Every finding on record at Cascades Health and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to maintain a sanitary environment in the kitchen as evidenced by closure by the county health department, due to uncleanliness and pest control issues. The findings included: 1). During an inspection by the Department of Health, on 12/11/25, the following were noted: *One live roach was observed in the multi-function oven.*Two egg cases were observed in the multi-function oven. 2). During a second inspection by the Department of Health, on 12/12/25, the following were noted: *Seven live roaches were observed in a floor stand mixer.*Two live roaches were observed in a Cambro unit.*Two live roaches were observed behind the reach in cooler next to the exit door of the kitchen. *One live roach was observed in the dish washing area.*Two live roaches were observed at the tilt skillet.*One live roach was observed on the wall behind the tilt skillet.*Two live roaches were observed on a 2-burner pot stove.*One dead roach was observed inside of the paper towel dispenser. 3). During a tour of the pantry on the 400 unit, on 12/14/25 at 12:00 PM, the following were noted: *1 live mature roach and 1 live juvenile roach were observed on the counter by boxes of supplements.*2 live mature roaches, as well as what appeared to be roach excrement in a cabinet over the counter that contained tubing and supplies.*Dead roaches were observed in a cabinet under the sink. On 12/14/25 at 12:10 PM, the Administrator was made aware of and acknowledged the concerns. During an interview, on 12/15/25 at 2:52 PM, with the Inspector from the Department of Health, the Inspector confirmed conditions in the main kitchen that were listed in his report.

Based on observation, interview and record review, the facility failed to implement and follow appropriate interventions for resident at risk for elopement for 1 of 1 resident reviewed for elopement, with the potential to affect 5 residents at risk for elopement (Resident #85).The findings included:Review of the facility policy titled Elopement and Wandering revised on 01/01/25 revealed the following: 1. A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. 2. Each incapacitated resident will be assessed for wandering and elopement upon admission, re-admission, and whenever an elopement attempt or new wandering behavior is observed or identified. Assessments are also done quarterly and annually.Record review revealed Resident #85 was admitted to the facility on [DATE] to the memory care unit. Diagnoses included metabolic encephalopathy and hypertensive urgency. The Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 15/15, which indicated no cognitive impairment. No prior Elopement Risk Evaluations were found in his clinical record. Review of the Care Plan dated 09/26/2025 documented that Resident # 85 is at risk for exit seeking behaviors. Goals were to decrease episodes of exit seeking behaviors; resident will remain safe within the facility and will make no attempt to exit facility without being accompanied. Interventions were to increase supervision, admit resident to a locked unit and distract resident from exit seeking.Resident #85 also has a care plan dated 09/26/2025 documenting that Resident #85 has a history of exhibiting aggressiveness, violence and yelling. Goals were to decrease the identified behaviors. Interventions were to offer psychology and psychiatry services as needed and encourage/assist the resident to develop more appropriate methods of coping and interacting as able.Review of the assessments indicated that no assessments for risk of elopement were conducted for Resident #85.Review of the progress notes dated 12/01/2025 at 1:00 PM indicated the following: Staff observed resident attempting to exit window. The resident is alert with a BIMS a 15 and not easily redirected. While staff attempted to redirect the resident, the resident became aggressive and started yelling. Nursing assessment completed and revealed the resident deny any pain or discomfort. No change in the resident's loc or rom. No new skin impairments noted. The resident's daughter and the medical provider notified. BP 148/63, p89, O2 97%, R19.In an interview conducted on 12/01/2025 at 10:35 AM, Resident #85 stated that all he can think about is going home to Thailand. Resident further explained that he does not wish to talk because he wants to go back home.In an observation conducted on 12/01/2025 at 12:40 PM, Resident #85 was seen outside by his roommate's window with staff present trying to redirect resident to get back to the facility. Closer observation showed that the window screen was pushed outside with the window partially open.In an interview conducted on 12/02/25 at 10:00 AM with Registered Nurse (RN), Staff A stated that he has been working in the facility for 15 years and usually works the morning shift (7:00 AM to 3:30 PM). RN further explained that he is very familiar with Resident #85. According to RN, Resident #85 is very friendly and never mentioned to him that he wanted to go home. Staff A was very shocked after the attempt to elope incident and stated that Resident #85 was not at risk for elopement. Resident #85 was placed in the memory care unit due to an episode of wandering prior to being admitted in the facility.In an interview conducted on 12/03/25 at 10:35 AM with the Minimum Data Set (MDS) Director, she stated that she has been working for the facility for 6 months. She further stated that they have morning meetings every day, which is where they discuss residents' particularities. For Resident #85 the behavior care plan was put in place during a morning meeting. The MDS Director explained that the expectation when a resident is found to be at risk of elopement is to be placed in the locked unit and conduct an assessment. She stated for Resident #85, an elopement risk assessment was conducted on 09/25/25. The surveyor informed her that she was unable to locate an elopement risk assessment for Resident #85 in his clinical record. The MDS Director was not able to show the surveyor a copy of this elopement risk assessment. She further explained that Resident #85 came to the facility from the hospital. Review of the hospital records revealed the resident initially came from Canada where he hopped on a plane to Florida and wandered around, lost his ID and got transported to the hospital.During an interview on 12/03/25 at 10:52 AM with the Certified Nurse Assistant (CNA) Staff B, who stated that he has worked at the facility for 17 years and always on the memory care unit. He stated he is familiar with the resident. Usually, he would come to the dining room for breakfast and lunch. The day in question, the resident was not in the dining room for lunch and he (CNA) went to the resident's room to let him know that lunch was in the dining room; the resident stated he would be right there. A few minutes prior to the dining room closing for lunch, he heard from security that the resident had escaped. The CNA stated the resident never mentioned to him that he wanted to go outside. He also acknowledged that he was not aware that the resident was at risk for elopement.In an interview conducted on 12/03/25 at 10:30 AM, the Director of Nursing (DON) stated that residents at risk of elopement are put in the binder with their picture and the face sheet. There are 3 binders, one at the front desk, one at the nurses station of Poinciana, and one in memory care unit. It's updated whenever they are aware of a new person. It's discussed in daily meetings. When the binder is being updated, they make sure the staff knows and are used during the elopement drills. The elopement drills are conducted once a month, and they try for all shifts. The DON acknowledged the elopement incident that happened on 12/01/25 and further stated that staff members had their eyes on the resident at all time.A tour of the facility was conducted on 12/03/25 at 11:20 AM with the DON, with the objective of locating the 3 elopement risk binders. Two binders were found, 1 at the front desk that had a list of all residents at risk for elopement excluding Resident #85, and was last updated on 10/27/25. The second binder was found on the locked memory care unit, and did not have a list of residents at risk of elopement and updated date, but Resident #85's face sheet was in this binder. The third binder was not found at the nurses station on Poinciana. The DON further stated that she updates the front desk binder and staff make copies and update the binders on the memory care unit and on the Poinciana unit.

Based on interviews, record reviews and observations, the facility failed to protect the residents' right to be free from neglect when it failed to provide the required structures and processes to maintain and secure the exit doors to meet the needs of residents, for 1 of 1 sampled resident (Resident #1). The deficient practice allowed Resident #1 to leave the facility through an unlocked exit door on 09/12/24 between 4:00 AM and 5:00 AM. Resident #1 wheeled himself in his wheelchair to the facility's loading dock, where he fell and was seriously injured. Resident #1 was transferred to the hospital. There were eighty-nine residents in the facility at the time of the survey. The facility's administrator was notified of Immediate Jeopardy and was given the Immediate Jeopardy Templates on 12/05/24 at 6:22 PM. The Immediate Jeopardy was removed at the time of the facility exit on 12/06/24. Cross reference to F689. The findings included: The facility's policy titled Abuse, Neglect, and Exploitation, Revision date: 09/20/24 defines Neglect as follows: Neglect means failure of the facility, its 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. Resident #1 admitted to the facility on [DATE]. Resident #1 had the diagnoses that included but were not limited to the following: Malignant Neoplasm (cancer) of the Prostate, Anemia (a low number of red blood cells that can affect oxygen supply), Gastrointestinal Hemorrhage (bleeding), Acute Respiratory Failure (a condition in which there is not enough oxygen or too much carbon dioxide in the body), Hypertension (high blood pressure), Adult Failure to Thrive (a state of decline in physicial and functional abilities, leading to a decrease in overall well-being), and Physical Debility (weakness caused by an illness, injury, or aging). Resident #1 had his comprehensive assessment completed on 08/26/2024. Resident #1 was admitted to the facility after being hospitalized for Gastrointestinal Hemorrhage. At the time of the comprehensive assessment, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15. This means he was cognitively intact. According to the facility's investigation of the incident on 09/12/24 between 4:00 AM and 5:00 AM, Resident #1 left through the exit door on the north side of the facility, near his room. The resident subsequently wheeled himself to the facility's loading dock where he had a fall with serious injuries. This exit door had a door release bar and was labeled with the following instructions: Push Until the Alarm Sounds; The door can be opened in 15 seconds. The Root Cause Analysis, done by the facility on 09/12/24 revealed the door's alarm and magnetic lock had been deactivated, which allowed the door to be opened without the alarm sounding. Resident #1 exited undetected from this door. Review of the hospital records revealed Resident #1's fall on 09/12/24 resulted in Type II and Type III fractures of the second cervical (neck) vertebra (a small bone that is part of the backbone) (C2) and fractures of the first cervical vertebra (C1). The radiology report indicated that the results were critical. On 12/02/24 at 2:24 PM, a telephone interview was conducted with Staff A, a Registered Nurse (RN), who was Resident #1's assigned nurse at the time of the incident. Staff A explained that when she went out the same door Resident # 1 used, she noted the door opened easily without an alarm sounding. On 12/02/24 at 3:00 PM, A telephone Interview with Staff B, a Certified Nursing Assistant. Staff B stated that she did not hear any alarms when Resident #1 left the building. Staff B stated that Resident #1 was in bed when she checked on him early in her shift between 11:00 PM and 12:00 AM. She stated he complained he was cold, and she helped him put on clothing and offered him an extra blanket. Staff B stated she did not remember if the resident was able to transfer himself to the wheelchair. Staff B stated that during the search for Resident #1 she tried the door at the end of the 400-hallway and it just opened without the alarm sounding. On 12/02/24 at 4:00 PM, an interview was conducted with Staff C, a CNA. Staff C explained that she was not assigned to Resident #1, but she was the CNA who found Resident #1. Staff C showed the surveyor exactly where Resident #1 was found outside. The CNA explained that she moved the wheelchair off Resident #1 and called the nurse to tell the nurse where Resident #1 was found. Staff C stated she found Resident #1 because he was calling out to send someone to help him. Staff C stated Resident #1 didn't want anyone to move him except for the ambulance people. On 12/05/24 at 3:21 PM, an interview was with Staff D, Maintenance Technician. Staff D stated he checks the doors at 8:00 AM every day he works, which is Tuesday through Saturday, he checks all the exits in the building by pushing on the release bar for 15 seconds. He stated the alarm sounds if it is working correctly. The maintenance technician provided documentation that he was working on 9/12/24. Staff D stated the door was working on 09/12/24 when he checked the door at 8:00 AM, which was after the incident had occurred. On 12/05/24 at 3:53 PM a telephone interview was conducted with the former administrator who worked for the facility at the time of the elopement. The former administrator stated he was on site at approximately 6:30 AM on 09/12/24. He stated he was able to reactivate the key code for the door which put the door back in service and activated the alarm. The former administrator stated he had a conversation with the vendor of the company that placed the key code pads to override the door locks. The vendor explained the door had been in maintenance mode, which deactivated the alarm and magnetic lock. On 12/05/24 at 3:25 PM, the Director of Plant Operations (DPO) explained that the facility provides key codes to staff because the dietary, housekeeping, and maintenance staff need to travel from the facility to the adjacent building where the kitchen, housekeeping and maintenance departments are located. The DPO provided a repair document that showed the key code for the door was changed on 09/12/24, the day of the incident. On 12/05/2024 at 4:28 PM, an interview was conducted with Staff E, Dietary Assistant. When asked if she knew the code to go to the kitchen she said yes, it's [code number], which is the correct code as provided by the DPO. Staff E stated she started working for the facility on August 14, 2024. She stated that since she started that was the only code she was given. On 12/05/2024 at 4:36 PM, an interview was conducted with Staff F, Dietary Assistant. Stated she has been working for the facility for 9 months. She stated she only has one code for the 4-North door, [code number]. At that time the surveyor accompanied Staff F to the 4-North door for a demonstration of how the door worked when functioning correctly. Staff F entered the code and pressed the door open button. The door swung open with the alarm sounding. Staff F stated the alarm sounded until the door fully closed. This was witnessed to be true. The surveyor attempted to use a four-digit code as had been described by the DPO and the former administrator. The code did not unlock the door or allow it to open when the door open button was pressed. On 12/06/2024 at 10:54 AM, an interview was conducted with Staff G, a housekeeper, regarding the 4-North door key code and using the 4-North door. Staff G stated she has been working for the facility for [AGE] years. She stated she uses the 4-North door approximately 4 times a day. Staff G stated she uses the door if she needs to see the supervisor, for daily huddles (meetings), to get housekeeping supplies and occasionally to bring resident laundry to the laundry room. Staff G stated she primarily does room cleaning. Staff G stated she works from 7:30 AM until 3:30 PM. On 12/06/24 at 11:13 AM, an interview was conducted with Staff H, Custodian. Staff H stated he has worked for the facility for 8 years. Staff H stated he uses the 4-North door more than 5 times a day. He stated he transports laundry, trash, and equipment using that door. He stated that after the incident the staff were trained to make sure there were no residents following them out the door and to make sure the door was closed fully before leaving the area. Staff H stated he works from 6:00 AM to 2:00 PM daily. On 12/06/24 at 4:46 PM, an interview was conducted with Staff I, who works for the facility as a maintenance worker and in a second capacity on the weekends as a Security Guard. He confirmed the hours have changed to arm [turn on] the screamer alarm, which is the loud alarm added to the 4-North door after the elopement. The Security Guard stated the screamer alarm is now armed at 8:00 PM instead of 11:00 PM. Staff I confirmed that this was a change made as of 12/06/24. Staff I confirmed that he patrols the facility and tests all the doors to ensure they remain locked. Staff I stated he checks the doors often as he patrols. *The facility submitted an acceptable Immediate Jeopardy Plan on 12/06/2024, the surveyor verified the implementation of the following immediate actions in the Immediate Jeopardy Removal Plan: 1. Resident #1 was no longer a resident in the facility. 2. From 12/05/24 to 12/6/24, Johnson Controls, the company that installs and maintains the key code pad, cleared all historical code system data and recoded doors for safety and security. On 12/05/24 Johnson Controls changed maintenance code access. The community will not have access to the maintenance code. 3. On 12/05/24 Security will round on the Health Center and activate multi-functional door alarm on Poinciana North from 8 p.m. to 7 a.m. daily. 4. On 12/5/24 the Executive Director completed one to one education with Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily. 5. On 12/06/24, the NHA, who is also the Abuse coordinator, and Director of Plant Operations began the education of Health Center maintenance team members and administration team members on the neglect policy. Health center maintenance team members will not be allowed to work until education is completed. There are 9 of 9 health center maintenance team members who have completed the neglect training. There are currently 11 administrative team members of which 10 have completed the neglect training and 1 is out on PTO [Paid Time Off] and will be educated upon return. **On 12/06/2024 the surveyor collected and verified the follwing removal plan immediate actions: 1. During interviews with kitchen staff on 12/05/24 and 12/06/24, the surveyor and a kitchen staff employee went to the door to try the code needed to open the door. After the employee successfully operated the door, the surveyor performed a test by putting in the proper code first. After the proper code was used the surveyor attempted to imitate the use of a fourth digit as a repeat of the third digit. The door failed to open as the code was rejected. The keypad had lights on the keypad display to determine if the correct code was entered. The light changed to green for the correct code and flashed yellow for the incorrect code. When the door successfully opened; the alarm sounded continuously until the door closed. 2. An interview on 12/06/24 with the Security Guard on duty revealed the facility changed the alarm check routine and the activation time for the loud alarm which was added after the incident. The Security Guard confirmed the loud alarm would be activated at 8:00 PM every night and it would be deactivated at 7:00 AM every morning. The Security Guard confirmed all the doors would be checked for failure and alarms sounding at various intervals throughout the night. 3. The facility provided electronic evidence of staff education on Neglect, for 109 of 112 employees in the Health Center, as of 12/06/24. 4. The facility provided evidence of education of the Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily.

Based on interviews, record review and observations, the facility failed to provide supervision and a secure environment to prevent 1 of 1 sampled resident (Resident #1), from exiting the safety of the facility and subsequently experiencing a fall with serious injuries. The deficient practice occurred on 9/12/24 between 4:00 AM and 5:00 AM. While in his wheelchair, Resident #1, exited out an unlocked exit door at the end of the 400-Hallway, on the north side of the facility. Resident #1 then wheeled himself down a concrete walkway to the loading dock where there was a set of three steps. Resident #1 fell down the steps with his wheelchair where he suffered serious injuries to his cervical (neck) spine (vertebrae). Resident #1 was transferred to the hospital via ambulance. There were eighty-nine residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and was given the Immediate Jeopardy Templates on 12/05/24 at 6:22 PM. The Immediate Jeopardy was removed by the time of the facility exit on 12/06/24. Cross reference to F600. The findings included: The facility's policy titled Elopement, Unsupervised Absence, Hazardous Wandering and Missing Residents, revised 11/07/24 defines a Missing Resident as follows: A resident is considered missing when they are absent from the place where they ought to be and their whereabouts is unknown. Resident #1 was admitted to the facility on [DATE] after being hospitalized for Gastrointestinal Hemorrhage. Resident #1 had the diagnoses that included but were not limited to the following: Malignant Neoplasm (cancer) of the Prostate, Anemia (a low number of red blood cells that can affect oxygen supply), Gastrointestinal Hemorrhage (bleeding), Acute Respiratory Failure (a condition in which there is not enough oxygen or too much carbon dioxide in the body), Hypertension (high blood pressure), Adult Failure to Thrive (a state of decline in physicial and functional abilities, leading to a decrease in overall well-being), and Physical Debility (weakness caused by an illness, injury, or aging). Resident #1 had his comprehensive assessment completed on 08/26/2024. At the time of the comprehensive assessment, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15. This means he was cognitively intact. According to the facility's investigation of the incident, on 09/12/24 at between 4:00 AM and 5:00 AM, Resident #1 went out of the exit door on the north side of the facility, near his room, which was at the end of the 400-hallway closest to the exit used. The Root Cause Analysis, completed by the facility on 09/12/24, revealed the exit door's alarm and magnetic lock had been deactivated, which allowed the door to be opened without the alarm sounding. Resident #1 exited undetected from this door. Resident #1 subsequently propelled himself in his wheelchair down a concrete walkway to the right of the exit, to the loading dock area, to a set of 3 steps that are part of the loading dock. Resident # 1 was found at the bottom of the steps with his wheelchair on top of him. On 12/02/24 at 10:15 AM, a tour of the exit route was taken accompanied by the Director of Plant Operations (DPO). The DPO provided measurements of the 3 steps where Resident #1 went down. The height of the stairs is approximately 16 inches and the distance from the front edge of the top step to the base at the bottom step is approximately 23 inches. On 12/03/24 at 4:42PM, a review of the hospital records revealed Resident #1's fall on 09/12/24 resulted in Type II and Type III fractures of the second cervical (neck) vertebra (a small bone that isa part of the backbone) (C2) and acute fractures to the left and posterior ring of the first cervical vertebra (C1). The radiology report indicated that the results were critical. Resident #1 was admitted to the hospital's trauma unit on 09/12/24. On 12/02/24 at 3:00 PM, an interview was conducted with Staff B, the CNA assigned to Resident #1 on the 11:00 PM to 7:00 AM shift which spanned from 09/11/24 to 9/12/24. Staff B stated she last saw Resident #1 at approximately 3:00 AM. Staff B stated that when she went to Resident #1's room at approximately 4:20 AM, on 09/12/24, to start morning care, she noticed he was missing. Staff B stated that Resident #1 was awake earlier and complained of being cold, Staff B stated she assisted Resident #1 to put on warmer clothes and offered him a blanket. Staff B stated she did not hear the door alarm sounding at the time Resident #1 was found missing. Staff B reported she informed Staff A, the nurse assigned to Resident #1, immediately upon finding Resident #1 missing. Staff B stated that when she checked the door at the end of the 400-hallway, where Resident #1 left, she found it to be unlocked and easily opened without the alarm sounding. On 12/02/24 at 2:24 PM, an interview was conducted with Staff A, the nurse assigned to Resident #1. Staff A stated that a search was conducted for Resident #1 when Staff B reported him missing. Staff A stated that when he was found she had been told, by the CNA who found him, that Resident #1 was found with his wheelchair on top of him. Staff A stated Resident #1 had blood on his face and an open cut on his left arm. Staff A reported Resident #1 shouted he did not want anyone to touch him until the ambulance arrived. Staff A stated Resident #1 did not want to answer any questions regarding the incident. On 12/02/24 at 4:00 PM an interview was conducted with Staff C, a CNA. Staff C stated she was not assigned to care for Resident #1, but she was the one who found him. Staff C stated she found Resident #1 at the bottom of the stairs that are part of the loading dock. Staff C stated Resident #1 was calling for someone to help him. Staff C stated she found Resident #1 at the bottom of the stairs with the wheelchair on top of him. Staff C stated Resident #1 did not want to be touched until the ambulance people got there and would not tell anyone what happened. On 12/05/24 at 3:53 PM an interview was conducted with the former Administrator, who was the Administrator of record at the time of the incident. According to the former Administrator, he arrived at the facility by 6:30 AM on 09/12/24. The former Administrator stated he found the 400-hallway door unlocked when he arrived and reset the key code at that time. The former Administrator stated he discussed the situation with the vendor who explained that the door had been in maintenance mode and that was why the door was unlocked with the alarm off. On 12/05/24 at 3:25 PM, the Director of Plant Operations (DPO) explained that the facility provides key codes to staff because the kitchen, housekeeping, and maintenance staff need to travel from the facility to the adjacent building where the kitchen, housekeeping and maintenance departments are located. The DPO provided a repair document that showed the key code for the door was changed to prevent employees from accidentally entering the maintenance code to deactivate the door. This change was made on 09/12/24, the day of the incident. The DPO stated the vendor explained the code to unlock the door and disarm the alarm to put the door into 'maintenance mode' was like the code provided to the employees. On 12/05/2024 at 4:28 PM, an interview was conducted with Staff E, Dietary Assistant. When asked if she knew the code to go to the kitchen, she replied yes, it's [code number], which is the correct code as provided by the DPO. Staff E stated she started working for the facility on August 14, 2024. She stated that since she started that was the only code she was given. On 12/05/2024 at 4:36 PM, an interview was conducted with Staff F, Dietary Assistant. Stated she has been working for the facility for 9 months. She stated she only has one code for the 400-Hallway exit door, [code number]. At that time, the surveyor accompanied Staff F to the 4-N door for a demonstration of how the door worked when functioning correctly. Staff F entered the code and pressed the door open button. The door swung open with the alarm sounding. Staff F stated the alarm sounded until the door fully closed. This was witnessed to be true. The surveyor attempted to use a four-digit code as had been described by the DPO and the former Administrator. The code did not unlock the door or allow it to open when the door open button was pressed. On 12/06/24 at 10:54 AM, an interview was conducted with Staff G, a housekeeper, regarding the 400-Hallway exit door key code and using this exit door. Staff G stated she has been working for the facility for [AGE] years. She stated she uses this exit door approximately 4 times a day. Staff G stated she uses the door if she needs to see the supervisor, for daily huddles (meetings), to get housekeeping supplies and occasionally to bring resident laundry to the laundry room. Staff G stated she primarily does room cleaning and she works from 7:30 AM until 3:30 PM. Staff G stated she has seen the maintenance department checking the doors several times a day since the incident. On 12/06/24 at 11:13 AM, an interview was conducted with Staff H, Custodian. Staff H stated he has worked for the facility for 8 years. Staff H stated he uses the 4-north door more than 5 times a day. He stated he transports laundry, trash, and equipment using that door. He stated that after the incident the staff were trained to make sure there were no residents following them out the door and to make sure the door was closed fully before leaving the area. Staff H stated he has witnessed maintenance staff check the doors in the morning. He stated he was unsure if he has seen maintenance checking the doors other times. Staff H stated he works from 6:00 AM to 2:00 PM daily. On 12/06/24 at 4:46 PM, an interview was conducted with Staff I, who works for the facility as a maintenance worker and in a second capacity on the weekends as a Security Guard. He confirmed the hours have changed to arm [turn on] the screamer alarm, the loud alarm added to the 4-North door after the elopement, at 8:00 PM instead of 11:00 PM previously scheduled. Staff I confirmed that this was a change made as of 12/06/24. Staff I confirmed that he patrols the facility and tests all the doors to ensure they remain locked. Staff I stated he checks the doors often as he patrols. *The facility submitted an acceptable Immediate Jeopardy Removal Plan and on 12/06/2024, the surveyor verified the implementation of the following immediate actions in the Immediate Jeopardy removal plan: 1. Resident #1, who was not determined to be an elopement risk, was no longer a resident in the community. 2. From 12/05/24 to 12/06/24, Johnson Controls, the company that installs and maintains the key code pad, cleared all historical code system data and recoded doors for safety and security. 3. On 9/12/24 Johnson Controls changed maintenance code access. The community (employees and security guards) will not have access to the maintenance code. 4. Starting on 12/05/24 Security will round on the Health Center and activate the screamer loud alarm on Poinciana North from 8pm to 7am daily. 5. On 12/05/24 the Executive Director completed one on one education with Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily. 6. On 12/06/24, the NHA, who is also the Abuse coordinator and Director of Plant Operations, began education of Health center maintenance team members and administration team members on the missing person policy and exit door and alarm checks. Health center maintenance team members will not be allowed to work until education is completed. There were 9 of 9 health center maintenance team members who had completed this training. There are currently 11 administrative team members, of which 10 have completed this training and 1 is out on PTO (Paid Time Off) and will be educated upon return. **On 12/06/24 the surveyor collected and verified the folloing removal plan immediate actions: 1. During interviews on 12/05/24 and 12/06/24, with kitchen staff, the surveyor and a kitchen staff employee went to the door to try the code needed to open the door. After the employee successfully operated the door, the surveyor performed a test by putting in the proper code first. After the proper code was used, the surveyor attempted to use a four-digit code to place the door in maintenance mode. This attempt with the four-digit code failed as expected. 2. An interview on 12/6/24 at 4:46 p.m. with the Security Guard on duty revealed the facility changed the alarm check routine and the activation time for the loud alarm that was added after the incident. The Security Guard confirmed the loud alarm would be activated at 8:00 PM every night and it would be deactivated at 7:00 AM every morning. The Security Guard confirmed all the doors would be checked for security and alarms sounding at various intervals throughout the night. 3. The facility provided electronic evidence of staff education on Missing person and door/alarm checks and with written records. There were 109 out of 112 employees educated as of 12/06/24, when the spreadsheet was completed. This equals 97%. 4. The facility provided evidence of education of the Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily.

Based on interview, record review, and observation the facility failed to provide appropriate Perineal Care to prevent Urinary Tract Infections (UTIs) for 1 of 1 resident observed for Perineal care (Resident #2). Findings included: The facility's policy titled Perineal Care, date February 2018, included: For a female resident .it states Wash perineal area, wiping from front to back. Subitem (1) documented Separate the labia and wash area downward from front to back. Subitem (2) documented Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. On 12/03/24 at 10:00 AM an observation was made of Perineal Care for Resident #2. At the time of the observation, Infection Notes documented that Resident #2 was being treated for a Urinary Tract Infection. The observation was as follows: The Certified Nursing Assistant (CNA) provided dignity and privacy to the resident by closing the door and drawing the curtains. The CNA placed her supplies, which were in a plastic bag, on the overbed table. The CNA failed to disinfect the surface of the table before starting. The CNA provided the resident with a bath towel to cover her perineum for privacy and dignity. The CNA used proper technique to remove the peri pad and incontinent brief from the resident and placed a towel under the resident to protect the bed linens from contamination. The CNA removed her gloves, washed her hands and put on clean gloves. The CNA proceeded to put soap on a wet washcloth to clean the resident. The CNA started from the inner thighs and moved inward. The CNA washed the inner right thigh first. The CNA washed the resident's thigh in an upward motion from back to front. The CNA continued to wash in toward the right outer labia. The CNA then proceeded to wash the inner left thigh from back to front and in toward the left outer labia. The CNA washed the left labia upward from back to front, proceeding to the inner folds of the left labia. The CNA repeated this way with the right labia. The CNA then used a clean washcloth wet from the basin to rinse the resident's perinium. The CNA removed her gloves, washed her hands and put on clean gloves. The CNA assisted Resident #2 onto her left side and proceeded to wash the resident's posterior without any further concerns. On 12/03/24 at approximately 10:45 AM the surveyor interviewed the Director of Nursing (DON) regarding the observation of the perineal care. The DON agreed that the CNA did not use proper technique for perineal care. The DON stated the CNA would be re-educated immediately.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for: 2 of 4 Residential Units (Gulfstream & Garden), public/staff rest rooms (2), soiled utility rooms ( 4 of 4 ), main dining room, and skilled therapy room. The findings included: 1) During the initial resident screenings conducted by the surveyors on 06/3-4/24, and the Environment Tour Conducted on 06/06/24 at 10 AM with the Maintenance Supervisor, the following were noted: * Gardens Unit: room [ROOM NUMBER]: Electrical box loose and falling out of the wall behind the resident's bed, 2 of 6 dresser drawers not closing properly, and wall mounted lamp broken and falling from wall. room [ROOM NUMBER]: Privacy curtain too short to promote resident dignity/privacy, 2 pull knobs missing from bathroom drawer, a/c door requires re-caulking, and room windows soiled and in need of cleaning. room [ROOM NUMBER]: Privacy curtain too short to promote resident dignity/privacy, and room wall damaged, peeling paint and in disrepair. room [ROOM NUMBER]: Privacy curtain too short to promote resident dignity/privacy, and large area of bathroom floor was cracked. room [ROOM NUMBER]: Bathroom toilet requires re-caulking, and bathroom window blinds was broke and hanging off the window. * Gulfstream Unit: Community Shower: Handrail rusted. TV/Dining Room: Windows soiled. Satellite Kitchen Entrance: Entry door heavily damaged and in disrepair. Nurses Station: Exterior of lockers (18) soiled and rust laden, and 2 of 2 individual lockers were heavily soiled and storing foods and personal supplies. room [ROOM NUMBER]: Bathroom drawers broken and in disrepair, room walls damaged and peeling paint, bathroom walls in disrepair, and closet doors in disrepair. room [ROOM NUMBER]: Bathroom emergency call bell pull cord was wrapped around the hand rail numerous times (3) resulting in the unit not operational when pulled (noted on 4 of 4 survey days - 06/3-6/24) . * Resident Library/Conference Room: 13 of 13 chairs were heavily damaged and the seat covers torn and in disrepair. 2) Observation of the main dining room conducted on 06/03/24 and 06/06/24 noted the following: (a) The exteriors of 15 of 15 dining room tables were noted to be worn, in disrepair, and noted to have areas of exposed wood and sharp edges. (b) Numerous room windows were covered in a green algae type substance. (c) Two of four rooms walls noted to have areas of peeling paint and large black scuff markings. 3) During the laundry observation tour conducted on 06/04/24 at 1 PM accompanied with the Housekeeping Supervisor and Corporate Regional Nurse, the following were noted: * Poinciana Soiled Utility Room: (a) large amounts of dried brown matter covering the ceiling mounted light cover and room walls. (b) open trash container with loose trash and no covering lid. (c) large rolling trash bin with exposed garbage and trash with the bin, and exterior of bin noted to have large areas of dried brown matter. (d) specimen refrigerator noted to have soiled gaskets. * Garden Soiled Utility room: (a) numerous dead bugs in room light fixture. (b) uncovered trash container with loose trash. (c) biohazardous container with no lid cover. * Cobblestone Soiled Utility Room: (a) Biohazardous containers (2) with no lids. * Gulfstream Soiled Utility Room: (a) Trash container with no lid with loose trash within the container. (b) Biohazardous container with no lid cover and loose biohazard waste within the container. Photographic Evidence Obtained for examples: #1, #2, #3, and #4. 4) Observation of the public /staff bathrooms (male/female) on 06/3-6/24 noted that the sink basins were in disrepair and had a large accumulation of a black mold type matter around the basin drain. Photographic Evidence Obtained. 5) During the observation of the skilled therapy room on 06/05/24 at 8 AM and accompanied with the Director of Skilled Therapy, the following were noted: (a) The Parallel Bars were noted to be old and worn. Specifically the left and right bars shook from side to side approximately 6 inches when tested . It was also noted that the non skid floor tape was worn off. The floor area was also noted to be soiled and heavily worn. Interview with the Director at the time of the observation noted to state the the bars should be more secure when in use for residents. (b) The seat exterior of the New Step exercising machine was noted to have 4 large tears across the entire seating surface and was in need of replacement . The machine was noted to be old, worn, and outdated.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: 1) During the initial Kitchen/Food Service Observation Tour conducted on 06/03/24 at 9 AM and accompanied with the Corporate Food Service Director (CFSD), the following were noted: (a) The door gasket of Walk-in refrigerator #1 was noted to have a large tear. It was discussed with the CFSD that the large tear could result in an inappropriate internal temperature. (b)The entrance of walk-in refrigerator #1 noted that there was a large area (3' X 6') of peeling paint. It was discussed with the CFSD that peeling chips of paint could result in food contamination . (c) The ceiling area around the internal motor of the walk-in refrigerator #1 was noted to be covered with a thick layer of dust and dirt. it was discussed with the CFSD that the dust/dirt could result in food contamination. (d) Observation of the walk-in freezer noted that foods were not properly covered for freezing. It was noted that a pan containing approximately 5 pound of fish fillets was not properly covered and was noted to be freezer burned. The CFSD discarded the fish. (e) Observation of the dish machine room noted that the entire wall area behind the dish machine had a thick layer of dust and dirt. The surveyor requested that the wall be cleaned prior to the next use of the dish machine. (f) The ceiling mounted wall vent located in the middle of the food production area noted that the filter was dust laden. (h) Observation the the bakery room noted that a soiled broom and dust pan were stored in the corner of the room and were in contact with clean bakery production equipment. The surveyor discussed with the CFSD that cleaning equipment be properly stored in the soiled room after use in the bakery room. (i) The commercial bench mounted can opener was noted to have a thick layer of black mold type substance and a build-up of metal shaving around the blade area. The surveyor requested that the can opener not be used until the unit was cleaned, sanitized, and a new blade inserted. (j) Observation noted that there was an open bin of used/soiled linens located in the food production area. The surveyor requested to the CFSD that the soiled linen bin be covered at all times and be moved from the food production area. (k) Observation of the food production area noted that there were 2 reusable drinking cups with straws that staff were drinking from while preparing foods. It was discussed with the CFSD that the was a potential for saliva from the cup and straws be spread to foods resulting in food contamination. The surveyor also requested that the cups be removed immediately and staff in-serviced. (l) Observation of the food production area noted that the were approximately 20 commercial containers of spices and 3 - 1 gallon containers of cooking oils that failed to have an labeled opening date. (m) The Robot Coupe (blender) was noted to have approximately 1/2 inch of fluid in the bottom of the mixing container. It was discussed with the CFSD that the containers must be inverted and air dried after each cleaning. (n) The ceiling area (10' X 10)located in the food production area was covered with dried food matter. The surveyor requested that the ceiling area be cleaned as soon as possible, (o) The exterior of the ceiling air-condition vent located in the food production area was noted to have a build-up of black mold type matter. (p) Observation of the canned food storage room noted that there was a #10 can of Fruit Mix that had large dent. The CFSD stated that the can should have been removed from potential use. (q) The convection ovens (2) located in the food production area were noted to have a thick layer of black carbon build-up. It was discussed with the CFSD that the ovens were not being properly cleaned on a regular basis. Photographic Evidence Obtained examples (a) - (q) 2) During the observation of the Poinciana Satellite Kitchen conducted during the lunch meal of 06/03/24 at 11:30 AM, and accompanied with the Certified Dietary Manager and Corporate Food Service Director, the following were noted: (a) Floor drain covered with trash. (b) Kitchen Utility Carts (2) were soiled, areas of dried food matter, and stained. (d) Two diet aides noted to be wearing small earrings. Surveyor requested removal. (e) Entire floor area of serving kitchen covered with black type mold matter. (f) Room wall base boards soiled and dried matter-(approximately 5 feet). (g) Dessert cups not stacked properly and staff handling in a non-sanitary manner. (h) Main entree plates (10) noted to be heavily stained. (i) Entry/exit door to satellite serving kitchen soiled and stained. Photographic Evidence Obtained for examples (a) - (i) 3) Observation of the completion of the breakfast meal in the main dining room on 06/04/24 at 9:45 AM noted the Diet Aide (Staff I ) was replacing soiled table cloths with clean table cloths. Further observation noted that Staff I failed to sanitizing the soiled table tops before donning a clean table cloth. Interview with the Dining Manager at the time of the observation noted that the satellite kitchen failed to have a chemical sanitizing solution available to properly clean and sanitize the table tops between meals. The Dining Room Manager confirmed the findings of the surveyor's observation. 4) During the observation of the completion of the breakfast meal on 06/04/24 at 10 AM, it was noted that a Diet Aide (Staff J) was pushing a cart full of soiled pots and pans (12) from the satellite kitchen through a entire hallway of resident rooms. Further observation noted that the pots and pans were not covered and were heavily soiled. Interview with Staff J at the time of the observation, he was aware that all soiled equipment must be properly covered when going through resident areas. Staff J stated that he forgot to cover the cart. 5) Observation of the Gulfstream satellite kitchen conducted on 06/04/24 at 10 AM, and accompanied with the facility's Certified Dietary Manager noted the following: (a) The cupboard area below the sink was noted to have a drain laden with a thick black mold type matter. (b) Clean silverware was not being handled in a sanitary manner. Staff were noted to handle the eating portion of the silverware prior to rolling in a linen napkin. (c) Ceiling mounted air-conditioning unit located in the middle of the kitchen was soiled and dust laden. (d) Kitchen utility cart (1) was soiled, stained, and areas of dried food matter. (e) The counter area behind the kitchen sink faucets was noted to have a build-up of black type mold matter. (f) Food storage cupboards exteriors were heavily worn and dented sodas cans in storage. (g) Soiled cleaning rags were being stored in the sink basis and were not being stored in a sanitizing solution when not in use. (h) Reach-in refrigerator gaskets were soiled and a build-up of black mold type matter. (i) The entrance/exit door to the satellite kitchen was in disrepair, heavily damaged, soiled and stained. Photographic Evidence Obtained for example (a) - (i) 6) During the observation of the lunch meal in the main satellite kitchen (Poinciana Unit) on 06/03/24 at 12 PM, temperatures of foods were taken by the use of the facility's calibrated digital food thermometer. The findings noted that cold foods were not being held at the regulatory temperatures of 41 degrees or below and hot food temperatures were not being kept at a minimum of 135 degrees F or above as evidenced by the following: * Tossed Salads (12 individual portions) = 57 degrees F. * Pureed Southern Succotash (6 portions) = 130 degrees F. 7) During the observation of the breakfast meal in the main satellite kitchen (Poinciana Unit) on 06/04/24 at 8 AM, temperatures of foods were taken by the use of the facility's calibrated digital food thermometer. The findings noted that cold foods were not being held at the regulatory temperatures of 41 degrees or below and hot food temperatures were not being kept at a minimum of 135 degrees F or above as evidenced by the following: * Milk (10-8 ounce containers) = 45 degrees F * Orange Juice (half gallon container) = 60 degrees F * Cranberry Juice (half gallon container) = 48 degrees F * Apple Juice (32 ounce container) = 58 degrees F * Butter Pats (30 individual) = 70 degrees

Based on observation and interview, the facility failed to a sanitary soiled utility room [ROOM NUMBER] of 4, and failed to have a designated clean area area in the laundry room. The findings included: 1. A tour of the facility's soiled utility rooms (4) was conducted on 06/06/24 at 11:00 AM with the Regional Nurse Consultant. All four soiled utility rooms contained biohazard containers that were uncovered revealing used sharp containers (used needles) and biohazard bags. [NAME] substance was observed on the walls and ceilings, and the light fixtures were soiled with dirt and debris. 2. A tour of the laundry room revealed a dirty glove on the clean folding table in direct contact of clean clothes. There was no designated clean area as the soiled laundry was sorted directly next to the washers and the soiled laundry cart was stored on the other side of the 4 commercial washers. The laundry baskets were observed dirty with debris on the inside bottom of the cart. The ceiling vents located directly above the clean folding table were observed with dust and debris. The Regional Nurse Consultant acknowledged the above.

Based on interview and record review, the facility failed to appropriately respond to allegations of sexual assault in 1 of 1 sampled resident for sexual assault (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses that included Dementia. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Resident #33 was care planned for being alert and oriented x 2 (to person and place) and impaired cognitive function/dementia, inattention, and forgetfulness. Record review revealed a progress note dated 05/28/24 at 3:57 PM that documented: Resident was visited by SW (Social Worker) today to discuss grievance with another resident. Staff member saw male resident touched her inner thigh and attempt to put hand up blouse. Resident is confused and unaware of the incident. Resident was evaluated/checked by nursing staff. SW contact family to make her aware and also reported concern to APS (Adult Protective Services). SW to monitor resident behavior for any changes. Further record review revealed a progress note dated 05/28/24 at 5:44 PM that documented: This writer notified resident has fallen out of her wheelchair in the dining area. Upon entering the dining area resident noted with a laceration to above left eyebrow. 911 was called. Resident has left the facility alert, responsive and oriented. MD and resident daughter made aware. Resident #33 returned to the facility on [DATE] at 2:16 AM. There was no documentation of the resident's condition or psychosocial status post sexual assault. A review of Resident #33's orders revealed an order dated 05/31/24 for a Psych consult to address decreased appetite. An interview was conducted with the Director of Nursing (DON) on 06/05/24 at 10:00 AM. The DON stated they did a skin check on Resident #33 and separated the two residents. The other resident, Resident #39, was placed on 1:1. The DON further stated they interviewed other female residents on the same unit and staff. The Social Service Director interviewed both residents and notified the physician and other agencies. The DON provided a preliminary psych note dated 06/03/24. The DON stated the psych physician left a preliminary note and will then send a progress note. A review of the preliminary note documented Resident #33 seemed more confused and tearful. The plan was to continue same medications, rule out Urinary Tract Infection, and re-consult in 2 weeks. The note did not address the sexual assault on the resident. A phone interview was conducted with the Psychiatrist on 06/05/24 at 10:30 AM. The Psychiatrist stated he was familiar with Resident #33. He stated he was told that Resident #33 was touched by another resident and the resident's appetite was decreased. The Psychiatrist acknowledged he did not address the resident's sexual assault in his preliminary note. He stated the resident has Dementia and does not remember anything. An interview was conducted with the Central Supply Coordinator on 06/05/24 at 11:30 AM. The Coordinator stated she witnessed the sexual assault on Resident #33 on 05/28/24. She was walking in the hall and saw Resident #33 in the middle of dining room with a male resident, Resident #39, sitting next to each other/facing each other. Resident #39 was rubbing between Resident #33's legs and up her blouse. Resident #33 looked uncomfortable/fidgeting. The Coordinator stated she walked over to Resident #33 and asked if she was finished, and wanted to go back to the room. As she was pulling Resident #33 away from the Resident #39, Resident #33 said Thank you for rescuing me. The Coordinator told the DON, who told her to report it to the SSD. An interview was conducted with the Social Service Director (SSD) on 06/05/24 at 11:45 AM. The SSD stated she was told by a staff member that Resident #33 was in dining room and was rubbed on by another resident, Resident #39. The SSD approached Resident #33 the same day, and the resident could not recall anything. The SSD went to Resident #39 and he said that Resident #33 was his friend. The SSD stated Resident #33 was more confused than usual that day when she talked to her. The SSD reported to nursing staff and supervisor, and called the family. The SSD acknowledged she documented SW to follow up, but Resident #33 went out to the hospital the same day. The SSD stated she did see Resident #33 when she came back to the facility, but did not document it. Record review revealed Resident #39 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact with a BIMS of 13 out of 15.

Based on observation, interview, and record review, the facility failed to discontinue a Peripherally Inserted Central Catheter (PICC) line in a timely manner for 1 of 1 resident reviewed for PICC line (Resident #67). The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (infection of the bone). A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required substantial/maximum assistance with activities of daily living. Record review revealed an order for Intravenous (IV) antibiotics daily dated 04/19/24 to start 04/20/24 until 05/24/24. An interview was conducted with Resident #67 and his spouse on 06/03/24. Resident #67's spouse stated the resident had finished his antibiotics 10 days ago, and still had the PICC line in place. The spouse stated she had requested the IV to be discontinued a few times for fear of an infection and it had not been done. The spouse stated she again requested the IV to be discontinued today, and was told by the nurse she would call the doctor to get an order to discontinue the IV. An interview was conducted with Resident #67's spouse on 06/04/24 at 12:50 PM. The spouse stated Resident #67 still had the IV line in place. An interview was conducted with Staff H, a Registered Nurse, on 06/04/24 at 1:00 PM. Staff H acknowledged Resident #67 had a PICC line, and last received IV antibiotics on 05/24/24. Staff H further acknowledged Resident #67 and his spouse requested the PICC line to be discontinued. Staff H stated she did not call the physician as requested. An interview was conducted with the Infection Control Preventionist (ICP) on 06/04/24 at 1:10 PM. The ICP stated the best practice is to remove a PICC line as soon as possible to avoid risk of infection.

Based on observations, interviews and record reviews, the facility failed to provide adaptive equipment as ordered to 2 of 2 residents reviewed for assistive devices, Residents #5 and 15. The findings included: The facility's policy, 'Assistance with Meals', revised March 2022, documented: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who may benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 2. Assistance will be provided to ensure than residents can use and benefit from special eating equipment and utensils. 3. Residents may choose not to use adaptive devices. 1. Resident #5 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 09, indicating that the resident was 'moderately' cognitively impaired. The MDS documented that the resident required 'supervision or touching assistance' for eating. Resident #5's diagnoses at the time of the assessment included: Speech and Language deficits following cerebral infarction, Aphasia following cerebral infarction, Contracture to right elbow, Cognitive communication deficit, Flexion deformity to the right finger joints. Resident #5's care plan for 'malnutritional problem', created on 11/08/18 and most recently revised on 06/05/24, documented, Resident has nutritional problem or potential nutritional problem related to diagnoses: speech and language deficits, aphasia, dysphagia, cerebrovascular disease, hypothyroidism, anxiety, hypertension, hyperlipidemia, GERD, major depression, history of weight loss; requires adaptive equipment with meals. The goal of the care plan was documented as, The resident will maintain adequate nutritional status as evidenced by maintaining weight without significant changes, no signs/symptoms of malnutrition . 12/05/18 with a revision date of 06/04/24 and a target date of 08/07/24. Interventions to the care plan included: Adaptive equipment for eating: standard built up fork/spoon, plate guard, built up knife and soup in mug all times. Resident #5's orders included: Adaptive equipment for eating: standard built up fork/spoon, plate guard, built up knife and soup served in mug at all meals every shift - 08/18/21. Resident #5 was not interviewable. During an observation of lunch being served to the residents in the dining room on the 400 unit, on 06/04/24 at 12:46 PM, Resident #5 was noted with a built up fork and spoon, with traditional knife. The tray ticket that accompanied the meal documented the order for 'built up Spoon/fork/knife. During an observation of breakfast being served to the residents in the dining room on the 400 unit, on 06/05/24 at 8:34 AM, Resident #5 was served scrambled eggs and toast with a pre-portioned butter on the side. It was noted that the resident was provided a built up spoon and fork and a traditional knife. During an interview, on 06/05/24 at 1:41 PM, with Staff A, CNA, when asked about preparing the dining room for the residents prior to meals, Staff A stated, tables are already set for the residents. When asked about the lack of built up knives provided to the residents, Staff A replied, they had knives. They come from the kitchen (referring to the satellite kitchen in the dining room on the 400 unit) and they would place for the residents at the tables. During an interview, on 06/05/24 02:01 PM, with Staff B, CNA, when asked of the availability of adaptive equipment for the residents that have orders, Staff B replied, there are no residents that use adaptive equipment in the unit. All of them eat in the dining room (referring to the dining room on the 400 unit). 2. Resident #15 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly MDS, dated [DATE], Resident #15 had a BIMS score of 12, indicating 'moderately' cognitively impaired. The assessment documented that the resident required 'Setup or clean up assistance' for eating. Resident #15's diagnoses at the time of the assessment included: Coronary Artery Disease, Seizure disorder, Hereditary and idiopathic neuropathy, Spondylosis of the cervical region, Idiopathic peripheral autonomic neuropathy, disorders of muscle. Resident #15's care plan for nutritional problem, created on 05/12/21 and most recently revised on 06/03/24, documented, The resident has nutritional problem or potential nutritional problem related to hyperlipidemia, hypertension, spondylosis, heart disease, history of wounds, history of weight loss, declines weights to be taken at times; requires adaptive equipment . The goal of the care plan was documented as, The resident will maintain adequate nutritional status as evidenced by maintaining weight as medically indicated and attainable; remain comfortable and tolerate food, fluid and/or supplements. 05/12/21 with a revision date of 05/02/24 and a target date of 07/15/24. Resident #15's orders included: Built-up/curved fork, spoon and built-up rocker knife with all meals. 01/09/23. During an observation of breakfast served to the residents in their rooms, on 06/05/24 at 9:29 AM, Resident #15 was served breakfast with built up fork that was not curved, a built up spoon that was not curved and a traditional knife, Resident #15 stated that the staff cut the sausage patties for her (noted to be two patties with one cut in half and the other intact). Resident #15 further stated she was not sure that she would be able to use the knife regardless of the nature of the utensil. During an interview, on 06/06/24 at 8:32 AM, with the Certified Dietary Manager (CDM) from sister facility, when the concerns were brought to their attention, the Dietary Manager stated that the facility had no built up knives. During an interview, on 06/06/24 at 8:46 AM, with Staff C, Occupational Therapist, and Staff D, Occupational Therapist, when asked about Resident #5 and 15 not receiving appropriate utensils for meals, Staff C stated, it would have to be a grip/grasp knife (referring to Resident #15, we just gave the CDM for the sister facility a whole bunch. Staff D stated that the built up forks and spoons were designed so that staff could easily curve the utensils by bending them. During the interview, it was noted that there were several bins that contained various adaptive equipment, including the built-up knives, built-up spoons, built-up forks and rocker knives.

Based on interview and record review, the facility failed to provide an appropriate discharge plan for 1 of 3 sampled residents (Resident #3). The findings included: Record review revealed Resident #3 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required extensive to total two-person assist with activities of daily living. The assessment further documented the resident did not have a pressure ulcer, but was at risk for the development of a pressure ulcer. A review of Resident #3's physician orders revealed an order dated 11/30/22 for a wound care consult for coccyx excoriation. A skin/wound progress note dated 12/06/2022 at 12:05 PM documented: Resident was seen by wound care on 12/5/22 related to Stage II wound on the coccyx that she was admitted with. The wound measurement are: 5.0 x 3.0 x 0.1 (centimeters) and is being treated with Hydrophilic paste. Will be followed by the wound NP (Nurse Practitioner) weekly. A Social Service (SS) progress note dated 12/13/22 at 11:57 AM documented: Care plan meeting held today 12/13/22. Resident and her son and daughter in law participated in meeting in person. IDT (interdisciplinary team) reviewed care plans, medications, advance directives, nursing care, therapy services and discharge plan. She is here for short term stay and goal is to return with services to the ALF (assisted living facility). A Social Service progress note dated 12/30/2022 at 4:39 PM documented: SS spoke with resident family -son and daughter-in-law today regarding her discharge plan which is tentatively scheduled for Fri 01/06/23 to return to ALF. SS reviewed discharge plan and protocol and services that will be set up for resident upon discharge home. Resident was here for short term rehab stay and has met her goals in rehab. MD will review the need for Home Health services for PT (physical therapy), OT (occupational therapy) and Nursing. Resident owns wheelchair, rolling walker, commode and shower chair. Resident will be discharge with her medications and 1823 form and family will coordinate transportation. SS will continue to provide services and assist with discharge plan. A review of Resident #3's Wound Care Progress Notes revealed a note dated 01/03/23 documented: wound measurements 7.0 x 2.0 x 0.8 centimeters. Wound coccyx tissue depth has changed, wound stage has changed from stage 2 to unstageable. Recommendation for wheelchair cushion and sharp debridement of non-viable, necrotic, devitalized tissue and accumulation debris to establish the margin of viable tissue to decrease bacterial load and stimulate contraction, granulation, and wound epithelization. Plan of care discussed with facility staff. Follow up in one week for reassessment. A progress note dated 01/06/23 at 11:30 AM documented: Resident admitted to the facility with a dx (diagnosis) of left hip FX (fracture), while here received PT/OT Services. Discharge home today with remaining medications. Resident to return to ALF. Family to transport resident. An interview was conducted with Resident #3's family member on 6/21/23 at 10:00 AM via telephone. The family member stated they were not informed of a pressure ulcer on the resident's coccyx. The resident returned to an ALF (assisted living facility) with a coccyx wound on 01/06/23, with home health orders. The family member stated the resident should not have been discharged with a wound like that, and the ALF should not have accepted her. The ALF stated the resident could not stay there with the wound. An interview was conducted with the Social Services Director (SSD) on 06/21/23 at 2:00 PM. The SSD stated discharge planning starts on admission, and reviewed during care plan meetings. The SSD stated she was not the SSD at this facility when Resident #3 was discharged . The SSD further stated stage 2 pressure ulcers and above, including unstageable pressure ulcers, should not be transferred to an ALF. They do not have the skilled services to care for such wounds. The SSD stated she would notify family and ALF that the resident was not acceptable for return. Resident #3 should not have been discharged to an ALF with her unstageable wound. The ALF should not have accepted her.

Based on interview and record review, the facility failed to prevent the worsening of a pressure ulcer for 1 of 3 sampled residents (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required extensive to total two-person assist with activities of daily living. The assessment further documented the resident did not have a pressure ulcer, but was at risk for the development of a pressure ulcer. A review of Resident #3's care plan revealed a care plan for potential for impairment to skin integrity related to fragile skin and decreased mobility, dated 12/01/22. A review of Resident #3's physician orders revealed an order dated 11/30/22 for a wound care consult for coccyx excoriation. Further review of the resident's orders revealed an order dated 12/06/22 to cleanse sacrum with Normal Saline, pat dry, and apply Triad every shift and as needed, repositioning often. A skin/wound progress note dated 12/06/2022 at 12:05 PM documented: Resident was seen by wound care on 12/5/22 related to Stage II wound on the coccyx that she was admitted with. The wound measurement are: 5.0 x 3.0 x 0.1 (centimeters) and is being treated with Hydrophilic paste. Will be followed by the wound NP (Nurse Practitioner) weekly. A review of Resident #3's Treatment Administration Record (TAR) and progress notes revealed the wound care orders were not documented as being performed, between 12/6/22 to 12/31/22. A review of Resident #3's orders revealed an order dated 12/30/22 to cleanse sacrum with Normal Saline, pat dry, and apply Tegaderm foam dressing daily every night shift for sacrum wound care. A review of Resident #3's TAR revealed the dressing changes were performed on 12/31/22 until 01/03/23. A review of Resident #3's orders revealed an order dated 01/03/23 to cleanse sacrum with Normal Saline, pat dry, apply Calcium Alginate with Honey and cover with bordered gauze every night shift for sacrum wound care and as needed. A review of Resident #3's Wound Care Progress Notes revealed a note dated 01/03/23 documented: wound measurements 7.0 x 2.0 x 0.8 centimeters. Wound coccyx tissue depth has changed because wound stage has changed from stage 2 to unstageable. Recommendation for wheelchair cushion and sharp debridement of non-viable, necrotic, devitalized tissue and accumulation debris to establish the margin of viable tissue to decrease bacterial load and stimulate contraction, granulation, and wound epithelization. Plan of care discussed with facility staff. Follow up in one week for reassessment. An interview was conducted with the Assistant Director of Nursing (ADON) on 06/21/23 at 2:00 PM. The ADON acknowleged the above.

Based on observation, interviews, and records review, the facility failed to ensure that the residents had access to handrails in 4 of 5 units of the facility (Garden, Poinciana, Cobblestone, & Gulfstream). The findings included: Observations conducted on 03/12/23 to 03/14/23 from 9:00 AM to 12:20 PM revealed that all handrails at the facility were removed. The facility was undergoing renovation. Further inquiries revealed that out of five units at the facility, four were residents occupied, and none of the four units had handrails affixed or secured on the walls. During an interview with the Administrator on 03/14/23 at 3:28 PM, he informed that the repairs had started on February 14, 2023. The facility's objectives were to replace the light fixtures, to repaint the walls, and replace the handrails. He said that they were currently in the process of repainting and replacing the wall papers. The painting should take about two to three weeks, he added. The light fixture upgrades were completed. He also reported that all residents were notified by mail or during the resident council meetings and or posted signs throughout the facility. On 03/15/23 at 9:08 AM subsequent to a conversation with the Administrator and the Executive Director on 03/14/2023 questioning the removal of the handrails, the handrails were reinstalled on one side of the hallways the night of 3/14/2023. The Administrator informed that they ordered new handrails, and they would not be delivered until later this month. During an interview with the Executive Director on 03/15/23 at 9:40 AM, he said that the new handrails were already on site. They were waiting for the painting job to be completed before reinstalling all of them up. He later brought a document dated 3/15/2023 which indicated that the handrails will be completely reinstalled on Thursday 3/ 2023. Later that day at 11:20 AM, the Administrator retuned with a corrected letter showing that the new handrails will be installed on Thursday 3/23/2023. On 03/16/23 at 10:45 AM, it was observed that all the handrails were not reinstalled. The handrails were placed only on one side of the walls throughout the entire facility except the Yellowstone unit which is closed. Interview was conducted with the Activity Director on 03/17/23 at 9:47 AM. He said that he received no complaints from the residents regarding noise at the facility. The Assistant Director of Nursing (ADON) informed on 03/17/23 at 9:50 AM that no one had complained to her about noise, before or during the renovation. She added that none of her team members had reported any residents' complaints to her about issue of noise. During an interview with the Director of Nursing (DON) on 03/17/23 9:55 AM, she said that none of the residents complained to her about environmental noise or nuisance. What she heard was that the facility will look nice once the work are completed. In a follow-up interview with the Administrator on 03/17/23 at 9:59 AM, he reiterated that the project started on 2/14/2023. The first part was to remove the wallpapers, one side at a time. He said they did not send any letters to the residents informing them of the renovations. What they did was that they spoke to the residents at the Residents' council meeting, informed many residents and their representatives (family members) from the Poinciana Unit, and they also posted signs throughout the entire facility to let residents know about the ongoing renovation. The repairs were scheduled to be done during office hours, from 9:00 AM to 5:00 PM. He continued and said that the work started before the recertification survey, but since the survey they had to suspend all works. The Administrator informed that they had to work on Tuesday in the evening to reinstall some of the handrails that were removed, following the team's questioning regarding the missing handrails.

Based on review of policy and procedure, observation and interview, it was determined that the facility failed to ensure that it secured and locked up four (4) over-the-counter (OTC) medications for the sampled residents observed, Resident #58, Resident #34, Resident #347 and Resident #28. The facility failed to discard a loose, 1/4 sized portion of a pill in 1 of 5 Medication Carts, in the Gulfstream Locked Alzheimer's/Dementia Unit. And, failed to promptly discard an expired OTC stock dry mouth moisturizing medication in 1 of 4 Medication rooms, in the Gardens Unit. The findings included: Review of the facility policy and procedure titled Storage and Expiration Dating Medications, Biologicals revised 01/01/22, documented in the Policy Statement: Applicability. This policy sets for the procedure relating to the storage and expiration dates of medications biologicals, syringes and needles. Procedure 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding Facility should ensure that medications and biologicals that: (1) have an expiration date on the label; .or (3) have been contaminated or deteriorated, are stored separately from other medications until destroyed or returned to the pharmacy or supplier .Bedside Medication Storage 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration 15. Facility should ensure that medications and biological for expired or discharged or hospitalized residents stored separately, away from use, until destroyed or returned to provider. 1) Resident #58 was readmitted to the facility on [DATE]. He had a Brief Interview Mental Status (BIM) score of 12 (moderately impaired). During the facility tour conducted on 03/13/23 at 11:19 AM, Resident #58's room was observed to have a full syringe of OTC Normal Saline Midline IV 10ml flush solution with an expiration date of 06/30/25 sitting atop his bedside table. It was accessible and exposed to other residents, employees and visitors. Photographic evidence was obtained. 2) Resident #34 was readmitted to the facility on [DATE]. She had a Brief Interview Mental Status (BIM) score of 12 (moderately impaired). During the facility tour conducted on 03/13/23 at 11:25 AM, Resident #34's room was observed to have a used/open OTC bottle of Systane Lubricant Eye Drops with an expiration date of 08/24 sitting atop her bedside table. It was accessible and exposed to other residents, employees and visitors. Photographic evidence was obtained. On 03/14/23 at 10:44 AM, Resident #34's room was still observed to have a used/open OTC bottle of Systane Lubricant Eye Drops sitting atop her bedside table. On 03/15/23 at 11:24 AM, Resident #34's room was still observed to have a used/open OTC bottle of Systane Lubricant Eye Drops sitting atop her bedside table. 3) Resident #347 was admitted to the facility on [DATE]. She had a Brief Interview Mental Status (BIM) of 15 (cognitively intact). On 03/13/23 at 11:40 AM, during the facility tour conducted of Resident #347's room, it was observed to have a used/open OTC bottle of Tums expiration date 09/25 sitting atop her bedside table. It was accessible and exposed to other residents, employees and visitors. Photographic evidence was obtained. On 03/14/23 at 10:30 AM Resident #347's room was still observed to have a used/open OTC bottle of Tums sitting atop her bedside table. 03/15/23 at 11:17 AM Resident #347's room was still observed to have a used/open OTC bottle of Tums sitting atop her bedside table. 4) Resident #28 was admitted to the facility on [DATE] with diagnoses which included Hyperlipidemia, Overactive Bladder, Vitamin D Deficiency, Macular Degeneration, unspecified, Vitamin B12 Deficiency, Hypertensions and Seborrheic Dermatitis. She had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired). A facility tour was conducted on 03/13/23 at 11:13 AM of Resident #28's room in which it was observed that there was a used/open OTC Tube of Triad Hydrophilic zinc-oxide based Wound Dressing with an expiration date 09/2023, located on the top of the resident's shared bathroom sink counter. It was accessible and exposed to other residents, employees and visitors. Photographic evidence was obtained. On 03/14/23 at 10:17 AM, Resident #28's room, was still observed as having a used/open Tube of OTC Triad Hydrophilic zinc-oxide based Wound Dressing located on the resident's shared bathroom sink counter. 03/15/23 at 11:09 AM Resident #28 was still observed as having a used/open Tube of OTC Triad Hydrophilic zinc-oxide based Wound Dressing located on the resident's shared bathroom sink counter. An interview was conducted on 03/15/23 at 11:52 AM with Resident #58, Resident #34, Resident # 347, and Resident #28's nurse, Staff F, a Registered Nurse (RN), regarding the OTC Normal Saline Midline flush solution, the Systane Lubricant Eye Drops, the bottle of Tums and the Tube of OTC Triad Hydrophilic zinc-oxide based Wound Dressing observed each of the Resident's bedside table or on their sink, and he acknowledged that none of the OTC medications should have been there. 5) During a Medication Storage Observation conducted on 03/15/23 at 1:10 PM with the Assistant Director of Nursing (ADON) and with Staff J, an RN, for Gulfstream Locked Alzheimer's Dementia Unit Medication Cart, it was noted that there was 1/4 size portion of an unidentified loose white pill in the bottom of the 3rd drawer of the Gulfstream medication cart. Photographic evidence was obtained. 6) During a Medication Storage Observation conducted on 03/15/23 at 1:46 PM with the ADON, of the Medication Room Gardens Unit, it was noted that there was an OTC spray bottle of Biotene Dry Mouth Moisturizing Spray Floor stock located on the shelf with an expiration date of 02/23. Photographic evidence was obtained. On 03/15/23 at 2:17 PM the Director of Nursing (DON) acknowledged and recognized that none of the residents self-administer any of their own medications and neither were any of them assessed to be able to do so. The DON further indicated that none of the OTC medications should have been left at any of the resident's bedsides and said that all resident medications should be kept locked/secured at all times with any expired medications promptly discarded; this was not done.

Based on record review and interview, it was noted that 1 of 3 sampled residents (Resident #299) did not receive a notification of Medicare non-coverage (NOMNC) 48 hours prior to termination of skilled rehabilitation services. The findings included: On [DATE] at 9:21 AM, three residents were selected for the Beneficiary Notification review. Review of the Skilled Nursing Facility Protection Notification Review showed that Resident #299's skilled rehabilitation services started on [DATE] and ended on [DATE]. However, Resident #299 did not sign the Notification of Medicare Non-Coverage (NOMNC). The admission records showed Resident #299's diagnoses included: Primary Osteoarthritis; History Of Falling; Rhabdomyolysis; Pain In Right Hip. Section G of the Minimum Data Set (MDS) dated [DATE], documented that Resident #299 required extensive assistance for bed mobility, dressing, personal hygiene, and locomotion on unit. She required limited asssitance for transfer, and toilet use, total dependence for bathing, and supervision for eating. Resident #299's skilled services started on [DATE] and the last covered day was on [DATE]. After termination of skilled services by the facility staff, Resident #299 remained at the facility. On the Notification of Medicare Non-Coverage (NOMNC), the Social Worker (SW) noted on [DATE] that the Resident's son was notified by phone. There was no evidence provided to show that the Resident or her authorized representative had received the NOMNC 48-hours before termination of skilled services. During an interview with the SW on [DATE] at 9:31 AM, she stated that she used to work in a hospital setting. She stated that the NOMNC procedure from the hospital is not the same as that of the nursing home. She said that before skilled services was discontinued, she spoke with Resident #299's son, but she did not send a letter. The SW further reported that the phone communication with the Resident's son occurred the day of benefits termination or on [DATE]. Consequently, the time to appeal the benefits termination had already expired. Resident #299 was observed in bed on [DATE] at 10:14 AM awake and alert. She said that she was going home today and was happy about that. That information was in reality incorrect. Resident #299 had no discharge plan in place.

Based on observations, interviews, and record review the facility failed to perform adequate fingernail care for 1 of 1 resident's reviewed for fingernail care (Resident #27). The findings included: Review of the facility policy titled Care of Fingernails/Toenails, dated February 2018 revealed the following: Nail care includes daily cleaning and regular trimming. This policy also stated all fingernail care should be documented in the resident's chart, including the date and time, the name and title of the individual who administered the care, the condition of the resident's nails and nail bed, any difficulties in cutting the nails, and any problems or complaints made by the resident. During the initial tour of the facility conducted on 03/13/23 at 11:30 AM, the surveyor observed that Resident #27 had long, jagged fingernails which were caked with orange/brown matter. Resident #27 stated she would like for her fingernails to be cut. When asked when the staff cut them last, Resident #27 could not provide an answer except that it should be happening soon. It should be noted, it appeared to the surveyor that Resident #27's fingernails had not been cared for in over two weeks. Resident #27 was admitted to the facility on [DATE]. Resident #27 had a medical history significant for a bone infection related to a sacral pressure ulcer, hydrocephalus, chronic nerve pain, heart disease, seizures, falls, muscle weakness, and high blood pressure. A Significant Change Minimum Data Set (MDS) was completed on 01/09/23. This MDS documented Resident #27 had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she was cognitively intact. This MDS also documented Resident #27 required extensive assistance of staff for personal hygiene needs. Review of Resident #27's Care Plans revealed there was a care plan in place regarding actual impaired skin integrity. This care plan included an intervention which stated, Avoid scratching and keep hands any body parts from excessive moisture; keep fingernails short. An interview was conducted with Resident #27 on 03/15/23 at 11:28 AM. During this interview, the surveyor observed that Resident #27's fingernails remained long, jagged, and caked with orange/brown matter. When the surveyor asked if the staff had addressed her fingernails, she stated they had not. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) on 03/16/23 at 8:32 AM. When asked what staff are responsible for resident fingernail care, she stated the CNAs are responsible for this task. When asked how often the CNAs performs fingernail care on the residents, she stated the residents receive fingernail care on Fridays. When asked where the CNAs document the fingernail care, Staff B stated the CNAs document in a computer system called POC [Point of Care]. The surveyor asked if the CNAs POC system transfers to the nurses PCC [Point Click Care] system. Staff B stated it did, but that it did not specify if fingernail care was done. She stated it only documents that general care were done. When asked if Staff B would perform the fingernail care for Resident #27, Staff B stated the care would be performed the next day. An interview was conducted with the facility Assistant Director of Nursing (ADON) on 03/16/23 at 4:30 PM. She stated that it is the CNAs responsibility to perform fingernail care on the residents. She stated it was not possible to print the CNA charting showing when fingernail care were last performed. A secondary interview was conducted with Resident #27 on 03/17/23 at 9:42 AM. The surveyor observed that Resident #27's fingernails appeared to be freshly cut. Resident #27 confirmed that the staff had performed fingernail care for her that morning. Resident #27 stated she was happy to have her fingernails cleaned and cut.

Based on interview, observation, and record review, the facility failed to provide a leg band for an indwelling urinary catheter (Resident #52, Resident #55, Resident #202, and Resident #205). The findings include: The facility policy titled Catheter Care, Urinary, taken from the Nursing Services Policy and Procedure Manual for Long-Term Care, revised September 2014, has steps describing the proper way to perform care. Step 18 states Secure Catheter utilizing a leg band. According to the American Journal of Nursing article, Techniques for Stabilizing Urinary Catheters. Stabilizing indwelling urinary catheters dramatically reduce adverse events such as accidental dislodgement as well as tissue trauma and inflammation induced by excessive traction of the tubing or drainage bag. 1. On 03/16/23 at 2:46 PM, an observation of urinary catheter care for Resident #55 was made of Staff E, a Licensed Practical Nurse (LPN). Staff E performed the care competently except for step 18 where she failed to secure the catheter as expected. The nurse indicated that hanging the catheter bag from a hook on the lower part of the bed frame was sufficient. 2. On 03/16/23 at 3:50 PM, an observation was made of Resident #202. The resident was sleeping in bed with an indwelling catheter attached to tubing and a drainage bag. The drainage bag was suspended from a hook on the bed frame. Resident #202 did not have a leg band or other device to stabilize the catheter tubing. 3. On 3/16/23 at 3:55 PM, an interview was conducted with Resident #205. Resident #205 stated he has a leg bag during the day, and he has two bands to keep the leg bag secure. Resident #205 stated at night the facility did not put a leg band on to hold the tubing in place they just hung the bag from the bed frame by a hook. 4. On 03/16/23 at 4:05 PM, an observation was made of Resident #52, who was sleeping in bed with an indwelling catheter attached to tubing and a drainage bag. The drainage bag was suspended from a hook on the bed frame, connected to the drainage bag. Resident #52 did not have a leg band or other device to stabilize the catheter tubing. 5. On 03/16/23 at 4:15 PM, an interview was conducted with the Director of Nursing (DON) regarding the lack of leg bands for indwelling urinary catheters for the residents observed and interviewed. The DON was surprised that the nurse did not place a leg strap for Resident #55. The DON was concerned to learn there were four residents who did not have leg straps for indwelling urinary catheters. The DON stated that she knew that there were supplies for the leg straps. The DON stated she did not know why the nurses were not using the straps. The DON agreed that leg straps should always be used to stabilize indwelling urinary catheters.

Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide Trauma Informed Care for 1 of 1 sampled residents, Resident #41. The findings included: Review of the facility policy and procedure Trauma Informed and Culturally Competent Care, revised 08/29/22, documented: Trauma Informed Care (TIC) is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans or trauma-informed approach. We believe that Trauma Informed Care should not only meet professional standards but are delivered using multi-disciplinary approaches which are culturally competent and account for individual experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization .As a result, principles of trauma-informed care must be addressed and applied purposefully in our health care settings at Life space Policy for Trauma Survivors: 1. Trauma Survivors will receive culturally competent, trauma-informed care in accordance with professional standards and state and federal regulatory requirements .2. We will utilize a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences .3. Thorough assessment and interdisciplinary care planning are essential to providing quality care and culturally competent services 4. It is important to be aware of the impact of culture and culture preferences in the provision of care, and development of the resident's individualized plan of care Resident #41 was readmitted to the facility on [DATE] with diagnoses which included Dysphagia, Morbid Obesity, Peripheral Vascular Disease, Gastroesophageal Reflux Disease, Osteoarthritis, Atrial Fibrillation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Colostomy Status, Anxiety Disorder, Hypertension and Neuromuscular Dysfunction of the Bladder. She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On 06/27/19, 09/16/20, 08/09/22 and 09/09/22, Resident #41's four (4) care plans only documented the following four (4) different types of behaviors: 1) On 06/27/19---Behaviors (accusing staff of stealing or breaking things, calling staff inappropriate names, screaming that there are bombs under her bed and they are setting off missiles sometimes being negative and inappropriate verbally and lashing out during care---goal was to help demonstrate effective coping skills. 2) On 09/16/20---Periods of Hallucination, Paranoia and thinking that others are laughing at her and says that there were two ladies passing by her and screaming. The goal was for fewer episodes of behaviors; she is on medication for Anxiety Xanax 0.25mg 1 tablet every four (4) hours as needed and 3) and 4) On 08/09/22 x2, respectively,---Creating stories, verbally abusive to staff, threatening to get them fired, repeatedly calling 911 saying that she is on a 15th floor apartment needing help. During a Colostomy Care Observation conducted on 03/15/23 at 12:23 PM, Resident #41 proceeded to disclose the following information, to both Surveyors present. She proceeded to relay a series of multiple differing accounts, to include all of the following events: 1) About her childhood when she was escaping [NAME] and how she got displaced from her parents. She said that a lady helped her and returned her back to her parents, who had been residing in a concentration camp. She also showed the antique doll which she says she had during that time frame while she was going through these events. 2) She has no other family here in this Country and she is all alone; she also said that she had an Apple I-pad when she was first admitted to the facility in October 2022 (in which the resident stated that the previous Administrator provided the I-pad to her), until it broke. She went on to say that she was aware that her nephew took it with him to get repaired in [NAME], which she felt that the facility had. However, she added that she had never received it. Resident #41 elaborated the fact that she believed that the Ipad had been missing for about 3-4 months, when in fact, it was in [NAME] with her nephew getting repaired. Resident #41 explained that her nephew told her that he had a friend in Miami who mailed the Ipad from there to this facility, for her about 3 days ago. Resident #41 stated that she felt that the CNAs assigned to her a few days ago, had come into her room taunting her that the I-pad Mail package had actually came in, but she said they told her that they would not give it her. Resident indicated that they never told her what happened to it. 3) Resident #41 gave a brief account of how she was missing various jewelry items to include large sums of money upwards of maybe $800 or so. During an interview conducted on 03/16/23 at 10:32 AM with Staff I, a Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator, in which she stated that she first became aware of Resident #41's accounting of her memories of her childhood trauma, over a twenty (20) minute time frame, following some current events shown on T.V. (to include a possible Earthquake). Staff I explained how Resident #41 continued to speak at length about her childhood, how she escaped [NAME], got displaced from her parents, how a strange lady helped her and returned her back to her parents, who had been residing in a concentration camp. Staff I also indicated that Resident #41 showed her the [AGE] year old antique doll which she says she had with her during that time frame while she was going through these events. Finally, Staff I stated to this Surveyor that she did bring all of the above information to the Team, who in turn, informed her that they were already aware of this. An interview was conducted on 03/17/23 at 11:42 AM with the Social Services Director, in which she stated that she was recently made aware, just prior to this survey, that Resident #41 had voiced her experiences of Childhood Trauma/Holocaust Survivor. The Social Services Director acknowledged that nothing was done, at the time, nor did she reveal this information to any of the staff members. She also further acknowledged that she would be the person, in general, who would be responsible for completing the Resident Admission/Evaluation which included only a handwritten single general question on the back of the form indicating, Have you suffered any traumatic events? According to the Social Services Director, she acknowledged that there was no documentation in Resident #41's facility record, since the policy became effective 10/24/22, to indicate that this resident ever received any assessment regarding her history of trauma, nor were any triggers identified related to her childhood trauma, and she further acknowledged that, Resident #41was not care-planned for this; only for behaviors. Record review indicated that there was no documented evidence to show that Resident #41's care plan reflected a multi-disciplinary approach to address the issue of Trauma Informed Care subsequent to her re-admission to the facility in October 2022; it only addressed Resident #41's Behaviors. Further record review revealed that the facility was utilizing an Admit/Discharge Form which only included the following question written on the back of the form, Have you suffered any traumatic events? which would indicate there has not been any current formal system in place to address the resident's needs, with no indication as to exactly when it was implemented. The facility had not delivered care and services, nor utilized approaches, which were culturally-competent, to account for her experiences and preferences. Neither did the facility address the needs of this trauma survivor by recognizing triggers and/or minimizing re-traumatization for this resident, subsequent to her re-admission to the facility in October 2022 During an interview conducted on 03/17/23 at 11:13 AM with the DON, in which she said that since the new regulation came into effect October 2022, the resident clinical assessment now has a section to assess for Trauma Informed Care, for all new admissions. However, she stated that the facility did not initiate Trauma Informed Care for Resident #41, subsequent to her re-admission in October 2022. The DON further recognized and acknowledged that on 03/17/23 at 10 AM, that Resident #41, a Holocaust Survivor, should have been receiving the necessary care and services to meet her needs.

Based on review of policy and procedure, observation and interview, it was determined that the facility staff failed to: 1) ensure that privacy was maintained for a resident during toileting for 1 of 1 sampled residents observed, Resident #58; and 2) ensure that it addressed a resident in a respectful manner for 1 of 1 sampled resident observed, Resident #41. The findings included: Review of the facility policy and procedure titled Resident's Rights revised 12/13/20, documented in the Policy Statement: Life space's philosophy of care is founded upon its commitment to promote and protect the rights of each resident. Life space, is dedicated to enhancing resident's quality of life, treating residents as individuals with dignity, courtesy and respect, and promoting the right to choose the way they live and the care they receive To be treated with consideration, courtesy, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for all personal needs 1) Resident #58 was readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Diabetes, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Hypertension. He had a Brief Interview Mental Status (BIM) score of 12 (moderately impaired). During facility room tour conducted on 03/13/23 at 9:56 AM, Resident #58, was initially observed by this surveyor with his wheelchair inside of the bathroom and facing away from the inside entrance door to the bathroom, which opens outward and out of reach of the resident. Resident #58 was visibly seen from the facility hallway trying to sit on the toilet in the shared bathroom. It was also noted that there was a second outside alcove entrance door which also opens inward from the outside and which is capable of being closed for resident privacy, without disturbing the resident. Subsequently, 5 minutes later he was now seen by this Surveyor, sitting down on the toilet with his pants pulled down to his knees, and his body exposed sounding as if he were breathing heavy in an attempt to have a BM, with the door wide open, seen from hallway for a period of ten to fifteen minutes. Several staff members, to include his nurse Staff F, a Registered Nurse (RN), Staff G, a Certified Nursing Assistant, (CNA) and, an Occupational Therapist, all were observed walking by the resident's two (2) open doors, but making no attempts to either inform the resident that they would close the inside bathroom door nor any efforts to close the outside alcove door, to ensure his privacy and dignity. Photographic evidence was obtained. On 03/14/23 at 11:58 AM during a brief interview conducted with Resident #58, he confirmed via head gesture yes, that he is able to go to the bathroom on his own, but he indicated that once inside the bathroom, he is often unable to remember or be able to reach the outside door to close it. He also nodded his head yes to indicate that he did have a BM yesterday. Resident #58 further nodded his head yes in understanding, when asked by this surveyor whether or not he preferred privacy when utilizing the bathroom facilities. On 03/15/23 at 11:53 AM simultaneous interviews were conducted with both Staff F and with Staff G in which they acknowledged that privacy and dignity should have been provided to the resident. During a subsequent interview conducted on 03/15/23 at 2:28 PM with, the Occupational Therapist, she also acknowledged that privacy and dignity should have been provided to the resident. 2) Resident #41 was readmitted to the facility on [DATE] with diagnoses which included Dysphagia, Morbid Obesity, Peripheral Vascular Disease, Anxiety Disorder and Hypertension. She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During an interview, conducted on 03/14/23 at 11:11 AM, this Surveyor was engaged in conversation with Resident #41 regarding some missing items, the Maintenance Technician, Staff H, requested to enter Resident #41's room, at the time, in order to check on the hot water temperature. Resident #41 then proceeded to try and explain to him some concerns she had about some people who came into her room and sat in her wheelchair and broke it. Staff H, stated that the resident always has a tendency to say something of this nature. Staff H, went on to say that once her wheelchair brake was broken, he did fix it. However, as the resident was speaking to him, Staff H, looked away, dismissing what the resident was trying to say/explain to him. This Surveyor was disturbed by the apparent lack of listening and understanding of the resident's concerns by this Maintenance Technician. Staff H, stated to the Surveryor, she is just confused and crazy, and even made a circular motion gesture with his right hand next to his ear as if to indicate that the resident is crazy, directly in front of this Surveyor. An interview was conducted on 03/15/23 at 1:37 PM with Staff H, regarding his earlier comment and gesture referring to Resident #41; he acknowledged that this should not have been done. The DON further recognized and acknowledged on 03/15/23 at 1:37 PM, that all residents should be treated and referred to in a dignified and respectful manner at all times.