, the facility, licensed for 180 beds, failed to employ a qualified social worker on a full-time basis. The findings include: The personnel file for Director of Social Services (DSS) L was reviewed during random record reviews for facility staff. An application, dated 5/3/2024, for the position of Director of Social Services was observed. (Photographic evidence obtained) There was no documentation in the personnel file verifying DSS L's credentials for the position of DSS. On 6/27/2024 at 1:15 PM, the Human Resources Director (HRD) provided a copy of what she stated were DSS L's credentials. (Photographic evidence obtained) Per the documentation, DSS L received a Bachelor of Science degree in Interdisciplinary Studies. The HRD stated she knew the degree was invalid. She confirmed that DSS L was hired as the DSS. She stated it should have been Manager and not Director due to lack of credentials. She confirmed the facility did not have another individual staffed as the DSS. A phone interview was conducted on 6/27/2024 at 1:33 PM with the educational institution, where based on documentation provided, DSS L had obtained her degree. The HRD was also present during the call. The educational institution advised the survey team that the program of study DSS L had obtained her degree in did not focus on social work or psychology. The representative at the educational institution stated it was a brotherhood program intended for individuals seeking missionary work. Upon hearing this, the HRD stated a new position title and job description would be generated for DSS L. A review of the facility's employee roster revealed DSS L's Job Code: SSDIR 1 (Social Services Director) with a hire date of 5/15/2024. (Photographic evidence obtained)

Based on observations, interviews, and facility policy and procedure review, the facility failed to help prevent the development and transmission of diseases and infections by failing to properly clean and disinfect a glucometer for one (Resident #59) of six residents observed during medication administration, from a total of 33 residents sampled for the survey. The findings include: On 6/26/2024 at 10:13 AM an observation was made of Licensed Practical Nurse (LPN) A cleaning and disinfecting the glucometer used for Resident #59. LPN A wiped the glucometer with an antibacterial wipe for 30 seconds and immediately placed it back in the pouch, wet. On 06/26/2024 at 10:22 AM, an interview was conducted with LPN A. She was asked to explain the process for sanitizing the glucometer. She stated, I wipe it down after each use and put it back in the pouch. She was asked, according to her training and the facility's policy, how long she should wipe the glucometer. She stated, I'm not sure about that. I just know I must sanitize it between each resident. She was asked, according to her training and the facility's policy, how long the glucometer should be allowed to dry before it was placed back in the pouch. She stated, I'm not sure. I usually wipe them down and put them back in the pouch, but I will find out and get back with you. On 6/27/2024 at 11:30 AM, a review of the facility Skills Competency Assessment for Glucometers (10/2021) revealed the employee should demonstrate skills and competence in cleaning and disinfecting the meter with a disinfectant wipe per the manufacturer's recommended wet time to include: Follows the two-step process for cleaning and disinfecting. Cleaning: Cleans the entire surface of meter three times horizontally and three times vertically, inverts the meter so the test strip is facing down and cleans around the test strip port. Disposes of the wipe. Disinfecting: Obtains a new disinfectant wipe and repeats the procedure above to remove blood-bourne pathogens. Disposes of the wipe. The surface remains wet per the manufacturer's instructions. Wipes the meter dry with a paper towel after the recommended wet time. A review of the facility's policy and procedure for Blood Glucose Monitoring and Disinfecting (effective 11/30/2014, revised 3/1/2021 - Document Name: N-700), revealed that the procedure for cleaning and disinfecting the meter was with disinfecting wipes per the manufacturer's guidelines. A review of the instructions provided by the Assure Prism Multi Blood Glucose Monitoring System revealed that the meter should be cleaned and disinfected after each use on each patient. Cleaning included wiping the entire surface of the meter three times horizontally and three times vertically using one towelette and properly disposing of the towelette. The disinfecting of the meter included wiping the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens. Properly dispose of the towelette. The treated surface must remain wet for the recommended contact time. Once contact time is complete, wipe meter dry. A review of the Super Sani-Cloth Gemicidal Disposable Wipe Technical Data Bulletin revealed that the contact times for multi-drug resistant bacteria, enveloped viruses, non-enveloped viruses and bloodborne pathogens was two minutes.

Based on observation, resident and staff interviews, facility pest control management documentation, and facility policy and procedure, the facility failed to ensure the pest control service was effective when cockroaches and flying insects were observed in resident rooms and the activities room. Ineffective pest control could lead to transmission of disease and infection. The findings include: On 06/24/2024 at 10:30 AM, 12:32 PM, and 1:20 PM, live cockroaches were observed in the activities room. (Photographic evidence obtained) On 06/25/24 at 10:35 AM, one gnat flying in the room and two gnats on the privacy curtain were observed in room [ROOM NUMBER]A on the East Wing. A black fly was observed on the B-bed in room [ROOM NUMBER]A. (Photographic evidence obtained) During an interview with Resident #24 on 06/25/2024 at 10:22 AM in room [ROOM NUMBER]A on the East Wing, a gnat flew by his face and he swatted at it. It landed on the privacy curtain. When asked if the gnats bothered him, he stated, You see me doing this. He waved his hand in front of his face to show how he tried to swat them away. He stated the facility had a pest control program, but it was not working. He stated, I know they spray. During an interview with the Administrator on 06/27/2024 at 5:30 PM, she stated the facility filed for bankruptcy on June 1, 2024. The contracted pest control company at that time refused to provide anymore services due to past due bills not being paid. The last time the pest control company provided services was on 05/30/2024. She stated she had a new company ready to begin services, but the corporate office had not signed the contract yet. She acknowledged that there were pests in the building. A review of the contracted pest control receipts for service, dated 05/28/2024, revealed the company treated multiple areas for cockroaches and monitored five fly lights for flying insects. The next receipt for service prior to 05/28/2024, was dated 04/05/2024. On both occasions the activities room was treated for cockroaches. On both occasions the service technician documented no activity, indicating that he/she did not observe pests in the facility. (Copies obtained) A review of the facility's policy and procedure titled Pest Control HL-200 (effective 11/30/2014), revealed: Policy: The facility will maintain a pest control program, which includes inspection, reporting and prevention. Procedure: 1. A pest control contract will be maintained with a licensed exterminator. 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor. Proper action will be taken. (Copy obtained)

Based on observations, interviews, and facility policy review, the facility failed to ensure the bathroom shared by two (Residents #1 and #4) residents, out of three resident bathrooms observed were maintained in a safe, functional, sanitary, and comfortable environment. The findings include: On 2/29/24 at 9:55 AM, the shared bathroom for Residents #1 and #4 was observed to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom had an unpleasant odor of feces. The sink was partially separated from the wall and loose. The baseboard was separated from the wall in two areas. (Photographic evidence obtained) On 2/29/24 at 12:15 PM, the shared bathroom for Residents #1 and #4 was observed for a second time. The bathroom continued to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom continued to have an unpleasant odor of feces. The sink was still partially separated from the wall and loose. The baseboard was still separated from the wall in two areas. (Photographic evidence obtained) An interview was conducted with Employee A, Certified Nursing Assistant (CNA) on 2/29/24 at 1:00 PM, who was caring for Resident #1 and Resident #4. When asked if Resident #1 uses the bathroom in their room. She stated, Her roommate (Resident #4) uses the bathroom. She (Resident #1) is incontinent and has that care provided in her bed. She was asked who is responsible for keeping the resident bathrooms clean. She stated, The janitors, housekeepers. We do change the trashcan liners, but the housekeepers do the actual cleaning. When asked if she noticed if Resident #1's bathroom needed any additional cleaning today. She stated, When I went in there this morning, I noticed that it did need to be cleaned. I noticed all the stuff on the wall. When asked if she had reported any issues with Resident #1's bathroom to maintenance. She stated, No, I haven't. On 2/29/24 at 1:20 PM, the shared bathroom for Residents #1 and #4 was observed for a third time. The bathroom continued to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom continued to have an unpleasant odor of feces. The sink was still partially separated from the wall and loose. The baseboard was still separated from the wall in two areas. An interview was conducted with Employee B, Licensed Practical Nurse (LPN) on 2/29/24 at 1:30 PM, who was caring for Resident #1 and Resident #4. When asked if Resident #1 uses the bathroom in her room. She stated, Not at this time, she did in the past. She used to walk around all the time. She doesn't really walk around now; she has declined a little bit. She was asked if her roommate, Resident #4, uses the bathroom in her room. She stated, I think so. She was asked if she had noticed or been made aware of any issues in their bathroom today. She stated, No. I just went into her bathroom, and it was ok. She was asked if she noticed any debris or splatter on the bathroom walls. She stated, No. The CNA or the housekeeper would probably clean it. Employee B, LPN was then asked to observe Resident #1's bathroom. When asked if she saw the brown debris on the walls. She stated, Yes, I see that now. When asked if she knew how long the brown splatter/debris has been on the walls in this bathroom. She stated, No, I don't know. On 2/29/24 at 2:20 PM, the Maintenance Director was interviewed. He was asked if he has any work orders for the bathroom belonging to Residents #1 and #4. He stated, No, I do not. He was asked to observe their bathroom. Upon entering the bathroom, he was asked if he had been made aware of the sink coming loose from the wall or the baseboard coming off the wall. He stated, No, ma'am, I have not. I may need to replace the baseboard because that has been taped before, and when it is open like that, it can attract roaches because of the glue inside. I did not know about the sink. A review of the facility's policy titled 5-Step Daily Room Cleaning (revised 10/25/16) revealed: Purpose: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a health care facility. 3. Spot clean walls: Vertical surfaces are not completely wiped down daily- but must be spot cleaned daily. Walls- especially by the trash cans, light switches, and door handles- will need special attention. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an adequate system to prevent the misappropriation/drug diversion of controlled medications for 8 (Residents #1, #3, #4, #5, #6, #7, #8, and #9) of 9 sampled residents, with the potential to affect all residents prescribed controlled drugs. The findings include: An interview was conducted with the Director of Nursing (DON) on 09/13/23 at 11:13 am regarding an incident related to Resident #1. The DON stated that on 7/27/23 at 7:00 am, Licensed Practical Nurse (LPN) A asked LPN B, to count the narcotics with her because the nurse who was relieving her was late. While counting the medications LPN B reported to the Unit Manager that a tape was seen on the back of an Oxycodone card for Resident #1. After reviewing the pill, it was determined that a Lipitor tablet (medication for high cholesterol) was inserted in the place of an Oxycodone. An attempt was made to stop LPN A before leaving the property, but she exited the building and boarded a vehicle that was waitng for her. Upon further investigation, it was discovered that LPN A had signed for 120 oxycodone pills for Resident #3, and 60 of the pills were unaccounted for. Further investigation also revealed that LPN A had several notations of medication wastage with no reason that were not signed off by two nurses. In addition, several dosages were given to residents outside of the required time. The DON could not provide any specific names for the resident's affected. He stated that it was too much, and some incidences happened before his tenure, and it was difficult to follow through. He added that the facility implemented a plan which included education for all licensed staff to ensure that two nurses receive medication from the pharmacy and add the medication to the narcotic sheet count log. He stated that two nurses should verify the pharmacy manifest with the count and sign off the narcotic sheet. A copy of the manifest should be kept at the nurses station. The unit manager audits the narcotic sign off sheets and the pharmacy manifest weekly, and the DON audits the sheet monthly. When requested, the DON was unable to provide a copy of the in-service sign-off sheets or details on when the education was completed and the audits. On 9/13/23 at 11:35 am, a tour of the North Wing was conducted with the DON. When he was asked to provide the pharmacy manifest for that unit, he looked around without success. When he asked the nurse on the unit, the nurse said that she was not sure what he was talking about (no pharmacy requisition form was found). When asked to provide the audits that he had been conducting, he confirmed he had not conducted any audits. The DON stated that he had delegated the work to the unit managers and thought that it was done. During an interview with LPN C on 9/13/23 at 12:07 pm, she was asked about the process of receiving medication from the pharmacy. She stated that once the medication arrives the nurse should verify the medications received with the narcotic sheet (at the top of the narcotic sheet it shows the medication delivered and then sign as delivered). She stated that she was not aware about the facility retaining the pharmacy manifest. She added that the pharmacy delivery person normally takes a signed copy back. When asked about the facility's process for narcotic reconciliation, she said, At the beginning of the shift, two nurses count the cards in the cart and then count the narcotic for each resident individually. She added that if a resident refuses medication, two nurses should witness and discard appropriately. When asked when medication is signed off from the narcotic sheet during medication administration, she said, As soon as you take it from the cart. On 9/13/23 at 12:35 pm, a tour of the South Wing was conducted with the DON. Resident #7 was observed in her scooter chair at the nurses' station upset, as she was asking for her morning medication. The assigned nurse was not at the unit and the resident went into the dining room. The DON contacted LPN D via her phone to return to the unit. While waiting for LPN D to return to the unit Resident #9 approached the nurse's station. She stated that she wanted her morning medication. Resident #9 reported to the DON that she had not received her morning medication. She added that there were three other times that the same nurse administered the medication very late. When the DON asked her why she did not report these incidences. Resident stated that the nurse does not work every day and therefore she does not remember, she added, I don't want to put anyone in trouble, I just want my medication. The DON reassured the resident that she would investigate her concerns. The DON was once again asked to provide the pharmacy manifest and audits for the unit. He stated that he could not find any. During an interview with Resident #7 on 9/13/23 at 12:50 am, she confirmed that she had not received her morning medication. She stated she had been asking for her medication since 10:30 am, and she was told that the nurse was on break. She stated that this wasn't the only time she hadn't received her morning medications. When asked about the other occasions, the resident was unable to give any specific timelines. When asked what medication she takes in the morning she said, I really need my anxiety and blood pressure medication, I'm not sure what other medications I get. A clinical record review for Resident #7 indicated that she was admitted to the facility on [DATE], with diagnoses that included anxiety, depression, manic depression, bipolar type schizophrenia and high blood pressure. The quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident had a brief interview for mental status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. The MDS further indicated that resident was receiving antianxiety, antidepressant, opioid and antipsychotic medications. During an interview with Resident #9 on 9/13/23 at 12:55 pm, she confirmed that she had not received her morning medication. She added that it was already time for her afternoon medication and yet she had not received the morning medications. When asked if she has had issues with her medication previously, she said, Not really because there are different nurses working, but this nurse working today is always late getting the medication. When asked if she knew what medication she had not received, she said, My pain pill, blood pressure pill, acid reflux medication and I think there are some others, I can't remember them all. A clinical record review for Resident #9 indicated that she was admitted to the facility on [DATE], with diagnoses that included cirrhosis, Gastroesophageal reflux disease (GERD) and high blood pressure. The quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 15, indicating that she was cognitively intact. She required extensive assistance for bed mobility, transfer and toilet use. On 9/13/23 at 1:00 pm, LPN D arrived at the unit. When asked about her whereabouts, she stated that she was on break. When asked about the facility's protocol for breaks, she mentioned that staff can take two fifteen-minute break and one 30-minute break. When asked if staff are required to clock out during their break time, she said, During the 15 minutes break, we don't have to clock out as long as we do not leave the facility. When asked how long she was away, she said, I had taken a 15 minutes break, and I was in my car, so I didn't clock out. When asked what time she left the unit, she confirmed that she had left around 12:20 pm. When asked if she clocked out because it was more than 15 minutes, she did not answer. When asked if she had completed her morning medication pass, she said, Yes. She opened the computer system and revealed the resident medication administration record for her assigned residents which were green in color (indicating that the medications were administered). When asked if she had administered the medications for Resident #7 and #9. She said that she had administered the medication for Resident #7, but she had not administered to Resident #9, as she was outside smoking. She added, It's my fault, I should have gone to look for her after the smoke break. A random narcotic count was conducted for the cart and multiple discrepancies were identified for the following residents: Resident #4 missing two Ativan Resident #5 missing one Clonazepam and one Oxycodone. Resident #6 missing Acetaminophen and Hydrocodone (Norco) Resident #7 missing one Lorazepam Resident #8 missing two Oxycodone Resident #9 missing Oxycodone (Copies obtained) LPN D and the DON confirmed the discrepancies. LPN D stated that she administered the medications and forgot to sign off. When asked when the medications are signed off during medication administration, she said, As soon as they are taken off from the cart, I should have signed off at the narcotic sheet and the computer. An interview was conducted with the Administrator on 9/13/23 at 2:06 pm. She stated that she had removed LPN D from the floor and an investigation would be initiated. When asked if there was a performance improvement plan after the incident on 7/27/23 she stated, No. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation (Document # N- 1265, Revision date 11/16/202) revealed: Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human right including right to be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse neglect, neglect mistreatment, exploitation and misappropriation of property. The policy further indicates on page 9 that the center will review allegations of abuse, neglect, misappropriation of property and exploitation during the QAPI meetings. QAPI committee will review information including but not limited to: I. The thoroughness of the investigation II. Protection of resident(s) III. Risk factors identified IV. Root cause analysis of the investigation V. Systemic changes that may be required (Copy obtained)

Based on record reviews and staff interviews, the facility failed to prevent pressure ulcers, consistent with professional standards of practice, by failing to 1) Perform peripheral neurovascular assessments, and 2) Conduct weekly skin assessments for a resident who was admitted to the facility with a splinting device. The deficient practice involved one (Resident #1) of three residents reviewed for pressure injuries. Resident #1 was admitted on [DATE] with a splinting device to his left ankle. The facility failed to assess his peripheral neurovascular status each shift per its policy and practice standards, and it failed to assess his skin integrity weekly per its policy. On 12/30/2020, the resident was transferred to the hospital for gangrene of the left foot and underwent amputation of the affected area. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified on 2/11/21 at 4:27 PM. On 12/04/20, the Immediate Jeopardy began. On 2/15/21 at 4:50 PM, the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed at the time of survey exit on 2/16/21 at 2:35 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: A review of Resident #1's medical record revealed an admission date of [DATE]. He was admitted for short-term rehabilitation following hospitalization for a fractured left ankle. Secondary [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment, dated 11/25/20, revealed the resident's Brief Interview for Mental Status (BIMS) score was recorded as a 7 out of a total of 15 possible points, indicating severe cognitive impairment. He required extensive to total assistance from staff for activities of daily living (ADLs). Resident #1 was admitted to the facility with a splint to his left ankle and a plan to repair the ankle fracture after soft tissue swelling had resolved. No unhealed pressure ulcers, venous or arterial ulcers, or foot problems were documented. A Federal Five-Day report submitted by the facility to the State Agency, revealed that Resident #1's daughter notified the facility's corporate compliance hotline regarding concerns that the resident had developed bed sores, suffered an infection, and staff had not communicated the resident's health concerns to her. (Photographic Evidence Obtained) A summary of the complaint, provided by the facility, indicated that the resident's daughter believed that due to inadequate care, her father had developed bed sores and suffered a severe infection, which resulted in the resident's leg being amputated. (Photographic Evidence Obtained) Continued review of the record revealed a physician's orders [REDACTED]. A nursing assessment conducted at the time of admission revealed the resident's skin was intact and that he had a [MEDICAL CONDITION] lower leg. A physician's orders [REDACTED]. A skin assessment, dated 11/28/20, indicated the resident's skin was intact. Skin assessments for 12/4, 12/11, 12/18, and 12/24/20 were not completed. (Photographic Evidence Obtained) A skin assessment, dated 12/30/20, indicated, Left foot and left toes gangrene. (Photographic Evidence Obtained) A physician's orders [REDACTED]. During an interview with the wound care nurse on 2/11/21 at 3:03 p.m., she explained that she had been on vacation and the resident was not evaluated until 12/30/20. She further explained that the resident had been transferred to the hospital immediately following her evaluation due to gangrene of the left foot. Continued review of Resident #1's medical record revealed no documentation of peripheral neurovascular assessments. According to the Lippincott Nursing Center at https://www.nursingcenter.com/getattachment/Clinical-Resources/nursing-pocket-cards/Neurovascular-Assessment/Neurovascular-Assessment.pdf.aspx, accessed on 2/26/21, The neurovascular assessment of the extremities is performed to evaluate sensory and motor function (neuro) and peripheral circulation (vascular). The components of the neurovascular assessment include pulses, capillary refill, skin color, temperature, sensation, and motor function. Pain and [MEDICAL CONDITION] are also assessed during this examination. Comparison of assessment findings bilaterally is extremely important. Even subtle changes can have significant implications. Remember to include neurovascular assessment findings of all extremities in your documentation and to notify the appropriate health care provider of any changes. Risk factors for increased neurovascular compromise may include (Schreiber, 2016; Judge, 2007): · Musculoskeletal, nerve, or vascular injury · Infections · Tissue [MEDICAL CONDITION] · Burns · Surgery · Cardiac catheterization (due to restrictive dressings) · Assistive devices · Fracture · Crush injury · Drug, alcohol, or tobacco use · Coagulation abnormalities A review of the facility's policy titled Clinical Guideline - Cast Care, with an effective date of 11/30/2014, revealed that a circulation evaluation should be conducted every shift, and the physician should be notified of abnormal circulation evaluations. The policy also indicated that drainage should be monitored by inspecting the entire cast, and the physician should be notified of changes in drainage amount. The policy further indicated that visible skin integrity should be inspected, and neurovascular checks should be recorded in the medical record. A review of the facility's internal investigation was conducted. The facility's written statement by Employee B, Registered Nurse (RN) Supervisor, dated 1/8/21, indicated he was notified by Employee A, Licensed Practical Nurse (LPN), that there was a bandage on Resident #1's left ankle, and there was no treatment order for dressing changes. The statement indicated that Employee B observed the resident's foot wrapped with a bandage, and then wrote a treatment order and an order for [REDACTED]. On 2/11/21 at 3:03 p.m., an interview was conducted with Employee C, RN/Wound Care Nurse. She explained that she evaluated the resident on 12/30/20 at the request of the nursing department. She explained that she observed an ulceration to the resident's left ankle and that the entire lower leg was discolored. Employee C explained that she immediately notified the nurse practitioner and primary physician who also evaluated the resident at bedside. Both providers immediately noticed the severity of the resident's change in condition and ordered the resident to be sent to the emergency room . On 2/11/21 at 3:50 p.m., an interview was conducted with the Director of Nursing (DON). She was asked about the facility's internal investigation and the process by which the facility investigated the resident's daughter's complaint. She explained that the resident had been admitted on or around the last day of the facility's annual survey, and that the resident's medical record likely had not been reviewed by the management team as a result. The DON was asked what had led to the resident developing such severe complications in the facility. She stated, I really don't have an answer for you. On 2/11/21 at 4:15 p.m., an interview was conducted with Employee B, RN Supervisor, via telephone. His written statement was reviewed, and he confirmed it was correct. He was asked whether he notified the physician of the change in condition. He stated he wrote the physician's treatment order but did not contact the physician. Employee B also confirmed that he did not conduct any assessments of the resident's leg, to include a peripheral neurovascular assessment. On 2/11/21 at 4:44 p.m., an interview was conducted with Employee A, LPN, via telephone. She explained that she was familiar with Resident #1. She explained that while the resident was being assisted out of bed for [MEDICAL TREATMENT], she noted the bandage was coming off the resident's leg and it needed to be changed. She described the bandage as being heavily soiled. Employee A explained that she notified the supervisor, but she did not notify the resident's physician or his family. The nurse further confirmed that she had not conducted routine peripheral neurovascular assessments per the facility's policy and practice standards. Continued review of the resident's medical record revealed [REDACTED]. During an interview with Employee D, Unit Clerk, on 2/15/21 at 2:30 p.m., she confirmed that she was responsible for scheduling resident appointments. She explained that the earliest appointment she was able to secure for Resident #1 was on 1/4/21. Employee D was unable to recall the date during which she placed the call to schedule the appointment, but she acknowledged that she hadn't informed the resident's nurse or provider of the extended period of time the resident would go without being seen by the orthopedic clinic. A review of the resident's hospital History and Physical, dated 11/18/20, prior to his long-term care facility admission revealed: Chief Complaint: Fall Skin: No [MEDICAL CONDITION] or rashes noted, skin warm to touch Assessment: (Resident #1) presented to the emergency room with a fall resulting in fractured left ankle status [REDACTED]. A review of the resident's hospital Consult, dated 11/18/20, prior to his long-term care facility admission revealed: Maintain splint to left lower extremity (LLE) clean, dry and intact. Patient should follow up with (orthopedic (musculoskeletal system) physician) in Ortho trauma clinic in 1 week for alignment check. Patient should call (telephone number) to schedule their appointment. A review of the resident's hospital History and Physical, dated 12/30/20, upon readmission from the long-term care facility revealed: Patient was initially admitted on ,[DATE] for left lower extremity wound following a distal fibular fracture that resulted from a fall in mid-November. Wound was concerning for wet gangrene, so patient went for left above the knee amputation on 12/31/20 with general surgery. According to the Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/gangrene/symptoms-causes/syc- 567, accessed on 2/26/21, Gangrene (tissue death) is referred to as wet if there is a bacterial infection in the affected tissue. Swelling, blistering and a wet appearance are common features of wet gangrene. Wet gangrene may develop after a severe burn, frostbite or injury. It often occurs in people with diabetes who unknowingly injure a toe or foot. The earlier gangrene is identified and treated, the better your chances for recovery. On 2/15/21 at 4:28 p.m., the Director of Nursing explained that she was not aware that the resident's appointment had to be scheduled so far out. She confirmed that the facility had not attempted to contact any alternative orthopedic offices, however, she stated she had spoken with the nurse practitioner on 2/15/21, and the two had determined that the facility probably should have sent the resident to the hospital when we weren't able to get an appointment with ortho. On 2/16/21, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team: On 2/15/21 at 7:00 p.m., the facility's interdisciplinary team conducted an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting. A root cause analysis was performed, and a performance improvement plan was developed. On 2/15/21, a skin sweep of current residents was completed by the facility's nursing Unit Managers. The facility identified that any resident with a non-removable dressing, cast, splint, or device would have been at risk to be affected by the deficient practice. The facility identified no other residents that were at risk. On 2/15/21, the Regional Director of Clinical Services provided in-service training to the Director of Clinical Services, the facility's three Unit Managers, and the Wound Care Nurse related to care of residents with casts or splints, weekly skin assessments, and notification to providers for changes in skin integrity. On 2/15/21, the Regional Director of Clinical Services provided in-service training to the facility's Medical Records Coordinator related to audits of the weekly skin assessments and communication of findings to the Director of Clinical Services or designee for immediate action. On 2/15/21 and 2/16/21, the Director of Clinical Services provided in-service training to 22 of the 23 licensed nurses employed by the facility with a compliance rate of 96%. The training was related to care of residents with casts or splints, weekly skin assessments, and notification to providers for changes in skin integrity. The licensed nurses were given a post-test to determine competency.

Based on closed resident record reviews and interviews with staff, the facility failed to notify residents, residents' representatives, and the ombudsman of a transfer in writing prior to the transfer, or as soon as practicable, for two (Residents #2 and #3) of two residents transferred under a Baker Act, out of a total of five residents reviewed for transfer/discharge. The findings include: An interview was conducted with the Assistant Executive Director on 5/2/19 at 10:35 am. When asked to provide information regarding any facility-initiated discharges, she reported there had been two residents who were Baker Acted, and neither returned to the facility. One was a resident who was non-compliant with smoking. He used oxygen, so he was deemed a danger to himself and others by smoking in the facility. The second resident was a woman who struck someone else in the facility. 1. A closed record review for Resident #2 found he was admitted to the facility on [DATE] and discharged 12 days later on 1/15/19. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/19, found a return was anticipated, and that it was an unplanned discharge to the community, but not documented in the resident's record. Resident #2 was assessed with [REDACTED]. He required supervision with activities of daily living (ADL). [DIAGNOSES REDACTED]. There was no active discharge plan to return to the community. Per the admission MDS, dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. He used oxygen before he was a resident and while a resident in the facility. Resident #2 had a baseline plan of care, dated 1/3/19, for his oxygen use. He was also care planned to be free from injury, and to smoke safely. The intervention was to evaluate him for safe smoking, and for him to follow the facility smoking policy. The discharge section of the form was not marked indicating whether Social Services would assist him with discharge planning or with adjustment to long-term care (LTC). Resident #2 had a physician's orders [REDACTED]. An Admission/Readmission Data Collection Tool, dated 1/3/18, assessed Resident #2 as a safe smoker. A Social Services Admission Evaluation, dated 1/3/19, revealed that Resident #2's plan for discharge was to remain in this facility for long-term care. A review of nursing progress notes revealed that on 1/14/19, on the 7:00 am - 3:00 pm shift, Resident #2 was smoking in his room. Smoking in the room was reported again in a subsequent progress note dated 1/14/19 on the 3:00 - 11:00 pm shift. This was noted as the second occurrence. A psychiatric progress note, dated 1/15/19, stated that a Baker Act was initiated for Resident #2. The Certificate of Professional Initiating Involuntary Examination dated 1/15/19, noted Resident #2 was a danger to himself and everyone in this building. It stated he was not appropriate for this setting, and was smoking in his room with oxygen. An AHCA Nursing Home Transfer and Discharge Notice was located in Resident #2's chart. There was no date indicating when the notice was given, and no effective date of the transfer/discharge. The location of the transfer was left blank. The reason included the resident's needs could not be met, and the health and safety of others was endangered. The form further explained the resident had been caught smoking while wearing oxygen inside the facility, but denied it. Patient hides his cigarettes, and is a danger to himself and others. The form was signed by the facility's Administrator and the psychiatric Advanced Registered Nurse Practitioner (ARNP) on 1/15/19. The form was not signed by Resident #2 to indicate that he had received the notice. The space indicating when the facility provided notice to the local long-term care ombudsman's council was left blank. 2. A closed record review for Resident #3 revealed she was admitted on [DATE] and was discharged on [DATE]. A discharge return anticipated MDS assessment with an ARD of 4/22/19, revealed she had an unplanned discharge to an acute care hospital. She was assessed with [REDACTED]. She had difficulty focusing, and disorganized thoughts fluctuated. Physical behavioral symptoms directed toward others occurred on 1-3 days over the assessment period, and verbal symptoms on 4-6 days over the assessment period. Resident #3 required supervision with ADLs. [DIAGNOSES REDACTED]. Active discharge planning was occurring for Resident #3 to return to the community. Resident #3 had a baseline plan of care dated 3/19/19 for social services to assist with discharge planning. A history and physical examination [REDACTED]. Resident #3 received [MEDICATION NAME] for depression. A review of nursing progress notes revealed that on 4/19/19, Resident #3 presented with combative behavior on the 11:00 pm - 7:00 am shift. On 4/22/19, a Certificate of Professional Initiating Involuntary Examination was completed for the resident being a danger to herself and/or others, assaulting the Social Services Director with a cane, causing bodily harm, and threatening to hit/kick anyone who came into the room. She was noted as highly agitated and paranoid. Suspect possible origin as a urinary tract infection and removal of antipsychotic medications to allow for acceptance into the facility. Pt (patient) dump. Patient reports having been in many facilities. A psychiatric progress note dated 4/22/19 noted Resident #3 had been highly agitated, and struck the Social Worker with her cane. Her hostility was increased, and she was Baker Acted for being a danger to herself and/or others. Further review of the record found there was no AHCA Nursing Home Transfer and Discharge Notice informing Resident #3, her representative or the Ombudsman of the date of the transfer/discharge, the effective date, the reason for the transfer/discharge, or the location where she was going. An interview was conducted with the Social Services Director (SSD) on 5/2/19 at 1:30 pm. She stated that she was not responsible for Baker Act transfers, the nursing staff were. The psychiatric advanced registered nurse practitioner (ARNP) started Resident #2's transfer/discharge notice, but she did not know why the form was not completed. She stated again that the nursing department was responsible for those transfers. The SSD stated that she had spoken with the detective who came out to the facility to pick up Resident #2, but she did not know what happened to him, where he went, or whether or not he was permitted to return to the facility. When asked about the circumstances surrounding Resident #3's discharge, the SSD stated the resident hit her with a cane and was then Baker Acted. It was the day she was to discharge home. We were looking at transitioning her back home. The hospital called looking for her information, so she may have discharged home following the Baker Act. She stated she did not know where the resident went. A telephone interview was conducted with the Executive Directior (ED) on 5/2/19 at 2:40 pm. When asked whether the residents received notification of their discharges, the ED stated he had communicated verbally to Resident #2 that he was not to return, and communicated this to the hospital staff. When asked about the missing written notification of the transfers for these two residents, and informed that the residents were to be notified of not only the transfer, but of their appeal rights, in writing at the time of transfer or as soon as was practicable, he stated they had verbally communicated the right to appeal the decision to Resident #2, explaining to him that he could appeal the discharge process. The ED had no answer for what had happened with Resident #3's transfer/discharge notice. .

Based on closed resident record reviews and interviews with staff, the facility failed to permit a resident admitted for long-term care (Resident #2) readmission to the facility following a Baker Act transfer. Resident #2 was one of two residents transferred under a Baker Act, out of a total of five residents reviewed for transfer/discharge. The findings include: An interview was conducted with the Assistant Executive Director on 5/2/19 at 10:35 am. When asked to provide information regarding any facility-initiated discharges, she reported there had been two residents who were Baker Acted, and neither returned to the facility. One was a resident who was non-compliant with smoking. He used oxygen, so he was deemed a danger to himself and others by smoking in the facility. A closed record review for Resident #2 found he was admitted to the facility on [DATE] and discharged 12 days later on 1/15/19. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/19, found a return was anticipated, and that it was an unplanned discharge to the community. Resident #2 was assessed with [REDACTED]. He required supervision with activities of daily living (ADL). [DIAGNOSES REDACTED]. There was no active discharge plan to return to the community. Per the admission MDS, dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. He used oxygen before he was a resident and while a resident in the facility. Resident #2 had a baseline plan of care, dated 1/3/19, for his oxygen use. He was also care planned to be free from injury, and to smoke safely. The intervention was to evaluate him for safe smoking, and for him to follow the facility's smoking policy. The discharge section of the form was not marked indicating whether Social Services would assist him with discharge planning or with adjustment to long-term care (LTC). Resident #2 had a physician's orders [REDACTED]. An Admission/Readmission Data Collection Tool, dated 1/3/18, assessed Resident #2 as a safe smoker. A Social Services Admission Evaluation, dated 1/3/19, revealed that Resident #2's plan for discharge was to remain in this facility for long-term care. A review of nursing progress notes revealed that on 1/14/19, on the 7:00 am - 3:00 pm shift, Resident #2 was smoking in his room. Smoking in the room was reported again in a subsequent progress note dated 1/14/19 on the 3:00 - 11:00 pm shift. This was noted as the second occurrence. A psychiatric progress note, dated 1/15/19, stated that a Baker Act was initiated for Resident #2. The Certificate of Professional Initiating Involuntary Examination dated 1/15/19, noted Resident #2 was a danger to himself and everyone in this building. It stated he was not appropriate for this setting, and was smoking in his room with oxygen. An AHCA Nursing Home Transfer and Discharge Notice was located in Resident #2's chart. There was no date indicating when the notice was given, and no effective date of the transfer/discharge. The location of the transfer was left blank. The reason included the resident's needs could not be met, and the health and safety of others was endangered. The form further explained the resident had been caught smoking while wearing oxygen inside the facility, but denied it. Patient hides his cigarettes, and is a danger to himself and others. The form was signed by the facility's Administrator and the psychiatric Advanced Registered Nurse Practitioner (ARNP) on 1/15/19. The form was not signed by Resident #2 to indicate that he had received the notice. The space indicating when the facility provided notice to the local long-term care ombudsman's council was left blank. Further review of the resident's record found no documentation of the facility's attempt to meet the resident's needs, or the services available at the receiving facility to meet the resident's needs. No documentation was available to confirm that the facility ascertained an accurate status of the resident's condition once hospitalized or determined what medications, treatments or services the hospital provided to improve the resident's condition. There was no documented evidence that the facility followed up with the hospital after the emergent transfer via Baker Act. An interview was conducted with the Director of Nursing (DON) on 5/2/19 at 2:30 pm. She stated Resident #2 had been in the facility before, and he always had behaviors. The day he was Baker Acted, he was seen smoking in his room with his oxygen on. She tried to confiscate his cigarettes in order to secure them, but he refused. The SSD spoke with him, but then that evening on the 3:00 pm - 11:00 pm shift, he was reported to be smoking again in his room. She thinks the next day was when he was Baker Acted, and stated she had no idea where he went. The psychiatric ARNP communicated that he was a danger to himself and/or others, and from what the DON understood, he was not coming back. The DON stated she did not want to put words into the Execuative Director's mouth, but she believed that was what happened. A telephone interview was conducted with the Executive Director (ED) on 5/2/19 at 2:40 pm regarding Resident #2. Resident #2 was interesting. This was his second admission. When he decided to try to smoke in the building with his oxygen on, we spoke with the nurse practitioner. We felt he would continue to be non-compliant with the smoking process, and not take into account the fact that he had compromised the safety of himself and all of the residents in the facility, therefore, he was not permitted to return. .