Every finding on record at Eagleridge Health and Rehabilitation Center

Based on record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to protect the resident's right to be free from neglect for 1(Resident #1) of 3 residents reviewed.The facility failure to prevent the neglect of Resident #1 created a likelihood of serious harm or death of the resident from exposure to excessive heat which can cause heat related illness, including heat exhaustion and heat stroke and resulted in the determination of Immediate Jeopardy (IJ).On 4/23/26, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed, effective 4/16/26.The findings of Immediate Jeopardy were determined to be corrected on 4/21/26.The findings included:Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Uknown Origin (ANEMMI) with a revision date of 03/2025 revealed, The resident has the right to be free from . neglect . Neglect. means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Review of the facility's policy and procedure titled, Facility Transportation with a revision date of 04/2026 revealed, Purpose: To ensure all residents are transported safely . Residents shall always remain under the continuous supervision of facility staff during transport, including while the vehicle is stationary, parked, or awaiting appointments. Under no circumstances shall a resident be left unattended in a vehicle . Drivers are strictly prohibited from leaving the vehicle unattended while residents are onboard . Drivers are responsible for maintaining visual and physical accountability of all residents during all phases of transport, including loading, transport, waiting periods, and unloading at destinations.Review of the clinical record for Resident #1 revealed an admission date of 3/3/26. Diagnoses included Surgical Aftercare Following Surgery On The Digestive System, Chronic Kidney Disease (progressive loss of kidney function) and Adjustment Disorder With Mixed Anxiety and Depressed Mood.Review of the Brief Interview for Mental Status (BIMS), screening tool used to evaluate a person's memory and orientation dated 3/4/26 revealed Resident #1 scored 13 of 15, indicating intact cognition.Review of the Care Plan initiated on 3/5/26 revealed that Resident #1 was at risk for fluid imbalance, related to the use of diuretic (medication that help eliminate excess water and sodium through urine) use, colostomy (opening in the abdominal wall to divert waste). The goal was for Resident #1 to be free from symptoms of dehydration.The care plan documented that Resident #1's participation with Activities of Daily Living varied due to fatigue, and chronic medical conditions. Resident #1 required maximum assistance of 1 for transfer.Review of a late entry nursing progress notes dated 4/17/26 at 8:40 a.m. revealed that while being transported to the hospital for evaluation for fistula (abnormal connection between two body parts) following her follow up appointment, the resident was left temporarily unattended and called 911. Resident had no signs of distress and was evaluated out of an abundance of caution.Review of the facility provided investigation revealed that on 4/16/26 at 11:15 a.m., a police officer contacted the facility Administrator and notified her that Resident #1 had called 911 stating that she was in the facility's transportation bus in a parking lot waiting for the driver who was in the Dentist office.Review of a redacted police report dated 4/16/26 revealed that at approximately 10:51a.m., officers were dispatched to assist an elderly female advising that she was locked in a bus and that it was getting warm inside. Upon arrival at approximately 11:03 a.m., officers met with the Fire Department who were attempting to remove an elderly female identified as (Resident #1) from a shuttle bus. The bus was not running and only had the driver door window down and the front passenger door ajar a couple inches. The officers noted that (Resident #1) was visibly sweating. The Fire Department removed Resident #1 from the van and stated that she was only dehydrated and did not appear to be in any further distress at that time.The police report noted that the officers were simultaneously looking for the driver of the shuttle bus who showed up on scene at approximately 11:30 a.m. The driver informed officers at first that he was at the dentist because he had an emergency and he only thought it would take between five and ten minutes.The police report noted that the temperature was approximately 83 degrees Fahrenheit outside and felt much warmer inside of the shuttle bus. The shuttle bus was not parked in a shaded area.The police report documented an offense code of Crimes against person-Neglect Elderly Disabled Adult WO (without) Great Harm.Review of the CDC Heat Health dated June 25, 2024, noted that Even in cool temperatures, cars can heat up to dangerous temperatures very quickly. Leaving a window open is not enough- temperatures inside the car can rise almost 20 degrees Fahrenheit within the first 10 minutes, even with a window cracked open. People age [AGE] or older are more prone to heat-related health problems. Older adults do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that affect the body's ability to control its temperature or sweat.https://www.cdc.gov/heat-health/risk-factors/heat-and-older-adults-aged-65.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fextreme-heat%2Frisk-factors%2Fextreme-heat-and-older-adults-aged-65.htmlReview of the Emergency Department Physician Progress note dated 4/16/26 revealed that the patient (Resident #1) was a [AGE] year-old female. She was seen by urology today and was told she needed to go to the ER (Emergency Room), she had abnormal labs. Patient was left in the van by driver. Patient reports she feels weak.On 4/22/26 at 10:22 a.m., in a telephone interview, an employee of the dentist's office where CNA Staff A attended an appointment on 4/16/26 said that CNA Staff A checked in at 10:21 a.m. for a routine appointment and checked out at 11:10 a.m.On 4/22/26 at 10:30 a.m., in a telephone interview CNA Staff A verified that on 4/16/26, he left Resident #1 unattended and strapped in a wheelchair in the back of the facility's transport van. He said, I was bleeding in my mouth. I had an appointment so I stopped off. I made a little mistake. The window was a little open. CNA Staff A said that he had already talked to the police and the Nursing Home Administrator and declined to continue the interview.Review of CNA Staff A's employee file revealed on 7/10/24, he signed a Certified Nursing Assistant (CNA)-Driver job description which included, Requirements/Qualifications for CNA-Driver position: . Must be knowledgeable of resident rights and ensures an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment.Review of the facility Fleet Management Manual manual revealed, Never leave a resident unattended. If assistance is required, then call a staff member to request assistance while remaining with the resident . Facility owned vehicles are to be used ONLY for facility business and activities .On 7/10/24, CNA Staff A signed the Fleet Safety Acknowledgement Form, acknowledging that he had received and read a copy of the Facility Fleet Management Program and agreed to comply with the policies and procedures contained in the program.On 4/22/26 at 11:59 a.m., in a telephone interview, Resident #1's son said his mother was a cancer patient, had many health concerns and remained hospitalized . On 4/16/26, she got directed to the ER from the urologist. She has a nephrostomy tube (a flexible tube inserted through the back into the kidney to drain urine into an external bag) and they were worried there was a fistula. She needed to go to the ER. His mother said that the van was not running, the windows were up and she could not get out. After some time, she started to get hot and worried. She remembered that she had her phone and she called 911. His mother said it felt like she was left in the van for an hour. Resident #1's son said that his mother was a strong lady, very strong. She got to the part about her not knowing what to do, she said she was stuck. She broke down and started crying while telling him the story. He could hear the fear in her voice. She said the unbelievability of how she could not get out of that situation.On 4/22/26 at 12:57 p.m., in an interview, the NHA said that on 4/16/26 she talked to CNA Staff A very briefly. He said that he was stupid and he should not have done it. He said that his gums were bleeding. She told him that he should not have done that (leave the resident in the van) and he said he knew.On 4/23/26 at 11:40 a.m., an interview was held with the Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON) and the Director of Rehab (DOR).The ADON said Resident #1 was in a wheelchair and to his knowledge was not able to walk. He said that the van was equipped with an electric lift. They wheel the resident in the wheelchair into the van. Once the resident is in the van, they must secure them with a belt. He said that he had never seen Resident #1 ambulate and had only seen her in a wheelchair. The DOR said that Resident #1 could not walk. She would not have been able to get out of the wheelchair in the van.The NHA said Resident #1 was out of the van she got there. They said the Fire Department got her out but did not go into specifics. They said they had to force the door open. She said, I'm assuming they had to carry the wheelchair out. She had a lot of tubes coming out of her as well with the nephrostomy.On 4/24/26 at 10:01 a.m., in a telephone interview, Resident #1said, I hate to even think about it but here we go. She said that CNA Staff A took her to the doctor's office but she never got to see the doctor. The medical assistant said that she needed to go to the ER as soon as possible because the lab report saw something suspicious. From there, she thought that CNA Staff A was taking her to the ER but he turned into a shopping center. When she said that it didn't look like the ER, CNA Staff A said, Oh no, we are going there later. He then left her in the van. All the doors and windows were shut, it was hot and she was in the back of the van all by herself. Resident #1 said, It was so hot. Thank God I had my cell phone. I called 911. The Fire Department came within like 5 minutes. One of the big strong, nice firemen could not get the doors open. The doors were electric and we had no keys. They were getting desperate to get me out of there. She said the Fireman got the front door of the van open, picked her up and carried her out the driver's door. She said the Firemen took a good look at her and could not believe that the driver did that to her. Resident #1 appeared to be crying during the interview and said, If I had not been rescued, I would be dead right now.On 4/23/26, the immediate actions implemented by the facility and verified by the survey team included:On 4/16/26, the NHA immediately went to assist the resident.On 4/23/26, the survey team verified through interview with the NHA. She confirmed that on 4/16/26 at 11:15 a.m. immediately went to assist Resident #1 when the police officer called her.On 4/16/26, the NHA scheduled transportation for Resident #1 to go to the hospital.On 4/23/26, the survey team verified through interview with the NHA that on 4/16/26, she arranged transportation through a third party company and accompanied Resident #1 to the hospital.On 4/16/26, the NHA suspended CNA Staff A immediately pending investigation.On 4/23/26, the survey team verified through review of the suspension documents and interview with the NHA that on 4/16/26, CNA Staff A was immediately suspended. The NHA said CNA Staff A resigned later that day and provided CNA Staff A's resignation letter.On 4/16/26, the NHA immediately suspended all facility transports and rescheduled current and future transports with a 3rd party vendor to provide all facility transportation moving forward until a complete and thorough investigation can be completed.On 4/23/26, the survey team verified through review of the memo of suspension of transport, review of the rescheduling of transport and interview with the NHA that all facility transportation were immediately suspended and rescheduled with a 3rd party vendor. The NHA said that they had not restarted using their facility transportation at this time.On 4/16/26, the NHA rode with the transportation and Resident #1 to the hospital.On 4/23/26, the survey team verified through interview with the NHA who confirmed that on 4/16/26, she rode with Resident #1 to the ER and stayed with her.On 4/16/26, the facility staff scheduled 3rd party transportation for all residents currently scheduled with facility transportation.On 4/23/26, the survey team verified through review of orders to reschedule transportation through a third party vender for 6 residents.On 4/16/26, the NHA verified driver's Fleet Education and completion of training.On 4/23/26, the survey team verified through review of CNA Staff A's Fleet education training and interview with the NHA who confirmed she verified completion of CNA Staff A's education.On 4/16/26, the NHA verified drivers CNA certification, clearinghouse and background were completed and in good standing.On 4/23/26, the survey team verified through record review and interview with the NHA that CNA Staff A's background screening and CNA certification were complete and in good standing.On 4/16/26 at 3:00 p.m., the NHA started education with onsite staff (dietary, nursing, therapy, office staff, management) and contracted employees (laundry, housekeeping) regarding Keeping our Residents Safe- Transportation, Protecting from heat exposure, and Abuse/Neglect Training. All educations included a staff competency that had to be completed with a passing grade or they had to redo the education. No facility staff member/contracted employee was allowed to work without education. On 4/23/26, the survey team verified through review of the education provided and staff competencies and interviews with 6 staff members who verified completion of the education and competency. On 4/16/26, an Ad-Hoc (unplanned) Meeting was completed which included Temporarily suspending all facility transports, Education for Transporting residents, not leaving them alone, Protecting against Heat exposure, reviewed facility assessment. Removed van from facility. Staff included: (Administration, Dietary, Activities, Nursing, management, office, housekeeping, laundry, therapy) Staff must be educated prior to working. Updating the Fleet Safety Manual with additional safety acknowledgement page, Transportation policy with additional resident safety items for what to do in an emergency and never leaving a resident alone and adding driver checks in's so it doesn't happen again. Targeted Abuse/Neglect training leaving a resident alone and secured in van not running when it was 83 degrees on & not protecting residents. Reviewed and updated the facility assessment with above items.On 4/23/26, a copy of the Ad-Hoc sign in sheet was provided and verified.On 4/17/26, an Ad-Hoc Meeting was completed which included Continued review of effectiveness of education, Approved Updated Facility Assessment with training and education and competency's, POC (Plan of Correction) and continue suspension of Facility Transports, Education added to new hire orientation, Approve facility plan of correction. On 4/23/26, a copy of the Ad-Hoc sign in sheet was provided and verified.On 4/16/26, the facility interviewed other residents recently transported for potential other issues or concerns. No other residents had an issue with their transports and completed the driver for his kindness.On 4/23/26, the survey team verified through review of facility provided residents' interviews and interview with the NHA.On 4/16/26, the facility Updating the Fleet Safety Manual with additional safety acknowledgement page. Addition includes never leaving the resident alone and remaining with resident at all times. What to do in emergency and calling 911. Includes employee signature page as attestation that they will follow rules and keep the residents safe.On 4/23/26, the survey team verified through review of the updates to the Fleet Safety Manual and acknowledgment page and interview with the NHA. The NHA confirmed that transport was currently stopped.On 4/17/26, the facility transport communication education on Driver must call when Leaving appointments now. The facility transportation policy was updated. On 4/23/26, copies were provided and verified to include calling 911 in the event of an emergency, notify the facility and facility administrator and remain with the resident until appropriate authorities or assistance arrives. The facility also added that the driver will call and notify the facility prior to leaving the pickup location and the estimated time of return. If the drive does not return by the estimated time, the NHA will be notified.On 4/23/26, copies of the forms were provided and verified by the survey team.On 4/16/26, the Facility Bus was removed from property so that it cannot be used and NHA with all keys.On 4/23/26, the NHA provided a written statement that the Facility Bus was removed from property and she has the keys.Ongoing audits to monitor completion of education completed on 4/18/26, 4/19/26, 4/20/26 and 4/21/26.On 4/23/26, the survey team verified through review of the audits of staff education provided.On 4/16/26, 4/17/26, and 4/21/26, the Facility Assessment was reviewed by the IDT (Interdisciplinary Team) and the Medical Director. Updates or changes included: Updated Fleet Safety Manual; Updated Transportation Policy; All education added to New Hire Orientation; All education must be at the start of the shift, prior to starting, regarding not leaving residents alone in Van, reviewed and updated Transportation Policy, and Transport Communication.On 4/23/26, the survey team verified through NHA interview and review of the facility assessment, the updates or changes to the Fleet Safety Manual, Transportation Policy, and education included in New Hire Orientation.

Based on record review, and interviews, the facility failed to provide a safe and appropriate discharge for 2 (Residents #1and #2) of 3 residents reviewed for transfer and/or discharges. The facility failed to confirm Resident #1's transportation, causing the resident to leave the facility in her wheelchair after waiting over two hours and attempt to wheel herself to her discharge location which is located 10 miles from the facility.The findings included:Review of the facility Transfer and Discharges policy (last revised 2/2024) revealed, The facility will develop and implement an effective discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care . A resident, and/or his or her representative (sponsor), will be given thirty (30)- day advanced notice of an impending transfer or discharge from our facility when feasible. The policy specified the notice will be given as soon as it is practicable but before the transfer or discharge under the following circumstances, The transfer is necessary for the resident's welfare and the residents needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; An immediate transfer or discharge is required by the resident's urgent medical needs; The resident has not resided in the facility for thirty (30)days; and/or the facility ceases to operate. The reason for the transfer or discharges will be documented in the resident's medical record.1. Record review for Resident #1 revealed an admission date of 3/6/26, and a discharge date of 3/24/26. Diagnoses included Pulmonary Embolism with Acute Cor Pulmonale (a life-threatening condition where a large clot blocks the lungs arteries), Acute Respiratory Failure, Type-2 Diabetes, presence of a Cardiac Pacemaker, Anxiety Disorder, Depression, Unspecified Affective Mood Disorder (significant impairing emotional symptoms that cause distress) and Parkinson's Disease without Dyskinesia (involuntary movements).The Brief Interview for Mental Status (BIMS) dated 3/9/26 revealed Resident #1 scored 15 of 15 on the BIMS, indicating intact cognition.The Discharge summary dated [DATE] at 11:00 a.m., revealed Resident #1 was given a copy of the discharge summary and after discharge instructions.Review of the progress notes revealed that on 3/24/26 at 4:52 p.m., the Social Service Director documented she contacted the resident's insurance and arranged transportation through an outside transport company to take Resident #1 to her place of residence, an Assisted Living Facility (ALF). The note specified the transportation was arranged for today at 4:50 pm.The clinical record lacked documentation of the date and time Resident #1 was picked up by the transport company.On 3/31/16 at 1:23 p.m., an interview was held with the Nursing Home Administrator (NHA), the Assistant Director of Nursing (ADON) and the Social Services Director (SSD).The SSD said when a resident is discharged , We usually walk them to the door and help them with all their personal belongings. She said the nurse usually documents when the resident is discharged from the facility. She said that on 3/24/26, she notified the ALF that transportation was arranged for Resident #1. On 3/24/26, she left work a little after 5:00 p.m. Resident #1 was in the activities room.The ADON said that when he left the faciity on 3/24/26 around 5:45 p.m., Resident #1 was at the nurse's station asking about her ride. He told Resident #1 that the ALF was coming to pick her up, her ride was coming. He said 30 minutes later, Registered Nurse (RN) Staff A notified him via a text message that Resident #1 was anxious and wanted to leave. A few minutes later, he received another text message from RN Staff A telling him that Resident #1 had left.The NHA said that from what she knew, on 3/24/26, Resident #1 was sitting in the lobby. She did not want to wait for her transportation, so she left. The nurses thought the resident had left the facility with her ride. The Director of Nursing then informed her that EMS (Emergency Medical Services) called to say they were with Resident #1. The resident refused to go back to the facility and was sent to the hospital.Review of the physician's progress note from the Emergency Department (ER) dated 3/24/26 at 9:02 p.m. revealed that the resident was being discharged to her ALF. Patient states she was waiting all day. Patient states she got sick of waiting and left. Patient was found on the side of the street in her wheelchair. EMS was called and patient was brought to the ER for further evaluation .On 3/31/26 at 11:31 a.m., in a telephone interview, the ALF Administrator at Resident #1's place of residence said that on 3/24/26 at approximately 7:00 p.m., the ALF staff notified her that the nursing home staff had called to say the ALF had not picked up Resident #1. She sent a text message to the NHA who replied that Resident #1 had left half an hour ago. The ALF Administrator said she then received a phone call from the hospital's case manager, informing her that someone had found Resident #1 on the side of the road and EMS brought the resident to the hospital ER. She said Resident #1 arrived at the ALF via ambulance that night around midnight.On 3/31/26 at 3:40 p.m., Resident #1 was interviewed at the ALF where she resided. She said the nursing home discharged her on 3/24/26 at 11:00 a.m. Staff removed her from her room around 3:00 p.m. and put her in the activities room. The staff kept telling her that transportation was on their way. Resident #1 said, Then the big wigs left and the night nurses did not know what to do with her. She said she finally left the facility between 7:00 p.m., to 8:00 p.m. She said she just pushed on the door and left; no one even knew she had left. When she got to the end of the driveway, she did not know the way to get to her ALF, so she took a left. She said a woman and a man stopped to help her and called 911. Resident #1 said that she was self-propelling her wheelchair in the road, going left and right, trying to find a major road. She felt abandoned, scared, afraid and alone. She did not have her phone, hearing aids or dentures. She couldn't even call her daughter. Resident #1 started to cry during the interview. She said it was eye opening to be alone and scared. On 4/1/26 at 10:12 a.m., in an interview, the NHA said that discharged residents waiting for transportation after business hours can wait in their room, the activities room or anywhere in the building until transport gets there. The NHA said that after hours, it was the nurses responsibility to make sure discharged residents get in their transportation. The NHA said no one saw Resident #1 get in her ride, but it was assumed she did.On 4/1/26 at 10:22 a.m., in a telephone interview, a representative of the transport company said that the transportation was scheduled at 4:49 p.m., for a pick-up time of 4:50 p.m. The request for transport was cancelled on 3/24/26 at 5:14 p.m., since they require 2-day notice for transportation and 3 to 4 hours' notice for medical transportation.On 4/1/26 at 12:13 p.m., in a telephone interview, the psychiatric Advanced Practice Registered Nurse (APRN) said that Resident #1 was alert enough to decide to leave on her own and made a poor decision.On 4/1/26 at 2:20 p.m., in a telephone interview, Registered Nurse (RN) Staff A said when she arrived at work on 3/24/26 at 3:00 p.m., Resident #1 was in the dining room. The resident told her she had been waiting for transportation since 12:00 p.m. Sometime later (no time), the Social Worker at the hospital called to notify them that Resident #1 was at the hospital. RN Staff A said it was unusual for residents to wait alone in the lobby for transportation. She said the nursing staff were responsible to make sure discharge residents get in the transportation vehicle.On 4/1/26 at 3:47 p.m., in an interview, Licensed Practical Nurse (LPN) Staff C said she primarily works the 3:00 p.m. to 11:00 p.m. shift. She said residents waiting for transport or discharge can wait in their rooms or by the nurses station. LPN Staff C said if a resident's ride does not show up, they notify the on-call staff, or the Director of Nursing.On 4/1/26 at 3:57 p.m., in an interview, LPN Staff B said she primarily works the 3:00 p.m. to 11:00 p.m. shift. She said that discharged residents waiting for transportation can wait by the nurses station. She said if the transportation does not show up, they must call to find out what happened.2. Review of the clinical record for Resident #2 revealed an admission date of 5/7/2020 and a discharge date of 3/2/26. Diagnoses included Intervertebral Disc Degeneration (condition where spinal discs lose structural integrity, water content and elasticity), Type-2 Diabetes, Insomnia due to other Mental Disorder and Depressive Episodes.Review of the Brief Interview for Mental Status (BIMS) dated 11/25/25 revealed Resident #2 scored 15 of 15, indicating intact cognition.A Psychology Progress Note dated 2/27/26 noted current diagnoses of Insomnia, other specified depressive episodes and Adjustment Disorder with mixed anxiety and depressed mood. The note stated, There has been a minor complication. (Resident #2) is unstable and is having episodes of agitation. Due to situational concerns of being transferred to a new nursing home next week.Review of the Discharge summary dated [DATE] revealed Resident #2's status during stay at the nursing home was Long Term Care. The summary noted that the resident was being discharged to a nursing home located in another county.Review of the physician's orders revealed a discharge order dated 3/2/26 at 4:51 p.m. The order did not include a reason for transfer, level of care or assistance needed.The Nursing Home Transfer and Discharge Notice form noted the date the notice was given to Resident #2 was 3/2/26 with an effective date of 3/2/26. The Reason for Discharge or Transfer was Your health has improved sufficiently so that you no longer need the services provided by this facility. The form noted, Resident refused to sign. The form was signed by the Social Services Assistant.On 4/2/26 at 9:20 a.m., in a telephone interview, Resident #2 said he was given 3 options of places to go. He said he was told that he would be evicted if he didn't choose a place. Resident #2 said the facility told him that they needed to free up his room since it was being converted to a different type of care. Resident #2 said he chose a nursing home in [NAME], Florida but was transported to a nursing home in Sarasota, Florida. Resident #2 said 2 days later he ended up in the hospital due to medical complications. The new nursing home would not take him back when he was discharged from the hospital. Resident #2 said he had to pay $275.00 for a ride company to take him back to Fort [NAME] and was currently living in hotels because he had no home.On 4/2/26 at 10:47 a.m., an interview was held with the Nursing Home Administrator, the Social Services Assistant and the Assistant Director of Nursing.The Social Services Assistant said Resident #2 chose to go to the nursing home in Sarasota. She said if a resident refuses to sign the form and wants to stay, they can stay. The Social Services Assistant said Resident #2 was not given a 30-day notice of transfer but was given a 3-week verbal notice of transfer. She confirmed there was no documentation that the resident received a verbal notice of transfer. She also confirmed that on 3/2/26, Resident #2 refused to sign the transfer form and was unsure as to why he was transferred.The NHA said they give residents a 72-hour notice if they cannot provide the skills or services to meet the resident's maximum potential. The NHA said Resident #2 was transferred because they are transitioning to more short-term beds. She said, We asked if they have any community ties and if they are ok with going. The NHA said the forms were not filled out correctly and there was no documentation to prove Resident #2 was ok with transferring facilities. The NHA confirmed that Resident #2 ended up at a facility in Sarasota, Florida.The ADON said there was no medical reason for Resident #2 to be transferred, he was not a danger to himself or others. He said Resident #2 still needed to be in a long-term care facility. The nursing home in Sarasota did not provide any additional care that their facility could not provide.

Based on record review and interview, the facility failed to ensure that the full amount of funds owed to a resident upon discharge were refunded within 30 days of discharge for 1, Resident #3 of 3 residents reviewed for refund of funds due.The findings included:Review of facility policy dated March 10, 2023, revised January 29, 2024, revealed, In the event a credit balance has resulted on a resident private account. This balance will be refunded based on the following:Resident account is clear except for the said credit. (Insurance, Medicaid, and/or Third Party Payers are paid and show no deducible or copays) as prescribed by the appropriate State regulations for Killed Nursing Facilities as directed by state Medicaid and Federal programs. Refund will be issued by check within 30 days of confirmation of the above items.Review of facility records revealed that Resident #3 was discharged on 6/9/2025. At the time of discharge the resident had a balance due to Resident #3 in the amount of $7,582.31 from prepaid charges.On 3/31/26 at 1:00 p.m., in an interview, the Business Office Manager (BOM) confirmed that on 5/9/2025, Resident #3 had prepaid the facility $11,067.31. She confirmed that after co-pays were paid, the total amount due back to Resident #3 upon discharge for over payment was $7,582.31. The BOM said that the turnaround time for a refund to be issued from the facility is about 30-60 days.On 3/31/26 at 2:28p.m., the BOM provided documentation that a refund check for $4,011.31 was sent to Resident #3 on 7/14/25. On 10/22/25, a second refund check for $1,112.00 was sent to Resident #3. The BOM said that as of today, 3/31/26, the facility still owed a refund of $2,459.00.

Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services to ensure a clean environment for 7 (rooms 135, 139, 138, 126, 205, 203 and 207) of 20 rooms observed on the Memory care and the North unit. The findings included:Review of the facility's Environmental General Cleaning policy (last updated 01/2024) revealed, it is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive homelike environment . Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. On 8/17/2025 at 10:14 a.m., observation of room [ROOM NUMBER] revealed the front air conditioning vents were coated with multiple spots of a black substance. Photographic evidence obtained. On 8/17/2025 at 11:55 a.m., the front air conditioning vents of room [ROOM NUMBER] were observed coated with multiple spots of a black substance. On 8/18/2025 at 10:45 a.m., the air conditioning vents in room [ROOM NUMBER] were observed coated with multiple spots of a black substance. Photographic evidence obtained. On 8/20/25 at 9:27 a.m., the observation of the multiple spots of black substance on the air conditioning vents of rooms 203, 204 and 207 was shared with the Director of Environmental Services. In an interview he said he was the one responsible to clean the air conditioning vents. On 8/20/25 at approximately 9:35 a.m., the Director of Environmental Services observed the black substance on the air conditioning vents of room [ROOM NUMBER] and said it should not look like that. On 8/17/25 between 10:00 a.m., and 11:00 a.m., the following observations were made during a tour of the memory care unit: room [ROOM NUMBER]: Floor tile missing. The caulking around the toilet was cracked and discolored. Photographic evidence obtained. room [ROOM NUMBER]: Peeling wallpaper with orange discoloration on the wall under the wallpaper, water damage to the wall, molding and floor in the bathroom. Photographic evidence obtained. room [ROOM NUMBER]: Bathroom floor tiles stained and cracked. The caulk around the toilet was discolored and cracked. Photographic evidence obtained. room [ROOM NUMBER]: Large gap in tiles, the wall by the air conditioning was cracked, embedded dirt in tiles, cracked, discolored caulking around the toilet. Photographic evidence obtained. On 8/20/25 at 2:30 p.m., the observations, and photographic evidence of the environmental concerns in the memory care unit were shared with the Director of Environmental Services. The Director of Environmental Services said he was aware of the concerns, and they have been slowly trying to work their way through the unit to address identified environmental issues.

Based on record review and staff interviews, the facility failed to provide care and services in accordance with professional standards of practice by failing to communicate a significant weight loss to the physician for 1 (Resident #10) of 2 residents reviewed for nutrition.The findings included:On 8/18/25, review of the clinical record for Resident #10 experienced a significant weight loss. The documented weights were:2/10/25: 185.0 pounds (lbs.)3/05/25: 187.8 lbs.4/04/25: 186.0 lbs.4/24/25: 182.5 lbs.4/29/25: 183.0 lbs.5/06/25: 185.6 lbs.6/03/25: 181.0 lbs.7/03/25: 171.4 lbs.8/05/25: 168.0 lbs.8/13/25: 161.4 lbs.Review of the physician's orders revealed a dietary order dated 5/6/25 for Regular diet, large portions for weight loss.On 7/31/25, a Registered Dietitian progress note documented the resident's weight was 171.4 lbs. negative 5% change over 30 days.On 8/17/25 a Dietary progress note indicated Resident #10 was having an evaluation for significant weight change. Resident #10's usual body weight was in the 180s with a 13% weight loss (24 lbs.) over 180 days. Resident #10 was not receiving supplements. Dietary interventions were large portions. The resident's usual meals intake were 51% to 75%, 76% to 100%. The resident was tolerating oral diet with good appetite. Recent medication changes: Donepezil and Memantine (medications to treat Alzheimer's/dementia) associated with weight change may be contributing factor.The progress note specified: Defer to MD (physician). The clinical record lacked documentation the physician/provider was notified of the resident's significant weight loss.Review of the progress notes revealed on 7/2/25, 7/8/25, 7/10/25, 7/15/25, 7/17/25, 7/22/25, 7/24/25, 7/29/25, 7/31/25, 8/5/25, 8/8/25, 8/12/25, 8/15/25 and 8/18/25, the provider documented, His weight is stable. Review of System: Constitutional: (-) weight loss.On 8/19/25 at 3:07 p.m., in an interview the Regional Dietitian (RD) said when a dietary progress note is entered, there is a box that is checked for a physician/nursing communication report, and the doctor would have to review it. The Regional Dietitian reviewed the dietary progress notes. She said the box was checked on dietary progress note for 7/31/25 but had not been checked on the dietary progress note for 8/17/25. The RD said she could not explain why the physician's progress notes continued to say negative for weight loss.On 8/20/25 at 9:30 a.m., in an interview Licensed Practical Nurse (LPN) Staff E said she was Resident #10's nurse. She said the resident ate and did not refuse food.On 8/20/25 at 11:15 a.m., in an interview the Advanced Practice Registered Nurse (APRN) said she had been off for a week. She said she was looking through the system this morning and noticed the weight difference. She noticed a 10.0 lbs., then a 3.0 lbs. weight loss., then another weight. She said she asked staff to reweigh the resident as one of the weight was obtained standing and others were sitting.On 8/20/25 at 3:51 p.m., in a follow up interview the RD said there was no way to verify that the physician reviewed the communication reports. There was no place to sign off or acknowledge the physician had seen the communication report. The RD said she was not aware of any policy addressing the communication reports.

Based on interview and record review the facility failed to complete a Comprehensive Minimum Data Set (MDS) Assessment within 14 calendar days of admission for 1 (Resident #70) of 45 reviewed.The findings included:Review of medical records revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses muscle wasting and atrophy, Type II Diabetes Mellitus and pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment revealed a completion date of 3/27/25, 21 days after admission.On 8/20/2025 at 4:33 p.m., in an interview MDS coordinators, Registered Nurse (RN) Staff C and Licensed Practical Nurse (LPN) Staff D verified Resident #70 was admitted to the facility on [DATE] and the MDS admission Assessment was not completed until 3/27/25, 21 days after admission. LPN Staff D said the MDS admission Assessment should have been completed by 3/20/25 and was not sure why the admission MDS assessment was not completed within 14 days of admission as required. LPN Staff D said they follow the instructions on the Resident Assessment Instrument (RAI) manual specifying that the admission MDS assessment must be completed within 14 days of admission.

Based on interview and record review the facility failed to ensure adequate supervision to prevent one resident (resident #1) of three residents sampled for falls to prevent multiple falls and major injuries to the resident, multiple falls, a fracture of to the right hip on 11/1/24 for which the resident was hospitalized for surgical intervention, and a fracture to the to the right humorous on 11/17/24. The findings included: Review of facility titled, Falls- Managing, Preventing and Documentation, revised 1/2024, which stated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) or with a history of falls .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been previously identified. Resident #1 is an [AGE] year-old male who was admitted to the facility 10/15/24 with a history of Dementia, Post Traumatic Stress Seizures, Delerium, Dysphagia, Encephalopathy, Cirrhosis of the liver, and Stage III kidney disease. Clinical records for Resident #1 were reviewed. The Minimum Data Set (MDS) assessment completed on 10/28/24 documented in Section C Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of 01. Section J Resident #1 had 2 or more falls since admission. Section GG documented that the resident is dependent on facility staff for ADL (activities of daily living) care including dressing, bathing and toileting needs. The Fall Risk Evaluation completed on 10/15/25, on admission, documented Resident #1 had a Lack of understanding of physical limitations, lack of understanding of cognitive limitations, history of multiple falls, needs assistance with toileting and taking two of the medications identified to increase risk of falls. Resident #1 had a care plan for falls initiated on 10/16/24. The care plan stated the resident is at risk for falls related to cognitive deficit, history of falls, and unsteady gait/ poor balance. The interventions listed on the care plan initiated on 10/16/24 included: Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etc. as indicated. Encourage and assist the resident to wear appropriate FOOTWEAR such as rubber-soled shoes, non-slip bedroom slippers, non-skid socks, etc. when ambulating, transferring, or mobilizing in w/c. The care plan was revised on 10/17/24 to add intervention frequent rounding during sleep hours. Resident #1 had 5 documented falls in the facility including 10/15/24, 10/16/24, 10/21/24, 11/1/24, and 11/17/24. Progress note dated 10/15/24 at 3:23 p.m. stated, Caregiver alerted nurse that resident was on the floor in room. Upon arriving to resident's room, nurse observed room door to be open, light in the room, and in front of closet, resident was laying face down on the floor with his head turned to the side . Resident is confused and unable to explain how he ended up on the floor . Resident educated on call light and his safety. On 10/15/24 at 9:49 p.m. the nurse charted for behavior charting, Resident restless, attempting to stand in the dining room, attempting to climb out of his bed, very impulsive and non-cooperative .resident redirected with no success, resident has to be one on one with staff in order to remain where seated or remain in bed for constant reminders to not climb out of bed or chair. On 10/16/24 at 10:00 p.m. the nurse documented resident #1 was found on the floor and became aggressive with staff when attempting to assess the resident. Resident #1 was administered Haldol 5 mg intramuscularly (an antipsychotic medication). A progress note dated 10/17/24 documented The IDT (Interdisciplinary team) met at 9:24 a.m. to discuss the resident's fall on 10/16/24. The progress note reads, Resident noted to be floor next to bed with mattress on top of him, resident was only wearing his brief. Resident was unable to provide details regarding how he ended up on the floor, resident was yelling profanities and threats . The Team determined the root cause analysis of the fall was secondary to the resident's onset of psychotic state. On 10/21/24 at 8:08 a.m., the Advanced Nurse Practitioner documented a progress note which read, Patient seen and examined today for follow-up visit. He had a fall while I was at the facility, he was found in the floor, apparently he didn't hit the head, upon my assessment a skin tear was noted to his Rt elbow, wound care provided, VS taken under baseline. He was alert to name only . Education provided w/ [with] verbalized understanding about call for help to avoid any fall. On 11/1/24 a post fall investigation found Resident #1 had been found on the floor by staff at approximately 5:30 a.m. The resident was described as confused and unable to respond. At around 7:00 a.m. Resident #1 was complaining of pain in his right hip. An x-ray obtained by the facility showed Resident #1 had a right hip fracture. A witness statement obtained on 11/1/24 by the certified nursing assistant, Staff A, documented she was doing frequent rounds on Resident #1 on the morning of 11/2/24. The Statement documents she assisted the resident to his bed at 3:00 a.m. and at 5:00 a.m. she found Resident #1 on the floor. After Resident #1 had surgical intervention to repair his right hip and was readmitted to the facility another progress note documents Resident #1 had another fall on 11/17/24. On 11/20/24 at 9:10 a.m. the Advanced Nurse Practitioner documented, .he had another fall on 11/17 no apparent injury during this fall were reported by staff but today he is screaming in pain to his Rt Shoulder upon my exam, he can barely move the extremity, pt keep holding the arm, x-ray STAT was ordered. The shoulder x-ray obtained on 11/20/24 showed Resident #1 had an, Acute .overlapping fracture of the proximal right humerus predominantly involving the humeral neck. On 1/30/25 at 2:25 p.m., in an interview by phone Staff A said on 11/1/24 at 3:00 a.m. she put Resident #1 in his bed, and she did not see the resident again until 5:00 a.m. when she found the resident on the floor. Staff A was asked to define frequent rounds. She said frequent rounds would be every 15 minutes. On 1/30/25 2:45 p.m., The Director of Nursing (DON) said she had not been at the facility at the time of resident #1's falls. The DON could not show from the facilities documentation how staff were providing appropriate supervision to prevent Resident #1 from falling multiple times. The DON verified nursing staff currently did not have an adequate definition of frequent rounds.

Based on record review, review of facility policy and procedures, and staff interviews, the facility failed provide the necessary supervision and assistance to prevent multiple falls for 1 (Resident #999) of 3 residents reviewed for falls. On 1/9/24, and 2/1/24, Resident #999 was not adequately supervised and fell . Each time the resident sustained a laceration to her face resulting in a transfer to an acute care hospital. The findings included: The facility policy Falls, Managing, Preventing and Documentation (revised 1/24) documented Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. Review of the clinical record for Resident #999 revealed an admission to the facility of 12/19/23 with a most recent re-admitted [DATE]. Diagnoses included dementia, depression, anxiety, and history of falling. The Admission Minimum Data Set (standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE] showed Resident #999 required maximum assistance with transfers and ambulation. Resident #999 required substantial to maximal assistance for sit to stand (The ability to safely come to a standing position from sitting in a chair or on the side of the bed). The MDS noted a Brief Interview for Mental Status (BIMS) was not conducted as the resident is rarely or never understood. The cognitive skills for daily decision making were severely impaired. The MDS noted Resident #999 had a fall in the last month prior to admission and the last two to six months prior to admission. Review of the plan of care initiated on 12/26/23 identified Resident #999 was at risk for falls related to cognitive deficit, history of falls, use of antihypertensive medications, use of psychotropic medications and incontinence. The goal noted, The resident potential for sustaining a fall-related injury will be minimized by utilizing fall precautions/interventions through next review date. The interventions included to, Encourage and remind resident to use call bell and wait for staff assistance with transfer, ambulation, toileting, etc., as indicated. The clinical record showed documentation Resident #999 sustained five falls since admission to the facility on [DATE]. On 2/8/24, review of the falls with the Director of Nursing (DON) since 1/7/24 revealed: Fall #1. On 1/9/24 at 3:30 p.m., an incident investigation showed Resident #999 had a fall. The nursing progress note dated 1/9/24 at 4:09 p.m. documented Resident #999 stood out of the wheelchair and fell forward hitting the left side of her head and face, sustaining a laceration above the left eyebrow. Resident #999 was transferred to the hospital via 911. On 1/9/24 at 10:30 p.m., the progress note documented the Resident returned to facility with three sutures to the left eyebrow. The care plan was not updated with new interventions after Resident #999 sustained a fall with injury. On 2/8/24 at 1:15 p.m., in an interview the DON said she the Resident's care plan was updated but it would only show on her computer. On 2/8/24 at 1:45 p.m., the DON returned with a new care plan documenting on 1/9/24 the care plan was updated with the intervention, Resident to use drop seat in wheelchair (w/c) and dycem (non-slip mat) as tolerated. The instructions for the drop seat and dycem were not added to the Certified Nursing Assistant (CNA) Kardex (Provides instructions for care). The DON said the instructions were not placed on the CNA Care Kardex because it was a therapy thing. Therapy educates the staff; they bring the chair and show the CNAs how to do it. The DON said the root cause of the fall was the resident was trying to stand up but leaned forward and fell . The DON said, we can't stand beside her all day, even if we had a one on one sitter it would not hold her in the chair. She is in a highly visible area and when they see her stand, they run to her but they don't reach her in time to stop her from falling and the resident's cognition does not let her understand. Fall #2. On 1/18/24 at 5:38 p.m., an incident investigation showed Resident #999 had a fall. The incident investigation specified that the resident was observed in the hallway and fell forward out of the w/c. Resident #999 did not sustain any injuries from the fall. The DON said the root cause of the fall was positioning, she always looks like she is leaning forward and to the right side. The DON said on 1/19/24 therapy did an evaluation and said it was an issue with her position in the w/c. A high back w/c was initiated with a drop seat, dycem and a 1/2 tray table. Fall #3. On 2/1/24 at 2:00 p.m., Resident #999 was found on the floor. A nurse's progress note dated 2/1/24 at 4:42 p.m., documented the resident was discovered on the floor in the hallway. The resident had multiple skin tears to the arms and left hand. The resident also had stiches (sutures) to her left forehead that were bleeding. The progress note dated 2/1/24 at 4:06 p.m., noted the resident was discovered on the floor in the hallway on the unit, the stiches from the previous event (fall) were open and bleeding. The incident investigation revealed Resident #999 was at the nurse's station. A delivery person was at the desk talking to the nurse. He then pointed to the resident. The nurse stood up, looked and the resident was on the floor. Resident #999 was sent to the local emergency department for treatment. Resident #999 returned to the facility with three sutures above the left eyebrow. On 2/2/24 the care plan was updated with the intervention Use antiroll back to wheelchair as resident tolerates. On 2/8/24 at 11:30 a.m., in an interview Unit Manager, Registered Nurse (RN) Staff A said Resident #999, sits at the front of the nurse's station, and I will watch her up there. She is alert but doesn't comprehend a lot of speech. She used to have a small table in front of her on the wheelchair. We tried everything, activities, keeping her occupied and therapy but she does not comprehend. On 2/1/24 she was sitting in her high back wheelchair. I had a delivery representative with me at the station and he pointed to her. I was sitting down so I stood up to look and she was face down on the floor. She landed on the same spot where she recently had sutures from a fall. Her foot was tangled in the footrest. We got her untangled and got her up. It took several of us to get her up. We took her vital signs and got orders to send her back out to the emergency room . She hit her face pretty hard on the floor. She split open where she just had split open before and had stiches, in the same spot. On 2/8/24 at 11:45 a.m., in an interview CNA Staff B said, the resident is on my usual assignment. When I come in, I get her up in the morning, she is always sleeping and tries to get up and walk and we watch her. I watch her a lot because she tries to walk around. She is always asleep; her eyes are closed, and I tell her to open her eyes. When she tries to walk her eyes are open. I was not working anytime she fell . On 2/8/24 at 1:51 p.m., in an interview the Director of Rehab said, the resident was always a one person assist. She could walk 300 feet with us one day and the next minute she had no interaction with us. Her cognitive status was just up and down, always changing. We have staff at different intervals so she could be seen at different times if she was not interactive with us. She has been on case load five times a week for Physical Therapy and Occupation Therapy since her admission. She was seen almost daily; I stagger the staff assignments. We had worked on three to four different wheelchairs for her. We tried a drop seat to change her seating position, so she was seated back more. We tried a breakaway lap tray. She was receiving Speech Therapy to find things to keep her engaged cognitively. She had single step commands more tactile like place the walker in front of her and help her to stand and walk. I would say less than 50% of the time she was engaging to commands. For her safety 24 hours one to one supervision would be ideal. On 2/8/24 at 3:00 p.m., in an interview, the DON said the root cause of fall #3 was, the residents advanced dementia, cognitive loss and she is impulsive. She has a sleep disorder. On 2/8/24 at 3:15 p.m., in an interview the Administrator said, the care plan interventions were effective because she had a decrease in injuries, and we tried something different every time. This will be her fourth chair. Requested any additional documents, and information related to each of the resident's falls. On 2/8/24 at 5:45 p.m., the DON and the Administrator did not provide any additional documentation at the end of the survey. On 2/9/24 the facility provided Enhanced Supervision Worksheets that were not provided during the survey. The three Enhanced Supervision Worksheets dated 1/9/24 documented on 1/9/24 Resident #999 was checked at 3:00 p.m., and 3:30 p.m. (Fall #1 was at 3:30 p.m.). Two of the forms had 1 (In room lying in bed) entered in the behavior code on 1/9/24 at 3:30 p.m., 3:45 p.m., and 4:00 p.m., at the time of the resident's fall from the wheelchair. The Enhanced Supervision Worksheets for 1/9/24 noted Resident #999 was supervised every 15 minutes from 3:30 p.m., to 10:30 p.m., when Resident #999 was at the hospital. The Enhanced Supervision Worksheets dated 1/18/24 documented Resident #999 was placed on 15-minute checks beginning at 5:45 p.m., after fall #2 had occurred. The enhanced monitoring form dated 2/2/24 documented the resident was placed on 15 minute checks after her return from the emergency room from fall #3.

Based on observation, review of facility policy and procedures and staff interviews the facility failed to treat 1 (Resident #45), and seven of 26 random residents with a diagnosis of dementia observed on the secured unit with dignity, and respect. The findings included: The facility policy Quality of Life - Dignity (revised 8/2009) documented Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall speak respectfully to residents at all times. On 1/22/24 at 8:34 a.m., Resident #45, and four other residents were observed in a wheelchair at the nurse's station of the secured unit. Registered Nurse (RN) Staff I was next to Resident #45 yelling, I need someone to babysit these people, I have to give medications. RN Staff I walked down the hall as she kept yelling out loud, I need someone to babysit these people, I have to give medications. Three residents were observed in the hallway. On 1/23/24 at 10:20 a.m., in an interview Certified Nursing Assistant (CNA) Staff C said he was working on the memory care unit on 1/22/24 when Staff I was calling out for a babysitter. Staff C said, I think she was just kidding around when she said it. I don't think she meant anything by it. On 1/25/24 at 9:33 a.m., in an interview RN Staff I said she recalled yelling for the staff to babysit the residents so she could administer her medications. RN Staff I smiled and said, yes, I did say that. When asked about the residents' rights to be treated with dignity and respect, RN Staff I smiled and said, Well, what should have I said?

Based on observation, record review, review of facility policy and procedure, resident and staff interviews, the facility failed to provide the necessary care and services to maintain hygiene, for 8 (Residents #26, #37, #8, #45, #83, #85, 103 and #366) of 8 dependent residents reviewed for activities of daily living. The findings included: The facility policy Activities of Daily Living (ADLs), Supporting (revised 2018) documented Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . 1. Review of the clinical record revealed Resident #45 had an admitted [DATE] with diagnoses including depression and dementia. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 12/20/23 documented N/A (not applicable) for bathing assistance and supervision/touching for personal hygiene. The MDS noted Resident #45's cognitive skills for daily decision making were severely impaired with a Brief Interview for Mental Status score of 03. Review of the plan of care initiated on 12/26/23 noted Resident #45 had an ADL self-care deficit. The interventions included to, Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. On 1/22/24 at 2:42 p.m., Resident #45 was observed in his wheelchair in the hallway of the memory care unit. The resident had approximately seven days of facial hair growth. Resident #45 said he wanted a shave, shower, and a haircut. His hair was uncombed, looked greasy and extending past his jaw line. On 1/23/24 at 8:48 a.m., Resident #45 was observed in the dining room and remained unshaven and appeared unkempt. Review of the shower schedule revealed Resident #45 was scheduled for showers on Tuesdays, Thursdays, and Saturdays during the 3:00 p.m., to 11:00 p.m., shift. Review of the Certified Nursing Assistant (CNA) documentation for 1/1/24 to 1/23/24 showed Resident #45 received four of the 10 scheduled showers. On 1/9/24 the CNA noted the resident refused the shower. On 1/11/24 and 1/13/24 the CNA documented a sponge bath was provided. On 1/18/24 N/A (Not applicable) was entered for the scheduled shower. Review of the December 2023 CNA charting revealed Resident #45 received a sponge bath in place of the scheduled shower on 12/14/23, 12/16/23 and 12/29/23 No shower was documented on 12/19/23. Not applicable was documented on 12/21/23, and 12/23/23. The CNA documented the scheduled shower was refused 12/26/23. The clinical record lacked an explanation for the showers that were not given as per the schedule. 2. Review of the clinical record revealed Resident #85 had an admitted [DATE] with diagnoses including, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting his left side, vascular dementia and depression. Review of the Admission MDS with a target date of 11/19/23 documented Resident #85 was dependent on staff for bathing, dressing and personal hygiene. The MDS noted Resident #85's cognitive skills for daily decision making were moderately impaired with a Brief Interview for Mental Status of 10. Review of the plan of care initiated on 11/19/23, showed Resident #85 had an ADL self-care deficit due to chronic medical conditions. The Interventions included to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, and personal/oral hygiene. On 1/22/24 at 2:26 p.m., Resident #85 was observed in bed with approximately seven days of facial hair growth. The resident said, they do not take good care of me here. They don't change me until the afternoon, they don't shower me or shave me. I don't get anyone to shave me, I ask but they don't do it. On 1/23/24 at 10:17 a.m., Resident #85 was observed out of bed in a high back wheelchair in the bathroom with CNA Staff E. In an interview, CNA Staff E verified Resident #85 approximately seven days of facial hair growth and needed to be shaved. Review of the shower schedule revealed Resident #85's showers were scheduled on Tuesdays, Thursdays, and Saturdays was scheduled on the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA documentation for December 2023 documented Resident #85 received a sponge bath on 12/2/23, 12/28/23 and 12/30/23. The CNA documented the resident was unavailable for a shower on 12/7/23. A full bed bath was provided on 12/9/23, 12/12/23 and 12/14/23 in place of the scheduled showers. Review of the CNA documentation for 1/1/24 to 1/24/23 showed Resident # 85 refused showers on 1/2/24, 1/18/24 and 1/20/24. He received sponge bath on 1/13/24, and a full bed bath on 1/16/24 and 1/23/24. The clinical record lacked an explanation for the showers not provided as scheduled. On 1/24/24 at 12:03 p.m., in an interview CNA Staff F said the said she follows the unit shower schedule and if a resident refused, she would tell the nurse so she could document it. 3. Review of the clinical record revealed Resident #103 had an admitted [DATE] with diagnoses including acute kidney failure, dementia, psychotic mood disorder and depression. Review of the Admission MDS with a target date of 11/27/23 documented Resident #103 was dependent on staff for bathing, dressing and personal hygiene. The MDS noted Resident #103's cognitive skills for daily decision making were severely impaired. On 1/22/24 at 2:20 p.m., Resident #103 was observed with approximately seven days of facial hair growth. During the observation, Resident #103's wife said she was concerned the staff were not shaving or bathing her husband. She said she did not know if he had been showered since he arrived at the facility several weeks ago. The spouse was observed running her fingers through the resident's uncombed hair. Review of the memory care unit shower schedule revealed Resident #103 was scheduled for showers on Mondays, Wednesdays, and Friday on the 3:00 p.m., to 11:00 p.m., shift. Review of the CNA documentation showed Resident #103 received no scheduled showers from 1/1/24 to 1/23/24. He received a sponge bath on 1/1/24, 1/3/24, 1/8/24, 1/10/24, 1/15/24, 1/17/24, and 1/22/24. The documentation showed on 1/19/24 Resident #103 refused his shower. On 1/5/24 he received a full bed bath in place of the scheduled shower. The CNA documentation for December 2023 showed no scheduled showers were provided to Resident #103. The documentation showed not applicable on 12/1/23. refused his shower on 12/8/23 and 12/22/23. He received a sponge bath on 12/4/23, 12/6/23, 12/11/23, 12/13/23,12/15/23, 12/18/23, 12/20/23, 12/25/23, 12/27/23 and 12/29/23 in place of the scheduled showers. The clinical record failed to show documentation why the showers were not provided as scheduled. On 1/23/24 at 10:30 a.m., in an interview Unit Manager Registered Nurse Staff B said the men residing on the memory care unit are to be shaved daily and during showers. Staff B said you have to remember where you are, this is a dementia unit and they can refuse care if they want. The expectation is to provide a shave daily. If they refuse the CNA tells the nurse and it is documented. On 1/25/24 at 2:36 p.m., in an interview the Director of Nursing (DON) said the expectation was the scheduled showers were to be given and that applied to the residents on the memory care unit as well. On 1/25/24 at 6:45 p.m., the DON failed to provide documentation showing the residents received the scheduled showers. 44824 4. The facility Standards and Guidelines for Call lights Issued on 3/2018 and revised 1/2024 stated Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. The guidelines were Resident's call light is to be within reach and answered promptly by facility personnel. Answer call light promptly. All facility personnel are expected to respond to call lights; turn off call light; Listen to residents' requests. Do NOT make residents feel that you are too busy; Offer services before leaving the room; Respond to the resident's request, if unable to assist, notify the nurse. Return to the resident promptly with a reply. Clinical record review showed Resident #8 was admitted to the facility on [DATE]. The Annual MDS assessment with a target date of 12/19/23 noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 08. Resident #8 required substantial to maximal assistance for activities of daily living, including, transferring, and toileting. On 1/24/24 at 12:45 p.m., observed Resident #8 call light flashing. Unit Manager Registered Nurse Staff J and three other staff members were observed distributing lunch trays to residents on the hallway. They did not respond to the resident's call light. RN Staff J walked into Resident #8's room with a lunch tray and walked out of the room without addressing the call light. On 1/24/24 at 12:55 p.m., in an interview Resident #8 said he turned on the call light 30 minutes ago to request assistance to go to the bathroom. On 1/24/24 at 1:10 p.m., the call light was still on. In an interview RN Staff J said she did not notice the call light on when she delivered Resident #8's lunch tray to his room, and the resident did not say he needed assistance. Staff J said it was important to hand out lunch trays to prevent the food to be cold. On 1/25/2024 at 11:00 a.m., Resident #8 was observed dressed and sitting up at bedside in his wheelchair. He said he'd like to receive at least one shower a week but has not had one in at least two weeks. Resident #8 said when he asks for a shower they always tell him tomorrow, but tomorrow never comes. Review of the shower schedule provided by the Director of Nursing showed Resident #8's scheduled shower days were Mondays, Wednesdays, and Fridays. Review of the shower documentation for January 1, 2024, through January 24, 2024, showed Resident #8 received two of the nine scheduled showers. The CNA documentation was left blank on 1/3/24, 1/8/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, and 1/22/24, making it impossible to determine if the resident received the scheduled shower. 5. Review of the clinical record for Resident #26 revealed an admitted [DATE]. The Quarterly MDS assessment with a target date of 12/28/23 showed the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The resident was frequently incontinent of bowel and bladder. Resident #26 was dependent on staff for all activities of daily living, including toileting. The care plan revised on 8/17/23 noted to encourage and assist Resident #26 with activities of daily living tasks as indicated and tolerated by resident, including toileting tasks. The care plan noted the resident required two staff assistance for transfer with the use of a mechanical lift. On 1/22/24 at 9:40 a.m., in an interview Resident #26 said he felt the facility was short staffed as it frequently takes staff two hours to respond to his call light requests for assistance with toileting. On 1/25/24 at 11:30 a.m., Resident #26 was lying in bed and said he needed to be changed. He said staff just turned off the call light, and said they'll be back with help. Resident #26 said, Now I'll have to wait another two hours to be changed. On 1/25/24 at 2:00 p.m., in an interview Resident #26 said being wet or worse is uncomfortable and humiliating. Review of the ADL care documentation for January 1,2024 through January 25, 2024 failed to show documentation Resident #26 received assistance with ADL care, including toileting and personal hygiene on 1/1/24, and 1/22/24 (all three shifts), on 1/4/24, 1/10/24, 1/11/24, 1/15/24, 1/16/24, 1/18/24, 1/19/24, 1/20/24, 1/22/24, 1/23/24 or 1/24/24 (Morning shift), on 1/2/24, 1/5/24, 1/13/24, 1/17/24, 1/18/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, and 1/124/24 (Evening shift), on 1/2/24, 1/8/24, 1/11/24, 1/12/24, 1/14/24, and 1/22/24 (Night shift). 6. Review of the clinical record revealed Resident #37 was admitted on [DATE]. The Quarterly MDS assessment with a target date of 11/25/23 noted a Brief Interview for Mental Status score of 12, indicative of moderately impaired cognition. The MDS showed the resident was frequently incontinent of urine. Resident #37 was dependent on staff for toileting hygiene. On 1/23/24 at 10:32 a.m., Resident #37 said staff changed her incontinent brief maybe once a shift. Resident #37 said she felt the facility did not have enough staff as it took a while, usually 30 to 45 minutes to answer the call lights. On 1/24/24 at 11:20 a.m., in an interview Resident #37 said the average wait time to answer the call light was about 30 minutes. She said then staff comes in, turn it off come back later. Review of the CNA ADL documentation flowsheets for January 1, 2024, through January 25, 2024, failed to show documentation Resident #37 received assistance with toileting on 1/4/24 and 1/22/24 (all three shifts), on 1/1/24, 1/2/24, 1/3/24,1/4/24, 1/8/24, 1/12/24, 1/13/24, 1/14/24, and 1/22/24 (morning shift), on 1/4/24, and 1/22/24 (evening shift), on 1/1/24, 1/2/24, 1/4/24, 1/6/24, 1/7/24, 1/8/24, 1/9/24, 1/11/24, 1/12/24, 1/13/24, 1/18/24, 1/19/24, 1/20/24, and 1/22/24 (night shift). 7. Review of the clinical record revealed Resident #366 had an admitted [DATE]. The 5-day MDS assessment with a target date of 1/21/24 noted the resident was cognitively intact with a Brief Interview for Mental Status score of 15. The care plan initiated on 1/17/24 noted the resident needed assistance with ADL care related to multiple factors, including weakness, decreased mobility status post recent hospitalization , illnesses including arthritis, pneumonia, and flu. The interventions included encouraging and assisting the resident with all ADL tasks as indicated and as tolerated by resident, including personal hygiene. On 1/22/24 at 10:20 a.m., in an interview Resident #366, she has been here since last Tuesday (1/22/24). The resident said she was recently hospitalized for pneumonia and flu and needed assistance for showers and hygiene. Resident #366 said she was supposed to get a shower on Mondays, Wednesdays, and Fridays but to date has not received one despite her daily requests for shower. Resident #366 was in bed, dressed in a nightgown. She said she had a wipe off bath yesterday and has only brushed her teeth one time. Review of Resident #366's CNA shower record for January 16, 2024, through January 25, 2024, failed to show documentation the resident received the scheduled showers. On 1/17/24, 1/18/24, 1/21/24, and 1/24/24, sb (sponge bath) was entered with no explanation for the missed showers. On 1/25/24 at 11:10 a.m., in an interview Resident #366 said she did not receive any shower since her admitted [DATE]. She said she'll shower when she's discharged home. On 1/25/24 at 1:20 p.m., in an interview the Director of Nursing said the expectation was for residents to receive their showers on the scheduled days. She said there was no expectation to answer the call lights. She said staff could be busy and not able to answer the call lights. She said staff at the desk should get up and answer the call lights. 22651 8. Review of the clinical record revealed Resident #83 had an admitted [DATE]. The Quarterly MDS assessment with a target date of 1/16/24. Resident #83's cognition was intact with a Brief Interview for Mental Status score of 13. Resident #83 was dependent on staff for showers. On 1/22/24 at 11:46 a.m., Resident #83 was interviewed with the assistance of the facility's Medical Record Staff translating in Spanish, the resident's native language. Resident #83 said he had been at the facility for approximately six months and has not had a shower for at least three months. Resident #83 was unshaven with medium facial hair growth. A brown substance was observed underneath his fingernails. Review of the shower schedule showed Resident #83's showers were scheduled on Mondays, Wednesdays, and Fridays on the evening shift (3:00 p.m., to 11:00 p.m.). Review of the shower documentation for October 2023, November 2023, December 2023, and January 2024 revealed Resident #83 received two of the 44 scheduled showers (12/29/23 and 1/12/24). N/A (not applicable) was entered on October 13, October 15, October 17, October 18, October 23, October 25, November 1, November 3, November 6, November 8, November 10, November 13, November 24, and December 8, 2023. A Full Bed Bath was documented for November 17, November 29, December 10, and December 15. A sponge bath was documented On October 14, October 16, October 19, October 27, November 22, November 29, December 1, December 4, and December 13, 2023. Resident unavailable was documented on November 20, November 27, November 29, December 27, January 3, and January 15. There was no explanation documented in the clinical record for the bed baths, sponge baths, the not applicable, and the unavailable entries on the scheduled shower days.

Based on observation, record review, residents, resident representative and staff interviews, the facility failed to ensure sufficient nursing staffing to meet the needs of 8 (Residents #26, #37, #8, #45, #83, #85, 103 and #366) of 8 dependent residents. The failure to meet the residents' needs could lead to the residents not receiving services timely and not attaining or maintaining their highest practicable physical, mental and psychosocial well-being. The findings included: 1. On 1/22/24 at 2:42 p.m., Resident #45 was observed in a wheelchair in the hallway of the memory care unit. The resident's hair was uncombed, looked greasy and extended past his jaw line. Resident 345 had approximately seven days of facial hair growth. Resident #45 said he wanted a shave, shower, and a hair cut. On 1/23/24 at 8:48 a.m., Resident #45 was observed in the dining room. He remained unshaven and appeared unkept. Review of the Certified Nursing Assistants (CNAs) documentation for 1/1/24 to 1/23/24 showed Resident #45 received four of the 10 scheduled showers with no explanation for the missed showers or the sponge baths provided instead of the shower. 2. On 1/22/24 at 2:26 p.m., Resident #85 was observed in bed with approximately seven days of facial hair growth. The resident said, they do not take good care of me here. They don't change me until the afternoon, they don't shower me or shave me. I don't get anyone to shave me, I ask but they don't do it. On 1/23/24 at 10:17 a.m., Resident #85 was observed out of bed in a high back wheelchair in the bathroom with CNA Staff E. In an interview, CNA Staff E verified Resident #85 approximately seven days of facial hair growth and needed to be shaved. Review of the CNA documentation failed to reveal Resident #85 received all the scheduled showers. There was no explanation documented for the missed showers. 3. On 1/22/24 at 2:20 p.m., Resident #103 was observed with approximately seven days of facial hair growth. During the observation, Resident #103's wife said she was concerned the staff were not shaving or bathing her husband. She said she did not know if he had been showered since he arrived at the facility several weeks ago. The spouse was observed running her fingers through the resident's uncombed hair. The CNA documentation showed Resident #103 refused a shower on 12/8/23, 12/22/23, and 1/19/24. There was no explanation for the sponge baths provided instead of the showers on the days Resident #103 was scheduled for a shower and did not refuse. On 1/23/24 at 10:30 a.m., in an interview Unit Manager Registered Nurse Staff B said the men residing on the memory care unit are to be shaved daily and during showers. On 1/25/24 at 2:36 p.m., in an interview the Director of Nursing (DON) said the expectation was the scheduled showers were to be given and that applied to the residents on the memory care unit as well. 4. On 1/24/24 at 12:45 p.m., Resident #8 call light flashing. Unit Manager Registered Nurse Staff J and three other staff members were observed distributing lunch trays to residents on the hallway. They did not respond to the resident's call light. RN Staff J walked into Resident #8's room with a lunch tray and walked out of the room without addressing the call light. On 1/24/24 at 12:55 p.m., in an interview Resident #8 said he turned on the call light 30 minutes ago to request assistance to go to the bathroom. On 1/24/24 at 1:10 p.m., the call light was still on. In an interview RN Staff J said it was important to hand out lunch trays to prevent the food to be cold. On 1/25/2024 at 11:00 a.m., Resident #8 said he'd like to receive at least one shower a week but has not had one in at least two weeks. Resident #8 said when he asks for a shower they always tell him tomorrow, but tomorrow never comes. Review of the shower documentation for January 1, 2024, through January 24, 2024, showed Resident #8 received two of the nine scheduled showers. The CNA documentation was left blank on 1/3/24, 1/8/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, and 1/22/24, making it impossible to determine if the resident received the scheduled shower. 5. On 1/22/24 at 9:40 a.m., in an interview Resident #26 said he felt the facility was short staffed as it frequently takes staff two hours to respond to his call light requests for assistance with toileting. On 1/25/24 at 2:00 p.m., in an interview Resident #26 said being wet or worse is uncomfortable and humiliating. Review of the ADL care documentation for January 1,2024 through January 25, 2024 failed to show documentation Resident #26 received assistance with ADL care, including toileting and personal hygiene on 1/1/24, and 1/22/24 (all three shifts), on 1/4/24, 1/10/24, 1/11/24, 1/15/24, 1/16/24, 1/18/24, 1/19/24, 1/20/24, 1/22/24, 1/23/24 or 1/24/24 (Morning shift), on 1/2/24, 1/5/24, 1/13/24, 1/17/24, 1/18/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, and 1/124/24 (Evening shift), on 1/2/24, 1/8/24, 1/11/24, 1/12/24, 1/14/24, and 1/22/24 (Night shift). 6. On 1/23/24 at 10:32 a.m., Resident #37 said staff changed her incontinent brief maybe once a shift. Resident #37 said she felt the facility did not have enough staff as it took a while, usually 30 to 45 minutes to answer the call lights. On 1/24/24 at 11:20 a.m., in an interview Resident #37 said the average wait time to answer the call light was about 30 minutes. She said then staff comes in, turn it off come back later. Review of the CNA ADL documentation flowsheets for January 1, 2024, through January 25, 2024, failed to show documentation Resident #37 received assistance with toileting on 1/4/24 and 1/22/24 (all three shifts), on 1/1/24, 1/2/24, 1/3/24,1/4/24, 1/8/24, 1/12/24, 1/13/24, 1/14/24, and 1/22/24 (morning shift), on 1/4/24, and 1/22/24 (evening shift), on 1/1/24, 1/2/24, 1/4/24, 1/6/24, 1/7/24, 1/8/24, 1/9/24, 1/11/24, 1/12/24, 1/13/24, 1/18/24, 1/19/24, 1/20/24, and 1/22/24 (night shift). 7. On 1/22/24 at 10:20 a.m., in an interview Resident #366, she has been here since last Tuesday (1/22/24). Resident #366 said she was supposed to get a shower on Mondays, Wednesdays, and Fridays but to date has not received one despite her daily requests for shower. She said she had a wipe off bath yesterday and has only brushed her teeth one time. Review of Resident #366's CNA shower record for January 16, 2024, through January 25, 2024, failed to show documentation the resident received the scheduled showers. On 1/17/24, 1/18/24, 1/21/24, and 1/24/24, sb (sponge bath) was entered with no explanation for the missed showers. 8. On 1/22/24 at 11:46 a.m., Resident #83 was interviewed with the assistance of the facility's Medical Record Staff translating in Spanish, the resident's native language. Resident #83 said he had been at the facility for approximately six months and has not had a shower for at least three months. Resident #83 was unshaven with medium facial hair growth. A brown substance was observed underneath his fingernails. Review of the shower documentation for October 2023, November 2023, December 2023, and January 2024 revealed Resident #83 received two of the 44 scheduled showers (12/29/23 and 1/12/24). There was no explanation for the missed showers or the sponge baths, full bed baths and not applicable documented on the day of the scheduled showers. 9. On 1/22/24 at 8:34 a.m., Resident #45, and four other residents were observed in a wheelchair at the nurse's station of the secured unit. Registered Nurse (RN) Staff I was next to Resident #45 yelling, I need someone to babysit these people, I have to give medications. RN Staff I walked down the hall looking for staff as she kept yelling out loud, I need someone to babysit these people, I have to give medications. Three residents were observed in the hallway. 10. On 1/25/24 at 1:20 p.m., in an interview the Director of Nursing said the expectation was for residents to receive their showers on the scheduled days. She said there was no expectation to answer the call lights. She said staff could be busy and not able to answer the call lights. She said staff at the desk should get up and answer the call lights.

Based on record review and interviews, the facility failed to provide an active Hospice contract for 6 (Residents #1, #11, #21, #24 #38, and #71) of 6 residents receiving Hospice services. The findings included: Review of the facility's matrix on 1/22/24 revealed Residents #1, #11, #21, #24 #38, and #71 were currently receiving hospice services. The hospice contract provided by the facility was dated 4/25/17, and was from the facility's previous owner. On 1/24/24 at 4:00 p.m., in an interview the Administrator verified the contract provided was from the previous ownership.

Based on record review and interview, the facility failed to provide an active dialysis contract for 1 (Residents #46) of 1 resident reviewed for dialysis. The findings included: Resident #46 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (ESRD). Review of the clinical record revealed Resident #46 received dialysis on Mondays, Wednesdays, and Fridays at a local dialysis center as per the physician's order dated 6/14/23. The dialysis contract provided by the facility was dated 12/1/15, and was from the previous facility's owner. On 1/25/24 at 10:30 a.m., in an interview the Administrator confirmed there was no current contract with the dialysis center.

Based on clinical records review, resident and staff interviews the facility failed to develop and implement an individualized care plan to meet the needs of 2 (Residents #25, and #83) of 32 sampled residents. The findings included: 1. Review of Resident #25's clinical records revealed an admitted [DATE]. Diagnoses included Cerebral Palsy (congenital disorder of movement, muscle tone and posture), and a history of intestinal obstruction. Review of the Significant Change Minimum Data Set (MDS) assessment with a target date of 10/26/23 noted Resident #25 received 500 milliliters or more of fluids daily through a feeding tube (tube inserted into the stomach for nutrition and/or hydration). The clinical record lacked documentation of an individualized care plan, with goals and interventions related to the use of a feeding tube. On 1/25/24, at 2:30 p.m., in an interview the Director of Nursing verified the lack of a care plan addressing the use of the feeding tube for Resident #25. On 1/25/24, at 2:45 p.m., in an interview the MDS Coordinator verified no care plan related to the use of the tube feeding was developed for Resident #25. 2. Review of clinical record for Resident #83 revealed an admitted [DATE]. The Admission MDS with a target date of 10/16/23 noted the resident's primary language was Spanish and he needed an interpreter to communicate with the physician and healthcare staff. Resident #83 scored a 15 on the Brief Interview for Mental Status, indicating intact cognition. The triggered care areas in the Care Area Assessment Summary and Care Planning did not include communication. Resident #83's care plan did not address the limited English proficiency and the communication needs of the resident. On 1/22/24 at 11:46 a.m., Resident #83 was interviewed using the facility's Spanish speaking Medical Record Staff as a translator. A monthly activity calendar was observed posted on the wall, in the resident's room. The calendar was written in English. Resident #83 said he spoke very little English and could not read English. On 1/23/24 at 8:52 a.m., in an interview the Activity Coordinator verified there was not activity calendar available in Spanish for the Spanish speaking residents. On 1/23/24 at 4:04 p.m., in an interview, Registered Nurse Staff W said she was contracted from an outside nursing agency and did not speak Spanish. She said the facility has not told her who she could use as a translator. Staff W said she sometimes is able to find a Certified Nursing Assistant who speaks Spanish to communicate with Spanish speaking residents. On 1/23/24 at 4:15 p.m., in an interview the MDS Coordinator verified the lack of care plan to address Resident #83's language and communication needs. On 1/23/24 at 4:25 p.m., in an interview the Dietary Manager said residents' menu were not available in Spanish.

Based on observation, record review and staff interview, the facility failed to post the federal staffing hours daily at the beginning of each shift. The findings included: On 1/22/24 at 7:30 a.m., upon entrance, the daily staffing information displayed in the main lobby was dated 1/19/24. No staffing information was observed for 1/20/24, 1/21/24, or 1/22/24. On 1/25/24 at 2:53 p.m., the Director of Nursing verified the staffing information was not displayed on 1/20/24, 1/21/24, or 1/22/24 for the morning shift. She said the staffing information should be displayed daily, including weekends.

Based on record review, review of facility's policy and procedure, resident and staff, the facility failed to implement processes to ensure timely acquiring and receiving of physician's ordered medications to meet the needs of 1 (Resident #367) of 7 newly admitted residents reviewed. The findings included: The Standards and Guidelines for Medication Reconciliation Admission/Re-Admission Issued 7/2017 and revised 2/2023 standard stated, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Review of the clinical record for Resident #367 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia (lack of sufficient oxygen in the blood), Emphysema (type of lung disease), pneumonia and anxiety. The admitting physician's orders dated 1/17/24 included Albuterol inhaler (used to prevent and treat difficulty breathing) every four hours as needed for wheezing, and Xanax 2 milligrams every 12 hours as needed for anxiety. Resident #367's care plan initiated on 1/17/24 noted the resident uses anti-anxiety medications related to Anxiety disorder. The interventions included to administer the anti-anxiety medications as ordered by the physician. The care plan also noted the resident was at risk for altered respiratory status and difficulty breathing due to Chronic Obstructive Pulmonary Disease (COPD), Emphysema and Pneumonia. The interventions included to administer medication, inhalers and nebulizers as ordered. On 1/22/24 at 11:00 a.m., in an interview Resident #367 said she uses an Albuterol inhaler every four hours and had the inhaler with her when she arrived at the facility on 1/17/24. She said the staff took the inhaler from her and she hasn't had her Albuterol inhaler since 1/17/24. Resident #367 said it made her anxious not to have her inhaler available in case she needed it for her shortness of breath. On 1/23/24 at 10:25 a.m., Resident #367 complained she still had not received her Albuterol inhaler or her Xanax since 1/17/24. She said she's asked for the Albuterol and the Xanax every day and still has not received them. Resident #367 said she did not sleep at all the night before since she did not have her Xanax (anti-anxiety) that she usually takes twice a day. On 1/23/24 at 3:30 p.m., in an interview Unit Manager Registered Nurse (RN) Staff J verified the Albuterol and the Xanax have not been available to administer to the resident since her admitted [DATE]. She said it should not take more than 24 hours to obtain a medication for a new resident. Upon reviewing the clinical record, Staff J said the Albuterol order was entered incorrectly in their system therefore the pharmacy did not fill the prescription. On 1/24/24 at 9:45 a.m., in an interview the Director of Nursing (DON) said if the Physician wrote the order for a medication on 1/17/24, it should be at the facility by 1/19/2024 at the latest. The physician's orders for the Albuterol inhaler and the Xanax 2 milligrams every 12 hours as needed for anxiety specified a start date of 1/17/24. On 1/24/24 at 12:10 p.m., in an interview the DON said the pharmacy missed the order and they have been calling nightly to get the medication. The DON was not able to provide documentation of the nightly calls to the pharmacy. Review of the Medication Administration Record (MAR) for 1/17/24 through 1/23/24 failed to show documentation Resident #367 received the physician's ordered Albuterol or Xanax since the admitted [DATE].

Based on review of the clinical record, and staff interviews, the facility failed to act upon the consultant pharmacist's recommendation for behavior monitoring for 1 (Resident #85) of 5 residents sampled for unnecessary medications review. The findings included: Review of the clinical record for Resident #85 revealed a physician order dated 11/8/23 to administer Quetiapine Fumarate 12.5 milligrams by mouth at bedtime for psychosis. Review of the Pharmacy Consultant medication review dated 11/29/23, documented Please consider adding an order to monitor behaviors r/t (related to) the Quetiapine use. On 11/30/23, the physician agreed with the recommendation and documented, agree, please write order. Review of the Medication Administration Record (MAR) for December 2023, and January 2024 showed no documentation of behavior monitoring. On 1/25/24 at 12:07 p.m., the DON confirmed there was no documentation of behavior monitoring as ordered by the physician on 11/30/23 for Resident #85.

Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin was properly dated when opened and failed to dispose of expired insulin stored in 1 of 1 medication cart observed on the secured unit of the facility. The findings included: The facility policy Storage of Medications (revised ,d+[DATE]) documented, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. On [DATE] at 8:30 a.m., during an observation of the memory unit medication cart with Registered Nurse Staff I the following was observed: 1. Resident #85 had one open bottle of Humalog sliding scale insulin date opened was [DATE] with the expiration date [DATE]. There was an additional opened bottle of Humalog insulin without a date of when it was opened. Photographic evidence obtained. 2. Resident #45 had one open bottle of Lispro/Humalog with expiration an expiration of date [DATE]. There was an additional opened bottle of Humalog insulin for Resident #45 without a date of when it was opened. Photographic evidence obtained. 3. Resident #43 had two opened bottles of Humalog insulin without a date of when they were opened. Photographic evidence obtained. Staff I verified the findings of the expired and undated insulin's stored in the medication cart.

Based on observation, record review, review of facility's policy and procedure, staff, resident and resident representative interviews, the facility failed to document a grievance and ensure prompt efforts to replace lost dentures for 1 (Resident #8) of 3 residents sampled for grievance resolution. The findings included: The facility Standards and Guidelines for Grievances - Resident Rights issued 4/2017 and revised 6/2023 states Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Guideline states the Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Review of the clinical record for Resident #8 revealed an admitted [DATE]. The Annual Minimum Data Set (MDS) assessment with a target date of 12/19/23 noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 08. Review of the Nutritional assessment dated [DATE] noted Resident #8 will be seeing a dentist to have his bottom denture replaced. On 1/22/2024 at 9:00 a.m., in a telephone interview Resident #8's Power of Attorney said Resident #8's got new lower dentures around October 2023 and they went missing at the facility three days later. She said she reported the missing dentures multiple times to the Administrator, and the Director of Social Services. They have offered no resolution; the dentures were still missing. On 1/22/24 at 10:00 a.m., in an interview Resident #8 said his bottom dentures went missing months ago. The facility has not done anything to replace them. Resident #8 was not observed with bottom dentures at the time of the interview. The grievance log from August 2023 until present was reviewed. There were no grievances documented regarding Resident #8's missing dentures. On 1/24/2023 at 3:30 p.m., in an interview the Social Service Assistant Staff L said she remembers Resident #8 getting new dentures but could not recall the dentures going missing. The Director of Social services present during the interview said she remembered something about the resident's dentures missing but could not recall any details. The Social Services Director did not offer any documentation or action taken related to the resident's missing dentures. She said normally a grievance would be filed. On 1/25/2024 at 10:55 a.m., in an interview Social Service Assistant Staff L verified the resident's bottom dentures were missing, and no grievance was filed. She said she arranged for the resident to get new dentures.

Based on observation, record review, and interviews, the facility failed to ensure adequate supervision and assistive devices to prevent multiple falls, including falls with injury for 1 (Resident #2) of 3 residents reviewed for falls. The findings included: Review of the clinical record for Resident #2 revealed an admission to the facility of 6/28/23 with a most recent re-admitted [DATE]. Diagnoses included Dementia with other behavioral disturbances, Parkinsonism, and depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 10 which indicated severe cognitive impairment. The care plan initiated on 6/30/23 showed Resident #2 was at risk for falls related to a history of multiple falls, unsteady balance, confusion, diagnosis of dementia with behaviors. The interventions included encourage and assist the resident to wear appropriate footwear such as nonskid socks, encourage and remind resident to use call bell and wait for staff assistance with transfers, toileting, ambulation, etc. date initiated 6/30/23. Nonslip surface to wheelchair as tolerated, date initiated 7/11/23, revised 12/6/23. Encourage the resident to use wheelchair positioning/safety devices anti roll backs initiated 7/27/23. Psych evaluation due to behaviors date initiated 11/03/23. Request medication review initiated 8/1/23 and again on 11/2/23. The care plan noted Resident #2 was uncooperative. On 12/6/23 at 12:30 p.m., Resident #2 was observed in a wheelchair. There was no nonskid cushion in the wheelchair. On 12/6/23 at 12:50 p.m., Resident #2 was observed in the dining room with his wife. Resident #2's wife said the resident did not have a cushion in his chair to stop him from slipping out of the chair. The wife said he had one at one time. The nurse corrected the resident's wife and said there was a cushion. The nurse verified he did not currently have a cushion on his chair. When asked if he had one available, she said to speak with the unit manager about it. On 12/6/23 at 1:05 p.m., the Unit Manager verified there was not a nonskid cushion in the resident's wheelchair, and there was not one available in the resident's room. Review of the facility's incident reports revealed Resident #2 sustained multiple falls since admission to the facility. Fall #1. On 7/11/23 at 11:49 a.m., the Incident Report showed Resident #2 was found on the floor in his room near his wheelchair. He got up to go to the bathroom and his legs gave out. The resident sustained skin tears to the left arm. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and the Director of Nursing (DON), the Administrator said the investigation showed the resident slid out of his wheelchair. He said the intervention added to the care plan on 7/11/23 was non-slip cushion to wheelchair. Fall #2. On 7/26/23 at 6:25 p.m., an incident report showed Resident #2 had a fall. Resident #2 was found on the floor in front of the nurses station. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation showed the resident was leaning forward and fell forward out of wheelchair. He said the intervention added on 7/27/23 was anti rollback device to wheelchair. The DON said, all safety measures were in place. Fall #3. Review of Facility Fall Incident Log showed Resident #2 had a fall on 8/1/23 at 16:30 p.m. Review of Incident Report showed Resident #2 was found on the floor. The resident was not able to explain what happened. Resident lost his balance, fell , and hit his head. The resident was sent out to hospital for evaluation. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said a medication review was conducted by physician of 8/2/23. A psychiatric evaluation was also conducted for behaviors. There were no other interventions at that time. The DON said he was sent to the hospital due to the behavior of pulling out his IV (intravenous line used for antibiotic therapy) and pulling out his foley catheter (catheter inserted in the bladder to drain urine) which caused bleeding. He also had one staple for a laceration on his head. The administrator said Mirtazapine (medication used for depression and anxiety) was ordered for the resident, but his wife refused it. She did not like him being sedated. She refused all psych medications for her husband. Fall #4 Review of Facility Fall Incident Log showed Resident #2 had a fall on 10/7/23 at 4:00 p.m. Review of Incident Report showed Resident #2 was found in bed with blood on the linens. There was also blood on the floor next to his bed. The resident was unable to explain what happened. The resident was bleeding from the left side of forehead. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident had been on the floor and got back into bed himself. The intervention was to move the resident to a room closer to the nurses' station. A perimeter (raised edges) mattress was also ordered. Fall #5 Review of Facility Fall Incident Log showed Resident #2 had a fall 11/1/23 at 7:59 a.m. Review of Incident Report showed Resident #2 was found lying face down on the floor next to his bed. The resident had a pillow under his head. The resident was lifted back into the bed with a mechanical lift. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident had fallen out of bed. The intervention was to order a wider perimeter mattress. Fall #6 Review of Facility Fall Incident Log showed Resident #2 had a fall 11/2/23 at 5:07 a.m. Review of Incident Report showed Resident #2 was found on the floor next to the bathroom. The resident said he was getting off the toilet, his legs got weak, and he fell . He fell on his buttocks. He complained of pain in his buttock area. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident was getting up in the bathroom unassisted. The intervention was a medication review and psych evaluation. The DON said medications were ordered for a urinary tract infection on 11/2/23. Fall #7 Review of Facility Fall Incident Log showed Resident #2 had a fall 11/3/23 at 11:21 p.m. Review of Incident Report showed Resident #2 had a witnessed fall by four (4) staff members. The staff said the resident stood up and then he fell to the floor. The resident had a skin tear to the left forearm and left calf. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident had behaviors that put him at risk for falls. Multiple medication changes were made after this fall. Fall #8 Review of Facility Fall Incident Log showed Resident #2 had a fall 11/8/23 at 19:18 p.m. Review of Incident Report showed Resident #2 had a fall from his wheelchair at the nurses station. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident stood up unassisted and fell forward hitting the left side of his head. The resident sustained head lacerations and was sent to the hospital. The intervention was another room change. The resident was moved to the memory care unit due to elopement risk. The DON said, The resident's wife left him outside of the public viewing area. The physician explained to the resident's wife that the resident was at a high risk for falls. The wife was educated about the resident's safety but continued to refuse all pharmacological interventions. Fall #9 Review of Facility Fall Incident Log showed Resident #2 had a fall 11/18/23 at 11:10 a.m. Review of Incident Report showed Resident #2 was found on the floor next to his bed. The wheelchair was at the bedside. The resident suffered a laceration to the right side of his forehead. The resident was unable to explain what happened. On 12/7/23 at 12:25 p.m., during an interview with the Administrator and DON, the Administrator said the investigation found the resident fell in his room with the wheelchair at his bedside. The intervention was to order lab work. On 12/7/23 at 4:00 p.m., the administrator and DON both said Resident #2's wife is always with him, into the late evening hours. His wife is at the facility all day, every day. They have a resident right to be alone in the resident room. They said they had not discussed the need for increased supervision of the resident to decrease falls with the wife. On 12/7/23 at 4:15 p.m., during a tour of the dementia unit Resident #2 was observed sitting in his wheelchair alone at a table in the dining room. Licensed Practical Nurse (LPN) Staff A was in the dining room passing medications. Staff A said she works full time in the dementia unit. She said Resident #2's wife already went home. Staff A said, She is usually gone when I come on duty for the 3 to 11 shift. On 12/7/23 at 5:15 p.m., the DON said she does not have documentation to show the wife is always with Resident #2 during the evening hours. The administrator said the facility can't put the resident on long term one to one supervision. The only thing we could do would be to give a 30 day discharge notice. On 12/7/23 at 5:20 p.m., the administrator said he had no other documentation showing the facility provided adequate supervision to prevent the resident's falls.

Based on observation, record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure 1 (Resident #410) of 2 sampled residents at risk for development of pressure ulcers received necessary services to prevent the worsening and development of pressure ulcers. Resident #410's pressure ulcer significantly deteriorated, and the resident developed additional pressure ulcers. The findings included: Review of the Facility's Skin Management Guidelines with an original date of 2/2022 revealed, Purpose: To describe the process steps required for identification of patients at risk for the development of skin alterations, identify, prevention techniques and interventions to assist with the management of pressure injuries and skin alterations . Body audits are completed: By the licensed nurse daily for patients with pressure injuries and documented on the eTAR (Electronic Treatment Administration Record); new findings are documented in a progress note . Skin preventions strategies that can be implemented upon admission for any patient may include . Repositioning and offloading pressure . Pressure reducing support surfaces . On 3/22/22 record review revealed Resident #410 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment with a target date of 3/14/22 revealed the Resident required extensive physical assistance of two persons for bed mobility (How the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS noted Resident #410 was admitted with one stage 2 pressure ulcer (Partial thickness loss of skin presenting as a shallow open ulcer). The Admission/Re-Admission Evaluation form dated 3/8/22 noted Resident had redness to the coccyx (bone structure at the base of the spine) and a left buttock stage 2 pressure ulcer. Review of the Braden Scale (Tool used for predicting pressure ulcer risk) dated 3/8/22 and 3/15/22 showed Resident #410 was at high risk for developing pressure ulcers. Resident #410 was bedfast (confined to bed); had very limited ability to change and control body position; skin was constantly moist by perspiration, urine; dampness detected every time patient is moved or turned. The Braden Scale also showed friction and shear was a problem. The Resident required moderate to maximum assistance in moving. Complete lifting without sliding against sheets was impossible; frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Review of Resident #410's care plan showed on 3/8/22 the facility initiated a care plan noting the Resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, and peripheral arterial disease. Preventive measures included to apply barrier cream to the peri area and buttocks as needed, elevate heels as able and tolerated, encourage to reposition as needed, observe skin condition with care daily and report abnormalities and pressure redistributing device on bed. The care plan did not address Resident #410's existing stage 2 pressure ulcer to the buttocks or specific measures to promote healing and prevent the worsening of the pressure ulcer. The Treatment Administration Record (TAR) lacked documentation of daily body audits per the facility's policy. Review of the wound care practitioner's progress notes dated 3/10/22 revealed Resident #410 had a stage 2 pressure ulcer to the superior left buttock measuring 2.17 centimeters (cm) in length, 3.66 cm in width and 0.1 cm in depth. The practitioner documented Specialty low air loss mattress ordered. The clinical record lacked documentation the facility obtained and applied the low air loss mattress (specialty mattress to help prevent and heal pressure ulcers by eliminating high pressure points) to the bed as ordered. On 3/17/22 the wound care practitioner documented the presence of a new stage 2 pressure ulcer to the left lateral malleolus (ankle). She documented, Low air loss mattress was ordered 3/10/22. I viewed order in chart. I reordered today . [Resident #410] is . basically immobile. Complains of pain L (left) lateral malleolus and buttocks . It's concerning that this patient is developing a new pressure ulcer, however it is attributable to her immobility . The left upper buttock wound now measured 2.3 cm (length) by 3.8 cm (width) by 0.1 cm (depth). The newly identified left lateral ankle wound measured 0.4 cm (length) by 0.6 cm (width) by 0.1 cm (depth). On 3/21/22 at 9:54 a.m., 3/22/22 at 11:09 a.m., and 3/23/22 at 9:59 a.m., Resident #410 was observed in bed. The low air loss mattress was not observed on the bed. On 3/24/22 at 8:21 a.m., observation of Resident #410's wounds with the wound care Advanced Practice Registered Nurse (APRN) revealed the Stage 2 pressure ulcer to the left upper buttock had worsened. The APRN said the wound was now unstageable due to the presence of slough (dead tissue) and DTI (Deep tissue injury) next to it. The APRN said she will consider the whole area as one unstageable wound that measured 5.2 cm (length) by 5.9 cm (width). The APRN was not able to measure the depth of the wound due to the presence of dead tissue. During the wound care observation, Resident #410 complained of pain to the right lateral leg. Observation of the right lateral leg revealed a new open area which the wound care APRN said was a stage 2 pressure ulcer measuring 2.0 cm (length) by 2.0 cm (width). Resident #410 now had a total of 3 pressure ulcers injuries. On 3/24/22 at 6:08 p.m., in an interview the Director of Nursing (DON) said there was a breakdown in communication. The DON said there was a lack of nursing interventions to prevent new pressure ulcers and minimize the deterioration of the pressure ulcer Resident #410 was admitted with. The DON acknowledged the failure to obtain and apply the low air loss mattress to the bed contributed to the worsening of Resident #410's existing pressure ulcer and the development of two new stage 2 pressure ulcers.

Based on record reviews and interviews, the facility's Administrator failed to conduct a thorough investigation of a fatal incident and failed to recognize the deficient practice that occurred at the facility on [DATE]. The Administrator failed to ensure adequate training was provided to facility staff in response to the deficient practice. A facility staff person was feeding a resident with a swallowing disorder. The resident continued to be fed while not swallowing, developed breathing difficult, was transferred to Hospice, and died the following day. On [DATE] at 1:45 p.m., the Administrator was informed of the determination of immediate jeopardy. The findings included: During an interview on [DATE] at 4:10 p.m., the Hospice Nurse reported on [DATE] during breakfast, Certified Nursing Assistant (CNA) Staff A was observed speaking on her cellphone in Resident #1's dark room. CNA Staff A was spoon feeding Resident #1 pureed thin food and did not notice Resident #1 still had food in her mouth. The Hospice Nurse said CNA Staff A put another spoonful of food in Resident 1's mouth while continuing her cell phone conversation. The CNA did not notice Resident #1 was not swallowing. The Hospice Nurse said she told the CNA not to feed the resident anymore food. CNA Staff A ended her cell phone conversation. After cleaning Resident #1's mouth of food, the Hospice Nurse requested Licensed Practical Nurse (LPN) Staff B and Registered Nurse (RN) Unit manager Staff C to get oxygen equipment for Resident #1. Resident #1 had a low oxygen saturation level of 74% with labored breathing and a grey appearance. The Hospice Nurse said Resident #1 was transferred to Hospice House early in the afternoon. The Hospice Nurse said, upon arrival the Hospice House staff reported Resident #1 still had food in her mouth. Resident #1 died on [DATE] at 4:15 a.m. at Hospice House. In an interview on [DATE] at 12:30 p.m., the Administrator who is also the Risk Manager said she conducted her facility investigation on [DATE] and completed it on [DATE]. The Administrator said the allegations were not substantiated based on her investigation. The Administrator said CNA Staff A is still working at the facility. The Administrator said she received a call on [DATE] at 10:15 p.m. from the Supervisor of the Hospice Nurse informing her about Staff A video chatting on her cell phone while feeding Resident #1. The Administrator said she interviewed Staff A on [DATE] who said she was not using her phone on [DATE] while feeding Resident #1. The Administrator admitted she did not interview the Hospice Nurse. The Administrator showed signed statements from her staff during her investigation. Staff A signed a statement which said there was food coming from Resident #1's mouth. During an interview on [DATE] at 2:30 p.m., Licensed Practical Nurse (LPN) Staff B said she has witnessed CNA Staff A using her cell phone. LPN Staff B said the Administrator did not interview her during the facility investigation. On [DATE] at 11:00 a.m., the Administrator said her previous Director of Nursing (DON) had spoken to Department of Children and Families (DCF) Nurse on [DATE] .The Administrator said she was aware of his findings and the DCF nurse had recommended education for all staff. The administrator said she had no contact with DCF. The last 90 day list of active employees was provided from the facility, which included 63 CNAs, 37 RNs and LPNs. On [DATE] at 11:00 a.m., the four in-services conducted by the facility, all with different topics were reviewed with the Administrator who said the previous DON taught the in-services. The first sign-in sheet had 15 signatures. The second sign-in sheet had 24 signatures. The third sign-in sheet had 13 signatures. The fourth sign-in sheet had 25 signatures. The administrator said she was not aware the staff had not all been in-serviced. She said she did not know because it was the DON's job. The Administrator's job description was requested from the Administrator, but never recieved. District 21 (Lee County) Medical Examiner autopsy report #,[DATE] signed [DATE] showed cause of death for Resident #1 as [MEDICAL CONDITION] (low oxygen in tissue) due to food asphyxiation (deprivation of oxygen). Review of Investigative Summary for DCF case# (YEAR)-,[DATE] involving Resident #1 showed closed with verified findings of asphyxiation and inadequate supervision. The Administrator failed to fully investigate an incident involving a resident who died due to deficient practice at the facility. The Administrator failed to ensure adequate training was provided to facility staff in response to the Resident #1's death.

Based on record reviews and interviews, the facility failed to provide services to a resident that are necessary to avoid physical harm for 1 (Resident #1) of 3 residents reviewed. A certified nursing assistant (CNA) was feeding a resident with a swallowing disorder. The resident continued to be fed while not swallowing, developed breathing difficult, was transferred to Hospice, and died the following day. On [DATE] at 1:45 p.m., the Administrator was informed of the determination of immediate jeopardy that had started [DATE]. The findings included: Review of Resident #1's Admission Record showed she was initially admitted [DATE]. Resident #1's Medical [DIAGNOSES REDACTED]. Physician order [REDACTED]. Admission Documentation for Section GG included: Eating: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity . During an interview on [DATE] at 4:10 p.m., the Hospice Nurse reported on [DATE] during breakfast, CNA Staff A was observed speaking on her cellphone in Resident #1's dark room. CNA Staff A was spoon feeding Resident #1 pureed thin food and did not notice Resident #1 still had food in her mouth. The Hospice Nurse said CNA Staff A put another spoonful of food in Resident 1's mouth while continuing her cell phone conversation. The CNA did not notice Resident #1 was not swallowing. The Hospice Nurse said she told the CNA not to feed the resident anymore food. CNA Staff A ended her cell phone conversation. After cleaning Resident #1's mouth of food, the Hospice Nurse requested Licensed Practical Nurse (LPN) Staff B and Registered Nurse (RN) Unit manager Staff C to get oxygen equipment for Resident #1. Resident #1 had a low oxygen saturation level of 74% with labored breathing and a grey appearance. The Hospice Nurse said she administered the oxygen to Resident #1 and the oxygen level rose to 87%. The Hospice Nurse said Resident #1 was transferred to Hospice House early in the afternoon. The Hospice Nurse said, upon arrival the Hospice House staff reported Resident #1 still had food in her mouth. Resident #1 died the following morning at 4:15 a.m. at Hospice House. In an interview on [DATE] at 9:45 a.m., CNA Staff A said she had attempted to feed 2 small spoons of pureed food to Resident #1 the morning of [DATE], but the resident refused to eat. Staff A denied speaking on her cell phone the morning of [DATE]. CNA Staff A said she keeps her cell phone in her pocket; if someone calls her, the phone will vibrate. Staff A said if she is not busy, she checks the cell phone screen to see who is calling her. Staff A said she uses her cell phone as a watch as she does not have a watch. She said she is aware staff are not to use cell phones in resident areas. On [DATE] at 2:30 p.m., LPN Staff B said she has witnessed CNA Staff A using her cellphone on the Thalia unit (a dementia unit), where she works. LPN Staff B said the Administrator did not interview her during the facility investigation of the incident. On [DATE] at 12:30 p.m., the Administrator said she does not allow the Hospice Nurse who witnessed CNA Staff A feeding Resident #1 back into the facility. This was because the Administrator did her own investigation and the story was different. The Administrator said she received a call on [DATE] at 10:15 p.m., from the supervisor of the Hospice Nurse, informing her about CNA Staff A video chatting on her cell phone while feeding Resident #1. The Administrator said the supervisor told her the Hospice Nurse had to remove eggs from Resident #1's mouth. When the resident arrived at the Hospice House, more eggs were found in Resident #1's mouth. The Administrator said she interviewed CNA Staff A on [DATE]. Staff A reported she was not using her phone on [DATE]. The administrator, who is also the facility risk manager said she conducted her facility investigation on [DATE] and completed it on [DATE]. The Administrator said the allegations were not substantiated. The Administrator said the incident did not happen. The Administrator said she had suspended CNA Staff A for 5 days during the investigation of the incident on [DATE]. CNA Staff A is currently back working at the facility. The Administrator showed Staff A's signed statement said there was food in Resident#1's mouth. The Administrator admitted she did not interview the Hospice Nurse. Review of the District 21 (Lee County) Medical Examiner autopsy report #,[DATE] signed [DATE] showed cause of death for Resident #1 as [MEDICAL CONDITION] (low oxygen in tissue) due to food asphyxiation (deprivation of oxygen). The Administrator said her previous Director of Nursing (DON) had spoken to a Department of Children and Families (DCF) nurse on [DATE] who had recommended education for the facility staff. The Administrator said she herself had no contact with DCF. Review of Investigative Summary for DCF case# (YEAR)-,[DATE] involving Resident #1 showed closed with verified findings of asphyxiation and inadequate supervision.

Based on record reviews and interviews, the facility failed to ensure 1 (Resident #1) out of 3 residents reviewed had feeding assistance from a competent and supervised certified nursing assistant (CNA). A certified nursing assistant (CNA) was feeding a resident with a swallowing disorder. The resident continued to be fed while not swallowing, developed breathing difficult, was transferred to Hospice, and died the following day. On [DATE] at 1:45 p.m., the Administrator was informed of the determination of immediate jeopardy that had began [DATE]. The findings included: Review of Resident #1's Admission Record showed she was initially admitted [DATE]. Resident #1's Medical [DIAGNOSES REDACTED]. Physician order [REDACTED]. Admission Documentation for Section GG included: Eating: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity . During an interview on [DATE] at 4:10 p.m., the Hospice Nurse reported on [DATE] during breakfast, CNA Staff A was observed speaking on her cellphone in Resident #1's dark room. CNA Staff A was spoon feeding Resident #1 pureed thin food and did not notice Resident #1 still had food in her mouth. The Hospice Nurse said CNA Staff A put another spoonful of food in Resident 1's mouth while continuing her cell phone conversation. The CNA did not notice Resident #1 was not swallowing. The Hospice Nurse said she told the CNA not to feed the resident anymore food. CNA Staff A ended her cell phone conversation. After cleaning Resident #1's mouth of food, the Hospice Nurse requested Licensed Practical Nurse (LPN) Staff B and Registered Nurse (RN) Unit manager Staff C to get oxygen equipment for Resident #1. Resident #1 had a low oxygen saturation level of 74% with labored breathing and a grey appearance. The Hospice Nurse said Resident #1 was transferred to Hospice House early in the afternoon. The Hospice Nurse said, upon arrival the Hospice House staff reported Resident #1 still had food in her mouth. Resident #1 died the following morning at 4:15 a.m. at Hospice House. In an interview on [DATE] at 9:45 a.m., CNA Staff A said she had attempted to feed 2 small spoons of pureed food to Resident #1 the morning of [DATE], but the resident refused to eat. Staff A denied speaking on her cell phone the morning of [DATE]. CNA Staff A said she keeps her cell phone in her pocket; if someone calls her, the phone will vibrate. Staff A said if she is not busy, she checks the cell phone screen to see who is calling her. Staff A said she uses her cell phone as a watch as she does not have a watch. She said she is aware staff are not to use cell phones in resident areas. On [DATE] at 2:30 p.m., LPN Staff B said she has witnessed CNA Staff A using her cellphone on the Thalia unit (a dementia unit), where she works. LPN Staff B said the Administrator did not interview her during the facility investigation of the incident. On [DATE] at 12:30 p.m., the Administrator said she does not allow the Hospice Nurse who witnessed CNA Staff A feeding Resident #1 back into the facility. This was because the Administrator did her own investigation and the story was different. The Administrator said she received a call on [DATE] at 10:15 p.m., from the supervisor of the Hospice Nurse, informing her about CNA Staff A video chatting on her cell phone while feeding Resident #1. The Administrator said the supervisor told her the Hospice Nurse had to remove eggs from Resident #1's mouth. When the resident arrived at the Hospice House, more eggs were found in Resident #1's mouth. The Administrator said she interviewed CNA Staff A on [DATE]. Staff A reported she was not using her phone on [DATE]. Staff A said she did not remember if Resident #1's door to her room was closed, if the room was dark, or if the curtains were pulled on [DATE]. The Administrator said she conducted her facility investigation on [DATE] and completed it on [DATE]. The Administrator said the incident did not happen. The Administrator said she had suspended CNA Staff A for 5 days during the investigation of the incident on [DATE]. CNA Staff A is currently back working at the facility. The Administrator admitted she did not interview the Hospice Nurse. The Administrator said her previous Director of Nursing (DON) had spoken to a Department of Children and Families (DCF) nurse on [DATE] who had recommended education for the facility staff. The Administrator said she herself had no contact with DCF. Review of Investigative Summary for DCF case# (YEAR)-,[DATE] involving Resident #1 showed closed with verified findings of asphyxiation and inadequate supervision. Four in-service records were reviewed on [DATE] at 11:00 a.m. with the Administrator. The Administrator said the in-services were taught by the previous DON. The first in-service on [DATE] was titled Thalia Dining Room but there was no start or end time and no agenda or content. A sign-in sheet had 15 signatures (7 RN/LPNs and 8 CNAs). The next in-service was on [DATE] titled Use of telephone/ cell phone but had no presenter, start time or end time and no agenda or content. There were 24 names on the sign-in sheet. The next in-service was on [DATE] titled Identify risks of aspiration when assisting patient during meal. There was no presenter, no start or end time and no agenda or content. There were 13 signatures on the sign-in sheet. The fourth in-service was on [DATE] titled, Nurses are to assist and monitor tray pass. There was no start time or end time. There were 25 signatures on the sign-in sheet, with RNs and LPNs. The Administrator said she was not aware all staff were not in-serviced because she said that was the DON's job. A list from the facility the last 90-day list of active employees showed 63 CNAs, 37 licensed nurses (RN and LPN). District 21 (Lee County) Medical Examiner autopsy report #,[DATE] showed cause of death for Resident #1 as [MEDICAL CONDITION] (low oxygen in tissue) due to food asphyxiation (deprivation of oxygen).