Every finding on record at Aviata at Saint Lucie

Based on observations, interviews and record reviews, the facility failed to serve, store and prepare food under sanitary conditions and in accordance with standards for food safety professionals. The findings included:1). During the initial kitchen tour, on 07/07/26 at 8:55 AM, accompanied by the Account Manager, the following were noted: a. There was an accumulation of dust on the air vent over the ice machine.b. Ice scoops were stored on top of the ice machine and were not covered or protected from contaminates and dust from falling onto the surfaces of the scoops.c. The table that supported the juice dispenser was covered in foil that created an uncleanable surface and there was an accumulation of residue that resembled the juices on the surface of the foil and table.d. There was an accumulation of residue on the blade of the bench mounted manual can opener.e. There was an accumulation of ice on the plastic curtains in the door going into the walk-in freezer.f. There was an accumulation of residue and food debris on the walls around the mechanical dishwasher and in the exhaust vent over the machine.g. There was an accumulation of residue on the exhaust vent over the mechanical dishwasher.h. There was an accumulation of dust on the air vent at the entrance from the unit into the kitchen.i. There was an accumulation of dust on the air vent over the 3-compartment sink.j. There was an accumulation of dust and peeling paint on the air vents over the cooking equipment.k. There was an accumulation of food residue on the top of the range top.l. There was an accumulation of food residue on the handles of the oven and the handle of the door on the left side of the convection oven was dislodged.m. An oven mitt that was stored on a shelf under in the cooking and hot holding area was noted to be torn.n. The floor drains throughout the kitchen were clogged and had standing water and debris in them at the steamer, the three compartment sink and at the coffee/beverage station. 2). During an observation of the unit pantry on the [NAME] unit, on 07/09/26 at 9:54 AM, accompanied by the Regional Account Manager, the following were noted:a. The cabinets under the hand sink were damaged and there was an accumulation of debris and a black mold-like substance.b. There was an accumulation of debris under and behind the upright refrigerator/freezer unit. C). During an observation of the Emerald Unit pantry, on 07/09/26 at 9:56 AM, the following were noted: a. The counter to the right of the hand sink had a large piece of material missing.b. There was an accumulation of debris under and behind the refrigerator/freezer.c. The wall and the floor around and behind the refrigerator/freezer was damaged.

Based on record review and interview, the facility failed to follow physician's orders for lab work for 1 of 1 resident reviewed for labs, Resident #13. The findings included:Review of Resident #13 medical records revealed the resident was admitted to the facility 12/10/22 with a diagnosis to include Dementia, Major Depressive Disorder, Type II Diabetes Mellitus with Diabetic Neuropathy, Benign Prostatic Hyperplasia, and Essential Hypertension. His Annual MDS (Minimum Data Set) dated 05/08/26 documents he has a BIMS of a 4 which means his cognition is severely impaired.A review of Resident #13 physician orders document that on 07/01/26 at 10:58 AM a lab order for a CBC with Differential Comprehensive Panel was ordered. On 07/08/26 at midnight a lab order for a CBC with Differential Comprehensive Panel, Hemoglobin A1C, Lipid Profile, T4 Total, T4 Free, TSH 3rd Generation Microalbuminuria was ordered. A review of the lab results does not document that the labs on 07/01/26 nor were the labs on 07/08/26 ever drawn. There are no progress notes documenting why they were not drawn or if resident refused.During an interview on 07/10/26 at 8:02 AM with the DON (Director of Nursing), she was asked to pull up Resident #13 orders for labs/results. She acknowledged that there are orders and no results. She stated she will have to call lab and have a stat blood work completed.During an interview on 07/10/26 at 8:55 AM with Staff L, LPN (Licensed Practical Nurse), she was asked about Resident #13 and his labs. She went to the lab book and was unable to find any documents in the lab book from 07/01/26 through 07/10/26. She stated the third shift is responsible for putting the documents in the lab book. She stated the lab company comes every day to draw blood. She was asked to review lab orders and results. She was unable to find results since 06/22/26. She had no answer about why it was not done and no response on what she would do going forward.

Based on interview and record review, the facility failed to ensure drug regimen was free from unnecessary drugs for 1 of 5 residents sampled as evidenced by failure to document observed side effects for Resident #50.The findings included:Review of the record revealed that Resident #50 was admitted to the facility on [DATE] with diagnoses that include Paranoid Schizophrenia, Unspecified Dementia, Psychotic Disturbance, Major Depressive Disorder, Traumatic Brain Injury and Anxiety.Review of the care plan dated 06/11/26 documented in part that Resident #50 had impaired cognitive function/dementia or impaired thought processes r/t Dementia and that Resident #50 was on antipsychotic therapy related to Paranoid Schizophrenia, Dementia, and Depression and had interventions that included administer medications as ordered and monitor/document for behavioral symptoms, side effects and effectiveness. Review of the Medication Administration Record (MAR) for May 2026 revealed that documentation for the Physicians Order for nursing to monitor for side effects for antidepressant, antipsychotic, antianxiety or hypnotic use had a #10 (Other: see progress notes) on the night shift of 05/02, 05/24 and 05/25/26. Review of the progress notes revealed that no progress notes were written on 05/02, 05/24 and 05/25/26. Review of the MAR for June 2026 revealed that under the same order as above a #10 was on the night shift of 06/13/26 and again no progress note was written.An interview was conducted on 07/10/2026 at 11:06 AM with the Director of Nursing (DON) who was asked if the MAR has #10 documented should there be progress note on that date with the side effects that were observed and she agreed and stated that if the MAR says to look in progress note there should be a progress note and after reviewing the MAR's for Resident #50 she thinks that it was a certain nurse and education will be done. The DON agreed with the findings.

Based on policy review, observation, interview and record review, the facility failed to properly assess and evaluate accident hazards for 2 of 2 sampled residents reviewed for Accidents. This is evidenced by failure to ensure a completed quarterly smoking evaluation for Resident #59 and to ensure accurate fall risk assessments for Resident #4.The findings included:1) Review of the policy titled, Smoking-Supervised, effective date 11/30/14, documented, Residents that wish to smoke will be evaluated on admission/readmission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. Review of the record revealed Resident #59 was admitted to the facility on [DATE]. Medical diagnoses included Nicotine Dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #59 was cognitively intact. This MDS assessment also documented the resident's vision was severely impaired.Review of the smoking evaluation forms lacked documentation since 01/09/26.During an observation on 07/07/2026 at 10:33 AM and 07/08/2026 at 11:01 AM, Resident #59 was observed smoking on the smoking patio with the staff present.During an interview with the Director of Nursing on 07/10/2026 at 9:17 AM, she stated smoking evaluations were done by the nurses, or the Activity staff. They meet with the residents, review the policy, the resident then sign an agreement. She confirmed these evaluations were to be done on admission, quarterly and with a significant change. 2) Review of the policy titled, Fall Management, revision date 07/09/26 documented, Residents are assessed for fall risk provided with individualized interventions and monitored for effectiveness to prevent falls and minimize injury. At admission, quarterly, annually, with any significant change in condition, and following each fall, a fall risk assessment will be completed.Review of the record revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses which included Dementia, Type 2 Diabetes with Diabetic Neuropathy and a Non-displaced Intertrochanteric Fracture of the Left Femur (break in the upper portion of the thigh bone). Review of the current MDS assessment dated [DATE] revealed a BIMS score of 11, indicating Resident #4 had moderate cognitive impairment.Review of the record revealed Resident #4 fell on [DATE] and 06/28/26. The fall risk assessment done on 04/21/26 documented the resident at a low risk for falls. The record lacked documentation of a fall risk assessment on 06/28/26. Review of the physician's progress notes dated 04/22/26 documented the resident at a high risk for falls.During an interview and side by side record review conducted on 07/09/26 at 11:00 AM, Staff I, Registered Nurse (RN), was asked the process when a resident fell. She stated for an unwitnessed fall, neurological checks were done on the residents for 72 hours; vital signs, a post fall assessment, a fall risk assessment and any imaging studies, if injury was suspected, were also completed. The doctor and the resident's family would be notified. Staff I reviewed the record and confirmed the resident fell on [DATE]. She also confirmed that the resident's fall risk assessment was inaccurate based on the resident's medications, medical history and mental status. These indicators were incorrectly completed on the assessment. Staff I stated Resident #4 was at a high risk for falls.During an interview and side by side record review conducted on 07/09/26 at 11:26 AM with Staff J, Registered Nurse /Unit Manager (RN/UM) confirmed the resident fell on [DATE] and again on 06/28/26. She confirmed the resident 's fall risk assessment on 04/21/26 should have reflected Resident #4 was a high fall risk; and a fall risk assessment should have been completed on 06/28/26.

Based on observation, record review and interviews, the facility failed to provide care and services to maintain range of motion for 1 of 2 sampled residents, as evidenced by failure to follow a Physicians order for Resident #102 for Occupational Therapy (OT) to evaluate and treat as indicated. The findings included:Review of the record revealed that Resident #102 was admitted to the facility on [DATE] with recent hospitalizations on 04/07/26, 05/01/26 and 05/29/26 with the most recent admission back to the facility on [DATE]. Further review of the record revealed that Resident #102 had a diagnosis, in part, of Hemiparesis following Cerebral Infarction affecting Right Dominant Side and had a Physicians order dated 06/05/26 for OT to evaluate and treat as indicated. During an initial interview on 07/07/26 at 9:47 AM, Resident #102 stated that his right hand is contracted after a stroke and that his left ring finger is locked at several joints making it difficult to do things independently. Resident #102 denied getting any therapy recently for his hands. Resident #102's right hand was in a fully fisted position with no bracing or palm protector in place and his left ring finger appeared to be extended, and he was unable to bend/move it. Review of the care plan dated 05/28/26 documented that Resident #102 had limited physical mobility related to contractures, had an alteration in musculoskeletal status related to contracture in his right hand, and had an ADL self-care performance deficit related to musculoskeletal impairment with interventions that include Passive Range of Motion Exercises to Right Upper Extremity daily and to apply soft palmer guard to right hand up to 6 hours daily. An interview was conducted with Staff A, Occupational Therapist (OT) on 07/10/26 at 8:58 AM who was asked if Resident #102 has a palm protector and she stated that he had one in the past but since he went out to the hospital a couple of times recently his right hand contracture got worse. Staff A went on to say that Resident #102 used to have a private caregiver and that person was trained with donning and doffing the right-hand splint. Staff A was asked if residents typically get screened by therapy upon return from the hospital and she stated that they do and located the screening book and the last screen for Resident #102 was for 03/05/26. When surveyor requested to see the OT evaluation from the 03/05/26 screening, Staff A stated that they do not have access to any documentation from the previous therapy company, since they transitioned to in house therapy with the new company at Aviata at Saint [NAME]. Staff A was then asked if Resident #102 was screened or evaluated after his recent admission on [DATE] and she stated that they would first get a payer source, but she was unable to show proof of funding verification in the payer source logbook. Staff A then stated that they do not currently have a Rehab Director and things may have been missed since the Rehab Director is the one who would typically ensure that therapy screens are scheduled with the staff therapists and follow up with any funding verifications /payer sources for therapy services. Staff A then stated that she is the only OT and she was not notified by nursing or the facility that Resident #102 had an order for an OT evaluation or need for one and she hopes that when the new Rehab Director starts working things will go back to normal.

Based on review of the Arbitration Agreement and interviews the facility failed to explain the arbitration agreement in a language that the resident/representative understands and Failure to have evidence that resident/representative acknowledge understanding of agreement. The findings included:Review of the Arbitration list that the facility provided the surveyor documents 64 residents refused to sign the agreement and 50 signed though after reviewing the surveyor was unable to find any recent admitted residents that signed the agreement. The Arbitration Agreement that the facility calls Optional Arbitration Agreement revised 08/19. The document is 1 1/2 pages long. It is missing the verbiage that the agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman. It documents that only 1 arbitrator is required to resolve any dispute and the arbitrator shall be selected by agreement of the parties. The panel shall consist of at least 3 individuals who are qualified by the state to serve as an arbitrator, who have experience and knowledge of the health care industry or have served as mediators .The document is confusing to read and not in a language for the residents/representative to understand as well as if the resident declines the arbitration agreement they have nowhere to sign that they acknowledge that the document was explained to them in a manner that they understand. Surveyor chose three names that signed for the arbitration and gave the list to Staff M, Hospital Clinical Liaison (Marketing). She stated she is unable to find Resident #13 but gave surveyor Resident #21 who was admitted [DATE] and Resident #91 who was admitted 2017. The agreement does not have a date on the document. Surveyor then asked for the document showing the residents did not want to sign for arbitration. Surveyor reviewed Resident #3, Resident #56.During an interview on 07/09/26 at 11:40 AM with Staff M, Hospital Clinical Liaison (Marketing) she was asked if she does the Arbitration Agreements. She stated Yes. She was asked to show surveyor the Arbitration document, and she gave Surveyor 1 1/2 pages with the bottom having resident or representative signature if they accept the agreement. She was asked what does she told the resident? She stated, she asks them if they know what an arbitration agreement is She then reads them the 2 pages. She tells them that by signing this agreement they are giving up the right to a jury trial. She began [DATE] and was trained by the [NAME] President and offsite Marketer. She says they do the admission packet within 72 hours of admission.During an interview on 07/09/26 at 1:50 PM with Resident #3, she was asked about the Arbitration agreement. Surveyor asked if she remembers them explaining it to her. She stated they did not explain it to me. They had me read it and it was hard to understand what it said. She did not sign for it since she did not understand it.During an interview on 07/10/26 at 8:26 AM with Resident #56, she was asked if she remembers signing the arbitration document? Did she understand what she signed? Surveyor presented her with the document. She stated it was not discussed with her.

Based on observation, interview, and record review, the facility failed to ensure appropriate medication administration by leaving residents unattended during physician-ordered nebulizer treatments without physician authorization for self-administration, a self-administration assessment, or appropriate nursing supervision for 2 of 2 residents (Residents #14 and #122) reviewed for nebulizer medication administration and had the potential to place residents at risk for ineffective medication administration, respiratory distress, or other adverse events.The findings included:1) Clinical record review revealed Resident #14 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/25/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #14 was cognitively intact.Review of the physician's orders dated 06/23/26 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 mL, inhale via nebulizer every four hours as needed. The order instructed staff to check lung sounds, heart rate, and respirations before and after the nebulizer treatment. The treatment was to be administered for 15 minutes.On 07/08/26 at 8:31 AM, after Resident #14 granted permission to enter the room, the surveyor observed the resident sitting upright in a wheelchair holding the nebulizer mask to his face and receiving the nebulizer treatment alone. No nurse was present in the room. The assigned nurse, Staff H, was observed standing in front of room [ROOM NUMBER], away from Resident #14's room [ROOM NUMBER]. From Staff H's location, Resident #14 was not within her direct line of sight. At 8:34 AM, an interview was conducted with Staff H regarding the nebulizer administration process. Staff H stated that staff were supposed to obtain oxygen saturation, assess lung sounds, respirations, and heart rate, place the medication in the nebulizer machine, and remain with the resident during the approximately 15-minute treatment. When informed that Resident #14 had been observed alone receiving the treatment, Staff H stated she had placed one vial of medication in the machine, but the resident's breakfast tray arrived, so she left the room. She stated she planned to return after the resident finished eating to start the machine, but believed the resident had probably started the machine himself. When asked whether the medication should have been left unattended, Staff H provided no response and instead asked the surveyor what she should have done in this situation. The surveyor instructed Staff H to discuss the matter with her supervisor.2) Clinical record review revealed Resident #122 was admitted to the facility on [DATE]. The quarterly MDS assessment with an ARD of 06/25/26 recorded a BIMS score of 3, indicating the resident was severely cognitively impaired.Review of the physician's orders dated 10/02/25 revealed an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) 0.083%, one vial via nebulizer three times daily for shortness of breath. The order instructed staff to assess lung sounds, heart rate, and respirations before and after each nebulizer treatment. The treatment was to be administered for 15 minutes.Clinical record review revealed no physician order authorizing self-administration of nebulizer treatments, no self-administration assessment, and no care plan addressing self-administration of respiratory medications.Review of the care plan dated 05/15/26 revealed Resident #122 was at risk for shortness of breath. Interventions included administering nebulizer treatments as ordered by the physician.On 07/09/26 at 9:13 AM, the surveyor entered Resident #122's room and observed the resident alone wearing a nebulizer mask and receiving the breathing treatment without nursing supervision. No nurse was present in the room.At 9:21 AM, the nebulizer treatment had completed, and no visible mist was being produced. The resident attempted to remove the nebulizer mask using her right hand but was unable to remove it. The resident then pushed the mask onto her forehead and held it up while the strap remained secure around her head.At 9:25 AM, Staff I, a registered nurse, entered the room and observed the resident with the mask positioned on her forehead. Staff I repositioned the mask back onto the resident's face. During an interview at that time, Staff I acknowledged she was supposed to remain with the resident until the nebulizer treatment was completed and apologized.On 07/09/26 at 9:31 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was informed of the observations involving Residents #14 and #122 being left unattended during nebulizer treatments.On 07/10/26 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the concern regarding residents being left alone during nebulizer medication administration.

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set Assessment for 1 of 1 sampled resident reviewed for Smoking, Resident #59.The findings included:Review of the record revealed Resident #59 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident as a non-smoker. Review of the admission smoking evaluation dated 10/16/25 documented the resident as a smoker.During an observation on 07/07/26 at 10:33 AM and 07/08/26 at 11:01 AM, Resident #59 was observed smoking on the smoking patio with staff supervision.During an interview and side by side record review conducted on 07/10/26 at 1:30 PM, the MDS Coordinator stated the nurses do the smoking evaluation for the residents on admission, quarterly and when there was a change in the resident's condition. Based on the evaluation, the MDS coordinator is provided with a list of residents who smoke. This is documented in the resident's care plan and admission MDS assessment. She confirmed there was a discrepancy with Resident #59's admission MDS assessment and the smoking evaluation. She stated Resident #59 was not on her list.

Based on interviews, the facility failed to orally present resident rights for 8 of 8 residents during Resident Council meeting, Resident #'s 21, 22, 24, 71, 85, 91, 114, and 118. The findings included:During a Resident Council meeting with surveyor on 07/09/26 at 10:00 AM, when the 8 residents were asked if staff talked about and reviewed the rights of residents in the facility, they responded, no, that they used to review them orally, but they do not anymore.During an interview with the Activities Director (AD) on 07/10/26 at 2:58 PM as she was leaving the dining room after the regularly scheduled monthly Resident Council meeting, she was asked which Resident Rights statement was reviewed at the meeting and she stated that she does not talk about or review residents' rights during the meetings but does give residents a copy of the written resident rights. The AD was then asked if there is any type of discussion about Resident Rights during Resident Council meetings and she stated only when residents bring up an issue and she relates it back to one of the resident rights.The AD was told that during the Resident Council meeting with the surveyor, some residents did not know that they were able to access the previous results of state surveys/inspections, and she was asked if she ever talked about that resident right and she stated she was not sure if she had. The AD acknowledged the findings.

Based on observations, interview and record reviews, the facility failed to provide foods prepared in a manner to preserve the nutritive value with the potential to effect 110 residents that eat meals provided by the kitchen; the facility failed to ensure residents received a complete meal for 1 of 18 residents reviewed for dining, Resident #44; the facility failed to ensure a palatable meal for 1 of 18 residents reviewed for dining, Resident #34. The findings included 1) Clinical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including malnutrition. The quarterly MDS assessment with a reference date of 04/20/26 recorded a BIMS score of 12, indicating moderate cognitive impairment. The MDS revealed Resident #44 required set-up or clean-up assistance with eating and identified no nutrition/swallowing concerns. Physician orders dated 07/22/20 indicated a regular diet, regular texture, and regular/thin liquids consistency. A nutrition assessment dated [DATE] documented Resident #44 was at risk for malnutrition related to multiple chronic diseases and advanced age. The care plan dated 04/16/26 identified risk for malnutrition with interventions including providing and serving diet as ordered. On 07/07/26 at 10:44 AM, during an interview, Resident #44 expressed concerns regarding the quality and availability of food. The resident stated she wanted better food and stated, the facility runs out of milk, they run out of food items a lot of times. On 07/08/26 at 9:48 AM, Resident #44 was observed consuming breakfast in bed. When asked about the meal, the resident stated the food was bad. On 07/09/26 at 9:01 AM, Resident #44 was observed with a breakfast tray containing two boiled eggs, two half pieces of toast with jelly, cereal with milk, and coffee. Review of the meal ticket revealed orange juice was listed as part of the meal; however, orange juice was not present on the tray and the resident confirmed it was not provided. On 07/09/26 at 1:32 PM, Resident #44 was observed during lunch and reported she received burnt lasagna from the kitchen. The resident stated she ate the meal because she was hungry. 2) Clinical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including malnutrition. The quarterly MDS assessment with a reference date of 06/19/26 recorded a BIMS score of 15, indicating the resident was cognitively intact. The MDS revealed Resident #34 required set-up or clean-up assistance with eating and identified a therapeutic nutritional approach. Physician orders dated 04/17/26 indicated a regular no added salt diet, regular texture, and regular/thin liquids consistency, with double entrée at breakfast and fortified foods at breakfast due to risk of malnutrition. A nutrition assessment dated [DATE] documented Resident #34 was at risk for malnutrition related to multiple chronic diagnoses, advanced age, therapeutic diet, and history of significant weight loss. The care plan dated 05/26/26 identified risk for malnutrition with interventions including providing and serving diet as ordered. On 07/07/26 at 10:23 AM, Resident #34 reported concerns regarding food quality and stated, the food is terrible, she wouldn't feed it to her dog, they serve the same thing over and over again, they don't care what they send out as long as they send out food. Most of the time the hot food is served cold. On 07/09/26 at 9:16 AM, Resident #34 was observed with a breakfast tray. The meal ticket indicated the resident was to receive two egg and cheese squares; however, only one egg and cheese square was provided. On 07/09/26 at 1:22 PM, Resident #34 was observed with a lunch tray containing cheese lasagna, Caesar salad, garlic bread, fruit cocktail, coffee, and red juice. The lasagna was observed to be burnt. Resident #34 stated she was not going to eat the meal and stated, I told you the food is terrible. When asked if she was hungry, the resident stated yes. When asked if she wanted an alternative meal, the resident stated, yes, but not from them. She advised she had peanut butter, which she started to consume. On 07/10/26 1:01 PM at 1:11 PM, interviews were conducted with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Dietary Manager, and District Manager. They were informed of the concerns regarding missing meal items according to meal tickets, resident complaints regarding food quality, and burnt lasagna. The DON stated nursing was responsible for providing the orange juice while passing trays. 3) Clinical record review revealed Resident #12 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and malnutrition. Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/04/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS further revealed no behaviors that would impair the resident's ability to express preferences or communicate needs. Review of the Nutrition assessment dated [DATE] revealed Resident #12 was at risk for malnutrition related to a Mini Nutritional Assessment (MNA) score reflecting malnutrition. On 07/07/26 at 10:07 AM, during an interview, Resident #12 stated, You wouldn't want to eat the food here. Even the hospital food is better than this crap. The food is nasty, it's dry. The pancakes you can throw them like a Frisbee, that's how hard they are. On 07/10/26 at 1:15 PM, the resident's concerns regarding the quality and palatability of the food were discussed with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Dietary Manager, and District Manager. The resident's complaints were brought to their attention. 4) During the initial kitchen tour, on 07/07/26 at 8:55 AM, Staff B, Dietary Aide, was noted to be placing a one-third sized 6-inch deep hotel pan of pureed peas into the convection oven. When Staff B was asked about the process for preparing the peas, the dietary Aide stated that she started cooking them at approximately 5:00 AM. Staff B stated that the peas were cooked in a steamer inside of a full sized 6 inch deep hotel pan and then a portion of the peas were removed and placed into the 1/3 sized pan to be pureed and then re-heated before being placed into the oven for hot holding. During the interview, the Dietary Aide and the Account Manager acknowledged that the peas would be under some type of heat source for more than six hours before being served. The Dietary Aide and the Account Manager acknowledged understanding of the concerns.

Based on observation, interview and record review, the facility failed to ensure residents received meals and fluids consistent with physician orders and meal tickets for 2 of 2 residents observed during dining observations. This involved Resident #104 and Resident #87.The findings included: 1)Clinical record review revealed Resident #104 was admitted on [DATE] with diagnoses including anemia. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/31/26 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required set-up or clean-up assistance with eating and had swallowing problems, including loss of food or liquids from the mouth, holding food in the mouth, and coughing or choking during meals. The MDS further documented that the resident required a mechanically altered diet and nectar-thickened liquids. Physician's orders included speech therapy for dysphagia dated 02/13/26 and a Consistent Carbohydrate (CCD), Dysphagia Advanced texture diet with nectar-thickened liquids and large portions of all meals dated 07/07/26 due to risk of malnutrition. A nutrition assessment dated [DATE] identified the resident as being at risk for malnutrition due to multiple chronic diagnoses, advanced age, mechanically altered therapeutic diet, and the need for thickened liquids. The care plan dated 05/28/26 directed staff to provide and serve the diet as ordered. A dietary progress note dated 07/07/26 at 10:31 AM documented the Registered Dietitian met with the resident regarding food preferences. The resident requested large portions, and the preferences were reportedly communicated to the kitchen. On 07/07/26 at 10:56 AM, Resident #104 stated the facility did not provide enough food and routinely served only small portions and one slice of toast for breakfast despite his request for larger portions. The resident stated he remained hungry after meals and reported staff continued serving pork despite being informed of his religious dietary preference. The resident further stated staff failed to provide water when requested and reported that, on one occasion, he obtained water from the bathroom sink after staff refused his request, stating they were not assigned to his care. On 07/08/26 at 10:01 AM, observation revealed Resident #104's breakfast tray contained two half slices of toast, regular thin apple juice, and regular thin water on the bedside table, although the physician's order and meal ticket required nectar-thickened liquids. On 07/09/26 at 8:56 AM, observation revealed the resident's breakfast tray contained two half slices of toast, one small egg and cheese bake, regular thin red juice, and oatmeal. The meal ticket indicated the resident was to receive one and one-half portions of egg and cheese bake, large portions, and nectar-thickened liquids. Resident #104 did not receive the ordered large portion or the prescribed nectar-thickened liquids. On 07/10/26 at 1:17 PM, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Dietary Manager, and District Manager were informed of the observations that Resident #104 had not consistently received the physician-ordered nectar-thickened liquids and meals consistent with the physician's orders and meal ticket. The facility failed to ensure the resident received meals and liquids as ordered, placing the resident at risk for aspiration, inadequate nutritional intake, and failure to honor individualized dietary preferences. 2). During an observation of lunch served to the residents in the Main Dining Room, on 07/07/2026 at 12:07 PM, Resident #87, was noted to be served ground chicken with gravy and large pieces of cabbage. It was noted that the tray ticket that accompanied the meal documented that the resident's diet orders included Consistent Carbohydrates – Dysphagia Advanced texture. The ticket documented that the resident was to receive chopped seasoned cabbage. During an interview, on 07/07/26 at 12:20 PM, the Regional Account Manager acknowledged that Resident #87 did not receive chopped cabbage and that the cabbage that was provided to the resident was not appropriate for a resident with the specific diet orders.

Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to ensure a clean and comfortable environment on 3 of 3 units and in the Main Dining Room. The findings included:1). During an observation in the Main Dining Room, on 07/07/26 at 9:45 AM, the following were noted: a. There was an accumulation of debris behind the vending machines. b. There was an accumulation of dust on 2 of 2 wall mounted air conditioning units. c. The cabinet under the hand washing sink was damaged and there was an accumulation of a black mold-like substance. 2). During an observation in room [ROOM NUMBER], on 07/07/26 at approximately 10:00 AM, it was noted that the drawers on 2 of 4 armoires had become dislodged and the perimeter covering of 2 of 4 over bed tables was missing exposing the particle board underneath. 3). On 07/07/26 at approximately 10:10 AM, it was noted that here was an accumulation of dust and peeling paint on the air conditioning intake vent to the left of the door to the Maintenance Office and an accumulation of dust on the fan over the exit to the courtyard. 4). On 07/07/26 at 10:42 AM, it was noted that there was an accumulation of dust on the air conditioning vent outside of the Employee Break Room and the hand rails were damaged and separating. The hand rails approaching the Main Dining Room were separating, and there was an accumulation of dust on the air conditioning vents in the corridor. 5). Upon entering room [ROOM NUMBER], on 07/08/2026 at 8:53 AM, it was noted that the temperature was noticeably warm. Upon approaching the wall mounted air conditioning unit, there was warm air blowing out of the unit. The temperature according to the Surveyor's state issued ambient air thermometer was 80.9 degrees Fahrenheit (F). The control panel on the unit showed 65 degrees F and that the unit was set to 'cool'. On 07/08/26 at 12:05 PM and the room again felt warm and there was warm air blowing out of the wall mounted air conditioning unit. The temperature in the room was 81 degrees F according to the Surveyor's state issued ambient air thermometer. During an interview, on 07/08/26 at 12:05 PM, Resident #65, with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, according to a Quarterly Minimum Data Set (MDS) with a reference date of 06/22/26, stated that the unit had not been working since the previous Thursday (07/02/26) which was 5 days prior. The resident stated that he notified staff and was provided with a fan. The resident stated that he reported that the room was still uncomfortable, despite being provided with the fan. During an interview, on 07/09/26 at 12:12 PM, with the Maintenance Director, the Maintenance Director stated that he had reset the compressor on 07/03/26 and after resetting the compressor, the unit was working. The Maintenance Director stated that he did not follow up with the unit and the residents in the room after resetting the compressor. During an interview, on 07/10/2026 at 10:37 AM, with Staff C, Maintenance Assistant, when asked, the Maintenance Assistant confirmed that he provided the fan to Resident #65 'a few days ago' and confirmed air conditioning unit was not working over the previous weekend. 6). On 07/08/26 at 8:57 AM, it was noted that the floor outside of room [ROOM NUMBER] was damaged and the floor laminates were peeling from the floor. There was an accumulation of dust on the air conditioning vent outside of room [ROOM NUMBER]. Part of the covering at the bottom right side of the door to the janitor closet was missing. The end caps of the hand rails by the public restroom was missing. 7). On 07/08/26 at 12:43 PM, it was noted that the wall behind the head of the bed in room [ROOM NUMBER]-C was unfinished and in need of being painted. 8). During an observation of the [NAME] Unit shower room, on 07/09/26 at 9:49 AM, it was noted that there was an accumulation of dust on an air vent, and a hole in the wall of the shower stall. 9). On 07/09/26 at 10:09 AM, it was noted that the end cap of a hand rail to the left of the entrance to room [ROOM NUMBER] was missing. 10). During an observation in room [ROOM NUMBER], on 07/09/26 at 10:598 AM, it was noted that the back of the closet had become separated, there was a bare threaded tip of a screw in the top of the inside of the closet. 11). On 07/08/2026 at 2:25 PM, Resident #27, with a BIMS score of 12 according to Quarterly Minimum Data Set with a reference date of 03/26/26, approached the Surveyor while at the nurse's station of the [NAME] Unit (Rooms 48-70) and stated his bathroom door was stuck. The Surveyor and the resident went to the resident's room, and the Surveyor turned the knob on the door and pulled the door open with the application of some force. The Surveyor then asked the resident to attempt to open the door and the resident succeeded with some struggle. At the time of the observation of the resident opening the door, the Housekeeping Account Manager and Staff G, Housekeeping, were walking by and the Surveyor requested they join in the observation and explained that the resident was having difficulty opening the door. Staff G stated, it has been like that for a while. During an initial tour of the residents' rooms the following concerns were noted: 12) During an observation of room [ROOM NUMBER]-A at 8:55 AM it was observed that the string behind the residents' bed is tied with a red rubber fitness band to make it longer. His wheelchair right arm rest is torn. 13) During an observation of room [ROOM NUMBER]-C at 9:36 AM it was observed that his wardrobe [NAME] drawer is broken. 14) During an observation on 07/08/26 at 9:39 AM it was observed in room [ROOM NUMBER]-B that one of the drawers on his wardrobe [NAME] is broken. 15) It was observed by the emergency doors on the Emerald Unit that the cap on the floor is missing and can cause a trip hazard. During an environmental tour, on 07/10/2026 at 10:37 AM, with the Maintenance Director and the Housekeeping Account Manager, the findings were acknowledged.

Based on observation, interview, and record review, the facility failed to honor a resident's preference and repeated requests for longer oxygen tubing for 1 of 2 residents reviewed for resident choices. This deficient practice involved Resident #12.The findings included:Clinical record review revealed Resident #12 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and malnutrition.Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/04/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS further revealed no behavior concern. Review of physician's orders dated 07/02/26 revealed an order for oxygen at 2 liters per minute via nasal cannula as needed for COPD to maintain oxygen saturation above 90%.On 07/07/26 at 10:07 AM, during an interview, Resident #12 stated he had multiple health issues and used oxygen. While pointing to his oxygen tubing, he stated, Look how short the oxygen tube is. I move around a lot in my sleep. If this oxygen tube falls off, I will be gasping for air. The resident further stated he had requested a longer oxygen tube approximately four times but had not received one, adding, They don't care, and reiterated that he had repeatedly asked for a longer tube.On 07/08/26 at 9:17 AM, the surveyor revisited Resident #12 and observed he continued to use the same short oxygen tubing. Resident #12 stated he still had not been provided with the longer oxygen tubing he had requested.On 07/09/26 at 9:40 AM, Resident #12 was observed sitting up in bed receiving oxygen through the same short oxygen tubing. The requested longer tubing had still not been provided.On 07/09/26 at 1:06 PM, Resident #12 was observed without the nasal cannula in place, and the oxygen tank was turned off. When asked why he was not wearing his oxygen, the resident stated he needed a new tube and said, I've been trying to get a new tube for the past week. Observation of the oxygen tubing revealed there was no date indicating when the tubing had been changed.On 07/10/26 at 12:00 PM, an interview was conducted with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Prevention and Control Officer (IPCO). They were informed that Resident #12 had repeatedly requested longer oxygen tubing but had not received it. The ADON stated, We have a lot of long oxygen tubing here. The DON immediately contacted nursing staff by telephone and instructed staff to provide Resident #12 with the longer oxygen tubing.

Based on CDC guidelines, policy review, observation, interviews, and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the transmission of communicable diseases and infections. Specifically, the facility failed to: (1) promptly implement Contact Precautions for a resident with suspected Clostridioides difficile (C. difficile) infection despite several days of documented diarrhea; (2) provide residents the opportunity to perform hand hygiene before eating foods with their hands in the dining room; and (3) maintain laundry in a manner that prevented the spread of infection. These deficient practices had the potential to expose residents, staff, and visitors to infectious organisms. This affected 1 of 2 residents reviewed for transmission-based precautions (Resident #123).The findings included:The Policy titled infection prevention and control program dated 04/15/26 indicated that this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The isolation protocol for transmission-based precautions indicated a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Policy titled isolation precaution dated 04/15/26 indicted isolation refers to the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection. The policy also documented Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact. The CDC guideline titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes for Health Care Providers dated June 28, 2024, indicated question # 3 asked was what are the differences between Enhanced Barrier Precautions and Contact Precautions? The guidelines documented Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed in a private room. Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Question # 4 asked when should nursing home staff use Contact Precautions versus Enhanced Barrier Precautions for a resident with a MDRO? The guideline indicated Contact Precautions are recommended if the resident has acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained or for a limited period of time during a suspected or confirmed MDRO outbreak investigation. Question # 5 asked are Enhanced Barrier Precautions recommended for residents with Clostridioides difficile infection or scabies? The guideline revealed, No. Enhanced Barrier Precautions are intended for MDROs (other than Clostridioides difficile) and do not replace existing guidance regarding use of Contact Precautions for other pathogens (e.g., Clostridioides difficile, scabies, norovirus) and conditions in nursing homes. 1) Clinical record review revealed Resident #123 was admitted to the facility on [DATE] with medically complex conditions. Review of the care plan dated 06/24/26 revealed Resident #123 required Enhanced Barrier Precautions related to chronic wounds and MRSA colonization and was identified as being at risk for multidrug-resistant organism (MDRO) infection. Review of physician orders revealed: An order dated 07/01/26 for Enhanced Barrier Precautions related to wounds. An order created on 07/02/26, effective 07/03/26, for a stool culture. An order dated 07/07/26 for a Clostridioides difficile toxin test due to diarrhea. A physician order dated 07/08/26 at 7:00 PM initiating Contact Precautions related to suspected Clostridioides difficile infection. Review of nursing progress notes revealed: On 07/02/26 at 3:11 PM, Resident #123 had multiple loose stools, and the provider was notified. On 07/02/26 at 5:41 PM, documentation indicated the resident continued to experience loose stools. On 07/07/26 at 3:36 PM, the provider documented nursing reported episodes of diarrhea, a stool specimen for C. difficile toxin testing had been ordered, results were pending, and staff were instructed to reinforce hand hygiene and Contact Precautions while awaiting test results. On 07/08/26 at 12:40 PM, documentation indicated the resident's daughter was informed the resident possibly had C. difficile. On 07/08/26 at 3:57 PM, documentation indicated Resident #123 was transferred to another unit, placed on isolation for suspected C. difficile, and a stool specimen was collected and sent to the laboratory. On 07/07/26 at 11:51 AM, observation of Resident #123's room revealed an Enhanced Barrier Precautions sign posted on the shared room occupied by four residents. No Contact Precautions signage was observed despite the resident's documented history of ongoing loose stool. On 07/08/26 at 9:24 AM, Resident #123 was observed sitting in the Emerald Unit dining room with seven other residents. On 07/10/26 at 12:26 PM, an interview was conducted with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Prevention and Control Officer (IPCO). The IPCO stated Resident #123 was placed on Contact Precautions beginning on 07/08/26 due to possible C. difficile infection. When asked why Contact Precautions were not initiated when the resident first developed documented loose stools on 07/02/26, the DON stated the facility did not receive communication regarding the need for precautions in a timely manner and acknowledged, We just missed it. 2) During an observation of lunch served to the residents in the Main Dining Room, on 07/07/26 at 12:07 PM Resident #116, with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, was observed eating a sandwich and cheese snacks with his hands, as meant to be eaten. When asked if he had been provided an opportunity to perform hand hygiene prior to eating with his hands, Resident #115 stated that he had not been provided with the opportunity and would have appreciated it. Resident #56, with a BIMS score of 14, indicating the resident was cognitively intact, was observed eating a sandwich with her bare hands, as meant to be eaten. When asked if she had been provided an opportunity to perform hand hygiene prior to eating with her hands, Resident #56 stated that she had not been provided with the opportunity and would have appreciated it. During an interview, on 07/07/26 at 12:19 PM, with Staff K, RN, when asked about the residents being provided an opportunity to perform hand hygiene prior to eating with their hands, Staff K stated residents were provided with an opportunity for hand hygiene prior to being brought to the Dining Room and during ADL (Activities of Daily Living) care performed by the CNAs (Certified Nursing Assistants). Staff K further stated that she did not observe the residents performing hand hygiene 3) During a tour of the Laundry, on 07/10/26 at 8:18 AM, accompanied by the Housekeeping Account Manager, the following were noted: a. The linen cart used to transport washed items to the drying room was noted to have debris in the bottom. b. There was an accumulation of dust on the air conditioning vent over the dryers. c. There was no means for staff to perform hand hygiene in the drying room. d. There was an accumulation of dust on the air conditioning vent directly over clean linens in the [NAME] Unit clean linen storage room. At the conclusion of the tour, the Housekeeping Account Manager acknowledged the findings.

Based on arbitration agreement and interview, the facility failed to have the arbitration agreement document a selection of a venue convenient to both parties. The findings included:Review of the Arbitration list that the facility provided the surveyor documents 64 residents refused to sign the agreement and 50 signed though after reviewing the surveyor was unable to find any recent admitted residents that signed the agreement. The Arbitration Agreement that the facility calls Optional Arbitration Agreement revised 08/19. The document is 1 1/2 pages long. It is missing the verbiage that the agreement of the selection of the venue is convenient to both parties.During an interview on 07/09/26 at 11:40 AM with Staff M, Hospital Clinical Liaison (Marketing) she was asked about the section about the venue being convenient to both parties? She acknowledged that the verbiage needs to be worded.

Based on observation, interview and record review, the facility failed to maintain complete and accurate documentation for 1 of 1 sampled resident reviewed for Activities, Resident #7.The findings included:Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Medical diagnoses included: Cerebrovascular disease, Peripheral Vascular Disease, Hemiplegia and Hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 09, indicating Resident #7 had moderate cognitive impairment. This MDS also documented the resident was dependent on staff for his Activities of Daily Living (ADLs). Review of the care plan dated 05/12/26 documented the resident was dependent on the staff for meeting emotional, intellectual, physical and social needs with a goal to maintain the resident's involvement in social activities. During an observation on 07/08/26 at approximately 2:00 PM, Resident #7 was observed in bed. The resident stated he had not been out of bed since yesterday. On 07/09/26 at 3:07 PM, the resident was again observed in bed. The resident was asked if he engaged in activities. He stated he mostly stayed in bed and watched TV, however he would like to be offered other things, such as games. Resident #7 stated the activity staff visited with him, but not every day. During an interview and side by side record review conducted on 07/09/26 at 3:48 PM, the Director of Activities stated each resident was evaluated to find out their preferences. This was documented in the resident's care plan. The activity staff followed a monthly calendar of activities. She further stated that all activities done with the residents are documented daily in the electronic record. The Director of Activities stated Resident #7 usually did not participate in activities outside his room but preferred to watch TV in bed. However, other activities were done and documented daily. She reviewed a 14-day task list of activities done with the resident from 06/26/26 to 07/09/26. The record lacked documentation of the activity therapy provided for Resident #7 on 06/27/26 to 06/29/26, on 07/01/26 to 07/05/26 and on 07/08/26. During an interview conducted on 07/10/25 at 11:00 AM, the Director of Nursing (DON) was asked about the expectation for the documentation of activity therapy. She stated all activity therapy done with the residents should be documented.

Based on observations, interviews and record reviews, the facility failed to provide an environment free from pests on 2 of 3 units, in the Dialysis Room, and in the kitchen. The findings included: 1) During the initial kitchen tour, on 07/07/26 at 8:55 AM, accompanied by the Account Manager, 8-10 live roaches were observed under the shelving in the dry storage. At the time of the observation, the Account Manager acknowledged the findings. 2) During a tour of the [NAME] Unit pantry (rooms 48-70), On 07/09/26 at 9:34 AM, accompanied [NAME] the Regional Account Manager, live and dead roaches in all stages of life and too numerous to count, were observed behind the refrigerator/freezer. The Regional Account Manager acknowledged the findings at the time of the observation. 3) During a tour of the Emerald Unit Pantry (Rooms 24-47), on 07/09/26 at 9:52 AM, accompanied by the Regional Account Manager, live and dead roaches in all stages of life and too numerous to count, were observed behind the refrigerator/freezer, and one live and mature roach was observed in the staff restroom. The Regional Account Manager acknowledged the findings at the time of the observation. 4) During a tour of the Dialysis Room, on 07/09/26 at 10:29 AM, accompanied by the Regional Account Manager, live and dead roaches in all stages of life and too numerous to count were observed behind a specimen cooler. Staff E, RN, Staff F, Customer Service, and the Regional Account Manager acknowledged the findings at the time of the observation. 5) On 07/07/26 at 8:54 AM, during medication administration in [NAME] Unit room [ROOM NUMBER]-A, the surveyor observed a large Palmetto roach crawling in the resident's room. Resident #89 stated the roaches had been coming into her room for approximately two weeks. Review of the quarterly MDS assessment with an Assessment Reference Date (ARD) of 06/25/26 revealed a BIMS score of 14, indicating Resident #89 was cognitively intact. 6) During an initial interview with Resident #12 on 07/07/26 at 10:07 AM, the resident stated that in the room shared with three other residents, there are roaches in the room, and stated, they crawl on the walls. The resident expressed dissatisfaction with the conditions and stated the facility was a shit hole, further stating that insurance paid approximately $500 per day for his stay and that he could be at a prestigious hotel for that price. On 07/09/26 at 1:06 PM, during a follow-up interview with Resident #12, while addressing concerns related to oxygen equipment, the surveyor observed the oxygen concentrator located near the headboard of the bed. While checking the oxygen concentrator and tubing, the surveyor observed 14 small live roaches crawling near the headboard next to the oxygen concentrator. Additional roaches may have been present, as they were observed moving throughout the area. On 07/09/26 at 1:50 PM, the Maintenance Director was interviewed regarding the observations. The Maintenance Director, who had been employed at the facility for approximately one month, was shown a photograph of the live roaches observed in Resident #12's room. He stated, That's not good. The Maintenance Director was also informed of the Palmetto roach observed in room [ROOM NUMBER]-A on the [NAME] Unit. 7) During an interview on 07/07/26 at 10:05 AM with Resident #61 he stated he has roaches in his room. Surveyor did not observe any live or dead ones. 8) During an observation and an interview on 07/07/26 at 11:30 AM with Resident # 98 a swarm of flies were observed flying around his room. He stated they come from the laundry room door across the hall. He also stated that there are roaches in his room. No live or dead ones observed by the surveyor. 9) During an interview with Resident #107 on 07/07/26 at 2:38 PM he stated he sees live roaches in his room all the time. A tour was completed on 07/09/26 at 11:55 AM with the Maintenance Director, he was advised of the roach concerns in the rooms.

Based on record review and interview the facility failed to ensure the physician completes the initial assessment within 30 days of admission for 3 of 3 residents reviewed (Resident #1, Resident #7 and Resident #8).The findings included:1. Review of Resident #1 medical records revealed he was admitted to the facility on [DATE] with diagnoses to include Dependence on Renal Dialysis, Type II Diabetes, Anemia, Acute Respiratory Failure, Major Depressive Disorder, Polyneuropathy, and Muscle Weakness. A review of the admission MDS (Minimum Data Set) dated 10/29/25 documents his BIMS (Brief Interview for Mental Status) score as a 15/15, which means his cognition is intact. The Physician Orders included an order to admit to facility skilled nursing facility dated 10/22/25. A review of the first physical assessment dated [DATE] documents that the resident was seen by the APRN (Advanced Practical Registered Nurse) on behalf of the medical doctor. 2. Review of Resident #7 medical records revealed she was admitted to the facility on [DATE] with diagnoses to include Short of Breath, Heart Failure, Atrial Fibrillation, Essential Hypertension, Cardiac Pacemaker, Seizures, and Major Depressive Disorder. Her admissions MDS dated [DATE] documents her BIMS as score 15/15 which means her cognition is intact. A review of initial physical assessment dated [DATE] documents that she was seen for the first physical assessment by the APRN on behalf of the medical doctor.3. Review of Resident #8 medical records revealed she was admitted to the facility on [DATE] with diagnoses to include Schizophrenia, Muscle Weakness, Chronic Pain and Tachycardia. Her admissions MDS dated [DATE] documents her BIMS score as a 12 means her cognition is moderately impaired. A review of the first physical assessment dated [DATE] documents that the APRN saw this resident on behalf of the medical doctor.4. During a telephone interview on 05/28/26 at 8:00 AM with the medical doctor he stated that he does rounds every Thursday. He stated he sees all his patients. Surveyor asked where his evidence was that he saw his patients and he stated, I review the notes from the ARNP and then sign off.During a secondary interview on 05/28/26 at 12:19 PM with the medical doctor by another surveyor when asked if he does the initial comprehensive assessments for his residents, he stated if the resident is admitted on a Wednesday or Thursday, he does them as he is here in the facility, but on the other days he does not. The physician confirmed his APRN completes the initial assessments on the other days. During an interview on 05/28/26 at 10:55 AM with Resident #7, she was asked if she has ever been seen by a doctor in the facility. She stated she thinks all she saw was a nurse practitioner. During an interview on 05/28/26 at 11:05 AM with Resident #8, she was asked if she has ever been seen by a medical doctor while in this facility and she stated she did not believe so.

Based on observations, record review and interviews the facility failed to ensure the resident was treated with respect and dignity related to going into the resident's room without his permission and removing his personal possessions from his room for 1 of 3 sampled resident (Resident #2). The findings included: Observations were made on 05/27/26 at 9:48 AM of Resident #2's semi-private room he is the only resident assigned to this room. He's by the window and he has his privacy curtain closed but it has split so he can view people coming in and out of his room. In his room he has stacks of boxes that are covered by two blankets, a bag of items on his wardrobe closet, a box on his chair, hygiene items lining the window sill, 2 packs of 40 water bottles on a wood pallet on his floor, two oversized wheelchairs with amazon packages and other boxes in stacks against the wall covered with blankets, and has clean loose diapers on top of the wheelchair and boxes. Photographic evidence obtained. A review of Resident #2's medical records revealed that he was admitted to the facility on [DATE]. His diagnoses includes Type II Diabetes, Generalized Anxiety, Primary Insomnia, Chronic Kidney Disease, Major Depressive Disorder, and Ankylosing Spondylitis of Cervical Region. His MDS (Minimum Data Set) document has a BIMS (Brief Interview for Mental Status) score of a 15/15 which means his cognition is intact. A review of his care plan documents the resident has a behavior problem related to stealing supplies from housekeeping carts, nursing stations, etc. The resident has a behavior problem related to hoarding silverware, trays, cups from the kitchen. Resident refuses to wear normal clothing, will only wear facility gowns. Resident will leave food at bedside without proper refrigeration. The resident has a behavior problem of manipulating staff into giving him more supplies, food, linen. The resident has behavior of hoarding and saving medication.During an interview on 05/27/26 at 9:50 AM with Resident #2, he stated that they came in my room when I went to a urology appt. I was not here. Credit cards are missing, $480.00 in cash missing, clothing, pillows and so much more. I called APS (Adult Protective Service) and the police, they came out and spoke with the Administrator. I was given my credit cards back but not all my money, only $111.00 of the $480.00.During an interview on 05/27/26 at 10:30 AM with the Executive Director he stated Resident #2 did go out to the doctor. It is impossible to get his room cleaned. He does not get out of bed. So, when he was gone, we had housekeeping do a deep cleaning. Surveyor asked if he asked permission from the resident. He stated no, did not get his permission. We can't put anyone else in that room. We have had at least 10 other residents that refused to stay in his room. He stated that they took pills out of his room. He doesn't know what kind they were.During an interview on 05/27/26 at 10:47 AM with the Director of Housekeeping. We did a deep cleaning in his room when he went out to the Doctor. He stated they threw a lot of this resident's stuff away. He said they found 3 baskets of clean linen in his room, food that turned bad. The Executive Director took the resident's credit cards and money and pills. He said I can't lie there were bugs in his room live and dead. We threw away old food and found pills in cups. Surveyor asked if the pills were in plain sight. He stated No, the pills were under a blanket on his wheelchair I believe. Surveyor asked him if he asked the resident to go in his room and he stated no, I received a text from the Director of Nursing dated 04/28/26 at 2:03 PM which stated go to the resident's room.During an interview on 05/28/26 at 11:45 AM with the DON (Director of Nursing) she acknowledged that she sent a text to the Director of Housekeeping. She stated it was a text to all the teams. It said to clean his room ASAP while he was out of the building. She acknowledged she did not get his permission.

Based on clinical and administrative record review and interview, the facility failed to ensure that residents receive the necessary treatment and care in accordance with professional standards of practice. This is evidenced by the facility failing to follow the prescribed monitoring, administration and accurate documentation for 2 of 6 sampled residents (Resident #1 and Resident #2). The findings included:1) Review of the clinical record for Resident # 1 revealed that the resident was admitted to the facility on [DATE] with pertinent diagnosis of prosthetic heart valve. Further review of the physician orders revealed that the physician prescribed on 02/06/26 Warfarin Sodium (anti-coagulant) 5 mg by mouth every other day for valve replacement to begin on 02/07/26 and she prescribed for labs for warfarin (PT/INR), CBC with diff and comprehensive metabolic panel (CMP). However, the 02/07/26 labs drawn for PT/INR are noted as invalid. Then on 02/07/26 at 5:23 PM, the physician prescribed to hold Warfarin pending PT/INR results. On 02/08/26, the nurse noted that the results of the PT/INR were received and the physician was contacted. The physician prescribed for the resident to receive Warfarin 2.5 mg on 02/08/26 and to resume Warfarin 5.0 mg daily on 02/09/26. Review of the Medication Administration record for Resident # 1 revealed that the nurses placed their initials in the appropriate boxes to indicate that the Warfarin 2.5 mg was administered on 02/08/26 and Warfarin 5.0 mg was administered on 02/09/26, 02/10/26 and 02/11/26. Further review of the physician orders revealed that the warfarin 5 mg was placed on hold 02/07/26 to 02/10/26 and 02/13 to 02/16/26. However, the nurse documented that the resident's INR was 3.38 on 02/09 and 02/10/26. Additionally, the 02/11/26 warfarin 5.0 mg was administered, the nurse documented the INR was 9.12, yet the nurse still administered the medication despite the INR being elevated. Also, there is no evidence that the nurse contacted the physician when the resident's INR were elevated for guidance regarding administration of the warfarin.On 02/13/26 when the INR was noted as critically elevated at 17.63, the physician prescribed for the resident to received Vitamin K 10 mg intramuscular injection and to have the PT/INR labs done for 2 days. Further review of the lab results failed to provide evidence that the labs were drawn and there is no evidence that the staff followed up with the lab to ensure the physician order was followed. Labs were not completed until 02/16/26. However, by this time, the resident was noted to have a change in condition, in which her condition deteriorated becoming nonresponsive and not eating, requiring additional intervention and eventual transfer to the hospital for further evaluation on 02/16/26. Review of the Medication Administration Record (MAR) revealed multiple entries for Warfarin Sodium Oral Tablet 5 MG on 02/07/26, 02/09/26, and 02/12/26: Warfarin 2.5 mg on 02/08/26.An interview was conducted on 04/14/26 at 2:30 PM with the Director of Nursing, who confirmed the labs were not drawn on 02/14/26 and 02/15/26. The labs were not drawn until 02/16/26. She further confirmed there is no evidence that the nurses contacted the physician before noting they administered the warfarin when the resident's INR was elevated. She stated that the evening supervisor did contact the physician, when she noted that the nurse administered the warfarin on 02/11/26 when the INR was 9.12. That nurse no longer works for the facility, and the other nurses also are unavailable or no longer work for the facility.Further review of the pharmacy records for Resident # 1. According to the dispensary records for Resident # 1, the pharmacy records noted that warfarin 5 mg dispensed 7 tablet three times for a total of 21 tablets of Warfarin 5 mg. However, 20 tablets were returned to the pharmacy upon the resident's discharge. Please note, that the nurse placed their initials on 4 doses of administered doses of Warfarin: Warfarin 2.5 mg once and Warfarin 5 mg three times.Further inquiry was made with the Director of Nursing on 04/14/26 in the afternoon, who reported that despite the facility having an Emergency Drug kit, no Warfarin tablets were removed from the E-Kit (emergency kit), and the facility did not have any other residents on Warfarin and have not had any residents on Warfarin in over a year. 2) An observation of medication administration for Resident # 2 was conducted on 04/14/26 beginning at approximately 5:45 PM with the Licensed Nurse, Staff A. The nurse prepared the resident's medication and the surveyor verified with the nurse the 6 pills (Acidophilus 1 capsule, carvedilol 6.25 mg, docusate sodium 100mg, metformin HCL 1000 mg, Topamax 25 mg and Trazadone 50 mg). The nurse administered the 6 pills. The surveyor confirmed with the nurse, the resident did not have any additional medication to be given other than the Lantus, which was held because the resident's blood sugar was 109. However, upon medication reconciliation, the nurse documented on the medication administration record that she also had administered polyethylene Glycol 3350 powder, give 17 GM by mouth twice daily for constipation. Mix with 8 ounces of fluid. This medication was not administered during the observed medication administration.An interview was conducted with Staff A on 04/14/26 at approximately 6:30 PM, regarding her signing that she administered the polyethylene. She confirmed she had not administered the medication but signed that she had administered it. The nurse then proceeded to go through the medication cart to retrieve the medication and noted that there wasn't any on the cart. She then went to supply room and retrieved the bottle and administered the prescribed order. The surveyor further questioned the nurse regarding her administering the medication because the resident is prescribed this medication twice daily. She stated she must have retrieved the medication from the other cart, when she administered the medication this morning, since none was available on this cart.

Based on record review and interviews, the facility failed to ensure newly admitted residents received dialysis services in a timely manner causing one resident to be transferred to a higher level of care, affecting 1 of 3 residents reviewed for dialysis (Resident #1). The facility failed to ensure resident rights to prevent neglect regarding care and services for dialysis communication for newly admitted residents, resulting in serious harm and possibly the death of the resident (Resident #1). Upon admission to the hospital emergency department, Resident #1 was discovered to have a critically high serum potassium level, which could lead to heart problems including arrhythmia, heart attack, and death. On 10/31/24, it was determined that the findings of the survey posed Immediate Jeopardy to the health and safety of the dialysis residents residing in the facility. The facility's Executive Director was informed of the Immediate Jeopardy on 10/31/24 at 5:15 PM. The facility had 8 inhouse dialysis residents. The Immediate Jeopardy began on 07/23/24 and removed on 08/19/24. The facility continued to implement corrective actions until they achieved substantial compliance for F698. During the survey, the facility provided a corrective action plan on November 1, 2024. The survey team verified the facility's corrective actions to correct the noncompliance for F600 and F698 on August 23, 2024, prior to the survey visit. F698 was determined to be past noncompliance. Cross reference to F600. The findings included: A review of Resident #1's medical record revealed the resident was originally admitted to the facility on [DATE], transferred to the hospital on 07/07/24, and readmitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease, colostomy, pressure ulcer of the sacral region, contracture, aphasia following cerebral infarction, end stage renal disease, myocardial infarction (heart attack), dependence on renal dialysis, congestive heart failure (a condition when your heart cannot pump blood well enough to give your body a normal supply), and Type II diabetes. This resident was also dependent on gastrostomy tube feeding (a tube placed surgically through the stomach to provide nutrition). A review of the physician orders on admission included, but not limited to, Hemodialysis (a medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) at Aspire 611 South 13th Street, Monday, Wednesday, and Friday The date of this order was 07/23/24. Hemodialysis - Assess site Central Venous Catheter (a thin flexible tube that is inserted into a large vein to provide access to the circulatory system) (right chest) for bleeding/symptoms of infection every shift dated 07/23/24. Vital signs post dialysis in the evening every Monday, Wednesday, Friday dated 07/23/24. Vital signs prior to dialysis one time every Monday, Wednesday, Friday, dated 07/23/24. A review of Resident #1's Medication Administration Record (MAR) revealed documentation that vital signs were done prior to dialysis on 07/24/24, 07/26/24, and 07/29/24. There is documentation of the hemodialysis access site in the right chest being assessed for bleeding and infection on every shift for every day the resident was in the facility, starting on 07/23/24 on the evening/night shift though 07/29/24 on the day shift. A review of Resident #1's care plans revealed a care plan dated 07/25/24 stating the resident needs dialysis related to end stage renal failure. Hemodialysis at MLK Renal Institute 611 S 13th St., Fort [NAME] FL 34950 M-W-F [Monday-Wednesday-Friday]. The interventions on the care plan are listed as: Check and change dressing daily at access site and document. Encourage resident to go for the scheduled dialysis appointments. Resident received dialysis. Monitor labs and report to doctor as needed. Monitor/document/report as needed any signs or symptoms of infection to access site. Monitor/document/report as needed any signs or symptoms of the following: bleeding, hemorrhage, bacteremia (bacteria in the blood), septic shock. A review of the Minimum Data Set (MDS) assessment dated [DATE], which was the 5-day admission assessment, stated under section O - Special Treatment, Procedures, and Programs that Resident #1 received dialysis while he was a resident. Section H - Bladder and bowel documents the resident had a urinary catheter and an ostomy. The Brief Interview Mental Status (BIMS) score was 00, which indicated severe cognitive impairment. A review of the nursing progress notes for Resident #1 revealed the resident was admitted on [DATE] and documented in part: the resident is oriented to person, swallowing problems are not noted and resident receives PEG (Percutaneous Endoscopic Gastrostomy) tube feedings. Bladder issues not noted, No urinary catheter. No ostomy noted. Dialysis status is hemodialysis [via] right upper chest [catheter], no bleeding noted. The nurse's note for 07/24/24 by Staff C, a Licensed Practical Nurse (LPN) documented in part: Dialysis status is hemodialysis [via] right upper chest [catheter] and dialysis site is dry and intact. There was not a nursing progress note for an assessment done on 07/26/24 by Staff D, a LPN and Resident #1's day shift nurse (7AM to 7 PM). On 07/29/24 Staff D documented at 4:45 PM that Resident #1 was sent out to the ED (Emergency Department) to get dialyzed per physician order, due to the resident not receiving dialysis for 7 days. On entrance conference on 08/07/24 at approximately 9:10 AM the facility policy and procedure for dialysis services was requested. The facility Director of Nursing (DON) stated they did not have a policy for dialysis services and did not have a policy for the process of new admissions requiring dialysis services. On 08/07/23 at 11:30 AM, an interview with Staff A, Admissions Personnel, revealed when a new admission comes, requiring dialysis, the dialysis provider is emailed the required information for that resident. Staff A stated she had sent Resident #1's information to the DON with the dialysis provider on 06/25/24, which was prior to his first admission on 07/05/24. The resident did not receive dialysis due to being sent out to the hospital on 07/07/24. Staff A stated she received notification the dialysis provider did not have the documentation required for Resident #1 on 07/29/24, so it was sent to them again on 07/29/24. Staff A stated all of this is done by email and a copy of the emails were provided for surveyor review. On 08/07/24 at approximately 11:45 AM, a telephone interview with Dialysis Staff H (DON of the dialysis provider) revealed that Dialysis Staff H had not received any communication from the nursing home regarding dialysis for Resident #1 until it was requested on 07/29/24 after the dialysis nurse informed Dialysis Staff H that there was a resident in need of dialysis at the facility. When the resident was brought to the inhouse dialysis area by the dialysis nurse the resident was not feeling well and was not stable enough to have dialysis there. The resident's physician was contacted, and an order was obtained to send the resident to the ED for dialysis. The resident had not had dialysis for 7 days. An interview with the facility DON on 08/07/24 at 12:00 PM revealed the DON was aware of the resident not receiving dialysis since the admission on 07/23/24 and was awaiting on more information from Staff A, who was not in the facility at this time. An interview with Staff B, a Certified Nursing Assistant (CNA) on 08/07/24 at 12:17 PM revealed Staff B was Resident #1's caregiver on the 7 AM until 3PM shift on 07/24/24. Staff B stated after cleaning him up she put a pad under him so he would be ready to go to dialysis when the dialysis nurse came to pick the resident up. Staff B stated she let the nurse know he was ready to go about 12:30 PM because no one had shown up yet to pick up the resident. Staff B left for lunch and upon returning at approximately 2:30 PM noticed the resident was still in his bed how she had left him. Staff B reminded the nurse that she had him ready for dialysis and stated the nurse was aware the resident was a dialysis patient. Staff B left at 3:00 PM when the shift was over and is unaware what happened after that. Staff B further stated she was Resident #1's CNA on Monday 07/29/24 and had cleaned the resident up that day so he was ready to go to dialysis. Staff B further stated the resident was not feeling well that day and the resident ended up being transferred to the hospital. An interview with Staff C, an LPN, on 08/07/24 at 1:40 PM revealed Staff C was Resident #1's nurse on 07/24/24. Staff C stated she did not remember what happened on 07/24/24 with this resident regarding dialysis. Staff C further stated she would know if a resident had dialysis if told in report from the previous shift or the dialysis nurse would come to pick them up. Staff C stated again she does not remember the day and that she was doing good to remember yesterday. An interview with Staff E, CNA, on 08/07/24 at 1:45 PM revealed she works on that hall on Fridays and every other Sunday. Staff E stated she was not informed Resident #1 needed to go to dialysis on 07/26/24. Usually, the dialysis nurse comes to get the resident who needs to go to dialysis. Staff E reiterated she was not informed Resident #1 was supposed to go to dialysis that day. An interview with Dialysis Staff F, A Registered Nurse (RN), and Dialysis Staff G, a Certified Clinical Hemodialysis Technician (CCHT), on 08/07/24 at 2:15 PM revealed both staff are employed by the dialysis provider and do dialysis onsite at this facility. Dialysis Staff G stated the process for new patients is the facility admissions department will contact the DON of the dialysis provider, and the DON will pass it along to the dialysis staff to go assess the resident and get consent. Dialysis Staff G was at this facility while Resident #1 was in the facility and stated they were not informed of the need for dialysis until Monday, 07/29/24. On that day he was very unstable, so the decision was made to send the resident to the ED for dialysis. Prior to Monday 07/29/24, they were not informed of the resident being in the facility. Both Dialysis Staff F and G were aware of the new system for new dialysis patients. The facility will be putting new patient information in a box outside of their door and the email will still be going to the Dialysis DON. An interview with Staff D, a LPN, on 08/07/24 at 2:30 PM via telephone revealed she remembers being Resident #1's nurse on 07/29/24 but does not remember 07/26/24. Per staff assignment records it was verified Staff D was the resident's nurse on 07/26/24. Staff D stated typically the dialysis team will come and let them know who is going to dialysis and they will get them ready. Staff D further stated it is also on the resident's physician orders so the nurse should see it there as well. Staff D does recall seeing the order for dialysis on 07/29/24. Staff D is not aware of the process used for a new resident admitted who requires dialysis. An interview with Staff A, Admissions Personnel, via telephone on 08/07/24 at 4:05 PM revealed her co-worker, Staff I, admissions staff, had faxed the information on 07/23/24 to the Dialysis DON. Staff A is not able to provide documentation of the fax being sent and confirmation of receipt to the Dialysis DON. Staff A stated they could not email due to internet issues that day. Staff A was informed on 07/29/24 that the dialysis provider did not receive Resident #1's documentation or request for dialysis services and she refaxed it on 07/29/24. A review of the hospital records revealed Resident #1 arrived in the ED via Emergency Medical Services (EMS) on 07/29/24 at 5:16 PM. On arrival the resident was diagnosed with severe hyperkalemia (high level of potassium in the blood) and uremia (abnormally high levels of waste products in the blood to which the treatment is dialysis). The resident's serum potassium level was 7.6 Critically High (3.5 -5.2 mmol/L) and Blood Urea Nitrogen level was 155 High (6-22 mg/dl) on 07/29/24 in the ED. The resident also had a discharge diagnosis of sepsis, due to a large stage 3 decubitus (pressure injury) and chronic sacral (portion of the spine between the lower back and tailbone) osteomyelitis (bone infection). The resident was started on IV antibiotics and had a poor prognosis per the hospitalist notes and admitted to the hospital. The resident passed away in the hospital on 07/31/24. *The facility submitted an acceptable Immediate Jeopardy Removal Plan on November 1, 2024, and the surveyor verified the following immediate actions were implemented: The facility submitted appropriate reporting through the AHCA portal on 08/17/24 and 08/22/24. On 08/18/24 staff education was initiated for all nursing personnel (RN, LPN, and CNA), therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/19/24 with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement. Staff interviews were conducted with the staff involved with the event (Staff B, C, D, and E) on 10/31/24 and 11/1/24. On 08/17/24 the facility installed a communication box outside the dialysis room at the facility as an additional way to communicate with the nurses in the dialysis unit. Nursing and Admission staff were educated on the improved communication process. During survey on 11/1/24, interviews with the dialysis staff and nurses were conducted and they confirmed they are following the proper communication process. ***The facility provided a corrective action plan on November 1, 2024 and the surveyor verified the following corrective actions: The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure no concerns related to abuse/neglect are identified. The findings will be reviewed monthly by the QAPI committee until substantial compliance is identified. All newly hired staff will receive education in orientation regarding abuse/neglect. On 08/20/24 a full house audit was completed on all residents to determine any concerns for abuse/neglect. No issues were identified. As of 08/23/24, 142 of 178 staff had completed the education. A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed. The monthly QAPI meetings were held on 09/26/24 and 10/31/24 to discuss and review the corrective action plan. Education sign-in sheets were reviewed and verified with random staff interviews on 11/1/24. All audits were reviewed and have been completed as stated. There have been no further concerns regarding neglect for newly admitted dialysis residents or current dialysis residents receiving dialysis care. Random resident interviews were conducted over the course of the survey on 10/30/24, 10/31.24 and 11/1/24, and there were no allegations/complaints of abuse or neglect. On 10/31/24 at 9:45 AM during an interview with the Medical Director, he stated he does participate in QAPI meetings, and he was involved with the corrective action plan for this event. He further stated the implications for a resident who does not have needed dialysis treatment can lead to fluid overload causing dyspnea (shortness of breath) and cardiac issues such as heart failure. It can also cause increased potassium levels leading to cardiac concerns. An interview with the Executive Director on 10/31/24 at 12:30 PM revealed the facility has changed dialysis companies to do in-house dialysis. The new company started on 10/07/24. The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company. Electronic confirmations are obtained to verify the communication is complete. A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff. The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are. All residents have assigned chair times for dialysis, which was reviewed and verified during the survey. Audits are being done weekly now and have been in 100% compliance. During survey on November 1, 2024, the surveyor reviewed the dialysis audits which were completed for the week of 8/27/24, 9/3/24, 9/10/24, and 9/17/24. The monthly audit for October was completed on 10/30/24, and reviewed by the surveyor. The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day. This was verified through staff interviews as well on November 1, 2024. On 10/31/24 12:55 PM the External Business Development/Interim Admission Coordinator (IAC) was interviewed. She stated the process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back by the following morning, she reaches out to them again. She always gets confirmation of the admission. A bright colored form and one goes to dialysis, and one goes to the executive director. The box outside the dialysis door is used for every resident so nurses are aware of a new patient. An interview with the dialysis nurse, and RN on 10/30/24 at 10:59 AM verified the above process for dialysis admissions. The facility obtained substantial compliance with their corrective action plan on 08/23/24 with 100% of the staff either completing training or being notified of the training requirement before returning to their position in the facility and implementing ongoing audits to ensure compliance.

Based on record review and interviews, the facility failed to protect the residents' rights to be free from neglect for newly admitted residents requiring dialysis treatments. The facility failed to ensure a newly admitted resident received dialysis services in a timely manner causing the resident to be transferred to a higher level of care, affecting 1 of 3 residents reviewed for dialysis (Resident #1). The facility failed to ensure resident rights to prevent neglect regarding care and services for dialysis communication for newly admitted residents, resulting in serious harm and possibly the death of the resident (Resident #1). Upon admission to the hospital emergency department, Resident #1 was discovered to have a critically high serum potassium level, which could lead to hear problems including arrhythmia, heart attack, and death. On 10/31/24, it was determined that the findings of the survey posed Immediate Jeopardy to the health and safety of the dialysis residents residing in the facility. The facility's Executive Director was informed of the Immediate Jeopardy on 10/31/24 at 5:15 PM. The facility had 8 inhouse dialysis residents. The Immediate Jeopardy began on 07/23/24 and removed on 08/19/24. The facility continued to implement corrective actions until they achieved substantial compliance for F600. During the survey, the facility provided a corrective action plan on November 01, 2024. The survey team verified the facility's corrective actions to correct the noncompliance for f600 and F698 on August 23, 2024, prior to the survey visit. F600 was determined to be past noncompliance. Cross reference to F698. The findings included: A review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation, document name N-1265, Effective 11/30/2014, revised date, 11/16/2022 stated in part: Definition - Neglect is the failure of the center, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy - 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, mistreatment, exploitation and/or misappropriation of property. 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 occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents so that they are free from abuse, neglect, mistreatment, and/or misappropriation of property. A review of Resident #1's medical record revealed the resident was originally admitted to the facility on [DATE], transferred to the hospital on 07/07/24, and readmitted to the facility on [DATE] with diagnoses including, but not limited to, chronic kidney disease, colostomy, pressure ulcer of the sacral region, contracture, aphasia following cerebral infarction, end stage renal disease, myocardial infarction (heart attack), dependence on renal dialysis, congestive heart failure (a condition that happens when your heart cannot pump blood well enough to give your body a normal supply), and Type II diabetes. This resident was also dependent on gastrostomy tube feeding (a tube placed surgically through the stomach to provide nutrition). A review of the physician orders on admission included, but not limited to, Hemodialysis (a medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) at Aspire 611 South 13th Street, Monday, Wednesday, and Friday The date of this order was 07/23/24. Hemodialysis - Assess site Central Venous Catheter (a thin flexible tube that is inserted into a large vein to provide access to the circulatory system) (right chest) for bleeding/symptoms of infection every shift dated 07/23/24. Vital signs post dialysis in the evening every Monday, Wednesday, Friday dated 07/23/24. Vital signs prior to dialysis one time a day every Monday, Wednesday, Friday, dated 07/23/24. A review of Resident #1's Medication Administration Record (MAR) revealed documentation that vital signs were done prior to dialysis on 07/24/24, 07/26/24, and 07/29/24. There is documentation of the hemodialysis access site in the right chest being assessed for bleeding and infection on every shift for every day the resident was in the facility, starting on 07/23/24 on the evening/night shift though 07/29/24 on the day shift. A review of Resident #1's care plans revealed a care plan dated 07/25/24 stating the resident needs dialysis related to end stage renal failure. Hemodialysis at MLK Renal Institute 611 S 13th St., Fort [NAME] FL 34950 M-W-F [Monday, Wednesday, Friday] (onsite dialysis at the nursing home facility). The interventions on the care plan are listed as: Check and change dressing daily at access site and document. Encourage resident to go for the scheduled dialysis appointments. Resident received dialysis. Monitor labs and report to doctor as needed. Monitor/document/report as needed any signs or symptoms of infection to access site. Monitor/document/report as needed any signs or symptoms of the following: bleeding, hemorrhage, bacteremia (bacteria in the blood), septic shock. A review of the Minimum Data Set (MDS) assessment dated [DATE], which was the 5-day admission assessment, stated under section O - Special Treatment, Procedures, and Programs that Resident #1 received dialysis while he was a resident. Section H - Bladder and bowel documents the resident had a urinary catheter and an ostomy. The Brief Interview Mental Status (BIMS) score was 00, indicating severe cognitive impairment. A review of the nursing progress notes for Resident #1 revealed the resident was admitted on [DATE] and documented in part: the resident is oriented to person, swallowing problems are not noted and resident receives PEG (Percutaneous Endoscopic Gastrostomy) tube feedings. Bladder issues not noted, No urinary catheter. No ostomy noted. Dialysis status is hemodialysis [via] right upper chest [catheter], no bleeding noted. The nurse's note for 07/24/24 by Staff C, a Licensed Practical Nurse (LPN) documented in part: Dialysis status is hemodialysis [via] right upper chest [catheter] and dialysis site is dry and intact. There was not a nursing progress note for an assessment done on 07/26/24 by Staff D, a LPN and Resident #1's day shift nurse (7 AM to 7 PM). On 07/29/24 Staff D documented at 4:45 PM that Resident #1 was sent out to the ED (Emergency Department) to get dialyzed per physician order, due to the resident not receiving dialysis for 7 days. On entrance conference on 08/07/24 at approximately 9:10 AM the facility policy and procedure for dialysis services was requested. The facility Director of Nursing (DON) stated they did not have a policy for dialysis services and did not have a policy for the process of new admissions requiring dialysis services. On 08/07/23 at 11:30 AM an interview with Staff A, Admissions personnel, revealed when a new admission comes, requiring dialysis, the dialysis provider is emailed the required information for that resident. Staff A stated she had sent Resident #1's information to the DON with the dialysis provider on 06/25/24, which was prior to his first admission on 07/05/24. The resident did not receive dialysis due to being sent out to the hospital on 07/07/24. Staff A stated she received notification the dialysis provider did not have the documentation required for Resident #1 on 07/29/24, so it was sent to them again on 07/29/24. Staff A stated all of this is done by email and a copy of the emails were provided for surveyor review. On 08/07/24 at approximately 11:45 AM a telephone interview with Dialysis Staff H (DON of the dialysis provider) revealed that Dialysis Staff H had not received any communication from the nursing home regarding dialysis for Resident #1 until it was requested on 07/29/24 after the dialysis nurse informed Dialysis Staff H that there was a resident in need of dialysis at the facility. When the resident was brought to the inhouse dialysis area by the dialysis nurse the resident was not feeling well and was not stable enough to have dialysis there. The resident's physician was contacted, and an order was obtained to send the resident to the ED for dialysis. The resident had not had dialysis for 7 days. An interview with the facility DON on 08/07/24 at 12:00 PM revealed the DON was aware of the resident not receiving dialysis since the admission on 07/23/24 and was awaiting on more information from Staff A, who was not in the facility at this time. An interview with Staff B, a Certified Nursing Assistant (CNA) on 08/07/24 at 12:17 PM revealed Staff B was Resident #1's caregiver on the 7 AM until 3 PM shift on 07/24/24. Staff B stated after cleaning him up she put a pad under him so he would be ready to go to dialysis when the dialysis nurse came to pick the resident up. Staff B stated she let the nurse know he was ready to go about 12:30 PM because no one had shown up yet to pick up the resident. Staff B left for lunch and upon returning at approximately 2:30 PM noticed the resident was still in his bed how she had left him. Staff B reminded the nurse that she had him ready for dialysis and stated the nurse was aware the resident was a dialysis patient. Staff B left at 3:00 PM when the shift was over and is unaware what happened after that. Staff B further stated she was Resident #1's CNA on Monday 07/29/24 and had cleaned the resident up that day so he was ready to go to dialysis. Staff B further stated the resident was not feeling well that day and the resident ended up being transferred to the hospital. An interview with Staff C, a LPN, on 08/07/24 at 1:40 PM revealed Staff C was Resident #1's nurse on 7/24/24. Staff C stated she did not remember what happened on 07/24/24 with this resident regarding dialysis. Staff C further stated she would know if a resident had dialysis if told in report from the previous shift or the dialysis nurse would come to pick them up. Staff C stated again she does not remember the day and that she was doing good to remember yesterday. An interview with Staff E, a CNA, on 08/07/24 at 1:45 PM revealed she works on that hall on Fridays and every other Sunday. Staff E stated she was not informed Resident #1 needed to go to dialysis on 07/26/24. Usually, the dialysis nurse comes to get the resident who needs to go to dialysis. Staff E reiterated she was not informed Resident #1 was supposed to go to dialysis that day. An interview with Dialysis Staff F, a Registered Nurse (RN), and Dialysis Staff G, a Certified Clinical Hemodialysis Technician (CCHT), on 08/07/24 at 2:15 PM revealed both staff are employed by the dialysis provider and do dialysis onsite at this facility. Dialysis Staff G stated the process for new patients is the facility admissions department will contact the DON of the dialysis provider, and the DON will pass it along to the dialysis staff to go assess the resident and get consent. Dialysis Staff G was at this facility while Resident #1 was in the facility and stated they were not informed of the need for dialysis until Monday, 07/29/24. On that day he was very unstable, so the decision was made to send the resident to the ED for dialysis. Prior to Monday 07/29/24, they were not informed of the resident being in the facility. Both Dialysis Staff F and G were aware of the new system for new dialysis patients. The facility will be putting new patient information in a box outside of their door and the email will still be going to the Dialysis DON. An interview with Staff D, a LPN, on 08/07/24 at 2:30 PM via telephone revealed she remembers being Resident #1's nurse on 07/29/24 but does not remember 07/26/24. Per staff assignment records it was verified Staff D was the resident's nurse on 07/26/24. Staff D stated typically the dialysis team will come and let them know who is going to dialysis and they will get them ready. Staff D further stated it is also on the resident's physician orders so the nurse should see it there as well. Staff D does recall seeing the order for dialysis on 07/29/24. Staff D is not aware of the process used for a new resident admitted who requires dialysis. An interview with Staff A, Admissions Personnel, via telephone on 08/07/24 at 4:05 PM revealed her co-worker, Staff I, admissions staff, had faxed the information on 07/23/24 to the Dialysis DON. Staff A is not able to provide documentation of the fax being sent and confirmation of receipt to the Dialysis DON. Staff A stated they could not email due to internet issues that day. Staff A was informed on 07/29/24 that the dialysis provider did not receive Resident #1's documentation or request for dialysis services and she refaxed it on 07/29/24. A review of the hospital records revealed Resident #1 arrived in the ED via Emergency Medical Services (EMS) on 07/29/24 at 5:16 PM. On arrival the resident was diagnosed with severe hyperkalemia (high level of potassium in the blood) and uremia (abnormally high levels of waste products in the blood to which the treatment is dialysis). The resident's serum potassium level was 7.6 Critically High (3.5-5.2mmol/L) and Blood Urea Nitrogen level was 155 High (6-22 mg/dl) on 07/29/24 in the ED. The resident also had a discharge diagnosis of sepsis, due to a large stage 3 decubitus (pressure injury) and chronic sacral (portion of the spine between the lower back and tailbone) osteomyelitis (bone infection). The resident was started on IV antibiotics and had a poor prognosis per the hospitalist notes and admitted to the hospital. The resident passed away in the hospital on 07/31/24. *The facility submitted an acceptable Immediate Jeopardy Removal Plan on November 1, 2024 and the surveyor verified the following immediate actions were implemented: The facility submitted appropriate reporting through the AHCA portal on 08/17/24 and 08/22/24. On 08/18/24 staff education was initiated for all nursing personnel (RN, LPN, and CNA), therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/19/24 with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement. Staff interviews were conducted with the staff involved with the event (Staff B, C, D, and E) on 10/31/24 and 11/1/24. On 08/17/24 the facility installed a communication box outside the dialysis room at the facility as an additional way to communicate with the nurses in the dialysis unit. Nursing and Admission staff were educated on the improved communication process. During survey on 11/1/24, interviews with the dialysis staff and nurses were conducted and they confirmed they are following the proper communication process. ***The facility provided a corrective action plan on November 1, 2024 and the surveyor verified the following corrective actions: The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure no concerns related to abuse/neglect are identified. The findings will be reviewed monthly by the QAPI committee until substantial compliance is identified. All newly hired staff will receive education in orientation regarding abuse/neglect. On 08/20/24 a full house audit was completed on all residents to determine any concerns for abuse/neglect. No issues were identified. As of 08/23/24, 142 of 178 staff had completed the education. A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed. The monthly QAPI meetings were held on 09/26/24 and 10/31/24 to discuss and review the corrective action plan. Education sign-in sheets were reviewed and verified with random staff interviews on 11/1/24. All audits were reviewed and have been completed as stated. There have been no further concerns regarding neglect for newly admitted dialysis residents or current dialysis residents receiving dialysis care. Random resident interviews were conducted over the course of the survey on 10/30/24, 10/31.24 and 11/1/24, and there were no allegations/complaints of abuse or neglect. On 10/31/24 at 9:45 AM during an interview with the Medical Director, he stated he does participate in QAPI meetings, and he was involved with the corrective action plan for this event. He further stated the implications for a resident who does not have needed dialysis treatment can lead to fluid overload causing dyspnea (shortness of breath) and cardiac issues such as heart failure. It can also cause increased potassium levels leading to cardiac concerns. An interview with the Executive Director on 10/31/24 at 12:30 PM revealed the facility has changed dialysis companies to do in-house dialysis. The new company started on 10/07/24. The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company. Electronic confirmations are obtained to verify the communication is complete. A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff. The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are. All residents have assigned chair times for dialysis, which was reviewed and verified during the survey. Audits are being done weekly now and have been in 100% compliance. During survey on November 1, 2024, the surveyor reviewed the neglect audits which were completed on 8/27/24, 9/3/24, 9/6/24, 9/10/24, 9/13/24, 9/17/24, 9/20/24, 9/27/24, 10/4/24, 10/11/24, 10/18/24, and 10/24/24. The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day. This was verified through staff interviews as well on November 1, 2024. On 10/31/24 12:55 PM the External Business Development/Interim Admission Coordinator (IAC) was interviewed. She stated the process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back by the following morning, she reaches out to them again. She always gets confirmation of the admission. A bright colored form and one goes to dialysis, and one goes to the executive director. The box outside the dialysis door is used for every resident so nurses are aware of a new patient. An interview with the dialysis nurse, and RN on 10/30/24 at 10:59 AM verified the above process for dialysis admissions. The facility obtained substantial compliance with their corrective action plan on 08/23/24 with 100% of the staff either completing training or being notified of the training requirement before returning to their position in the facility and implementing ongoing audits to ensure compliance.

Based on record review and interviews, the facility failed to protect the residents' rights to be free from neglect for newly admitted residents requiring dialysis treatments. The facility failed to ensure a newly admitted resident received dialysis services in a timely manner causing the resident to be transferred to a higher level of care, affecting 1 of 3 residents reviewed for dialysis (Resident #1). The facility failed to ensure resident rights to prevent neglect regarding care and services for dialysis communication for newly admitted residents, resulting in serious harm and possibly the death of the resident (Resident #1). Upon admission to the hospital emergency department, Resident #1 was discovered to have a critically high serum potassium level, which could lead to hear problems including arrhythmia, heart attack, and death. On 10/31/24, it was determined that the findings of the survey posed Immediate Jeopardy to the health and safety of the dialysis residents residing in the facility. The facility's Executive Director was informed of the Immediate Jeopardy on 10/31/24 at 5:15 PM. The facility had 8 inhouse dialysis residents. The Immediate Jeopardy began on 07/23/24 and removed on 08/19/24. The facility continued to implement corrective actions until they achieved substantial compliance for F600. During the survey, the facility provided a corrective action plan on November 01, 2024. The survey team verified the facility's corrective actions to correct the noncompliance for f600 and F698 on August 23, 2024, prior to the survey visit. F600 was determined to be past noncompliance. Cross reference to F698. The findings included: A review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation, document name N-1265, Effective 11/30/2014, revised date, 11/16/2022 stated in part: Definition - Neglect is the failure of the center, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy - 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, mistreatment, exploitation and/or misappropriation of property. 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 occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents so that they are free from abuse, neglect, mistreatment, and/or misappropriation of property. A review of Resident #1's medical record revealed the resident was originally admitted to the facility on [DATE], transferred to the hospital on 07/07/24, and readmitted to the facility on [DATE] with diagnoses including, but not limited to, chronic kidney disease, colostomy, pressure ulcer of the sacral region, contracture, aphasia following cerebral infarction, end stage renal disease, myocardial infarction (heart attack), dependence on renal dialysis, congestive heart failure (a condition that happens when your heart cannot pump blood well enough to give your body a normal supply), and Type II diabetes. This resident was also dependent on gastrostomy tube feeding (a tube placed surgically through the stomach to provide nutrition). A review of the physician orders on admission included, but not limited to, Hemodialysis (a medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) at Aspire 611 South 13th Street, Monday, Wednesday, and Friday The date of this order was 07/23/24. Hemodialysis - Assess site Central Venous Catheter (a thin flexible tube that is inserted into a large vein to provide access to the circulatory system) (right chest) for bleeding/symptoms of infection every shift dated 07/23/24. Vital signs post dialysis in the evening every Monday, Wednesday, Friday dated 07/23/24. Vital signs prior to dialysis one time a day every Monday, Wednesday, Friday, dated 07/23/24. A review of Resident #1's Medication Administration Record (MAR) revealed documentation that vital signs were done prior to dialysis on 07/24/24, 07/26/24, and 07/29/24. There is documentation of the hemodialysis access site in the right chest being assessed for bleeding and infection on every shift for every day the resident was in the facility, starting on 07/23/24 on the evening/night shift though 07/29/24 on the day shift. A review of Resident #1's care plans revealed a care plan dated 07/25/24 stating the resident needs dialysis related to end stage renal failure. Hemodialysis at MLK Renal Institute 611 S 13th St., Fort [NAME] FL 34950 M-W-F [Monday, Wednesday, Friday] (onsite dialysis at the nursing home facility). The interventions on the care plan are listed as: Check and change dressing daily at access site and document. Encourage resident to go for the scheduled dialysis appointments. Resident received dialysis. Monitor labs and report to doctor as needed. Monitor/document/report as needed any signs or symptoms of infection to access site. Monitor/document/report as needed any signs or symptoms of the following: bleeding, hemorrhage, bacteremia (bacteria in the blood), septic shock. A review of the Minimum Data Set (MDS) assessment dated [DATE], which was the 5-day admission assessment, stated under section O - Special Treatment, Procedures, and Programs that Resident #1 received dialysis while he was a resident. Section H - Bladder and bowel documents the resident had a urinary catheter and an ostomy. The Brief Interview Mental Status (BIMS) score was 00, indicating severe cognitive impairment. A review of the nursing progress notes for Resident #1 revealed the resident was admitted on [DATE] and documented in part: the resident is oriented to person, swallowing problems are not noted and resident receives PEG (Percutaneous Endoscopic Gastrostomy) tube feedings. Bladder issues not noted, No urinary catheter. No ostomy noted. Dialysis status is hemodialysis [via] right upper chest [catheter], no bleeding noted. The nurse's note for 07/24/24 by Staff C, a Licensed Practical Nurse (LPN) documented in part: Dialysis status is hemodialysis [via] right upper chest [catheter] and dialysis site is dry and intact. There was not a nursing progress note for an assessment done on 07/26/24 by Staff D, a LPN and Resident #1's day shift nurse (7 AM to 7 PM). On 07/29/24 Staff D documented at 4:45 PM that Resident #1 was sent out to the ED (Emergency Department) to get dialyzed per physician order, due to the resident not receiving dialysis for 7 days. On entrance conference on 08/07/24 at approximately 9:10 AM the facility policy and procedure for dialysis services was requested. The facility Director of Nursing (DON) stated they did not have a policy for dialysis services and did not have a policy for the process of new admissions requiring dialysis services. On 08/07/23 at 11:30 AM an interview with Staff A, Admissions personnel, revealed when a new admission comes, requiring dialysis, the dialysis provider is emailed the required information for that resident. Staff A stated she had sent Resident #1's information to the DON with the dialysis provider on 06/25/24, which was prior to his first admission on 07/05/24. The resident did not receive dialysis due to being sent out to the hospital on 07/07/24. Staff A stated she received notification the dialysis provider did not have the documentation required for Resident #1 on 07/29/24, so it was sent to them again on 07/29/24. Staff A stated all of this is done by email and a copy of the emails were provided for surveyor review. On 08/07/24 at approximately 11:45 AM a telephone interview with Dialysis Staff H (DON of the dialysis provider) revealed that Dialysis Staff H had not received any communication from the nursing home regarding dialysis for Resident #1 until it was requested on 07/29/24 after the dialysis nurse informed Dialysis Staff H that there was a resident in need of dialysis at the facility. When the resident was brought to the inhouse dialysis area by the dialysis nurse the resident was not feeling well and was not stable enough to have dialysis there. The resident's physician was contacted, and an order was obtained to send the resident to the ED for dialysis. The resident had not had dialysis for 7 days. An interview with the facility DON on 08/07/24 at 12:00 PM revealed the DON was aware of the resident not receiving dialysis since the admission on 07/23/24 and was awaiting on more information from Staff A, who was not in the facility at this time. An interview with Staff B, a Certified Nursing Assistant (CNA) on 08/07/24 at 12:17 PM revealed Staff B was Resident #1's caregiver on the 7 AM until 3 PM shift on 07/24/24. Staff B stated after cleaning him up she put a pad under him so he would be ready to go to dialysis when the dialysis nurse came to pick the resident up. Staff B stated she let the nurse know he was ready to go about 12:30 PM because no one had shown up yet to pick up the resident. Staff B left for lunch and upon returning at approximately 2:30 PM noticed the resident was still in his bed how she had left him. Staff B reminded the nurse that she had him ready for dialysis and stated the nurse was aware the resident was a dialysis patient. Staff B left at 3:00 PM when the shift was over and is unaware what happened after that. Staff B further stated she was Resident #1's CNA on Monday 07/29/24 and had cleaned the resident up that day so he was ready to go to dialysis. Staff B further stated the resident was not feeling well that day and the resident ended up being transferred to the hospital. An interview with Staff C, a LPN, on 08/07/24 at 1:40 PM revealed Staff C was Resident #1's nurse on 7/24/24. Staff C stated she did not remember what happened on 07/24/24 with this resident regarding dialysis. Staff C further stated she would know if a resident had dialysis if told in report from the previous shift or the dialysis nurse would come to pick them up. Staff C stated again she does not remember the day and that she was doing good to remember yesterday. An interview with Staff E, a CNA, on 08/07/24 at 1:45 PM revealed she works on that hall on Fridays and every other Sunday. Staff E stated she was not informed Resident #1 needed to go to dialysis on 07/26/24. Usually, the dialysis nurse comes to get the resident who needs to go to dialysis. Staff E reiterated she was not informed Resident #1 was supposed to go to dialysis that day. An interview with Dialysis Staff F, a Registered Nurse (RN), and Dialysis Staff G, a Certified Clinical Hemodialysis Technician (CCHT), on 08/07/24 at 2:15 PM revealed both staff are employed by the dialysis provider and do dialysis onsite at this facility. Dialysis Staff G stated the process for new patients is the facility admissions department will contact the DON of the dialysis provider, and the DON will pass it along to the dialysis staff to go assess the resident and get consent. Dialysis Staff G was at this facility while Resident #1 was in the facility and stated they were not informed of the need for dialysis until Monday, 07/29/24. On that day he was very unstable, so the decision was made to send the resident to the ED for dialysis. Prior to Monday 07/29/24, they were not informed of the resident being in the facility. Both Dialysis Staff F and G were aware of the new system for new dialysis patients. The facility will be putting new patient information in a box outside of their door and the email will still be going to the Dialysis DON. An interview with Staff D, a LPN, on 08/07/24 at 2:30 PM via telephone revealed she remembers being Resident #1's nurse on 07/29/24 but does not remember 07/26/24. Per staff assignment records it was verified Staff D was the resident's nurse on 07/26/24. Staff D stated typically the dialysis team will come and let them know who is going to dialysis and they will get them ready. Staff D further stated it is also on the resident's physician orders so the nurse should see it there as well. Staff D does recall seeing the order for dialysis on 07/29/24. Staff D is not aware of the process used for a new resident admitted who requires dialysis. An interview with Staff A, Admissions Personnel, via telephone on 08/07/24 at 4:05 PM revealed her co-worker, Staff I, admissions staff, had faxed the information on 07/23/24 to the Dialysis DON. Staff A is not able to provide documentation of the fax being sent and confirmation of receipt to the Dialysis DON. Staff A stated they could not email due to internet issues that day. Staff A was informed on 07/29/24 that the dialysis provider did not receive Resident #1's documentation or request for dialysis services and she refaxed it on 07/29/24. A review of the hospital records revealed Resident #1 arrived in the ED via Emergency Medical Services (EMS) on 07/29/24 at 5:16 PM. On arrival the resident was diagnosed with severe hyperkalemia (high level of potassium in the blood) and uremia (abnormally high levels of waste products in the blood to which the treatment is dialysis). The resident's serum potassium level was 7.6 Critically High (3.5-5.2mmol/L) and Blood Urea Nitrogen level was 155 High (6-22 mg/dl) on 07/29/24 in the ED. The resident also had a discharge diagnosis of sepsis, due to a large stage 3 decubitus (pressure injury) and chronic sacral (portion of the spine between the lower back and tailbone) osteomyelitis (bone infection). The resident was started on IV antibiotics and had a poor prognosis per the hospitalist notes and admitted to the hospital. The resident passed away in the hospital on 07/31/24. *The facility submitted an acceptable Immediate Jeopardy Removal Plan on November 1, 2024 and the surveyor verified the following immediate actions were implemented: The facility submitted appropriate reporting through the AHCA portal on 08/17/24 and 08/22/24. On 08/18/24 staff education was initiated for all nursing personnel (RN, LPN, and CNA), therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/19/24 with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement. Staff interviews were conducted with the staff involved with the event (Staff B, C, D, and E) on 10/31/24 and 11/1/24. On 08/17/24 the facility installed a communication box outside the dialysis room at the facility as an additional way to communicate with the nurses in the dialysis unit. Nursing and Admission staff were educated on the improved communication process. During survey on 11/1/24, interviews with the dialysis staff and nurses were conducted and they confirmed they are following the proper communication process. ***The facility provided a corrective action plan on November 1, 2024 and the surveyor verified the following corrective actions: The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure no concerns related to abuse/neglect are identified. The findings will be reviewed monthly by the QAPI committee until substantial compliance is identified. All newly hired staff will receive education in orientation regarding abuse/neglect. On 08/20/24 a full house audit was completed on all residents to determine any concerns for abuse/neglect. No issues were identified. As of 08/23/24, 142 of 178 staff had completed the education. A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed. The monthly QAPI meetings were held on 09/26/24 and 10/31/24 to discuss and review the corrective action plan. Education sign-in sheets were reviewed and verified with random staff interviews on 11/1/24. All audits were reviewed and have been completed as stated. There have been no further concerns regarding neglect for newly admitted dialysis residents or current dialysis residents receiving dialysis care. Random resident interviews were conducted over the course of the survey on 10/30/24, 10/31.24 and 11/1/24, and there were no allegations/complaints of abuse or neglect. On 10/31/24 at 9:45 AM during an interview with the Medical Director, he stated he does participate in QAPI meetings, and he was involved with the corrective action plan for this event. He further stated the implications for a resident who does not have needed dialysis treatment can lead to fluid overload causing dyspnea (shortness of breath) and cardiac issues such as heart failure. It can also cause increased potassium levels leading to cardiac concerns. An interview with the Executive Director on 10/31/24 at 12:30 PM revealed the facility has changed dialysis companies to do in-house dialysis. The new company started on 10/07/24. The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company. Electronic confirmations are obtained to verify the communication is complete. A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff. The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are. All residents have assigned chair times for dialysis, which was reviewed and verified during the survey. Audits are being done weekly now and have been in 100% compliance. During survey on November 1, 2024, the surveyor reviewed the neglect audits which were completed on 8/27/24, 9/3/24, 9/6/24, 9/10/24, 9/13/24, 9/17/24, 9/20/24, 9/27/24, 10/4/24, 10/11/24, 10/18/24, and 10/24/24. The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day. This was verified through staff interviews as well on November 1, 2024. On 10/31/24 12:55 PM the External Business Development/Interim Admission Coordinator (IAC) was interviewed. She stated the process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back by the following morning, she reaches out to them again. She always gets confirmation of the admission. A bright colored form and one goes to dialysis, and one goes to the executive director. The box outside the dialysis door is used for every resident so nurses are aware of a new patient. An interview with the dialysis nurse, and RN on 10/30/24 at 10:59 AM verified the above process for dialysis admissions. The facility obtained substantial compliance with their corrective action plan on 08/23/24 with 100% of the staff either completing training or being notified of the training requirement before returning to their position in the facility and implementing ongoing audits to ensure compliance.

Based on record review and interview, the facility failed to ensure newly admitted residents, dependent on dialysis, received dialysis services in a timely manner causing the resident to be transferred to a higher level of care affecting 1 of 3 residents reviewed for dialysis (Resident #1). The findings included: A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic kidney disease, colostomy, pressure ulcer of the sacral region, contracture, aphasia following cerebral infarction, end stage renal disease, non-ST elevation myocardial infarction, dependence on renal dialysis, congestive heart failure, and type II diabetes. This resident was also dependent on gastrostomy tube feeding. A review of the physician orders on admission included, but not limited to, Hemodialysis at Aspire 611 South 13th Street, Monday, Wednesday, and Friday The date of this order was 07/23/24. Hemodialysis - Assess site Central Venous Catheter (right chest) bleeding/symptoms of infection every shift Dated 07/23/24. Vital signs post dialysis in the evening every Mon, Wed, Fri dated 07/23/24. Vital signs prior to dialysis on time every Mon, Wed, Fri, dated 07/23/24. A review of Resident #1's medication administration record (MAR) revealed documentation that Vital signs were done prior to dialysis on 07/24/24, 07/26/24, and 07/29/24. There is documentation of the hemodialysis access site in the right chest being assessed for bleeding and infection on every shift for every day the resident was in the facility, starting on 07/23/24 on the evening/night shift though 07/29/24 on the day shift. A review of Resident #1's care plans revealed a care plan dated 07/25/24 stating the resident needs dialysis related to end stage renal failure. Hemodialysis at MLK Renal Institute 611 S 13th St., Fort [NAME] FL 34950 M-W-F. The goals on the care plan are listed as: check and change dressing daily at access site and document. Encourage resident to go for the scheduled dialysis appointments. Resident received dialysis. Monitor labs and report to doctor as needed. Monitor/document/report as needed any signs or symptoms of infection to access site. Monitor/document/report as needed any signs or symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock. A review of the Minimum Data Set (MDS) dated [DATE], which is the 5-day admission assessment, stated under section O - Special Treatment, Procedures, and Programs that Resident #1 received dialysis while he was a resident. Section H - Bladder and bowel documents the resident has a urinary catheter and an ostomy. Brief Interview Mental Status (BIMS) 00. A review of the nursing progress notes for Resident #1 revealed the resident was admitted on [DATE] and documents in part: the resident is oriented to person, swallowing problems are not noted and resident receives peg tube feedings. Bladder issues not noted, No urinary catheter. No ostomy noted. Dialysis status is hemodialysis right upper chest, no bleeding noted. The nurse's note for 07/24/24 by Staff C, a Licensed Practical Nurse (LPN) documents in part: Bowel has no ostomy noted. Dialysis status is hemodialysis right upper chest and dialysis site is dry and intact. There was not a nursing progress note for an assessment done on 07/26/24 by Staff D, an LPN and Resident #1's day shift nurse (7 AM - 7 PM). On 07/29/24 Staff D documented at 4:45 PM that Resident #1 was sent out to the ED (Emergency Department) to get dialyzed per physician order, due to the resident not receiving dialysis for 7 days. On entrance conference on 08/07/24 at approximately 9:10 AM the facility policy and procedure for dialysis services was requested. The facility DON stated they did not have a policy for dialysis services and did not have a policy for the process of new admissions requiring dialysis services. On 08/07/23 at 11:30 AM, an interview with Staff A, Admissions Personnel, it was revealed when a new admission comes, requiring dialysis, the dialysis provider is emailed the required information for that resident. Staff A stated she had sent Resident #1's information to the Director of Nursing (DON) with the dialysis provider on 06/25/24, which was prior to his first admission on 07/05/24. The resident did not receive dialysis due to being sent out to the hospital on 07/07/24. Staff A stated she received notification the dialysis provider did not have the documentation required for Resident #1 on 07/29/24, so it was sent to them again on 07/29/24. Staff A stated all of this is done by email and a copy of the emails were provided for review. On 08/07/24 at approximately 11:45 AM, a telephone interview with Dialysis Staff H (DON of the dialysis provider) revealed that Dialysis Staff H had not received any communication from this facility regarding dialysis for Resident #1 until it was requested on 07/29/24 after the dialysis nurse informed Dialysis Staff H that there was a resident in need of dialysis at the facility. When the resident was brought to the inhouse dialysis area by the dialysis nurse the resident was not feeling well and was not stable enough to have dialysis there. The resident's physician was contacted, and an order obtained to send the resident to the ED for dialysis. The resident had not had dialysis for 7 days. An interview with the facilty DON on 08/07/24 at 12:00 PM revealed the DON was aware of the resident not receiving dialysis since the admission on 07/23/24 and was awaiting on more information from Staff A, who was not in the facility at this time. An interview with Staff B, a Certified Nursing Assistant (CNA) on 08/07/24 at 12:17 PM revealed Staff B was Resident #1's caregiver on the 7 AM until 3PM shift on 07/24/24. Staff B stated after cleaning him up she put a pad under him so he would be ready to go to dialysis when the dialysis nurse came to pick the resident up. Staff B stated she let the nurse know he was ready to go about 12:30 because no one had shown up yet to pick up the resident. Staff B left for lunch and upon returning at approximately 2:30 PM noticed the resident was still in his bed how she had left him. Staff B reminded the nurse that she had him ready for dialysis and stated the nurse was aware the resident was a dialysis patient. Staff B left at 3:00 PM when the shift was over and is unaware what happened after that. Staff B further stated she was Resident #1's CNA on Monday 07/29/24 and had cleaned the resident up that day so he was ready to go to dialysis. Staff B further stated the resident was not feeling well that day and the resident ended up being transferred to the hospital. An interview with Staff C, an LPN, on 08/07/24 at 1:40 PM revealed Staff C was Resident #1's nurse on 07/24/24. Staff C stated she did not remember what happened on 07/24/24 with this resident regarding dialysis. Staff C further stated she would know if a resident had dialysis if told in report from the previous shift or the dialysis nurse would come to pick them up. Staff C stated again she does not remember the day and that she was doing good to remember yesterday. An interview with Staff E, CNA, on 08/07/24 at 1:45 PM revealed she works on that hall on Fridays and every other Sunday. Staff E stated she was not informed Resident #1 needed to go to dialysis on 07/26/24. Usually the dialysis nurse comes to get the resident who needs to go to dialysis. Staff E reiterated she was not informed Resident #1 was supposed to go to dialysis that day. An interview with Dialysis Staff F, A Registered Nurse (RN), and Dialysis Staff G, a Certified Clinical Hemodialysis Technician (CCHT), on 08/07/24 at 2:15 PM revealed both staff are employed by the dialysis provider and do dialysis onsite at this facility. Dialysis Staff G stated the process for new patients is the facility admissions department will contact the DON of the dialysis provider, and the DON will pass it along to the dialysis staff to go assess the resident and get consent. Dialysis Staff G was at this facility while Resident #1 was in the facility and stated they were not informed of the need for dialysis until Monday, 07/29/24. On that day he was very unstable, so the decision was made to send the resident to the ED for dialysis. Prior to Monday 07/29/24, they were not informed of the resident being in the facility. Both Dialysis Staff F and G were aware of the new system for new dialysis patients. The facility will be putting new patient information in a box outside of their door and the email will still be going to the Dialysis DON. An interview with Staff D, an LPN, on 08/07/24 at 2:30 PM via telephone revealed she remembers being Resident #1's nurse on 07/29/24 but does not remember 07/26/24. Per staff assignment records it was verified Staff D was the resident's nurse on 07/26/24. Staff D stated typically the dialysis team will come and let them know who is going to dialysis and they will get them ready. Staff D further stated it is also on the resident's physician orders so the nurse should see it there as well. Staff D does recall seeing the order for dialysis on 07/29/24. Staff D is not aware of the process used for a new resident admitted who requires dialysis. An interview with Staff A via telephone on 08/07/24 at 4:05 PM revealed her co-worker, Staff I, admissions staff, had faxed the information on 07/23/24 to the Dialysis DON. Staff A is not able to provide documentation of the fax being sent and confirmation of receipt to the Dialysis DON. Staff A stated they could not email due to internet issues that day. Staff A was informed on 07/29/24 that the dialysis provider did not receive Resident #1's documentation or request for dialysis services and she refaxed it on 07/29/24. A review of the hospital records Resident #1 was transferred to revealed the resident arrived in the ED via Emergency Medical Services (EMS) on 07/29/24 at 5:16 PM. On arrival the resident was diagnosed with severe hyperkalemia (high level of potassium in the blood) and uremia (abnormally high levels of waste products in the blood to which the treatment is dialysis). The resident also had a diagnosis of sepsis, due to a large stage 3 decubitus (pressure injury) and chronic sacral (portion of the spine between the lower back and tailbone) osteomyelitis (bone infection). The resident was started on IV antibiotics and had a poor prognosis per the hospitalist notes and admitted to the hospital. The resident passed away on 07/31/24. The above findings revealed the facility neglected to communicate the need for dialysis for a newly admitted resident, Resident #1, to the dialysis provider. The lack of communication resulted in the resident failing to receive dialysis services for 7 days, which then resulted in an emergent transfer of the resident to the ED for emergent dialysis services. There was a physician's order in the resident's medical record, but it was not followed or addressed by the resident's nursing staff on Wednesday 07/24/24 and Friday 07/26/24. There was a care plan in place to provide dialysis to this resident and the care plan was not followed by the facility staff.

Based on interview, observation, and record review, the facility failed to provide adequate supervision and properly functioning wanderguard doors (wander monitoring system device) for 1 of 3 sampled residents reviewed for elopement risk (exiting the facility unsupervised) (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on 03/27/24 at approximately 6:00 PM and walk 1.4 miles away from the facility. Resident #1 was found by the police while displaying confusion, resulting in a transfer to a local hospital. These actions resulted in Immediate Jeopardy. The facility administrator was informed of the Immediate Jeopardy on 04/10/24 at 4:48 PM. At the time of the investigation there were 11 residents who were identified as wander/elopement risk. The findings included: A review of the facility's Policies and Procedures titled Elopement/Wandering Risk Guideline dated 09/21/16 and revised 08/01/20 documented: If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 0 out of 15. The resident was ambulatory without any assistive devices. The resident was care planned for at risk for elopement on 03/19/24, with an intervention of an electronic monitoring device (wanderguard) in place on the right ankle. An Elopement sreening dated 03/25/24 documented the resident as high risk for elopement. Resident #1 exited the facility on 03/27/24 at approximately 6:00 PM without the knowledge of any staff. The resident was determined missing by staff on 03/27/24 at approximately 8:00 PM. Staff notified police of the missing resident, and was informed by the police that the resident had been found by an officer at a gas station 1.4 miles from the facility at 8:26 PM. The resident was taken to the hospital by the officer (per the local Police Department Incident/Investigation form dated 03/27/24 at 8:26 PM, the resident was [NAME] Acted). The resident returned to the facility from the hospital on 03/28/24 at 12:30 AM. A review of the route Resident #1 walked revealed an area where there are hazards for an unsupervised cognitively impaired resident with poor decision-making skills. The resident walked 1.4 miles to a gas station, on a 4-lane divided road, with speed limits up to 45 MPH. While Resident #1 was out of the facility unsupervised, there was a high likelihood that he could have been seriously injured or harmed. He could have been hit by a car, fallen, or become lost. An interview was conducted with the Nursing Home Administrator (NHA) on 04/09/24 at 11:30 AM. The NHA stated it was believed Resident #1 had exited the north unit emergency exit doors. The NHA stated the north unit was closed and under construction. The NHA stated the doors must have been left unlocked/disalarmed by the construction crew. The NHA stated surveillance video from the outside security cameras were reviewed by corporate, and Resident #1 was not seen on video. The NHA stated there were no security cameras for the north unit emergency exit doors. The security cameras covered the parking lot and employee entrance/exit. The NHA stated after the incident occurred, they placed a lock keypad to the entrance of the north unit. Upon request, the NHA stated he did not have access to the surveillance video from the outside security cameras, and could not provide access to the surveyor. The NHA stated an elopement book was located at both nursing stations and the receptionist desk. An interview was attempted with Resident #1 on 04/09/24 at 12:00 PM. The resident was observed lying in bed on top of the covers with his hands crossed behind his head and legs crossed. When questioned about leaving the facility, Resident #1 stated, I can't leave this place. The resident could not answer any further questions. The resident was clean and fully dresses with a shirt, pants, and sneakers on. The resident had a sitter outside the his door. An interview was conducted with Staff B, a Licensed Practical Nurse, on 03/09/24 at 2:00 PM. Staff B stated he was Resident #1's primary nurse on 03/27/24 from 7:00 PM-7:00 AM. Staff B stated when he came on duty, Resident #1 was not in his room or unit area. Staff B stated he was told the resident was wandering around the facility by the offgoing nurse. Staff B stated he was informed by the CNA (Certified Nursing Assistant) that Resident #1 could not be found at approximately 8:00 PM. Staff B stated all staff began searching for Resident #1. Staff B stated he searched the north unit. The emergency exit doors were not alarming. Staff B further stated he tested the locks by attempting to open the doors and the doors started to alarm. The doors were locked. An interview was conducted with Staff G, Assistant Maintenance Director, on 04/09/24 at 3:30 PM. Staff G stated he checks all exit doors for functionality daily. Staff G stated he checked the emergency exit doors on 03/27/24 prior to leaving the facility on 03/27/24. Staff G stated the doors were locked. Staff G further stated he does not check doors with the wanderguard device. An interview was conducted with Staff C, a CNA, on 04/09/24 at 5:00 PM. Staff C stated she assisted Resident #1 with dinner on the day of the incident around 5:30 PM. Staff C stated she last saw the resident in church services at the facility at approximately 7:00 PM on 03/27/24. An telephone interview was conducted with the Clergy on 04/09/24 at 5:30 PM. The Clergy stated Resident #1 did not attend church services on 03/27/24. The Clergy stated she knows everyone that attends service. The Clergy stated she was let out of the facility by staff between 7:00 PM-7:30 PM. No one followed her out. An interview was conducted with Staff D, a part time receptionist, on 04/10/24 at 10:00 AM. Staff D stated she was not familiar with Resident #1 and had never seen the resident before 03/27/24. Staff D stated she saw Resident #1 at the time clock hallway where the employee entrance/exit doors were located around 6:00 PM on 03/27/24. The resident was standing there like a regular employee, and was seen trying to press buttons on the time clock. Staff D stated she could not see the door at the time clock from where she sits, but did hear the door close and did not see the resident or any other employees in the area. Staff D stated when she came into work on 03/29/24, she was told a resident had eloped. The resident was described to her as carrying a yellow bag. Staff D stated that jogged her memory of the resident standing next to the time clock. Staff D explained she did not see the resident exit, but saw the resident go towards the employee door and heard the door shut. No alarm went off. Staff D stated she told the facility in a written statement. Staff D left the facility a little after 6:00 PM on 03/27/24. Staff D stated she did not know Resident #1 was a resident at the time. Staff D further stated she was not aware of an elopement book at the receptionist desk. She knew that residents who are at risk of elopement usually have a band on the arm or leg. Staff D stated she did not see a band on Resident #1's arm. An interview was conducted with Staff G, Assistant Maintenance Director, on 04/10/24 at 12:00 PM. Staff G confirmed there are 3 exit doors with wanderguard sensors: the front entrance, the employee entrance and the [NAME] unit entrance. The Surveyor was able to exit the employee entrance door without the door alarming, while holding the wanderguard in hand, with the NHA, Director of Nursing (DON), and Staff G present. It was tested several times. It was observed at times the door would remain locked while trying to exit, other times the door would open and alarm. It was confirmed by all parties present that the door should not open with the wanderguard band in place. The NHA and DON were notified of review for Immediate Jeopardy on 04/10/24 at 12:20 PM. The facility then posted staff at the employee entrance until the door could be properly secured. Surveillance footage was still not available for surveyor review. On 04/10/24 at 4:48 PM, the NHA and DON were notified of ongoing Immediate Jeopardy. At the time of the survey, the facility had 11 residents identified as at risk for elopement.