Every finding on record at Davenport Nursing and Rehab Center

Based on observations, record reviews, and interviews the facility failed to ensure transmission-based precautions were adhered to for one (#7) of one resident, failed to ensure staff completed hand hygiene appropriately while delivering meal trays and assisting residents with meals, and staff failed to manage laundry in a manner preventing cross contamination.Findings include: An observation was made on 1/26/26 at 9:52 a.m. of two signs posted on the door to Resident #7's room. The signs showed staff and visitors of Enhanced Barrier Precautions and Contact precautions were to be utilized with the residents of the room. The sign for Contact precautions instructed for all family and visitors to report to the nursing station or see staff before entering the room. The sign detailed that Everyone MUST perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear gown before entering and remove upon exiting. Wear gloves before entering and remove upon exiting. Review of Resident #7s physician orders revealed an order dated 1/9/26 for Contact Precautions. An order was written on 1/25/26 at 12:54 p.m. for the resident showing Contact precautions every shift until 03/03/26 23:59. Review of the resident's orders revealed the resident was to receive the antiviral medication valacyclovir three times a day for shingles for two weeks (1/20/26) and erythromycin ophthalmic ointment three times a day for shingles until 2/18/26 (1/20/26). An observation was made on 1/26/26 at 12:52 p.m. of Staff E, previous Nursing Home Administrator (NHA) entering Resident #7's room, without donning any Personal Protective Equipment (PPE) and sat on the resident's bed. Staff E, previous NHA stood up walked to the roommate's side of room and spoke with them before returning to Resident #7. Staff E, left the room. Staff E, stated knowing the contact precautions were for Resident #7's roommate (indicated by bed letter) but did not know the reason. Staff E reported on 1/26/26 at 12:55 p.m. of speaking out of turn, that it was Resident #7 (indicated by bed letter) on contact precautions due to shingles and put hand up to eye area. Staff E, stated but I didn't touch her. An observation on 1/26/26 at 1:02 p.m. occurred of Staff F, Registered Nurse (RN) removing the contact precaution sign from the Resident's #7's door. Staff F, RN stated staff still have to honor the sign that is posted. Review of the policy – Infection Control Guidelines for All Nursing Procedures, revised April 2013, revealed Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. An observation was made on 1/26/26 at 12:20 p.m. of Staff A, Certified Nursing Assistant (CNA) delivering meal trays to resident rooms. The staff member came out of the resident room, moved the meal cart in front of room [ROOM NUMBER], took tray from cart and delivered it to resident in the window bed, exited the room, took another meal tray from the top of the cart and delivered it to the first bed of room [ROOM NUMBER]. The staff member took a tray from the bottom of the cart and delivered it to the second bed of room [ROOM NUMBER]. The staff member removed a meal tray from the cart and delivered it to the second bed of room [ROOM NUMBER], asking another CNA to assist in repositioning the resident. The observation showed Staff A did not perform hand hygiene while delivering and setting up residents for dining. Review of the policy – Hand Hygiene, effective 5/2025, revealed The organization considers hand hygiene the primary means to prevent the spread of infection. The policy described the process of hand hygiene using soap and water and alcohol-based hand rub. The policy did not show when hand hygiene should be performed. On 1/28/26 at 12:20 p.m., an observation of Staff E, former NHA did not perform hand hygiene prior to handling food trays On 1/28/26 p.m. at 12:20 p.m. an observation of Staff R, Business Office Manager (BOM) did not perform hand hygiene prior to handling food trays. On 1/28/26 at 12:35 p.m. an observation occurred that no hand sanitizers or hand hygiene was offered to residents prior to meal service. On 1/28/26 at 12:43 p.m. Staff B, CNA was observed exiting resident room [ROOM NUMBER]. Staff B walked to a plastic container in the hallway, took a PPE gown and gloves and re-entered resident room [ROOM NUMBER]. Staff B, pulled the privacy curtain closed and donned the gown and gloves. An interview was conducted with Staff R, BOM on 1/29/26 at 11:09 a.m. who confirmed passing out meal trays on 1/28/26. Staff R stated the process for hand hygiene is after every tray passed, hand hygiene should occur. An interview conducted on 1/29/26 at 11:23 a.m. with Staff I, CNA who confirmed assisting with meal tray service yesterday. Staff I stated the process for hand hygiene when passing meal trays is to thoroughly wash hands and use hand sanitizers before entering a resident room and sanitize hands after exiting the resident room. An interview conducted on 1/29/26 at 11:34 a.m. with Staff J, CNA . Staff J, CNA confirmed passing meal trays on 1/28/26. Staff J, CNA stated completing hand hygiene with friction and in between each finger and counts 30 seconds to a minute because staff J does not like hand sanitizers. Staff J uses paper towels to touch the knobs at the sink before staff J attends the patients. Staff J repeats handwashing when attending the next resident because staff J does not like hand sanitizers. On 1/28/26 at 10:40 a.m., an observation and interview occurred with Staff P, laundry aid (LA) with the Maintenance Supervisor interpreting. Staff P, LA was observed at the nurses' station pushing a large gray bin on wheels with clear bags of laundry. Staff P, LA acknowledged the laundry was dirty and was on the way to the laundry room. Staff P was not wearing gloves. Staff P, LA entered the dirty laundry room. Staff P, LA demonstrated how she would take dirty linen into the wash area. Staff P stated she would put on gloves and retrieve the dirty clothes and place them into the washing machine. Staff P stated next would remove the gloves along with the large plastic bag in the garbage container between the two washing machines, and dispose. When the laundry cycle was complete, Staff P stated she would grab a clean cart from the dryer area. Put on gloves and transport the clean clothes from the washer via cart to the dryer area. At no time did Staff P, LA utilize the PPE (apron and elbow high gloves) hanging on the wall, nor mention using the PPE. On 01/29/2028 at 8:18 a.m., an interview with the Director of Nursing (DON). The DON stated she had heard about the incident yesterday in the laundry room and stated when handling soiled linen, the staff should wear the apron and utilize the rubber gloves provided followed by washing hands. The DON stated she knew the rubber gloves and apron were located and provided in the laundry area. During an observation on 1/28/2026 at 12:25 p.m. Staff E, Previous NHA, walked into a resident room passed a food tray, exited the room, no hand hygiene was performed. Staff E proceeded back to the meal delivery cart, removed another tray, walked to another room and set the tray on top of a PPE caddy. Staff E, donned PPE and delivered the food tray to a resident. No handy hygiene was observed. During a observation on 1/28/2026 at 12:41 p.m. in the dining room, Staff M, Registered Nurse Supervisor (RNS), moved glasses from her head to her face, removed a meal tray from the meal cart and delivered the tray to a resident at a table. Staff M, RNS removed a phone from her pocket, put the phone back in her pocket, and proceeded to re-arrange the meal trays on the cart. Staff M pulled up her pants and removed a meal tray from the cart and delivered the tray to the dining room. No hand hygiene was observed. During an observation on 01/28/2026 at 12:44 p.m. in the dining room, Staff Q, Licensed Practical Nurse (LPN), passed a meal tray to a resident proceeded back to the food cart. Removed another meal tray, set the tray on a table in front of the resident. By touching the residents' wheelchair via the handlebars, readjusted the resident to the table. Proceeded back to meal cart, rearranged the meal trays on the cart. No hand hygiene was observed. During an interview on 01/28/2026 at 1:03 p.m., Staff M, RNS stated assisting with the meal service with residents. During this process, I pass trays, observe residents to ensure they are not having any issues with eating and ensure they have the correct meals. We do hand hygiene in between each resident. I don't remember if I did hand hygiene during meal service today. During an interview on 01/29/2026 at 9:44 a.m., the Director of Nursing (DON), stated we should do hand hygiene in-between residents or when we are touching other surfaces. We should not put meal trays on PPE caddy. Review of the policy – Hand Hygiene, effective 5/2025, revealed The organization considers hand hygiene the primary means to prevent the spread of infection. The policy described the process of hand hygiene using soap and water and alcohol-based hand rub. The policy did not show when hand hygiene should be performed.

Based on interviews, observations, and record reviews, the facility failed to ensure a dignified experience during dining for two (#8 and #43) of eight residents during mealtime.Findings include: On 1/28/26 at 12:12 p.m. an observation was made on the 200 unit of staff delivering meal trays. Staff G, Certified Nursing Assistant (CNA) opened the cart stood in the hallway and said all the remaining trays are for feeders. Staff I, CNA was observed delivering a tray and stated this resident is a feeder. On 1/26/26 at 12:20 p.m. during the dining observation of the 200 unit, in the center of the hallway, Staff A, CNA asked the Assistant Director of Nursing (ADON) if a resident was a feeder prior to removing a meal tray from the cart. This continued down with Staff A asking the ADON multiple times if a resident was a feeder while standing in the hallway. On 1/28/26 at 12:30 p.m. during the meal tray delivery on the 200 unit Staff J, CNA was observed entering a resident's room, uncovered the meal tray and began assisting the resident to eat. The staff member remained standing against a thigh-high raised bed while assisting the resident with eating. On 1/26/26 at 12:32 p.m. Resident #8s meal tray was observed sitting on an over-bed table not within reach of the resident. A covered plate and covered cup of orange-colored liquid was observed sitting on the meal tray. An observation on 1/26/26 at 12:45 p.m. showed Resident #8s covered plate and cup continued to be untouched on the over-bed table. On 1/26/26 at 12:48 p.m. Staff C, Registered Nurse (RN) left Resident #8s room without acknowledging Resident #8s meal was untouched and continued to be covered. Staff A, CNA dressed in Personal Protective Equipment (PPE), at 1:06 p.m., entering the resident's room and was observed at 1:09 p.m. standing up against Resident #8s bed with the cup of orange-colored liquid in hand. The staff member was heard asking the resident if (resident pronoun) wanted it or wanted something else. The staff member stated (staff pronoun) thought the food was warm enough (was observed sitting on over-bed table for 37 minutes). On 1/26/26 at 12:58 p.m. Staff D, CNA was observed standing up at the end of Resident #43's over-bed table located next to wall, with a meal utensil in hand scooping food onto it, assisting Resident #43 to eat. A review of Resident #8's admission record revealed an admission date of 9/8/2025. A review of Resident #8's Minimum Data Set (MDS) for functional abilities, dated 12/13/2025, revealed the resident required supervision or touching assistance with eating. A review of Resident #8's care plan revealed Resident #8 has an impaired ability to self-feed related to rheumatoid arthritis and dementia as evidenced by dependence for personal care and functional limitations. A review of Resident #43's admission record revealed an admission date of 11/11/2022. A review of Resident #43's Minimum Data Set for functional abilities, dated 12/20/2025 revealed the resident is dependent, or requires the complete assistance of a helper, with eating. A review of Resident #43's care plan revealed the Resident #43 needs total care provided for all activities of daily living (ADL) needs. On 1/28/2026 at 1:20 pm, an interview was conducted with Staff G, CNA. Staff G, CNA stated food trays are passed out one by one. If a resident requires assistance the tray should be left on the cart until a staff member is available to assist the resident. Staff G, CNA said there are six residents in the 200 hall who need assistance with eating and there have been times when CNAs have to stand while assisting residents with eating because there are no additional chairs available. She stated the facility does not want CNAs to pull chairs from other rooms into resident rooms. If a chair is available, the CNAs will sit while helping. On 1/28/2026 at 1:29 pm, a follow up interview was conducted with Staff G, CNA. When asked if Resident #8 was assisted with eating, Staff G responded, the feeder?. Staff G stated she assisted Resident #8 with eating at the beginning of the meal service and forgot to remove the tray from the room. Staff G went into the resident's room at 1:30 pm and collected the tray. On 1/29/26 at 9:30 am, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is for CNAs to be seated while assisting a resident with their meal. CNAs should never be standing over the resident. The DON stated staff should assist the resident at the time the tray is taken into the room, the tray should not be left in the resident's room. The DON stated residents should never be referred to as feeders and CNAs should always knock on the resident's door before entering their room with a food tray. Review of the facility's policy titled Resident Rights, revised October 2009, revealed employees shall treat all residents with kindness, respect, and dignity. Policy and Implementation . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observations, record reviews, and interviews the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) were accurately completed and obtained prior to admission with mental health diagnoses and/or intellectual disorders for four (#5, #8, #9, and #33) of 15 sampled residents.Findings include: Review of Resident #5s admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to generalized anxiety disorder (onset 12/12/25), unspecified depression (onset 12/12/25), unspecified anxiety disorder (onset 12/12/25), and unspecified psychosis not due to a substance or known physiological condition (onset 1/8/26). Review of Resident #5s PASRR dated 12/9/25 and completed at an acute care facility showed the resident had diagnoses of anxiety disorder and depressive disorder. The PASRR did not include the diagnosis of unspecified psychosis not due to a substance or known physiological condition (onset 1/8/26). Review of Resident #5s PASRR dated 12/23/25 and completed at an acute care facility showed the resident did not have a mental illness or suspected mental illness diagnosis. The PASRR showed the resident did not have any functional limitations, no difficulty with interpersonal functioning, concentration, persistence, or pace difficulties, and or any serious difficulty in adapting to typical changes. The screening revealed the resident had no diagnosis or suspicion of a serious mental illness or intellectual disability and a level 2 screening was not required. Review of Resident #5's psychiatric admission note, dated 1/14/26, showed Resident #5 did have a psychiatric history, continued to tolerate psychiatric medications without complications, voiced no concerns with depression or anxiety but did have poor sleep. The resident had reported having a history of psychosis, depression, anxiety, and reported taking the antipsychotic medication risperidone for the past year with good effect. The mood behavior score was 4 = mild/moderate depression. The resident reported insomnia with loss of energy and aggravating factors with being in the facility, ongoing medical problems, and life stressors. The assessment/plan included adjustment insomnia, chronic recurrent moderate major depressive disorder, unspecified psychosis due to a substance or known physiological condition, and generalized anxiety disorder. An interview was conducted on 1/29/26 at 10:30 a.m. with the Social Services Director (SSD). The SSD stated the currently dated PASRR trumps an older one and a level 2 was only done if the resident was exhibiting behaviors. The SSD reviewed Resident #5's diagnoses and stated she would have to look at the resident. The SSD reviewed the PASRR dated 12/23/25 and stated she didn't know why this one was uploaded because the resident hadn't been gone for 30 days. 2. A review of Resident #8's admission record revealed an admission date of 9/8/25, with diagnosis to include but not limited to: generalized anxiety disorder. A review of Resident #8's annual minimum data set (MDS) for medication, dated 12/13/25, revealed the following under high-risk drug classes: antianxiety usage. A review of Resident #8's care plan revealed the following focus areas to include: mood and behavioral status as evidenced by/ related to behavioral disturbance and generalized anxiety disorder. A review of Resident #8's physician orders dated January 2026 revealed the following: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day for mood disorder. -Observe closely for significant side effects of anti-anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior. A review of Resident #8's PASRR, level 1 screen dated 9/2/25, revealed no diagnoses were marked under Section A-Mental Illness (MI) or suspected MI. On 1/29/26 at 10:25 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated when a resident is admitted to the facility with a PASRR, the admissions department is responsible for updating the document. The SSD stated admissions would either reach back out to the hospital to request an updated PASRR be sent to the facility or the facility would correct the PASRR. The SSD confirmed Resident #8 was admitted with a diagnosis of generalized anxiety disorder, and stated the diagnosis should have been marked on the PASRR. Review of Resident #9's admission Record revealed an admission date of 11/01/24. Resident #9 was admitted to the facility with diagnoses to include psychotic disorder with delusions due to known physiological condition (11/01/2024), insomnia (11/06/2024), depression (11/06/2024), mood disorder due to known physiological condition with mixed features (10/20/2025), and major depressive disorder, recurrent (10/25/2025). Review of Resident #9's Minimum Data Set (MDS), dated [DATE] for Medications revealed, Resident #9 received antipsychotic, antidepressant, and anticonvulsant, regularly. Review of the Level I PASRR, dated 1/23/2025, revealed: Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During an interview on 01/27/26 at 3:46 p.m., the Regional Nurse Consultant stated we do not have any Residents in house with a Level II PASRR. During an interview on 01/29/26 10:25 a.m., the SSD, stated Resident #9 receives extra psychological services. Resident #9 is seen weekly by psychotherapist. The SSD stated since Resident #9 is not currently exhibiting any behavior, we do not answer the questions on section II. Question 2. A, B, and C as yes. The SSD stated if Resident #9 was not controlled/treated, then yes, Resident #9 would have issues with interpersonal functioning. If the questions were marked yes, then it would have triggered for a level II PASRR. 4. Review of Resident #33's admission record revealed an admission date of 12/24/25, with diagnoses to include by not limited to: depression (unspecified). A review of Resident #33's MDS, dated [DATE] under Medications for high risk drug classes: revealed antianxiety and antidepressant medications, being recieved. A record review of Resident #33's physician orders showed the following: -Alprazolam oral tablet 0.5 milligram (mg) to give one tablet by mouth three times a day for anxiety/restlessness/agitation, ordered on 01/07/2026 -Duloxetine HCL (hydrochloride) oral capsule delayed release particles 60 mg to give one capsule by mouth two times a day for depression, ordered on 01/07/2026 -Hydroxyzine HCL oral tablet , give 50 mg by mouth at bedtime for anxiety, ordered on 12/24/2025. -Trazadone HCL oral tablet 50 mg, give 0.5 tablet by mouth at bedtime for depression. (0.5 tab=25 mg), ordered on 01/07/2026. A record review for Resident #33's medical record did not reveal a PASSR. On 01/29/26 at 10:40 a.m., an interview was conducted with the SSD. The SSD stated Hospice did not fill out a PASSR on the resident but agreed the PASSR would fall onto the facility to update a PASSR on the resident to capture Mental Illnesses and behaviors. During an interview on 01/29/26 at 10:55 a.m., the SSD stated we do not have a policy for PASRR we use the regulation.

Based on observations, interviews and record review, the facility failed to develop a care plan related to antipsychotic medications for one (#8) of five residents reviewed for unnecessary mediations and failed to update a care plan for wound management for one (#46) of one resident reviewed for wound care.Findings include: On 01/26/2026 at 11:28 a.m., Resident #46 was in his room asleep with a dressing noted to his foot dated 01/25/2026. A record review of Resident #46's physician orders showed the following: -Wound consult ordered on 01/07/2026 -Wound care: left medial toe cleanse with normal saline, apply Calcium Alginate with bordered dressing everyday shift for arterial wound, ordered on 01/14/2026. -Wound care: cleanse left lateral foot with normal saline, apply medicinal honey cover with dry dressing every evening shift every other day for unable to stage (UTS), ordered on 01/27/2026. -Wound care: cleanse right heel with normal saline; paint with betadine cover with border dressing and rolled gauze every evening shift every other day for UTS, ordered on 01/27/2026. A record review of Resident #46's care plan showed a focus of potential/actual impairment to skin integrity related to (r/t) abrasion initiated on 11/06/2025. On 01/29/2026 at 11:16 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident #46 has a wound and this current wound should have a care plann. The DON reviewed Resident #46's medical record and confirmed there was not a care plan for the wound to the foot. On 01/29/2026 at 11:33 a.m., the DON stated she contacted the MDS (Minimum Data Set) coordinator who stated Resident #46 was care planned for a wound. The DON reviewed the care plan again and stated the wound was imputed as an abrasion. The DON stated the wound should be marked appropriately as a pressure wound with an updated revision date. 2. A review of Resident #8's admission record revealed an admission date of 9/8/2025, with diagnosis to include but not limited to: Dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, and generalized anxiety disorder. A review of Resident #8's annual minimum data set (MDS) for medication, dated 12/13/2025, revealed the following under high-risk drug classes: antianxiety usage. A review of Resident #8's physician orders dated January 2026 revealed the following: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day for mood disorder. -Observe closely for significant side effects of anti-anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior. A Resident #8's care plan revealed there were no focus areas or interventions related to the medication administered daily for anxiety and mood disorder. An interview was conducted on 1/29/2026 at 9:52 a.m. with the MDS Corporate Director. The MDS director reviewed Resident #8's care plan and confirmed not seeing an active care plan for high-risk medication use. The MDS director said because of Resident #8's diagnosis and related medication use, Resident #8 should have care plan for high-risk medication use. A review of the facility's policy titled Care Plan- Comprehensive with an effective date of 9/01/2022, revealed the following: POLICY: Our facility .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. PROCEDURE: 2. Each resident's comprehensive care plan is deigned to: a. incorporate identified problem areas; b. Incorporate risk factors associated with identified problem; e. Reflect treatment goals, timetables, and objectives in measurable outcomes; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels .4. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are developed through an interdisciplinary process .6. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; 7. The Care Planning/ Interdisciplinary Team is responsible for the review and updating of care plans: a. when there has been a significant change in the resident's condition.

Based on observations, interviews and record review, the facility failed to provide rehabilitative therapy services in a timely manner for two (#17 and #46) out of two residents. Findings include: On 01/27/2026 at 9:57 a.m., a telephone interview was conducted with the resident representative (RR) for Resident #46. The RR stated being happy with the care provided by the facility but stated Resident #46 has not had therapy. The RR stated Resident #46 is always in bed, when he comes to visit every day. The RR stated the staff are scared to get Resident #46 out of bed because of past seizures. The RR stated Resident #46 had a swallow study during his last hospitalization and was supposed to have the swallow test repeated. The RR states not knowing the status of this repeat swallow study. The RR stated Resident #46 speaks to him and ate yogurt yesterday. The RR stated when Resident #46 originally arrived at the facility, he was talking and walking. The RR stated he knows Resident #46 can get back to his previous status. A record review of Resident #46's physician orders showed on 01/07/2026 an order for PT (physical therapy) to eval (evaluate) and treat as indicated. PT treatment by 5 x/wk (week) for 4 wks. PT treatment by thera ex (therapeutic exercise), thera act (therapeutic activities), NMR (neuromuscular re-education), group therapy, gait training and AD (assistive device). PT/Cg (physical therapy contact guard assist) safety education fall prevention/precautions. Pt (patient) discharge planning with recommendations for follow up care.A physician order, dated 01/07/2026, for Occupational Therapy Clarification order- Skilled Occupational Therapy 5 times a week for 4 weeks to include therapeutic exercise, self-care, neuromuscular reeducation, therapeutic activities, wheelchair management, safety awareness , diathermy (high frequency electromagnetic currents or ultrasound waves to generate deep heat within body tissue mobility), and ultrasound.On 01/27/2026 at 1:29 p.m., an interview was conducted with Staff K, Physical Therapist (PT). Staff K, PT stated Resident #46 was not on caseload. Staff K, PT reviewed physician orders and verified the orders, dated 01/07/2026, for physical therapy to evaluate and treat. Staff K, PT stated his director would be the one to view the order to then place the resident on a therapists calendar for evaluation or treatment. Staff K, PT showed his calendar for the day of 01/07/2026 and the day after and stated Resident #46 was not on his calendar for evaluation. Staff K, PT stated the calendar would be his only way of seeing his workload. On 01/27/2026 at 2:56 p.m., an interview was conducted with Staff L, Occupational Therapist (OT). Staff L, OT stated after looking at her documentation for Resident #46, she had completed an evaluation on 01/07/2026 but was told to discharge him off service from the administrative staff on 01/07/2026. Staff L, OT confirmed physical therapy had not seen the resident on 01/07/2026. On 01/27/2026 at 3:07 p.m., an observation was made during of the former nursing home administrator walking into the rehab gym and told Staff L, OT to, put [Resident #46] on your work order today.On 01/27/2026 at 3:28 p.m., an interview was conducted with Staff O, Interim Director of Rehabilitation(iDOR). The iDOR stated Resident #46 had an order for PT/OT evaluation and treat dated 01/07/2026 but stated she could not see any emails indicating reason to remove from the list of residents for therapy. The iDOR stated if the physician orders therapy then the facility should provide. On 01/27/2026 at 6:07 p.m., the iDOR called and stated she could not find in any of her email correspondence why Resident #46 was removed from therapy. A review of Resident #46's admission Record showed an original admit date of 11/06/2025 with a recent readmission of 01/06/2026 and diagnoses to include but not limited to:Traumatic hemorrhage of cerebrum, unspecified with loss of consciousness of unspecified duration , subsequent encounter.Epilepsy, unspecified, intractable , without status epilepticusMuscle weakness (generalized)Need for assistance with personal careDifficulty in walking, not elsewhere classifiedPost traumatic seizures. A record review of Resident #46's Minimum Data Set (MDS) admission dated 11/10/2025 showed a Brief Interview for Mental Status (BIMS) score of 12, which showed moderate cognitive impairment. Functional Abilities showed Resident #46 as independent from sit to stand, lying to sitting on side of bed, sit to lying on the side of the bed, chair/bed to chair transfer supervision or touching assistance with the ability to toilet transfer. A record review of Resident #46's MDS dated [DATE] showed a BIMS score of 99, which showed the resident was unable to complete or was not attempted. Functional Abilities showed Resident #46 showed supervision or touching assistance for walking 50 feet with two turns: the ability to walk at least 50 feet and make two turns, and not attempted due to medical condition or safety concerns; for walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. A record review of Resident #46's care plan showed: -Focus of alteration/at risk for alteration in functional performance as evidenced by: weakness and debilitation related to recent illness/hospitalization., medical condition/s limit activity tolerance, date initiated: 11/16/2025. The Goal for focus area: will achieve highest practical functional level by next review with target date of 04/09/2026. Interventions to include but not limited to:PT referral/eval/treat as indicated/ordered, date initiated 11/16/2025.Ot referral/eval/treat as indicated/ordered, date initiated 11/16/2025.Provide assist of 2 helpers with: toileting hygiene, toileting transfers, bed mobility, eating mobility dressing/grooming, date initiated 01/15/2026Report changes in functional performance, dated initiated 11/16/2025 -Focus of limited physical mobility, eval for PT OT and ST, date initiated 11/06/2025. The Goal: will increase level of mobility through the review date with target date of 04/09/2026.Interventions to include but not limited to:Provide supportive care, assistance with mobility as needed. Document assistance as needed, date initiated 11/06/2025PT, OT referrals as ordered, PRN, date initiated 11/07/2026 On 01/27/2026 at 4:07 p.m., an interview was conducted with Staff M, Registered Nurse (RN)/Supervisor. Staff M, RN, stated being told Resident #46 was custodial upon last admission by the Admissions department. Staff M, RN stated Resident #46 will lift his leg up for assistance with staff during wound dressing changes and can sit on the edge of the bed. On 01/28/2026 at 12:03 p.m., Staff K, PT stated evaluated Resident #46 yesterday (1/27/2026) and stated the resident is cognitively intact and answers questions appropriately. Staff K, PT stated Resident #46 has lost weight and would be a good candidate for therapy. Staff K, PT stated being surprised how weak Resident #46 has gotten. On 01/28/2026 at 4:23 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Both had stated being unfamiliar with Resident #46 because of their new tenure at the facility. Both agreed there was an order for PT and OT and the resident should have received therapy despite payor source. On 01/26/2026 at 2:21 p.m., an interview was conducted with Resident #17. Resident #17 stated she was still waiting for the physical therapy department to order her a new roller but has not received it. Resident #17 stated having the equipment at home and stated being ready for discharge. Resident #17 stated I will order the roller myself to be delivered here if that is what needs to be done. A record review of Resident #17's progress notes showed the following entry on 01/19/2026 13:27 (1:27 p.m.): Patient returned from [spine and pain outpatient appointment]. New orders for Eval and PT for 10 visits. Therapy notified. A record review of Resident #17's current physician orders did not show an order for physical therapy. On 01/27/2026 at 1:29 p.m., an interview was conducted with Staff K, PT. Staff K, PT stated Resident #17 was not on case load. Staff K, PT reviewed the calendar for 01/19-01/20/2026 but was unable to state if Resident #17 had been evaluated. Staff K, PT stated not having documentation to show Resident #17 had been seen by therapy. Staff K, PT stated being aware of the order for Resident #17 but was not able to follow the order without approval from administration. Staff K, PT stated the DOR will place the resident(s) on the calendar. A record review of Resident #17's care plan showed:-Focus of alteration in functional performance as evidenced by : weakness and debilitation related to recent illness/hospitalization., medical condition/s limit activity tolerance, date initiated: 8/12/2025. The Goal- [#17] will achieve highest practical functional level by next review, target date: 04/29/2026. Interventions to include but not limited to:PT referral/eval/treat as indicate/ordered, date initiated: 08/12/2025OT referral/eval/treat as indicate/ordered, date initiated: 08/12/2025A record review of Resident #17's admission Record showed an admit date of 8/04/2025 with diagnoses included but not limited to:Chronic obstructive pulmonary disease with (acute) exacerbationMuscle weakness (generalized)Unspecified abnormalities of gait and mobilityOn 01/28/2026 at 4:23 p.m., an interview was conducted with the NHA and the Director of Nursing (DON). The DON stated the progress note written should have been placed in as an order. The DON stated it was a lack of communication. The facility stated there was not a facility policy for Rehabilitative services.

Based on interview and record review the facility failed to report an allegation of neglect related to an elopement for one resident (#4) out of three residents reviewed for elopement risk. Findings included: An interview was conducted on 12/8/24 at 11:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated on 6/15/24 around 11:00 a.m. she was notified Resident #4 could not be found. The DON stated she had instructed staff to continue the search and notified the NHA. The NHA stated she instructed staff to notify the police. Review of the timeline prepared by the NHA at the time of the event showed: - On 6/15/24 at 11:00 a.m. notified by the facility Resident #4 was unable to be located. - A family member reported to the facility they saw Resident #4 sitting on the outside bench at the front of the facility. When staff went to the bench, Resident #4 was not there. The facility continued to search the building and surrounding areas. - At approximately 11:10 a.m. the facility contacted the police department for the missing resident. - At approximately 11:20 a.m. NHA arrived to the facility and an officer who was on site stated the police department would deploy a helicopter, drone and scent dogs. - At approximately 12:00 p.m. the police department contacted the facility and stated Resident #4 was found and unharmed. The police stated they would be taking Resident #4 to the local hospital per protocol. Review of the admission record of Resident #4 showed an admitted [DATE] with diagnoses including malignant neoplasm of the lung and bones, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the right side and other co-morbidities. Review of Resident #4's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/11/24 revealed in section C - Decision Making Capacity Patient [Resident #4] required a surrogate. Review of Resident #4's medical records showed a care plan with a focus dated 6/14/24, showing Resident #4 was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. Resident #4 makes needs known but has impaired decision making due to alcohol abuse. Another focus dated 6/14/24 showed Resident #4 had a mood problem related to Admission, alcohol abuse, anxiety and disease process of adult failure to thrive. A baseline care plan for Resident #4 dated 6/11/24 showed, Summary long term care admitted . Diagnosis of lung cancer with metastasis to bone and spine. Malnutrition severe. Adult failure to thrive. Neurocognitive disorder. Receiving anti-psychotropic medications. Chronic pain. Fall while in the hospital. History of substance abuse and suicidal comments . Review of Resident #4's progress notes dated 6/13/24 showed, BIMS summary score: 10 meaning resident is moderately impaired. Resident stated knowing family unable to care for him. Resident #4 states owning a house, but family cannot assist. Resident is mildly depressed and will be seen by psych. Review of the facility's Reportable Log did not show any reports related to Resident #4. On 12/8/24 at 10:30 a.m. the Nursing Home Administrator (NHA) confirmed this was a complete list of reported incidents. An interview was conducted on 12/8/24 at 11:04 a.m. with the DON and the NHA. The NHA stated an elopement would meet the requirements of needing to be reported. On 12/8/24 at 10:30 a.m. the NHA stated the facility did not have a policy specific to Elopement. Review of a facility policy titled, Reporting Abuse to Facility Management dated revised February 2014, revealed: Policy Statement: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident of or suspected incidents of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Policy interpretation and implementation: . (f.) Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Based on interviews and record review, the facility failed to ensure interventions in the comprehensive care plan were implemented for eight residents (#27, #7, #8, #10, #29, #31, #37, and #41) out of nine residents sampled for anticoagulant medications. Findings included: Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered, notify physician, and monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation, with a start date of 6/12/23. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's MAR and Treatment Administration (TAR) did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including chronic atrial fibrillation. Review of orders showed Resident #7 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for atrial fibrillation. Start date 4/10/23. -Aspirin 81 mg. Give one tablet by mouth once daily for heart failure. Start date 4/10/23. Review of Resident #7's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 4/20/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #7's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #8 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage. Review of orders showed Resident #8 had the following orders: -Eliquis 2.5 mg. Give one tablet by via peg tube twice daily for atrial fibrillation. Start date 10/7/22. Review of Resident #8's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 11/25/19. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #8's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #10 was admitted on [DATE] with diagnoses including acute embolism and thrombosis of left popliteal vein and iron deficiency anemia secondary to blood loss. Review of orders showed Resident #10 had the following orders: -Eliquis 2.5 mg. Give one tablet by mouth twice daily for deep vein thrombosis prevention. Start date 10/7/22. Review of Resident #10's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/27/22. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #10's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #29 was admitted on [DATE] with diagnoses including history of thrombophlebitis. Review of orders showed Resident #29 had the following orders: -Xarelto 20 mg. Give one tablet by mouth one daily for bilateral lower extremities thrombophlebitis. Start date: 12/26/22. Review of Resident #29's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/4/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #29's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #31 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Review of orders showed Resident #31 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 10/7/22. -Aspirin 81 mg. Give one tablet by mouth once daily for CAD clot prevention. Start date 11/19/21. Review of Resident #31's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 12/2/21. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #31's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #37 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Review of orders showed Resident #37 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 5/3/23. Review of Resident #37's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 5/17/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #37's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #41 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation. Review of orders showed Resident #41 had the following orders: -Xarelto 15 mg. Give one tablet by mouth once daily for atrial fibrillation. Start date: 7/6/23. Review of Resident #41's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 7/18/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #41's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. An interview was conducted on 10/3/23 with Staff A, Registered Nurse (RN.) Staff A, RN said they do not have side effect monitoring documentation for residents on anticoagulants. An interview was conducted on 10/4/23 at 10:01 a.m. with Staff B, RN. Staff B, RN said they do not have a flow sheet or monitoring to sign on specific to anticoagulant use or signs and symptoms of bleeding. An interview was conducted with the Director of Nursing (DON) on 10/4/23 at 9:57 a.m. The DON said there is not a flow sheet for nurses to monitor for signs and symptoms of bleeding for residents on anticoagulants. She confirmed there is no documentation for anticoagulants triggered on the MAR or TAR. The DON said she would have to check and see if it is noted on the right side of the order sheets. She was observed pulling out an order sheet and confirmed nothing is noted on the order sheet for the nurses to watch for signs and symptoms of bleeding related to anticoagulant use. The DON said there should be monitoring and documenting for signs and symptoms of bleeding for residents on anticoagulant therapy. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the following: Policy: Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record.

Based on interviews and record review the facility failed to refer five residents (Residents #7, #16, #25 #40 and #41) of 14 residents reviewed for Pre-Admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a level II PASRR resident review upon a significant change in status assessment. Findings included: Review of Resident #7's admission record showed Resident #7 was readmitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, moderate. The level I PASRR dated 08/30/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #16's admission record showed Resident #16 was readmitted to the facility on [DATE] with a diagnosis of Anxiety disorder, unspecified, Unspecified mood [affective] disorder and Vascular Dementia, unspecified severity, with mood disturbances. The level I PASRR dated 01/24/22 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #25's admission record showed Resident #25 was readmitted to the facility on [DATE] with diagnoses of Vascular Dementia, unspecified severity, with agitation, Anxiety disorder, unspecified, Bipolar disorder, unspecified, and Schizoaffective disorder, bipolar type. The level I PASRR dated 06/06/2020 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) was marked for Bipolar Disorder and Depressive Disorder but not for Anxiety disorder or Schizoaffective disorder. Review of Resident #40's admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, recurrent, unspecified, Anxiety disorder, unspecified and Vascular Dementia, severe, with mood disturbances. The level I PASRR dated 07/21/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident 41's admission record showed Resident #41 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, recurrent, moderate, Mood disorder due to physiological condition with depressive features, Unspecified mood [affective] disorder and Vascular Dementia, unspecified severity, with mood disturbances. The level I PASRR dated 06/16/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated, when a Resident gets a new psych diagnosis the Resident should be submitted for a level II PASRR review. The DON reviewed and confirmed the five PASRR's were not correct for Residents' #7, #16, #25, #40 and #41 and stated those Residents should have been submitted for a level II PASRR review upon being diagnosed with a new psych diagnosis. Review of the facility's Policies and Procedures titled, Preadmission Screening and Resident Review (PASRR), dated 11/08/2021 showed 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for service will be followed.

Based on interviews and record review the facility failed to ensure five residents (Residents #10, #12, #18, #23 and #43) of 14 residents reviewed for Pre-Admission Screening and Resident Review (PASRR) had a level I completed prior to admission and two residents (Residents #7 and #40) of 14 residents had a level I PASRR completed by an appropriate and authorized staff member. Findings included: Review of Resident #10's admission record showed Resident #10 was admitted to the facility on [DATE] with diagnoses of displaced interochanteric fracture of right femur, subsequent for closed fracture with routine healing, Iron deficiency, lack of coordination and abnormalities of gait and mobility. There was no PASRR available to review in Resident #10's medical chart. Review of Resident #12's admission record showed Resident #12 was admitted to the facility on [DATE] with diagnoses of psychotic disorder with delusions due to know physiological condition, major depressive disorder, recurrent, unspecified, generalize anxiety disorder and post Traumatic Stress Disorder, chronic. There was no PASRR available to review in Resident #12's medical chart. Review of Resident #18's admission record showed Resident #18 was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified, major depressive disorder, recurrent, moderate and unspecified dementia, severe without behavioral disturbance. There was no PASRR available to review in Resident #18's medical chart. Review of Resident #23's admission record showed Resident #23 was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified and insomnia. There was no PASRR available to review in Resident #23's medical chart. Review of Resident #43's admission record showed Resident #43 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of the cerebrum, unspecified without loss of consciousness and bipolar disorder, unspecified. There was no PASRR available to review in Resident #43's medical chart. During an interview on 10/03/23 at 4:07 p.m., the Director of Nursing (DON) stated that if there was no PASRR in the hard copy medical chart then there was not a PASRR available. The DON reviewed Residents #10, #12, #18, #23 and #43 medical charts and confirmed there were no PASRRs available for review. Review of Resident #7's admission record showed Resident #7 was readmitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, moderate. The level I PASRR dated 08/30/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #40's admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, recurrent, unspecified, Anxiety disorder, unspecified and Vascular Dementia, severe, with mood disturbances. The level I PASRR dated 07/21/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated when a Resident gets a new psych diagnosis the Resident should be submitted for a level II review. The DON stated that she had never completed a PASRR in the facility because she had never been given access to the system and allowed to complete PASRR. The DON stated the previous Nursing Home Administrator (pNHA) always completed them because the pNHA was the only person in the facility who had access to the PASRR system. The DON reviewed Resident #7's PASRR dated 08/30/23 and Resident #40's PASRR dated 07/21/23 and confirmed both were not correct and Resident #7 and #40 should have been submitted for a level II review. During the review of Resident #7 and #40's PASRRs the DON noticed the PASRRs were electronically signed with the DON's name and credentials. The DON shook her head no and again stated she never had access to the PASRR system and these PASRRs had been signed falsely. The DON stated she never discussed with anyone information about these two PASRRs and these PASRRs had been signed with her name and credentials without her permission and her knowledge. During an interview on 10/03/2023 at approximately 3:50 p.m., the DON called the Social Service Director (SSD) on the phone for a phone interview. While on speaker phone with the survey team the SSD stated the only person in the facility who had completed any PASRR was the previous NHA (pNHA) and no PASRR was needed to be completed since the pNHA left in September 2023. The SSD confirmed all PASRRs were completed in the state portal and that only the pNHA had ever had access to that portal. Review of the Kepro FL [Florida] PASRR Provider Portal Frequently Asked Questions (FAQ) website on 10/03/23 (https://floridapasarr.kepro.com) Level 1 Review showed Who is able to complete a Level I screening? Anyone who works for a hospital or nursing facility and holds the following credentials: Masters of Social Work, or license in the State of Florida as a Clinical Social Worker (LCSW), Mental Health Counselor (LMHC), Physician (MD/DO), Physician Assistant (PA), Registered Nurse (RN), or Psychologist. During an interview on 10/03/2023 at 4:20 p.m., the previous Nursing Home Administrator (pNHA) stated she had worked for the facility for two years prior to leaving on 09/08/2023. The pNHA stated most of the time PASRRs did not need to be completed at the facility as most residents came to the facility with the PASRRs completed by the hospital prior to admission to the facility. The pNHA stated she was the only staff member in the facility that had access to the PASRR portal in Kepro. The pNHA stated she only remembered a couple of PASRRs she had to complete because the Residents did not come with a PASARR. The pNHA stated she remembered both she and the DON sat down and completed the PASARR together but the pNHA had to submit the PASARR as the DON did not have access to the PASRR online system. The pNHA stated when signing the PASRR electronically it was submitted by just typing the name down and submitting the form. During an interview on 10/03/23 at 4:35 p.m., The DON stated,No, I never did any PASRRs with [name of previous Nursing Home Administrator] The DON stated I never talked about any PASRRs with the pNHA and never sat down with her. The pNHA was the only person with access to the PASRR system and the pNHA signed my name falsely without my permission and without my knowledge. Review of the facility's policy Preadmission Screening and Resident Review (PASRR) dated 11/08/2021 showed 1. It is the responsibility of the center to assess and assure the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for service will be followed.

Based on observations, interviews, and record review the facility failed to ensure proper infection control practices related to handwashing, cleaning of reusable equipment, and washing of reusable water pitches in two of two resident halls. Findings included: An observation was made on 10/1/23 at 9:18 a.m. of a bedpan sitting in a basket in the bathroom of Resident #7. The bedpan was uncovered, and wet washcloths were in the basket with it. Resident #7 said the bedpan had been sitting in her bathroom like that since she had to give a urine sample several days ago. (Photographic evidence obtained.) Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including urinary tract infection (UTI). Review of Resident #7's quarterly Minimum Data Set (MDS,) dated 7/14/23, Section C, Cognitive Patterns showed her Brief Interview for Mental Status (BIMS) score was 12, indicating she had moderately impaired cognition. Review of Resident #7's laboratory documents showed she had a urinalysis collected on 9/25/23. An interview was conducted on 10/4/23 at 3:25 p.m. with Staff A, Registered Nurse (RN.) She said Resident #7 uses the toilet in her room and she didn't know why the bedpan was there. She said it is possible the resident uses it at night. An interview was conducted on 10/4/23 at 2:22 p.m. with the Director of Nursing (DON.) She reviewed the photo of the bedpan in the bathroom of Resident #7. The DON confirmed the bedpan and used washcloths should not have been left in the bathroom. She said a straight catheter should have been used for the urine sample. An observation was made on 10/3/23 at 9:01 a.m. of Staff A, RN using a blood pressure cuff on two different residents during medication pass without cleaning the blood pressure cuff between residents. The blood pressure cuff was observed to be a wrist cuff that was made of a cloth material. The cloth was observed to have soiled spots on it. (Photographic evidence obtained.) During this same medication pass, Staff A, RN took a resident's blood pressure, returned to the cart without performing hand hygiene, gathered medications, realized a medication was not in the cart, called a provider from her cell phone, went to the medication room to access the emergency drug kit, signed out the medication, returned to the cart, then went to the resident room to administer medications. Throughout this process no hand hygiene was performed. An interview was conducted on 10/4/23 at 2:20 p.m. with Staff A, RN. Staff A, RN said the blood pressure cuff should be cleaned between each resident. She said she usually wipes it with the cleaning wipes in her cart. Staff A, RN confirmed the blood pressure cuff was cloth on the inside portion that touches the residents. She said you can't use sanitizer or anything liquid because the cuff will stay wet. She said the wipes work ok. An interview was conducted on 10/4/23 at 2:22 p.m. with the DON. The DON said the blood pressure cuffs should be cleaned between every resident. When asked about the wrist cuffs being used, she said those are the nurses' personal blood pressure cuffs, they do not belong to the facility. The DON looked at the blood pressure cuff and acknowledged the cloth could not be sanitized. The DON also confirmed staff should be performing proper hand hygiene every time they go in and out of a resident room. An observation was made on 10/2/23 at 10:55 a.m. of a Certified Nursing Assistant (CNA) refilling resident's pink plastic water pitchers for the morning. The CNA was observed picking up a water pitcher from a resident's bedside table, dumping the water in the sink, taking it to a cooler in the hallway, filling it with ice and water, and she then returned it to the resident's tray table. The CNA did not wash the pitcher prior to refilling. The pitcher did not have a date or label on it. The CNA finished in one resident's room and proceeded to another resident's room to repeat the process without completing any hand hygiene. 49227 On 10/01/23 during an interview Resident #12 said the facility no longer uses Styrofoam cups and pointed to a pink plastic water pitcher on her bedside table, labeled with her room number and bed assigned. (Photographic evidence obtained) On 10/01/23 a Certified Nurse Assistant (CNA) was observed refilling pink plastic hydration pitchers and returning them to residents. On 10/02/23 CNAs were observed removing, sometimes rinsing in the bathroom sink, refilling, and returning pink plastic hydration pitcher to residents. On 10/03/23 during a random interview a CNA said that she rinses out the pink plastic hydration pitchers, refills and returns them to the residents. During an interview on 10/03/23 at 10:20 a.m., the Dietary Manager said most residents use Styrofoam cups and We do not have to wash for hydration the pink plastic hydration pitcher should be washed in the Dietary department after every use. During an interview on 10/03/23 at 10:25 a.m., Staff A, Dietary Assistant said, No, we don't wash those pink pitchers, I haven't seen them. During an interview on 10/03/23 at 10:30 a.m. with Staff C, CNA , about the pink plastic hydration pitcher said, When I fill them, I usually wash the pitcher out myself first and then refill. On 10/04/23 during a tour of the Laundry Department (LD) clean linen was observed in a room between the washing machines and the maintenance and housekeeping hallway with two doors propped open. (Photographic evidence obtained) On 10/04/23 at 02:38 p.m., during an interview the DON stated the process to wash the pink plastic hydration pitchers had not been determined prior to distributing to each resident and she had not observed the clean linen storage in the LD. A review of the facility's policy titled, Cleaning and Disinfecting of Resident Care Items and Equipment, dated 12/2008, revealed the following: Policy statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations, for disinfection and OSHA Bloodborne Pathogen Standard. Procedures to include: 2) Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) use 3) Durable Medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4) Equipment that is designated reusable shall be used by more than one resident A review of the facility's policy titled Handwashing/ Hand Hygiene policy, revised April 2012, revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedures: 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact; i. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse of blood pressure); v. After completing duty. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: a. Before and after direct contact with residents; d. Before preparing or handling medications; g. After contact with a resident's intact skin; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on interviews and record review, the facility failed to ensure the residents' medical records included documentation 1)indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, and 2) the resident had received or had not received the immunization due to medical contraindications or refusal for five (# 7, #12, #37, #246 and #296) out of five resident for immunizations. Findings included: A review of the facility's admission forms, provided to all new admissions, did not reveal influenza and pneumococcal immunization education, or consents related to vaccines. A review of the medical records for Residents #7, #12, #37, #246, and #296 revealed no documentation indicating 1) the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, or 2) the resident had received or had not received the immunizations due to medical contraindications or refusal were located in the medical records. On 10/03/23 at 2:36 p.m. an interview was conducted with the Director of Nursing (DON), she stated vaccine status can be found in the admission section of the medical record. During a review of Resident # 12's medical record with the DON, she verified vaccine information was missing. The DON said she would check the Online Immunization Information System for documentation regarding immunizations for Residents #7, #12, #37, #246, and #296. On 10/04/23 at 1:00 p.m. the DON confirmed she did not find 2022 influenza vaccine or pneumonia vaccine documentation for Residents #7, #12, #37, #246, and #296. The facility did not provide a requested policy related to resident vaccines by the exit of the survey team on 10/4/23 at 4:45 p.m.

Based on interviews and record review, the facility failed to ensure a discharge care plan was in place, a discharge summary was completed, and post care discharge plans were documented for one resident (#45) out of 3 residents sampled for discharge. Findings Include: A review of the face sheet revealed Resident # 45 was admitted to the facility on [DATE], and was discharged on [DATE], with diagnosis to include but not limited to Parkinson's disease, Alzheimer's disease, unspecified, Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified, chronic obstructive pulmonary disease, and major depressive disorder. A review of the medical record revealed no physician discharge order, no discharge summary, and no post care discharge plan was present for Resident #45's discharge on 7/14/2023. On 10/4/2023 at 3:22 PM., an interview was conducted with the Director of Nursing (DON). The DON said when she reviewed Resident #45 medical record, she found no discharge physician order and no documentation indicating a post-discharge plan, and discharge summary was completed. The DON said the normal process was a discharge summary should have been completed with all the Interdisciplinary Team, the nurse would write a discharge note and the physician would provide a discharge order to permit the resident to leave the facility. On 10/4/2023 at 3:43 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO said she do not have a discharge policy because she has not had a chance to update the policy for the facility.

Based on interviews and record review, the facility failed to ensure laboratory results were completed as ordered and results were tracked for two residents (#27 and #9) out of 14 residents sampled. Findings included: Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation with a PT (Prothrombin time)/INR (International normalized ratio) lab to be drawn every Monday, with a start date of 6/12/23. PT measures how long it takes for a clot to form in a blood sample and INR is a calculation based on PT results. The PT/INR is used to monitor the effectiveness of the anticoagulant Warfarin. On 10/1/23 a review of Resident #27's lab results showed a PT/INR result dated 9/18/23 as high at 20.3 with a reference range of 9.6-12.2. The results for the next lab, due to be drawn on 9/25/23, could not be found. Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery. The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered and notify physician. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's Treatment Administration Record (TAR) showed the PT/INR to be drawn on 9/25/23 was signed off as completed. Review of admission records showed Resident #9 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #9's orders showed the following: -Depakote Sprinkles 125 mg once a daily. 6/16/23 discharged [DATE]. -Depakote Sprinkles 125 mg three times a day. 9/22/23. -Depakote and Ammonia Levels every six months. September and March. 9/22/23 Review of Care plans for Resident #9 showed a plan in place for Seizure Disorder. Interactions/Approaches included monitor lab values per orders and report to physician. Review of the laboratory book showed the resident's Depakote level was drawn by the lab on 9/29/23. However, no results could be found in the medical record. An interview was conducted on 10/2/23 at 2:02 p.m. with the Director of Nursing (DON). The DON said she knows Resident #27's PT/INR was drawn on 9/25/23 because it was signed off in the lab book by the phlebotomist. (Lab book with phlebotomist initials observed). The DON reviewed the record as well as several other locations and said she didn't know where the results were. She said she would contact the lab to get the results of the PT/INR. The DON was observed reviewing the medical record of Resident #9. She confirmed she could not find the results for the Depakote level drawn on 9/29/23. The DON said the lab book shows it was drawn but she doesn't know where the results are and confirmed she had not seen any results. On 10/2/23 at 3:10 p.m. the DON provided a copy of the results of Resident #9's Depakote level drawn on 9/29/23. She said she had to call the lab and get them to send over the results. She stated the resident's Depakote level was low and she notified the doctor. Review of Resident #9's lab results showed the Depakote level (Valproic acid) was drawn on 9/29/23 and the results were reported on 9/29/23. The Valproic Acid level was low at 33.4 with a reference range of 50.0-100.0. The Valproic Acid lab measures the amount of anticonvulsant medication in the blood sample. On 10/2/23 at 3:50 p.m. the DON said she still did not have the results of Resident #27's PT/INR. She said the lab continues to only fax the results for her lab drawn on 9/18/23 and she didn't understand why. On 10/3/23 at 10:05 a.m. the DON confirmed she still does not have results for Resident #27's PT/INR from 9/25/23. A phone interview was conducted on 10/3/23 at 12:31 p.m. with the laboratory the facility uses for testing. The lab said all results are faxed to the facility since they do not use electronic charting. They said the PT/INR lab results are faxed first then all other labs follow. They also said the facility can login to the computer and see all lab results. The lab looked up Resident #27's record and said no lab was drawn on 9/25/23. An interview was conducted on 10/3/23 at 12:48 p.m. with the DON. When asked how the facility tracked labs to ensure they were completed and results returned she said they do not track that and added, we should. The DON said labs results are returned the same day they are drawn, typically on the 3:00-11:00 p.m. shift. The DON said if a nurse is administering Warfarin, they should make sure the lab results were ok. She confirmed the nurses continued to administer Warfarin to Resident #27 without having lab results to review. Staff A, Registered Nurse (RN) joined the interview. Staff A, RN said labs are drawn in the morning and it is usually passed down during nurse-to-nurse report at shift change since results typically come back on the 3:00-11:00 p.m. shift. The DON and Staff A, RN reviewed Resident #27's medical record and confirmed there was no documentation the resident had refused for the lab to be drawn. Neither the DON or Staff A, RN were aware no results had come back and agreed no one followed up with the lab to check on them. An interview was conducted on 10/3/23 at 12:52 p.m. with the Chief Nursing Officer (CNO). The CNO was notified of labs not being tracked to see if they were completed or if results came back. She stated, We will have to fix this. The CNO said the DON should take the lab book with her to every morning meeting to review what should have been completed the day prior. An interview was conducted on 10/3/23 at 3:56 p.m. with Resident #27's primary physician. He said he would have expected to have been notified if a lab had been missed and of abnormal lab results. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the following: Policy: Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record.

Based on observations, interviews, and record review, the facility did not ensure the kitchen was maintained in a sanitary manner and food was stored appropriately related to cleanliness of the walk -in cooler and freezer, storage and dating of opened foods, and repair of a leaking pipe in the dishwashing area. Findings included: An initial kitchen tour was conducted on [DATE] from 9:15 a.m. to 9:45 a.m., facilitated by Staff E, Cook. Photographic evidence of the following observations was obtained. During the tour of the walk -in cooler a 1-gallon bottle of soy sauce was noted with bio growth inside, dated opened [DATE]. A carton of French vanilla coffee mixer noted please do not use, for Christmas party dated [DATE]. A bottle French vanilla coffee mix next to the carton was noted with bio growth inside. Staff E who saw the bio growth stated, That is not good. we will throw them out. In the walk-in cooler, a tube of ground beef thawing in a shallow pan was observe on the bottom shelf noted leaking blood, overflowing to the floor of the cooler. Above the ground beef that was thawing, a pipe going through the cooler wall was noted with bio-growth on the base of the pipe. Bio- growth was also observed on the door to the main freezer within the cooler. The inside of the freezer was observed with plastic dividers on the doorway, mounted with built up frost and icicle formations. Staff E said, Be careful, the floor is slippery because of the melting ice. Staff E stated that this had been an on-going problem. The floor of the freezer was noted with brown-looking matter, food crumbs, and red-saucy paste dried on the floor. On the freezer shelves, yellow looking-icy melting formations were observed dripping on an opened box of ice-cream cups. An unlabeled, undated small bowl with a yellow frozen food item was observed wrapped in plastic food wrap. Staff E stated, It looks like ice-cream. It should not be there. She stated she would toss it. Staff E stated that all food items should be labeled and dated. Staff E was asked how often the freezer and walk -in cooler were cleaned. Staff E said, We should clean more. Staff E stated that CDM (Certified Dietary Manager) oversees the scheduling. During a tour of the dry good storage area, a bag of noodles not labeled, dated, or properly sealed was observed on the shelf. A tour of the main kitchen area revealed a pipe leaking underneath the dishwashing table. A blue tub was noted collecting the dripping water and towels laid around to catch the overflow. On [DATE] at 9:39 a.m., an interview was conducted with Staff F, Dietary Aide. Staff F stated that the pipe had been leaking for a few days, but she could not remember how long. Staff F said, it was recent. The CDM is aware. On [DATE] at 12:41 p.m., an interview was conducted with the CDM. He stated that they would throw out the expired food items and clean the freezers. He said that they have called a plumber for the leaking pipe and are awaiting parts for repairs. The CDM stated that the pipe had been leaking only a few days. On [DATE] at 12:06 p.m., a review of kitchen concerns was discussed with CDM and RD (Registered Dietician). After reviewing photographic evidence, the CDM stated that he cleaned out the freezer and cooler and threw out all the items that were expired and that were with bio growth. The CDM said, We should not have kept it there. It should not be served to the residents. The CDM stated that the freezer door did not close very well and hence the built-up frost and melting ice. He said he was aware of the on-going concern. The RD said, All food that is open should be tightly sealed and dated. On [DATE] at 1:33 p.m., an interview was conducted with NHA (nursing home administrator). She said she was notified by the RD and the CDM of the concerns identified in the kitchen. The NHA said she understood there was a problem with excessive frosting and some food items not properly stored. She said her expectation was that the facility maintained a clean and sanitary environment. Review of an undated facility policy titled, Food Storage revealed that food items should be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: all products should be dated upon receipt and when they are prepared. Leftovers should be dated according to the leftover policy. Remember to cover, label and date Storage: (3.) Foods to be frozen should be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Label and date all food items. Thawing: (4.) Thaw meat by placing in deep pans and setting on lowest shelf in refrigerator. Storage: (2.) The walls, ceiling and floors should be maintained in good repair and regularly cleaned.

Based on observation, record reviews, and interviews, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives for two (Resident #19 and Resident #12) of four sampled residents for hospitalization s. Findings included: 1) On 9/8/21 at 10:40 a.m., Resident #19 was observed lying in the bed covered with a blanket. An attempt to interview the resident revealed the resident to be confused and unable to answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Minimum Data Set, dated dated [DATE], for Resident #19 revealed a Brief Interview of Mental Status score of 03, indicating severe cognitive impairment. A review of the medical record revealed Resident #19 had an order to send to the emergency room for evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the resident was sent to the emergency room for further evaluation via 911 call for an ambulance. A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge Notice completed on 6/6/21 for Resident #19. The first page of the form indicated a Resident Representative with name, address, and phone number listed. The reason for discharge/transfer was listed as needs cannot be met in this facility. The second page of the form had the name of the Resident Representative written in and a date of 6/6/21. Verbal Consent was written under the signature line. On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer that took place on 6/6/21. He stated the facility always called him, but he could not state that he received anything officially in writing. 2) On 9/09/21 at 4:11 p.m., Resident #12 was observed lying in the bed with the head of the bed elevated. The resident was observed with a tube feeding running via pump at 45 milliliters per hour. The resident was moaning continuously. The resident was not able to communicate or answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Minimum Data Set for Resident #12, dated 6/13/21, revealed a Brief Interview of Mental Status score unable to be determined due to the resident being rarely/never understood. A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the resident was sent to the emergency room for further evaluation via ambulance. A review of transfer documents provided by the facility revealed a Nursing Home Transfer and Discharge Notice completed on 8/5/21 for Resident #12. The first page of the form indicated a Resident Representative with name, address, and phone number listed. The reason for discharge/transfer was listed as needs cannot be met in this facility. The second page of the form had the name of the Resident written in and unable to sign with a date of 8/5/21. On 9/9/21 at 4:21 p.m., an interview was conducted with the Administrator and the Director of Nursing. The Administrator stated the transfer document and Ombudsmen notice was her responsibility once a resident was transferred. She stated she got the transfer document ready, and she faxed the document to the Ombudsmen's office. The Administrator stated she did not send a copy of the transfer form to the Resident Representative in the event the Resident did not have capacity for health care decision. The Administrator and the Director of Nursing stated they were not aware the documents needed to be sent in writing to Resident Representatives. The Administrator confirmed she had not sent the written notifications for transfer to either Resident Representative for Resident #19 or Resident #12. On 9/9/21 at 4:45 p.m. a telephone message was left for the Resident Representative listed for Resident #12. The call was not returned. A facility policy was requested from the Administrator and Director of Nursing regarding requirements for written notification of transfer/discharge. The facility stated there was no such policy for this requirement.

Based on observation, record reviews, and interviews, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for two (Resident #19 and Resident #12) of four sampled residents for hospitalization s. Findings included: 1) On 9/8/21 at 10:40 a.m Resident #19 was observed lying in the bed covered with a blanket. An attempt to interview the resident revealed the resident to be confused and unable to answer any questions related to care and services. A review of the Resident Face Sheet (undated), revealed that Resident #19 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Minimum Data, dated 6/28/21, Set for Resident #19 revealed a Brief Interview of Mental Status score of 03, indicating severe cognitive impairment. A review of the medical record revealed Resident #19 had an order to send to the emergency room for evaluation due to a fall dated 6/6/21. A review of the nursing notes indicated on 6/6/21 at 5:48 a.m., the resident was sent to the emergency room for further evaluation via 911 call for an ambulance. A review of the Bed Hold Policy indicated on 6/6/21, the policy was verbally communicated to the Resident Representative at 5:18 a.m. On 9/10/21 at 11:09 a.m., a telephone interview was conducted with the Resident Representative for Resident #19. The Representative stated he did not recall seeing any written letters regarding the transfer that took place on 6/6/21. He stated the facility always calls him, but he could not state that he received anything officially in writing. 2) On 9/09/21 at 4:11 p.m. Resident #12 was observed lying in the bed with the head of the bed elevated. The resident was observed with a tube feeding running via pump at 45 milliliters per hour. The resident was moaning continuously. The resident was not able to communicate or answer any questions related to care and services. A review of the Resident Face Sheet( undated), revealed that Resident #12 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Minimum Data Set, dated dated [DATE], for Resident #12 revealed a Brief Interview of Mental Status score unable to be determined due to the resident being rarely/never understood. A review of the medical record revealed Resident #12 had an order to transfer to the emergency room for evaluation and treatment dated 8/5/21. A review of the nursing notes indicated on 8/5/21 at 5:15 p.m., the resident was sent to the emergency room for further evaluation via ambulance. A review of the Bed Hold Policy indicated on 8/5/21 the policy was given to the resident and sent to the emergency room with resident. The signature line of the bed hold policy had resident unable to sign written on it. On 9/9/21 at 4:21 p.m. an interview was conducted with the Administrator and the Director of Nursing. The Administrator stated nursing was responsible for sending the bed hold policy with the resident if they could sign the document. The Administrator stated she did not send a copy of the bed hold policy to the Resident Representative in the event the Resident did not have capacity for health care decision. The Administrator and the Director of Nursing stated they were not aware the bed hold policy needed to be sent in writing to Resident Representatives. The Administrator confirmed she had not sent the bed hold policy to either Resident Representative for Resident #19 or Resident #12. On 9/9/21 at 4:45 p.m., a telephone message was left for the Resident Representative listed for Resident #12. The call was not returned. facility policy was requested from the Administrator and Director of Nursing regarding requirements for written notification of the bed hold policy. The facility stated there was no such policy for this requirement.

Based on observations, interviews, and record reviews, the facility failed to provide necessary services to maintain good nutrition for one (Resident #40) of one resident sampled for Activities of Daily Living (ADLs). Findings included: A review of Resident #40's Medical Record revealed that she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's Quarterly Minimum Data Set (MDS) Assessment, dated 08/13/2021, revealed under Section G - Functional Abilities, that Resident #40 required Extensive Assistance with one person physical assistance with eating. A review of Resident #40's Care Plan revealed a problem, dated on 02/16/2021, that Resident #40 needed extensive assistance with ADLs related to [CONDITION(S)] and decreased range of motion with a goal for Resident #40 to receive level of assistance required to maintain or improve present level. Interventions included to ensure all needs are met and assist with feeding of meals. The Care Plan also revealed that the resident could hold a cup and some finger foods with her left hand. Her Care Plan also revealed a problem, dated on 02/04/2021, that she was at risk for decline in nutritional status related to a therapeutic diet, impaired skin, depression, and [CONDITION(S)] with a goal for her to consume greater than 75 percent of meals and for the resident to be adequately hydrated. Interventions included to provide diet as ordered, observe resident's food intake, document on flow sheet, and assist with dining as needed. An interview with Resident #40 was conducted on 09/08/2021 at 11:00 a.m. She stated that she suffered from bad arthritis and that the Certified Nurse's Aide's (CNA's) assisted her during her meals due to her not being able to hold regular utensils very well. Resident #40 also stated that she was able to grip some items with her left hand and that she was not able to move her right hand. She stated that she had received therapy services at the facility previously and was supposed to have a special utensil to assist her with feeding herself, but the utensil was never brought to her. An observation was conducted on 09/08/2021 at 12:46 p.m. of Resident #40 during lunch meal service. The resident was observed sitting up in her bed during lunch service. She was observed attempting to feed herself lunch but was not able to grip a regular fork with her left hand. An interview was conducted with her following the observation. She stated that she attempted to balance the fork with her left 5th finger while taking bites of food but that it doesn't work very well. Resident #40 also stated that she would usually end up getting food all over herself during her meal and that she needed assistance with her meal. She stated that she would like a drink of her tea that came with her lunch meal, but she was not able to hold a regular cup with her left hand. A follow up observation was conducted on 09/08/2021 at 1:09 p.m. of Resident #40 during the lunch meal. She was not observed eating at the time of the observation and had only consumed 25 percent of her lunch meal. She stated, I'm ready to give up. She was not observed being provided assistance during the meal service. A review of Resident #40's Quarterly Minimum Data Set (MDS) Assessment, dated on 08/13/2021, revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status score of 13, which indicated that the resident was cognitively intact. Her MDS Assessment also revealed under Section G - Functional Status, that she required Extensive, one person physical assistance with eating. An observation was conducted on 09/09/2021 at 12:53 p.m. of Resident #40 during lunch meal service. She was observed sitting up in her bed during lunch service. She was observed attempting to feed herself lunch using a regular fork to feed herself ground chicken and rice. She stated that she was having a lot of difficulty trying to feed herself and was observed with several bits of food on her gown. An observation was conducted at 09/09/2021 at 1:28 p.m. during lunch service. The Director of Nursing (DON) was observed entering Resident #40's room and asked Resident #40 what can I help you with?. Resident #40 stated that she had dropped her spoon somewhere in her bed and she was not able to grab it. The DON left the room and brought the resident another spoon. Resident #40 asked the DON to assist her with taking a drink of her orange juice. Facility staff were observed removing Resident #40's lunch tray at 1:45 p.m. and Resident #40 stated that she was finished. The resident had consumed less than 25 percent of the meal. An interview was conducted on 09/09/2021 at 2:58 p.m. with the Therapy Director (TD). The TD stated that Resident #40 had been assessed for self feeding abilities previously and that they wanted to trial a universal cuff (a wrist cuff which holds a utensil) to assist Resident #40 with self feeding. The TD stated that the resident was not able to be trialed with the universal cuff because they did not have one in the facility. The TD also stated that the facility's Nursing Home Administrator (NHA) had attempted to order the universal cuff for Resident #40, but it was on back order. The TD stated that Resident #40 definitely required assistance with meals until the universal cuff could be trialed and that Resident #40 had difficulty feeding herself with regular utensils. A review of Resident #40's Occupational Therapy Treatment Encounter Notes, dated on 06/21/2021, revealed that Resident #40 reported increased difficulty with grasping of utensils during self feeding and that Resident #40 required minimum to moderate assistance for self feeding. Resident #40's Occupational Therapy Treatment Encounter Notes also revealed a note, dated on 07/28/2021, which documented that Resident #40 was assisted with self feeding while awaiting adaptive equipment. An interview was conducted on 09/09/2021 at 4:31 p.m. with the NHA. The NHA stated that she attempted to order the universal cuff for Resident #40 but the device was on back order from the supplier. A request was made for verification for placement of the order during the time of the interview. A follow up interview was conducted on 09/10/2021 at 11:24 a.m. with the NHA and the DON. The NHA stated that the universal cuff for Resident #40 was reordered that morning and would arrive at the facility on 09/13/2021. The NHA also stated that the previous order for the universal cuff was canceled and refunded that morning because the item never shipped. The NHA stated that Resident #40 would require assistance with meals until the universal cuff arrived. The DON also stated that Resident #40 would require assistance with meals until the universal cuff arrived. The NHA provided a receipt for an order, placed on 06/28/2021, for a universal cuff for Resident #40, which was marked as not yet shipped. The NHA was not able to state if the order was followed up on and stated that the item was re-ordered that morning. An observation was conducted on 09/10/2021 at 1:20 p.m. of Resident #40 during lunch meal service. The resident was observed eating an egg salad sandwich with half of the sandwich remaining on her plate. She stated that it took her until just then to eat half of the sandwich and that no staff had been in the room to assist her with the meal. An interview was conducted on 09/10/2021 at 2:43 p.m. with Staff B, Certified Nurses Aide (CNA). Staff B stated that Resident #40 required assistance with meals because she had trouble grabbing items and did not have any adaptive equipment. Staff B also stated that Resident #40 was able to handle sandwiches well but had difficulty holding cups and regular utensils. A review of the facility policy titled Assisting the Resident with In-Room Meals, last revised in February of 2014, revealed under the section titled Purpose that the purpose of the procedure was to provide appropriate assistance for residents who choose to receive meals in their rooms. The policy also revealed, under the section titled Preparation that staff were to review the resident's care plan and provide for any special needs of the resident. Photographic evidence obtained.

Based on interviews, record reviews, and review of facility policy, the facility failed to provide restorative services to maintain or improve mobility for one (Resident #21) of 18 residents receiving restorative nursing services. Findings included: A review of Resident #21's Medical Record revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 09/08/2021 at 9:58 a.m. with Resident #21 in his room. He stated that he was supposed to be receiving restorative therapy services, but was not receiving restorative therapy because they've had to pull the aide to work the floor. A review of Resident #21's Physician's Order Sheet for September 2021 revealed the following orders, listed under the section titled Ancillary: - Restorative Nursing: Yes. - Orders continued for 40 days unless otherwise specified. An interview was conducted on 09/09/2021 at 3:09 p.m. with the facility's Therapy Director (TD). The TD stated that Resident #21 had recently been discharged from Physical Therapy and was receiving restorative therapy services for ambulation. The resident's goal was to ambulate a certain amount of feet using a two wheeled walker. A review of Resident #21's Physical Therapy to Restorative Program Referral, dated 08/18/2021, revealed that Resident #21 had a goal to ambulate a distance of 60 feet as tolerated with a rolling walker. A review of Resident #21's Restorative Nursing Daily Charting revealed that Resident #21 received restorative therapy on 09/06/2021 and 09/07/2021, which included walking a distance of 60 feet or as tolerated with a 2 wheeled walker with one assist. Resident #21's Restorative Nursing Daily Charting also revealed that he did not received restorative therapy services from 09/01/2021 to 09/05/2021, 09/08/2021, or 09/09/2021. Resident #21's Medical Record did not reveal any Restorative Nursing Daily Charting for August of 2021. A follow up interview was conducted on 09/10/2021 at 12:41 p.m. with Resident #21. He stated that he was still receiving restorative therapy and that he would usually receive restorative therapy about 5 days a week. An interview was conducted on 09/10/2021 at 2:21 p.m. with the facility's MDS (Minimum Data Set) Coordinator and the TD. The MDS Coordinator stated that the Restorative Aide was not signing off on the Restorative Nursing Daily Charting sheet until 09/02/2021 and was not able to state why the documentation was not completed. The TD stated that the Restorative Aide sat down earlier in the week to organize the Restorative book and realized that she was not signing off on the documentation. The TD was not able to state what the Restorative Aide's normal schedule was but stated that she was not at the facility that day. The TD stated that the Certified Nurse's Aide's (CNA's) on the floor were conducting Restorative Nursing tasks when the Restorative Aide was not in the facility. An interview was conducted on 09/10/2021 at 2:43 p.m., with Staff B, CNA and Staff C, CNA. Staff C stated that the Restorative Aide performed restorative tasks from Monday to Friday and that they did not provide restorative services to the residents. Staff B also stated that restorative services were only provided by the Restorative Aide and not by the CNA's working the floors. Staff B and Staff C were unable to state who provided restorative services for the residents if the Restorative Aide was not in the facility. An interview was conducted on 09/10/2021 at 4:13 p.m. with the facility's Nursing Home Administrator (NHA), the facility's Director of Operations (DO), and the facility's Director of Nursing. The NHA stated that the facility's previous DON was working on re-implementing the facility's restorative program and that the Restorative Aide was usually at the facility from Monday through Friday, but needed to be rescheduled due to personal reasons. The DO stated that the facility was developing a plan to put into place for when the Restorative Aide was not in the facility, but the NHA confirmed that there was no plan in place currently. A review of the facility policy titled Rehabilitative Nursing Care, revised in April of 2013, revealed under the section titled Policy Interpretation and Implementation, that Rehabilitative nursing care is performed daily for those residents who require such service. The policy also revealed that the facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Photographic evidence obtained.

Based on observations, interviews and record review, the facility did not ensure respiratory equipment was stored appropriately for four (Residents # 191, #192, #193 and #194) of seven sampled residents. Findings included: 1) During a facility tour on 09/08/21 at 10:38 a.m., Resident #191's Nebulizer machine was observed on top of the nightstand, not covered. Resident #191 stated that he used his machine two times daily to take his medicine. Resident #191 said, they don't clean it. On subsequent tours on 09/08/21 and 09/09/21, the nebulizer machine was observed on the same spot, on top of the nightstand. Review of Resident #191's face sheet revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An initial MDS (minimum data set) dated 09/02/21, revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition. Review of Resident #191's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . inhale via nebulizer b.i.d (2 times per day) for [CONDITION(S)] ([CONDITION(S)]) and [MEDICATION(S)] [MEDICATION(S)] 0.5mg/2ml inhale 1 vial nebulizer, b.i.d for [CONDITION(S)]. 2) During multiple tours on 09/08/21 and 09/09/21 an observation was made of Resident # 192's nebulizer machine sitting on top of the nightstand uncovered. A review of Resident #192's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inhale one pre-mixed vial via nebulizer every six hours as needed - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] / sol [MEDICATION(S)] 0.5 - 2.5mg/3ml dated 08/30/21. Give one vial via nebulizer every 6 hours for [CONDITION(S)]. Review of Resident #192's face sheet revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial MDS (minimum data set) dated 08/26/21, revealed a BIMS (brief interview for mental status) score of 13, indicating intact cognition. 3) Resident #193 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During multiple tours on 09/08/21 and 09/09/21, Resident # 193's nebulizer was observed stored inside an opened nightstand drawer, noted uncovered and unlabeled. Review of Resident #193's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] sol [MEDICATION(S)] dated 8/28/21, inhale one nebule via nebulizer every six hours for [CONDITION(S)] An initial MDS (minimum data set) dated 09/02/21 revealed a BIMS (brief interview for mental status) score of 14, indicating intact cognition. 4) During multiple tours on 09/08/21, 09/09/21 and 09/10/21, Resident #194's nebulizer was observed inside a drawer on his nightstand noted uncovered and not labeled. Resident # 194 was admitted to the facility with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #194's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] / sol [MEDICATION(S)] dated 08/23/21. Inhale one pre-mixed vial via nebulizer twice daily at 9:00 a.m. and 9:00 p.m. [MEDICATION(S)] [MEDICATION(S)] 0.5mg/2ml (order date 08/23/21) inhale one pre-mixed vial via nebulizer twice daily at 9:00 a.m. and 9:00 p.m. A Baseline care plan for Resident # 194 revealed cognitive status alert and oriented. A Care plan dated 09/06/21 with a target date of 12/06/21 revealed a goal under [CONDITION(S)], related to [CONDITION(S)]. The goal identifies that Resident #194 will have no shortness of breath and will actively participate in therapy through the next review date. Interventions include to monitor for shortness of breath and increased respirations. Treatment / medications as ordered. On 09/10/21 at 12:50 p.m., an interview was conducted with Resident #194. Resident #194 stated that since he moved into the facility, his nebulizer machine sat in the drawer or on top. He stated he never saw it in a bag or anything. He stated that he used his nebulizer machine two times daily. On 09/10/21 at 12:56 p.m., an interview was conducted with Staff A, LPN. Staff A walked into the resident rooms with the surveyor and made the observations of the nebulizers. She said, It [nebulizer] should not be laid on top of the nightstand. It should be covered. Staff A said she would get a bag. She stated, All of them [nebulizers] should be stored in a dated bag. A follow-up interview was conducted with the NHA (Nursing Home Administrator) on 09/10/21 at 1:33 p.m. The NHA stated, They [nebulizers] should be stored per policy. The facility's policy was requested. On 09/10/21 at 4:24 p.m., an interview was conducted with the Regional Director (RD). The RD stated that the facility did not have a policy related to Nebulizer equipment, use, maintenance, and storage. An interview was conducted on 09/10/21 at 2:58 p.m. with the DON (Director of Nursing). She said, We are supposed to have a bag for each equipment, store the face mask and nebulizer mouth pieces in a bag. The nurses should clean the equipment after each use and store accordingly. I will in service and train the staff. She further stated that she would implement a procedure for cleaning masks, changing tubing, and dating the bag.

Based on observations, interviews, record review, policy review, and manufacturer's instructions the facility did not ensure the medication error rate was below 5% for two (#21 and #199) of three sampled residents who were administered medications. This resulted in two errors from 26 medication administration opportunities for a medication error rate of 7.69%. Findings included: 1. On 2/18/20 at 9:07 a.m., Staff A, Registered Nurse (RN), was observed administering medications for Resident #21. Staff A unlocked the medication cart and poured medications for Resident #21, including Carbamazepin 200 mg ER (extended release) capsule . Resident #21 took the pills whole with water. Staff A exited the resident's room and signed the medication sheet. A review of the physician's orders [REDACTED].#21 revealed the following: 11/26/18 Carbamazepin cap 200 mgER on e capsule every night at bedtime-Diagnosis: [REDACTED].>11/26/18 Carbamazepin tab 100 mgER on e tablet by mouth in the morning-Diagnosis: [REDACTED].>On 2/18/20 at 1:25 p.m., an interview was conducted with Staff A. The surveyor asked Staff A to retrieve the medication, Carbamazepin, that she had dispensed to Resident #21 that morning. Staff A handed the surveyor the 200 mg Carbamazepin blister pack. There were instructions on the label to give one every night at bedtime. Staff A confirmed she had given 200 mg Carbamazepin that morning. On [DATE] at 11:35 a.m., the Consultant Pharmacist stated [MEDICATION NAME] (name brand for Carbamazepin) was an extended release so the resident was getting the same dose, 300 mg in the 24 hour period. The facility did contact the doctor, and the next dose to be given was 100 mg. The consultant pharmacist said the nurse reversed the administration times. She also said, the facility tries to identify the different dosages with highlighting, coloring it differently. On 2/20/20 at 8:46 a.m., the Regional Director of Clinical Services stated they spoke to the physician, and he said that as long as we give the smaller dose of Carbamazepin in the evening there was no ill effect. Review of the policy titled Administering Medications, revised December 2012, revealed the following: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required timeframe. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. On 2/18/20 at 12:02 p.m., Staff B, Licensed Practical Nurse (LPN), was observed administering medications for Resident #199. Staff B performed a blood glucose check with a result of 302. Staff B retrieved Resident #199's [MEDICATION NAME] Kwikpen and dialed the device to 20 units. Staff B administered the 20 units of [MEDICATION NAME] into the resident's right lower abdomen, without priming the [MED] pen prior to administration. A review of the physician's orders [REDACTED].#199 revealed the following: 1/30/20 [MED] [MEDICATION NAME] Kwikpen Inj (injection) fingerstick blood glucose monitoring QID (4 times a day) before meals and at bedtime. Inject sub-q (subcutaneous) per sliding scale: 301-350=8 units. 1/31/20 [MED] [MEDICATION NAME] 12 units 3 times daily AC (before) meals - Diagnosis: [REDACTED].>On 2/20/20 at 8:46 a.m., the Interim Director of Nursing (DON) stated the facility has the pharmacy consultant do medication pass with the nurses. She agreed, the [MED] pen needed to be primed. She reported that when she conducted in-servicing, most of the nurses knew to prime the pen. It was just Staff B who was not aware the pen needed to be primed. Review of the [MED] [MEDICATION NAME] Kwikpen's manufacturer's instructions at http://pi.lilly.com/[MED]-[MEDICATION NAME]-kwikpen-us-ifu.pdf revealed: Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little [MED]. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see [MED] at the tip of the Needle. - If you do not see [MED], repeat priming steps 6 to 8, no more than 4 times. - If you still do not see [MED], change the Needle and repeat priming steps 6 to 8.