Every finding on record at Aviata at Lake Mary

Based on interview, and record review, the facility failed to report an alleged violation of neglect for 1 of 4 residents reviewed for care concerns, of a total sample of 4 residents, (#1).Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including other lack of coordination, Chronic Obstructive Pulmonary Disease, repeated falls, trouble swallowing, difficulty in walking, dementia in other diseases classified elsewhere, anxiety disorder, restlessness and agitation. Review of the Minimum Data Set (MDS) Medicare 5 Day assessment with assessment reference date of 6/24/26 revealed resident #1 had a Brief Interview for Mental Status score of 1/15 which indicated he was severely cognitively impaired. The document indicated he required supervision or touching assistance for eating and required partial to moderate assistance for transfers and ambulation. The assessment identified resident #1 as frequently incontinent of urine, always incontinent of bowel and required substantial to maximal assistance for toileting hygiene. In a phone interview on 7/28/26 at 8:42 AM, resident #1's wife stated her husband was admitted on the Friday before Father's Day (6/26/26). She recalled she informed the facility her husband had dementia and was assured by staff they could take care of him. Resident #1's wife reported that every time she visited her husband at the facility, he was wet. She explained one day he was up walking unassisted in the hallway, and his brief was so wet it was hanging down to his knees. She recalled another day she visited and observed he was in bed, but his breakfast tray was on a table out of his reach. Resident #1's wife explained he could feed himself slowly, but he had difficulty walking and could not get the tray himself. She stated a friend visited on the last day and observed a nurse standing over him administering medication. She explained the friend said the nurse got an attitude when the visitor asked what they were giving him. Resident #1's wife stated the friend called her and she went to the facility immediately, got her husband and went to the Unit Manager's (UM) office. She explained the UM was busy, so she waited about 20 minutes and then went to the front desk. She reported she spoke to someone and told them she was taking her husband home because he was being mistreated. Resident #1's wife recalled she was asked to come to the conference room where she met with seven or eight people including the Administrator on the phone. She stated she reported to those staff that were present the facility was not taking care of her husband; they had left him in the bed with wet briefs and did not feed him. She explained the staff present tried to convince her to let him stay and said they would address her concerns and do better. Resident #1's wife recalled she told them she was not going to leave him there to be mistreated and she was leaving the facility with him that day. She stated she then went to her husband's room, got him ready, signed a discharge paper from the facility and took him home. Review of the grievance log revealed a grievance filed on 6/24/26 on behalf of resident #1's wife. The grievance form read, Alleges that every time she came to visit, he was in bed and wet. Food next to him while he sleeps. In a joint interview with the Director of Nursing (DON), Social Services Manager and Unit Manager on 7/28/26 at 12:50 PM, the UM verified resident #1's wife approached her on 6/24/26 and had concerns about her husband's care. She recalled they gathered an Interdisciplinary Team (IDT) and held a care conference with her. The DON provided a copy of the Care Conference Record which read, [Resident #1's] spouse has care concerns [related to incontinent] of bladder, saturated five days in a row when visiting. States spouse needs assistance with feeding when visiting Monday [resident] sleeping food on other side of room. The record indicated the DON, Social Services Manager, Business Office Manager, Wound Care Nurse, Infection Control Nurse, Staff Development Coordinator and MDS Coordinator were present at the meeting. The DON stated they had a conversation with resident #1's wife and offered to address her concerns but she declined. The DON explained they felt she just wanted to take him home. In review of the note written in the Care Conference Record, neither the DON, UM nor Social Services Manager could explain why no one present at the meeting considered the concerns expressed by resident #1's wife as allegations of neglect. The DON acknowledged the concerns could be seen as allegations of neglect and verified that a report of neglect had not been filed. In a phone interview on 7/28/26 at 1:08 PM, the Administrator stated she had been made aware of the care conference with resident #1's wife. She explained the information was not given to her in a way that would indicate an allegation of neglect. The Administrator stated she could not speak directly to the allegations or provide any further information as she was not present in the meeting and had not spoken directly to resident #1's wife. The facility's Abuse, Neglect, Exploitation and Misappropriation policy and procedure dated 11/30/14 defined neglect as the failure of the center, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples included failure to provide adequate nutrition and fluids and intentional lack of attention to physical needs including toileting and bathing. The document clarified that continued omission in providing daily care could constitute neglect. The document indicated that any employee or contracted service provided who witnessed or had knowledge of an allegation of abuse, neglect, exploitation or mistreatment was obligated to report such information immediately to the Administrator but no later than 24 hours if the allegation did not involve abuse and did not result in bodily injury.

Based on observation and interview, the facility failed to maintain exterior waste areas in sanitary condition for 1 of 1 waste handling locations reviewed. Unsanitary waste conditions may attract pests and increase risk for food contamination.Findings:On 4/20/26 at 8:30 AM, during a tour of the exterior dumpster area with the Certified Dietary Manager (CDM), widespread litter and food related debris was strewn around the receptacle. Sugar packets, salt packets, powdered creamer packets, paper towels, used disposable gloves, graham crackers, and condiment packets were scattered across the concrete surfaces inside the enclosure and throughout the surrounding ground. Debris extended 15-20 feet beyond the enclosure and over the fence line into the grass and the gravel. Some of the trash on the ground was weathered, indicating the debris had accumulated over time rather than resulting from a single disposal event. The CDM confirmed the findings.A few minutes later, behind the building, thirteen cigarette butts were on the ground near the shut off valve and grease trap. Grease staining and residue were visible around the grease trap access point. There was no No Smoking signage posted in the area despite the presence of cigarette waste.On 4/20/26 at 8:35 AM, the (CDM) reported he had no knowledge of staff who smoked and stated the building operated as a nonsmoking facility. He explained dietary staff held the responsibility for keeping waste areas clean outside and were expected to remove debris during each shift.On 4/20/26 at 1:55 PM, the CDM acknowledged trash around the dumpster and cigarettes around the shut off valve weren't acceptable per facility expectations. He stated staff must remove debris daily, monitor for food waste accumulation, and maintain waste areas free from trash that could attract pests or create odors. CDM explained his expectation was staff should immediately clean the area.

Based on observation, and interview, the facility failed to ensure food was stored and handled in a sanitary manner for 2 of 2 kitchen areas reviewed (dry storage and tray service area). Improper storage of bulk food items and improper employee hygiene practices placed residents at risk for contamination and foodborne illness.Findings:On 4/20/26 at 8:00 AM, on a tour of the kitchen dry storage area with the Certified Dietary Manager (CDM), a clear, large cylindrical container was found stored directly inside the bulk flour container. The container was in direct contact with the flour. The container showed visible flour residue on the outside, indicating repeated placement inside the bulk flour.On 4/20/26 at 8:05 AM, the CDM confirmed containers were not supposed to be stored inside bulk flour and acknowledged this practice was not consistent with facility policy. He stated utensils and scoops were required to be stored outside of dry goods to prevent cross contamination.Later that day, on 4/20/26 at 1:55 PM, the CDM confirmed staff were expected to store scoops and utensils outside of bulk dry goods at all times and stated this expectation had been reviewed with staff previously.On 4/20/26 at approximately 8:49 AM, a Regional Kitchen Manager was standing at the tray cart with uncovered food items next to him. The Regional Manager had a full beard but did not utilize a cover over his facial hair in close proximity to exposed, ready to serve food. He engaged in close physical contact with kitchen staff, including hugging, while in the food service area. The Regional Kitchen Manager explained he had just arrived and confirmed he should have donned a beard guard before coming into the kitchen.Later that day, on 4/20/26 at 9:10 AM, the CDM acknowledged all staff, including regional and visiting staff, were required to follow facility hygiene and personal protective equipment (PPE) policies. He stated beard covers were required when handling or being near exposed food and acknowledged the Regional Manager should not have been near uncovered the food without proper facial covering.

Based on observation, interview, and record review, the facility failed to ensure a midline intravenous (IV) catheter had appropriate care including dressing changes and monitoring in accordance with professional standards of practice, for 2 of 2 residents reviewed for parenteral fluids/IVs, of a total sample of 48 residents, (#4, and #16).Findings:1. Review of resident #16's medical record revealed resident #16 was initially admitted on [DATE] with diagnoses of urinary tract infection.On 4/20/26 at 8:50 AM, resident #16 was sitting in chair in a breakfast area awaiting breakfast. The resident had a clear midline IV catheter dressing which contained a small piece of gauze with dried rusty brown colored substance which resembled dried blood underneath the dressing. The clear dressing was dated 4/18/26. His IV line was connected to a bag of fluids which was running, and the bag was covered for dignity. The resident stated he did not recall staff changing the dressing since the IV was placed a few days ago. A midline is a type of IV catheter usually in your upper arm designed for people who need IV therapy lasting one to four weeks or whose veins are difficult to access with a regular IV. A common complication of midline IV's are infection, (retrieved on 5/06/26 from www.scienceinsights.org). Review of resident #16's current physician orders revealed orders for normal saline flush orders dated 4/20/26, and IV antibiotic orders dated 4/19/26. There were no orders for midline IV catheter care, assessment, dressing changes or IV fluids. Review of the Treatment Administration Record for April 2026 revealed no documentation by staff of any dressing changes, assessments, or catheter care. On 4/20/26 at approximately 2:52 PM, Licensed Practical Nurse (LPN) A confirmed resident #16's midline IV dressing dated 4/18/26 with the dried rusty brown substance on the small gauze, underneath the clear dressing. The LPN confirmed the resident was receiving one liter of normal saline which was indicated it was administered on 4/20/26 at 6:00 AM as written in black marker on the bag. LPN A stated the fluids were started before her shift. A few minutes later at approximately 2:55 PM, LPN A and the Staff Development Coordinator were at the nurse's station and reviewed resident #16's medical record. They confirmed resident #16's midline dressing had not been changed since it was inserted. They stated there were no orders related to the care of the resident's midline IV, such as dressing changes or monitoring of the site. The LPN and Staff Development Coordinator acknowledged there was no documentation of monitoring the IV site nor care of the resident's IV catheter. The Staff Development Coordinator stated that IV dressings changes were done 24 hours after initial insertion to prevent possible infection, then the dressing should be changed at least every seven days or as needed. 2. Review of resident #4's medical record revealed she was initially admitted on [DATE] with diagnoses of Extended-Spectrum Beta-Lactamase (ESBL), Klebsiella pneumoniae wound infection to her bilateral heels. Review of resident #4's current physician orders on 4/20/26 at 12:25 PM, revealed an order to re-insert the midline IV dated 4/17/26. There were no other physician orders for the midline IV. Further review of resident #4's April 2026 TAR showed no documented care or assessment for the midline catheter for dressing changes, monitoring or flushes. On 4/20/26 at approximately 2:42 PM, LPN A confirmed the rusty brown colored substance on the gauze underneath resident #4's clear IV catheter dressing with a date of 4/17/26. She acknowledged midline IV dressings should be changed 24 hours after insertion and at least every seven days after that for infection control and patency of the line. At approximately 2:55 PM, LPN A and the Staff Development Coordinator reviewed resident #4's medical record and confirmed there were no physician orders for care of her midline IV such as flushes, dressing changes or monitoring the IV site for signs and symptoms of infection or leaking. They both confirmed resident #4's IV dressing had not been changed since it was inserted on 4/17/26, nor was there documentation of any care or monitoring in the record. On 4/21/26 at 3:55 PM, the Director of Nursing (DON), stated nurses should place orders for a newly placed IV to include monitoring the site for signs and symptoms of infection, changing the dressing after the first 24 hours of insertion, weekly and as needed dressing changes and flushes. Review of the policy, Guidelines for Preventing Intravenous Catheter - Related Infections revised August 2014 revealed, the insertion site should be observed every shift and with dressing changes. The policy detailed the initial IV dressing should be changed within 24 hours of placement then every five to seven days or as needed. The documentation section indicated objective information regarding appearance of insertion site, catheter, dressing, and any interventions done should be recorded in the resident's medical record.

Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to transmission-based precautions for 1 of 3 residents reviewed on isolation for infection control, of a total sample of 48 residents, (#4).Findings:Review of resident #4's medical record revealed she was initially admitted on [DATE] with diagnoses of Extended-Spectrum Beta-Lactamase (ESBL), Klebsiella pneumoniae wound infection to her bilateral heels.Review of resident #4's current physician orders revealed the resident was placed on contact isolation every shift for ESBL in the heel wounds on 4/20/26 at 8:41 AM.ESBL infections are resistant to common antibiotics and may require complex treatments, good hand hygiene and infection prevention practices can help reduce infection risk, (retrieved on 4/24/26 from www.cdc.gov).On 4/20/26 at 11:43 AM, resident #4 was in bed awake and alert. A sign on the door indicated the resident in bed A (resident #4) was on transmission-based precautions (TBP), this signage specified the type of precaution being contact, and that personal protective equipment (PPE) including gown and gloves must be used before entering the room for the A bed. A few minutes after 11:43 AM, the Social Service Assistant entered the room without donning a gown or gloves even though the sign on the door indicated the resident was on contact precautions. The Social Service Assistant went to the side of resident #4's bed, shook her hand while speaking to her then proceeded toward resident #4's roommate who was in a wheelchair near the window. The assistant patted the roommate, who was not on contact precautions, on her shoulder with her bare hand, then went to the bathroom, washed her hands and exited the room.On 4/20/26 a short time later at approximately 11:46 AM, the Director of Nursing (DON) was standing outside resident #4's room. The DON confirmed the Social Services Assistant entered the room without donning gown or gloves and then addressed the assistant once she exited the room. The Social Service Assistant explained she had not noticed the resident was on contact isolation and directed the assistant to the sign on the door.Review of the Categories of Transmission-Based Precautions policy revised on October 2018, revealed under contact precautions staff would wear gloves when entering room, gloves would be removed and hand hygiene performed before leaving room. The policy specified staff would wear a disposable gown upon entering the room, remove the gown before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown was removed.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Comprehensive Assessments were completed within the regulatory time frame for 5 of 8 residents reviewed for Resident Assessment, of a total sample of 40 residents, (#82, #88, #227, #228, and #233). Findings: 1. Resident #82 was admitted to the facility on [DATE]. Review of the resident's Annual MDS assessment with an Assessment Reference Date (ARD) of 4/13/24 revealed section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator and verified completion of the assessment on 5/01/24, 4 days late. 2. Resident #88 was admitted to the facility on [DATE]. Review of the resident's Significant Change MDS assessment with ARD of 4/10/24 revealed section Z0500 was signed by the RN Assessment Coordinator and verified completion of the assessment on 4/26/24, 2 days late. 3. Resident #227 was admitted to the facility on [DATE]. Review of the resident's Admission MDS assessment with ARD of 6/23/24 revealed section Z0500 was signed by the RN Assessment Coordinator and verified completion of the assessment on 7/09/24, 9 days late. 4. Resident #228 was admitted to the facility on [DATE]. Review of the resident's Admission MDS assessment with ARD of 6/30/24 revealed section Z0500 was signed by the RN Assessment Coordinator and verified completion of the assessment on 7/19/24, 12 days late. 5. Resident #233 was admitted to the facility on [DATE]. Review of the resident's Admission MDS assessment with ARD of 6/30/24 revealed it was incomplete and in progress. Section Z0500 was not signed by the RN Assessment Coordinator and verified as complete. On 7/24/24, the assessment was 7 days late. On 7/25/24 at 11:04 AM, the MDS Coordinator explained the facility's process was to review the MDS in progress list each morning with the Interdisciplinary Team (IDT) where she reminded the team of the due dates and incomplete sections. She checked residents #82, #88, #227, #228, and #233's medical record, and acknowledged their most recent MDS assessments were completed late. She said it was important to submit all MDS assessments to the Centers for Medicare and Medicaid Services (CMS) timely to accurately report residents' current status. On 7/25/24 at 11:07 AM, the Regional Director of Clinical Reimbursement said she provided support to the facility for MDS assessments completions. She explained, the facility was behind and experienced difficulties in getting some of the specialized sections completed on time. She stated the facility's process was to follow the CMS Resident Assessment Instrument (RAI) guidelines which outlined the timeframes required for completion and submission. Review of the facility's standards and guidelines titled, MDS N-1025 and dated 9/25/17 read, The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to the collection of date regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Quarterly Assessments were completed within the regulatory time frame for 2 of 8 residents reviewed for Resident Assessment, of a total sample of 40 residents, (#63, #111). Findings: 1. Resident #63 was admitted to the facility on [DATE]. Review of the resident's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 6/11/24 revealed section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator and verified completion of the assessment on 7/18/24, 23 days late. 2. Resident #111 was admitted to the facility on [DATE]. Review of the resident's Quarterly MDS assessment with ARD of 6/27/24 revealed section Z0500 was signed by the RN Assessment Coordinator and verified completion of the assessment on 7/18/24, 7 days late. On 7/25/24 at 11:04 AM, the MDS Coordinator explained the facility's process was to review the list each morning with the Interdisciplinary Team (IDT) where she reminded the team of MDS assessment due dates and incomplete sections. She checked the medical record and acknowledged resident #63 and #111's assessments were completed late. She said for approximately 3 months, since she started working at the facility, there were issues with some of the sections getting completed on time. She explained, the facility followed the the Resident Assessment Instrument (RAI) guidelines for time frames. On 7/25/24 at 3:10 PM, the Regional Director of Clinical Reimbursement checked the facility's MDS assessments in progress list, and conveyed there were multiple additional incomplete and late assessments. On 7/25/24 at 2:44 PM, the Director of Nursing (DON) explained the facility was aware of ongoing late MDS assessments and noted they did not currently have a Social Worker. The DON stated, moving forward, we have a plan in process. Review of the facility's job description titled, MDS Nurse-LPN (Licensed Practical Nurse) I read, . 5. Complete required documentation in an accurate and timely manner. Review of the facility's standards and guidelines titled, MDS N-1025 and dated 9/25/17 read, The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to the collection of date regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI.

Based on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center and ensure post-dialysis assessments were completed for 1 of 4 residents reviewed for dialysis of a total sample of 40 residents, (#56). Findings: Review of the medical record revealed resident #56 was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, and type 2 diabetes. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 6/01/24 revealed resident #56's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated intact cognition. The assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The assessment revealed resident #56 required dialysis. Review of the medical record showed resident #56 received dialysis treatments every Monday, Wednesday and Friday. Review of the Dialysis Communication Record showed 3 sections, the first and third were to be completed by the facility's nurses and the middle section was to be completed by the dialysis center. There were multiple Dialysis Communication forms missing from January to June 2024. Review of 8 forms provided for January showed 1 of 8 forms contained no documentation from the dialysis center and 4 of 8 forms had incomplete documentation in the facility sections. Review of communication forms for February 2024 showed 2 forms had no documentation from dialysis on either form and 1 of 2 forms were missing documentation from the facility. March 2024 forms noted 1 of 2 forms were missing dialysis documentation and both forms had incomplete documentation from the facility. There were 5 forms provided for April 2024 and 4 of 5 forms had no documentation from dialysis and all 5 forms were missing documentation from the facility. There were 8 forms for May 2024 and 6 of 8 forms had no documentation from the dialysis center and 5 of 8 forms were missing documentation from the facility. June 2024 showed 4 forms and 2 of 4 forms had no dialysis documentation and 2 of 4 forms were missing documentation from the facility. Of the 29 forms reviewed for a 5-month period, only 8 forms had all three areas completed. Review of the progress notes did not reveal any contact made with the dialysis center. On 07/25/24 at 11:06 AM, Licensed Practical Nurse A explained the facility sent a communication form with the resident to dialysis. She said the facility nurse completed the top portion of the form prior to the resident leaving the facility and the dialysis center completed the middle portion of the form. She said the facility nurse would complete the bottom portion of the form when the resident returned from dialysis. She stated if the dialysis staff did not complete the form, the facility nurse was to send the form back to the dialysis center for completion. On 7/25/24 at 11:48 AM, the 100 hall Unit Manager (UM) stated if the communication record was returned with incomplete information, the dialysis center should be called and the form should be sent back. The UM reviewed several of the communication records and acknowledged they were not complete. She stated she had emailed the dialysis center multiple times regarding the incomplete communication records but did not get a response to her emails. The UM explained when she called the dialysis center, she spoke to a nurse but the communication forms continued to come back with no documentation. She was not able to explain why so many of the communication records were missing documentation form the facility nurses and the dialysis center. She stated her expectation was for the nurses to complete the documentation when the resident returned from dialysis and for the nurse to inform the dialysis center when the communication records were not completed. The Policy and Procedure, Coordination of Hemodialysis Services dated 11/30/14 and revised on 7/02/19 read: The dialysis Communication form will be initiated by the facility for any resident going to an End Stage Renal Dialysis (ESRD) center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD center. The ESRD facility is to review the Dialysis Communication Form and either: a. Complete the communication form and return with the resident or b. Provide treatment information to the facility. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center or the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical Record.

Based on record review, and interview, the facility failed to identify and report a medication for hypotension (low blood pressure) was given when it should have been held 110 times over a 4-month period for 1 of 5 residents reviewed for unnecessary medications, (#38). Findings: Review of the medical record revealed resident #38 was admitted to the facility on [DATE] and then readmitted from acute care hospital on 6/4/23. The resident had diagnoses that included hypotension (low blood pressure), chronic hepatic failure, diabetes mellitus type 2, cirrhosis of the liver, chronic obstructive pulmonary disease, hypertension (high blood pressure) and portal hypertension. Review of resident #38's physician order to start on 4/2/24 directed nurses to administer Midodrine (medication to treat low blood pressure) 10 milligrams by mouth every 8 hours for hypotension, give for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmhg). The resident's care plan revised on 5/24/24 for hypotension with the goal that she would be free of signs and symptoms of hypotension and intervention included to give medications as ordered. Review of the Consultant Pharmacist Medication Regimen Reviews showed the pharmacist recommended to order specific parameters for Midodrine on 3/30/24, and the physician gave orders to hold for SBP less than 110 mmhg. Review of the medication administration records (MARs) showed the nurses failed to hold the medication 110 times from 4/3/24 to 7/24/23 and the failed to identify nurses were not following parameter orders for 4 months until brought to their attention at time of survey. On 7/24/24 at 2:29 PM, the assigned day Registered Nurse (RN) D said she had just taken resident #38's BP which was 118/73 mmhg and administered the 2 PM dose of Midodrine. The RN acknowledged that she made errors by giving medication when it should have been held per parameter orders 7 times in July, 7 times in June, 5 times in May and 6 times in April. RN D said she thought she made an error because usually the parameter to hold Midodrine is for SBP less than 130 mmhg. The RN then pulled the pill card on her medication cart that read, hold if BP less than 110. The RN verified that she knew that Midodrine was used to help raise BP and did not know why she made errors. On 7/24/24 at 2:45 PM, the Director of Nursing (DON) reviewed resident #38's MARs from April to July and validated that multiple nurses over 2 shifts did not hold Midodrine as ordered, and noted the pharmacist should have picked up on the errors as during their monthly review. The DON validated the pharmacist had not reported any discrepancies to date regarding the nurses administering Midodrine and not holding per physician ordered parameters. On 7/25/24 at 06:35 AM, a telephone interview was conducted with night Licensed Practical Nurse (LPN) C. Review of the MAR showed this nurse had given Midodrine when it should have been held 10 times in July, 7 times in June, 7 times in May and although she only worked 1 week in April she made 3 errors. The LPN was not aware Midodrine was used to raise BP. She noted, I should have looked it up. On 7/25/24 at 7:14 AM, a telephone interview was conducted with night LPN B who said she had only worked on the unit that resident #38 resides 2-3 times per month as she normally worked on other side of the facility. She was informed that she made errors regarding administering Midodrine to the resident when her SBP was over 110 mmhg three times in July, twice in June and one time in April. LPN B said she knew if the BP was low that Midodrine will help raise it and thought the parameter to hold medication was for SBP under 120 mmhg and did not realize the order was for 110 mmhg. On 7/25/24 at approximately 10 AM, an interview was conducted with day LPN A who was resident #38's usual day nurse. She said, she did not realize that on 7/5/24 at 10 PM, she gave Midodrine when the resident's BP was 124/84 and on 6/21/22 at 2 PM, when the BP was 119/55. She acknowledges not following physician parameter orders and said she would be more careful as she knew the medication was used to raise BP. On 7/25/24 at 10:35 AM, the Consultant pharmacist explained, Midodrine is typically given to raise blood pressure when needed. She explained she did monthly reviews of the residents MARs as well as random audits and did not identify the nursing staff were not giving Midodrine to resident #38 per parameter orders from April to July 2024. She agreed the nurses should look up medications they were not familiar with to find out the indication and possible side effects. The Consultant added, she needed to do some education with nursing staff as well as observe them do medication administration pass. She noted the potential reaction or adverse effect of not giving Midodrine as ordered was high blood pressure and increased risk of stroke. The facility policy for Administering Medications revised April 2019, read Medications are administered in a safe and timely manner, and as prescribed . Each nurses' station has a current Physician's Desk Reference [PDR] and or other medication reference .

Based on observation, and interview, the facility failed to ensure dishes were handled in a manner to prevent bacterial growth, specifically that cups, bowls, pellet bases, and lids were air dried between use. FINDINGS: On 7/22/24 at 2:32 PM, during tour of the kitchen, observations were made of plastic pellet bases wet nesting and a row above the dish machine counter with cups and bowls inverted on trays that would not allow to completely air dry. At this time, Dietary Aide I stated the bases were kept there to dry and were stacked on top of each other next to the tray line for service. When one of the base was removed from the other, the base was noted to be wet. Upon observing the wet-nested dishes, the Dietary Manager stated he needed liners between dishes and trays and needed to have a different method to store bases to prevent wet-nesting. He stated it was important to have air flow between dishes and trays and between the bases so bacteria would not grow.

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) therapy was administered as per physician orders for 2 of 2 residents reviewed for oxygen therapy of a total sample of 40 residents, (#327, #90 ). Findings: 1. Resident #327 was admitted to the facility on [DATE] with diagnoses to include heart failure, atrial fibrillation, cardiomyopathy, and shortness of breath. The Minimum Data Set (MDS) 5-day assessment with Assessment Reference Date (ARD) dated 7/25/24 revealed a Brief Interview for Mental Status, (BIMS) of 15 which indicated the resident was cognitively intact. The assessment noted the resident received oxygen. Review of the resident's clinical record noted physician orders dated 7/20/24 for continuous oxygen at 2 liters per minute. Observations on 7/22/24 at 9:52 AM and 12:53 PM revealed the oxygen concentrator was set at 4.5 liters per minute. On 7/22/24 at 1:15 PM, Licensed Practical Nurse (LPN) observed resident #327 oxygen concentrator and acknowledged it was set at 4.5 liters per minute. She stated the resident's oxygen should have been at 2 liters. She said she usually checked the oxygen rate when she was in the room but was running behind today and could not explain who set the oxygen at 4.5 liters. She acknowledged the resident could not have increased the rate because she could not reach the concentrator. On 7/22/24 at 1:22 PM, the Unit Manager (UM) confirmed that resident #327 should have been on 2 liters of oxygen. She said she expected nurses to check the liter flow when they were in the resident rooms. The UM stated the nurse should also verify the physician order in the clinical record to ensure it is the correct liter flow. On 7/25/24 at 2:50 PM, the Director of Nursing stated her expectation was that the nurse would know the resident was on oxygen and know the liter flow of oxygen the resident should receive. She stated she also expected the nurse to check the oxygen liter flow when in the room to ensure the oxygen was at the correct rate. 50401 2. On 7/22/24 at 9:40 AM, resident #90 was lying in bed with the head of bed slightly elevated. There was an oxygen concentrator machine in the resident's room with bag attached containing oxygen tubing dated 7/19/24. The resident did not have nasal canula on and the oxygen was not being used. On 7/23/24 at 10:45 AM, the oxygen concentrator remained in the resident's room. The oxygen was not being administered. Review of the Medication Review Report showed oxygen was ordered on 7/10/24 at 2-4 liters per minute via nasal cannula continuous every shift. On 7/23/24 at 12:47 PM, LPN A stated the oxygen order dated 7/9/24 was for 2-4 liters per minute continuously. She said the oxygen was started the other day when the resident did not look well and was leaning to one side. She added, the resident's oxygen saturation level measured 94 today. She explained that with the current oxygen saturation level, she would set the oxygen flow rate at 2 liters/minute. LPN A also noted the resident was known to pull the nasal cannula out. Upon entering the resident's room, the resident was observed leaning to one side. The oxygen concentrator was turned off and the nasal canula was not connected to the concentrator. LPN A did not explain why the resident's oxygen was not being administered or why the concentrator and the oxygen tubing was not attached. On 7/23/24, review of the physician orders noted the previous oxygen order was discontinued after it was brought to the facility's attention. A new physician order for oxygen noted oxygen at 2 liters as needed (PRN). On 7/24/24 at 11:29 AM, Registered Nurse (RN) D stated she was the RN for the resident on Monday 7/22/24. She acknowledged the resident did not receive oxygen as per physician orders on 7/22/24. She explained she was told the resident's oxygen sats were up, so oxygen was not needed. The electronic Medication Administration Record (MAR) indicated the same order for oxygen, 2-4 liters via nasal cannula continuously with start date of 7/10/24 and discontinued date of 7/23/24 at 2:34 PM. It also indicated oxygen was signed off as provided to this resident by nursing staff for all shifts from 7/10/24 through when it was discontinued on 7/23/24. The facility's Oxygen Therapy policy noted oxygen therapy must be reviewed by the nurse on a regular basis, the nurse will organize the oxygen therapy as ordered by the physician, and will document the time the oxygen started, the flow rate, and the resident's response to the oxygen therapy.

Based on observation, interview, and record review, the facility failed to provide wound care and services according to professional standards to prevent the development and worsening of pressure injuries for 2 of 4 residents reviewed for pressure injuries, of a total sample of 10 residents, (#6 & #10). The facility's failure to implement appropriate preventative interventions, follow physician orders, and execute policies and procedures for skin and wound care, repeatedly over all shifts, resulted in preventable pressure injuries, actual harm, for residents #6 and #10. Findings: 1. Review of the medical record revealed resident #10, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, dementia, osteoarthritis, and adult failure to thrive. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 3/27/23 revealed resident #10's Brief Interview for Mental Score was 3, which indicated she had severe cognitive impairment. The document showed the resident did not reject care or exhibit behavioral symptoms in the look back period. The MDS assessment showed the resident was at risk for developing pressure injuries and on admission, she had one unhealed stage III pressure injury and four deep tissue injuries. The resident had a pressure reducing mattress and received pressure injury care. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by pressure and can present as either intact skin or an open ulcer. According to the National Pressure Injury Advisory Panel, a stage I pressure injury is a localized area of redness on intact skin. Stage II pressure injuries show partial-thickness skin loss with an exposed pink or red wound bed. A Stage III pressure injury shows full-thickness skin loss with visible fat and/or granulation tissue. A stage IV pressure injury involves full-thickness loss of skin and tissue that leaves muscle or bone exposed. A deep tissue pressure injury (DTI) is a persistent non-blanchable deep red, maroon or purple discoloration or a blood-filled blister that is covered with intact or non-intact skin. An unstageable pressure injury involves full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed as it is hidden by dead tissue (retrieved on 4/10/23 from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the Wound Care physician's initial Wound Care Consult note dated 3/24/23 revealed resident #10 had six pressure injuries. The document listed a left hip stage 3/DTI that measured 4.5 centimeters (cm) x 3.5 cm x 0.1 cm; a left heel DTI that measured 5.0 cm x 5.0 cm; a left lateral foot DTI that measured 1.0 cm x 1.0 cm; a left distal plantar/lateral foot DTI that measured 2.5 cm x 2.5 cm; a right heel DTI that measured 4.0 cm x 4.0 cm; and a right foot distal plantar DTI that measured 2.0 cm x 2.0 cm. The wound care physician ordered treatments and preventative interventions that included offloading the resident's heels and placing a pillow between her knees. He noted resident #10 had paper thin skin on extremities specifically her left hip, bilateral feet, and bilateral heels. A Wound Follow-Up note dated 3/31/23 revealed the Wound Care physician assessed resident #10 and noted improvement of the left hip wound which measured 2.0 cm x 1.5 cm x 0.1 cm. Her left foot distal plantar/lateral wound was stable and measured 2.5 cm x 2.5 cm. He noted a new DTI on resident #10's right lateral ankle that measured 3.5 cm x 2.5 cm and wrote an order for daily application of skin protectant and a foam dressing to the area. Review of the Order Summary Report revealed physician orders dated 3/24/23 to apply skin protectant to resident #10's bilateral heels every shift, and cleanse the left hip wound with Normal Saline, pat dry, apply Calcium Alginate, and cover with a foam dressing once daily and as needed. An order dated 3/31/23 instructed nurses to cleanse the left foot distal plantar and lateral areas with normal saline, pat dry, apply skin protectant, and cover with a foam dressing daily and as needed. An additional order dated 3/31/23 revealed the Wound Care physician required skin protectant and a foam dressing applied daily to resident #10's new right lateral ankle pressure injury. Resident #10 had a care plan for potential for impaired skin integrity initiated on 3/29/23. The goal was the resident would maintain clean and intact skin. The care plan interventions included follow facility protocols for treatment of injury, and monitor and document the location, and size of skin injuries. The document included instructions for nurses and Certified Nursing Assistants (CNAs) to report any skin abnormalities such as signs and symptoms of infection to the physician, and identify and eliminate possible causative factors. Review of the medical record revealed resident #10 had a care plan for pressure injuries on her left hip, left heel, and left foot that was initiated on 4/05/23. The care plan did not identify or address area(s) of concern on the the resident's right foot. The interventions instructed nurses to administer treatments as ordered and monitor for effectiveness. assess/monitor/record wound healing. and follow facility policies for the prevention and treatment of skin issues. The care plan indicated nursing staff were expected to monitor, document, and report any new skin breakdown. On 4/06/23 at 11:54 AM, CNA B transferred resident #10 from her wheelchair to bed in preparation for wound care. CNA B placed resident #10 in a supine position but the resident immediately rolled herself onto her right side and curled into a semi-fetal position. Resident #10 was very thin, frail, and had pronounced bony prominences. CNA B explained the resident preferred to lie on her right side at all times and would not remain on her left side or back unless she was turned and repositioned by staff. A pair of sheepskin heel protector boots was noted on the right side of the resident's nightstand. On 4/06/23 at 11:56 AM, Licensed Practical Nurse (LPN) A stated she was ready to begin resident #10's wound care tasks. She gathered supplies from the treatment cart and entered the room. LPN A glanced at the resident's tray table which had a cup of water, small scattered debris, and visible smears. She went to the resident's bathroom, removed a brown paper towel from the dispenser, placed it on the tray table, and stacked the treatment supplies on top of paper towel. LPN A washed her hands in the bathroom and applied clean gloves from a box in the bathroom. She removed the soiled foam dressing from resident #10's left hip and placed it on the the tray table to the left of the clean dressing supplies. While wearing the same gloves, LPN A opened the packets of Calcium Alginate, gauze pads, and foam dressing, and arranged them near the front edge of the tray table. Next, she wiped her scissors with an alcohol wipe and wet the gauze pads with Normal Saline. LPN A removed her dirty gloves and dropped them in a trash can near the bathroom door. She retrieved clean gloves from the bathroom and applied them without performing hand hygiene. LPN A used the moistened gauze to clean resident #10's left hip wound, then folded the gauze in half and used it to wipe the same area again. She dropped the soiled gauze and empty paper packets on the growing pile of trash on the left side of the tray table. LPN A continued wound care with the same gloves as she cut the Calcium Alginate and placed it on the resident's left hip wound. Next, she removed the resident's left sock and noted a foam dressing on the left lateral and distal foot that was dated 3/31. LPN A validated the treatment order was to change the dressing daily but it had not been done for five days. She removed her gloves, dropped them in the trash can, washed her hands in the bathroom, and applied clean gloves. LPN A moistened a gauze pad and wiped the resident's left distal foot DTI, applied skin protectant around the intact blister and applied a foam dressing. The nurse used the same gloves to apply skin prep to the resident's left heel and left outer ankle. LPN A did not recognize the dark red area on the resident's left lateral foot as a pressure injury noted on the physician's orders so she did not apply skin protectant to the DTI as ordered. Next, LPN A wore the same gloves to remove the resident's right sock and apply skin protectant to the right heel and to an undocumented DTI on the right lateral foot. LPN A removed her gloves and applied clean gloves without performing hand hygiene. She then removed a foam dressing on the resident's right outer ankle and verified it was also dated 3/31. The tissue surrounding the dark purple area on the resident's ankle was red, and LPN A applied skin protectant around the edges of the reddened area rather than to the intact skin on the bony prominence, and covered it with a foam dressing. CNA B positioned resident #10 on her left side, fluffed the pillows under her head for comfort, and covered her with a sheet and blanket. CNA B did not offload the resident's heels or place a pillow between her knees as ordered by the Wound Care physician. CNA B was asked if she planned to apply the sheepskin boots that were on the night stand. She said, I have never seen them before today. It was not even there this morning when I got her dressed. The facility's policy and procedure for Dressings, Dry/Clean revised in September 2013 provided guidelines for the application of dry,clean dressings. The policy instructed nurses to verify physician orders, check the treatment record, and gather equipment and supplies. The document indicated the first step in the procedure was Clean bedside stand. Establish a clean field. Place the clean equipment on the clean field. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field.Wash and dry your hands thoroughly. Put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Nurses were expected to open clean dressing supplies using clean technique and then perform hand hygiene before applying clean gloves. The procedure specified a clean gauze should be used for each cleansing stroke from the least to most contaminated area. The document indicated gloves should be discarded once the dressing change to the wound was completed and the nurse would perform hand hygiene. Lastly, the nurse would clean the bedside stand and perform hand hygiene before leaving the room. On 4/06/23 at 12:31 PM, during review of the electronic CNA care plan or Kardex with CNA B, she confirmed there were no instructions for staff regarding placement of heel protector boots, offloading heels, placing a pillow between the knees, or turning and repositioning resident #10. On 4/06/23 at 12:40 PM, during an interview with the Director of Nursing (DON) and LPN A, the DON was informed of multiple concerns related to pressure ulcer prevention and treatment, and promotion of wound healing for resident #10. LPN A acknowledged she did not clean the tray table, a high-touch surface, prior to setting up treatment supplies, nor use an impermeable barrier to maintain a clean field. She confirmed she utilized the left side of the table to accumulate discarded and soiled treatment supplies and empty packets instead of the trash can. LPN A provided the DON with the dressings dated 3/31/23 that she removed from resident #10's bilateral feet. The DON validated the date on the dressings proved the treatment was not done daily as ordered. The DON was informed LPN A did not perform hand hygiene appropriately, and did not practice a clean technique during wound care to prevent contamination and promote wound healing. He was told LPN A omitted one wound treatment, applied skin protectant to a new DTI that was not documented in the medical record, and applied the skin protectant to the periwound areas instead of to the intact blood blisters as the orders were not transcribed accurately. The DON was not aware pressure ulcer prevention measures ordered by the Wound Care physician were not included in the plan of care or implemented by nursing staff. He confirmed he expected all nurses to follow accepted standards of practice and facility policies and procedures related to wound care, application of treatments, and transcribing and following physician orders Resident #10's TAR for April 2023 revealed the order for the right ankle dressing was on the document, and there were no nurses' initials to indicate the dressing was done on 4/01/23 and 4/05/23. The initials NP6 on 4/02/23, 9580 on 4/03/23, and jme on 4/04/23 indicated three nurses signed the TAR to verify they changed resident #10's right ankle dressing as ordered although the task was not done. On 4/07/23 at 8:56 AM, resident #10 was in bed on her right side. Her heels were not offloaded and there were no pillows between her knees and ankles to prevent skin breakdown. The sheepskin heel protectors remained on the resident's night stand in the same position as the day before. CNA B stated she assumed care of the resident this morning at 7:00 AM and the heel protectors were still on the night stand where she left them yesterday. CNA B acknowledged she did not put the devices on the resident this morning. On 4/07/23 at 9:06 AM, during weekly rounds with the Wound Nurse and the Wound Care physician they observed resident #10's sheepskin heel protector boots on the night stand. They were informed the devices were provided yesterday but staff had not yet placed them on the resident's feet. The Wound Care physician stated he ordered the heel protectors two weeks ago at the time of his initial assessment and he assumed staff had been applying them. He explained resident #10 had fragile skin, was at high risk for skin breakdown, and her heels were particularly susceptible to pressure injuries. He stated a pressure relieving mattress was a basic intervention, but this resident required an additional level of protection to include the boots, frequent turning and repositioning, offloading devices, and use of pillows for positioning. The Wound Care physician expressed frustration regarding the futility of evaluations, assessments, and selecting appropriate treatments if staff were not aware of them or compliant with implementation. He assessed resident #10's left hip wound and noted it had worsened since wound rounds last week. He explained the wound was now deeper and had connective tissue rather than the 100% epithelial tissue noted last week when it had been healing. When informed LPN A used a single gauze pad to wipe the wound more than once, and did not maintain proper infection control practices throughout the task, the Wound Care physician stated it was essential to follow clean technique to prevent contamination and worsening of wounds. He measured the resident's left foot distal plantar blood blister and stated it had increased in size. He was informed LPN A applied skin protectant to the periwound area. The Wound Care physician clarified his orders were to apply skin protectant to the surfaces of the blood blisters and DTIs as the purpose was to protect the skin so that it remained intact. He assessed resident #10's right lateral foot and said, This is a new area. It was not here last week and not reported to me. The Wound Nurse denied knowledge of the newly acquired DTI. She explained all assigned nurses and CNAs should have seen the area during care and notified her or the physician. The Wound Care physician assessed resident #10's right ankle and stated that DTI had worsened as it increased in size over the past week. He noted redness around the dark purple area. He was informed the dressing applied during last week's wound rounds had remained in place for five days and when changed yesterday, the nurse did not apply the skin protectant to the pressure injury. Review of the Wound Follow-Up note dated 4/07/23 revealed within the past seven days resident #10's left hip wound had declined and the left foot distal plantar/lateral wound had increased in size from 2.5 cm x 2.5 cm to 3.0 cm x 3.5 cm. The document indicated the resident's right lateral ankle wound that measured 3.5 cm x 2.5 cm on 3/31/23 had declined and now measured 4.0 cm x 3.0 cm. The wound note described a new DTI on the resident's right lateral foot that measured 1.0 cm x 1.0 cm. On 4/07/23 at 1:16 PM, Central Supply Staff E stated the facility usually had items such as air mattresses, heel protectors, and offloading cradle cushions in stock. She recalled the DON called her yesterday to request heel protectors for resident #10. Central Supply Staff E said, I dropped them on the bed yesterday morning. [Name of Wound Care physician] told me this morning that he ordered the heel protectors two weeks ago.Nobody told me anything about it or else I would have brought them before. I had them in stock. On 4/07/23 at 3:34 PM, the Wound Care physician reiterated nursing staff had to be diligent in their actions and follow orders to prevent skin breakdown and promote wound healing. He acknowledged staff failure to do thorough skin evaluations daily, follow treatment orders, and implement preventative approaches contributed to resident #10's two acquired pressure injuries since admission and the declining status of some wounds. He explained if resident #10's dressings were not changed for five days, the skin was more prone to break down underneath the dressing and nursing staff would not be able to observe the condition of her skin. On 4/07/23 at 3:54 PM, the Wound Nurse confirmed she expected floor nurses to follow professional standards of practice related to all skin concerns. She stated the failure of assigned nurses to change resident #10's dressings as ordered, and to do so for such a long time, was inhumane and neglectful. The Wound Nurse explained the dressings remained on the resident's feet for five days, and the skin protectant was not applied as ordered, possibly causing the new and worsening skin breakdown on her feet. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility from the hospital on 4/04/23. His diagnoses included osteomyelitis or bone infection, and amputation of the fourth toe on his left foot. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/04/23 revealed resident #6's primary diagnosis was left fourth toe pain. The form showed resident #6 had a red area on his tailbone, and a surgical incision on his left foot. The document did not list any other lesions, wounds, pressure ulcers or pressure injuries. Review of the Admission/Readmission Data Collection form dated 4/04/23 at 4:30 PM revealed a skin evaluation showed the resident had a fourth left toe amputation, redness to the coccyx or tailbone, and a rash above his left hip. The document indicated resident #6's skin was warm, dry, and otherwise intact. On 4/05/23 at approximately 1:30 PM, resident #6 was in bed with the privacy curtain partially closed. The resident's lower legs were visible from the hallway outside the room and a white dressing was noted around the left foot which rested on the mattress. Two visitors stood near the foot of the bed. On 4/05/23 at 1:35 PM, from the hallway, one visitor was observed lifting the resident's legs while the other visitor placed a pillow to offload resident #6's heels and separate his ankles. Resident #6's daughter stated her father was admitted to the facility on the previous afternoon. She explained on arrival this morning, she removed her father's post-surgical shoe to check his foot and noted a new skin issue, a reddened area on his left ankle. Physical Therapist G entered the room and the daughter pointed to a light red, nonblanchable area on her father's left inner ankle. Physical Therapist G informed the daughter it might not be a pressure injury. The daughter explained she was a nurse and recognized the nonblanchable redness on a bony prominence was a stage I pressure injury. Resident #6's daughter informed Physical Therapist G the red area was not there the day before. Physical Therapist G informed the resident's daughter she was there to do an evaluation for Physical Therapy and the skin issue would be a nursing concern. On 4/06/23 at 12:49 PM, Advanced Practice Registered Nurse (APRN) C stated she assessed resident #6 yesterday and observed redness to his left ankle. She said, I assumed there were orders in place. She explained the facility had a Wound Nurse and Wound Care physician who should also be notified of all skin and wound concerns to ensure they were addressed appropriately. On 4/06/23 at 1:39 PM, APRN C assessed resident #6's left ankle and confirmed the red area was now a darker red color than it was when she noted it yesterday. She confirmed no staff updated her on the change in appearance of the pressure injury. APRN C explained she would order a skin protectant treatment to prevent the area from becoming a stage II pressure injury. Review of the Order Summary Report revealed the order, Left ankle inner: apply skin prep every shift for wound prevention dated 4/06/23 at 2:14 PM. On 4/06/23 at 1:53 PM, CNA F checked the CNA care plan or Kardex for instructions related to care of resident #6's skin. She confirmed there were no resident care instructions on the Kardex on promotion of skin integrity and explained she received information via verbal report from other CNAs. She stated after the assigned nurse changed the resident's dressing this morning, she told her to keep his foot elevated with a pillow. On 4/06/23 at 2:13 PM, the DON stated every newly admitted residents had a complete skin assessment on admission. He explained staff members who cared for residents were required to report any changes in skin condition. He was informed resident #6's daughter reported a new reddened area on her father's ankle to Physical Therapist G. The DON confirmed Physical Therapist G should have informed the assigned nurse immediately. On 4/06/23 at 2:44 PM, Physical Therapist G said, I did not report the skin issue to the nurse. She was not there at the time. On 4/06/23 at 3:42 PM, the Assistant Director of Nursing (ADON) explained any areas of skin breakdown must be reported, evaluated, and treated per protocol to prevent worsening. She stated it was usually necessary to obtain a physician's order for offloading boots, skin protectant, air mattresses, and padded cradle cushions. However, the ADON validated offloading potential pressure areas, floating heels, and regularly turning and repositioning residents were nursing interventions that could be implemented without a physician's order. On 4/07/23 at 8:51 AM, resident #6 was supine in bed, with his heels on the mattress and his ankles touching. The resident had slid down to the foot of the bed, and the plantar surface of his foot from the ball to the heel was pressed onto the footboard. There was no pillow under the resident's lower legs or between his ankles. CNA F confirmed the resident's heels were not floated when she arrived at work and she had not placed a pillow as directed by the nurse yesterday. She explained members of nursing management rounded earlier that morning to check the dates on all dressings, but none of them attempted to reposition resident #6's feet or instructed her to do it. When asked where the extra pillows were, CNA F pointed to a pillow resting on the bed above the resident's head. On 4/07/23 at 11:55 AM and 3:46 PM, the Wound Care physician assessed resident #6 and confirmed the stage I pressure injury on the left inner ankle. He was informed APRN C was made aware there were no orders for skin protectant and she ordered the treatment two days after admission. He noted a dressing on the resident's sacrum and was told there was no physician order for a treatment to the area. The Wound Care physician removed the dressing and stated the area required skin protectant only. He explained it was important for staff to be able to inspect the skin on the resident's coccyx regularly. He said, If intact skin stayed covered, there was the possibility a wound would develop and be unnoticed. The Wound Care physician explained it was as important to prevent wounds as it was to treat wounds. A new offloading cradle cushion was noted on the resident's night stand. The facility's Clinical Guideline Skin & Wound effective 4/01/17 revealed the facility would .provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The document indicated nursing staff would complete skin observations and evaluations and report and document new skin impairment as indicated. The clinical guideline read, Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. The document revealed the facility would develop person-centered goals and interventions and make the information available on the nursing and CNA care plans. Review of the Facility assessment dated [DATE] revealed the facility could provide care and services for skin integrity issues including pressure injury prevention and care, skin care, and wound care. Competencies for all staff included infection transmission and prevention and hand hygiene, and CNAs are required to show competency in skin and wound care.

Based on interview and record review, the facility failed to identify and arrange the appropriate mode of transportation and provide adequate supervision to prevent accidents during transfer to an outside appointment for 1 of 4 residents reviewed for transportation concerns, of a total sample of 10 residents, (#2). The facility's failure to provide care and services to ensure safety during transport resulted in preventable fractures and hospitalization , actual harm, for resident #2. Findings: Review of the medical record revealed resident #2, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included mood disorder, anxiety disorder, obesity, type 2 diabetes, generalized muscle weakness, osteoarthritis, rheumatoid arthritis, osteoporosis, chronic pain, pressure injury on her sacrum, metabolic encephalopathy (disorder or disease that affects brain function), and functional quadriplegia (inability to move due to severe disability or frailty, without spinal cord injury). The Quarterly Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed resident #2 had a Brief Interview for Mental Status score of 11 out of 15 which indicated she had moderately impaired cognition. The document showed the resident did not reject care in the look back period. She required extensive assistance of one staff member for bed mobility and locomotion, and was totally dependent on two or more staff members for transfers between surfaces. The MDS assessment revealed the resident had unsteady balance during transitions and was only able to stabilize with staff assistance. The document indicated resident #2 used a wheelchair for mobility. Review of resident #2's medical record revealed she had a care plan for behaviors related to refusing medication, screaming, and yelling for help despite receiving requested and necessary care. The document read, Resident requested to get [out of bed] after [morning] care. Per request resident was assisted [out of bed] in [wheelchair] approximately after 5 mins of being in [wheelchair]. Resident stated if we didn't put her back in bed she would throw herself on the floor. The interventions instructed nursing staff to anticipate and meet the resident's needs [and] provide emotional support. Review of Progress Notes revealed a Skin/Wound Note dated [DATE] regarding the declining status of the pressure injury on resident #2's sacrum. The note indicated a Magnetic Resonance Imaging (MRI) exam was ordered to rule out osteomyelitis or a bone infection as the cause of the worsening wound. A Nursing Progress Note dated [DATE] revealed the resident left the facility for her MRI appointment at 1:17 PM. A Change in Condition note dated [DATE] at 2:15 PM read, While assisting with getting patient off the transport with staff assist. Patient was noted to be unresponsive with sternum rub. The document listed vital signs obtained the day before, [DATE] at 10:22 PM, but did not include data on resident #2's blood pressure, pulse, temperature, or oxygen saturation at the time of the change of condition. The section of the form titled Resident/Patient Evaluation indicated no changes observed related to mental status, functional status, behavior, respiratory status, cardiovascular status, and skin evaluation. The Change in Condition form revealed the resident had no pain and no neurological deficits such as abnormal speech or altered level of consciousness. The inaccurate document was signed by the Long Term Unit Manager (UM). A Nursing Progress Note dated [DATE] at 2:28 AM, written by Licensed Practical Nurse (LPN) H, revealed resident #2 had been admitted to the hospital with fractures of the shoulder and hip. On [DATE] at 3:26 PM, Receptionist I recalled on Friday [DATE], she worked at the facility's reception desk. She stated resident #2 had an outside appointment that day and a Certified Nursing Assistant (CNA) brought her to the lobby via wheelchair to wait for transportation personnel. Receptionist I stated the driver arrived soon afterwards, retrieved the resident, and pushed her wheelchair up a ramp and into the van. Receptionist I confirmed no facility staff accompanied resident #2 in the van. She recalled about an hour later, the driver returned and informed her he could not transport the resident because of the way she was positioned in the wheelchair. She said,He seemed nervous and scared. Receptionist I explained she immediately notified the Long Term and Short Term UMs and the Director of Nursing (DON) who came to the lobby area to assist the driver to take the resident out of the van. Receptionist I said, She was sweating really bad and they rubbed her sternum and could not arouse her and they called for oxygen.Someone called 911 and they transported her out. On [DATE] at 4:07 PM, in a telephone interview, Transportation Scheduler L confirmed she scheduled the transportation for resident #2 to get to the MRI appointment. She explained she sometimes traveled with residents in the company van used to transport the resident, but on that day she drove another resident to an appointment in the facility's van. Transportation Scheduler L stated the arrangement was she would drop off the other resident and drive to meet resident #2 at her appointment. She recalled she was on the way meet resident #2 when she received a call from the facility and was instructed to return to the facility. Transportation Scheduler L stated resident #2 was already gone to the hospital when she got back. On [DATE] at 4:31 PM, the Short Term UM recalled on [DATE] he walked through the facility's lobby and noted the driver of the van speaking to Receptionist I. He stated the driver explained he had to bring resident #2 back to the facility as she slipped a little from the chair and his supervisor instructed him to bring her back. The Short Term UM said, He told me, we tried to pull her up and we couldn't do it. The Short Term UM stated he went into the van and noted the resident was slumped over in the wheelchair and it was hot in the van. He stated he tried a sternal rub but the resident only grunted, and he noted she had a weak pulse. The Short Term UM stated resident #2's wheelchair was held in place by multiple straps and he had to wait until the driver released them. He recalled, once inside the facility's lobby nursing staff attempted to get vital signs but were unsuccessful. He stated the resident wore a thin, long-sleeved sweater, and when they removed it, they noted large skin tears on both arms The Short Term UM explained the facility's protocol was confused residents were to be accompanied to appointments either by staff or a family member. He stated the resident's daughter approved of the arrangement for Transportation Scheduler L to meet her mother at the MRI appointment. On [DATE] at 4:48 PM and [DATE] at 4:57 PM, the Long Term UM recalled on the day of the incident, two CNAs got resident #2 ready for her appointment and transferred from the bed to the wheelchair with a full-body mechanical lift. She said,I knew she did not like to be up in the wheelchair. She pretty much stayed in bed. She stated she last saw resident #2 seated in her wheelchair in the lobby, waiting for transportation personnel to arrive. The Long Term UM said, I can't recall on that day why she did not have an escort. She recalled she next saw resident #2 that afternoon at about 2:15 PM when she was notified the driver had returned with resident #2 and needed assistance to take her off the van. She stated she joined the Short Term UM in the van but resident #2 did not respond her greeting either. The Long Term UM stated resident #2 still had the mechanical lift sling under her body in the wheelchair. She said, But it had slipped down a little. It was not the same as it had been when I saw her earlier. She explained while other staff attempted to obtain the resident's vital signs, she called 911. The Long Term UM stated a few days later the facility discovered resident #2 suffered fractures of the right shoulder and left hip. She explained prior to the incident, resident #2 was alert and oriented to person and place, and although her speech was slow, she was able to make her needs known and interacted well with staff. The Long Term UM recalled resident #2 was readmitted to the facility about one week later. She said, She came back totally different. Not talking, and staring at you like she didn't know who we were. On [DATE] at 10:27 AM, the Assistant Director of Nursing (ADON) stated she was in the lobby on [DATE] when staff removed the resident's sweater. She stated the resident had multiple, actively bleeding skin tears on both forearms. The ADON described the wounds as very noticeable. On [DATE] at 4:20 PM, in a telephone interview with resident #2's daughter, she stated her mother was recently hospitalized and died on [DATE]. She recalled prior to the MRI appointment on [DATE], her mother had not tolerated being seated in a wheelchair for almost one year. The daughter stated she was a nurse, visited her mother in the facility at least once weekly, and was very aware of her mother's abilities and behaviors. She said, She could not sit up anymore. She had become very stiff, and she had not left her room for a long time. In the wheelchair, she would throw herself back. I even told her several times she had to stop doing that because she was either going to hurt herself or somebody else. It was the mistake of all mistakes to transport her in a wheelchair. That's where they dropped the ball. The daughter stated there was always a regular wheelchair folded up in the corner in her mother's room, but she did not use it. She said, I cannot understand why, all of a sudden, they would think she could go in a wheelchair. I don't know what happened on that van trip, but I do feel like she pushed herself back in the wheelchair and slid down. In either sliding down or someone pulling her up, I can see that's how the injuries possibly happened. She had no bruises, lacerations, bumps, or wounds on her head, body, or extremities to indicate she fell out of the chair. Resident #2's daughter stated after the incident in February, she felt her mother probably willed herself to die. On [DATE] at 5:28 PM, CNA J stated in the past, she was assigned to care for resident #2 sometimes and also assisted other CNAs with bathing the resident. She recalled staff used a full body mechanical lift to transfer her and she would not tolerate sitting in a wheelchair for 15 minutes. CNA J said, She would throw herself back, whine, and complain of pain in minutes.We offered to get her up every day and she refused. CNA J stated resident #2 would not sit in the shower chair, so staff used a shower bed for bathing her. On [DATE] at 5:34 PM, CNA K stated during her last year in the facility, resident #2 remained in her bed and hardly even allowed staff to turn and reposition her. She stated the resident did not use the wheelchair in her room. On [DATE] at 5:38 PM, Registered Nurse (RN) N stated she was full time staff and regularly assigned to care for resident #2. She said, I never saw the lady up in a wheelchair. She transferred over here from the other unit about six months ago and she's been in bed ever since she's been over here. There was a regular wheelchair folded in the room. Never seen her in it. On [DATE] at 5:42 PM, LPN M verified resident #2 always refused offers to get out of bed. She stated the wheelchair in the resident's room was never used. On [DATE] at 5:43 PM, CNA O stated she was very familiar with resident #2's care needs and recalled in the six to twelve months prior to the incident in February 2023, she had not gotten out of bed except for mechanical lift transfers to the shower bed. On [DATE] at 8:44 AM, CNA P recalled on one or two occasions staff got resident #2 up to the wheelchair. She said, When they tried, she would scream and scream. They had to get her back in bed quick. They did bed baths or used the shower bed. She would not stay in a chair for long. On [DATE] at 8:46 AM, CNA Q recalled resident #2 verbalized her wheelchair was uncomfortable. She said,She wanted to go right back to bed, right away. CNA Q explained resident #2 could not stand, required a mechanical lift for transfers, and used a shower bed. On [DATE] at 12:19 PM, in a telephone interview, Transportation Scheduler L explained she probably asked the resident's assigned nurse about the required mode of transportation for the MRI appointment. She stated to her knowledge, either the nurse or the UM decided whether a resident required a wheelchair or stretcher for transportation to outside appointments. Transportation Scheduler L denied knowing resident #2 threatened or attempted to slide down or throw herself out of the wheelchair. When asked how she planned to get resident #2 out of the wheelchair and onto the MRI examination table, Transportation Scheduler L stated she was going to transfer her. She was informed the resident could not stand and required two or more staff members with a full body mechanical lift to move between surfaces. Transportation Scheduler L paused and said, If the resident could not stand, the MRI facility would use a [mechanical] lift. On [DATE] at 12:41 PM, in a follow up telephone interview, the Office Manager of the MRI Imaging Center stated the clinic site for resident #2's appointment on [DATE] did not have a full body mechanical lift. When asked if the Imaging Center accepted patients via stretcher, she stated the location had wheelchairs for patients. On [DATE] at 5:50 PM, the DON and the Administrator were informed interviews with resident #2's daughter and direct care staff on the Long Term Unit revealed she refused to remain seated in a wheelchair. They were told the resident would scream, try to slide out of the wheelchair, or throw herself backwards if not returned to bed. The Administrator stated the nursing management team never mentioned the resident's behavioral issues or discomfort in a wheelchair as possible causative factors for her injuries. On [DATE] at 2:09 PM, in a telephone interview with a Supervisor at the transportation company used by resident #2, he explained on [DATE], the assigned driver picked up the resident and secured her wheelchair inside the van. He stated at some point during the trip, the driver noted resident #2 was sliding down in the wheelchair so he pulled into a parking lot. The Supervisor explained the driver called him about the issue, and since he was nearby, he met the driver in the parking lot to offer assistance. The Supervisor stated they did not unbuckle or remove resident #2 from her wheelchair, but they used the mechanical lift sling that was under her body to reposition her. He stated he instructed the driver to take the resident back to the facility. He said, She needed a different wheelchair. The wheelchair seemed to be very small for the resident. She was squeezed into the wheelchair and appeared uncomfortable. She was sliding little by little while transporting. [The driver] noticed because her knees were coming forward. The Supervisor stated the van was appropriately equipped to transport patients in wheelchairs and the equipment was inspected every six months. He explained resident #2's wheelchair was secured in place by four straps, and there were two or three additional straps to secure the resident in the wheelchair. He stated if requested by the facility, the transportation company was able to provide services for patients who required stretchers or bariatric wheelchairs. On [DATE] at 4:20 PM, the Regional Director of Clinical Services (RDCS) explained the DON was responsible for overseeing that assessments, evaluations, and care plans were revised when necessary to reflect residents' current safety and care needs. She confirmed she was never made aware there might have been an issue with the mode of transportation selected or that resident #2's known behaviors in the wheelchair could have suggested an escort was advisable. The RDCS confirmed the facility was responsible for determining the safest mobility devices, transfer methods, and appropriate types of transportation for all residents throughout their time in the facility. Review of the facility's policy and procedure for Plans of Care revised on [DATE], revealed the facility would review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident. The Facility assessment dated [DATE] revealed the facility could meet the needs of residents with common diseases including psychiatric and mood disorders, quadriplegia, osteoarthritis, and diabetes. The document indicated care and services offered to meet residents' needs included assistance with activities of daily living and mobility. The Facility Assessment indicated residents would receive person-centered care such as identification of hazards and risks and inclusion of the family in care planning.

Based on interview and record review, the facility failed to implement policies and procedures to prohibit Abuse and Neglect related to an incident that resulted in major injuries and transfer to a higher level of care for 1 of 2 residents reviewed for Abuse and Neglect, (#2), and failed to ensure frontline and management staff adhered to the policies and procedures to promote the safety and well-being of all residents in the facility. Findings: Review of the medical record revealed resident #2, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included mood disorder, anxiety disorder, obesity, type 2 diabetes, generalized muscle weakness, osteoarthritis, rheumatoid arthritis, osteoporosis, chronic pain, pressure injury on her sacrum, metabolic encephalopathy (disorder or disease that affects brain function), and functional quadriplegia (inability to move due to severe disability or frailty, without spinal cord injury). The Quarterly Minimum Data Set (MDS) assessment with assessment reference date of 1/26/23 revealed resident #2 had a Brief Interview for Mental Status score of 11 out of 15 which indicated she had moderately impaired cognition. She required extensive assistance of one staff member for bed mobility and locomotion, and was totally dependent on two or more staff members for transfers between surfaces. The MDS assessment revealed the resident had unsteady balance during transitions and was only able to stabilize with staff assistance. On 4/05/23 at 3:26 PM, Receptionist I recalled on Friday 2/24/23, she worked at the facility's reception desk. She stated resident #2 had an outside appointment that day and a Certified Nursing Assistant (CNA) brought her to the lobby via wheelchair to wait for transportation personnel. Receptionist I stated the driver arrived soon afterwards, retrieved the resident, and pushed her wheelchair up a ramp and into the van. Receptionist I confirmed no facility staff accompanied resident #2 in the van. She recalled about an hour later, the driver returned and informed her he could not transport the resident because of the way she was positioned in the wheelchair. Receptionist I explained she immediately notified the Long Term and Short Term Unit Managers (UMs) and the Director of Nursing (DON) who came to the lobby area to assist the driver to take the resident out of the van. Receptionist I said, She was sweating really bad and they rubbed her sternum and could not arouse her and they called for oxygen.Someone called 911 and they transported her out. Review of the facility's policy and procedure Abuse, Neglect, Exploitation & Misappropriation revised on 11/16/22, listed the seven essential components for prohibition of Abuse and Neglect: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting. The policy indicated all employees would be educated on the topics of Resident Rights and Abuse Reporting which included immediately reporting injuries of unknown source no later than two hours if Abuse was involved or if serious bodily harm resulted. Otherwise, staff were required to report injuries of unknown origin within 24 hours. The document revealed the information should be reported .to the Administrator and to other officials in accordance with State law. In the absence of the [Administrator], the [DON] is the designated abuse coordinator. The policy indicated all reported events including skin tears would be investigated by the DON or his/her designee and findings that potentially constituted Abuse or Neglect would be forwarded to the Administrator. The procedure involved documentation of a thorough nursing evaluation and notification of the physician, and an incident report shall be filed by the individual in charge.This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. The facility would obtain statements and prepare a detailed report of investigative findings. The document revealed the Administrator was responsible for submission of timely and appropriate reports according to Federal and State regulations.Facility staff should be aware of, and comply with, individual requirements and responsibilities for reporting as may be required by law. The policy noted preliminary reports could be biased, therefore a thorough investigation was required to ascertain the facts. The investigative findings would be submitted to the State Survey Agency within five working days, and if Abuse and/or Neglect was substantiated, appropriate corrective actions would be implemented. On 4/06/23 at 10:27 AM, the Assistant Director of Nursing (ADON) stated she was present when staff attempted to arouse resident #2 and observed them removing her sweater. She recalled the resident had multiple, actively bleeding skin tears on both forearms. The ADON described the wounds as very noticeable. A Change in Condition note dated 2/24/23 at 2:15 PM read, While assisting with getting patient off the transport with staff assist. Patient was noted to be unresponsive with sternum rub. The document listed vital signs obtained the day before, 2/23/22 at 10:22 PM, but did not include data on resident #2's blood pressure, pulse, temperature, or oxygen saturation at the time of the change in condition. The section of the form titled Resident/Patient Evaluation indicated no changes observed related to mental status, functional status, behavior, respiratory status, cardiovascular status, and skin evaluation. The Change in Condition form revealed the resident had no pain and no neurological deficits such as abnormal speech or altered level of consciousness. The document was signed by the Long Term UM. A Nursing Progress Note dated 2/26/23 at 2:28 AM, written by Licensed Practical Nurse (LPN) H, revealed resident #2 had been admitted to the hospital with a severe infection and fractures of the shoulder and hip. A Nursing Progress Note dated 2/27/23 at 10:16 AM, written by the Short Term UM read, Physician notified about patient condition and reported fractures that were reported. Review of the facility's incident log from 2/01/23 to 4/05/23 revealed no entries regarding resident #2's significant change in level of consciousness and skin impairments when she was returned to the facility by transportation personnel on 2/24/23. The document did not reflect the discovery of fractures on 2/26/23 in any category on the log. The facility's log for Federal Reportable incidents for February 2023 showed an entry dated 2/27/23 for resident #2 regarding an injury of unknown origin. There was no reportable incident listed on the log for 2/24/23. Review of the facility's policy and procedure for Accident and Incident Investigation effective 11/30/14 indicated the facility would investigate certain Accidents and Incidents, including injuries of unknown origin.to determine root cause and provide for opportunity to decrease future occurrences of the event. The document indicated injuries of unknown origin included skin tears and fractures which had no known cause. The procedure revealed any happening that was inconsistent with routine operations of the facility or routine care of a resident required completion an incident report. The document revealed the Administrator and DON would immediately be notified of injuries of unknown origin. The procedure showed the Administrator, DON, or a designee would initiate a written investigation of the cause of the injury to include interviews with and statements from with all staff involved and family. The policy read, All injuries of unknown origin or allegations of suspected abuse must be reported to the appropriate agencies per state specific protocols. On 4/05/23 at 1:43 PM, the Administrator described resident #2's injuries recorded on the Federal Reportable log as a very unfortunate incident. He stated she suffered five skin tears and two fractures. He explained resident #2 was transferred to the hospital on 2/24/23, but the facility did not identify the incident as a reportable incident at that time. The Administrator stated it was not until 2/27/23 that staff found a nurse's note dated 2/26/23 regarding the resident's significant injuries, and they filed the required Federal Reports as required on days one and five of the investigation. He acknowledged the facility did not file a Federal Report related to the resident's skin tears identified on 2/24/23. The Administrator stated the transportation company would not provide a statement. so after the investigation, the facility did not substantiate the resident's injury of unknown origin as Abuse or Neglect. He said, We do not know what happened. On 4/06/23 at 10:15 AM, the DON stated on Friday 2/24/23, staff called him to the lobby and he observed resident #2 in a lethargic state. He recalled both facility UMs were attending to the resident. The DON said, I said get 911.I followed up with the Unit Managers in stand-down meeting after 3:00 PM. The DON stated he instructed the Long Term UM to get a full report from the transportation company regarding the events that occurred while the resident was in their van. The DON stated he left the facility after 5:00 PM that evening and neither made nor received any telephone calls over the weekend regarding resident #2's status, nor followed up on any investigative documentation and findings. He stated he discovered LPN H's progress note regarding the resident's fractures during review of the 24-hour report in the daily clinical / management meeting on Monday 2/27/23. On 4/06/23 at 9:46 AM, in a telephone interview, LPN H acknowledged she received information on resident #2's fractures on 2/26/23. She said, I did not bother to go further because I figured the patient was in the hospital getting care. LPN H confirmed she received mandatory annual education on Abuse and Neglect prohibition, but did not feel it was necessary to report it to the physician, charge nurse, or on-call supervisor. LPN H stated she expected administration to follow up, and did not recall being interviewed by any member of management during resident #2's incident investigation. On 4/06/23 at 10:32 AM, the DON verified resident #2's unresponsive status and skin tears on return to the facility were not noted on the incident and Federal Reportable logs on 2/24/23, the day they happened. He explained when incidents occurred off the facility's premises, staff would complete either a progress note or a Change in Condition form. The DON did not respond when asked if the facility would deem possible signs physical Abuse or Neglect of a resident unworthy of investigation based on where the incident occurred. He acknowledged the facility was ultimately responsible for residents' welfare. He stated not all changes in condition rose to the level of reportable incidents, but he could not explain how the facility identified potential allegations of Abuse and Neglect that needed to be investigated and reported. The DON stated he was unsure which types of occurrences were transcribed to the incident log and offered to find out. On 4/06/23 at 10:43 AM, the DON returned and stated he just spoke to the Regional Director of Clinical Services (RDCS) who clarified that any change in a resident's condition which resulted in an injury should be documented on a Risk Management report. He validated all nurses and nurse managers had access and authorization to create Risk Management reports. The DON explained the assigned nurse and the Long Term UM were not sure whether to document the incident on a Risk Management report in addition to completing a Change in Condition form. The DON validated resident #2's skin tears were injuries and should have been recorded and investigated per protocol. On 4/06/23 at approximately 10:46 AM, the Administrator said,Now that we have reviewed the issue we agree we should have done the reporting. We did not identify this as an issue until this discussion today, and it was not addressed. He stated he was not at work on Friday 2/24/23, and was not made aware of resident 2's incident in the van, her skin tears, or her fractures until it was discussed on Monday morning. On 4/06/23 at approximately 10:48 AM, the ADON stated after a transfer to the hospital, facility staff should call to get information. She acknowledged resident #2's condition on return to the facility and her skin tears rose to the level of a significant incident. The ADON stated she was not sure why an incident report was never completed. On 4/06/23 at 11:02 AM, the Long Term UM stated Risk Management reports should been initiated for resident #2's injuries. She acknowledged the resident's condition on return to the facility on [DATE] included a significant change in mental status and multiple skin tears, followed by notification on 2/26/23 of two fractures. The Long Term UM validated the incident and findings suggested the potential for Abuse and/or Neglect. On 4/06/23 at 11:34 AM, the DON stated on Friday 2/24/23, the Administrator was not in the facility and he was the acting or default Risk Manager. The DON acknowledged he was therefore responsible for implementing the facility's Abuse and Neglect prohibition policy by identifying possible Abuse and Neglect, starting the investigation, and filing Federal reports as necessary. The DON said, Based on the report of the driver, and he said that his supervisor had to help pulling her up; I think I decided it did not need to be reported then. The DON explained he had been employed at the facility for almost one year, since May 2022, but only got access to the Federal reporting system within the last month. The DON acknowledged he did not have access to the Federal reporting system at the time of resident #2's incident. He verified he did not reach out to the corporate office for assistance with determining whether this was a reportable event. On 4/06/23 at 4:05 PM, the Administrator explained he was the facility's Risk Manager, and the DON fulfilled those duties when he was not in the building. The Administrator stated if the DON was unsure about Risk Management issues, the RDCS was always available to provide guidance on investigative processes and reporting. On 4/06/23 at 5:50 PM, the DON and the Administrator were informed interviews with resident #2's daughter and direct care staff on the Long Term Unit revealed the resident refused to remain seated in a wheelchair. They were told the resident would scream, try to slide out of the wheelchair, or throw herself backwards if not returned to bed. The Administrator stated the nursing management team never mentioned the resident's behavioral issues or discomfort in a wheelchair as possible causative factors for her injuries. The DON explained once the management team learned of resident #2's fractures, the facility conducted an investigation, but did not identify the mode of transport used by resident #2 as an issue. However, he stated the morning meeting review of residents who were scheduled for outside appointments now included verification of whether they required a wheelchair, stretcher, or no device. When asked why he would focus on the mode of transportation if it was not identified as a problem, the DON offered an incoherent, garbled response. The DON then quickly contradicted his previous statement and stated his investigation showed a root cause of a breakdown in communication of the nursing team not identifying the correct mode of transportation. He stated UMs spoke with staff and discovered concerns related to transporting resident #2 in a wheelchair instead of on a stretcher. The Administrator was asked to clarify the facility's investigative findings, root cause analysis, and the decision to not substantiate and report Neglect. The Administrator wore a surprised facial expression and again denied knowledge of possible negligent practice related to an inappropriate mode of transportation for the resident. He said, It was never mentioned in my presence. This is the first time I am hearing about it.It was not my understanding until today, just now, that there was an issue with using a wheelchair. The Administrator confirmed he would expect the DON and other members of nursing management to provide him with all investigative findings as he was the Risk Manager and ultimately responsible for investigating and reporting Abuse and Neglect allegations. The Administrator explained he would have to re-open the investigation due to the new information, and revise and re-submit the Federal report. He confirmed the facility's Quality Assurance and Performance Improvement committee had not yet addressed the the newly identified root cause. On 4/07/23 at 12:29 PM, in a telephone interview with resident #2's daughter, she explained when she arrived at the hospital on Saturday 2/25/23 to see her mother, she found out about the hip and shoulder fractures. The daughter recalled when she spoke to the DON she got the impression the facility was going after the transportation company as the cause of her mother's injuries. Resident #2's daughter said, I told the DON I was not looking to close anyone down. I didn't want to get anyone in trouble.I mentioned to the DON that I feel the mistake was made and I used the exact words that 'the ball got dropped' when they put her in a wheelchair. On 4/07/23 at 4:20 PM, the RDCS confirmed neither the DON, ADON, nor UMs reached out to her regarding resident #2 on Friday 2/24/23, or at any time over the weekend. She stated her expectation was that the DON would have initiated an investigation and followed up with the hospital to obtain additional information. The RDCS said, I was very upset that the DON did not call about this incident. If so, I would have told him it was a reportable [incident] and instructed him to immediately start a thorough investigation. She stated the DON was knowledgeable of how to access the Federal Reporting system as she provided instruction on the task. She stated she was never made aware he had problems accessing the reporting systems. The RDCS stated the concerns regarding resident #2's use of a wheelchair instead of a stretcher should have been discovered during the investigation. Review of the Facility assessment dated [DATE] revealed the facility would provide person-centered care to include identification of hazards and risks for residents, involve the resident and family in care planning, and prevent Abuse and Neglect. The document read, Every staff member has knowledge competency in: abuse, neglect, exploitation and misappropriation; resident rights; identification of condition change; and resident preferences.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement policies and procedures to prohibit Abuse and Neglect; and nursing administration failed to ensure necessary oversight, care and services to maintain the highest practicable well-being for all residents at risk for skin breakdown. Findings: 1. On 4/05/23 at 1:43 PM, the Administrator described a very unfortunate incident that occurred on 2/24/23, in which a resident who used a transportation company to attend an outside appointment returned to the facility with a significant decrease in level of consciousness and five skin tears. He explained the resident was assessed by nursing staff and transferred to the hospital by Emergency Medical Services. He stated he was not in the facility on the day of the incident, and on return to work on 2/27/23, he discovered on 2/26/23, the hospital informed the facility the resident also had two fractures. The Administrator said, We do not know what happened. On 4/06/23 at 10:15 AM, the Director of Nursing (DON) stated on Friday 2/24/23, he observed nursing staff including the Long Term and Short Term Unit Managers (UMs) in the lobby, attending to a lethargic resident with skin tears on both arms. The DON said, I said get 911.I did not stay on the scene. I had to attend to other things.I followed up with the Unit Managers in stand-down meeting after 3:00 PM. The DON stated he instructed the Long Term UM to get a full report from the transportation company regarding the events that occurred while the resident was in their van. The DON stated he left the facility after 5:00 PM that evening and neither made nor received any telephone calls over the weekend regarding the resident or followed up on any investigative documentation and findings. He stated he discovered a progress note regarding the resident's fractures during review of the 24-hour and shift reports in the daily clinical / management meeting on Monday 2/27/23. On 4/06/23 at 10:27 AM, the Assistant Director of Nursing (ADON) acknowledged she joined the Long Term and Short Term UMs in the lobby to assess the resident and treat the bleeding skin tears on both forearms. On 4/06/23 at 11:02 AM, the Long Term UM acknowledged the resident lived on her unit, but she did not document a Risk Management report although she observed the resident's skin tears, nor follow up on the resident's status in the hospital. The Long Term UM explained she was off that weekend but expected either the assigned nurse or the on-call supervisor to inquire about the resident's status and obtain any pertinent information. She explained she had no access to the electronic medical record (EMR) from home, and could not check shift reports. The Long Term UM stated the Administrator and DON might have remote access to shift reports, but none of the on-call managers had that privilege. On 4/06/23 at 5:50 PM, the DON confirmed he obtained information from nursing management staff during the incident investigation that he had not shared with the Administrator. The Administrator stated he would expect the DON and other members of nursing management to provide him with all investigative findings. The DON validated no member of nursing management followed up over the weekend to ensure nurses obtained the resident's status in the hospital. He acknowledged he and the ADON had remote access to all residents' EMRs and the 24-hour and shift reports. When asked why he did not check on the resident's condition or review the EMR for additional information for his investigation, the DON said, I did not take my laptop home. I called to check on other things but that was not discussed. He verified UMs and on-call managers did not have remote access to the EMR and reports, and did not review them between Friday and Monday. The DON explained there was a clinical manager on call every weekend, but there was no requirement for the person to come into the facility to review the 24-hour and shift reports. 2. On 4/07/23 at 9:06 AM and 3:46 PM, the Wound Care physician expressed frustration regarding the futility of wound evaluations, assessments, and selection of appropriate treatments if nursing staff were not aware of them or compliant with implementation. He explained if the facility had a designated Wound Nurse, resident outcomes related to pressure injury prevention and wound treatment would be improved. The Wound Care physician acknowledged the facility's Wound Nurse rounded with him once weekly, but she did not regularly monitor all residents with wounds. He stated it would be ideal if the Wound Nurse were able to assess residents with complex wounds daily and evaluate all new residents on admission to identify their needs. On 4/07/23 at 3:54 PM, the Wound Nurse stated she was supposed to be the facility's designated nurse specialist for all residents' skin concerns. She explained although she was hired to be the facility's Wound Nurse, her assigned duties also included those of a floor nurse, Social Services staff, and she also assisted nurse managers when necessary. She stated she usually only performed the duties of a Wound Nurse on Fridays when she rounded with the Wound Care physician and applied the treatments he ordered. She said, That's the only day I see the wounds. The Wound Nurse explained floor nurses did wound treatments and skin evaluations, but they were overwhelmed by their workload due to staffing ratio regulations. She was informed the regulations provided maximum staff to resident ratios, not minimum ratios, and the expectation was the facility's administration would assign as many staff as needed to provide optimal care for residents. She was informed of concerns identified related to wound care and treatments not done as ordered, absence of preventative measures, and professional standards for wound care not followed. The Wound Nurse validated nursing administration was responsible for ensuring nurses demonstrated competency in all aspects of wound prevention and care. On 4/07/23 at 4:20 PM, the Regional Director of Clinical Services (RDCS) stated she participated in the DON's orientation when he was hired. She confirmed he was made aware of his responsibilities including Risk Management duties. She stated he should have followed up with the hospital himself or verified it had been done by other staff. The RDCS said, If he does not have his laptop at home, he needs to come into the building. She explained the on-call weekend managers were expected to keep in touch with facility staff at a minimum of once every shift since they no longer had remote access to the 24-hour and shift reports. The RDCS stated she was not aware of any concerns related to oversight of the nursing department, specifically regarding wound care, incident investigations, and monitoring of occurrences and resident care needs on the weekends. Review of the Facility assessment dated on 1/16/23 revealed the facility was a 120-bed skilled nursing facility that specialized in Short Term Rehabilitation, but also provided Long Term Care services. The document indicated the facility could meet the needs of residents with common diseases and special conditions including psychiatric and mood disorders, diseases of the musculoskeletal system, and skin ulcers. The document indicated residents would receive care and services as determined by their needs and plans of care to include assistance with activities of daily living care, transfers, pressure injury prevention and care, wound care, and mental health and behavioral issues. The Facility Assessment noted the necessary resources to provide competent care for residents included adequate Administrative and Nursing staff. The document read, Every staff member has knowledge competency in: abuse, neglect, exploitation and misappropriation; resident rights; identification of condition change; and resident preferences. The document indicated competencies were based on current standards of practice, and job descriptions reflected staff roles and responsibilities. Review of the undated job description for the Administrator revealed he/she would .direct the day-to-day functions of the facility.to ensure that the highest degree of quality care can be provided to our residents at all times. The undated job description for the Director of Nursing read, The primary purpose of your job description is to plan, organize, develop and direct the overall operation of our Nursing Services Department.to ensure the highest degree of quality care is maintained at all times. The document read, In the absence of the [Administrator], you are charged with carrying out the resident care policies established by this facility. The job description revealed the DON's duties and responsibilities included demonstrating the highest degree of honesty and integrity, maintain and guide implementation of facility policies and procedures, and direct the Nursing team.

Based on observation, interview, and record review, the facility failed to notify the physician, residents, and/or their representatives of changes in condition related to skin impairments for 2 of 4 residents reviewed for pressure ulcers, (#6 & #10), and fractures for 1 of 1 resident reviewed for accidents, (#2), of a total sample of 10 residents. Findings: 1. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility from the hospital on 4/04/23. His diagnoses included osteomyelitis or bone infection, and amputation of the fourth toe on his left foot. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/04/23 revealed resident #6's primary diagnosis was left fourth toe pain. The form showed resident #6 had a red area on his tailbone, and a surgical incision on his left foot. The document did not list any other lesions, wounds, or pressure injuries. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by pressure and can present as either intact skin or an open ulcer. According to the National Pressure Injury Advisory Panel, a stage I pressure injury is a localized area of nonblanchable redness on intact skin (retrieved on 4/10/23 from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the Admission/Readmission Data Collection form dated 4/04/23 at 4:30 PM revealed a skin evaluation showed the resident had a fourth left toe amputation, redness to the coccyx or tailbone, and a rash above his left hip. The document indicated resident #6's skin was warm, dry, and otherwise intact. On 4/05/23 at 1:35 PM, resident #6's daughter stated her father was admitted to the facility on the previous afternoon, and this morning she observed a new skin issue. Physical Therapist G entered the room and the daughter pointed to a light red, nonblanchable area on her father's left inner ankle. Resident #6's daughter informed Physical Therapist G the red area was not there the day before. She explained on arrival this morning, she removed her father's post-surgical shoe to check his foot and noted the redness. Physical Therapist G informed the resident's daughter she was there to do an evaluation for Physical Therapy and the skin issue would be a nursing concern. Review of a Progress Note dated 4/05/23 indicated on the day after admission, Advanced Practice Registered Nurse (APRN) C noted resident #6 had slight redness on left ankle inner. The document read, No issue voiced per nursing. On 4/06/23 at 12:49 PM, APRN C stated she assessed resident #6 yesterday and observed redness to his left ankle. She explained nursing staff did not inform her the area developed after admission. APRN C said, I assumed there were orders in place. She explained the facility had a Wound Nurse and Wound Care physician who should also be notified of all skin and wound concerns to ensure they were addressed appropriately. On 4/06/23 at 1:39 PM, APRN C assessed resident #6's left ankle and confirmed the red area was now a darker red color than it was when she noted it yesterday. She confirmed no staff updated her on this change in appearance of the pressure injury. APRN C validated this change in condition required physician notification as the resident needed a physician order for a skin protectant treatment to prevent the area from becoming a stage II pressure injury. On 4/06/23 at 2:13 PM, the Director of Nursing (DON) stated every newly admitted resident had a complete skin assessment on admission. He explained staff members who cared for residents were required to report any changes in skin condition. He was informed resident #6's daughter reported a new reddened area on her father's ankle to Physical Therapist G. The DON confirmed Physical Therapist G should have informed the assigned nurse immediately. On 4/06/23 at 2:44 PM, Physical Therapist G recalled resident #6's daughter spoke to her yesterday about a pressure area on the resident's left ankle. She verified she observed the reddened area. Physical Therapist G said, I did not report the skin issue to the nurse. She was not there at the time, and the Unit Manager had already gone in there to talk to them about other things. Review of resident #6's Physical Therapy Evaluation dated 4/05/23 revealed Physical Therapist G noted redness to his ankle. There was no documentation to indicate she notified the nurse and/or the physician of the change in the resident's skin condition. On 4/07/23 at 3:39 PM, the Wound Care physician stated he was not informed of the reddened area on resident #6's ankle when he arrived at the facility this morning to conduct wound rounds. He stated he expected nursing staff to contact him and/or the attending physician to report any newly identified skin concerns. The facility's Clinical Guideline Skin & Wound effective 4/01/17 revealed nursing staff would complete skin observations and evaluations and report and document new skin impairment as indicated. The document read, Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. 2. Review of the medical record revealed resident #10, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, dementia, osteoarthritis, and adult failure to thrive. Review of the Minimum Data Set Admission assessment with assessment reference date of 3/27/23 revealed resident #10's Brief Interview for Mental Score was 3, which indicated she had severe cognitive impairment. The document showed the resident did not reject care or exhibit behavioral symptoms in the look back period. Resident #10 had a care plan for potential for impaired skin integrity initiated on 3/29/23. The goal was the resident would maintain clean and intact skin. The care plan interventions included follow facility protocols for treatment of injury, and monitor and document the location, and size of skin injuries. The document included instructions for nurses and Certified Nursing Assistants (CNAs) to report any skin abnormalities such as signs and symptoms of infection, to the physician. On 4/06/23 at approximately 12:15 PM, CNA B assisted Licensed Practical Nurse (LPN) A to reposition resident #10 during observation of wound care. As CNA B held the resident's right hand and rolled her onto her left side, resident #10 cried out, quickly pulled her right hand away, and complained of pain. CNA B carefully examined resident #10's right hand and exclaimed, There's an infection! Observation of the resident's right hand revealed a dark red to purple-colored area on the outer aspect of the thumb which extended from the tip of the digit to the first joint. There was a white pus-filled area beside the left base of the resident's thumbnail that measured approximately 0.5 centimeters (cm) in diameter. LPN A evaluated the resident's right thumb, verified it showed signs and symptoms of infection, and said, I'll have to call the doctor about that. Review of resident #10's medical record revealed as of 4/07/23 at approximately 8:50 AM, there were no nursing progress note or a change in condition form to reflect physician and representative notification of the area on the resident's thumb that was identified the previous day. On 4/07/23 at 9:27 AM, during weekly wound rounds, the Wound Care physician was informed nursing staff discovered an area on resident #10's right thumb that appeared to be infected. The Wound Care physician stated he was never notified of the issue. The Wound Nurse confirmed she was not aware of the concern and stated she would have expected nursing staff to be bring it to her attention. Observation of the resident's right thumb with the Wound Care physician and the Wound Nurse revealed the pus-filled area was significantly increased in size and now had green and white fluid visible beneath the inflamed skin. The Wound Care physician measured the pus-filled area and stated it was 2.4 cm x 1.7 cm. He confirmed the resident's initial signs and symptoms of infection with complaint of pain required immediate physician notification. The Wound Care physician acknowledged the increased size of the area of infection and the change in color and appearance were changes in condition that required prompt attention from a physician, a treatment and medication orders. He explained resident #10's representative would need to be contacted for permission to proceed with the required incision and drainage procedure with topical and injected anesthetic medication, and notified that a course of oral antibiotics would be prescribed. On 4/07/23 at 4:20 PM, the Regional Director of Clinical Services (RDCS) verified the facility was not aware resident #10 had an abscess on her right thumb as the assigned nurse, LPN A, did not follow up appropriately. The RDCS explained this situation definitely met the criteria for a change in condition and LPN A should have notified the physician and the family. The RDCS stated it was not acceptable that the nurse did not follow professional standards and the facility's policy. 3. Review of the medical record revealed resident #2, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, generalized muscle weakness, osteoarthritis, rheumatoid arthritis, osteoporosis, chronic pain, metabolic encephalopathy (disorder or disease that affects brain function), and functional quadriplegia (inability to move due to severe disability or frailty, without spinal cord injury). A Change in Condition note dated 2/24/23 at 2:15 PM read, While assisting with getting patient off the transport with staff assist. Patient was noted to be unresponsive with sternum rub. Resident #2 was transferred to the hospital by Emergency Medical Services. A Nursing Progress Note dated 2/26/23 at 2:28 AM, written by LPN H, revealed she spoke with a nurse at the hospital who informed her resident #2 had been admitted with diagnoses of sepsis (a life-threatening infection) and fractures of the shoulder and hip. Review of the medical record showed no additional progress notes, change in condition form, or incident documentation by LPN H to indicate the physician was notified of the resident's severe infection and major injuries. A Nursing Progress Note dated 2/27/23 at 10:16 AM, written by the Short Term Unit Manager (UM) read, Physician notified about patient condition and reported fractures that were reported. On 4/06/23 at 9:46 AM, in a telephone interview, LPN H stated she was regularly assigned to resident #2 for the 11:00 PM to 7:00 AM shift. She explained she had not worked Friday 2/24/23 and when she returned to work the following day, she discovered the resident had been transferred to the hospital for a change in condition. She recalled she checked the medical record and there was no documentation on Friday or Saturday that any staff called the hospital per protocol to find out the resident's admitting diagnosis and room number. LPN H stated she called the hospital early on Sunday morning and obtained the necessary information. She acknowledged she did not notify the physician, the on-call supervisor, or any member of nursing management of resident #2's diagnoses. LPN H said,I did not bother to go further because I figured the patient was in the hospital getting care. There was nothing [name of the facility] could do then.I did not report to the physician as the patient was not there. I expected administration to follow up.I overheard that the doctor said that nobody informed him. On 4/06/23 at 10:43 AM, the DON stated LPN H should have immediately notified the charge nurse and the physician once she was made aware resident #2 sustained major injuries. On 4/06/23 at 11:40 AM, APRN C stated she worked with resident #2's attending physician. She recalled she was about to leave the facility on Friday 2/24/23 when the Short Term UM informed her of an incident regarding the resident and transportation. APRN C said, He told me he was sending the resident out. He told me she was hot and had skin tears. I did not make a note or inform the physician. APRN C validated resident #2's fractures would be classified as a significant finding, and the nurse should have notified the on-call physician. The facility's policy and procedure for Notification of Change in Condition revised on 12/16/20, revealed the facility would .promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in status or condition. The procedure instructed nurses to notify the attending physician and the resident's representative of a significant change in physical status, an acute condition, and/or the need for a new treatment. The document indicated nurses were to complete an evaluation of the resident, note it in the medical record, and contact the attending physician. The policy revealed notification should be documented in the resident's medical record.

Based on interview and record review, the facility failed to obtain and implement wound treatment orders on admission to ensure the provision of essential care and services for 1 of 3 newly admitted residents, of a total sample of 10 residents, (#6). Findings: Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility from the hospital on 4/04/23. His diagnoses included osteomyelitis or bone infection and amputation of the fourth toe on his left foot. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/04/23 revealed resident #6's primary diagnosis was left fourth toe pain. The form showed resident #6 had a surgical incision on his left foot. Review of the Admission/Readmission Data Collection form dated 4/04/23 at 4:30 PM revealed a skin evaluation showed the resident had a fourth left toe amputation. On 4/05/23 at 1:35 PM, resident #6 had an undated, white gauze dressing that covered his left foot and extended above the ankle to his lower shin. The top of the dressing hung loosely from his shin and slid towards the resident's ankle when he moved his leg. The resident's daughter stated her father was admitted to the facility on the previous afternoon with the current dressing in place. On 4/05/23 at 2:27 PM, the resident's daughter stated she saw her father's hospital discharge wound care order before he left the hospital and recalled the surgeon's order was to apply a dry dressing every other day. Review of resident #10's electronic medical record (EMR) revealed no physician orders on admission related to wound care and treatments. An order dated 4/05/23 indicated the resident was to receive the antibiotic Ciprofloxacin 500 milligrams every 12 hours for five days to treat his left toe wound infection. As of 4/06/23 at 9:43 AM, the EMR did not reflect wound care and treatment orders related to the resident's left fourth toe amputation site. Review of the resident's hard copy paper chart revealed hospital discharge medication orders, but no wound treatment orders. The paper chart included a Baseline Care Plan and Summary form dated 4/04/23 with the section designated for Orders and Services left blank. On 4/06/23 at 11:01 AM, resident #6 was seated in a wheelchair with the same undated gauze dressing around his left foot and shin. The top of the dressing had become looser and was now bunched around his ankle. On 4/06/23 at 12:49 PM, Advanced Practice Registered Nurse (APRN) C stated she removed resident #6's left foot dressing to assess his surgical wound yesterday, and then reapplied the same dressing. She explained she did not enter orders for wound care and treatments as she assumed there were already physician orders in place. APRN C was informed the EMR showed resident #6 had no left foot wound care or treatment orders until today, 4/06/23, two days after admission. Review of the EMR with APRN C revealed the new order directed staff to cleanse the resident's left fourth toe with normal saline, pat dry, place gauze to the toe, wrap with gauze, and secure with tape once daily on the evening shift. Review of the Order Audit Report revealed the treatment order was entered approximately one hour ago, at 11:43 AM, by the Long Term Unit Manager as a telephone order from the attending physician. She stated sometimes newly admitted residents did not come from the hospital with physician orders and the facility would implement standing orders until the resident was seen by the Wound Care physician. APRN C was not able to verbalize the facility's standing orders for surgical amputation sites. She acknowledged the admission nurse was responsible for reviewing all hospital discharge orders with a physician, and he or she should have requested wound care orders if none were received. APRN C searched resident #10's paper chart and validated it contained only hospital discharge medication orders. On 4/06/23 at 1:47 PM, Licensed Practical Nurse (LPN) D, confirmed she changed resident #6's left foot dressing this morning although it was scheduled to be done on the evening shift. She explained the resident could not have participated in therapy sessions due to the condition of the dressing. LPN D said,It pretty much slid off and described the dressing as mangled. On 4/06/23 at 2:13 PM and 3:08 PM, the Director of Nursing (DON) stated on discharge from the hospital, residents should receive wound care orders. He explained the admitting nurse was responsible for making sure appropriate orders were in place at the time of admission. The DON acknowledged the nurse did not obtain treatment orders or initiate a baseline care plan that detailed orders and services necessary for the resident's care. On 4/07/23 at 4:20 PM, the Regional Director of Clinical Services (RDCS) stated if resident #10 arrived at the facility with no wound care and treatment orders, nursing staff or nursing management should have immediately contacted the hospital, the surgeon, or the attending physician to obtain admission orders. She confirmed it was essential for all residents to have physician orders on admission to ensure their immediate needs were met and to promote continuity of care.

Based on observation, interview, and record review, the facility failed to ensure the Treatment Administration Record (TAR) accurately reflected wound care and treatments ordered and provided for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 10 residents, (#10). Findings: Review of the medical record revealed resident #10, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, dementia, osteoarthritis, and adult failure to thrive. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 3/27/23 revealed resident #10's Brief Interview for Mental Score was 3, which indicated she had severe cognitive impairment. The document showed the resident did not reject care or exhibit behavioral symptoms in the look back period. The MDS assessment showed she had five unhealed pressure injuries and received pressure injury care. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by pressure and can present as either intact skin or an open ulcer (retrieved on 4/10/23 from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the Order Summary Report revealed a physician order dated 3/31/23 to cleanse the left foot distal plantar and lateral areas with normal saline, pat dry, apply skin protectant, and cover with a foam dressing daily and as needed. A Wound Follow-Up progress notes dated 3/31/23 revealed the Wound Care physician wrote an order for resident #10's new right lateral ankle pressure injury. The order instructed nurses to apply skin protectant to the area and apply a foam dressing daily. Review of the medical record revealed resident #10 had a care plan for pressure injuries initiated on 4/05/23. The interventions instructed nurses to administer treatments as ordered and monitor for effectiveness. assess/monitor/record wound healing. On 4/06/23 at 12:03 PM, Licensed Practical Nurse (LPN) A prepared to complete wound care and apply treatments as ordered for resident #10. She removed the resident's left sock and noted the foam dressing on her left lateral and distal foot was dated 3/31. LPN A removed the dressing and confirmed it had been in place for six days. Next, LPN A removed resident #10's right sock and validated the foam dressing on her right outer ankle was also dated 3/31. She was prompted to retain the dressings. On 4/06/23 at 12:40 PM, the Director of Nursing (DON) was provided with the dressings that were removed from resident #10's bilateral feet by LPN A. He validated they were applied on 3/31/23 and not changed daily as ordered. The DON confirmed he expected all nurses to follow standards of practice and facility policies and procedures related to wound care, application of treatments, and transcribing and following physician orders. Resident #10's TAR for April 2023 revealed the physician's order for the right ankle dressing was on the TAR, and there were no nurses' initials to indicate the dressing was done on 4/01/23 and 4/05/23. The initials NP6 on 4/02/23, 9580 on 4/03/23, and jme on 4/04/23 indicated three nurses signed the TAR to verify they changed resident #10's right ankle dressing as ordered although the task was not done. On 4/07/23 at 3:54 PM, the Wound Nurse stated floor nurses were responsible for following physician orders for wound care and accurately documenting completion of the task and any identified concerns in the medical record. She explained any nurse who rounded with the Wound Care physician was responsible for ensuring new or revised orders were accurately transcribed to the Physician Order Summary and the TAR. On 4/07/23 at 4:20 PM, the Regional Director of Clinical Services (RDCS) stated it was unacceptable for nurses to document that they did resident #10's treatments when they were obviously not done. She explained nurses who left blank spaces on the TAR with no associated progress note did not maintain a complete medical record. The RDCS confirmed her expectation was floor nurses and Unit Managers would ensure the Wound Care physician's orders were transcribed accurately and timely so the resident's medical record was up to date and reflected the current plan of care. Review of the undated job descriptions for Clinical Nurse (LPN) and Clinical Nurse I [Registered Nurse] revealed a duty and responsibility to complete required documentation in an accurate and timely manner.

Based on interview and record review, the facility failed to provide written Notification of Transfer/Discharge forms to the residents or their representative and the Ombudsman for 5 of 6 residents reviewed for hospitalization s out of a total sample of 43 residents, (#59, #410, #411, #412 and #413). Findings: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses of right above knee amputation, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of resident #59's medical record revealed he was hospitalized on [DATE]. A progress note dated 12/01/22 indicated the resident went to a specialist's appointment and the physician requested the resident be sent to the hospital for worsening of heel wound. The resident returned to the facility and was transferred to the hospital per physician orders the same day. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . 2. Resident #410 was admitted to the facility on [DATE] with diagnoses of Klebsiella pneumonia and acute kidney failure. Review of resident #410's medical record revealed he was hospitalized on [DATE]. A progress note dated 10/25/22 indicated the resident was transferred to the emergency room for abnormal labs and complaints of chest pain. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . 3. Resident #411 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and history of Corona Virus Disease-2019. Review of resident #411's medical record revealed she was hospitalized on [DATE]. A progress note dated 10/30/22 indicated the resident was observed in respiratory distress, 911 was called and the resident was sent to the emergency room . The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . 4. Resident #412 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and cerebral infarction. Review of resident #412's medical record revealed she was hospitalized on [DATE]. A progress note dated 11/04/22 indicated resident was observed with facial drooping. The facility received an order to transfer the resident to the emergency room due to possible stroke. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . 5. Resident #413 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, non-Hodgkin lymphoma and history of Corona Virus Disease-2019. Review of resident #413's medical record revealed he was hospitalized on [DATE]. A progress note dated 11/09/22 indicated the resident was transferred to the emergency room due to low oxygen saturation levels. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . On 12/09/22 at 1:00 PM, the Social Services Director (SSD) stated she was not responsible for completing the Notice of Transfer or Discharge form for hospitalization . She explained the nurses completed the form and then provided a copy to social services to send to the Ombudsman. The SSD reported she had not received any Notice of Transfer or Discharge forms from the nursing department since February 2022. On 12/09/22 at 1:15 PM, the Director of Clinical Services stated the nurses were required to complete the Notice of Transfer or Discharge form when a resident was transferred to the hospital. He acknowledged the nurses had not completed the forms as required. On 12/09/22 at 2:44 PM, the Regional Director of Clinical Services reported the facility was unable to locate Notice of Transfer or Discharge forms for the identified residents who were hospitalized . The facility's policy and procedure for Transfer/Discharge Notification and Right to Appeal revised 10/24/22 read, Before a center transfers or discharges a resident the location must: Notify the resident and resident representative(s) of the transfer or discharge and the reason for the move in writing (in a language and manner they understand).

Based on observation, interview, and record review, the facility failed to complete quarterly elopement assessments for 1 of 2 residents reviewed for Accidents out of a total sample of 43 residents, (#30). Findings: Review of resident #30's medical record documented she was admitted to the facility on [DATE] with diagnoses of dementia, paranoid schizophrenia, and cognitive communication deficit. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] noted she had severe cognitive impairment and exhibited wandering behaviors in the past 4-6 days. Review of the physician orders showed an order dated 04/12/22 to place electronic monitoring device on her right ankle and to check for placement on every shift. Review of the plan of care initiated 04/12/22 revealed the resident was an elopement risk related to history of attempts to leave the facility unattended and an electronic monitoring device was placed on her right ankle. Review of the 11/14/22 psychiatric evaluation noted resident #30 was assessed on 10/25/22 and she continued to wander around the facility and entered other resident's rooms. The last time the resident had exit seeking behaviors was in 08/2022. On 12/06/22 at 9:57 AM, resident #30 was observed sitting in a chair in her room and had an electronic monitoring device on her right ankle. The resident explained the device on her ankle was placed so she would not get out of the facility. I have not tried to get out of the facility. On 12/08/22 at 9:38 AM, resident #30 was observed ambulating in her room and had the electronic monitoring device on her right ankle. On 12/09/22 at 9:17 AM and 10:18 AM, the resident stated she could walk in the halls and could go out to the courtyard but she could not leave the facility because of the thing on her ankle. Review of resident #30's medical record revealed an Elopement Risk Evaluation completed on 04/12/2022. The evaluation determined the resident was at risk for elopement. The medical record contained no other Elopement Risk Evaluations. On 12/08/22 at 3:17 PM, the Regional Nurse Consultant stated a resident with an electronic monitoring device was required to have quarterly Elopement Risk Evaluations to determine the need for continued electronic monitoring. She reviewed resident #30's medical record and stated the resident had an active order for the electronic monitoring device and had not had the quarterly Elopement Risk Evaluations completed as required in 08/2022. She indicated another elopement risk evaluation was due this month. Review of the Facility's Elopement/Wandering Risk Guideline Policy and Procedure, dated 0801/2020, read, Overview: To evaluate and identify patients/residents that are at risk for elopement and develop individualized interventions. Process: Patients/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly .

Based on observation, record and policy review and interviews with resident, resident family and staff, the facility failed to provide adequate supervision and a secure environment for 1 of 11 residents reviewed at risk for elopement of a total sample of 17 residents, (#2). These failures contributed to the elopement of resident #2 and placed him at risk for serious injury/impairment or death. While resident #2 was out of the facility unsupervised, there was a high likelihood he could have fallen, been hit by a car or become lost. On 7/3/20 at approximately 10:45 AM, resident #2 exited the facility through the main lobby when the lobby doors being monitored by staff and only opened manually using a key control on the wall. Resident #2 walked 0.19 miles down a sloping walkway and uneven sidewalks along a moderately trafficked 2-lane road to a convenience store located on a very busy corner of two major thoroughfares. The temperature on July 3rd was 90 degrees Fahrenheit which placed the resident at risk for dehydration and/or sun exposure. (www.weather.com) The resident was found by a Good Samaritan who noted that resident #2 appeared lost and became concerned for his safety. The Good Samaritan used resident #2's cell phone and located the resident's daughter's telephone number. The resident's whereabouts were unknown to the facility staff until the resident's daughter called the facility and informed them that her father was found at the convenience store parking lot. The facility's failure to provide adequate supervision and a secure environment resulted in Substandard Quality of Care at the Immediate Jeopardy level starting on 7/3/20. The Immediate Jeopardy was removed on 7/16/2020. Findings: Cross reference to F835 Resident #2 was an [AGE] year-old vulnerable adult, admitted to the facility from the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], noted that the resident's Brief Interview for Mental Status (BIMS) score was 10 indicating he had moderately impaired cognition. On 7/14/20 at 3:18 PM, resident #2 confirmed he left the facility and went to the convenience store. The resident stated he left the facility in the morning but could not recall the date. He recalled that it was very hot that day. The resident explicitly expressed that he did not want to be at the facility. He stated that he had a house, a pension and social security in his country, the Dominican Republic, and wanted to return there. The resident stated he left the facility through the lobby front entrance and there were staff/people there but did not identify the staff at the entrance. He said someone at the door, and the door opened, but he could not say how exactly he exited the facility. The resident insisted that he did not go into the convenience store and produced a flip style cell phone, which was kept in his sock. He said he met a Spanish speaking family with a truck and they brought him back to the facility. On 7/14/20 at 3:49 PM, a meeting with the Unit Manager (UM) and Assistant Director of Nursing (ADON) verified that resident #2 exited the facility on 7/3/20 at about 10:45 AM. The UM stated she could not recall the last time she saw resident #2 on the morning of 7/3/20. The ADON stated there was a Clinical Meeting on 7/3/20 that took place in the conference room. At approximately 10:45 AM, she left the room to make copies and saw the resident sitting near the Human Resource Offices and the Receptionist and Maintenance Director were talking to the resident. The ADON stated at 11 AM, the Nursing Unit received a telephone call, from resident #2's daughter informing that her father was found at the convenience store. They were told the convenience store employees would bring her father back to the facility. At 3:59 PM the Administrator joined the meeting and shared the facility's investigation. He stated that on the morning of 7/3/20 there was a discharge occurring at the front lobby and that discharge may have added to the 'busyness' at the front entrance. The Administrator and his staff could not explain how resident #2 left the facility undetected while the front lobby doors were being monitored by the COVID-19 Screener. The Administrator stated the receptionist was the COVID-19 Screener at the time the resident left the facility. He provided a copy of the receptionist's written statement which noted that she saw the resident at approximately 10:45 AM, in the lobby and redirected him back to his room. At 4:21 PM the Maintenance Director joined the meeting and stated that he was the COVID-19 Screener and was monitoring the front doors on 7/3/20 from 10 AM to 11 AM. At this time, the Administrator admitted he was not aware that the Maintenance Director was the COVID-19 Screener when resident #2 exited the facility. The Administrator stated, That's what's boggling to me. The Administrator verified he did not get a witness statement from the Maintenance Director. The Maintenance Director confirmed that the COVID-19 Screener used a key switch to open and close the front lobby doors. The Maintenance Director added that he knew resident #2 and would not have let him out. He stated that when he was assigned as the screener, he usually conversed with the receptionist. On 7/15/20 at 1:15 PM, a meeting with the Administrator, Director of Nursing (DON), ADON and the Regional Director of Clinical Services (RDCS) was conducted. Witness statements and facility polices were reviewed. The staff stated the resident, upon admission was assessed for elopement and he was not an elopement risk. A second elopement assessment was done on 7/3/20 after the resident had exited the facility. Despite having left the facility, without staff's knowledge, the facility did not consider resident #2 as an elopement risk. The staff stated that in the morning of 7/2/20, the resident was transferred to the hospital for agitation and aggression toward another resident. The resident returned to the facility the same afternoon of 7/2/20. The staff stated that the hospital was to provide a private sitter, for the long weekend, starting on the morning on 7/3/20 through the morning on 7/6/20. However, the private sitter did not arrive until after the resident had eloped from the facility. On 7/6/20, after the private sitter had left, the facility placed the resident back on 15-minute observation checks. The staff stated that when the resident returned from the hospital on [DATE] another BIMS was conducted and the resident scored 14 out 15, indicating he was cognitively intact. The staff could not explain why another BIMS was required. There was no evidence that an unscheduled Minimum Data Set assessment had been completed. The resident's medical record revealed there was no indication that a Significant Correction MDS was submitted that included the resident's updated BIMS. The Resident Assessment Instrument Version 3.0 Manual (RAI), noted that the BIMS is a brief screener that aids in detecting cognitive impairment and that the final determination of level of impairment should be made by the resident's physician or mental health care specialist. The RDCS stated that the root cause of the elopement incident was that resident #2 did not follow the Leave of Absence (LOA) policy. The 7/2/20 Admission/Readmission Data Collection noted that the resident had returned to the facility (post hospital) and resident #2's mood was pleasant. The resident was deemed by staff not to be at risk for elopement. The staff noted that the resident was confused to place and time. On 7/14/20 at 2:49 PM, the surveyors retraced resident #2's elopement route from the facility's front door to the convenience store parking lot where the resident was found. The facility was located on a two-lane road which was used as a short cut linking two very busy thoroughfares. The convenience store was located at a busy intersection of a 7-lane divided highway. These two highways served as major arteries for the area. The resident's route revealed he walked on a downward sloping sidewalk towards the convenience store. The resident would have crossed a two lane road to get to the convenience store. The pavement on the route was cracked and uneven and there were several business driveways along the two-lane road. Adjacent to the convenience store was a retention pond that was dry at the time. The total distance of the route was 0.19 miles from the facility. The weather was sunny and the temperature was approximately 90 degrees Fahrenheit at the time of the elopement. (www.weather.com) A review of the medical record did not reveal any indication that the facility had called resident #2's daughter for his history of wandering and/or elopement. On 7/15/20 at 10:11 AM, the resident's daughter was contacted by phone. She stated that a Good Samaritan, that spoke Spanish, found her father near the convenience store and used her father's cell phone to contact her. The Good Samaritan told her, that her father was very confused and could not say where he resided. The daughter stated she told the family to stay at the convenience store with her father, while she called the facility. The daughter stated she was very scared and kept calling the facility. She stated she called the facility at approximately 11 AM and the staff were not aware that her father was missing. She called the Good Samaritan back and asked him to bring her father back to the facility. The daughter stated she was concerned as her father could have been hit by a car and sustained major injuries. The daughter recalled the Social Service staff (SS) spoke to her about alternate placement. She said her father had history of confusion and had lived in a Senior Housing Apartment. He had left his apartment and was brought back by police as he could not find his way back. The daughter stated her father lived with her prior to hospitalization and facility admission. Further review of the Admission/Readmission Data Collection dated 7/2/20 (post hospital) revealed a section for Elopement Risk Evaluation. The questions and answers for elopement risk were noted as follows: 1. Is the resident cognitively impaired? - answer no 2. Is the resident independently mobile (ambulatory or wheelchair) -answer no 3. Does resident have poor decision making skills? -answer no 4. Has resident demonstrated exit-seeking behavior? -answer no 5. Does resident wander oblivious to safety needs? -answer no 6. Does resident have a history of elopement? -answer no 7. Dos resident have the ability to exit facility -answer no 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement. - answer no On 7/16/20 at 11:26 PM, Registered Nurse B (RN B) confirmed she completed the Admission/Readmission Data Collection when the resident returned from the hospital on [DATE] She stated the resident spoke Spanish and that she used staff to translate. RN B stated that the resident's memory was okay but believed that he was cognitively impaired. She stated that she believed that resident #2 used to walk the hallways but she had not been assigned to him before. RN B added that the resident's routine was to walk to the front lobby saying that he wanted to leave. She stated he was supposed to have a private sitter per the hospital report, but the sitter arrived the next day. RN B indicated that she was assigned to resident #2 on the 3 PM-11 PM shift and that observation checks every 15 minutes were initiated. The medical record and the staff could not provide any assessment/reason as to why the resident required 15-minute checks. The elopement evaluation questions and answers were reviewed with RN B. RN B explained that although the responses might have been incorrect, resident #2 was monitored closely. A second Elopement Risk assessment was completed by RN C after the elopement incident dated 7/3/20. RN C noted that the resident was not an elopement risk. Question number 6 asked, 'Does the resident have a history of elopement? RN C answered this question with 'no.' On 7/15/20 at 2:45 PM, RN C described what occurred after resident #2 had eloped from the facility. She stated staff brought him back to his room and she performed a Skin Assessment and an Elopement Assessment. RN C stated she asked the ADON about the questions on Elopement Assessment Form and the ADON told her that the resident's exit from the facility earlier that morning did not count as an elopement. On 7/14/20 at 4:03 PM, Registered Nurse (RN A), who spoke Spanish, stated he was not working on 7/3/20 but was aware that the resident had eloped. RN A stated he had been assigned to the resident in the past. RN A stated that the resident told him, about his wanting to go back to the Dominican Republic. RN A stated as time progressed resident #2 became more confused and continued to say he wanted to go home. RN A stated he did not report resident #2's desire to go back home to his superiors. Since the facility staff did not deem the resident as an elopement risk, an elopement care plan was not developed with approaches to ensure the resident remained in the facility. The Elopement Risk Evaluation dated 7/3/20, post elopement noted the resident was not cognitively impaired, he did not display exit seeking behavior and he was not at risk for elopement. 1. Is the resident cognitively impaired? - answer was no 2. Is the resident independently mobile (ambulatory or wheelchair)? -answer was yes 3. Does the resident have poor decision-making skills? -answer was yes 4. Has the resident demonstrated exit seeking behaviors? -answer was no 5. Does the resident wander oblivious to safety needs? -answer was no 6. Does the resident have a history of elopement? - answer was no 7. Does the resident have the ability to exit the facility? -answer was yes 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement. - answer no A review of the facility's investigation revealed that the facility failed to investigate and recognize how the resident eloped and make the necessary changes to prevent further elopements. On 7/15/20 at 2:47 PM the RDCS stated that they did not deem resident #2's incident on 7/3/20 as an elopement because his BIMS was 14. She stated that the resident did not follow the facility's Leave of Absence (LOA) policy. When asked if the resident had a physician's orders [REDACTED]. When asked if the resident #2 was educated on the facility's LOA Policy, in Spanish, the RDCS stated we will have to review the medical record. By the time of the exit meeting the facility failed to provide a physician's orders [REDACTED]. Due to the COVID-19 pandemic the Centers for Medicare and Medicaid had advised that only essential LOA such as physician/hospital/outpatient treatment should be allowed. The RDCS did not explain why a trip to a convenience store was deemed as essential. As noted earlier, on 7/14/20 the Administrator stated that the facility had a discharge at the time the resident eloped and that may have added to the confusion at the front lobby that day. However, there was no evidence that the facility's discharge procedures were reviewed, and changes made to ensure that only the discharge resident and/or their belongings were leaving the facility. A review of the medical record revealed that resident #2 was sent to the hospital in the early morning of 7/2/20. On 7/16/20 at 3:25 PM, the Hospital Case Manager (HCM) confirmed by telephone that resident #2 was in the emergency room (ER) on 7/2/20. He stated the ER Physician had Baker Acted the resident in order to get a Psych Consult, but the Baker Act was later rescinded. He stated that the nursing home conveyed, to him, that the resident was ready for discharge from the nursing home. He attempted to discharge the resident to his daughter's house, but she refused. When asked why the resident needed a sitter, the HCM did not answer. He stated that he offered a private sitter to facilities in order for them to take the resident back. He stated the sitter was to start on 7/3/20 and end on the morning of 7/6/20. The resident returned to the nursing home on the afternoon of 7/2/20 without a sitter. There was no indication in the resident's medical record that the resident needed a private sitter for supervision. On 7/14/20 at 4:49 PM, RN C stated she was assigned to resident #2 on the 7 AM to 3 PM shift, on 7/3/20. The nurse indicated that resident #2 was readmitted the day before and did not know if the resident had a private sitter on the night shift. RN C stated, He was a wanderer, and that she and the assigned Certified Nursing Assistant were doing 15-minute checks on him. RN C stated the last time she saw the resident on 7/3/20 was at 10:30 AM. RN C stated she was involved with a discharge that morning at the front lobby and when she got back to her work area the assigned CNA was looking for the resident. On 7/6/20 the resident was placed back on 15-minute checks after the private sitter had departed. On 7/14/20 at 3:59 PM, the Administrator was asked why the facility did not provide a private sitter until the hospital sitter arrived. The Administrator did not provide an answer but stated that the hospital private sitter showed up eventually. The Administrator did not explain why the facility did not provide a sitter prior to the hospital contracted sitter's arrival. The facility staff did not explain how they determined the resident could be placed back on every 15-minute checks. At the time of elopement, the assigned level of supervision for resident #2 was 15-minute checks. An extended survey was completed on 7/16/2020. Review of the facility's corrective measures implemented on 7/15/16 by the facility revealed the following: o On 7/15/20, resident #2 was reassessed by the DON and found to be at risk for elopement. He had an electronic wander bracelet implemented and was placed on enhanced supervision to include 1:1, 15-minute checks or sitter services as indicated by his needs. Review of resident #2's medical record revealed nursing progress notes, physician's orders [REDACTED]. o The electronic monitoring system and exit doors were checked daily with daily review of documentation done by the ED or his designee. Review of maintenance logs indicated the required monitoring was completed. o Elopement drills were initiated on 7/15/20 on the 3:00 PM to 11:00 PM shift. Drills were scheduled every shift for 1 week or until all staff successfully passed the elopement competency test. Documentation of elopement drills was reviewed, and drills were on-going to incorporate staff on all shifts. Review of the Elopement Binder at the reception desk revealed photographs and demographic information of all residents who were at risk for elopement, including resident #2. o A dedicated staff member was assigned to monitor the front door from 8:00 AM to 8:00 PM, and a secondary entrance equipped with a camera and speaker will be used between 8:00 PM and 8:00 AM. Dedicated staff will be trained on elopement and use of the elopement book to verify identity. The ED or his designee will audit the process daily for 4 weeks. o Residents who required increased supervision will be reviewed in the daily clinical meeting to ensure compliance with safety check documentation o Staff education began on 7/15/20 and will be ongoing until 100% compliance is achieved. Topics included evaluation of elopement risk, updating plans of care, elopement procedure, assessment with change in condition, neglect, elopement policy and procedures, triggers indicating exit-seeking, and the leave of absence policy. Staff will not be allowed to work until training has been received. Newly hired staff will receive the education in orientation. Interviews conducted indicated staff were knowledgeable about elopement procedures, supervision of residents at risk for elopement and elopement risk evaluations. Review of staff in-service attendance sheets revealed a current total of 70 of 145 staff (48%) had been educated. o The QAA committee will review audits of the interventions and re-educate and/or correct processes as needed. o On 7/15/20 and 7/16/20, the RDCS educated the ED and the DCS regarding auditing and correcting processes, ensuring safety with a focus on following elopement/LOA protocols, auditing safety processes including door function and the electronic wander system, ensuring staff understand processes and their roles, educating staff when processes are breached and about the role of QAPI. The ED and DON were also educated on ensuring accuracy of assessments to include family or representative input in obtaining pertinent history and developing the plan of care. Review of the in-service attendance sheet revealed signatures of the ED and DON to verify education topics addressed. o The sample was expanded to include all residents who wore monitoring devices due to the risk for elopement and 3 newly admitted residents who were evaluated for elopement risk. Observations and record reviews conducted revealed no concerns related to residents #5, 6, 7, 8, 9, 13, 14, 15, 16 & 17. The scope of severity of the deficiency was reduced to D-isolated, no actual harm with a potential for no more than minimal harm.

Based on observation, record and policy review and interviews with resident, resident family and staff, the facility failed to use its resources effectively to provide an adequate level of supervision and a secure environment to prevent elopement; and failed to conduct a comprehensive investigation to identify the root cause and develop appropriate interventions to ensure the safety of 1 of 11 residents reviewed for elopement risk, of a total sample of 17 residents, (#2). These failures contributed to the elopement of resident #2 and placed him at risk for serious injury/impairment/death. While resident #2 was out of the facility unsupervised, there was a high likelihood he could fallen, been hit by a car or become lost. On 7/03/20 at approximately 10:45 AM, resident #2, a vulnerable Spanish-speaking adult, exited the facility through the front lobby doors, less than 24 hours after re-admission from the hospital. Resident #2 walked across the facility's parking lot and turned left at the end of the driveway. He walked down a sloping and uneven sidewalk along a moderately trafficked 2-lane road towards a busy highway with a 7-lane intersection. Resident #2 crossed the 2-lane road and entered the parking lot of a gas station and convenience store approximately 0.19 miles from the facility. A Good Samaritan who spoke Spanish approached resident #2 and was able to determine he was from the nearby facility by looking through the contact list on the resident's cell phone and locating the daughter's telephone number. Resident #2's whereabouts were unknown to the facility until his daughter called the facility to inform staff her father was found at a convenience store in the area. The facility's failure to provide a secure environment, adequate supervision, additional safety interventions following the elopement and to conduct a thorough investigation of the incident to determine the root cause and thereby preventing reoccurrence, resulted in Immediate Jeopardy, starting on 7/03/20. The Immediate Jeopardy was removed on 7/16/20. Findings: Cross reference to F689 Resident #2 was an [AGE] year old male who was admitted to the facility on [DATE] for rehabilitation after hospitalization for a fall-related injury. His admission [DIAGNOSES REDACTED]. Resident #2 was transferred to the hospital on [DATE] for increased confusion, disorientation, delusions, agitation and physical aggression towards another resident. After evaluation in the hospital emergency department, resident #2 was readmitted to the facility later that same afternoon. The Minimum Data Set (MDS) 5-day Medicare assessment with assessment reference date (ARD) of 6/07/20 revealed resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The assessment indicated resident #2 was able to walk with supervision, had unsteady balance but was able to stabilize himself without assistance. On 7/14/20 at 3:59 PM, the Executive Director (ED) confirmed resident #2 was sent to the hospital on Thursday 7/02/20 due to aggressive behaviors. He stated the facility readmitted resident #2 later the same day, on the condition the hospital would provide private sitters for the weekend, from Thursday evening until the following Monday morning, while the facility looked for appropriate placement for him. The ED stated the private sitter did not show up as arranged, and resident #2 was placed on 15-minute checks instead of 1:1 continuous supervision. The ED did not answer when asked why the facility did not provide a 1:1 sitter if it was deemed necessary by admissions staff and administration. The ED confirmed resident #2 left the facility without knowledge of staff less than 24 hours after re-admission, on 7/03/20, the first morning of the holiday weekend. He explained resident #2 ended up at a nearby convenience store and his daughter spoke with someone at the store by telephone. The daughter notified the facility and asked the person to take her father back. The ED stated the facility investigated the incident and determined the root cause to be resident #2 left the facility because he wanted to go home to his daughter. The ED and Assistant Director of Nursing (ADON) stated at the time resident #2 went missing there were residents being discharged at the front door. Despite completion of an incident investigation, both the ED and ADON acknowledged they were still unsure how resident #2 was able to exit the facility since the front door was monitored by a staff member and had to be manually opened and closed. The ED stated he interviewed the receptionist who was monitoring the door at the time resident #2 left the facility. He provided the receptionist's written statement that indicated she spoke to resident #2 in the lobby on 7/03/20 at approximately 10:45 AM and instructed him to return to the nursing unit. On 7/14/20 at 4:12 PM, the receptionist confirmed resident #2 was in the lobby near the front door and she re-directed him away from the area. The receptionist stated the facility's Maintenance Director was seated at the screening table in the lobby and was responsible for opening, closing and monitoring the front door at that time. She recalled she was not seated at her desk behind the reception window, rather she stood in front of the Maintenance Director at the screening table. On 7/14/20 at 4:21 PM, the ED expressed surprise at the information provided by the receptionist. He said, That's what's boggling to me. Nobody told me (the Maintenance Director) was up there. That piece of information did not come across to me until now. To my knowledge (the receptionist) was watching the door. On 7/14/20 at 4:30 PM, the Maintenance Director confirmed he was assigned to monitor the door from 10:00 AM to 11:00 AM on the day resident #2 left the building. The Maintenance Director explained he had to manually open the door for every person who entered or exited the facility. He explained he knew resident #2 on sight and would never have opened the front door for him. When asked if he could have been distracted, the Maintenance Director said, Most times when I'm up there I talk to (the receptionist). On 7/15/20 at 1:15 PM, the ED and ADON continued to explain their investigation findings and actions taken after resident #2 was returned to the facility. The ED stated his investigation included a statement from the Spanish-speaking Assistant Business Development Coordinator (ABDC) who retrieved resident #2 from the Good Samaritan who returned him to the facility. The ED stated the statement indicated resident #2 was brought back by a construction worker who was working at the convenience store. Review of the ABDC's statement revealed a reference to the family that brought resident #2 back to the facility, but no mention of a construction worker. When asked how he arrived at that conclusion, the ED stated he assumed it was a construction worker. The ADON stated she assessed and interviewed resident #2 with translation assistance from the ABDC after he was returned to the facility. She stated she also spoke to resident #2's daughter and notified the Medical Director. However, review of resident #2's medical record revealed no documentation of the elopement incident, notifications made or revisions to the plan of care. The ADON stated she did not interview the Good Samaritan who returned resident #2 to the facility. She acknowledged she did not document many of her post-incident actions. She said, We were all busy doing the timeline and we slipped up. I did not go back to verify there was a nurse's note or a change in condition note. The ADON stated the facility's interdisciplinary team (IDT) including the ED and Regional Director of Clinical Director (RDCS) reviewed the incident in the daily clinical meeting on Monday, 7/05/20. She stated they reviewed the timeline of the event and actions taken. The ADON stated the IDT looked at resident #2's BIMS score and decided the incident did not meet the criteria of an elopement. She said, We decided the resident did not follow the Leave of Absence policy. The ADON explained resident #2 was re-assessed on 7/03/20 after he was returned to the facility, and he was still not deemed at risk for elopement although he left the building unsupervised that morning. She stated resident #2 did not need an elopement care plan or an electronic wander bracelet based on the nursing assessment findings and IDT review of the incident. The ED reiterated resident #2 was alert and oriented, knew what he wanted to do, and acted on a previously expressed desire to leave the facility. When asked about the definition of an elopement, the ED said, It's whatever is on the policy. Review of the facility's policy and procedure (P&P) for Missing Patient / Resident revised on 8/23/17, revealed an elopement was .when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The P&P directed staff to first determine if a missing resident was out on authorized leave, then conduct a search. The document indicated after a missing resident was found and returned to the facility, documentation would be made in the medical record regarding the incident, assessment findings and notifications. Staff were to Review and revise the interventions as indicated related to elopement and wandering risk and update the Care Plan and Kardex. The ADON acknowledged according to the facility's P&P, resident #2 had eloped. The ED and ADON confirmed the IDT reviewed the incident investigation and post-elopement risk evaluation but did not implement any additional interventions to ensure resident #2's safety. They explained resident #2 had a private sitter until the morning of 7/05/20 and then returned to 15-minute checks. The ED and ADON did not respond when asked why the facility would continue an intervention that was proven to be ineffective since resident #2 was able to elope between 15-minute checks. On 7/15/20 at 2:47 PM, the RDCS stated she met with the IDT and concurred with the team that resident #2 was not an elopement risk. She explained the event was not an elopement because resident #2's BIMS score was 14 which indicated he was cognitively intact. The RDCS said, He did not follow the leave of absence policy and process. However, she acknowledged resident #2 did not have a physician's orders [REDACTED]. She was informed resident #2 had a history of [REDACTED]. The RDCS confirmed it was necessary to interview family or representative of a cognitively impaired resident to accurately complete the evaluation form regarding elopement risk. The RDCS stated the IDT should have developed appropriate care plan interventions to address the root cause of the incident but she was not able to provide any supportive documentation. Review of resident #2's medical record revealed no new or revised care plans related to behaviors that caused resident #2 to leave the facility or his risk for elopement. On 7/16/20 at 11:55 AM, the Director of Nursing (DON) stated she was on vacation at the time resident #2 left the facility unsupervised. She stated she returned to work on 7/13/20 but was not aware a resident left the facility unsupervised until the survey team arrived on 7/14/20, 11 days after the incident occurred. She expressed astonishment and frustration that she was not notified of the incident by the ED and ADON as soon as possible. The DON confirmed the facility had procedures to prevent resident elopement that included accurate elopement risk evaluation and re-evaluation when indicated, comprehensive incident investigation, immediate interventions and care plan revisions. The DON stated she reviewed resident #2's medical record after she became aware of the incident. She confirmed resident #2 eloped from the facility as defined in the policy. The DON stated she noted inaccuracies and omissions in the investigation and nursing documentation. She confirmed the IDT did not identify resident #2 as an elopement risk even after he left the building unsupervised. The DON explained an elopement care plan was not triggered because of the inaccurate assessment. The DON stated she re-assessed resident #2 earlier that morning and determined he met elopement risk criteria that required an electronic wander bracelet for safety. The policy and procedure for Accident and Incident Investigation effective 11/30/14 read, Certain Accidents and Incidents . will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. The document indicated an incident report should be completed for any event that was inconsistent with routine resident care and facility operations. The procedure revealed the ED, the DON or her designee would document the investigation of the incident to include . interviews with the resident, all staff involved (directly or indirectly), any family, visitors, or volunteers, which may have had contact with the resident and may help with the investigation. On 7/16/20 at 12:37 PM, the ED stated he concluded resident #2 took advantage of activities related to other residents being discharged at the front door to exit the facility unnoticed. When asked if the facility implemented any new measures during the discharge process to prevent the same incident from happening again, the ED paused for a moment, shook his head and said, We'll have to look at that because discharges go on throughout the day. On 7/16/20 at 12:58 PM, the Medical Director was informed of concerns identified regarding incompleteness of the facility's investigation, and conflicting information on where resident #2 was found and who brought him back to the facility. He was apprised of ineffective safety interventions put in place before and after the elopement incident due to inaccurate elopement risk evaluations. On review of the facility's policy and procedure, the Medical Director said, By definition, this was an elopement. He acknowledged it was necessary to determine the accurate root cause of resident #2's elopement in order to correct the situation for him and to prevent any further resident elopements. Review of the Facility Assessment Tool dated 1/06/20 revealed the facility accepted residents with psychiatric and mood disorders and neurological system diseases including dementia. The document indicated staff was able to provide care and services to Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment . The assessment tool revealed residents would receive person-centered care including conversations to get to know resident and identify risks and hazards for residents. Review of the ED's job description revealed duties and responsibilities including Maintain and guide the implementation of facility policies and procedures . ensure a safe, clean and comfortable environment for residents . Maintain a file for and monitor incident reports. The ADON's job description revealed she would Assist in the implementation of and monitor compliance with policies, procedures, and standards of practice . assist in the development, implementation, and monitoring of an accurate and effective documentation system . An extended survey was conducted on 7/16/2020. Review of corrective measures implemented on 7/15/16 by the facility revealed the following: * On 7/15/20, resident #2 was reassessed by the DON and found to be at risk for elopement. He had an electronic wander bracelet implemented and was placed on enhanced supervision to include 1:1, 15-minute checks or sitter services as indicated by his needs. Review of resident #2's medical record revealed nursing progress notes, physician's orders [REDACTED]. * The electronic monitoring system and exit doors were checked daily with daily review of documentation done by the ED or his designee. Review of maintenance logs indicated the required monitoring was completed. * Elopement drills were initiated on 7/15/20 on the 3:00 PM to 11:00 PM shift. Drills were scheduled every shift for 1 week or until all staff successfully passed the elopement competency test. Documentation of elopement drills was reviewed, and drills were on-going to incorporate staff on all shifts. Review of the Elopement Binder at the reception desk revealed photographs and demographic information for all residents who were at risk for elopement, including resident #2. * A dedicated staff member will be assigned to monitor the front door from 8:00 AM to 8:00 PM, and a secondary entrance equipped with a camera and speaker will be used between 8:00 PM and 8:00 AM. Dedicated staff will be trained on elopement and use of the elopement book to verify identity. The ED or his designee will audit the process daily for 4 weeks. * Residents who required increased supervision will be reviewed in the daily clinical meeting to ensure compliance with safety check documentation * Staff education began on 7/15/20 and will be ongoing until 100% compliance is achieved. Topics included evaluation of elopement risk, updating plans of care, elopement procedure, assessment with change in condition, neglect, elopement policy and procedures, triggers indicating exit-seeking, and the leave of absence policy. Staff will not be allowed to work until training had been received. Newly hired staff will receive the education in orientation. Interviews conducted indicated staff were knowledgeable about elopement procedures, supervision of residents at risk for elopement and elopement risk evaluations. Review of staff in-service attendance sheets revealed a current total of 70 of 145 staff (48%) had been educated. * The Quality Assurance and Performance Improvement (QAPI) committee will review audits of the interventions and re-educate and/or correct processes as needed. * On 7/15/20 and 7/16/20, the RDCS educated the ED and the DCS regarding auditing and correcting processes, ensuring safety with a focus on following elopement and leave of absence protocols, auditing safety processes including door function and the electronic wander system, ensuring staff understood processes and their roles, educating staff when processes were breached and the role of QAPI. The ED and DON were also educated on ensuring accuracy of assessments to include family or representative input in obtaining pertinent history and developing the plan of care. Review of the in-service attendance sheet revealed signatures of the ED and DON to verify education topics addressed. * The sample was expanded to include all residents who wore monitoring devices due to the risk for elopement and 3 newly admitted residents who were evaluated for elopement risk. Observations and record reviews conducted revealed no concerns related to residents #5, 6, 7, 8, 9, 13, 14, 15, 16 & 17. The scope of severity of the deficiency was reduced to D-isolated, no actual harm with a potential for no more than minimal harm.

Based on record review and interview, the facility failed to provide nursing care and services to ensure proper post-fall nursing evaluation, and failed to conduct thorough assessments and provide appropriate, timely medical care for an identified change in condition, for 1 of 5 residents reviewed for falls and/or a change in condition (#41). The facility's failure to treat a change in condition resulted in actual harm. During a 3-week stay in the facility, resident #41 had 3 falls within 8 days of admission. One fall was not witnessed by staff, and it was unknown if resident #41 suffered a head injury at that time. During his last 5 days in the facility, resident #41 had changes from his baseline physical and mental status. He was eventually transferred to the hospital for symptoms of a stroke. Resident #41 was diagnosed with [REDACTED]. Findings: Resident #41 was admitted to the facility on [DATE] for rehabilitation services. His [DIAGNOSES REDACTED]. Review of the hospital transfer AHCA Form ,[DATE] ([DATE]) revealed resident #41 was Alert, disoriented, but can follow simple instructions. He required the assistance of 2 people for transfers, walked with an assistive device and had full weight-bearing status for both legs. The form indicated resident #41 was at risk for falls. The Minimum Data Set (MDS), discharge return anticipated assessment, dated [DATE], revealed resident #41 had moderately impaired cognitive skills for daily decision-making. The assessment indicated during the look back period, resident #41 had no behavioral symptoms and required extensive assistance for activities of daily living. He had 1 fall, his third, since the prior MDS assessment. Review of the medical record revealed resident #41 had a care plan for actual falls initiated on [DATE]. It directed staff to monitor and document on symptoms including bruises and change in mental status. The care plan specifically instructed nurses to report New onset: confusion, sleepiness, inability to maintain posture, agitation. Resident #41 had a care plan for anticoagulant or blood thinner medications initiated on [DATE]. The interventions directed staff to monitor, document and report signs and symptoms of bleeding including lethargy, bruising, shortness of breath, loss of appetite and sudden changes in vital signs or mental status. A care plan initiated on [DATE], revealed resident #41 planned to be discharged to another long term care facility after completion of therapy services. In a telephone interview on [DATE] at 4:18 PM, resident #41's son stated his father had [MEDICAL CONDITION] and was at risk for falls. He explained his father was at the facility for therapy after surgical repair of a [MEDICAL CONDITION]. The son stated facility staff notified him of 3 falls during the first week. Resident #41's son stated he and other family members noticed a difference in his father during the last few days in the facility. He said, My father almost looked paralyzed and he was sleeping most of the time. There was a change in his baseline. Resident #41's son recalled a scheduled care plan meeting was held a couple days before his father was sent to the hospital. He explained during the week prior to the meeting, his father was able to hold a can of soda and feed himself cookies. However, on the day of the meeting he was not able to do that. The son explained by the time his father was admitted to the hospital, doctors discovered he had suffered a stroke and 2 brain bleeds. Resident #41's son explained due to his father's condition, he was put on hospice services until he died on [DATE]. Resident #41's son said, We assumed everything was ok. He fell . He had a few x-rays and they were negative, but they did not send him for a CT to check his head. He didn't go to the hospital. A CT or computed tomography is a combination of x-rays and 2 dimensional computer pictures that shows more detail than a regular x-ray. This diagnostic test provides precise data related to brain injuries. (www.hopkinsmedicine.org) Review of a Change in Condition form dated [DATE] at 8:00 AM revealed resident #41 was Found on the floor in room. No injury noted. The primary physician was notified and no orders were received. Licensed Practical Nurse (LPN) N completed the form but did not record any medication alerts such as use of an anticoagulant. However, review of resident #41's Order Summary Report revealed he had an order dated [DATE] for [MED] 40 milligrams per 0.4 milliliters (mg/ml) to be injected once daily until [DATE]. [MEDICATION NAME] is an anticoagulant, also called a blood thinner. This medication prevents and treats blood clots by lowering the activity of proteins that cause blood to clot, and puts patients at higher risk for bleeding after an injury or certain types of [MEDICAL CONDITION]. (www.webmd.com) Review of a Neurological Assessment Flow Sheet form revealed instructions to complete neurological checks or Neurochecks every 15 minutes for 1 hour, every hour for 4 hours, and every 4 hour for an additional 19 hours. Neurological checks are usually done after an unwitnessed fall to identify signs of a head injury. The evaluation includes checking level or consciousness, vital signs, pupil size and reactivity to light, and hand grip strength. Standard clinical nursing practice suggests this evaluation should be done immediately after the fall, then at regular intervals, gradually decreasing in frequency over a specified time. (www.hcpro.com) After resident #41's fall on [DATE], LPN N recorded Neurochecks at 8:00 AM, 8:15 AM, 8:30 AM, 8:45 AM, 9:00 AM, 10:00 AM, 11:00 AM and 12:00 PM. However, there was no documentation of Neurochecks completed every 4 hours over the next 19 hours as recommended. Review of progress notes and a physician's orders [REDACTED].#41 was assessed by an Advanced Practice Registered Nurse (APRN) who requested a 2 view x-ray of his left hand due to swelling. The radiology report revealed resident #41 did not have a fracture. A Change in Condition form dated [DATE] at 11:50 AM revealed resident #41 had a witnessed fall and hit his right hip on the floor. The physician ordered an x-ray of the right hip and pelvis that showed no acute findings. A few days later on [DATE] at 9:43 AM, the APRN assessed resident #41 and wrote, Pt with recent fall, noted l knee swollen X-ray of knee. However, there was no order noted for an x-ray of resident #41's knee. Between [DATE] at 2:43 AM and [DATE] at 2:05 PM, resident #41 received 8 doses of a narcotic pain medication, [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg. for pain levels between 5 and 8 on a 0 to 10 scale. A skilled nursing note by LPN N dated [DATE] at 2:00 PM revealed resident #41 was oriented to person and had no respiratory or swallowing problems. However, later that evening, a Change in Condition form dated [DATE] at 11:01 PM revealed resident #41 was lethargic and had a low-grade fever of 99.3 degrees Fahrenheit. A nursing evaluation indicated compared to baseline, he had an altered level of consciousness, generalized weakness, and decreased appetite/fluid intake. LPN O wrote, Patient lethargic throughout shift, refused evening meal, this is a change in behavior in patient, MD ordered stat 2 view chest x-ray for congestion, patient is a fall risk. Review of the Order Summary Report revealed physician's orders [REDACTED]. On [DATE] at 11:06 AM, a nurse's note indicated resident #41 remained lethargic, responded to tactile stimulus and his name. He was evaluated to be tired, sluggish, and had little energy and poor appetite. A progress note later that afternoon at 1:06 PM indicated resident #41 was more awake and aware of his surrounding environment. and ate 100% of his lunch during his daughter's visit. However, his scheduled 2:00 PM dose of [MEDICATION NAME] anti-anxiety medication was held due to lethargy. On [DATE] at 3:36 PM, nursing documentation revealed resident #41's chest x-ray result was negative, but lab tests still had not been drawn. The stat labs were finally collected on [DATE] at 5:45 PM, approximately 22 hours after they were ordered. On [DATE] at 9:10 PM, LPN O's note read, Patient still lethargic awaiting stat lab results to treat if necessary. The medical record revealed on [DATE] at 1310, there was an interdisciplinary team meeting with resident #41's representative to discuss the plan of care. Later that evening at 9:00 PM, LPN O held resident #41's scheduled dose of [MEDICATION NAME]. On [DATE] at 3:03 PM, LPN H documented she did not administer a scheduled dose of [MEDICATION NAME] since resident #41 was sleeping all (morning to) noon with Staff awakening Him for ADLs, etc. A Change in Condition form dated [DATE] at 1:36 PM revealed resident #41 had a change in mental status, altered level of consciousness and was sleeping more. He had right side weakness with right facial drooping. Resident #41 was assessed by the APRN, who gave an order to send him to the hospital emergency room via 911 for a stat CT scan for Possible Stroke. Right Facial Drooping. Review of resident #41's hospital record revealed an Emergency Department (ED) Patient Care Record dated [DATE] at 3:09 PM. The document indicated resident #41 had right side deficit and right side facial droop. Family members informed hospital staff they noticed the right side deficit 4 days before and a right side facial droop within the past few hours. The triage assessment revealed Pt only respond(s) to painful stimuli. A CT scan of the head, done on [DATE] at 3:48 PM, showed resident #41 had Subacute and/or chronic subdural hemorrhages left larger than right with compression of cerebral hemispheres and shift of midline towards the right. Subacute subdural hematomas usually present between 4 and 21 days after injury. Chronic subdural hematomas can present more than 21 days after injury. A midline shift of >5 millimeters (mm) is usually treated by surgical intervention. (www.medscape.com) The History and Physical (H&P), dated [DATE], revealed resident #41's family was present in the emergency room (ER). The H&P read, Per family at bedside, they noticed that he has been shifting to his right side since Monday ([DATE]), decrease intake and food intake, unable to swallow yesterday ([DATE]). This morning, today they noted he had a right-sided facial droop. After an extensive discussion with the ED physician, the family members declined to pursue surgical intervention and changed resident #41's full code status to Do Not Resuscitate. On [DATE] at 5:55 AM, a follow up CT scan of resident #41's head showed Stable bilateral hemispheric subacute on chronic subdural hematomas, measuring up to 3 cm (centimeters) on the left and 1.4 cm on the right. 1.4 cm midline shift, compared to 1.2 cm previously. A hospital progress note, dated [DATE], revealed resident #41's admission and discharge [DIAGNOSES REDACTED]. A repeat CT showed hematomas were unchanged but there was increased midline shift. Due to increased secretions, and the worsening midline shift, resident #41's diet was stopped and he was admitted to hospice services. On [DATE] at 4:16 PM, LPN H explained she was not assigned to resident #41 regularly. She recalled he was normally confused and anxious. LPN H stated resident #41 experienced a significant decline in his last 5 days in the facility. She stated he always required some assistance with ADLs, but needed much more towards the end due to lethargy and diminished arousability. LPN H said, Even out in the hallway, I noticed he was leaning to one side the day before he went to the hospital. He did not eat well and the daughter came in. He perked up for a while and then went down. On the last day it just continued getting worse. He became more sleepy. He was up that morning and was leaning in the chair so we put him back to bed. He just didn't seem normal. LPN H recalled the APRN assessed resident #41 at about lunchtime and gave a stat order to send him to the hospital. LPN H said, We felt it was an emergency. On [DATE] at 4:46 PM, the Director of Rehab stated therapists were not required to complete daily progress notes on Medicare patients. She explained they documented only the time spent with residents, and not the specifics of activities that occurred during therapy sessions. Resident #41's therapy discharge summaries were reviewed with the Director of Rehab. The Physical Therapy Discharge Summary indicated resident #41 was on caseload from [DATE] to [DATE]. The Director of Rehab stated resident #41's baseline was moderate assistance on admission and declined to dependent and non-ambulatory on discharge. The Physical Therapy discharge summary revealed resident #41's limited progress was due to altered mental status, noticeable muscle imbalance, right side weakness and right facial droop. On [DATE] at 5:00 PM, physical therapist (PT) K stated she was familiar with resident #41 and noticed a change during a session on [DATE]. PT K said, There was significant weakness on the right side and I did not recall him having a history of a stroke. I documented because I noticed the significant change. He had a facial droop and right side weakness. He could not squeeze my hand or grab the walker. I tried to put him in the parallel bar to stand but he could not do it. PT K explained resident #41 had a significant issue with trunk control and could not sit up in the wheelchair. She stated she had the Occupational Therapy Assistant transition resident #41 from his wheelchair to a high back wheelchair. PT K stated she was a clinician and therefore felt it was her responsibility to assess resident #41 and communicate her findings to the nurse, LPN H. She explained LPN H was responsible for notifying the physician. However, PT K stated the following day on [DATE], she was surprised to see resident #41's name on her schedule. She went to his room and the Certified Nursing Assistant (CNA) informed her resident #41 was not eating. PT K said, The CNAs were worried. I went and got the APRN right away. I was really worried that he was still here. I was mad. In my judgement he should have been sent out the day before. PT K stated the APRN assessed resident #41 and instructed LPN H to transfer him to the hospital. Review of a Physical Therapy Treatment Encounter Note dated [DATE] at 4:48 PM read, Based on today's assessment, patient demonstrate(d) severe muscle imbalance and poor postural control. PT K noted resident #41 had a noticeable facial droop on the right side, and and his right arm, right leg and trunk were weaker on the right side. Her documentation detailed, R side poor motor control and flaccid/No Muscle tone. (LPN H) was notified and requested to notify (the attending physician). However, on [DATE] at 5:18 PM, LPN H stated she did not recall a conversation with PT K regarding informing the attending physician about resident #41's right-sided weakness. On [DATE] at 9:01 AM, the MDS Coordinator explained resident #41 had a care plan meeting on [DATE] that was attended by staff and family. She provided an attendance sheet with 6 signatures and explained she typically kept no notes regarding discussions in care plan meetings. On [DATE] at 9:33 AM, Physical Therapy Assistant (PTA) L stated he last treated resident #41 on [DATE], and he was at baseline that day. PTA L stated he attended the care plan meeting, attended by more than 1 family member, and advised them resident #41 was at maximum level because of his inability to follow instructions. On [DATE] at 10:21 AM, the [UNIT] Unit Manager (UM) stated she also attended the care plan meeting. She recalled there were multiple family members present and they discussed the plan of care and resident #41's decline. The [UNIT] UM stated she felt his decline, including decreased ability to chew, was more related to his dementia. She said, I don't remember the sequence of events, but I know we were following up on him closely. The [UNIT] UM stated she was not informed of resident #41's change in condition noted by PT K on [DATE]. On [DATE] at 11:07 AM, Speech Therapist (ST) M recalled there was a decrease in resident #41's arousability and fluctuations in the last 2 to 3 days she treated him. She stated he required more cueing that usual. ST M stated she did not document daily notes in the medical record. However, the first day she noticed resident #41's decreased arousability ST M stated she notified the nurse. She could not recall which nurse. ST M stated although the fluctuation in arousability continued she did not notify nursing staff again because it was possibly his new baseline. On [DATE] at 11:31 AM, LPN N stated she wrote an order on [DATE] to downgrade resident #41's diet texture from regular to mechanical soft to make it easier for him to chew. She said, The diet with him was more of a cognitive issue. LPN H stated she did not notify the attending physician because resident #41 did not have swallowing concerns and nurses were permitted to downgrade diets. During interviews on [DATE] at 12:00 PM, 1:35 PM and 3:17 PM, the Director of Nursing (DON) was informed resident #41 did not have Neurochecks completed per protocol after an unwitnessed fall. The DON stated the facility viewed resident #41's transfer to the hospital as a result of a change in clinical status related to his dementia disease process. She stated her understanding was resident #41 had fluctuations in his status during his stay, therefore the changes and decline noted would not have been significant. After review of the facility's annual education calendar for 2020 and the skills fair agenda from [DATE], the DON and Assistant DON stated the facility had not provided nursing staff with education on stroke symptoms. The DON was informed PT K's documentation showed that she informed LPN H of resident #41's significant change in condition on [DATE], but resident #41 was not transferred to the hospital until almost 24 hours later. The facility's policy and procedure for Abuse, Neglect, Exploitation & Misappropriation revised on [DATE], was reviewed with the DON. The document defined Neglect as failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm. The DON stated she did not feel resident #41 experienced Neglect. However, she said, I see that there was a delay in care. Review of resident #41's medical record revealed no nursing documentation of fluctuations in mental status or level of consciousness between admission on [DATE] and [DATE] when nursing staff noted a change in condition. Review of the nursing progress notes for January and February 2020 revealed no documentation of the necessity to hold resident #41's scheduled doses of [MEDICATION NAME] 1 mg for lethargy or over-sedation until [DATE]. There was no documentation the attending physician was informed at least 4 scheduled does of [MEDICATION NAME] were held over a 3-day period due to resident #41's change in level of consciousness. In addition, the medical record included a Skilled Note by Registered Nurse (RN) P, dated [DATE] at 3:40 AM. The note included vital signs and assessment findings for resident #41 although he was transferred to the hospital over 12 hours before. Although resident #41 was not in the facility, RN P also charted administration of a scheduled dose of [MEDICATION NAME] 1 mg on [DATE] at 6:00 AM. On [DATE] at 4:24 PM, the DON stated she was not able to explain how RN P completed a full assessment including vital signs and physical findings if resident #41 was not in the building. On [DATE] at 3:05 PM, during a telephone interview with the facility's Medical Director, he stated if there was a change a resident's condition, the expectation would be to first conduct a nursing assessment then notify the attending physician. The Medical Director stated familiarity with the resident's baseline was significant in observations related to a change in condition. He stated he was informed the nurses who assessed resident #41 did not notice anything different about him, as he had fluctuations in status and behaviors. The Medical Director explained facial drooping and weakness of one side were classic stroke signs. However, he stated stroke symptoms could resemble symptoms of a urinary tract infection or changes related to dementia. The Medical Director stated he was informed resident #41 was also on medication that should be held for over-sedation. He explained the type of hemorrhage resident #41 suffered could have occurred as long as 21 days before discharge. The Medical Director was informed PT K was familiar with resident #41, noted his right side weakness and facial drooping, and reported it to nursing staff the day before he was sent to the hospital. The Medical Director was informed there was no nursing documentation prior to resident #41's final week in the facility regarding fluctuations in mental status and arousability, and no physician notification of scheduled medication held for lethargy. The Medical Director re-stated the information provided to him by the facility.