Every finding on record at Aviata at Rosewood

Based on interview, and record review, the facility failed to effectively implement its compliance and ethics program by failing to promote ethical conduct related to reporting resident incidents and allegations of abuse, failing to provide effective oversight by high-level personnel to ensure adherence to ethical standards, and failing to maintain effective lines of communication that encouraged staff and residents to report concerns without fear of retaliation.Findings: On 7/08/26 at 2:50 PM, resident #4 stated the Director of Nursing (DON) yells at everybody and has nurses here crying. She stated a visitor had reported the DON to Corporate because the DON discussed other residents in front of residents and visitors. Resident #4 further stated staff were disrespectful toward Spanish-speaking residents, and some residents feared retaliation and therefore did not report their concerns. On 7/08/26 at 5:21 PM, resident #6 stated some residents were afraid to report concerns to staff because they feared retaliation. Resident #6 said, if you talk to someone, there's a lot of repercussions here, even from staff talking. On 7/08/26 at 9:27 PM, during a telephone interview, Licensed Practical Nurse (LPN) C stated she was concerned facility management changed staff statements and later claimed they were unaware of reported incidents. She further stated the facility was underreporting all the time. LPN C stated the DON instructed staff what to write to cover up incidents. She indicated nurses documented medications as administered when they were not even available to be given and staff were required to contact the DON before initiating any cardiopulmonary resuscitation, which could delay care. LPN C stated there was a lot of retaliation to the staff. On 7/08/26 at 10:24 PM, during a telephone interview, Registered Nurse (RN) D said, It is too much happening in the facility. Not sure if people are doing the right thing. RN D indicated the DON had insulted her and made comments such as Why are you with Hispanics? She stated staff was afraid of the DON because she screamed and yelled at them. RN D further stated residents had videotaped the DON yelling at her and later told her they were tired of the way the DON treated the staff. She stated someone from the corporate office contacted her regarding the video and instructed her to report the matter to Human Resources (HR). RN E stated she believed the DON's actions were retaliatory. On 7/09/26 at 10:35 AM, CNA J stated he was unaware of the facility's ethic and compliance telephone number and believed concerns should be reported to HR. CNA J further stated he was not familiar with the facility's ethics and compliance program. On 7/09/26 at 11:03 AM, Licensed Practical Nurse (LPN) F stated she was unsure whether she had completed the facility's ethics and compliance training. She indicated she would report required incidents to the Administrator (NHA) and grievances to the Social Services Director (SSD). However, LPN F was unable to explain when or how the facility's ethics and compliance line should be used. She stated ethics meant treating people with respect and not calling them names. On 7/9/26 at 11:23 AM, CNA E stated residents should be treated with dignity and respect, but she had observed several nurses speak to residents in a disrespectful manner, including telling residents, Go to your room. She stated she was afraid to report concerns because she feared losing her job. She stated she previously informed the NHA about the manner the DON reprimanded her in front of staff and residents. CNA E explained this was the reason she sought assistance from Social Services when residents voiced concerns rather than reporting directly through nursing leadership. On 7/09/26 at 3:12 PM, the NHA acknowledged staff had expressed concerns regarding the DON's behavior, including that the DON spoke harshly to staff and had been rough in her interactions. The NHA stated she discussed those concerns with the DON and described herself as serving as a mediator because the DON was passionate about getting stuff done. The NHA stated she had not reported those concerns to corporate leadership. She indicated staff received ethics and compliance education upon hire, and annually; for example, during staff meetings she reminded employees, if you see or hear something, say something. The NHA stated she was unaware, staff or residents, feared retaliation and reiterated staff could report concerns directly to her or though the corporate compliance hotline if they were uncomfortable reporting to their supervisor. On 7/09/26 at 5:19 PM, during a telephone interview, the Corporate Compliance Officer stated she monitored the corporate compliance hotline, which accepted anonymous and identified reports from staff, residents, family members, or community members. She explained concerns could also be submitted electronically through a QR code and categorized as employee concerns, abuse concerns, fraud, billing issues, or other compliance matters. She stated employees completed ethics and compliance training upon hire and annually, with training available in multiple languages. She explained the training concluded with a competency test and employee attestation. The Corporate Compliance Officer stated one compliance concern had been received that morning regarding a medication issue and assigned to the facility for follow up. She indicated the company received five compliance concerns during 2025 and two during 2026 to date. The Corporate Compliance Officer mentioned employee concerns were tracked separately through HR. She explained corporate oversight was provided by regional leadership through routine operational and clinical visits, and all concerns were forwarded to the Regional [NAME] President of Operations. Lastly, she stated she was also the Chief Nursing Officer, and the company took all compliance concerns seriously. Review of an undated Corporate Compliance poster hung near the staff clock in area, revealed the program was their code of business conduct. The poster instructed the reader that if they were faced with an issue or were aware of an issue that may be illegal or unethical the staff were expected to make that issue known. The poster indicated the expectation that all employees were aware of and should abide by all federal and state rules and regulations. The document described ongoing training and regular audits would be conducted to confirm compliance. The bottom of the poster detailed in bold, If you have any compliance concerns, please contact our Corporate Compliance Hotline, with a phone number in large letters at the bottom. (Photo evidence obtained) Review of the facility's Corporate Compliance Program, revised 9/01/23, revealed the company was committed to maintaining the highest ethical standards and complying with applicable federal and state laws and regulations. The policy stated the goals of the compliance program included preventing and correcting fraud, waste and abuse; promoting a culture of ethical behavior and compliance; and providing quality care to residents. The policy further identified seven elements of an effective compliance program, including written policies and procedures, compliance by a Corporate Compliance Officer and Compliance Committee, effective education and training, auditing and monitoring, open lines of communication, consistent disciplinary standards, and corrective action Review of the facility's Ethics, Conflict of Interest policy, revised 9/01/23, revealed all employees were required to comply with applicable federal, state, and local laws, rules, and regulations governing the company's operations. The policy included employees were responsible for reporting suspected ethical misconduct.

Based on interview, and record review, the facility failed to conduct thorough investigations of a resident-to-resident physical abuse allegation resulting in injury and a staff-to-resident verbal abuse allegation for 2 of 5 residents reviewed for abuse, of a total sample of 15 residents, (#2 and #9).Findings: 1. Review of resident #1's medical record revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizophrenia, major depressive disorder, anxiety, and anoxic brain damage. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/13/26 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Review of a Behavior Progress Note dated 5/04/26 revealed resident #1 was constantly going into other resident's rooms. The note documented that when staff attempted to redirect him to his room, the resident planted his feet firmly on the floor as he did not want to return. The documentation indicated staff redirected him several times during the shift, and the Social Worker was notified of the behavior. Review of a Progress Note dated 5/10/26 revealed resident #1 exhibited severe behavioral disturbances throughout the shift, including refusal of care, combative behaviors toward staff, and repeated attempts to enter other residents' rooms. Despite multiple redirections, interventions, and behavioral approaches, resident #1 continued exhibiting intrusive wandering behaviors and remained difficult to redirect for extended periods. The note indicated continued monitoring and behavioral interventions were maintained to promote resident and unit safety. Review of a provider Progress Note dated 5/13/26 revealed resident #1 was evaluated for behaviors. The provider documented the resident was sitting up in bed, had been acting out, attempting to get out of bed, and refusing medications. Review of a Progress Note dated 5/17/26 revealed at approximately 3:05 AM, officers met with resident #1. The note indicated the resident was not [NAME] Acted by officers, and the officers were aware of an occurrence where resident #1, physically attacked another resident causing harm. Provider made aware that resident was not baker acted by officers, Guardian made aware of recent events involving resident. Staff continues to monitor resident with enhanced supervision. 2. Review of resident #2's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, functional quadriplegia, adjustment disorder, and anxiety. Review of the admission MDS assessment with an ARD of 6/26/26 revealed resident #2 had a BIMS score of 15 out of 15, indicating intact cognition. Review of resident #2's Progress Note dated 5/17/26 revealed that, at approximately 2:45 AM, resident #2 approached the nurses' station in her wheelchair and reported resident #1 had entered her room and punched her in the face. The note further documented resident #1 was observed at end of the hallway and redirected by staff. Resident #2 complained of pain to her left jaw and the right side of her face, and staff noted a knot-like area on the right side of her face. Review of a Social Services Progress Note dated 5/18/26 revealed the Social Services Director (SSD) met with resident #2 to assess her well-being following the incident. Resident #2 stated, I'm doing okay. It was about 2:30 AM when this guy walked into my room. I was asleep when he entered. I was awakened by his presence. I yelled at him to leave the room. He walked towards the door then turned back towards me. This happened about 5 times. All he said to me was that this was his room. Yes, he walked towards me and was going away at my face. Yes, I had the call light on, and I was yelling for help. He closed the bathroom and room door. I am not sure how long he was in the room. The door was ajar and not fully closed. After he left, I got into my wheelchair and went to the Nursing Station for help. On 7/08/26 at 12:12 PM, resident #2 stated that resident #1 entered her room, sat at the foot of her bed, and began pulling her blankets. She stated she repeatedly asked resident #1 to leave but he refused. Resident #2 stated she activated her call light and attempted to pull her blankets back, at which time resident #1 punched her in the face with a closed fist. She reported staff did not respond to her repeated calls for help, so she transferred herself into her wheelchair and went to the nurses' station. Resident #2 stated she observed a Certified Nursing Assistant (CNA) asleep in the day room and recalled a nurse jokingly saying he was also asleep. Resident #2 stated she told the nurses she had been yelling and screaming for assistance while resident #1 remained in her room repeatedly saying, my bed, my bed, leading her to believe he thought he was in his own room. Resident #2 stated resident #1 walked toward the door several times but repeatedly returned instead of leaving. Resident #2 further stated resident #1 had entered other residents' rooms before coming into hers. She showed photographs of the bruising to her face following the incident and recalled it took a nurse and two CNAs to remove resident #1 from her room. Resident #2 stated she did not sustain any fractures but experienced significant facial pain. On 7/08/26 at 2:20 PM, resident #14 stated she recalled resident #1 entering her room and slamming the door. She stated she called the nurses' station after hearing another resident screaming for help for approximately 15 minutes. Resident #14 stated the incident lasted more than 20 minutes and resident #2 eventually went to the nurses' station in her wheelchair to seek assistance. She stated resident #2, whose room was across from hers, repeatedly screamed stop during the incident. Resident #14 further stated resident #2's face remained bruised for weeks following the incident. On 7/08/26 at 5:21 PM, resident #6 stated she learned about the incident involving resident #2 after receiving a text message from resident #2 that same night. She further stated the incident made her very afraid and remained fearful; because she believed something similar could happen to her. Resident #6 indicated resident #1 was able to walk throughout the hallways without staff intervening, despite nurses being present at the nurses' station. She stated resident #2 had been screaming for help and ultimately had to go to the nurses' station herself to obtain assistance. Resident #6 reported she had heard there was not CNA present on the unit at the time of the incident and mentioned staff were not as attentive during the night shift. Resident #6 further stated no one interviewed her regarding what she knew about the incident. On 7/09/26 at 3:35 PM, the Administrator (NHA) reviewed the investigation regarding the resident-to-resident physical abuse allegation involving residents #1 and #2. The NHA stated resident #1 had no history of aggression toward other residents but acknowledged he had a history of aggression involving objects. She indicated resident #1 remained on one-on-one (1:1) supervision following the incident, laboratory work was obtained, medications were reviewed, and the interdisciplinary team discussed interventions, including room placement, medications and supervision. She stated the facility attempted to transfer resident #1, however, his guardian wanted him to remain in the facility because it was closer to her. The NHA further stated the Director of Nursing (DON) completed the chart review and Progress Notes from 4/21/26 to 5/22/26 were printed as part of the investigation. However, the NHA confirmed the investigation did not identify or include the Behavior Progress Notes dated 5/04/26 and 5/10/26 documenting resident #1 repeated attempts to enter other residents' rooms, intrusive wandering behaviors, and difficulty with redirection during the week preceding the incident. The NHA stated the investigation included three witness statements consisting of a Social Services Progress Note on 5/18/26, an interview with Licensed Practical Nurse (LPN) C, and from a CNA who provided 1:1 supervision for resident #1 after the incident. The NHA indicated she and the SSD interviewed other residents, and no one reported hearing or witnessing the incident. The investigation file contained no evidence the staff assigned to resident #1, other staff working the unit the night of the incident, or residents occupying nearby rooms were interviewed. The NHA acknowledged she could not identify which staff or residents had been interviewed the night of the incident and stated interview forms were not available to support those interviews. She further stated no one reported resident #1 had attempted to enter other residents' rooms before entering resident #2's room. 3. Review of resident #9's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right femur fracture, end stage renal disease, and type 2 diabetes. Review of a Progress Note dated 5/07/26 revealed resident #9 had a BIMS score of 14 out of 15, indicating intact cognition. Review of the Agency for Health Care Administration (AHCA)'s Nursing Home Federal Report Form, submitted on 5/08/26, revealed an allegation of mental/verbal abuse involving resident #9 occurred on 5/01/26 at 2:51 PM. The report documented Registered Nurse (RN) D became aware of the allegation on 5/03/26 and the NHA was notified on 5/04/26. Review of resident #9's witness statement, obtained by the SSD on 5/08/26, revealed resident #9 stated, On Friday, May 1, 2026, I asked the CNA (CNA I) why didn't she take out the trays. I had my breakfast and lunch tray in the room at the same time they were bringing in my dinner tray. She said I had to wait with a bad attitude. Yes, she kept on walking while I was talking to her. (Unit Manager's name) went to talk with her after I spoke with SSA (Social Services Assistant). Later that day, her mom came to talk to me. She came up to me, pointed at my face and told me not to mess around with her daughter. She then said, f-k you. I told her all I did was file a complaint with Social Services about the trays. Her mom told me she will bring her family if I had any problems. I just told her that I had family too. She left me and went to speak with another CNA. On 7/09/26 at 3:35 PM, the NHA reviewed the investigation regarding the allegation of verbal abuse involving resident #9. The NHA stated the Unit Manager no longer worked at the facility and acknowledged the investigation file did not contain a statement from him. She further stated the investigation file did not contain a statement from the Social Services Assistant. The NHA stated the SSD interviewed resident #9 on 5/08/26, and the reportable event was submitted that same day. She stated CNA I was not assigned to resident #9. The NHA acknowledged she did not interview residents who were present in or near the hallway where the incident occurred because she did not know if ay residents had witnessed the event. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy, revised 11/16/22, revealed all reported events were be investigated by the DON or designee, with information forwarded to the Executive Director, who served as the Abuse Coordinator. The policy stated the Abuse Coordinator was responsible for investigating all reports and allegations of abuse, neglect, exploitation and misappropriation. The policy further required the Abuse Coordinator and/or the DON to conduct a thorough investigation by obtaining statements from the alleged victim, the alleged perpetrator, and all potential witnesses, including employees who were in the vicinity of the alleged incident. In the absence of the Executive Director, the DON served as the designated Abuse Coordinator. The policy also required allegations of abuse, neglect, exploitation, and misappropriation to be reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) program. The QAPI committee was responsible for evaluating the thoroughness of the investigation, measures taken to protect the resident, identified risk factors, the root cause of the incident, and any systemic changes necessary to prevent recurrence.

Based on interview, and record review, the facility failed to report allegations of abuse to the state Agency for Health Care Administration (AHCA) within the required timeframes for 2 of 5 residents reviewed for abuse, in a total sample of 15 residents, (#4 and #9).Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including gastritis, anxiety disorder, major depression disorder, and osteoarthritis. Review of the admission Minimum Data Set assessment with an Assessment Reference Date of 6/16/26 revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 7/08/26 at 2:50 PM, resident #4 stated on 7/01/26 her assigned nurse, Registered Nurse (RN) B, administered her prescribed Miralax in a clear medication cup. She shared that while swallowing the medication, she felt something else in her mouth, spit it out, and discovered two tablets in the cup. Resident #4 indicated she asked RN B what had been given to her, and the nurse responded it was something to make her stronger. She stated following the medication incident, RN B became upset, attempted to grab her telephone while she was speaking with her daughter, and tried to intimidate her. Resident #4 stated she felt RN B had assaulted her and RN B asked her not to report the incident. Resident #4 stated she verbally informed facility staff about the incident the previous week and later prepared a written letter describing the events, which she provided to the Social Services Assistant on 7/07/26. Resident #4 provided a signed, six-page typed letter dated 7/02/26. The letter described after the medication incident, RN B yelled at resident #4 and other residents who were sitting together in the hallway, asking who was going to speak with the Director of Nursing (DON). The letter further documented RN B followed resident #4 to her room while she was speaking with her daughter by telephone, screamed at her, attempted to take the telephone from her, and continued confronting her after the resident asked the nurse to leave the room. The letter stated, She (RN B) replied, 'Oh, you can stand, but you don't have any balance,' and used her body to push me. I walked away from her and told her that was assault. On 7/08/26 at 3:51 PM, the Social Services Director (SSD) confirmed he received a copy of resident #4's written letter from the Social Services Assistant the previous day. The SSD stated the letter was entered into the facility's grievance log, and the Administrator (NHA) had been notified and was addressing the matter. The SSD indicated the NHA served as the facility's Abuse Coordinator. On 7/08/26 at 4:04 PM, the Social Services Assistant stated he received resident #4's written letter at approximately 4:00 to 5:00 PM on 7/07/26. He stated he read the letter, recognized it contained allegations of abuse, and immediately emailed a copy to the NHA, the SSD and the DON. The Social Services Assistant indicated the email was sent on 7/07/26 at 4:45 PM. He stated resident #4 told him on Monday 7/06/26 she wanted to discuss a concern but preferred to put in writing first. He indicated resident #4 did not disclose any allegation of abuse before providing the written letter. On 7/08/26 at 4:40 PM, during a joint interview between the NHA and the DON, the NHA stated she was responsible for the overall health and safety of the residents and served as the facility's Abuse Coordinator. She indicated staff received education regarding abuse, neglect, and mandatory reporting requirements and were instructed to notify her immediately of any allegation of abuse by telephone or text message. The NHA stated allegations involving abuse must be reported to the appropriate agencies within two hours after the facility becomes aware of the allegation, with the investigation completed within five business days. She further stated reportable allegations were also reported to the Department of Children and Families, law enforcement, the regional team, the Medical Director and the resident's representative. The NHA stated she became aware of resident #4's allegation after reviewing the email and attached letter sent by the Social Services Assistant. She stated the facility was in the process of submitting the required report to AHCA; however, she acknowledged the required reporting timeframe had not been met because more than two hours had elapsed since the facility became aware of the allegation. The NHA confirmed the email containing resident #4's written allegation had been sent the previous evening. She stated the situation presented differently and resident #4 had not previously alleged abuse. The NHA acknowledged she had not yet spoken with staff regarding the alleged abuse incident. On 7/08/26 at 10:24 PM, during a telephone interview, RN D stated RN B informed her the medication incident involving resident #4 had been reported to the appropriate individuals during shift report. RN D recalled resident #4 appeared nervous and frightened while discussing the incident and expressed RN B had been rude to her. RN D further stated resident #4 did not describe any physical contact, only that RN B had been rude. RN D stated she did not report the resident's concerns to anyone because she believed RN B had already reported the incident. On 7/09/26 at 11:23 AM, Certified Nursing Assistant (CNA) E stated resident #4 told her on 7/02/26 about an incident that had occurred the previous day. CNA E indicated resident #4 appeared upset and was shaking while describing the events. According to CNA E, resident #4 reported RN B administered Miralax containing two tablets, and when she felt the tablets in her mouth, she spit them out and questioned the nurse about the medication. CNA E stated resident #4 reported RN B initially walked away without answering, then later made a muscle gesture with her arm and stated the tablets were vitamins that would make her stronger. CNA E continued that resident #4 reported she argued with RN B while speaking with her daughter by telephone, RN B attempted to take the telephone from her and the resident told RN B not to touch her. CNA E stated resident #4 reported RN B then moved very close to her, making chest-to-chest contact, in an intimidating manner. CNA E stated the resident told her she felt she had been assaulted by RN B. CNA E stated she advised resident #4 to notify Social Service staff. CNA E stated later that day, resident #4 told her she had spoken with the Social Services Assistant. CNA E stated she did not speak with the Social Services Assistant to verify what the resident reported. CNA E acknowledged she understood allegations of abuse were required to be reported immediately and that any employee could report concerns directly to either the SSD or the NHA. She stated each employee was responsible for reporting allegations of abuse and the facility had basically two hours or less to report it to the state. CNA E stated she looked for the SSD but could not find him and did not think the NHA was in the building. She acknowledged the NHA's phone number was posted and agreed it was her responsibility to report the allegation directly to the NHA but did not do so. 2. Review of resident #9's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right femur fracture, end stage renal disease, and type 2 diabetes. Review of a Progress Note dated 5/07/26 revealed resident #9 had a BIMS score of 14 out of 15, indicating intact cognition. Review of the Nursing Home Federal Report Form submitted to AHCA on 5/08/26 revealed an allegation of mental/verbal abuse occurring on 5/01/26 at 2:51 PM. The report documented Registered Nurse (RN) D became aware of the allegation on 5/03/26 and NHA was not notified until 5/04/26. Review of a Complaint/Grievance Report dated 5/04/26 documented resident #9 reported concerns regarding the behavior of a staff member who, according to the resident, addressed him in a very inappropriate manner. The grievance was communicated to the SSD and was classified as customer service rather than an allegation of abuse. On 7/08/26 at 10:24 PM, during a telephone interview, RN D in regard to resident #9's allegation of verbal abuse on 5/01/26, she stated she overheard a verbal altercation between CNA H and resident #9. She indicated she asked the resident what he wanted to do because she was not his assigned nurse. RN D recalled later completing a witness statement but could not recall whether she reported the incident directly to the NHA. She stated she heard CNA H ask resident #9, Why did you report my daughter? and use profanity toward the resident. RN D acknowledged she recognized the incident was serious and knew it should be reported. The nurse stated she did not know who served as the facility's Abuse Coordinator. On 7/09/26 at 11:23 AM, CNA E stated she cared for resident #9 on 5/02/26 and 5/03/26. She indicated resident #9 told her a CNA had said very horrible things to him, threatened to bring her family to the facility, and told him, Oh you do not know who my family is. CNA E stated resident #9 also reported the CNA cursed at him and threatened him. She recalled she overheard resident #9 discussing the incident with other residents while RN D was present. CNA E stated she asked RN D if the incident had really occurred and whether it had been reported. CNA E remembered, RN D responded it had been reported. Review of the CNA Assignment sheets dated 5/01/26 and 5/02/26 revealed CNA H was assigned to work the 11:00 PM to 7:00 AM shift on both dates. Review of CNA H's timecard for the payroll period from 4/23/26 through 5/06/26 confirmed she worked on 5/02/26 from 11:18 PM to 7:20 AM and on 5/03/26 from 11:20 PM to 7:22 AM. On 7/09/26 at 3:35 PM, the NHA stated RN D overheard the conversation between CNA H and resident #9 on 5/01/26 but did not report the incident to her until 5/04/26. The NHA provided a grievance form she completed on 5/04/26 after receiving a text message from RN D stating the nurse overheard the CNA H using obscenities toward resident #9. The NHA stated the text message did not include detailed information, so she contacted RN D for clarification. According to the NHA, RN D told her to just ask him, that conversation wasn't right, and stated she may have misinterpreted what she heard. The NHA stated she was under the impression it was not as the nurse stated, in regard to why she had not submitted an immediate report to AHCA on 5/04/26, as soon as she became aware of the allegation. The NHA acknowledged she did not ask RN D why the incident had not been reported on the day it occurred. She further acknowledged resident #9 remained exposed to the alleged perpetrator for approximately two additional days before the employee was suspended. The NHA stated CNA H was not assigned to care for resident #9. She explained the incident occurred in the hallway while another CNA was nearby. The NHA acknowledged neither RN D, CNA H, nor the other CNA reported the allegation to her until RN D sent the text message on 5/04/26, the same day resident #9 filed a grievance with the SSD. Review of a Witness Statement completed by RN D on 5/06/26 read, On 1 May 2026 I was in the subacute hallway when the CNA (CNA H's name) and a patient were having a conversation next to me. At that time I heard her say to the patient, Don't (explicit word) with me. You don't want me to bring my family! Review of resident #9's Witness Statement obtained by the SSD on 5/08/26 read, Met with resident in SSD' office to address resident's concern. He stated, On Friday, May 1, 2026, I asked the CNA (CNA I's name) why didn't she take out the trays. I had my breakfast and lunch tray in the room at the same time they were bringing in my dinner tray. She said I had to wait, with a bad attitude. Yes, she kept on walking while I was talking to her. (Name of Unit Manager) went to talk with her after I spoke with SSA (Social Services Assistant). Later that day, her mom came to talk to me. She came up to me, pointed in my face and told me not to mess around with her daughter. She then said, f- -k you. I told her all I did was file a complaint with Social Services about the trays. Her mom told me she will bring her family if I had any problems. I just told her that I had family too. She left me and went to speak with another CNA. Review of the facility's Complaint/Grievance policy, revised 10/24/22, revealed residents had the right to voice grievances without fear of discrimination of reprisal. The policy documented grievances meeting the definition of abuse, neglect, exploitation, or misappropriation would be handled in accordance with the facility's Abuse Policy. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy, revised 11/16/22, revealed all reported events were be investigated by the DON or designee, with information forwarded to the Executive Director, who served as the Abuse Coordinator. The policy included the Abuse Coordinator was responsible for investigating all reports and allegations of abuse, neglect, exploitation and misappropriation. Immediately upon an allegation of abuse, neglect, exploitation and misappropriation, including obtaining statements from the alleged victim, the alleged perpetrator, and potential witnesses. The policy further required any employee or contracted service provider who witnessed or had knowledge of an act or an allegation of abuse, neglect, exploitation or mistreatment, or misappropriation to report the information immediately, but no later than two hours after the allegation was made if the event involved abuse, or no later than 24 hours if the event do not involve abuse and did not result in serious bodily injury, to the Administrator and other officials in accordance with State law. The policy described in the absence of the Executive Director, the DON served as the designated Abuse Coordinator.

Based on interview, and record review, the facility failed to ensure accurate documentation of the clinical record for one of two residents reviewed for medication administration documentation, of a total sample of 15 residents, (#4).Findings:Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including gastritis, anxiety disorder, major depression disorder, and osteoarthritis. Review of the admission Minimum Data Set assessment with an Assessment Reference Date of 6/16/26 revealed resident #4 had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Review of resident #4's Medication Administration Record (MAR) for July 2026 revealed resident #4 had physician orders for MiraLAX Oral Powder 17 grams, reconstituted, given twice a day.On 7/08/26 at 10:47 AM, during the facility tour resident#4 approached in her wheelchair and requested to meet in her room to discuss a concern. Later at 2:53 PM, in the resident's room, she recalled events from 7/01/26 when she said License Practical Nurse (LPN) B gave her a medication cup that contained MiraLAX and two unidentified pills inside. Resident#4 stated upon noticing the pills inside the MiraLAX liquid she questioned LPN B about what the two pills were and why they were inside the MiraLAX. Resident #4 explained she spit out the pills and did not take the MiraLAX. She recalled LPN B took the medication cup away from her and said the pills were vitamins to make her stronger. Resident#4 stated this made her upset and she requested to speak with the Director of Nursing (DON) which led to a verbal confrontation between LPN B and the resident.On 7/09/26 at 1:53 PM, LPN B stated she did not administer the dose of MiraLAX on 7/01/26 at 5:00 PM to resident #4. She confirmed the documented 7/03/26 at 9:00AM dose of MiraLAX was actually given by another nurse. LPN B stated the documentation on the July MAR was wrong and confirmed it was erroneous. The nurse explained she did not see resident #4 after the incident on 7/01/26.Further review of the July 2026 MAR revealed LPN B documented on 7/01/26 at 5:00 PM, that resident #4 received MiraLAX when the resident did not actually receive the medication. On 7/03/26 LPN B documented she administered the medication to resident #4 when actually another nurse administered the medication.On 07/09/26 at 5:45 PM, the DON stated nurses were expected to document medication administration accurately at the time medications were administered, and that medication administration record should reflect whether medication was given or refused. The Director of nursing stated the nurse that gave the medication should be the nurse who documented the medication administration.

Based on observation, interview, and record review, the facility failed to adhere to infection prevention and control practices related to glove use, handling of soiled waste, and hand hygiene.Findings:On 7/08/26 at 11:47 AM, Certified Nursing Assistant (CNA) A came out a resident room and was walking in the hallway on her way to the soiled utility room. The CNA was wearing a glove on her left hand and holding plastic bags to take to soiled utility room.On 7/08/26 at 11:50 AM, CNA A stated she was new at the facility but had received training by computer and in person on infection control and prevention. CNA A confirmed she was not supposed to wear gloves in hallway. The CNA stated she wore the glove into the hallway because there was a lot of stool and urine in the trash. CNA A stated she should not wear gloves in hallway because the glove could spread infection.On 7/09/26 at 5:45 PM, the Director of Nursing stated staff were expected to remove gloves after completing resident care and perform hand hygiene after glove removal. She confirmed gloves were not to be worn in the hallway so as not to spread infection and to prevent cross contamination.Review of the Personal Protective Equipment (PPE) policy revised October 2018 revealed gloves were part of the PPE provided to protect staff from exposure to bodily fluids.Review of the undated, US Centers for Disease Control and Prevention, Sequence for Putting on PPE, revealed, Remove all PPE before exiting the patient room, (retrieved from www.cdc.gov on 7/22/26).

Based on observation, interview, and record review, the facility failed to assess whether a resident could safely self-administer medications and implement the required process for self-administration for 1 of 1 residents reviewed for self-administration of medications, out of a total sample of 15 residents, (#3).Findings: Review of resident #3's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF), atrial fibrillation, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following a stroke affecting the right dominant side, and type 2 diabetes. Review of the Minimum Data Set quarterly assessment with an Assessment Reference Date of 5/04/26 revealed resident #3 had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. On 7/08/26 at 10:50 AM, resident #3 stated he was scheduled for a surgical procedure the following day and had been instructed to hold his blood thinning medication, Eliquis beginning Sunday. He indicated the staff still administered the Eliquis on Monday and Tuesday morning but he did not take the medication. The resident unwrapped a piece of aluminum foil he kept next to his bed and showed four medications he had retained instead of taking: two Eliquis tablets, one Digoxin tablet, and one Doxycycline tablet. He stated some nurses left medications at his bedside for him to take later. Resident #3 explained had he not recognized the medications, he could have taken the Eliquis, resulting in cancellation of his scheduled procedure. He stated the medications he retained included one Eliquis tablet from Monday, one Eliquis tablet from Tuesday, and the Doxycycline and Digoxin tablets administered Tuesday. The resident further stated he intended to return the medications to the evening nurse, but the nurse instructed him to keep them instead. He stated nurses did not always read the physician's orders, and some became upset when he asked questions about his medications, even when he asked to be informed of what medications he was receiving. On 7/08/26 at 11:28 AM, Registered Nurse (RN) B entered resident #3's room and confirmed she was his assigned nurse. She stated she had not administered any medications to him that morning because the medications had already been given by the previous shift nurse. RN B confirmed the medications resident #3 had retained, then stated the resident was not supposed to have medications in his possession. She said she had no knowledge he was keeping medications at his bedside. Resident #3 told RN B she had administered one of the Eliquis tablets to him previously, which RN B denied. She stated she always remained with the resident until he swallowed his medications and, if he refused medications, she discarded them in the Drug Buster. On 7/08/26 at 11:38 AM, the Director of Nursing (DON) entered resident #3's room. She stated nurses always administered medications directly to residents and was unaware resident #3 had medications in his possession. Resident #3 told the DON if he had taken the Eliquis provided to him by the nurses, he could have experienced serious bleeding during his scheduled surgery. The DON stated she was aware the resident refused a lot of medications, but repeated she was unaware he retained medications in his possession. Review of resident #3's Admission/readmission Data Collection nursing evaluation dated 6/17/25 revealed a medication review was completed. Question number one asked whether the resident self-administered medications and was answered No. The form instructed staff if the answer was Yes, a Self-Administration Evaluation was to be completed. There was no evidence a Self-Administration Evaluation had been completed. Review of resident #3's care plan included focuses for anticoagulant therapy and CHF, initiated on 11/14/25, and antibiotic therapy, revised on 7/02/26. Interventions directed nurses to administer the medications as ordered by the physician. There was no care plan addressing self-administration of medications. Review of resident #3's July 2026 Medication Administration Record (MAR) revealed:*Digoxin 125 micrograms scheduled for 9:00 AM was documented as administered on 7/05 and 7/07 by Licensed Practical Nurse (LPN) F and on 7/06 and 7/08 by RN B.*Doxycycline 100 milligrams (mg) scheduled for 9:00 AM was documented as administered on 7/05 and 7/07 by LPN F and on 7/06 and 7/08 by RN B.*Doxycycline 100 mg scheduled for 9:00 PM was documented as administered on 7/05, 7/06, 7/07 by RN G. *Eliquis 5 mg scheduled for 9:00 AM and 9:00 PM was last documented as administered on 7/05 by LPN F. On 7/09/26 at 11:03 AM, LPN F stated resident #3 chose which medications he wanted to take each day. She confirmed she cared for him on Sunday, 7/05/26, and Tuesday, 7/07/26, from 7:00 AM until 7:00 PM. LPN F stated she observed resident #3 take his medications. She recalled that, sometime previously, resident #3 had asked her to leave his medications at the bedside because he did not want staff watching him take them. She stated she informed him facility policy required staff to observe residents taking their medications, which upset him. LPN F mentioned that after that conversation, the resident understood he was required to take his medications in her presence. She further stated the resident never told her another nurse had left medications at his bedside. On 7/09/26 at 2:21 PM, an attempt to interview RN G, the assigned evening nurse for resident #3's on 7/05/26, 7/06/26, and 7/07/26 was unsuccessful. Later, on 7/09/26 at 5:53 PM, the DON stated she could not explain how resident #3 came to have four medications in his possession. She indicated she had spoken with the nurses who cared for him during the month, and each reported they had not left medications at the bedside. The DON confirmed nurses were not permitted to leave medications unattended because anyone entering the room could access them. The DON acknowledged there was no physician order authorizing resident #3 to self-administer medications, no completed self-administration evaluation, no interdisciplinary team approval, no MAR identification of self-administered medications, and no locked bedside storage for the medication. Review of the facility's Self-Administration of Medications at Bedside policy, revised 8/22/17, revealed residents could keep medications at the bedside for self-administration only after meeting established criteria. The policy required verification of physician's order authorizing self-administration of specific medications, completion a Self-Administration Evaluation, interdisciplinary team review and approval, development of a care plan for approved self-administered medications, quarterly reassessment and reassessment with any change in condition, documentation on the MAR identifying medications approved for self-administration, nursing follow up regarding medication documentation and storage during each medication pass, and storage of bedside medications in a locked drawer. Review of the facility's Administering Medications policy, revised April 2019, revealed medications were to be administered safely, timely, and as prescribed. Staff administering medications were required to initial the resident's MAR after administering each medication and before administering the next medication. The policy further stated residents may self-administer medications only after the attending physician, in conjunction with the Interdisciplinary Care Planning Team, determined the resident had the decision-making capacity to safely self-administer medications.

Based on observation, interview, and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.Findings:On a previous survey dated 4/26/24, Centers for Medicare & Medicaid Services (CMS) Enforcements were issued that included: F0656 (Develop/Implement Comprehensive Care Plan), F0695 (Respiratory/Tracheostomy Care and Suctioning), and F0759 (Free of Medication Error Rate of 5 Percent or More).On 9/18/25 at 2:14 PM, the Nursing Home Administrator (NHA) explained their QAPI program included a four-step process with: identification of deficient practice, investigation of problem causes, correction of problems, and development of correction plans with goals, timelines, and education with retention tools, and audits to determine effectiveness.A joint review of the facility's Performance Improvement Plans (PIPs) since the last recertification was conducted with the NHA and Director of Nursing (DON). Documentation of monitoring for previously identified deficiencies with F0695 was incomplete or missing. For example, on 1/28/25, the facility identified a supplemental oxygen dependent resident in a state of lethargy (fatigue/sluggishness) and without the physician's ordered oxygen. The facility conducted an Ad Hoc (when necessary) QAPI meeting where the committee developed a PIP to ensure residents received supplemental oxygen per physician's orders that included daily checks and weekly audits. When asked to review the monitoring documentation and audits, the DON stated, we don't really have a track and trend record; we do it daily and keep a mental record; it's ongoing.From 9/15/25 to 9/18/25, a recertification survey was conducted, and deficient practice was again identified for F0656 (Develop/Implement Comprehensive Care Plan), F0695 (Respiratory/Tracheostomy Care and Suctioning), and F0759 (Free of Medication Error Rate of 5 Percent or More).The facility did not implement an ongoing, systematic QAPI program to ensure that identified problems were corrected and prevented from recurring. The failure of the facility to maintain complete monitoring documentation and address repeated deficiencies demonstrated that the QAPI program was not effective.Review of the facility's undated standards and guidelines titled 2025 QAPI Plan noted the facility was committed to using QAPI to improve performance and practices and assure regulatory standards were met or exceeded. The PIP projects process outlined that plans included goals, actions, target dates, and status/outcomes. The standards noted completed PIPs are filed in the QAPI notebook and monitored periodically to assure achievements are being sustained.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 1 of 5 residents observed during the medication administration task, of a total sample of 43 residents, (#50). There were 2 errors in 32 opportunities for a medication error rate of 6.25%.Findings:Review of resident #50's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart disease, combined systolic and diastolic heart failure, heart muscle damage, hypertension, nicotine dependence, and stage 2 chronic kidney disease. On 9/16/25 at 9:04 AM, Registered Nurse (RN) C prepared resident #50's scheduled medications at her medication cart. She removed one tablet of chewable 81 milligrams (mg) Aspirin from the cart's stock medication bottle and placed it in a pill cup with the resident's other oral medications. RN C then removed a Nicotine patch (Step 2) 14 mg /24 hour (HR) from the cart. The nurse then proceeded to administer the Aspirin and place the Nicotine patch on the resident's left upper arm. Review of the resident's Electronic Medication Administration Record (EMAR) revealed resident #50 had a physician order for Aspirin 81 Oral Tablet Delayed Release 81 mg daily for pain with a start date of 8/16/23 and Nicotine Step 1 Patch 24 Hour 21 mg/24 HR daily for smoking cessation with a start date of 10/30/23. Delayed release (DR) medications are medications that are designed to release the active ingredients later after taking it. This can help control where the medication is released in the body, such as the small intestines. This is usually done to prevent the medication from breaking down too early or lessen potential side effects such as upset stomach, (retrieved on 9/19/25 from www.goodrx.com/drugs/medication-basics). On 9/16/25 at 11:15 AM, RN C failed to acknowledge the mistake of administering chewable aspirin instead of the delayed-release aspirin that was ordered by the physician. RN C confirmed she administered the Nicotine patch 14 mg instead of the 21 mg patch ordered by the physician. She explained, 14 mg was what was in the cart. On 9/17/25 at 1:26 PM, the Director of Nursing (DON) confirmed she was aware of the medication errors which she discussed with RN C. The DON said RN C had no explanation for why the errors had occurred. The DON stated her expectation was for nurses to administer medications as ordered by the physician. She explained if a medication was not available, a nurse should never administer an alternative dose without consulting the physician. The facility's policy titled Administering Medications revised April 2019 indicated that medications were to be administered in a safe and timely manner, and administered in accordance with prescribed orders.

Based on observation, interview, and record review, the facility failed to administer Oxygen (O2) therapy as ordered by the physician for 2 of 3 residents reviewed for respiratory care, of a total sample of 43 residents, (#4 and #85).Findings:1. Resident #4 was re-admitted to the facility on [DATE] with diagnoses of hemiplegia (one-sided paralysis) following cerebral infarction (stroke), pressure ulcers, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 6/30/25 revealed the resident had severe cognitive impairment. The MDS assessment noted the resident was dependent on staff assistance with dressing/personal hygiene care and received oxygen therapy. The assessment also noted that the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and wellbeing. Review of resident #4's medical record revealed a care plan initiated on 3/31/25 which indicated a resident focus for Ineffective Airway Clearance/Aspiration due to SOB (shortness of breath) and use of 2 liters per minute (LPM) of oxygen continuously via nasal cannula. The goal was the resident would experience a clear airway with supplemental oxygen intervention. Review of resident #4's current active physician orders revealed an order for oxygen at 2 LPM via nasal cannula (NC) as needed (PRN) dated 5/02/25. On 9/15/25 at 10:50 AM, 1:50 PM, and 3:27 PM, resident #4 was lying in bed with O2 administered through a NC. Each time the O2 tubing was connected to an oxygen concentrator set at 1.5 LPM. 2. Resident #85 was re-admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD), systemic lupus, hypertension, atrial fibrillation, anemia and chronic kidney disease.Review of the MDS quarterly assessment with ARD date of 6/24/25 revealed she had moderate cognitive impairment and did not receive oxygen therapy at the time the assessment was completed. The assessment also noted the resident was dependent on staff assistance with dressing/personal hygiene care and did not exhibit behavioral symptoms or rejection of care necessary to achieve the resident's goals for health and wellbeing. Review of resident #85's medical record revealed a care plan with focus for Oxygen Therapy for Shortness of Breath related to her diagnosis of COPD revised on 8/19/24. The goal was that she would not have signs and symptoms of poor oxygen absorption and interventions included staff to give medications as ordered by the physician and oxygen settings at 2 LPM via NC PRN for SOB. Resident #85's current active physician order dated 6/25/25 was for oxygen at 2 LPM via NC continuously and included instruction for nurses to check the oxygen delivery every shift. On 9/15/25 at both 11:01 AM, and 3:28 PM, resident #85 was lying in bed with O2 administered through a NC. The O2 tubing was connected to an oxygen concentrator set at 2.5 LPM. On 9/15/25 at 3:54 PM, Registered Nurse (RN) A explained she was assigned to residents #4 and #85 and she checked both of their oxygen saturation rates earlier today but forgot to check the concentrators to ensure they received the flow rate as ordered by the physician. RN A checked in the residents' electronic medical records and said they were both to be on 2 LPM of oxygen. RN A observed and acknowledged both residents #4 and #85 were not getting their oxygen as ordered. She was observed changing resident #4's oxygen from rate from 1.5 LPM to 2 LPM and resident #85's from 2.5 LPM to 2 LPM. Post observation she said that she was very tall, and it was difficult for her to read the concentrator at eye level. On 9/17/25 at 3:53 PM, the Director of Nursing (DON) said the nurses were supposed to check the oxygen liter flow rate at eye level at least every shift. The DON verbalized the expectation that nurses should check the physician's order and give what was ordered. The DON added best practice was for nurses to check the concentrator every time they went in the resident room to ensure they were getting O2 as ordered by the physician. Review of the facility's Oxygen Therapy policy and procedure revised 8/28/17 indicated, Procedure: Physician's order for oxygen therapy shall include.PRN orders must include specific guidelines as to when resident is to use oxygen.Review physician's order.Start O2 flowrate at the prescribed liter flow .

Based on observation, interview, and record review, the facility failed to develop an individualized Comprehensive Care Plan to include actual skin impairments for 1 of 3 residents reviewed for pressure ulcers, of a total sample of 43 residents, (# 4).Findings: Review of resident #4's medical record revealed he was readmitted to the facility on [DATE] with diagnosis of cerebral infarction (stroke), stage three pressure ulcers- sacral region and right ankle, unstageable pressure ulcers- left ankle/right heel/right upper back and right/left buttocks. Review of resident #4's Quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 6/30/25 revealed the resident had severe cognitive impairment, was totally dependent on staff for all his activities of daily living, was at risk for pressure ulcers/injury, had four unhealed stage three pressure ulcers that he was admitted /readmitted to facility with, and had six unstageable pressure ulcers three of which he was admitted /readmitted with to the facility. Stage three pressure ulcer means full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage four pressure ulcer means full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling . Slough and/or Eschar in a pressure ulcer makes the wound unstageable due to coverage of wound bed by slough and/or eschar. Deep-Tissue Injury (DTI): Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. (Retrieved from Pressure Ulcer/Injury Coding Pocket Guide on 9/19/25). Review of resident #4's medical record revealed he did have comprehensive care plans in place for an indwelling urinary catheter, ineffective airway clearance, hospice, dependence on staff to meet emotional needs, dementia, communication problem, altered cardiovascular status, risk of falls, requires tube feeding, aspirin therapy, mood problem, risk of malnutrition and hemiplegia (one-sided paralysis). Resident #4 had a care plan revised on 5/20/24 for potential for pressure injury development, but the care plan did not mention any of the residents' actual pressure ulcers nor other alterations in his skin integrity. Review of resident #4's Wound Assessment Report dated 9/10/25 noted the following wounds with active orders: stage three pressure ulcer sacrum/right buttock acquired 5/17/22, stage three pressure ulcer left upper back acquired 5/29/25, stage three pressure ulcer spine acquired 6/18/25, stage four pressure ulcer left lateral ankle acquired 3/26/25, unstageable pressure ulcer right ischium acquired 4/30/25, Kennedy terminal ulcer right hip acquired 6/25/25, left medial ankle skin tear reopened 9/11/25, stage three pressure ulcer right lateral ankle acquired 3/11/25. There was a total of nine alterations in resident skin integrity that did not have a comprehensive care plan ever initiated with individualized interventions and person-centered goals. On 9/16/25 at 3:07 PM, assigned Certified Nursing Assistant (CNA) D was observed repositioning the resident and verified the resident had multiple wound dressings currently in place. Resident #4's active physician orders included wound care orders dated 9/04/25 for right flank, right ischium, right hip and right lateral ankle wounds. Orders dated 9/11/25 were for the sacrum/right buttock and left medial ankle. Orders dated 8/30/25 were for the spine, left upper back and left lateral ankle wounds. On 9/17/25 at 3:11 PM, an interview and concurrent record review was conducted with Assistant MDS Licensed Practical Nurse (LPN) and the Regional MDS nurse. The Assistant verified that resident #4 did not have any care plans to date for actual alterations in his skin integrity. The Assistant did not provide an explanation as to why they were not in place. The Regional MDS nurse said resident #4 should have comprehensive care plans for Potential for Alteration in Skin Integrity as well as Actual Alteration in Skin Integrity. The Regional nurse explained the care plans should be initiated and updated anytime a resident had pressure wounds, Kennedy ulcers or skin tears. The Regional MDS nurse validated there were no comprehensive care plans at this time to reflect the nine areas of alteration in resident #4's skin integrity. The Regional nurse explained the care plans should have been initiated and/or updated when the quarterly MDS was completed on 6/30/25 by the Assistant MDS nurse. She reviewed the medical record and said that the MDS assistant did document that resident #4 had four stage three pressure ulcers and six unstageable pressure ulcers. All four of the stage three pressure ulcers were facility acquired and three of the unstageable wounds were also facility acquired. The Regional nurse said when the MDS assessment was completed the comprehensive care plan needed to reflect the current resident status regarding skin alterations. The Regional MDS explained since resident #4 was on hospice the goals could address that he had potential for getting wound infections and that wounds may not heal because he was on hospice and his overall health due to end of life. On 9/17/25 at 3:53 PM, the Director of Nursing (DON) said that resident #4 was admitted with wounds and the nurse should have initiated a comprehensive care plan for actual alteration in his skin upon admit/re-admit. The DON added that the care plan could have been initiated as well when the quarterly MDS was completed or at their morning meetings when they went over new wound care orders. Review of the facility's policy and procedure titled Plans of Care revised 9/25/17 read, An individualized person centered plan of care will be established by the interdisciplinary team (IDT).Develop a comprehensive plan of care for each resident that included measurable objectives and timetable to meet the resident medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Review, update and/or revise the comprehensive plan of care based on changing goals .

Based on interview, and record review, the facility failed to conduct thorough, periodic reviews of Advance Directives to ensure resuscitation status related to Do Not Resuscitate (DNR) orders was accurately documented in the medical record to effectively communicate choices regarding withholding life-sustaining measures for 1 of 1 residents reviewed for Advance Directives, of a total sample of 43 residents, (#33).Findings:Review of the medical record revealed resident #33 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral atherosclerosis (hardening of brain arteries), severe vascular dementia with agitation, brain bleed, major depressive disorder, restlessness and agitation.Review of hospice paperwork revealed resident #33 was admitted to hospice on 4/30/25 with a primary terminal diagnosis of cerebral atherosclerosis. The document indicated resident #33 was at the facility for respite care from 5/30/25 till 6/04/25. A progress note dated 6/10/25 at 4:42 PM, revealed the resident was re-admitted to the facility from home with a hospice representative for inpatient respite care.Resident #33's electronic medical record (EMAR) revealed a Do Not Resuscitate (DNR) Order dated 5/01/25 which was signed by the resident's husband. A Do Not Resuscitate Order (DNRO) - Form 1896 was developed by the State of Florida Department of Health (DOH) to identify people who do not wish to be resuscitated in the event of respiratory or cardiac arrest. In order to be legally valid this form MUST be printed on yellow paper prior to being completed. [Emergency Medical Services] and medical personnel are only required to honor the form if it is printed on yellow paper, (retrieved on 9/20/25 from www.floridahealth.gov).Review of the resident's physician's order revealed an active order for Do Not Resuscitate with a start date of 5/30/25. Review of the resident care plan revealed the resident had a care plan for advanced directives related to DNR as evidence by DNR order initiated on 6/19/25. A progress note dated 6/11/25 at 4:06 PM, revealed a state agency investigator visited the facility to inform them that the state was exploring guardianship and long-term placement for resident #33. Review of a court order from the state of Florida dated 6/20/25 revealed the court determined resident #33 lacked capacity to consent to services and was a vulnerable adult in need of emergency protective services. The document also revealed that, no person shall honor any DNR related to the respondent. Such matter must be brought before the court.A court order dated 8/15/25 revealed the resident would remain at the facility due to a return home being inappropriate at that time. The document indicated the resident would remain in protective supervision by the agency for an additional 60 days. The document also detailed that no person shall honor any DNR related to the respondent. Such matter must be brought before the court.On 9/18/25 at 11:48 AM, the Administrator confirmed the facility incorrectly listed DNR as resident #33's code status in her medical record. She conveyed the resident should be a Full Code. The Administrator acknowledged she was ultimately responsible for coordinating the residents' care between the different agencies and the facility. The Administrator explained that although she read the court documents related to the resident, she surmised she did not read it thoroughly since she did not realize the resident's previous DNR order was nullified. She stated that while the facility reviewed advanced directives regularly, they failed to review the resident's medical record in its entirety and had looked solely at the DNR form and the physician order. The facility policy titled Advanced Directives revised on 11/14/18 revealed that advanced directives were to be reviewed quarterly and additional times as needed. The reviews were designed to identify situations where health care decision-making was needed and review the residents' condition. The policy detailed if upon notification from the resident or resident representative the desire to revoke an advanced directive, the physician would be notified, and the medical record would be modified accordingly.

Based on observation, interview, and record review, the facility failed to conduct scheduled safety/risk evaluations for 1 of 1 resident reviewed for Smoking, (#53), of a total sample of 43 residents. Findings:Review of the medical record revealed resident #53, a [AGE] year old male was admitted to the facility on [DATE], and re-admitted from the hospital on 1/02/25 with diagnoses that included muscle weakness, pain in left shoulder, acquired absence of right upper limb above elbow (amputation), acquired absence of left leg above knee, acquired absence of right leg below knee, rotator cuff tear of unspecified shoulder, and polyneuropathy (nerve damage to arms and legs).The most recent Comprehensive Minimum Data Set (MDS) Significant Change Assessment with an Assessment Reference Date (ARD) of 6/27/25 noted resident #53 scored 15 out of 15 on the Brief Interview for Mental Status that indicated his cognition was intact. The assessment showed during the look-back period there were no behaviors or rejections of evaluation or care necessary to achieve health and well-being, the resident had functional limitations in Range of Motion (ROM) on one side of his upper extremities (shoulder, elbow, wrist, hand) and both sides of the lower extremities (hip, knee, ankle, foot). There was normally use of a wheelchair, and the resident required set-up/clean-up assistance for eating, supervision or touching assistance for oral hygiene, substantial/maximum assistance for dressing, and moderate/substantial assistance for personal hygiene and bathing. The resident was dependent on staff to transfer from the bed/chair/toilet and required moderate/maximum staff assistance to change positions in bed. During the look-back period, the resident received scheduled and as needed pain medications, he experienced 5 out of 10 (numeric rating scale) pain that occasionally interfered with day-to-day activities, and he received high-risk anti-depressant, opioid (narcotic pain), anti-platelet (clot prevention), and anti-convulsant (seizure) medications.The Care Plan Report included Focuses for: (3/21/25) Self-releasing safety belt for injury risk in a motorized mobility chair, (2/13/25) Activities of Daily Living (ADL) self-care deficits related to impaired functional mobility with right arm and both leg amputations, non-compliance with care, and smoker with goals that read, The resident will not suffer injury from unsafe smoking practices through the review date.On 9/15/25 at 3:16 PM resident #53 was sitting in a wheelchair in his room. The resident said he had lived at the facility for eleven years and did not recall any recent questions or assessments by staff about smoking safety. On 9/18/25 at 12:38 PM, resident #53 was sitting in a wheelchair in his room. The resident said he always smoked since he lived at the facility with the exception of a few days, several months prior when he was re-hospitalized for gastrointestinal problems.On 9/16/25 at 2:28 PM, Registered Nurse M said she knew resident #53 well and he was often included in her assignments when she worked both 12-hour shifts. The nurse said the resident always participated in smoke breaks.On 9/17/25 at 1:25 PM, the Director of Resident Experience said resident #53 actively participated in smoke breaks.On 9/18/25 at 10:17 AM, the Assistant MDS Licensed Practical Nurse checked resident #53's medical record and recalled the Significant Change assessment with the ARD of 6/27/25 was completed because the resident had a decrease in functioning, increased pain and limitations in his shoulder.Review of resident #53's medical record showed Smoking Evaluations were conducted quarterly from 1/11/22 until 2/16/25. No additional quarterly evaluations were completed that should have been due in May or August 2025, and an incomplete evaluation was opened on 9/18/25, the last day of the survey.On 9/18/25 at 9:50 AM, the Director of Nursing (DON) said she knew resident #53 well, and he had always been an active smoker. She explained nursing leadership was responsible for conducting smoking assessments. She said they were scheduled on admission/re-admission and quarterly to identify changes like increased weakness or impairments that required additional safety measures like a smoking apron to prevent burns. The DON checked the medical record and acknowledged resident #53 was missing smoking safety evaluations due in May and August 2025. She did not explain why they were not completed and stated, smoking safety is big, big, big, and we have to make sure they are safe; evaluations are important to do every three months.Review of the facility's standards and guidelines titled Smoking-Supervised dated 2/07/20 read, Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking.

Based on interview, and record review, the facility failed to follow physician orders for surgical pin site dressing for 1 of 2 residents reviewed for surgical wounds, of a total sample of 7 residents, (#1). Findings: Resident #1, a 49- year-old female was admitted to the facility on [DATE]. Her diagnoses included anterior dislocation of proximal end of tibia, right knee, generalized weakness, pain in right knee, diabetes type II, cardiac murmur, depression, and anxiety disorder. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15 out of 15. The assessment noted the resident was dependent on staff assistance for activities of daily living, required substantial/maximal assistance of staff for chair/bed-to chair transfer, and had surgical wound(s). Review of the resident's clinical records revealed a physician order dated 3/05/34, to paint pin site with Betadine, pat dry, cover with dry gauze and secure with tape daily. This order was discontinued on 3/06/24. Review of the resident's Treatment Administration Record (TAR) revealed a blank space on 3/06/24, and there was no documentation to indicate the treatment was completed. Physician order on 3/07/24, noted to clean the pin site(s) with hydrogen peroxide and normal saline, pat dry, cover with dry gauze, and secure with tape every day shift. This order was discontinued on 4/11/24. Review of the resident's TAR revealed blank spaces on 3/08/24, 3/15/24, and 3/28/24. There was no signature or documentation to indicate the physician's orders were completed. On 3/09/24, and on 3/24/24, the code 2 was documented, indicating the resident refused, and on 3/12/24 the code 3 was documented, indicating a Leave Of Absence. Documentation to indicate the physician was notified of the resident's refusal on 3/09/24, and 3/24/24 was not identified. On 11/25/24 at 1:41 PM, the resident's clinical records were reviewed with the Assistant Director of Nursing/Unit Manager (ADON /UM). She acknowledged the blank spaces on the resident's TAR for the dates identified, and explained there should have been something documented, and the spaces should not be left blank. The ADON/UM said that if the resident refused the treatment, a code should be placed, and the TAR should be signed by the nurse. On 11/25/24 at 3:15 PM, the Director of Nursing (DON) stated that when treatment was provided the residents' TAR should be signed by the nurse. The resident's TAR was reviewed with the DON, she acknowledged that blank spaces were on the TAR for the dates identified, and that a progress note regarding the treatment could not be identified for the dates noted. As per the DON, the facility did not have a policy to address documentation on the residents' TAR. However, the facility's policy Administering Medications revised April 2019 read, Topical medications used in treatments are recorded on the resident's treatment record (TAR).

Based on observation, interview and record review, the facility failed to develop a comprehensive individualized care plan for 1 of 3 residents of a total 7 residents, (#5) Findings: Resident #5 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, anxiety, history of falls, and hypertension. On 10/3/24 she was re-hospitalized on chest pain and then returned to the facility on [DATE]. Review of resident's care plan on 11/25/24 revealed a care plan with only one focus which was initiated on 10/24/24. The focus noted the resident had nutritional problem or potential nutritional problem related to hypertension, anemia, major depressive, hemiplegia, hypotension, morbid obesity, venous thrombosis, iron deficiency anemia, anxiety disorder, muscle weakness, and Mini Nutritional Assessment score reflects risk for malnutrition. Review of a care plan initiated on 6/26/24 revealed the care plan had been cancelled following resident's transfer to the hospital. The care plan initiated on 6/26/24 included risk for falls related to deconditioning, use of antidepressant medications related to depression, use of anticoagulation therapy related to history of deep vein thrombosis and risk for acute pain related to impaired mobility. Review of resident #5's Minimum Data Set (MDS) history revealed a MDS Discharge Return Not Anticipated initiated on 10/3/24 which was followed by a MDS Discharge Return Anticipated on 10/3/24. Interview with the MDS coordinator at 11:45 am on 11/25/24 revealed the previous MDS coordinator initially noted the resident as discharge not anticipated which canceled the care plan. The resident was supposed to be listed as discharge return anticipated. The MDS coordinator agreed the resident went without an accurate care plan from 10/21/24 till 11/25/24. Review of the facility's Plan of Care policy and procedure revised on 9/25/17 revealed that an individualized person centered plan of care may include resident's strengths, services to attain residents highest practicable physical, mental and psychosocial well-being as required by state and federal regulatory requirements.'

Based on interview, and record review, the facility failed to ensure admission physician orders for immediate care of surgical sites were obtained for 1 of 2 residents reviewed of a total sample of 7 residents, (#2). Findings Resident #2, a [AGE] year-old female was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included fracture of upper and lower end of the right fibula, fracture lower end of the right tibia, and physeal fracture of the lower end of the right fibula. Review of the resident's Medical Certificate for Medicaid Long-Term Care Services And Patient Transfer Form (3008) dated 11/23/24 revealed the resident's primary diagnosis was right ankle fracture, and documentation noted the resident had sutures to her left lower extremity, and an ace bandage wrap to her right lower extremity. The hospital's Brief op (operative) note dated 11/19/24 revealed an operative fixation of the right ankle and removal of external fixator was performed on resident #2. The Orthopedic Trauma Surgery Discharge Instructions printed on 11/23/24 read, Wound Care/Dressings: Aquacel dressings should stay on for 5 days after surgery . After Aquacel is removed, perform daily (and as needed) dressing changes with gauze and tape (or ACE wrap) .Do not place any ointments, lotions, or creams on your surgical incisions. Do not submerge surgical sites in water. Aquacel is a hydrofiber dressing that is used to treat wounds .has been shown to be effective in .surgical wounds. (retrieved on 12/05/24 from pubmed.ncbi.nlm.nih.gov). A review of resident #2's Admission/Readmission Data Collection document dated 11/23/24, revealed the resident had a surgical wound on her left lateral knee with 11 stitches, the lower leg had two stitches, and there was a cast on her right lower leg. Clinical record review of the resident's active and discontinued physician orders revealed no orders for the surgical sites, until 11/25/24. On that date, the physician orders were, monitor surgical wound for s/s (signs/symptoms) of infection, cleanse surgical wound on left lower leg with normal saline, pat dry and cover with dry dressing every day shift, cleanse surgical wound on left lateral knee with normal saline, pat dry and cover with dry dressing every day shift. On 11/25/24 at 1:30 PM, Licensed Practical Nurse (LPN) B, acknowledged she was resident #2's primary nurse. LPN B stated the resident was readmitted to the facility on [DATE] and had a surgical wound with staples. She stated the resident would be seen by the wound care physician and continued with the hospital discharge orders for wound care. LPN B stated she had not completed the resident's dressing as yet. On 11/25/24 at 2:08 PM, resident #2 was sitting up in bed watching television. The resident uncovered her left leg to show staples from her knee down with no dressing present. The area/staples were open to air, and her right leg was wrapped with bandage wrap. On 11/25/24 at 4:22 PM, the Regional Nurse reviewed the resident's physician orders. She acknowledged the resident was readmitted to the facility on [DATE], and no orders were identified to address the surgical site (s) until 11/25/24. On 11/25/24 at 4:38 PM, the Director of Nursing (DON) explained when a resident was admitted to the facility, the admission nurse reviewed the resident's hospital's discharged orders, and would enter the orders into the facility's electronic medical record (EMR) for the individual resident. She stated that normally residents came to the facility with physician orders for wound care, and if there were no orders, the nurse needed to notify the physician and obtain orders. Resident #2's clinical records were reviewed with the DON. She acknowledged the resident was readmitted to the facility on [DATE], and orders for surgical site(s) care was not obtained and entered into the EMR until 11/25/24. She said the expectation was that admission physician orders should have been in place, and hospital's orders for the surgical site should have been transcribed to the resident's EMR. The facility's policy Physician Orders with effective date of 11/30/2014, and revision date of 3/03/2021 read, The center will ensure that Physician orders are appropriately and timely documented in the medical records. Admission Orders: Information received from the referring facility or agency be reviewed, verified with the physician and transcribed to the electronic medical record.

Based on observation, interview, and record review, the facility failed to ensure medications were administered per professional standards for 1 of 7 residents, (#3). Findings Resident #3, an 81- year-old female was admitted to the facility on [DATE], with her most recent readmission on 6/23/24. Her diagnoses included end stage renal disease, diabetes type II, hypertension, chronic pain, and major depressive disorder. On 11/25/24 at 9:57 AM, a medication cup with medications was observed on resident #3's tray table. The resident stated the medications were left there by the nurse, and she would be take the medication momentarily. The resident stated she had breakfast and the nurse bought the medications in, but she fell asleep before taking the medications. On 11/25/24 at 10:00 AM, observation of the cup with medications on the resident's tray table was conducted with Registered Nurse (RN) A the resident's assigned nurse. RN A acknowledged the cup with the medications was on the resident's tray table and confirmed she gave the resident her medications. Record review of the resident's Medication Administration Record (MAR) revealed the resident's medications were documented as given at 9:26 AM. This was acknowledged by RN A, who stated she was aware medications were not to be left at the resident's bedside. RN A verbalized she was called away from the resident for an emergency, but did not take the medications out with her, and forgot to go back and check on the resident. Review of the MAR revealed medications administered by RN A at 9:26 AM included Bumex 2 milligram (mg) for edema, [NAME]-Vita tablet for end stage renal disease, Sevelamar Carbonate 800 mg x 3 tablets, Ocular Vitamin for macular degeneration, Fish oil 500 mg for high triglyceride, and Cetirizine for sinus congestion. On 11/25/24 at 10:40 AM, the Director of Nursing (DON) stated medications should not be left at the resident's bedside, and nurses should ensure medications were taken by the resident before leaving. She stated that if the resident refused their medications, and wanted the nurse to come back, the nurse should take the medications with her. If responding to an emergency, the medications should be taken out with the nurse, and not left at the resident's bedside. On 11/25/24 at 3:24 PM, the Regional Nurse stated the expectation was that nurses should watch the resident take their medications, and medications should not be left at the resident's bedside. The policy Administering Medications revised April 2019 read, For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.

Based on interview and record review, the facility failed to ensure a resident who was continent of bladder and bowel received services such as scheduled toileting or prompted voiding, and the needed assistance to maintain their continence, for 1 of 3 residents reviewed for bowel and bladder/incontinence care, of a total sample of 4 residents, (#1). Findings: Resdient #1 was admitted to the facility on [DATE] with diagnoses that included stroke, type 2 diabetes mellitus, and partial weakness and paralysis of the left non-dominant side after stroke. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 was cognitively intact with no behavioral symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Section H of the assessment indicated she was always incontinent of bowel and bladder and that a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) had not been attempted upon admission or reentry. On resident #1's Quarterly MDS assessment dated [DATE] the same responses for Section H were present, as the previous assessment on 6/27/24. Toileting tailored to the resident's needs rather than using an absorbent brief has the potential of: increasing dignity, satisfaction, and support for the holistic needs of the resident when they achieve their highest level of continence, has the potential to reduce risk of skin breakdown and moisture-associated skin damage (MASD), and lowered risk of infection, (retrieved on 10/09/24 from www.medline.com.) On 10/03/24 at 10:20 AM, the MDS Coordinator stated she did not know if resident #1 had the sensation/urge to void, urinate or have a bowel movement. She said she had never heard resident #1 say if she had to urinate nor have a bowel movement. The MDS Coordinator confirmed she had heard resident #1 say after she had voided that she had urinated and/or had a bowel movement, but she was not sure if the facility even had a mechanical lift or mechanical lift toileting sling to assist resident #1 to the bathroom. On 10/03/24 at 12:40 PM, resident #1 explained she had the sensation/felt the urge to urinate or have a bowel movement before it happened. She stated she usually went in her adult brief, but she would use the toilet instead if it was offered. On 10/03/24 at 10:00 AM, the Director of Rehabilitation stated resident #1 needed maximum assistance for toileting and required use of a mechanical lift to transfer between her wheelchair and bed. She acknowledged there was nothing to prevent staff from utilizing a mechanical lift to transfer resident #1 to the bathroom/toilet. On 10/03/24 at 1:40 PM, the Director of Nursing (DON) explained the facility did not have any mechanical lifts designed to transfer residents to a toilet nor any slings to be used with the mechanical lifts designed to place a resident on a toilet. She said resident #1 had not told the facility she needed to be toileted and that resident #1 usually told staff after she had already voided. The DON said she was unaware if resident #1 had the sensation/urge to know she needed to void before she would go. She acknowledged she did not have any documentation of a toileting program trial or the offering of a bed pan for resident #1 since her admission. On 10/03/24 at 1:45 PM, the DON and Regional Nurse interviewed resident #1 with the surveyor present. Resident #1 stated she knew when she had to void, by both bladder and bowel. Resident #1 agreed she would be willing to use a toilet if it was offered.

Based on observation, interview, and record review, the facility failed to follow podiatry treatment plan and ensure a timely follow-up appointment with a podiatrist for 1 of 1 residents reviewed for podiatry, of a total sample of 4 residents, (#1). Findings: Review of resident #1's medical record revealed diagnoses of type 2 diabetes mellitus, peripheral vascular disease, hemiplegia (severe loss of strength) and hemiparesis (weakness) following stroke affecting left non-dominant side. The American Diabetes Association's in the section titled, Foot Complications described, People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications (retrieved from www.diabetes.org on 10/02/24). Review of resident #1's medical record revealed a podiatry visit report with a date of service of 8/22/24. The report detailed on physical exam the podiatrist noted resident #1 was unable to differentiate sharp/dull sensations in both feet. Resident #1 had three nonpalpable (could not be felt by hand) and one diminished pulse, regarding four pulse points, in her foot and ankle area indicating her blood circulation was diminished to these areas. Resident #1's diagnoses on this evaluation were: type 2 diabetes with other diabetic neurological complication, ingrowing nail, tinea unguium (toenail fungus), and nail dystrophy (abnormal changes in shape, color, texture and growth of nails). In the section of the note titled Follow-up indicated a partial nail avulsion (removal) was performed on the medial nail plate of the left great toe. Wound care orders were to apply a topical antibiotic ointment and band-aid to the left great toe for 10 days. The report listed a follow-up visit for podiatry in 2-3 months, or sooner should any concerns or problems arise. Review of resident #1's Treatment Administration Record (TAR) revealed that from 8/22/24 through 10/02/24 nursing staff had signed they had cleansed resident #1's left great toe with normal saline, applied Bactroban (a topical antibiotic) ointment, covered with dry gauze, and secured with tape daily. This treatment was 32 days longer than the podiatrist had recommended on 8/22/24. On 10/03/24 at 1:40 PM, the Director of Nursing (DON) reviewed resident #1's podiatry wound care report dated 8/22/24 for the left great toe and compared it to the TAR wound care orders for the left great toe which continued until 10/02/24. She could not explain why treatment was done longer than the 10 days recommended by the podiatrist, and confirmed the order on the TAR should have been discontinued. On 10/04/2024 at 10:56 AM, the DON stated resident #1's assigned nurse had asked her to have the Attending Physician examine resident #1's left great toe on 9/16/24 due to some redness. The DON confirmed she had not called the podiatrist about the left great toe concern made by the assigned nurse. The DON verified the attending physician ordered a podiatry referral on 9/16/24., but no podiatry visit had been scheduled for resident #1 since the referral was made. The DON said that Social Service staff should schedule the referral visit, and the podiatrist would come to the facility to provide care to the patient. On 10/03/24 at 3:29 PM, the Social Service Director confirmed the podiatry referral made on 9/16/24 for resident #1 had not been scheduled yet. He stated resident #1 was not scheduled to have an appointment until the next regular time the podiatrist was scheduled to visit the facility and that date had not yet been set. On 10/3/24 at 3:30 PM, in a telephone interview, the receptionist at the facility's contracted podiatrist office stated the podiatrist was not yet scheduled to have a service date at the facility. He confirmed no other facility visits were on their current schedule. On 10/04/24 at 10:20 AM, the Advanced Practice Registered Nurse (APRN) explained she examined resident #1's toes today at the request of the DON. She confirmed some redness on the left great toe where the toenail was no longer present. She explained the redness could relate to, remnants of an infection. The APRN said she was going to order an antibiotic medication for the possible infection and added that resident #1's toenails were elongated and should be clipped.

Based on interview and record review, the facility failed to revise a fall care plan to reflect fall interventions for 1 of 3 residents reviewed for care plans, of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple fractures of pelvis, fracture of left patella, dislocation of right hip, displaced fracture of lateral malleolus of left fibula and unsteadiness on feet. Review of resident #1's medical record revealed a Change in Condition evaluation completed dated 3/03/24 which indicated resident #1 slipped out of his wheelchair and was observed sitting on the footrest. Staff assisted resident back into his wheelchair. The form did not list any new interventions to be implemented. The medical record also contained a Change in Condition evaluation dated 3/24/24 which indicated resident #1 was observed as he slid from the seat of his wheelchair onto the footrests. The form also did not list any new interventions to be implemented. A fall care plan initiated 1/22/24 and revised 3/25/24 indicated resident #1 had an actual fall without injury on 9/11/23 and 3/24/24. The care plan did not identify the fall on 3/03/24 and did not indicate any new interventions related to the fall on 3/03/24. On 7/02/24 at 1:32 PM, the Administrator and Regional Nurse Consultant (RNC) reviewed the incident reports for resident #1's falls on 3/03/24 and 3/24/24. The NHA confirmed the falls were identical as to resident #1 sliding from his chair onto the footrests. The Administrator and RNC reviewed the medical record and verified that no new interventions were added to resident #1's care plan, task list or nurse aide Kardex. The Administrator acknowledged if an intervention had been added, the likelihood of the same incident occurring would be reduced. Review of the facility's Plans of Care policy and procedure indicated the interdisciplinary team would review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident.

Based on interviews and record review, the facility failed to provide the resident and his responsible party access to his personal and medical records following a written request for 1 of 1 residents reviewed for medical grievances, of a total of 6 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE], with a diagnosis of seizures, type 2 diabetes, protein-calorie malnutrition, hypertension, alcohol dependence, anxiety, and history of a brain abscess. The Admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12/15, which indicated the resident was cognitively intact. Review of the resident's electronic medical record revealed a document titled Healthcare Power of Attorney which was scanned into the resident's chart on 3/23/24. Under the section Designation of health care agent, the document listed the resident's brother to serve as his health care agent. Under the section titled Medical information and Medical records it indicated, acting on my behalf, my health care agent may have access to all of my medical information and photocopies of my medical record from my health care providers. This document was signed and notarized on 3/05/18. Review of the resident's electronic medical record revealed a document titled Authorization for Release of Protected health Information which was scanned into the resident's chart on 3/23/24. Under the section Appointment of Authorized Recipients, it stated the resident appoints the following persons as authorized recipients for health care disclosure under the Standards for Privacy of Individually Identifiable Heath Care Information under the Health Insurance Portability and Accountability Act of 1996. Individuals listed included resident #2's brother. Review of the resident's clinical record revealed the facility form Consent for Obtaining Medical Information. On the form it indicated the resident authorized the facility to release copies of the medical record to the resident's brother. The resident's brother checked the box that indicated he was requesting a complete copy of the medical record. Written underneath this section was a note that read, email to: [residents #2's email address]. Records to be emailed daily. This document was signed on 5/27/24. At the bottom of the document, resident #2's brother signed the form as the person authorized to act on the resident's behalf and written next to documentation required was the phrase on file. Interview with the Medical Records staff on 7/01/24 at 1:23 PM, revealed that typically it was her responsibility to handle the requests for medical records. She explained she had only been employed in the position for 2 weeks, so she did not handle resident #2's medical records request on 5/27/24. She stated the process was for medical records to send the filled-out Consent form to the corporate legal department for them to review before the release of information. Follow up interview with Medical Records staff later that day at 2:33 PM, revealed the receptionist handled the task of sending the filled-out consent forms to the corporate legal department while the facility was in between medical record personnel. On 7/01/24 at 2:37 PM, the Administrator revealed the facility just realized that day, the legal department did not receive the forms as they had been sent to the wrong email address. He stated they were going to send them to the correct email address and reach out to those who requested the medical records about the mix up. On 7/01/24 at 2:40 PM, the receptionist confirmed she was responsible for sending the medical records consent to the legal department while the facility was in between medical record personnel. She also stated she typically did not receive an email response from the legal department, nor did she receive a response from the wrong email address that informed her she sent the information to the incorrect email recipient. Review of the facility policy and procedure for Request for Medical Records/ Release of Information revised on 7/05/23 revealed that requests made by current residents to view their record will be granted within 24 hours of the request. In some instances, the legal department may be consulted. If the consent form was sent to the Legal Department for review, and the medical records custodian does not receive a response from the Legal Department with authority to release or not release the records within 72 business hours of the request, the medical record custodian will send the request a second time and follow up with a phone call.

Based on observation, interview and record review, the facility failed to obtain and implement orders in a timely manner after orthopedic consults to ensure appropriate care for 2 of 3 residents reviewed for consults, (#2 & #3); and failed to provide care and services in accordance with facility policies and procedures and professional standards of practice to prevent the development of a traumatic wound and promote wound healing for 1 of 6 residents reviewed for splints, (#3) of a total sample of 8 residents. Resident #3 suffered significant pain and discomfort as the splint remained on her left leg and foot continuously for six months. She was placed at risk for skin breakdown and infection, and subsequently sustained a traumatic injury to her left heel during removal of the splint, which required ongoing daily wound care. On 4/05/22, resident #3's orthopedic practitioner determined her ankle fracture was healed and a cast was removed and replaced with a splint. The orthopedic progress note indicated the splint was to be worn as needed, if desired by the resident for comfort, and should be removed daily to wash the area. The instructions were never transcribed to the resident's medical record and nursing staff did not attempt to obtain orders or clarification related to the splint. As a result, resident #3's splint remained in place and was never removed for evaluation of the skin underneath the device or to provide daily personal hygiene and skin care. Over six months later, on 10/11/22, resident #3 returned to the orthopedic practice with a complaint of pain in her left foot and heel. The orthopedic practitioner discovered the resident's splint was adhered to her skin and when she attempted to remove the device, resident #3 reported pain and had significant bleeding as the splint tore the skin away from her heel. The resident was transferred to the hospital Emergency Department (ED) for evaluation and was readmitted to the facility on [DATE] with orders to consult a wound care physician for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's failure to obtain orders for follow-up care, implement appropriate interventions for use and monitoring of splints, and complete wound care as ordered contributed to the development of a preventable wound for resident #3 and placed all residents who consulted outside providers and/or wore splints, or had wounds at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 4/05/22 and was removed on 10/21/22. Findings: Cross reference F600, F641, F726, and F842. 1. Review of resident #3's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old, and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Notes dated 2/09/22 revealed resident #3 injured her left foot in an accident with another resident's wheelchair. An x-ray showed an abnormal result and the resident's attending physician ordered an orthopedic consult. An orthopedic progress note dated 2/16/22 revealed resident #3 had a left distal tibia [NAME] fracture and distal fibula fracture. The tibia and fibula are the two bones in the lower leg that are attached to the weight-bearing bone in the ankle. A [NAME] fracture is a rare type of ankle fracture which usually results from a crushing force related to a high-impact event (retrieved on 10/31/22 from www.myclevelandclinic.org). The progress note indicated nonoperative treatment was selected due to resident #3's non-ambulatory status, and she received a short leg cast that was to be worn for eight weeks. An orthopedic progress note dated 4/05/22 revealed resident #3 returned for a follow-up appointment and was transitioned from the short leg cast to a splint. The orthopedic Certified Registered Nurse Practitioner (CRNP) wrote, Left lower extremity cast removed, posterior splint/[elastic bandage] placed. This is for [as needed] use only. Remove daily to wash and patient only needs to wear if it helps with comfort.Call if any concerns. Review of resident #3's medical record revealed no documentation on 4/05/22 to show the instructions regarding the splint were received and reviewed by nurses, nursing management or other interdisciplinary team (IDT) members. There was no evidence the attending physician was notified of the change in resident #3's treatment plan related to the removal of her cast and recommendation for a removable splint as needed. Review of the facility's policy and procedure for Notification of Change in Condition revised on 12/16/20 revealed the facility would promptly notify the attending physician and the resident's representative of the need to alter treatment, including a new treatment. Review of the facility's policy and procedure for Contractures, Prevention revised on 8/22/17 revealed instructions for care and services for residents who had braces or splints. The document read, Be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them. A progress note dated 4/10/22 at 12:07 PM, revealed the Wound Nurse noted a blister on resident #3's left great toe and that she had a posterior cast. Four months later, a Wound Care Consult note dated 8/25/22 revealed the Wound Care physician was consulted for resident #3's left toe wound, and he noted she had a splint on her left heel. Review of the medical record from April to October 2022 revealed facility staff did not contact the orthopedic practice or the attending physician for orders or clarification regarding the splint, and the plan of care was never updated to reflect necessary care and services for the resident related to the device. An orthopedic progress note dated 10/11/22 revealed resident #3 was seen by the orthopedic CRNP. The document read, Today the patient presents to me, over 6 months later, as she has been complaining of continued pain to the ankle/heel. and reported the splint had not been removed since the last visit. On physical examination, the orthopedic CRNP noted the same splint and elastic bandage were still in place and there was a foul odor. The document revealed the bandage that held the splint in place was soiled and the splint was significantly adhered to the resident's skin. The progress note indicated the orthopedic CRNP's attempt to remove the splint resulted in tissue loss and bleeding and had to be aborted. The practitioner notified the facility of her findings and that she would send resident #3 directly to the ED for appropriate treatment. Review of the hospital record revealed a Foot and Ankle Consult Note dated 10/11/22 regarding a traumatic abrasion to resident #3's left heel. The document read, Left plantar/posterior heel partial thickness ulceration with mild bleeding. An ED note dated 10/12/22 revealed the resident's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin avulsion is a type of wound that occurs when skin is torn from the body during an accident or injury (retrieved on 11/01/22 from www.drugs.com/cg/skin-avulsion-aftercare-instructions.html) A Nursing Progress Note dated 10/12/22 revealed resident #3 was readmitted to the facility. She was assessed by the Wound Care physician who gave treatment orders for the traumatic wound on her left heel. On 10/19/22 at 10:18 AM, resident #3 recalled that her ankle was fractured when another resident's wheelchair ran over her foot. She stated she went to the hospital and a doctor's office for treatment and then had a boot on her foot for an extended period of time. The resident stated she returned to the doctor's office recently because of foot pain. She said, It was hurting so bad. How can I describe pain? When asked to use a scale of zero to ten to rate her pain level, resident #3 stated her pain was like a twelve. She said, Right now, it is hurting, about a six. I am in a world of hurt. On 10/19/22 at 10:30 AM, Certified Nursing Assistant (CNA) E stated she was regularly assigned to care for resident #3 over the past six months and during daily care she washed above the resident's splint and between her toes. On 10/19/22 at 10:37 AM, CNA F stated when she cared for resident #3 in the past, she washed and applied lotion to her leg above the splint. She explained CNAs were not allowed to unwrap or remove devices unless instructed by a nurse. CNA F said, You can't go near her leg because it hurts so much. On 10/19/22 at 10:44 AM, CNA I recalled resident #3 had an elastic bandage on her leg for a long time and often complained of foot and leg pain. She stated she often wondered when the wrap would be removed. When asked how she bathed the resident, CNA I said, We take her to the shower and wrap the leg in a plastic bag. As a CNA, I would not remove any device unless the nurse directs me to do that. On 10/19/22 at 10:49 AM, CNA G stated whenever she was assigned to care for resident #3 within the past month, she washed above the wrap on her leg and her toes. CNA G said, It should be written down if it was supposed to come off. On 10/19/22 at 11:30 AM, Licensed Practical Nurse (LPN) A prepared to perform resident #3's wound care and dressing change. She checked all drawers of the South Wing treatment cart and explained she could not find the ordered medication, Santyl. LPN H was asked to check all drawers of the treatment cart and she validated the medication Santyl required for resident #3's wound care was not present in any of the drawers. LPN H stated she would check to see if the medication had been stored in the treatment cart on the North Wing in error. On 10/19/22 at 11:34 AM, LPN A removed a soft foam boot from resident #3's left foot to expose a soiled dressing. The dressing was dated 10/16 on 7-3 which indicated the dressing was applied three days earlier during the 7:00 AM to 3:00 PM shift. LPN A validated the dressing was dated 10/16/22, and confirmed it was not initialed to identify the nurse who applied it. LPN A said, I think it should be done every day, not every three days. On 10/19/22 at 11:41 AM, LPN H entered resident #3's room and stated she found the resident's tube of Santyl in the North Wing treatment cart. She provided LPN A with an unopened tube of Santyl which was labeled with resident #3's name and dated 10/12/22. LPN A applied clean gloves and unwrapped the soiled dressing that covered the resident's heel and foot. A moderate amount of dried drainage was noted on the dressing in the area of the resident's heel. LPN A then removed the gauze pads that covered the wound and the area immediately started bleeding quickly onto the pillowcase below. LPN A reached for gauze pads and held them to the resident's heel to stop the bleeding. After a few minutes, LPN A removed the gauze and blood clots were observed in the wound bed. She continued wound care after removing her gloves and applying clean gloves without performing hand hygiene. Observation of resident #3's wound revealed it measured approximately 1.5 centimeters (cm) by 2 cm and had significant periwound [CONDITION(S)] or redness around the edges. LPN A cleansed the left heel wound by squirting Normal Saline from an individual use tube into the wound and then wiping it with a gauze pad. She applied Santyl to the wound bed with a cotton-tipped applicator and covered it with a dry gauze pad. Next, LPN A used Normal Saline on a gauze pad to clean an abrasion on the top of the resident's left foot. She then reached for another gauze pad, wet it with Normal Saline and cleansed the resident's left great toe wound. LPN A removed her gloves and applied clean gloves, again without performing hand hygiene, and applied Iodosorb to a clean gauze pad. She placed it on the resident's toe wound and used rolled gauze to wrap the resident's foot and ankle. An open packet of a protective film wipe was left on the resident's bed and LPN A explained she did not use the film dressing as it was not appropriate for an open heel wound. Review of the Order Summary Report revealed physician orders for wound care. An order dated 10/12/22 directed nurses to cleanse resident #3's left heel wound with 1/4 Dakin's Solution, apply a protective film dressing to the periwound area, apply Santyl to the wound, place moistened gauze, then cover with gauze, and wrap with a woven gauze roll dressing. The order indicated resident #3's dressing was to be changed once daily on the day shift and as needed. On 10/19/22 at 12:03 PM, LPN A reviewed resident #3's electronic medical record and read the physician's treatment order. She validated the left heel wound required dressing changes once daily and as needed. LPN A acknowledged she did not wash or sanitize her hands between changing gloves, did not change gloves as required between clean and dirty procedures, and performed wound care on three separate wound sites with the same gloves. LPN A confirmed she used Normal Saline rather than Dakin's solution to clean the resident's left heel wound and did not apply the protective film dressing around the wound as ordered. Review of the facility's policy and procedure for Dressing Change revised on 12/06/17 revealed nurses would apply clean dressings to wounds as ordered to promote healing. The procedure directed nurses to perform hand hygiene, apply gloves, remove and dispose of soiled dressing, remove gloves and perform hand hygiene prior to applying clean gloves. Next, nurses cleanse the wound, remove gloves, perform hand hygiene, don clean gloves to apply the treatment as ordered and then discard soiled gloves. On 10/19/22 at 3:41 PM, in a telephone interview, the orthopedic CRNP stated her expectation was the facility would call her office for any questions regarding orders or treatment plans. The CRNP recalled incidents in the past when the facility waited sometimes up to one month after a resident's appointment to request a replacement for lost or misplaced progress notes. She stated she was surprised when resident #3's name appeared on her October schedule and wondered if she had injured herself again. The CRNP stated the resident was alert to person and situation and told her she returned due to pain. She recalled there was a definite odor from the resident's foot and the tan-colored elastic wrap was dirty. The CRNP stated the resident's left leg was slightly edematous and she noted lines and indentations in the skin as she removed the elastic wrap. She described seeing a large amount of flaking, dry, and dead skin falling from the resident's leg as she worked. The CRNP stated when she tried to loosen the splint, which was adhered to the resident's skin, the resident grimaced and verbalized, This hurts! She stated there was significant bleeding and she had to use thick, absorbent pads to compress the area to stop the bleeding. The CRNP explained she sent resident #3 to the ED for evaluation as she was concerned the skin and tissue were so fragile that continuing to remove the splint could have caused removal of tissue down to the heel bone. She confirmed the facility's failure to care for the resident according to her recommendations had a high potential for a negative outcome such as skin breakdown and associated complications. On 10/20/22 at 10:25 AM, the Wound Care physician reviewed his documentation and confirmed on 8/25/22 he noted resident #3 had a splint on her left foot. He explained he had been consulted at that time to assess and treat a wound on the resident's toe and observed the splint in place on her left foot. The Wound Care physician stated he was not sure if the device was applied daily or how long it was to be left in place. He was informed the splint was left in place for over six months and never removed for skin care, evaluation, or assessment, and removal caused the current heel wound he was consulted to treat. He said, Nurses are to remove any removable devices to conduct skin assessments to identify and prevent skin breakdown. The Wound Care physician explained any device left in place could have adverse consequences including development of a pressure ulcer and local or systemic infection as the device could get stuck to or embedded in the skin. He was informed of concerns related to nurses not following his orders for frequency of dressing changes, use of selected treatments, and adherence to infection control procedures. The Wound Care physician expressed concern that failure to follow his treatment orders could affect the resident's healing process. He acknowledged it did not matter what he ordered during once weekly visits if nurses did not implement the interventions. The Wound Care physician explained he selected specific treatments for resident #3's condition such as Dakin's Solution rather than Normal Saline to control the bacteria in the wound. He stated it was important to perform dressing changes daily as a dressing left in place for longer would stick to the new, healthy, healing tissue in the wound and cause bleeding when removed. He explained it was important for nurses to apply a moist gauze over the Santyl to activate the medication. The Wound Care physician predicted resident #3 would require a minimum of another four weeks of daily wound care. On 10/19/22 at 12:57 PM, the Director of Nursing (DON) stated resident #3 went to an orthopedic appointment in April 2022 and did not return to the facility with a progress note. She acknowledged if there was no progress note or other communication from an outside consult, facility staff were responsible for calling to obtain copies of documents and/or follow up instructions. The DON was unsure if anyone ever called the orthopedic practice and the facility was therefore not aware resident #3 returned from the appointment with a removable splint instead of a fixed cast. On 10/20/22 at 1:21 PM, the DON confirmed resident #3's splint remained in place as there were no new or clarification orders obtained to remove it, and no care plan approaches developed to ensure appropriate monitoring. She stated splints were not permanent devices and residents who wore them usually had either therapy or restorative nursing program orders. The DON said, I would have expected every nurse to note the device and check for orders, especially if they were seeing it on continuously. Review of the Facility Assessment Tool dated 9/29/22 revealed the facility would accept and care for residents with common conditions including fractures and provide assistance with activities of daily living such as bathing. Additional services included mobility, restorative nursing, skin care, wound care, prevention of infections and management of splints. The document read, The communication between providers and care givers is constant. Communication occurs through note transmissions, phone calls, telephone orders, and faxes. 2. Resident #2 was readmitted to the facility from an acute care hospital on 9/30/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . DMAC is a group of bacteria that can cause life threatening infections in people with severely compromised immune systems (retrieved on 10/24/22 from www.everydayhealth.com). The resident's Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #2 had intact cognition and displayed no physical or verbal behaviors toward himself or others. He required set up help only for transfers and bed mobility. The assessment showed resident #2 had a surgical wound for which he received nutrition, ointments and wound care. He received pain medications both scheduled and as needed and antibiotics during the look back period. Resident #2 had a care plan for a surgical wound to his right leg initiated 7/26/22 with goal for the surgical site to show signs of healing and have minimal risk of infection. Interventions included staff to provide pain relief measures, and to monitor/document the healing of the surgical site. Review of the Order Summary Report for 9/31/2022 through 10/31/22 revealed resident #2 had a completed order for a follow up appointment with the orthopedic physician related to his DMAC infection and right knee replacement on 10/07/22. An additional order dated 10/03/22 noted toe touch weight bearing with knee immobilizer that indicated it should be followed until resident #2 was seen at the follow up appointment with no range of motion to the right knee until that time. Review of the Progress Notes dated 10/07/22 by Registered Nurse (RN) B indicated resident #2 went for his follow up orthopedic appointment and when he returned, he was medicated for pain. The note did not indicate if resident #2 returned with any new orders or paperwork from his medical appointment. In a telephone interview on 10/20/22 at 3:06 PM, RN B stated resident #2 did not come back from the doctor's appointment with any paperwork. She stated she felt because resident #2 was alert and oriented and able to say what happened at the appointment she did not tell anyone the paperwork was missing nor did she follow up with the physician's office to have them send the information. RN B stated when residents return from appointments without paperwork, the nurse was supposed to call to follow up with the doctor for the information, but admitted she did not do this for resident #2. On 10/19/22 at 5:04 PM, the North Wing Unit Manager (UM) stated when a resident returns from an appointment the nurse was supposed to receive the paperwork, review it, then enter any pertinent information into the resident's record and call the attending physician to approve any new orders. The North Wing UM was unable to find the paperwork for resident #2's orthopedic appointment on 10/07/22 and stated he recalled resident #2 did not come back with it. He recalled he followed up with resident #2's orthopedic office to ascertain the date of the next appointment but could not remember if there was any other information given. The North Wing UM stated he did not know what, if any changes were made to resident #2's care because he did not document what, if anything was said nor did he ask the office to send a copy of the paperwork following the appointment. He acknowledged the order dated 10/03/22 for toe touch weight bearing with knee immobilizer to the right lower extremity until seen at the follow up appointment but was unable to say whether the order should be followed or if it was changed or discontinued after the 10/07/22 appointment. On 10/20/22 at approximately 9:00 AM, the facility presented the Orthopedic Total Knee Progress Note dated 10/07/22. The plan included 7 points: continuing the weightbearing status, continuation of medications including aspirin and antibiotics, and wound care for the incision site. The document indicated resident #2 was now cleared to shower but gave direction to avoid standing water such as a tub. The plan also included information for the next visit and instructions for non-pharmaceutical pain control as needed. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/11/22, the facility received an allegation of neglect regarding resident #3. *On 10/11/22, the DON initiated education with licensed nurses regarding ensuring residents who returned from appointments and any newly admitted residents had all necessary information and documents to include follow-up appointments and new physician orders. *On 10/11/22, the DON initiated education with licensed nurses regarding following physician orders and the importance of conducting a thorough skin assessment. *On 10/11/22, the DON initiated education with licensed nurses and Certified Nursing Assistants (CNAs) regarding observing residents' skin during showers or bed baths. CNAs were directed to document on a skin observation form any areas of skin concern to the nurse. Licensed nurses were educated to perform an assessment on those observations and document that assessment in the electronic medical record. *As of 10/11/22, weekly skin assessments and documentation is occurring by licensed nurses to monitor the status of skin integrity in the facility. Review of the skin integrity assessments by nursing leadership will occur in the daily clinical meeting to ensure accuracy and completion. *As of 10/11/22, the Executive Director intimated all-staff education on abuse, neglect, and empowering the staff to report to management. Staff who have not received the education will receive education before the next scheduled shift. *As of 10/11/22, the DON initiated education with Licensed Nurses regarding actions to be taken when a resident returns from an appointment without documentation: (i) Call the physician's office and request documentation to be faxed to the facility and document in the progress note (ii) Nurse will request verbal orders and document in the progress notes any communication received from the physician's office (iii) Notify the DON of any residents who returned without documentation from the appointment (iv) If the DON and the Licensed Nurse are unable to obtain the documentation from the appointment, the Executive Director will call the physician's office. *On 10/12/22, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the event and required follow up. In attendance were the Executive Director, DON, Social Services Director, Medical Director Central Supply, a CNA, a Licensed Nurse, Community Life, Medical Records, Minimum Data Set, Regional Nurse, maintenance Director, Director of Dietary Services, and Director of Rehabilitation. *On 10/12/22, the facility conducted an audit of all residents with splints and any other devices for contracture management or immobilizers to ensure, if removable, that the device is being removed for hygiene and skin integrity checks. *On 10/13/22, the DON completed a full house audit to determine if other residents had evidence of skin breakdown, No new skin issues were identified. *On 10/13/22, the Social Services Director/designee completed a 30-day lookback to ensure there were no other concerns with follow up appointments or physician orders. One of 108 residents reviewed was identified with concerns and documentation was received on 10/20/22, and new orders were implemented. *As of 10/13/22, residents with a Brief Interview for Mental Status (BIMS) score of 10 or greater were interviewed by the IDT with an abuse questionnaire to ensure no other residents are affected by the deficient practice. Residents with a BIMS score of 9 or less had a skin observation completed with no issues identified. *On 10/14/22, the facility mailed letters to employees with notice of mandatory education to ensure no staff work a shift without receiving education. *On 10/20/22, an Ad Hoc QAPI meeting was held to review audits and reevaluate the effectiveness of the plan. *As of 10/21/22, residents with appointments and new admissions are reviewed by the IDT in the daily clinical meeting, to ensure all essential orders have been obtained and are implemented in the plan of care, and any follow-up appointments are scheduled with transportation arranged. *As of 10/21/22, Braden risk assessment will be completed on current resident to determine residents at risk for skin impairment. Care plans and Kardexes will be updated to reflect any potential or actual skin impairment. *As of 10/21/22, facility mock surveyors will be provided with a list of residents with splints and devices and a wear schedule to ensure devices are applied and removed appropriately. *As of 10/21/22, the facility achieved 69% compliance with education of Licensed Nurses. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On 10/20/22 and 10/21/22, interviews were conducted with three Registered Nurses, 3 LPNs, and eight CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who had splints/devices and one additional resident with an allegation of neglect. Observations, interviews, and record reviews revealed no concerns for residents #1, #4, #5, #6, and #7.

Based on observation, interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to recognize and address the absence of physician and consultant orders for care, perform thorough and accurate skin evaluations, identify potential concerns related to a splint, follow wound treatment orders, and report significant findings to nursing management and the physician for 1 of 6 residents reviewed for splints of a total sample of 8 residents, (#3). Resident #3 suffered significant pain and discomfort as nursing staff left a removable splint on her left leg and foot continuously for six months. She was placed at risk for skin breakdown and infection, and subsequently sustained a traumatic injury to her left heel during removal of the splint, which required ongoing daily wound care. On 4/05/22, resident #3's orthopedic practitioner determined her ankle fracture was healed and a cast was removed and replaced with a splint. The orthopedic progress note indicated the splint was to be worn as needed, if desired by the resident for comfort, and should be removed daily to wash the area. The instructions were never transcribed to the resident's medical record and nursing staff did not attempt to obtain orders or clarification related to the splint. As a result, resident #3's splint remained in place and was never removed for evaluation of the skin underneath the device or to provide daily personal hygiene and skin care. Over six months later, on 10/11/22, resident #3 returned to the orthopedic practice with a complaint of pain in her left foot and heel. The orthopedic practitioner discovered the resident's splint was adhered to her skin and when she attempted to remove the device, resident #3 reported pain and had significant bleeding as the splint tore the skin away from her heel. The resident was transferred to the hospital Emergency Department (ED) for evaluation and was readmitted to the facility on [DATE] with orders to consult a wound care physician for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The failure of nursing staff to demonstrate competency in evaluation, assessment, advocacy, and identification of care needs contributed to the development of a preventable wound for resident #3 and placed all residents who consulted outside providers and/or wore splints or had wounds at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 4/05/22 and was removed on 10/21/22. Findings: Cross reference F600, F641, F684, and F842. Review of resident #3's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old, and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In interviews on 10/19/22 at 12:57 PM and 10/20/22 at 1:21 PM, the Director of Nursing (DON) recalled resident #3 had an ankle fracture in February 2022. The DON stated in August 2022 she happened to be on the South Wing and observed resident #3 seated in a wheelchair with a wrapped cast on her foot. She stated she immediately asked transportation staff to schedule a follow-up appointment with the orthopedic practice regarding the device. She explained the earliest available appointment was in September 2022, but due to inclement weather it was rescheduled for mid-October. The DON stated resident #3 was seen on 10/11/22 by the orthopedic Certified Registered Nurse Practitioner (CRNP) who sent her to the ED for evaluation and treatment when she discovered the splint was stuck to the resident's heel. The DON confirmed resident #3's splint had remained in place for six months as there were no new or clarification orders obtained to remove it, and no care plan approaches developed to ensure appropriate monitoring. She stated splints were not permanent devices and residents who wore them usually had either therapy or restorative nursing program orders. The DON said, I would have expected every nurse to note the device and check for orders, especially if they were seeing it on continuously. However, the DON acknowledged when she observed the wrapped device on resident #3's foot in August 2022, she did not call the orthopedic practice herself nor ask the assigned nurse and the Unit Manager (UM) to verify a removal date or that orders for care were in place. The DON stated she was not made aware of the missing orthopedic progress note or absence of orders until notified by the orthopedic CRNP in October 2022. Review of the job description for Director of Clinical Services or DON (undated), revealed he/she would .ensure that the highest degree of quality care is maintained at all times. The DON's duties and responsibilities included guiding implementation of facility policies and procedures, directing the nursing and care plan team, and implementing competency/skills checklists. On 10/20/22 at 9:02 AM, the North Wing Licensed Practical Nurse, (LPN) UM stated the facility's process was that the staff member who escorted a resident to an outside appointment was responsible for bringing any paperwork back to the facility and handing it to the assigned nurse. The North Wing LPN UM explained the assigned nurse was responsible for ensuring paperwork was requested if missing, but the UM was ultimately responsible to ensure it was obtained. He stated every nurse assigned to resident #3 shared responsibility for addressing her splint and its care. He confirmed a splint should have been noted on all her skin evaluations as all areas of the body must be visualized. Review of resident #3's medical record revealed documentation of skin evaluations completed during the six-month period the resident wore the splint on her left leg. Eight nurses, including the South Wing LPN UM, the DON and the Wound Nurse, evaluated the resident's skin and recorded their findings on a total of 25 Weekly Skin Integrity Review forms. Thirteen skin evaluations completed by LPNs A, H, J, K, and N did not include either observation of a splint or the skin underneath the device. The South Wing LPN UM completed seven skin evaluations during the six-month period, and only one form dated 5/24/22 noted a device. It read, Right lower leg (rear) soft cast, blister on toe instead of the left foot. Skin evaluations done by the Wound Nurse on 7/17/22 and 7/24/22 indicated only that resident #3's skin was intact, and on 8/26/22 she noted a treatment in place on the left great toe. The DON completed two skin evaluations during the six-month period and did not note the splint on the resident's left foot. On 5/17/22, the DON noted issues on the resident's left great toe and fourth toe, and on 8/14/22 she documented, skin intact. Review of the staffing schedule from 4/05/22 to 10/11/22 revealed 41 licensed nurses were assigned to care for resident #3 during the 27-week period the splint remained on her left foot. Review of nursing progress notes showed none of the licensed nurses identified, queried, or reported the absence of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's job description for a Registered Nurse (undated) revealed duties and responsibilities included conduct and document thorough assessments of residents' medical status, provide routine nursing services, maintain ongoing communication with physicians, and implement individualized treatment plans for assigned residents. The facility's job description for a Licensed Practical Nurse (undated) included responsibilities to provide regular updates on resident status as indicated, conduct and document thorough evaluations of residents' medical status, complete accurate and timely documentation, and provide routine nursing services as directed. On 10/20/22 at 11:20 AM, in a telephone interview, LPN J was informed she completed a skin evaluation for resident #3 on 4/08/22, three days after she returned to the facility with a wrapped splint on her left leg. She did not recall completing the skin evaluation but confirmed nurses should document if there was a cast or remove a splint to check for redness and impairment underneath the device. LPN J was informed the resident's splint was not removed for over six months. She said, I cannot understand how the shower was done. Even a cast does not stay forever. It's important to monitor so that it did not cause any problems. On 10/20/22 at 11:31 AM, in a telephone interview, LPN A stated nurses were to document everything observed on the resident's skin including the skin under a splint. She said, Most times when they come with a splint or cast there would be an order. I saw it and I looked at the wound on the toe. I did not look at the orders though to see if there was any other order beside wound care for the toe until the heel thing happened. LPN A explained residents' scheduled treatments were displayed by shift on her computer but there was never a task related to removal of a splint or assessment of a casted extremity on any shift she worked with the resident. She said, Nothing popped up on the screen. On 10/20/22 at 11:49 AM, the Wound Nurse stated her responsibilities included accompanying the Wound Care physician during weekly rounds and documenting findings, orders, and wound measurements. The Wound Nurse recalled the DON requested a Wound Care physician consult for assessment of an area of concern on resident #3's toe. The Wound Nurse said, I saw the cast. I asked the Unit Manager because I thought the cast had been there for a long time. The Unit Manager said [the resident] went to the doctor's office and they put another cast back on again. The Wound Nurse acknowledged she did not pursue a discussion with anyone else, including the Wound Care physician or the DON, regarding her concern about the device. She confirmed she did not contact the orthopedic practice for clarification regarding removal of the splint. On 10/20/22 at 12:10 PM, in a telephone interview with LPN L, she was informed she was the nurse assigned to resident #3 on 4/05/22, the day the resident went to an orthopedic appointment to have a cast removed and replaced with a splint. LPN L explained she worked for a staffing agency and only worked in the facility on one occasion. She said, It was hard to find the residents. Some of them were not in their room. It was very confusing. LPN L did not recall that one of her assigned residents went out to an appointment nor that she was assigned to any resident with a splint or cast. On 10/20/22 at 2:33 PM, LPN H confirmed she had been assigned to resident #3 during the past six months and her splint had always been present. LPN H recalled she once requested stronger pain medication due to the resident's complaints of pain. She explained no orders regarding the splint ever showed on the Treatment Administration Record during her shift. LPN H acknowledged residents with splints usually had orders for the duration of time the device should be worn but she never questioned why the splint was always in place. LPN H said, This is a big lesson for all of us. I am not making any excuse. That should have been a red flag when she came back from the doctor with something on her leg and no orders. On 10/20/22 at 3:17 PM, LPN N stated resident #3 was on his regular assignment and he recalled she had a splint in place for a long time. He said, I did not have a treatment ordered on my shift. Devices usually get removed. To be honest, I was not paying attention. I am not sure how long it was there. I never really wondered anything about it or asked anyone to check. LPN N acknowledged he did not call the physician for clarification of orders or notify the DON of the length of time the splint was on resident #3's leg. On 10/20/22 at 5:07 PM, in a telephone interview with Advanced Practice Registered Nurse (APRN) M, she stated she first assessed resident #3 a week or two before she went to the hospital for removal of the splint. APRN M explained leaving a splint in place continuously could cause problems. She said, At some point the skin would deteriorate. APRN M stated facility nurses should have called her or her after-hours staff to obtain orders to remove the splint. On 10/21/22 at 11:00 AM, after review of the staffing schedule, the North Wing LPN UM validated he was often assigned to care for resident #3 on the weekends. He confirmed he was aware the resident had a splint on her leg for a long time but said, I never really thought of calling anyone. On 10/21/22 at 1:14 PM, in a telephone interview, LPN O stated she was regularly assigned to care for resident #3 on the 11:00 PM to 7:00 AM shift between April and July 2022 but did not know the resident had a splint on her left leg. LPN O recalled the resident often complained of pain. On 10/20/22 at 10:25 AM, the Wound Care physician was informed resident #3's leg splint was left in place for over six months and never removed for skin care, evaluation, or assessment. He said, Nurses are to remove any removable devices to conduct skin assessments to identify and prevent skin breakdown. He was informed of concerns related to nurses not following his orders for frequency of dressing changes, and LPN A's failure to follow the ordered treatments and adhere to infection control procedures during wound care observation on 10/19/22. The Wound Care physician explained he selected specific treatments for resident #3's condition and he expected nurses to follow the plan of care. On 10/21/22 at 2:30 PM, the DON provided LPN A's Skills Competency Assessment: Clean Dressing Changing form dated 9/18/22. The document was signed by the DON to indicate LPN A fully met the standards of the task. The DON stated she expected nurses to administer treatments as ordered by the physician. She explained she maintained records of competency assessments for all licensed nurses. The DON acknowledged it was concerning that licensed nurses did not follow the facility's processes, policies and procedures related to following up after resident #3 returned from her orthopedic appointment and completing thorough skin evaluations. The DON said, I would have expected the Unit Manager to be on top of the skin assessments, to make sure they were done every week, and to make sure they were accurate. Review of the Facility Assessment Tool dated 9/29/22 revealed the facility would provide competent staff to support and care for residents. The document indicated competencies were based on current standards of practice and the needs of the resident population. Review of the facility's Education Calendar - 2022 revealed required annual competencies for nurses included hand hygiene, identification of a change in condition, and clean dressing changes. Review of the new hire orientation packet Roadmap On-boarding Action Items revealed clinical mandatory education for licensed nurses included skin and wound care and restorative nursing. Nurses were required to demonstrate competence in documentation of changes in condition, incidents, updating and creating care plans, skin or wounds, and the 24-hour report. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/11/22, the DON initiated education with licensed nurses regarding ensuring residents who returned from appointments and any newly admitted residents had all necessary information and documents to include follow-up appointments and new physician orders *On 10/11/22, the DON initiated education with licensed nurses regarding following physician orders, recognizing the orders on other shifts, knowing the resident's plan of care, and the importance of conducting a thorough skin assessment. *On 10/11/22, the DON initiated education with licensed nurses and Certified Nursing Assistants (CNAs) regarding observing residents' skin during showers or bed baths. CNAs were directed to document on a skin observation form any areas of skin concern to the nurse. Licensed nurses were educated to perform an assessment on those observations and document that assessment in the electronic medical record. *As of 10/11/22, the Executive Director initiated all-staff education on abuse, neglect, and empowering the staff to report to management. Staff who have not received the education will receive education before the next scheduled shift. *As of 10/11/22, the DON initiated education with Licensed Nurses regarding actions to be taken when a resident returns from an appointment without documentation: (i) Call the physician's office and request documentation to be faxed to the facility and document in the progress note (ii) Nurse will request verbal orders and document in the progress notes any communication received from the physician's office (iii) Notify the DON of any residents who returned without documentation from the appointment (iv) If the DON and the Licensed Nurse are unable to obtain the documentation from the appointment, the Executive Director will call the physician's office. *On 10/12/22, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the event and required follow up. In attendance were the Executive Director, DON, Social Services Director, Medical Director Central Supply, a CNA, a Licensed Nurse, Community Life, Medical Records, Minimum Data Set, Regional Nurse, maintenance Director, Director of Dietary Services, and Director of Rehabilitation. *On 10/14/22, the facility mailed letters to employees with notice of mandatory education to ensure no staff work a shift without receiving education. *On 10/19/22, the DON initiated competency testing and return demonstration on wound care, hand hygiene, and residents returning from appointments. *On 10/20/22, an Ad Hoc QAPI meeting was held to review audits and reevaluate the effectiveness of the plan. *On 10/21/22, education was updated to have therapy services to train staff on types of splints, removable and non-removable devices and what to do if not sure. *As of 10/21/22, the facility achieved 69% compliance with education of Licensed Nurses. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On 10/20/22 and 10/21/22, interviews were conducted with three Registered Nurses, 3 LPNs, and eight CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who had splints/devices and one additional resident with an allegation of neglect. Observations, interviews, and record reviews revealed no concerns for residents #1, #2, #4, #5, #6, and #7.

Based on observation, interview, and record review, the facility neglected to provide adequate oversight of staff, effectively utilize interdisciplinary team (IDT) communication, and implement processes to ensure the plan of care reflected care needs; and failed to provide necessary care and services to prevent the development of a traumatic wound for 1 of 6 residents reviewed for splints of a total sample of 8 residents, (#3). Resident #3 suffered significant pain and discomfort as a splint remained on her left leg and foot continuously for six months. She was placed at risk for skin breakdown and infection, and subsequently sustained a traumatic injury to her left heel during removal of the splint, which required ongoing daily wound care. On 4/05/22, resident #3's orthopedic practitioner determined her ankle fracture was healed and a cast was removed and replaced with a splint. The orthopedic progress note indicated the splint was to be worn as needed, if desired by the resident for comfort, and should be removed daily to wash the area. The instructions were never transcribed to the resident's medical record and nursing staff did not attempt to obtain orders or clarification related to the splint. As a result, resident #3's splint remained in place and was never removed for evaluation of the skin underneath the device or to provide daily personal hygiene and skin care. Over six months later, on 10/11/22, resident #3 returned to the orthopedic practice with a complaint of pain in her left foot and heel. The orthopedic practitioner discovered the resident's splint was adhered to her skin and when she attempted to remove the device, resident #3 reported pain and had significant bleeding as the splint tore the skin away from her heel. The resident was transferred to the hospital Emergency Department (ED) for evaluation and was readmitted to the facility on [DATE] with orders to consult a wound care physician for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's failure to identify and provide necessary care and services for use and monitoring of a splint contributed to the development of a preventable wound for resident #3 and placed all residents who consulted outside providers and/or wore splints or had wounds at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 4/05/22 and was removed on 10/21/22. Findings: Cross reference F641, F684, F726, and F842. Review of resident #3's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old, and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An orthopedic progress note dated 10/11/22 revealed resident #3 was initially treated at the practice on 2/08/22 for a left ankle fracture. The note indicated nonoperative treatment was selected due to resident #3's non-ambulatory status, and she received a short leg cast that was to be worn for eight weeks. Resident #3 returned to the orthopedic practice on 4/05/22 and her cast was removed and replaced with a posterior splint that was wrapped with an elastic bandage. The orthopedic Certified Registered Nurse Practitioner (CRNP) wrote, My [skilled nursing facility] orders stated the splint was [as needed] only for comfort only and not to remain on continuously. Today the patient presents to me, over 6 months later, as she has been complaining of continued pain to the ankle/heel. The orthopedic CRNP noted resident #3 reported the splint had not been removed since the last visit. On physical examination, the orthopedic CRNP noted the same splint and elastic bandage were still in place and there was a foul odor. The document revealed the bandage that held the splint in place was soiled and the splint was significantly adhered to the resident's skin. The progress note indicated the orthopedic CRNP's attempt to remove the splint resulted in tissue loss and bleeding and had to be aborted. She immediately sent resident #3 to the ED for appropriate treatment and the facility's Director of Nursing (DON) was informed of the situation. The orthopedic CRNP wrote, I will be escalating this issue of neglect from the facility. Review of the facility's policy and procedure for Abuse, Neglect, Exploitation & Misappropriation revised 11/28/17, read, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect. The policy defined neglect as the failure of the center, its employees or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The document indicated neglect included the failure to take preventive measures to protect a resident's health and well-being. On 10/19/22 at 12:57 PM, the DON reviewed the facility's incident investigation for the neglect allegation made by the orthopedic CRNP. She explained the facility's investigation showed resident #3 returned from her orthopedic appointment in April 2022 without a progress note and orders for care. The DON stated a root cause analysis of the incident showed, The resident did not return with a follow up appointment or orders. When asked whether the resident or the facility was responsible for ensuring appropriate orders for care were obtained and implemented, the DON said, We are supposed to get progress notes from consult appointments. She explained if a resident returned from an appointment without any paperwork, the facility's process required the assigned nurse to call the practitioner's office for follow- up instructions and/or orders. The DON stated the Unit Manager (UM) should verify new orders were transcribed and implemented as indicated. She confirmed this was not done and staff were not aware resident #3's device was a removable splint and not a cast. On 10/19/22 at 1:22 PM, the Executive Director (ED) stated he was the facility's Risk Manager. He explained during the neglect allegation investigation, he interviewed licensed nurses and Certified Nursing Assistants who stated they reported concerns about resident #3's splint to the South Wing Licensed Practical Nurse (LPN) UM. The ED did not have documentation of the reported concerns and stated the South Wing LPN never followed up and was no longer on staff. He stated the facility did not substantiate the allegation of neglect and said, Upon my review, I did not feel we were neglectful as Wound Care was still treating her foot and had eyes on the area. The ED was informed the Wound Care physician assessed and treated the resident's left great toe wound on 8/25/22 and did not follow her throughout the entire period she wore the splint. On 10/20/22 at 1:21 PM, the DON stated a major part of the facility's process to oversee resident care was for the IDT to meet every morning, Monday through Friday, for a daily clinical meeting. She explained the IDT discussed and reviewed medical records of newly admitted and readmitted residents and follow-up documentation from consultants. The DON said, I don't know if I was there on the day or days it was discussed, but nothing flags in my mind about her. The DON stated if information was missing or unclear, the appropriate member(s) of the IDT would obtain and/or clarify orders with the physician and ensure the medical record was updated. The DON stated the IDT included a Minimum Data Set (MDS) nurse who participated in the daily clinical meetings. She said, The MDS nurse should write and record. That is the time to create the care plan. She acknowledged resident #3's medical record did not include care plans neither for her cast, nor the splint. On 10/20/22 at 1:55 PM, the Director of Rehab confirmed she was a member of the facility's IDT. She stated all residents had screenings on readmission, with referrals, and on a quarterly basis. She stated resident #3 had a quarterly screening done on 8/29/22 and she had a left foot or ankle splint or cast in place, wrapped with an elastic bandage. The Director of Rehab stated she was not aware if the device was removable. She stated the Physical Therapist who screened resident #3 recommended follow-up with the physician to obtain a status update regarding permission to work with the resident's foot since the splint was in place. The Director of Rehab stated residents would usually have care plans or orders in place for splints. She described six months without a care plan as extensive. She did not recall any IDT discussion regarding resident #3's splint. When asked if she presented therapy screening forms for review in IDT meetings, the Director of Rehab stated she did not bring all that paperwork. She did not respond when asked how she ensured all therapy screenings were thoroughly reviewed and addressed by the IDT. On 10/20/22 at 2:49 PM, the Physical Therapist stated he completed a therapy screen for resident #3 on 8/29/22. He said, I saw the half splint a few screens ago. she did not want me to touch her, to look at the splint. The Physical Therapist recalled the resident complained of significant pain during the assessment and he was unable to complete the screening. He stated the resident told him she wanted the physician to see her for the pain in her foot; however, he did not tell the nurse that she was in pain and did not want to be touched. Review of the Interdisciplinary Therapy Screen dated 8/29/22 and signed by the Physical Therapist indicated resident #3 had a change in status related to pain and included the recommendation .nursing to schedule [physician] visit for updated status. Review of resident #3's medical record revealed the IDT met to discuss resident #3's status and care needs on 8/09/22, 8/16/2, 8/25/22, 9/02/22, and 9/08/22. An IDT note dated 8/25/22, written by the Wound Nurse, revealed the resident had a splint to her left foot. The IDT documentation did not reflect any discussion of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed between April and October 2022, resident #3 was seen 21 times by Physician P, seven times by Advanced Practice Registered Nurse (APRN) Q, and twice by APRN R. The providers' documentation did not address the resident's left foot splint which was secured to her leg with an elastic bandage at the time of every visit. The notes did not include any recommendations for clarification of orders from the orthopedic practitioner or necessary care and services to prevent skin breakdown. Physical examination findings by Physician P and APRN Q repeatedly indicated the resident's right ankle was wrapped, rather than her left ankle. Review of the staffing schedule from 4/05/22 to 10/11/22 revealed 41 licensed nurses were assigned to care for resident #3 during the 27-week period the splint remained on her left foot. Review of nursing progress notes showed none of the licensed nurses identified, queried, or reported the absence of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #3's medical record revealed documentation of skin evaluations completed during the six-month period the resident wore the splint on her left leg. Eight nurses, including the South Wing LPN UM, the DON, and the Wound Nurse, evaluated the resident's skin and recorded their findings on a total of 25 Weekly Skin Integrity Review forms. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/11/22, the facility received an allegation of neglect regarding resident #3. *On 10/11/22, the DON initiated education with licensed nurses regarding ensuring residents who returned from appointments and any newly admitted residents had all necessary information and documents to include follow-up appointments and new physician orders *On 10/11/22, the DON initiated education with licensed nurses regarding following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 10/11/22, the DON initiated education with licensed nurses and Certified Nursing Assistants (CNAs) regarding observing residents' skin during showers or bed baths. CNAs were directed to document on a skin observation form any areas of skin concern to the nurse. Licensed nurses were educated to perform an assessment on those observations and document that assessment in the electronic medical record. *As of 10/11/22, weekly skin assessments and documentation is occurring by licensed nurses to monitor the status of skin integrity in the facility. Review of the skin integrity assessments by nursing leadership will occur in the daily clinical meeting to ensure accuracy and completion. *As of 10/11/22, the Executive Director initiated all-staff education on abuse, neglect, and empowering the staff to report to management. Staff who have not received the education will receive education before the next scheduled shift. *As of 10/11/22, the DON initiated education with Licensed Nurses regarding actions to be taken when a resident returns from an appointment without documentation: (i) Call the physician's office and request documentation to be faxed to the facility and document in the progress note (ii) Nurse will request verbal orders and document in the progress notes any communication received from the physician's office (iii) Notify the DON of any residents who returned without documentation from the appointment (iv) If the DON and the Licensed Nurse are unable to obtain the documentation from the appointment, the Executive Director will call the physician's office. *On 10/12/22, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the event and required follow up. In attendance were the Executive Director, DON, Social Services Director, Medical Director Central Supply, a CNA, a Licensed Nurse, Community Life, Medical Records, Minimum Data Set, Regional Nurse, maintenance Director, Director of Dietary Services, and Director of Rehabilitation. *On 10/12/22, the facility conducted an audit of all residents with splints and any other devices for contracture management or immobilizers to ensure, if removable, that the device is being removed for hygiene and skin integrity checks. *On 10/13/22, the DON completed a full house audit to determine if other residents had evidence of skin breakdown, No new skin issues were identified. *On 10/13/22, the Social Services Director/designee completed a 30-day lookback to ensure there were no other concerns with follow up appointments or physician orders. One of 108 residents reviewed was identified with concerns and documentation was received on 10/20/22, and new orders were implemented. *As of 10/13/22, residents with a Brief Interview for Mental Status (BIMS) score of 10 or greater were interviewed by the IDT with an abuse questionnaire to ensure no other residents are affected by the deficient practice. Residents with a BIMS score of 9 or less had a skin observation completed with no issues identified. *On 10/14/22, the facility mailed letters to employees with notice of mandatory education to ensure no staff work a shift without receiving education. *On 10/20/22, an Ad Hoc QAPI meeting was held to review audits and reevaluate the effectiveness of the plan. *As of 10/21/22, residents with appointments and new admissions are reviewed by the IDT in the daily clinical meeting, to ensure all essential orders have been obtained and are implemented in the plan of care, and any follow-up appointments are scheduled with transportation arranged. *As of 10/21/22, facility mock surveyors will be provided with a list of residents with splints and devices and a wear schedule to ensure devices are applied and removed appropriately. *As of 10/21/22, the facility achieved 69% compliance with education of Licensed Nurses. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On 10/20/22 and 10/21/22, interviews were conducted with three Registered Nurses, 3 LPNs, and eight CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who had splints/devices and one additional resident with an allegation of neglect. Observations, interviews, and record reviews revealed no concerns for residents #1, #2, #4, #5, #6, and #7.

Based on observation, interview, and record review, the facility failed to identify and provide adequate supervision to prevent elopement and hospitalization for 1 of 4 sampled residents (#1) and failed to prevent potential for serious harm for 3 of 4 residents, (#2, #3, and #4) during a facility activity outing to a supercenter. During a supercenter outing, resident #1 left the premises and residents #2, #3 and #4 were placed at risk for potential serious harm as a result of inadequate supervision. The whereabouts of resident #1 were unknown for approximately 49 hours until she was located by law enforcement at an acute care hospital. The resident experienced chest discomfort while she was missing, a bystander contacted emergency medical services, and the resident was taken to the hospital for treatment. Residents #2, #3, and #4 were left unattended and unsupervised for unknown periods of time at a large supercenter which was approximately 180,000 square feet in size. The failure to provide adequate supervision during an outing to the supercenter resulted in substandard quality of care and immediate jeopardy starting on 7/29/16 and was determined to be ongoing at the survey exit date on 8/12/16. Findings: Cross reference to F224 Resident #1's medical record revealed she is 55-years-old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a court appointed guardianship for person and property dated 02/04/13. The minimum data set (MDS) assessments for resident #1 from 10/18/15 to 7/18/16 revealed all 7 assessments during that time had consistent brief interview for mental status (BIMS) scores of 13 out of 15 indicating she was cognitively intact. The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. The annual MDS assessment dated [DATE] noted that the resident required supervision with walking when off the unit where she resided. On 8/08/16 at 1:00 PM via telephone, the resident's guardian stated she had known the resident for over 3 years, since she was admitted to a hospital in the City of Deland and had been deemed incompetent. She said that resident #1's home had been foreclosed and the resident had been informed of this repeatedly, but she did not comprehend her situation due to her memory loss. The guardian said the resident eloped from three previous assisted living facilities both secure and non-secure from March 2012 to June 2014, prior to her admission to the current facility. A quarterly elopement risk evaluation was completed on 7/24/16 and it indicated resident #1 was not an elopement risk. The elopement risk evaluation form lists 7 questions to identify potential risk factors and 3 of the questions indicate the resident is at risk if the answer is yes to any one of them. The question for Does the resident have a history of elopement? If yes, number of times, if known was documented as no history of elopement. In an interview with the regional consultant on 8/12/16 at 11 AM, she said resident #1 had not eloped while she was at this facility and her elopements were prior to admission to the nursing home. When asked how the history of elopement question is answered if a resident elopes prior to admission to the facility or what is the timeframe for a history of elopement, she said that she did not know how long the lookback is for elopement. In an interview with the director of nursing (DON) on 8/08/16 at 3:15 PM, she was asked how residents are evaluated to go out of the facility on activity outings. She said that if the resident is alert and oriented and ambulatory, they can go. She said the resident is assessed by the physician and then the physician will write an order to go on leave of absence (LOA). A telephone interview with resident #1 ' s attending physician regarding what she considers in making the decision to write an order for [REDACTED]. She said she looks at the resident's cognition, mental status, and physical capacity, with the expectation that when the resident is on LOA, she will be supervised and will follow the rules of the facility. A physician's orders [REDACTED].#1 may go on a leave of absence (LOA) with a responsible party. On 8/09/16 at 4:00 PM during a telephone interview with the medical director, he stated that the expectation of LOA with responsible party order is, If facility staff take them (residents) out, the expectation is that the residents will be supervised and be brought back to the facility safely. On 8/09/16 at 10:00 AM, in an interview with resident #1 about the events on 7/29/16, she revealed that she got tired of shopping at the supercenter and went outside to smoke. She believed that she had met someone outside in the smoking area who called a taxi for her. She did not recall the events but, she had detailed handwritten notes regarding most of the events on 7/29/16 and 7/30/16. Her notes documented that on 7/29/16 she was woken by a CNA at 4:30 AM and had her blood pressure taken. She had put on black jeans and black lace top, got the newspaper, and put a letter under the social services office door. At 9:00 AM, she had two cigarettes and returned to her room to eat oatmeal. After this entry there was no further documentation until a note showing that she bought two lemonades from a gas station on Lee Road in Winter Park, Florida which was located approximately 5 miles from the supercenter. There were telephone numbers written for American Red Cross, Christian Services, and Triple A. There was no further documentation to account for what transpired on 7/29/16. The next notation on 7/30/16 read that she woke at 6:30 AM, came into the restaurant located across from the street from the gas station and used the rest room to wash herself. She had 2 cups of coffee and charged her cellular phone. At 10:27 AM she was still at the restaurant charging her phone, and then no account of what happened after this time. When the resident was asked where she had spent the night, she stated that she could not remember but probably stayed at the restaurant all night. She said that she remembered not feeling well, had pressure to her chest area and someone called the ambulance. She said she was outside of the restaurant across the street when this happened. The restaurant and gas station, from resident #1 ' s notes, on Lee Road in Winter Park, Florida were observed on 8/09/16 at 2:00 PM. They were located approximately 5 miles from the supercenter on a busy 4 lane road adjacent to the ramp to Interstate 4 surrounded by office buildings and business offices. At that time, 8/09/16 at 2:00 PM, the traffic was noted to be heavy and constant. Telephone interviews on 8/09/16 at 9:00 PM and on 8/10/16 at 1:05 PM with several of the restaurant managers revealed that this was a very busy location especially on Friday nights and it was open 24 hours. On 8/09/16 at 10:00 AM, certified nursing assistant (CNA) B revealed that she had worked at the facility for approximately 4 weeks and the supercenter outing was her first activity transportation assignment. She stated that on 7/29/16 at approximately 9:00 AM, she was instructed by the director of nursing, (DON) to transport resident #5 to a hemodialysis appointment scheduled for 11:30 AM on 7/29/16. She said that she met with the activities director, with CNA A present, to discuss the outing to supercenter. She stated that she informed the activities director that she had to transport a resident to dialysis for an 11:30 AM appointment, but the activities director instructed her to take the residents to the supercenter first. She said that she told the activities director that they would try to leave the facility by 10:30 AM so that she could get back to the facility to pick up resident #5 for his appointment. She stated that the activities director was aware that she would not be able to stay and supervise the residents at the supercenter. When they arrived at the supercenter at 11 AM, she gave CNA A her personal cellular phone number and told her that she would be back. When CNA B was asked what she thought about leaving CNA A with 4 residents to supervise, she stated that it was her first time on an outing and she, did not know how they run things here. She said that she returned to supercenter at approximately 12:00 PM on 7/29/16 and saw residents #2 and #3 with their walkers waiting at the garden entrance of supercenter where she had dropped them off earlier. She said that while she was assisting these residents into the van, resident #4 came out of the supercenter from the same entrance. He was in his wheelchair and he was unassisted. While she was assisting him into the van, she saw CNA A coming out of the supercenter, but from a different entrance, the grocery entrance, carrying shopping bags. She then asked CNA A for resident #1's whereabouts. CNA A stated that resident #1 must still be shopping. She said that both CNA A and CNA B waited for approximately 15 minutes and then one of the residents said that he had seen resident #1 smoking outside of the supercenter earlier. CNA A went outside to look for resident #1, but did not see her. She went inside the supercenter to search for resident #1, but could not locate her. She then called the facility from her personal cell phone sometime after 1:00 PM on 7/29/16 to inform the activities director that resident #1 was missing. She stated that the administrator, the director of nursing, activities director and social service director arrived at the supercenter at approximately 1:45 PM and law enforcement arrived at approximately 2:00 PM. The resident was still missing at that time. An interview with the administrator on 8/09/16 at 11:05 PM noted that he received a telephone call from law enforcement and the guardian for resident #1 on 7/31/16 at approximately 12:00 PM, after the resident had been missing for approximately 49 hours. He said he was informed that the resident had been located at a local hospital. The resident was transferred to the hospital after complaining of chest discomfort. A review of the resident's hospital discharge summary reflected that she was assessed by cardiology and psychiatric services and was discharged back to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. Wernicke's [DIAGNOSES REDACTED] is a degenerative brain disorder caused by the lack of thiamine (vitamin B1). It may result from alcohol abuse Symptoms include mental confusion, vision problems, coma, hypothermia, low blood pressure, and lack of muscle coordination (ataxia) Most symptoms of Wernicke's [DIAGNOSES REDACTED] can be reversed if detected and treated promptly and completely. Stopping alcohol use may prevent further nerve and brain damage. However, improvement in memory function is slow and, usually, incomplete. Without treatment, these disorders can be disabling and life-threatening. (www.ninds.nih.gov) On 8/09/15 at 12:10 PM CNA A revealed that she had worked at the facility for 3 years as an activity aide and had been on many previous outings to the supercenter. She said that she and CNA B, the van driver, accompanied residents #1, #2, #3 and #4 on an outing to the supercenter on 7/29/16. At the time of the outing, resident #1 was fully ambulatory, residents #2 and #3 used walkers and resident #4 used a wheelchair. She said that the group left the facility at approximately 10:45 AM and arrived at the supercenter, fifteen minutes later, at 11:00 AM. They assisted the residents from the van and then CNA B left the supercenter to go back to the facility to transport resident #5 to his appointment. Then CNA A and the 4 residents entered the supercenter together. During the course of shopping, CNA A assisted resident #4 in his wheelchair to the electronic section located in the back of the supercenter to exchange his cellular telephone (cell phone). She then had to assist him to the front of the supercenter to the customer service desk. During the time that she was assisting resident #4, residents #1, #2 and #3 were unsupervised in the supercenter. She said that she could not see the other residents while she was assisting resident #4. CNA A said the last time she observed resident #1 was at 11:20 AM in the women's clothing department. She said that after she finished assisting resident #4, she left him to complete some other shopping for other residents who did not come on the outing. During that time none of the residents were within her sight. She said that she did not realize resident #1 was missing until she returned to the van at approximately 12:15 PM. She stated that she searched the outside and inside of the supercenter, but could not locate the resident. She then asked the supercenter associate to page the resident. She stated that they usually have at least two staff on all outings and this was the first time that she was left alone supervising 4 residents. When she was asked if she had contacted anyone at the facility to make them aware that she was the only staff member supervising 4 residents, she stated that she did not voice any concerns because the residents were alert and oriented, and she had assumed that CNA B would be back in about half hour. She said that she did not question CNA B leaving because someone in authority, the director of nursing (DON), had instructed her to leave the outing to take a resident to a medical appointment. The Orlando Police Department Missing Adult Person Report documented that the security footage at supercenter was able to see resident #1 at 11:40 AM walking by herself in the front of the supercenter. He was unable to see where resident #1 went from there or locate her at any other time. The phone company was contacted and they said that resident #1's cell phone was off and the last time it was used was at 2:41 PM on 7/29/16. When she used it, she called two separate numbers. Both numbers belonged to taxi cab services. The officer contacted the taxi companies that resident #1 called. One company said that they remember resident #1 calling and asking to go to Interstate 4. The company told the resident the driver was too far out, so he transferred her to another taxi company. The officer called the other taxi company and they didn't remember coming into contact with resident #1. The report noted that a missing person affidavit was completed by law enforcement, an alert was initiated, and numerous officers searched the surrounding areas, but they were not able to locate resident #1. On 8/09/16 at 5:02 PM, resident #3 revealed that he used a walker for mobility. He stated that he attended the outing and was outside the supercenter when he spoke to resident #1 at unknown time. He said that she was outside by herself, smoking and had asked him if he had found everything he needed. He did not see her after this time. He said that he waited outside by himself for half an hour until the facility van arrived to pick him up. Review of the quarterly MDS assessment dated [DATE] noted the resident's BIMS score was 13 out of 15 to indicate he was cognitively intact and he required supervision with walking. Review of the clinical record showed he had [DIAGNOSES REDACTED]. In an interview with resident #2 on 8/09/16 at 3:15 PM, he revealed that he cannot go on outings to the supercenter by himself because he has a seizure disorder. He said he has been on the outing to the supercenter many times and said, there are staff on outings to help us. The quarterly MDS assessment dated [DATE] noted his BIMS score was 12 out of 15 to show his cognition was moderately impaired. His [DIAGNOSES REDACTED]. He requires supervision with ambulation while using a walker or wheelchair. Interview with resident #4 on 8/09/16 at 4 PM revealed that the trip on 7/29/16 was his first outing to the supercenter. The admission MDS dated [DATE] showed his BIMS was 13 out of 15 to indicate he was cognitively intact. The assessment showed he did not walk and used a wheelchair for mobility with assistance. On 8/11/16 at 1:50 PM the DON revealed that she was aware that CNA B was assigned to activities on Fridays. She stated that she had instructed CNA B at approximately 9:00 AM on 7/29/16 that she was to transport a resident for an 11:30 AM appointment. She said that she thought CNA B would take the resident to his appointment before going on the supercenter outing. When asked if she had clarified this instruction with CNA B who was newly hired, she stated, no. When asked if she communicated this change in the assignment with the activities director, she stated, no. On 8/12/16 at 11:45 AM the activities director was asked about supervision during outings. She said that there were always 2-3 staff supervising 4-6 residents on all outings. She stated that Fridays were activity days and that CNA B was assigned to activities only. She stated that she was not aware that CNA B would not be present during the outing. She did not remember CNA B informing her that morning that she was not going to be available to stay and provide supervision to the residents during the shopping trip. When she was asked how she expected one CNA to supervise 4 residents, she stated that it was not the facility policy; we always have at least 2 staff present on outings. On 8/12/16 at 1:15 PM the activities director was asked about the outing from assignment listed in the policy and procedure for Resident outings. She said that she had not seen the outing form and had not used it on any outings. The policy and procedures on Resident Outings RA-140 dated 11/30/2014 read that, on every outing, there must be at least one staff member and/or volunteer to accompany residents, in addition to the van driver. The policy included to, make sure people know for whom and what they are responsible as well as to whom they are responsible as per outing form assignment.

Based on interview and record review, the facility failed to assign sufficient staff to provide adequate support and supervision for 4 of 4 residents during a facility outing. One activity certified nursing assistant (CNA) was left with 4 residents at a large supercenter. The facility's failure to provide sufficient staff on a resident outing to a supercenter resulted in 1 resident (#1) wandering from the outing and her whereabouts were unknown for approximately 49 hours and 3 other residents were at risk for potential serious harm (#2, #3, and #4). Resident #1's whereabouts were unknown for approximately 49 hours until law enforcement contacted the facility and notified them that she was admitted to an acute care hospital with chest pain. Residents #2, #3 and #4 were left unsupervised and unattended for unknown periods of time at a large supercenter which was approximately 180,000 square feet in size. The failure to provide sufficient staffing during an outing to a supercenter resulted in immediate jeopardy starting on starting on 7/29/16 and was determined to be ongoing at the survey exit date on 8/12/16. Findings: Cross reference to F224, F323 On 08/08/16 at 1:49 PM and on 08/09/16 at 11:05 AM the Activities Director was asked to explain the process for resident outings. She stated that the residents sign up for outings with her and she decides how many staff will go on the outings based on the type and number of residents going on the outing. She said they can take up to 6 residents on an outing with 3 staff. The activities director reviewed the facility policy for Resident Outings and stated she was not aware that she had to have certain supervision for the outings. She stated that in regards to the outing on 7/29/16, she did not know that CNA B did not stay to supervise the residents leaving only 1 staff member to supervise 4 residents in a supercenter. She stated the CNA A could not possibly supervise 4 residents by herself. There should have been 2 staff members for 4 residents on the outing. She stated that Fridays were activity days and that CNA B was assigned to activities only. She did not remember CNA B informing her that morning that she was not going to be available to stay and provide supervision to the residents during the shopping trip. On 8/11/16 at 1:50 PM, the activity director stated that from now on she will attend all facility outings. She stated that she did not attend the outing on 7/29/16 because she had computer issues and needed to complete assessments that were due by the end of the month. On 8/12/16 at 1:15 PM the activities director was asked about the outing form assignment in the resident outing policy. She said that she had not seen the form and had not used it on any outings. In an interview with the director of nursing (DON) on 8/08/16 at 3:15 PM, she was asked how residents are evaluated to go out of the facility on activity outings. She said that if the resident is alert and oriented and ambulatory and/or mobile with a wheelchair, they can go. She said the resident is assessed by the physician and then the physician will write an order to go LOA. Review of the policy and procedure for Resident Outings dated 11/30/14 revealed any resident may attend off-premise activities unless noted by physician orders [REDACTED]. On 8/11/16 at 1:50 PM the DON revealed that she was aware that CNA B was assigned to activities on Fridays. She stated that she had instructed CNA B at approximately 9:00 AM on 7/29/16 that she was to transport a resident for an 11:30 AM appointment. She said that she thought CNA B would take the resident to his appointment before going on the supercenter outing. When asked if she had clarified this instruction with CNA B who was newly hired, she stated, no. When asked if she communicated this change in the assignment with the activities director, she stated, no. On 8/09/16 at 10:00 AM, CNA B revealed that she had worked at the facility for approximately four weeks and was to do her first outing transportation on 7/29/16 to the supercenter. She stated that on 7/29/16 at approximately 9:00 AM, she was instructed by the (DON) to transport resident #5 to an 11:30 AM medical appointment. She met with the activities director on 7/29/16 at approximately 10:00 AM to discuss the outing to supercenter. She stated that CNA A was present during this time. She stated that she informed the activities director that she had to transport a resident to [MEDICAL TREATMENT] for an 11:30 AM appointment. The activities director instructed her to take the residents to the supercenter first. She stated that the activities director was aware that she would not be able to stay and supervise the residents in the supercenter. She stated that when they arrived at the supercenter, I gave CNA A my personal cell phone number and told her that I would be back. She stated that she found it unusual that one staff would be supervising 4 residents, but did not question it because she was new. When she was asked why she did not question this, she stated, I did not know how things were run here, it was my first time on an outing. She said that she returned to supercenter at approximately 12:00 PM on 7/29/16 and saw residents #2 and #3 with their walkers waiting at the garden entrance of supercenter where she had dropped them off earlier, but CNA A was not with them. She said that while she was assisting these residents into the van, resident #4 came out of the supercenter from the same entrance. He was in his wheelchair and he was unassisted. While she was assisting him into the van, she saw CNA A coming out of the supercenter, but from a different entrance, the grocery entrance, carrying shopping bags. She then asked CNA A for resident #1's whereabouts. CNA A stated that resident #1 must still be shopping. She said that both CNA A and CNA B waited for approximately 15 minutes and then one of the residents said that he had seen resident #1 smoking outside of the supercenter earlier. CNA A went outside to look for resident #1, but did not see her. She went inside the supercenter to search for the resident #1, but could not locate her. She then called the facility from her personal cell phone sometime after 1:00 PM on 7/29/16 to inform the activities director that resident #1 was missing. She stated that the administrator, the director of nursing, activities director and social service director arrived at the supercenter at approximately 1:45 PM and law enforcement arrived at approximately 2:00 PM. The resident was still missing at that time. On 8/09/16 at 11:30 CNA A revealed that she had worked at the facility for 3 years as an activity aide. She was asked about the outing to the supercenter that occurred on 7/29/16. She stated that she was assigned to go on an outing to the supercenter on 7/29/16 with 4 residents (#1, #2, #3, and #4). She stated that there were always at least two staff on all outings and they stayed with the residents and went shopping from aisle to aisle. This was the first time that she was alone with 4 residents. She stated that she thought there would be two staff on this outing, but the other staff, CNA B, had to return to the facility to take another resident to a medical appointment. She stated that she felt comfortable supervising 4 residents because they were alert and oriented and she thought it would take half an hour for CNA B to return to the supercenter. She stated that she was assisting resident #4 who was in a wheelchair with his cell phone at the customer service counter at the front and back of the supercenter. She stated that she did not know how long she was with resident #4. She said she could not visualize residents #1, #2, and #3 while she was assisting resident #4. She confirmed that she did not have sight of the residents while she was doing personal shopping for other facility residents. She said that the last time she observed resident #1 was at 11:20 AM. She did not realize that the resident was missing until she returned to the van at approximately 12:15 PM. On 8/09/16 at 5:02 PM resident #3 confirmed he attended the outing to supercenter on 7/29/16. He stated that when he finished shopping, he went outside by himself to wait for the van. He was outside the supercenter for half an hour before the facility van arrived to pick him up. A review of the policy for Resident Outings effective date 11/30/2014, document name: RA-140 read, on every outing, there must be at least one staff member and/or volunteer to accompany residents, in addition to the van driver . Based on the needs of the residents and the activity planned, the Executive Director will determine the amount of additional staff needed . Staff member responsible for the outing must carry a cell phone .Make sure people know for whom and what they are responsible as well as to whom they are responsible as per outing form assignment . An interview with the administrator on 8/09/16 at 11:05 PM, he said that he received a telephone call from law enforcement and resident #1 ' s guardian on 7/31/16 at approximately 12:00 PM informing him that resident #1 had been located at a local hospital after staff became unaware of the resident ' s whereabouts during a resident outing. When the administrator was asked about how the Executive Director determines the amount of staff needed on a resident outing he said, the policy is vague.

Based on interview and record review, the facility administration failed to effectively coordinate resources to: -keep residents free from neglect by not providing adequate supervision during an outing outside the facility, resulting in elopement and serious harm for 1 resident (#1) and high potential for serious harm for three other residents (#2, #3, and #4) out of 4 residents reviewed for neglect. The administration failed to identify the inadequate supervision as neglect. -identify and provide adequate supervision to prevent elopement and hospitalization for 1 of 4 sampled residents (#1) and failed to prevent potential for serious harm for 3 of 4 residents, (#2, #3, and #4) during a facility activity outing to a supercenter. -assign sufficient staff to provide adequate support and supervision for 4 of 4 residents during a facility outing. One activity certified nursing assistant (CNA) was left with 4 residents at a large supercenter. The facility's failure to provide sufficient staff on a resident outing to a supercenter resulted in 1 resident (#1) wandering from the outing and her whereabouts were unknown for approximately 49 hours and 3 other residents were at risk for potential serious harm (#2, #3 and #4). -maintain an effective Quality Assessment and Assurance (QAA) program for resident outings to ensure residents will have the opportunity to participate and will not experience or have the potential to experience serious harm or neglect for 4 of 4 residents who attended a facility outing to a supercenter outing (#1, #2, #3, and #4). The facility's QAA committee failed to identify quality deficiencies by not identifying the root cause analysis of the elopement incident, and failed to evaluate and analyze the risk once an elopement and injury had occurred. The facility failed to recognize that the policy for resident outings was not followed did not develop and implement an appropriate plan of action. During a supercenter outing, resident #1 left the premises and residents #2, #3 and #4 were placed at risk for potential serious harm. The whereabouts of resident #1 were unknown for approximately 49 hours until she was located by law enforcement at an acute care hospital. The resident experienced chest discomfort while she was missing, a bystander contacted emergency medical services, and the resident was taken to the hospital for treatment. Residents #2, #3, and #4 were left unattended and unsupervised for unknown periods of time at a large supercenter which was approximately 180,000 square feet in size. The failure to identify and effectively coordinate resources resulted in substandard quality of care. Immediate jeopardy was identified in 4 other regulations: F224 Staff treatment of [REDACTED]. Findings: Cross Reference to F224, F323, F353, F520 An interview was conducted with the administrator on 8/08/16 at 12:10 PM. When he was asked about the incident during the supercenter outing that occurred on 7/29/16, he stated that they did not consider this to be neglect because resident #1 was alert and oriented. He stated that, she decided she wanted to leave on her own and she did, she did it willingly. When he was asked about the resident's history of dementia and elopement and need for supervision, he did not have an answer. When he was asked about the investigation for neglect for the other 3 residents who were left at the supercenter with one staff member who was not able to provide supervision for them, he said that the facility policy and procedure was not clear about the number of staff members required, so he did not consider neglect. An investigation for neglect was not initiated. An interview with the administrator on 8/09/16 at 11:05 PM noted that he received a telephone call from law enforcement and the guardian for resident #1 on 7/31/16 at approximately 12:00 PM, after the resident had been missing for approximately 49 hours. He said he was informed that the resident had been located at a local hospital. The resident was transferred to the hospital after complaining of chest discomfort. On 08/08/16 at 3:15 PM, the director of nursing (DON) revealed she was aware that CNA B was assigned to activities on Fridays. She stated that she had instructed CNA B at approximately 9:00 AM on 07/29/16 that she was to transport a resident for his 11:30 AM appointment. In my mind I thought CNA B would take the resident to his appointment before going on the supercenter outing. When asked if she had clarified this instruction with CNA B who was newly hired, she stated, no. When asked if she communicated this change in the assignment with the Activities Director, she stated, no. When she was asked if CNA B was aware of what instructions to follow, she did not have an answer. On 08/08/16 at 1:49 PM and on 08/09/16 at 11:05 AM the Activities Director stated the residents sign up for outings with her and she decides how many staff will go on the outings based on the type and number of residents going on the outing. On 8/12/16 at 11:45 AM the activities director was asked about supervision during outings. She said that there were always 2-3 staff supervising 4-6 residents on all outings. She stated that Fridays were activity days and that CNA B was assigned to activities only. She stated that she was not aware that CNA B would not be present during the outing. She did not remember CNA B informing her on the morning of 7/29/16, that she was not going to be available to stay and provide supervision to the residents during the shopping trip. When she was asked how she expected one CNA to supervise 4 residents, she stated that it was not the facility policy. When she was asked about the outing form assignment in the resident outing policy, she stated she had never seen the form before and had not used it. On 08/09/16 at 10:00 AM and 08/10/16 at 9:42 AM CNA B, the van driver revealed that she has worked at the facility for only 4 weeks and that this was the first time she was driving the van to a facility outing. She stated that she was not sure who is her supervisor. She stated when she functions as a CNA she takes direction from the DON, when she is on a facility outing she takes direction from the Activities Director, and when there is a van problem she takes direction from the Maintenance Director. I am really not sure who is my supervisor. CNA B stated that on 07/29/16 at approximately 9:00 AM the DON gave her instruction to take a resident to his 11:30 AM appointment. She then spoke to the Activities Director she was upset because Fridays were reserved for activity outings. The Activities Director was aware that I would not be able to stay with the residents during the outing on 07/29/16 and she instructed me to take the residents to the supercenter first. When asked what she thought about leaving CNA A with 4 residents to supervise, she said that it was her first time on an outing and she, did not know how they run things here. On 08/09/16 at 12:10 PM CNA A revealed that she had worked at the facility for 3 years as an activity aide. She said that she and CNA B (van driver) accompanied residents (#1, #2, #3 and #4) on an outing to the supercenter on 07/29/16. The group left the facility at approximately 10:45 AM and arrived at the supercenter by 11:00 AM. They assisted the residents from the van and CNA B left the supercenter to return to the facility. She said that she questioned CNA B about leaving because there were usually 2 staff present on the facility outings. CNA B told me the DON had instructed her to take a resident to an 11:30 AM appointment and the DON was the boss. She stated she had never been on an outing with only one staff supervising 4 residents, we usually have 2 people on all outings. She stated that she did not voice any concern because she assumed that CNA B would be back shortly from transporting the resident to his appointment. She also stated that all the residents were alert and oriented and she had told them to stay together. On 08/11/16 at 1:50 PM the Administrator was asked for details regarding the facility investigation related to the elopement and lack of supervision on 07/29/16. The Administrator stated that the facility did not consider the elopement to be a concern because the facility did not have control over the resident leaving the supercenter. He stated that resident #1 was alert and oriented and decided to leave the supercenter of her own free will. The administrator stated that he did not speak with the other residents, #2, #3 and #4, who were on the 07/29/16 outing, but the Activities Director spoke with them. When asked about the investigation that was done after the incident, he said that he had done everything by phone. The Administrator asked, do you want me to write a statement? The Administrator stated they did not have any education/training records for staff who supervise residents on facility outings and he did not have any documentation of an investigation regarding the events that occurred starting on 7/29/16 for the facility outing to a supercenter in which one resident sustained [REDACTED]. On 8/11/2016 at 1:50 PM, the administrator was asked about the QAA process following the events that occurred on 7/29/16 in which 4 residents went on a facility outing to a supercenter. One resident (#1) was missing for 49 hours and was transported via ambulance to an acute care hospital and the other 3 residents (#2, #3, and #4) were left unattended for unknown periods of time during the outing. He said that they did not have a QAA meeting since 7/29/16. The administrator was asked about the root cause analysis of resident #1's elopement on 7/29/16. He stated that the facility did not consider this to be an elopement as the facility did not have any control of what resident #1 did. He said that the resident was alert and oriented and left the supercenter on her own free will. He said she left willingly and, gave us the slip. He stated that even if there were more staff on the outing, she still could have walked away if she wanted to. He stated that he informed the medical director about the incident, but they did not have a QAA meeting. He said we discussed the incident at morning meeting on 8/01/16, 2 days after resident #1 eloped. When asked if any analysis or investigation was done post incident, he replied that he had not spoken to the other residents on the outing. He stated that he spoke to the staff verbally. When he was asked about what their conclusion was of the incident investigation, he repeated that the resident #1 was alert and oriented and left the supercenter on her own. When he was questioned about the policy for outings, he stated that there were no revisions made to the policy. When he was asked if the facility had followed their policy, he stated that the policy was vague. When the administrator was asked what training was provided to staff after the incident, he stated that coaching was provided to one staff member, certified nursing assistant (CNA) A, on 8/01/16. He stated that when a CNA goes on outings, she is expected to function as a CNA. A review of the policy and procedure for Resident Outings effective date 11/30/2014, document name: RA-140 read Policy: The Company will provide its residents with the opportunity to become and/or remain involved in the local community by planning off-premise outings and trips. The procedure read: . Unless noted by physician orders, and based upon availability, any resident may attend off-premise activities .Off-premise activities include, but are not limited to: .shopping, etc. On every outing, there must be at least one staff member and/or volunteer to accompany residents, in addition to the van driver . Based on the needs of the residents and the activity planned, the Executive Director will determine the amount of additional staff needed . Staff member responsible for the outing must carry a cell phone .Make sure people know for whom and what they are responsible as well as to whom they are responsible as per outing form assignment . This policy had not been reviewed or revised as of the exit date of the survey. A review of the policy and procedure provided by the facility for Resident Abuse N-1265 effective 11/30/14 with a revision date on 6/01/15 included information for neglect: It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect . The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED].violation of this standard will subject employees to disciplinary action, including dismissal. Definitions: Neglect .Failure to take precautionary measure to protect the health and safety of the resident .Failure to provide services that result in harm to the resident .Failure to adequately supervise a resident know to wander from the facility .Failure to report observed or suspected abuse, neglect .to the proper authorities. The Company is committed to the prevention of abuse, neglect .The following systems have been implemented .sufficient numbers of staff to meet the needs of the residents .monitoring of residents who may be at risk is the responsibility of all facility staff . The Executive Director I (Administrator) job description read, Purpose of Your Job Position: The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulation that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Job Functions: As Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for caring out your assigned duties. Responsible for the day-to-day clinical and administrative activities of the facility including ensuring compliance with all state and federal regulations. Duties and Responsibilities: Recruit, hire, and provide orientation/training for a sufficient number of qualified staff to carry out facility programs and services. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Ensure a safe, clean, and comfortable environment for residents, visitors, and staff. Maintain a file for and monitor incident reports.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for resident outings to ensure residents will have the opportunity to participate and will not experience or have the potential to experience serious harm or neglect for 4 of 4 residents who attended a facility outing to a supercenter outing (#1, #2, #3, and #4). During a supercenter outing, resident #1 left the premises and residents #2, #3 and #4 were placed at risk for potential serious harm as a result of failure to follow facility policies for resident outings and failure to provide adequate supervision. The whereabouts of resident #1 were unknown for approximately 49 hours until she was located by law enforcement at an acute care hospital. The resident experienced chest discomfort while she was missing, a bystander contacted emergency medical services, and the resident was taken to the hospital for treatment. Residents #2, #3, and #4 were left unattended for unknown periods of time at a large supercenter which was approximately 180,000 square feet in size. The facility's QAA committee failed to identify quality deficiencies by not identifying neglect due to lack of supervision, the root cause analysis of the elopement incident, and failed to evaluate and analyze the risk once an elopement and injury had occurred. The facility failed to recognize that the policy for resident outings was not followed and did not develop and implement an appropriate plan of action. As a result of this failure, the immediate threat to health and safety was not addressed which resulted in immediate jeopardy starting on 7/29/16 and was determined to be ongoing at the exit date of 8/12/16. Findings: Cross reference to F224, F323, F353, F490 On 8/11/2016 at 1:50 PM, the administrator was asked about the QAA process following the events that occurred on 7/29/16 in which 4 residents went on a facility outing to a supercenter. One resident (#1) was missing for 49 hours and was transported via ambulance to an acute care hospital and the other 3 residents (#2, 3 & 4) were left unattended for unknown periods of time during the outing. He said that he was the head of the QAA committee and they did not have a QAA meeting since the incident on 7/29/16. The administrator was asked about the root cause analysis of resident #1's elopement on 7/29/16. He stated that the facility did not consider this to be an elopement as the facility did not have any control of what resident #1 did. He said that the resident was alert and oriented and left the supercenter on her own free will. He said she left willingly and, gave us the slip. He stated that even if there were more staff on the outing, she still could have walked away if she wanted to. He stated that he informed the medical director about the incident, but they did not have a QAA meeting. He said, we discussed the incident at morning meeting on 8/01/16, 2 days after resident #1 eloped. When asked if any analysis or investigation was done post incident, he replied that he had not spoken to the other residents on the outing. He stated that he spoke to the staff verbally. When he was asked about what their conclusion was of the incident investigation, he repeated that the resident #1 was alert and oriented and left the supercenter on her own. When he was questioned about the policy for outings, he stated that there were no revisions made to the policy. When he was asked if the facility had followed their policy, he stated that the policy was vague. When the administrator was asked what training was provided to staff after the incident, he stated that coaching was provided to one staff member, certified nursing assistant (CNA) A, on 8/01/16. He stated that when a CNA goes on outings, she is expected to function as a CNA. On 8/09/16 at 4:00 PM during a telephone interview with the medical director, he stated that the expectation for a leave of absence (LOA) with responsible party order is that the resident will be brought back to the facility safely within 6 hours. If facility staff take them (residents) out, the expectation is that the resident will be supervised and be brought back to the facility safely. The policy and procedures on Resident Outings, dated 11/30/2014 read that, on every outing, there must be at least one staff member and/or volunteer to accompany residents, in addition to the van driver. The policy included, make sure people know for whom and what they are responsible as well as to whom they are responsible as per outing form assignment. The policy on Missing Resident Search, Document Name: 1033 effective date 11/30/2014 read that, A full investigation will be conducted and interventions implemented to prevent reoccurrence. A report of the investigation will be forwarded to the Safety Committee for review and action as indicated. A review of the policy and procedure provided by the facility for Resident Abuse N-1265 effective 11/30/14 with a revision date on 6/01/15 included information for neglect: It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect . The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED].violation of this standard will subject employees to disciplinary action, including dismissal. Definitions: Neglect .Failure to take precautionary measure to protect the health and safety of the resident .Failure to provide services that result in harm to the resident .Failure to adequately supervise a resident know to wander from the facility .Failure to report observed or suspected abuse, neglect .to the proper authorities. The Company is committed to the prevention of abuse, neglect .The following systems have been implemented .sufficient numbers of staff to meet the needs of the residents .monitoring of residents who may be at risk is the responsibility of all facility staff . The QAA committee failed to fully investigate the neglect and elopement incident on 7/29/16. They did not identify the root cause of the elopement and did not arrive at any conclusion except that the activity director will attend all outings. Therefore, no education/training was provided to staff on the expectations and supervision on outings based on each individual resident's needs. They failed to examine the current policies and procedures. They failed to implement a plan of corrective action for outings to include assessment of resident participation in the outings, communication and supervision during the outing, and a safe return to the facility.

Based on observation, interview, and record review the facility failed to keep residents free from neglect by not providing adequate supervision during an outing from the facility, resulting in elopement and serious harm for 1 resident (#1) and high potential for serious harm for three other residents (#2, #3 and #4) out of 4 residents reviewed for neglect. The facility staff failed to provide services to supervise residents on an outing to a supercenter on 7/29/16. One certified nursing assistant (CNA) was left to supervise 4 residents, 1 ambulatory (#1), 2 with walkers (#2 & 3), and 1 in a wheelchair (#4), during the shopping trip. Resident #1 had a history of [REDACTED]. The resident was last seen by facility staff on 7/29/16 at 11:20 AM shopping in the supercenter. She left the supercenter to smoke without the knowledge of facility staff and was observed alone outside the supercenter at 11:40 AM, according to security surveillance video. The staff were unaware that she was missing until they were getting ready to return to the facility at 12:15 PM. The resident's whereabouts were unknown until 7/31/16 at 12 PM, when law enforcement contacted the facility and notified them that she was admitted to an acute care hospital with chest pain. Residents #2, #3 and #4 were left unsupervised at different times during the outing. The facility failed to identify the inadequate supervision as neglect. The failure to identify and prevent neglect resulted in substandard quality of care and immediate jeopardy starting on 7/29/16 and it was determined to be ongoing as of 8/12/16. Findings: Cross reference to F323, F353, F490, F520 A review of the City of Orlando Police Department Missing Adult Person Report dated 7/29/16 at 2:01 PM revealed that they responded to a supercenter on Princeton street in Orlando, Florida in reference to a missing endangered adult. They met with the administrator of the facility who informed them that resident #1 went on an outing to the supercenter with facility staff on 7/29/16. The facility staff (CNA A) called the facility at approximately 1:25 PM to report that resident #1 had walked off and they were not able to locate her. The law enforcement officer (LEO) contacted the resident's guardian who advised him that resident #1 had run away approximately three other times while living at other facilities. A law enforcement alert was initiated and numerous LEOs searched all surrounding areas but resident #1 was not located. The LEO looked at supercenter supercenter's security footage and was able to see resident #1 at 11:40 AM walking by herself in the front of the supercenter, but was unable to see where she went from there or locate her at any other time. A review of the hospital records showed that the resident was admitted to the emergency department on 7/30/16 at 12:46 PM with chief complaint of chest discomfort. She was placed on cardiac monitoring to rule out [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] embolism. She was discharged back to the facility on [DATE] with a [DIAGNOSES REDACTED]. Wernicke's [MEDICAL CONDITION] is a [MEDICAL CONDITION] brain disorder caused by the lack of [MEDICATION NAME] (vitamin B1). It may result from [MEDICAL CONDITION] Symptoms include mental confusion, vision problems, coma, hypothermia, low blood pressure, and lack of muscle coordination (ataxia) Most symptoms of Wernicke's [MEDICAL CONDITION] can be reversed if detected and treated promptly and completely. Stopping alcohol use may prevent further nerve and brain damage. However, improvement in memory function is slow and, usually, incomplete. Without treatment, these disorders can be disabling and life-threatening. (www.ninds.nih.gov) A telephone interview was conducted on 8/08/16 at 1:00 PM with resident #1's guardian. She stated that she has known the resident for over 3 years, starting when the resident was admitted to a hospital in the City of Deland and had been deemed incompetent in February 2013. She said that the resident routinely telephoned the police, Department of Children and Families, lawyers and other government agencies stating that she was being detained in facilities against her will. She had eloped from 3 previous facilities, a secure nursing home, secure assisted living facility and a non-secure residential facility from March 2012 to June 2014. On 8/09/16 at 12:10 PM, CNA B, the van driver for the shopping outing on 7/29/16, revealed that she had informed the activities director that she would not be able to stay and supervise the residents in the supercenter that day. When she was asked what she thought about leaving CNA A with 4 residents to supervise, she stated that it was her first time on an outing and she, did not know how they run things here. She stated that she returned to the supercenter on 7/29/16 at approximately 12:00 PM. She said that residents #2 and #3 were waiting unattended outside the garden entrance and waved to her as she arrived. Both of these residents had their walkers and shopping bags with them. She said that resident #4 wheeled himself out of the supercenter alone and approached the van as she was assisting the other residents into the van. When she assisted resident #4 into the van, she said she saw CNA A exiting the supercenter from the grocery entrance of the supercenter at approximately 12:15 PM. She said that residents #2, #3, and #4 were by themselves without CNA supervision and she found this to be unusual. An interview was conducted with the administrator on 8/08/16 at 12:10 PM. When he was asked about the incident during the supercenter outing that occurred on 7/29/16, he stated that they did not consider this to be neglect because resident #1 was alert and oriented. He stated that, she decided she wanted to leave on her own and she did, she did it willingly. When he was asked about the resident's history of dementia and elopement and need for supervision, he did not have an answer. When he was asked about the investigation for neglect for the other 3 residents who were left at the supercenter with one staff member who was not able to provide supervision for them, he said that the facility policy and procedure was not clear about the number of staff members required, so he did not consider neglect. An investigation for neglect was not initiated. On 8/12/16 at 11:45 AM the activities director stated that there were always 2-3 staff members supervising 4-6 residents on all outings. She stated that she was unaware there was only one CNA supervising 4 residents during the supercenter outing on 7/29/16. She stated that she did not know that the second staff member, CNA B, had been instructed by the director of nursing to transport a resident to a [MEDICAL TREATMENT] appointment during the time of the outing, leaving only 1 staff member to supervise 4 residents in a supercenter. This contradicts the statement made by CNA B that she made her, the activities director, aware that she would not be able to supervise the outing because she was instructed by the DON on the morning of 7/29/16 to transport a resident to a [MEDICAL TREATMENT] appointment. An interview with CNA A on 8/09/16 at 11:30 AM revealed that she had worked at the facility for 3 years as an activity aide. She said, we usually have two people on all outings and this was the first time that I was alone supervising 4 residents. She stated that she did not voice any concern that she was the only one supervising 4 residents because she assumed that CNA B would be back shortly from transporting a resident to another appointment. She felt comfortable supervising all 4 residents because she thought they were alert and oriented. She stated that she thought it would take half an hour for CNA B to return to supercenter. When the total time involved for CNA B to leave the supercenter, return to the facility to transport another resident to an appointment, and then return to the supercenter was discussed to take at least 1 hour, she did not have a response. She stated that she was assisting resident #4 with his mobile phone at the customer service counter at the front and back of the supercenter. She stated that she could not see the other residents while she was assisting resident #4. She confirmed that she did not have sight of the other residents while she was later doing personal shopping for other facility residents. She said that the last time she observed resident #1 was at 11:20 AM. She did not realize that resident #1 was missing until she returned to the van at approximately 12:15 PM. An interview with resident #3 on 8/09/16 at 5:02 PM revealed that he used a walker for mobility. He stated that he had attended the outing on 7/29/16 and when he was finished shopping, he went outside by himself to wait for the van to arrive. He said that he was outside the supercenter for half an hour before the facility van arrived to pick him up. An interview with resident #1 on 8/09/16 at 10:00 AM revealed that she remembered going to supercenter. She stated that she got tired of shopping and went outside to smoke. She believed that she had met someone outside in the smoking area who called her a taxi. She had her own handwritten notes which documented her buying two lemonades from a gas station on Lee Road in Winter Park, Florida. The gas station was located approximately 5 miles from the supercenter located on Princeton Street and John Young Parkway. The next notation in her notes was on 7/30/16 which read that she woke at 6:30 AM, went into the restaurant which was located across from the gas station, and used the rest room to wash herself. She had 2 cups of coffee and charged her cellular phone. At 10:27 AM she was still at the restaurant charging her phone and then no account of what happened after this time. When the resident was asked where she spent the night, she stated that she could not remember, but probably spent the night going in and out of the restaurant. She said that she remembered not feeling well, had pressure to her chest area, and a stranger called the ambulance. She said she was outside of the restaurant across the street when this happened. The restaurant and gas station located on Lee Road in Winter Park, Florida was observed on 8/09/16. It was located adjacent to the ramp to Interstate 4, which is a busy area with office buildings and businesses. Telephone interviews were held with the restaurant managers on 8/09/16 at 9:00 PM and 8/10/16 at 1:05 PM. They did not recall anyone fitting resident #1's description or any incidents on the evening/night of July 29th or on the morning of July 30th. They said that the area was a very busy location, especially on Friday nights, and it was open 24 hours. They said that the resident would not have stood out to catch their attention as there were many customers on the night of July 29, 2016. A review of the policy for resident outings effective date 11/30/2014, document name: RA-140 read, on every outing, there must be at least one staff member and/or volunteer to accompany residents, in addition to the van driver. A review of the policy and procedure provided by the facility for Resident Abuse N-1265 effective 11/30/14 with a revision date on 6/01/15 included information for neglect: It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect . The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED].violation of this standard will subject employees to disciplinary action, including dismissal. Definitions: Neglect .Failure to take precautionary measure to protect the health and safety of the resident .Failure to provide services that result in harm to the resident .Failure to adequately supervise a resident known to wander from the facility .Failure to report observed or suspected abuse, neglect .to the proper authorities. The Company is committed to the prevention of abuse, neglect .The following systems have been implemented .sufficient numbers of staff to meet the needs of the residents .monitoring of residents who may be at risk is the responsibility of all facility staff .

Based on interview and record review, the facility failed to obtain treatment orders for wound care for 1 of 2 sampled residents reviewed for pressure ulcers of 4 residents with pressure ulcers (#2). This failure resulted in actual harm to the resident's right heel. The condition of the wound declined to an unstageable wound with purulent drainage that required debridement. Findings: Record review revealed resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission data collection on the skin assessment dated [DATE] indicated the resident had 4 areas of skin condition: site #1 on the left foot was identified as a pressure ulcer, site #2 on the groin was identified as rash, site #3 was on the right foot and was identified as a pressure ulcer, and site #4 was on the coccyx area and identified as redness. There was no description about the wound to include color, odor, any drainage, size, and no measurements of the wound were obtained. There were no admission orders [REDACTED]. Review of the treatment administration record (TAR) indicated the first treatment order was obtained on 5/30/15. It was an order to clean left plantar foot and right heel with normal saline and cover with gauze 7-3 shift and 3-11 shift and a wound consult. On 6/02/15 the physicians' order read, cleanse right heel with normal saline, pat dry and apply Hydro-gel and secure with dry dressing/tape daily. In an interview with the Assistant Director of Nursing (ADON) and the staff nurse on 6/08/15 at 1:30 p.m., they indicated that the treatment orders were not obtained until 5/30/15. For 10 days, from admission on 5/20/15 to 5/30/15, there was no treatment provided with the identified pressure ulcers in the lower extremities. A review of the 3008 assessment form from the hospital dated 5/20/15 indicated that there were scabs present/noted in the lower extremities. This wounds were not addressed and the physician was not informed. There were not physicians orders for the wounds, resulting in no treatment provided. The wound on the right heel progressed to become unstageable and had purulent draining as of 6/05/15.

Based on observation, interview and record review, the facility failed to conduct an accurate and complete assessment upon admission for skin when dark scabs/pressure ulcers were identified on bilateral lower extremities for 1 of 2 sampled residents reviewed for pressure ulcers of 4 residents with pressure ulcers (#2). This failure resulted in actual harm to the resident's right heel. The condition of the wound declined to an unstageable wound with purulent drainage that required debridement. Findings: Review of the medical records for resident #2 revealed the admission data collection dated 5/20/15 on the skin assessment indicated the resident had 4 areas of skin condition: site #1 on the left foot was identified as a pressure ulcer, site #2 on the groin was identified as rash, site #3 was on the right foot and was identified as a pressure ulcer, and site #4 was on the coccyx area and identified as redness. There was no description about the wound to include color, odor any drainage and size, no measurements, of the wound were obtained. A review of the minimum data set ((MDS) dated [DATE] indicated it was the admission assessment and it was a 5-day scheduled assessment. It indicated the resident was at risk for pressure ulcer. On skin conditions, the assessments were left blank. It did not identify if the resident had stage 1, reddened areas, on the coccyx or any pressure ulcers in any other parts of the body. The admission 3008 form assessment dated [DATE] from the hospital documented that the resident had scabs on bilateral lower extremities. This was not assessed to determine what was underneath those dark scabs. A review of the weekly skin integrity review dated 5/20/15 revealed open areas and redness to the right heel, left foot, and the coccyx. Entries were documented on 5/23, 5/30, and 6/06/15. The area to the left foot was not documented after 5/23/15. Printed instructions on the form were as follows: If any skin condition present, proceed to skin condition record for each site identified. Another weekly skin check form was provided by the assistant director of nursing (ADON) with an initial date of 5/23/15. She did not explain why she had 2 forms with different dates for the same resident. On 5/23/15 the skin on the left foot was documented as dry, flaky skin, protective dressing to left foot. The area on the right heel was not documented. On 5/30/15 the current skin condition was documented as open area to left foot. On 6/02/15 and open area was documented on the left outer foot and protective dressing on the right foot. The documentation for current skin condition was inconsistent on both skin integrity review sheets. A wound care observation was conducted by the staff nurse on 6/08/15 at 12:05 p.m. on the right heel wound. The wound edges were whitish/pinkish in color the wound bed has a cream color slough. Per nurse the wound care physician has evaluated and debrided the wound on 6/05/15 described as an unstageable pressure ulcer with purulent drainage.

Based on observation, interview, and record review, the facility failed to ensure wounds were assessed accurately and failed to ensure wound care orders were obtained upon admission and treatments were provided in a timely manner for 1 of 2 residents reviewed for pressure ulcers of 4 residents with pressure ulcers (#2). This failure resulted in actual harm to the resident's right heel. The condition of the wound declined to an unstageable wound with purulent drainage that required debridement. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history of the resident indicated she lived in an assisted living facility (ALF) and was sent to the hospital for generalized weakness. The resident was treated in the hospital with antibiotics and was discharged to the nursing home for rehabilitation. The 3008 form assessment from the hospital indicated her skin was intact with scabs noted in the lower extremities. It did not indicate the location of the scabs or their size. An admission data collection dated 5/20/15 at 8:30 p.m. indicated that on section M-Skin, the resident had 4 areas of impairment: 1. pressure ulcer on left foot, 2. rash in the groin area, 3. pressure ulcer on the right foot, and 4. redness on the coccyx area. There was no description of the pressure ulcers such as size, odor, drainage, or color. The section for current skin treatments was left blank. A Braden scale, tool used for predicting pressure sore risk, was conducted on admission and the score was 13. A score of 13-14 is moderate risk. The lower the score, the higher the risk for pressure ulcer with the range of score from 6-23. The admission minimum data set (MDS) assessment dated [DATE] assessed the resident with impaired cognition. The Brief Interview for Mental Status (BIMS) score was 99 meaning the resident was unable to complete the interview. The resident was severely impaired for cognitive skills for daily decision making. On functional status, the resident had total dependence with 2 persons to provide physical assistance with bed mobility and transfer. The section for does the resident have one or more unhealed pressure ulcers at stage 1 or higher was marked no. The section for other ulcers, wounds, and skin problems was marked none of the above. A review of the weekly skin integrity review dated 5/20/15 revealed open areas and redness to the right heel, left foot, and the coccyx. Entries were documented on 5/23, 5/30, and 6/06/15. The area to the left foot was not documented after 5/23/15. Printed instructions were as follows: If any skin condition present, proceed to skin condition record for each site identified. Another weekly skin check form was provided by the assistant director of nursing (ADON) with an initial date of 5/23/15. She did not explain why she had 2 forms with different dates for the same resident. On 5/23/15 the skin on the left foot was documented as dry, flaky skin, protective dressing to left foot. The area on the right heel was not documented. On 5/30/15 the current skin condition was documented as open area to left foot. On 6/02/15 and open area was documented on the left outer foot and protective dressing on the right foot. The documentation for current skin condition was inconsistent on both skin integrity review sheets. There was no documentation that the physician was notified to obtain orders for wound care until 10 days after admission on 5/30/15. A review of the physician's orders [REDACTED]. On 6/02/15 there was an order for [REDACTED]. A wound care observation was conducted on 6/08/15 at 12:05 p.m. with the ADON and the staff nurse A of the south wing. The resident was observed sitting on the gerichair inside her room, alert but non verbal. The ADON was in the room seated in a chair by the front of the chair and she was cleaning the right foot with a wet paper towel trying to remove whitish flakes and she was cleaning the skin in the area surrounding the pressure ulcer on the right heel. The ADON said the soiled dressing was removed prior to the start of the observation. The ADON said she already cleansed the area and therefore the observation could not identify if the would had any odor and/or drainage. When asked why she was scrubbing the foot with a paper towel, she indicated she was just removing the thick, whitish flakes of the skin. The resident's skin was dry and flaky. The nurse washed her hands and used gloves. She started by cleansing the wound on the right heel with normal saline (NS) and applied Santyl ointment, covered the wound with dry gauze, and wrapped with kerlix gauze. The wound edges on the right heel were whitish/pinkish and color in the wound bed had a cream color slough. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound (www.medical-dictionary.com) The nurse stated at that time that the wound care physician evaluated and debrided the wound on 6/05/15. Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds (www.medical-dictionary.com) After the procedure was completed, the nurse was asked to remove the sock on the left foot to observe the condition of the foot. When she removed the sock, there were whitish flakes of skin coming off. The skin was dry and flaky and a soiled dressing on the left plantar foot was noted. It was dated 5/31/15. The nurse was asked to remove the dressing since it had been in place for 8 days. There was a dark scab the size a little bigger than a quarter under the old dressing. Nurse A and the ADON said they were not aware of an existing wound on the left foot. Nurse A said she did not know about the dressing. The ADON proceeded to remove the black scab and she indicated it the skin was dry and was pinkish inside. She did not call the physician to obtain treatment orders but went ahead and scrubbed the black scab off at that time. Review of the treatment administration record (TAR) for the month of May, 2015 indicated orders on 5/30/15 to clean the left foot planter and right heel with normal saline and cover with gauze on 7-3 shift and 3-11 shift. This was initialed as done as ordered until 6/01/15 at 7-3 shift. However, the observation on 6/08/15 indicated that the last time the dressing was conducted on the left foot plantar wound was on 5/31/15. The rest of the dates were left blank, not initialed as completed, meaning the dressing was not conducted as ordered for 8 days. On 5/27/15 interdisciplinary progress notes (IDT) indicated orders for Lac-hydrin cream 12% to feet daily for extreme dry skin. This was not carried out/transcribed in the TAR. There was no record that the staff were applying the cream to the feet as ordered. Based on the observations conducted during wound care (see above), the feet were very dry with whitish flakes coming off the feet. A physicians' order for a wound care consult was dated 5/30/15. The wound care consult was not completed until 7 days later. Wound care consult notes dated 6/05/15 included a wound assessment by the wound specialist: Location: right heel medial unstageable wound. Etiology- pressure. Measurements 1.5 centimeters (cm) length x 1 cm width, depth-unknown. Wound edges- flat, serous drainage moderate purulent drainage. Debridement with scissor/scalpel-eschar/slough. Eschar is dead tissue that occurs in pressure wounds. It is typically tan, brown, or black and can be crusty. (www healthline.com) The wound recommendation order on 6/05/15 to right heel medial: Cleanse/ irrigate with normal saline, apply nickel thick Santyl, cover with moist gauze and secure with kerlix and tape daily. A review of the TAR revealed the dressing order by the wound care physician was not transcribed. This ordered treatment was not conducted until three days later on, 6/08/15. Review of the care plans dated 5/29/15 revealed the the focus problem of skin/wound. The resident has impaired skin integrity. It did not list any areas of impaired skin integrity. Approaches/Interventions: Administer treatments as ordered and monitor for effectiveness. Notify nurse for any new areas of skin breakdown; redness, blisters and bruises noted during daily care. Weekly skin checks, notify physician for change in condition. In an interview with the care plan coordinator on 6/08/15 at 2:30 p.m., she verified that there was no treatment orders for the wounds until 6/02/15. The actual wounds were identified on admission, but no treatment orders were obtained. The weekly skin assessments did not document any description of the wound. There were no measurements obtained. It checked an open area and described dry and flaky skin. The skin condition record was not completed. A review of the facility policies and procedures for pressure ulcer record dated 11/30/2014 revealed the following: Policy- to document the presence of skin impairment related to pressure when first observed and weekly thereafter until the site is healed. One site will be recorded per page. Procedure- residents will have a pressure ulcer record completed for each skin impairment is related to pressure. Mark the pressure area on the body description identifying the site. Enter the date. Enter the stage of the pressure ulcer. Enter the size of the pressure ulcer- length, width, and depth in centimeters. Enter the tissue type and color. Enter the wound edges and drainage. Enter the periwound information.