Every finding on record at First Coast Health and Rehabilitation Center

Based on record review, interviews and a review of facility policies and procedures, the facility failed to 1) Complete the notice of transfer or discharge (Discharge/Transfer Notice AHCA 3120-002 form), and 2) Send a copy of the notice of transfer/Discharge to the representative of the Office of the State Long-Term Care Ombudsman's office for three (Residents #90, #92 and #23) of three residents reviewed for discharge requirements. The findings include:1.A review of Resident #90's medical record revealed an initial admission date of 11/26/25 and a re-entry date of 12/4/25. The resident was then discharged to an acute care hospital via emergency medical services for shortness of breath/respiratory distress on 12/29/25. A physician's order, dated 12/29/25, instructed nursing staff to send the resident to the hospital for respiratory distress.An SBAR (Situation, Background, Assessment, Recommendation) Summary revealed that on 12/29/25 at 20:20 (8:20 PM), Resident #90 had a change in condition (shortness of breath) with provider recommendations to Send resident to the hospital via 911.No Discharge/Transfer Notice AHCA 3120-002 form was found in the resident's medical record. There was no indication that the Ombudsman's office was notified of the discharge.2. A review of Resident #92's medical record revealed an admission date of 12/13/25 and a discharge date of 12/16/25. The resident was transferred/discharged to an inpatient rehabilitation facility per the resident's request. No Discharge/Transfer Notice AHCA 3120-002 form was found in the resident's medical record. There was no indication that the Ombudsman's office was notified of the discharge.3. A review of Resident #23's medical record revealed an admission date of 10/23/25 and a discharge date of 12/18/25. The resident was discharged per the family's request to a facility in Ohio, closer to family. No Discharge/Transfer Notice AHCA 3120-002 form was found in the resident's medical record. There was no indication that the Ombudsman's office was notified of the discharge.On 1/22/26 at 11:04 AM, during an interview with the Director of Social Services (DSS), she was asked to explain the facility's Discharge Process. She stated she met with residents upon admission to determine their projected length of stay, and throughout their stay, she periodically followed up to see if anything had changed. She was asked how often she notified the Ombudsman's office of resident transfers/discharges. She stated, I'm not aware of that; that's not something I've done but you can speak to the DON (Director of Nursing) or the Administrator.On 1/22/26 at 11:25 AM, an interview was conducted with the Administrator. She was asked whose responsibility it was to notify the Ombudsman's office of resident transfers or discharges. She stated, You know. It's Social Services.On 1/22/26 at 11:39 AM, an interview was conducted with the DON who was asked whose responsibility it was to notify the Ombudsman of resident transfers or discharges. She stated, It's Social Services; we didn't have anyone in that position for a while and then we had someone on December 4, 2025, and then the current social worker started on December 30, 2025. She was asked how often the Ombudsman was notified of resident transfers or discharges. She replied, I'm not sure but I will get back with you on that. She was asked to provide evidence of Ombudsman notification of discharged or transferred residents for December 2025. On 1/22/26 at 12:15 PM, the DON confirmed that the facility's frequency for notifying the Ombudsman of resident transfers/discharges was monthly and that no notification of transfers or discharges was sent to the Ombudsman in December 2025. The DON provided a list or residents who transferred or discharged from the facility in December 2025. Residents #90, #92 and #23 were listed. A review of the facility's policy and procedure titled Discharge Documentation (effective November 2024, 8.1.8, 3 pages), revealed that for external transfers for medical services at a higher level of care, the following forms/documents were required:Long Term Care Ombudsman Council Request for Review of Nursing Home Transfer Discharge.Procedure: Discharges:1.Should the facility decide to discharge the resident while the resident is hospitalized , the facility will send Form 3120, Notice of Discharge/Transfer, to the resident and resident representative. A copy of the discharge notice will also be sent to the Office of the State LTC (long-term care) Ombudsman at the same time as the Notice of Discharge/Transfer is provided to the resident and resident representative.2.For any other types of facility-initiated discharges, the facility will provide the Notice of Discharge/Transfer to the resident and representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. A copy of the notice is sent to the Ombudsman at the same time as Form 3120 (Discharge/Transfer Notice AHCA 3120-200 form) is provided to the resident and resident representative.Emergency Transfers:1.When a resident is temporarily transferred on an emergency basis to an acute care facility, Form 3120, Notice of Transfer, is provided to the resident and resident representative as soon as practicable, but within 24 hours of the transfer.2.Copies of Form 3120 for emergency transfers are sent to the Ombudsman as soon as practicable, such as in a list of residents every month.

Based on observations, interviews and record review, the facility failed to maintain an effective pest control program, as evidenced by repeated observations of live roaches and fruit flies in four (#101, #103, #105, and #214) of 39 resident rooms and two (100 hall and 300 hall) of three hallways. Failure of the facility to eradicate pests can pose health risks to vulnerable residents including transmission of diseases, allergic reactions and discomfort/infection related to bug bites. Pests can potentially threaten sanitation, contaminate food and cause residents emotional distress.The findings include: On 1/20/26 at 8:34 AM, a live roach was observed crawling on the floor from room [ROOM NUMBER] into the hallway. (photographic evidence obtained)On 1/20/26 at 8:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) E, who witnessed and confirmed the live roach crawling from room [ROOM NUMBER] into the hallway. CNA E stated sightings of roaches and flies occurred daily.On 1/20/26, small flying insects were observed in Resident Rooms #101, #105 and #214.On 1/22/26 between 1:00 PM and 3:45 PM during the Life Safety facility tour, a live roach was observed crawling on the floor of the 300 hall near the nursing station.On 1/23/26 at 2:50 PM, a live roach was observed crawling on the floor of the 100 hall.On 1/23/26 at 7:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) G who stated she had been employed by the facility for approximately eight months. She further stated roaches and fruit flies were observed in the facility daily. LPN G said she last killed a roach on 1/22/26 in the 100 hall. The facility's protocol was to write the sightings in the logbook for pest control to check when they came in.On 1/23/26 at 1:18 PM, an interview was conducted with LPN D who stated she had been employed by the facility for four months. She explained that she had observed small flies in room [ROOM NUMBER] today. She denied seeing any roaches. LPN D further explained that pest sightings were documented in the pest log at the nurses' station, and the pest control technician initialed the log when he came to the facility for service.On 1/23/26 at 1:29 PM, an interview was conducted with the Maintenance Director who stated he had been employed with the facility for three months. He explained that the facility had pest control service who came out every two weeks; however, he stated he would be communicating with the Manager now, because he did not feel the treatment being provided as adequate. The Maintenance Director stated the roach sightings had decreased over the last three months, but the facility did have a problem with fruit flies. He further stated he was not permitted to spray anything in the facility between service calls, but he had not made any additional service treatment calls. A review of the pest control logbook with the Maintenance Director was conducted at the time of the interview. On 1/22/26, roaches were documented as having been sighted in rooms #103, #105 and #107. (photographic evidence obtained)A review of the pest control service record dated 1/7/26 revealed: flies activity in rehab center. (photographic evidence obtained) A review of the pest control service record dated 12/10/25 from the pest control company revealed: Tile in the kitchen has been found to be broken or missing allowing food and water to accumulate underneath. This allows harborage of small filth flies and cockroaches. Please replace the tile or seal cracked area with caulk. (photographic evidence obtained)A review of the facility's policy titled Pest/Insect Control (dated August 2024), revealed that the facility will evaluate effectiveness of services and contact pest control agency if additional services are needed. (photographic evidence obtained)

Based on observations, interviews, and record review, the facility failed to ensure the resident shower/bathroom in the East Wing and [NAME] Wing bathroom were maintain in a safe, functional, sanitary, and comfortable environment; and failed to secure the bathroom sinks to the walls in rooms [ROOM NUMBER]. The findings include: On 11/6/2024 at 10:17 am, during a tour of the East Wing, a foul odor was present upon entering the shower room used for residents. A bucket placed under the toilet tank was observed. When the toilet was flushed water immediately began to pour into the bucket from a crack in the tank. (Photographic evidence obtained) Observation of the shower revealed there was a leak in the neck that connected the shower head to the wall. When the shower was turned on, water sprayed from the neck and the wall of the shower. (Photographic evidence obtained) On 11/6/2024 at 10:43 am, while touring the [NAME] Wing, a blanket and towel were observed on the floor outside a restroom located near the nurses' station. (Photographic evidence obtained) The chrome water closet flushometer was disconnected from the toilet bowl. (Photographic evidence obtained) When the toilet was flushed water sprayed from the back of the toilet spilling onto the floor. (Photographic evidence obtained) Employee A, a Registered Nurse (RN), was seated at the nurses' station located across from the restroom. She called another staff member to come to assist and then picked up the blanket and towel that were on the floor. Employee C, a Certified Nursing Assistant (CNA), was located in a resident's room on the hall. She exited the resident's room with a blanket and placed it on the hall floor outside of the restroom door as Employee A had instructed her to do. When asked, Employee C stated they had been using linen to dry up the water. She stated the issue had persisted off and on for a while. She stated it was supposed to have been fixed on Monday [11/3/2024] and it was still leaking. Employee A was asked who used this restroom. She stated it was for resident use. There was no observation of an Out of Order sign on the door of the restroom nor was there anything in place to prevent/discourage residents from using the restroom. (Photographic evidence obtained) During an interview with Resident #3 in her room (#308) on 11/6/2024 at 10:57 am, the sink located in the resident's bathroom was observed not to be securely attached to the wall with a gap between the sink and the wall. When the resident was asked about the sink/wall, she stated that it had been that way for sometime and that she had reported it to multiple staff members. She stated that no one had come as of date to make the repairs. (Photographic evidence obtained) On 11/6/2024 at 11:20 am, an interview was conducted with Employee B, CNA. She confirmed that she knew that the restroom was broken on the [NAME] Wing. She also stated that she had not reported the issue to anyone. She denied awareness of any ongoing plumbing issues. She stated she would report any concerns to the nurse. She added that the facility does have a system where work orders can be submitted, however, she had not been trained on how to do it. On 11/6/2024 at 11:48 am, an interview was conducted with Employee C. She stated the restroom on the [NAME] Wing had been out of order intermittently for approximately two weeks. She confirmed the restroom was for resident use only. When asked if the restroom was currently out of order. She replied, normally there would be a sign on the door if it was out of order, so I guess they're [the residents] using it. When asked about the repairs needed in the restroom, she stated that the toilet was broken and that water was coming up from the tiled floor. On 11/6/2024 at 12:29 pm, an interview was conducted with the Maintenance Director. He stated that all work orders should be submitted into the TELS system which sends alerts to his personal phone. He stated that a work order could be submitted by any staff member and he had a list of vendors used for maintenance services. He explained that once a maintenance issue had been identified, he had to contact the corporate office to provide an estimate for repairs verses the estimate to replace. He stated he hadn't seen anyone come in to repair the sinks since he'd been employed at the facility nor had he seen any estimates. He stated he was not aware of any current concerns with the plumbing or water leaks at the time. A tour of the facility was then conducted with the Maintenance Director. During a visit of the East Wing, he stated he wasn't aware of any concerns on this wing. Upon entering the shower room on this wing, he observed the sink present and stated that it needed to be repaired. After turning on the shower and observing the leak from the neck of the shower connected to the wall, he stated that it also needed to be repaired. Upon entering the [NAME] Wing, he stated that restroom was repaired on Monday [11/4/2024]. The towels and blanket were observed once again on the floor outside of the restroom door. He stated he was not aware that it was broken again. He was taken to the resident rooms (#107, #200, and #308) where he observed the sinks hanging from the walls. He commented that he had not inspected the entire facility and that he would repair the sinks. He referred to the building as dated and stated that it would take time to make all of the necessary repairs. On 11/6/2024 at 1:39 pm, a follow up interview was conducted with Employee A. She stated she typically worked on the [NAME] Wing. She stated maintenance issues were reported in the TELS system, an electronic reporting system. If something needed to be done immediately, she would report it in TELS and also send a group text message to the department heads, which included the Administrator. She confirmed her knowledge of the leak/flooding in the restroom on the [NAME] Wing. She stated that the area was usually wet adding, especially when it rains. She stated someone came in on Monday [11/4/2024] to repair the toilet and that she had not seen the toilet replaced. She stated the issue was not resolved and that all residents were able to use that restroom not just the residents on that wing. On 11/6/2024 at 2:05 pm, an interview was conducted with Employee F, Licensed Practical Nurse (LPN). She stated she contacted the Maintenance Director when there were maintenance issues. She used the computer reporting system for maintenance requests, however, she had been having issues logging into it. So, it was easier for her to call the Maintenance Director. She was aware of the issues with the resident restroom on the [NAME] Wing and was advised that it had been repaired, and that now it was broken again. She stated she had not reported this and said, This is an old building. There are always problems. A record review of Plumbing/Electric invoices provided by the facility revealed the following. 10/03/24: Toilet tank rebuild 10/04/24: Customer had a toilet with an old worn-out stud that came detached . 10/07/24: Two toilets that were not draining and a shower that needed to be rebuilt

Based on interviews and record reviews, the facility failed to maintain sufficient nursing staff at all times to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being for three (Residents #50, #71, and #289) of three resident requiring one on one supervision, from a total of 26 residents in the sample. This had the potential to negatively impact all 90 resident in the facility at the time of the survey. The findings include: 1. A review of Resident #50's clinical record revealed an admitted [DATE] with diagnoses that included encephalopathy, seizures, anxiety, depression, and schizoaffective disorder. A quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident has a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. A review of the physician's orders dated 2/9/24 revealed Resident #50 was to have one to one (1:1) supervision every shift. 2. A review of Resident #71's clinical record revealed an admitted [DATE] with diagnoses that included dementia and depression. A MDS assessment dated [DATE], indicated the resident has a BIMS score of 5/15, indicating severely impaired cognition. A review of the physician's orders dated 2/9/24 revealed the resident was to have 1:1 to one supervision every shift. 3. A review of Resident #289's clinical record revealed an admitted [DATE] with diagnoses that included mild cognitive impairment of unknown etiology, anorexia, muscle weakness, history of falling, and schizophrenia. A MDS assessment dated [DATE], indicated the resident has a BIMS score of 3/15, indicating severely impaired cognition. A review of the physician's orders dated 2/24/24 revealed the resident was to have 1:1 monitoring every shift due to elopement risk. On 2/26/24 at 7:50 AM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN). She stated that she worked overnight from 7:00 PM on 02/25/24 to 7:00 AM on 02/26/24. She was waiting on her relief to show up so she could go home and there were staff call outs last night. The facility census was 90 and she was assigned 45 residents for her entire shift. There were two LPNs on the entire night shift, and both had 45 residents assigned. She stated there were only two Certified Nursing Assistants (CNA) that worked over night and each of them had 45 residents to take care of. When asked about Residents #50, #71, and #289, 1:1 supervision, Employee C, LPN confirmed there were no staff to provide their 1:1 supervision. She explained that staffing had been an ongoing issue for about three months. On 2/26/24 at 10:30 AM, an interview was conducted with the Director of Nursing (DON) and the Administrator. Both were aware of the insufficient staffing overnight from 2/25/24 to 2/26/24. The Administrator stated he was informed by staff that there were call outs. The DON also confirmed he was made aware of the insufficient staffing and that he made calls to staff that were not working to get staff to work. The DON stated he was unable to find anyone to work. The Administrator stated that the staffing coordinator resigned without notice on 2/19/24. Leadership took on the responsibility of the staffing coordinator. Both the DON and the Administrator confirmed that the facility census was 90 overnight. They also confirmed that there were only two LPNs and each of them had 45 residents assigned to them. The DON and administrator also confirmed that there were only two CNAs and that each of them also had 45 residents assigned to them. The Administrator confirmed that there were three residents with a 1:1 supervision order and that those three residents were not able to supervised 1:1 due to insufficient staffing. A review of the facility's policy titled Staffing with an effective date of 01/24, was conducted. Page one stated Each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). The projected staffing plans are re-evaluated on an on-going basis in response to changes in the facility, resident population or other circumstances. Staffing is monitored on an ongoing basis. Page one, #3, stated Adjust staffing throughout the day based on census and resident special care needs changes.

Based on employee record reviews and staff interviews, the facility failed to provide the required in-service training for nurse aides, to ensure the continuing competence of nurse aides, no less than 12 hours per year, which includes dementia management training and resident abuse prevention training to 3 Certified Nursing Assistants (CNAs) (CNA Staff D, E, and F) of 5 staff reviewed. This has the potential to jeopardize continued conpetence of CNAs. The finding include: A record review of training files revealed the following: CNA D was hired on 2/10/21. Further review revealed no evidence a current 12 hours of in-service education was provided. CNA E was hired on 9/25/06. Further review revealed no evidence a current 12 hours of in-service was provided. CNA F was hired on 2/9/23. Further review revealed no evidence a current 12 hours of in-service was provided. On 2/29/24 at 1:01 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant were requested to provide the CNA competence records for CNA D, E, and F. On 2/29/24 at 2:00 PM, the Administrator stated, We are getting them for you right now. On 2/29/24 at 2:15 PM, the Regional Nurse Consultant stated, We are looking for the documents now. On 2/29/24 at 2:40 PM, the Administrator was once again asked to provide the competencies documentation for CNA D, E, and F. On 2/29/24 att 3:17 PM, the facility failed to provide CNA D, E, and F's annual competencies. On 2/29/24 at 3:30 PM, the facility failed to provide CNA D, E, and F's annual competencies. During the exit conference on 2/29/24 at 3:50 PM, the facility acknowledged the documentation was not available.

Based on record reviews and interview, the facility failed to update and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for two (Residents #50 and #71) of four residents reviewed for comprehensive care plans, from a total sample of 26 residents. The findings include: 1. A review of Resident #50's clinical record revealed an admitted [DATE] with diagnoses that included encephalopathy, seizures, anxiety, depression, and schizoaffective disorder. A quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident has a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. Progress note dated 2/7/24 stated Resident #50 was observed kissing Resident #71 in her room. A review of the physician's orders dated 2/9/24 revealed Resident #50 was to have one to one supervision every shift. A review of resident's current care plan revealed no updates to reflect this behavior. 2. A review of Resident #71's clinical record revealed an admitted [DATE] with diagnoses that included dementia and depression. A MDS assessment dated [DATE], indicated the resident has a BIMS score of 5/15, indicating severely impaired cognition. Progress note dated 2/7/24 stated a Certified Nursing Assistant (CNA) entered Resident #71's room and saw Resident #50 and Resident #71 kissing. A review of the physician's orders dated 2/9/24 revealed the resident was to have one to one supervision every shift. A review of Resident #71's current care plan revealed no updates to reflect this behavior. On 2/29/24 at 11:20 AM, an interview was conducted with the Director of Nursing (DON). He confirmed that Resident #50 and Resident #71's care plan was not updated. He also confirmed that the care plan was supposed to be updated based on the incident that occurred 02/07/2024. A review of the facility's policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting with an effective date of 01/24, was conducted. Page one stated, The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions.

Based on observations, interviews, record review, and facility policy review for oxygen therapy, the facility failed to ensure that one (Resident #44) of three residents reviewed for respiratory care, received the correct number of liters of oxygen ordered by the physician, in a total sample of 26 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: On 2/26/24 at 10:25 AM, Resident #44 was observed lying in bed without oxygen via nasal cannula. The oxygen concentrator was located away from the bed with nasal cannula wrapped around the concentrator handle. (Photographic evidence obtained) A review of Resident #44's medical record revealed an admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with hypoxia, and unspecified asthma with (acute) exacerbation. A review of the annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental (BIMS) score of 15/15, indicating intact cognition. A review of the physician's orders dated 1/10/24 revealed Oxygen at 3 liters per minute (LPM) via nasal cannula continuously, every shift for shortness of breath. On 2/27/24 at 9:51AM, Resident #44 was observed lying in bed without oxygen via nasal cannula. The oxygen concentrator was positioned adjacent to the bed. The oxygen concentrator was turned off. The nasal cannula was rolled up and lodged under the concentrator handle. (Photographic evidence obtained) A review of Resident #44's care plan initiated on 2/18/20 and revised 1/5/24 revealed a focus for Emphysema/COPD related to smoking. Interventions included give oxygen therapy as ordered by the physician. On 2/28/24 at 2:07 PM, Employee A, Registered Nurse (RN) was interviewed in Resident #44's room. When asked if she was familiar with Resident #44, she replied, Yes. When asked what the oxygen order was for the resident. She did not respond, she in turn addressed the resident. Employee A RN then asked Resident #44 if he had been using his oxygen lately. Resident #44 stated, I'll use it if you start it up. Employee A RN asked Resident #44 if he was short of breath. He stated, Always. When Employee A RN was asked what the facility process is for administration of oxygen. She stated, First you gotta get the order, then get the concentrator, you see what the person is sating at, usually the desired oxygen saturation is 92% on room air, if its below 92% then we put on oxygen. On 2/28/24 at 2:14 PM, an interview was conducted with Employee B RN. She was asked to verify Resident #44's oxygen order. She reviewed the order in the electronic medication administration record and stated, It was supposed to be an as needed (PRN) order. When asked to recite the actual order as it appeared, Employee B RN stated, Oxygen at 3 liters per minute via nasal cannula, continuously, every shift for shortness of breath. She stated, the order was supposed to be PRN order but it's not. A review of the facility's policy and procedure titled: Oxygen Therapy read: Policy: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Procedure: 1. Verify physician order. Education 2. Indications for oxygen use: a. Obstructive pulmonary disease c. Hypoxemia e. shortness of breath (dyspnea)

Based on observations, interviews and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #3) of 3 residents sampled. Resident #3's wheelchair was observed with razors on his wheelchair and he was left unsupervised in the bathroom with them. This practice could result in injury to this resident or any other resident who had access to the razors. The findings included: On 12/4/23 as 12:20 pm, Resident #3 was observed entering the women's restroom unassisted on the East Wing of the facility. During this time there were no staff present at the nurses' station or on the wing. Employee D, Certified Nursing Assistant (CNA) was notified by the surveyor of the observation. Employee D knocked on the door of the women's restroom and advised Resident #3 that he could not be in the women's restroom and needed to leave immediately. The resident began to audibly yell that he had been shaving in that bathroom for years. She again explained he could not be in there. While Resident #3 was in his wheelchair, Employee D assisted him down the hall towards his room. At this time Resident #3 was observed having two blue razors on the right arm of his wheelchair. (Photographic evidence obtained) Employee D left the hall leading to the resident's room. Another unidentified staff member appeared on the hall. Resident #3 could be heard from his room saying, I have been shaving in there for years! An unidentified staff member entered the room of Resident #3. Shortly thereafter, the staff member exited the room assisting Resident #3 down the hall. She advised him that he needed to be supervised while he was in the women's restroom and escorted him into the women's room on the East Wing. The two blue razors remained on the right arm of the resident's wheelchair. Once she had wheeled him inside the restroom, she closed the door behind him, and went into another resident's room to provide feeding assistance. Resident #3 was left unsupervised in the women's restroom with the razors in his possession. On 12/4/23 at 12:32 pm, Resident #3 was observed leaving the women's restroom. The two blue razors were still on the right arm of his wheelchair. The Resident was asked about the observation. Resident #3 stated he had been in the facility for six years. He stated he does as much as he can for himself due to limited staffing in the facility. He stated he kept his shaving supplies in his room in a bowl in his drawer and used the women's restroom because he could see himself in the mirror and the water temperature in that bathroom is warmer. During the interview Resident #3 showed the surveyor his shaving supplies. (Photographic evidence obtained) A review of the medical record revealed that Resident #3 was admitted to the facility on [DATE], with his last readmission on 11/10/22. His diagnoses included encephalopathy, type 2 diabetes mellitus, muscle wasting, cognitive communication deficit, unspecified dementia, contracture of right hand, altered mental status, need for assistance with personal care, contracture of right elbow, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the quarterly minimum data set (MDS) assessment, dated 9/3/23, revealed that Resident #3 had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. He required total dependence with transfer, extensive assistance with bed mobility, toilet use, dressing and personal hygiene. He required limited assistance with locomotion on/off unit and was independent with eating. A review of Resident #3's care plan, last revised on 6/15/23 revealed he had an ADL (activities of daily living) Self-care performance deficit as evidence by: cannot complete ADL tasks independently and requires individualized interventions to improve function. Interventions included AM/HS routine care: provide assistance as needed to perform ADL functions including but not limited to personal hygiene, oral care, and bathing. (Copy obtained) During an interview with Employee D, CNA conducted on 12/4/23 at 2:48 pm, she stated it was her job to assist resident's with their ADLs. She stated that the CNAs provide the resident's with their ADL supplies and those residents who can shave independently are allowed to do so, however, they must be supervised at all times. She stated that staff should not leave the residents unattended. She explained that once the resident uses the razor, staff are to throw them in the sharps container. When asked about the observation of Resident #3 having the razors in his possession and being left unsupervised in the women's restroom. She stated Resident #3 should not have been left alone in the women's restroom because resident's should not be unsupervised when shaving or showering. She also stated he should not have had the razors in his possessions and residents should not store the razors in their rooms. During an interview with Employee F, CNA conducted on 12/4/23 at 4:17 pm, she was asked about providing ADL care for residents and shaving supplies. She explained she assisted residents with their ADLs, and it was the CNAs responsibility for getting the residents their supplies. She stated residents were not allowed to keep shaving supplies. She stated that after razors were used, they had to be discarded in the sharps container located in the shower room. She confirmed that residents were supposed to be supervised while they shaved. On 12/4/23 at 3:37 pm the Administrator/Risk Manager approached the surveyor and stated the facility would begin education on residents with sharps. He was asked to elaborate. He began to read from the facility's policy titled Standard Precautions emphasizing other sharp instruments and devices. He was asked about residents storing sharp items in their room. He stated used devices should be disposed of appropriately. He referenced Section 8 of the policy Titled Safe Needle Handling. He was asked if that applied to razors and other shaving supplies. He shrugged his shoulders and did not give a verbal answer. He was asked if residents were supposed to have razors and other shaving supplies in their rooms. He again stated used supplies should be properly disposed of. He did not provide any additional policies on storing sharp items such as razors. He did not answer if and/or where residents could store these items. No additional information was provided. An interview was conducted with Employee H, Licensed Practical Nurse (LPN) on 12/4/2023 at 5:20 pm. When asked about residents with sharps she stated the razors are one time use. She stated for safety purposes residents should be supervised when shaving. She stated the CNAs should be assisting the residents while shaving and then discarding the razor. She confirmed that the residents are not to store razors in their room. A review of the facility's policy Standard Precautions effective October 2021 revealed: 8. Safe Needle Handling a. Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. d. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as practicable to the area in which items were used.

Based on record review, staff interviews, and facility policy and procedure review, the facility failed to complete a discharge summary that included the required information for two (Residents #1 and #2) of three sampled discharged residents. The findings include: 1. A review of Resident #1's medical record revealed an admitted [DATE] and discharged home date of 01/03/2023. Resident's medical diagnoses included type 2 diabetes mellitus, chronic kidney disease, history of transient ischemic attack and hypertension (high blood pressure). An admission Minimum Data Set (MDS) assessment, dated 12/13/2023, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. Resident #1 required extensive assistance with transfers and toileting. Resident participated in the assessment and his overall expectation was to remain in the facility. Resident did not wish to return to the community and there were no active discharge plans. A review of Resident #1's physician's order dated 01/02/2023 indicated he may discharge home on 01/02/2023 with occupational therapy, physical therapy, and registered nursing (OT/PT/ and RN management). The order further indicated that resident may discharge home with the remaining medication. A review of the discharge summary for Resident #1 dated 01/03/2023 revealed sections G (Functional Abilities) and section H (Reviewed and Signed) were not completed. (Copy obtained) 2. A review of Resident #2's medical record revealed an admitted on 01/10/2023. Resident had a re-entry date of 01/17/2023 and discharged home date of 01/23/2023. Resident's medical diagnoses included type II diabetes mellitus, hypertension, and hyperlipidemia (high cholesterol). An admission MDS was incomplete and not done. A review of Resident #2's physician's order dated 01/21/2023 indicated he may discharge home on 01/23/2023 with occupational therapy, physical therapy and Registered nursing (OT/PT/ and RN management). The order further indicated that resident may discharge home with the remaining medication. A review of the discharge summary for Resident #2 dated 01/23/2023 revealed sections A (Recapitulation of Stay), G (Functional Abilities), and H (Reviewed and Signed) were not completed. (Copy obtained) On 1/27/2023 at 1:15 pm, an interview was conducted with the Director of Rehab (DOR). He stated that once residents are discharged from therapy, the nursing department is notified of the discharge functional abilities. The DOR stated the social service department is notified if the resident will require any durable medical equipment (DME). He added the therapy department was also responsible in completing the discharge summary regarding the functional abilities. When asked about Resident's #1 and #2 discharge summaries, he confirmed the functional abilities sections were not completed. On 01/27/2023 at 1:40 pm, an interview was conducted with the Social Services Director (SSD). She stated discharge planning is initiated upon admission and reviewed during care plan meeting. She stated, she was responsible for facilitating a discharge once the physician has written the discharge order. When asked about the discharge summary, she stated that interdisciplinary team (IDT) was responsible in completing their relevant section of the discharge summary. She added, she was responsible in ensuring that the summary was completed and then signed. When asked when the discharge summary should be completed, she said ,Within 48 hours of discharge. She confirmed that Resident's #1 and #2 discharge summaries were not completed. On 01/27/23 at 3:00 pm, the Administrator was asked about his expectation regarding the completion of the discharge summaries, he said, I am concerned that this is not being competed, but there is no timeline on when it should be completed. A review of the facility's policy and procedure titled Discharge Management effective October 2021 read, The facility preadmission process is designed to provide residents with access to the appropriate care, health plan professional(s), and service(s) based on their level of care, evaluated needs and the facility's ability to meet these needs. Residents are referred, transferred, or discharged based on their evaluated needs and by order of their attending physician. (Copy obtained) 3. Contribution to the final discharge plan by the interdisciplinary team will be completed in the following manner: a. Attending physician will provide: 1) Instructions regarding discharge. 2) Letter of Medical Necessity as needed for Health Plan. 3) Discharge summary Letter to community physician communicating patient's discharge status and disposition. c. Therapies (PT, OT, SLP, Respiratory) will provide: 1) Input into discharge plan regarding level of care, home versus outpatient therapies, DME recommendations following as needed home assessment. 4) Provide instructions/education to caregivers regarding maximum functional abilities of the resident and the safe use of DME. F. Social Services/ Discharge Planner will: 12) Summarize the finalized discharge plan in the social Service Section of the record.

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure food was properly labeled; dishwashing machine was operating at required temperatures; maintain dishwashing machine daily temperature logs; maintained food at safe temperatures; and document food temperatures on temperature log. The findings include: During a tour of the kitchen on 3/14/22 at 9:55 AM, the following concerns were identified: 1. The milk cooler door was observed with a black substance on the rubber trim and the rubber trim was disconnected from the door. (Photographic evidence obtained) 2. The dishwashing machine was observed with a brown debris, crumble-like substance on top of it. (Photographic evidence obtained) 3. The walk-in refrigerator had the following items with no dates: a) peaches in serving cups b) five, small Styrofoam boxes stacked up c) plastic container with an orange liquid, covered loosely with plastic wrap. (Photographic evidence obtained) 4. Green peppers were observed in the walk-in refrigerator with a grayish white fuzzy substance on them. (Photographic evidence obtained) 5. The dishwashing machine manufacturer's sticker was observed under the machine and read minimum temperature for wash cycle was 150° F and minimum for rinse cycle was 180° F. The dishwashing machine temperature log for March 2022 was observed and revealed the following: (Photographic evidence obtained) a. 3/1/22 - 03/03/22 were blank b. 3/4/22 - 03/10/22 revealed only one meal period (breakfast) c. 3/11/22 - 03/14/22 were blank d. 3/7/22 recorded a wash temperature of 144° F and rinse at 150° F e. 3/8/22 recorded a wash temperature of 136° F and rinse temperature of 160° F f. 3/9/22 recorded a wash temperature of 146°F and rinse temperature of 170° F g. 3/10/22 it was recorded that the wash temperature was 138° F and rinse cycle temperature was 140°F An interview was conducted with Employee Q, Cook about the dishwashing machine. He reported that on 3/10/22, he was having problems with the dishwashing machine and notified maintenance, but stated he ended up fixing the problem himself. During another visit to the kitchen on 3/16/22 at 11:00 AM, the following observations were made with Employee W, Consultant Certified Dietary Manager (CDM), and the RD present. 6. The steam table was observed uncovered for more than 10 minutes. 7. Temperature of the meatballs were at 136° F and the mechanical soft meat was 137° F. At this time, cook proceeded to put the meatballs in warmer. Employee Q was asked what the temperature of the food should be on the steam table and Employee Q reported 135°F. 8. Employee Q, Cook was observed mixing hot water with instant mash potatoes. The cook was observed using water from unmarked bowl and adding water from that bowl to the mash potatoes mixture. Employee Q was asked how he knows how much water to add to mash potatoes. He reported, He just eyes it. He was asked if he tastes his cooking. He replied, Often. Employee Q was asked why he pureed ham and not today's menu choice which was meatballs. Employee Q reported that he was told not to puree ground beef by his superior. On 3/16/22 at 11:45 AM, the RD was asked what he thought about the pureed ham that Employee Q, Cook had pureed for lunch. The RD stated it was too watery and residents could choke if it is too watery. RD spoke to Employee Q, Cook, and told him that he should add thickener or more meat to make the puree less watery. On 3/16/22 at 11:52 AM, Employee W, Consultant CDM, was asked how the pureed food should be made. She reported that the cook should be adding thickener and juices from meat to make pureed items, not water. Employee Q was directed by Employee W to throw out the pureed ham and make pureed meat from meatballs instead. At this time Employee Q was observed pureeing the meatballs in blender. Employee Q was asked to take the temperature of the pureed meatballs and it was 135°F. Employee Q put the pureed meatballs back in warmer. The food temperature log was observed and reviewed with Employee W. Employee W stated, the cook should be recording all food items cooked in this book. At this time, Employee W confirmed that there were several days in the food temperature logbook missing. (Photographic evidence obtained) On 3/16/22 at 12:30 PM, Employee R, Dietary Aide was observed touching the large garbage can to throw away her gloves. She opened the walk-in refrigerator to open, stepped in and came out moments later. She was then observed putting new gloves on without washing her hands. Shortly thereafter, Employee R was observed touching the air conditioner vent with her new gloves on. After she was made aware of her actions, Employee R removed her gloves and washed hands before putting on new gloves. During another visit to the kitchen on 3/17/22 at 2:19 PM, Employee T, Dietary Aide, was observed stacking trays and plastic domes directly from the washer on top of each other without letting them air dry. (Photographic evidence obtained) On 3/17/22 at 2:21 PM, the dishwashing machine wash temperature was observed below the recommended 150° F. During this time, the RD was asked what the staff should do if the temperature for dishwashing machine is lower than recommendations. He stated, the dishwashing machine should be paused, and temperatures should be observed that they are back up to correct temperature before starting wash again. Before exiting the kitchen, the dishwashing machine had reached 150° F after resting for 10 minutes or more. An interview was conducted with the RD on 3/17/22 at 2:35 PM. The RD was asked how often the kitchen is cleaned. RD reported they have cleaning schedule for daily, weekly, and monthly duties. RD was asked what the Cook could do to keep the food at appropriate temperatures for tray line service. RD stated, Make sure the hot water at good level in the steam table, use smaller pans, and use metal lids when not being served. RD was asked what the Cook should being following when preparing foods. The RD answered, The Cook should be following the recipes and normally the CDM would go over the recipes with the Cook. The RD was asked if the Cook should know the recipes, he replied Yes. A review of the facility's policy and procedure titled Therapeutic Diet with effective date of 9/21 revealed foods requiring texture modification will be prepared using standardized recipes. (Photocopy obtained) A review of the facility's policy and procedure titled Cleaning and Sanitation with effective date of 9/21 stated to wash dishes in high temperature dish machine per manufacturer guideline plate or at 150 to 165° F wash and 180° F final rinse and record dish machine temperatures 3 times a daily. (Photocopy obtained) A review of the facility's policy and procedure titled Cooking with effective date of 1/21 stated to cook food to a proper internal temperature to prevent foodborne illness. Follow recipes for proper cooking times and temperatures. Also record food temperatures prior to serving residents/patients in the food temperature log. Reheat foods to 165°F when food held on a steam table drops below 140 °F. (Copy obtained) A review of the facility's policy and procedure titled Food Temperature Record with effective date of 1/21 stated to take temperature of food items prior to meal service at breakfast, lunch, and dinner.

Based on record review, observations, interviews, and facility policy and procedure review, the facility failed to provide respiratory care as needed and ordered for one (Resident #71) of eight residents receiving respiratory treatment, from a total of 39 residents in the sample. The findings include: A review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 3/14/22 at 11:50 AM revealed Resident #71 was receiving oxygen through a nasal cannula at 2.5 LPM. On 3/15/22 at 10:00 AM, Resident #71 was observed receiving oxygen through a nasal cannula at 2.5 LPM. (Photographic evidence obtained) On 3/17/22 at 9:25 AM, Resident #71 was observed lying flat in bed asleep. The oxygen concentrator was set on 2.5 LPM and the tubing was not connected to machine. (Photographic evidence obtained). On 3/17/22 at 2:15 PM, Resident #71 was observed receiving oxygen through a nasal cannula at 2.5 LPM. The oxygen tubing did not reveal any visible date. The care plan for Resident #71, dated 3/2/22, noted oxygen therapy related to ineffective gas exchange and chronic obstructive pulmonary disease, history of respiratory failure. Interventions included oxygen at 2 Liters continuous via nasal cannula, special equipment oxygen; administer oxygen as ordered, give meds as ordered by medical doctor; monitor for signs and symptoms of respiratory distress, monitor for changes in or development of breathing differences and report, change and date respiratory equipment tubing weekly. During an interview with Employee J, Registered Nurse (RN) on 3/17/22 at 5:00 PM, she stated that she checks residents on oxygen almost every day. She explained that the oxygen tubing is checked weekly and as needed. She reported nursing staff should change tubing weekly. She was asked about Resident #71 oxygen order. She confirmed that the resident's order was for 2 LPM. Employee J, RN was asked to go to Resident #71's room to review the oxygen setting. Employee J, RN observed the oxygen concentrator and confirmed it was over 2 LPM. Employee J, RN was asked if there were any dates noted on the oxygen tubing or nasal cannula. She stated, No, I can't see any. Employee J, RN set the oxygen concentrator to 2 LPM. A review of the facility's policy and procedure titled Oxygen Therapy read: Initiation of Oxygen: 1) Verify physician order; 7) Apply device to patient. Oxygen Devices: 1) Nasal cannula: e. Change out weekly and PRN. (Photocopy obtained)

Based on record reviews, interview, and facility policy and procedure review, the facility failed to ensure drug regimen was reviewed at least once a month by a licensed pharmacist for two (Residents #44 and #58) of five residents reviewed for unnecessary medication, from a total of 39 residents in the sample. The findings include: 1. A review of Resident #44's medical record revealed he was admitted on [DATE] with a readmitted [DATE]. Resident had orders for [MEDICATION(S)] 275 milligrams (mg) twice daily for mood stabilization; [MEDICATION(S)] 7.5 mg at bedtime for depression; [MEDICATION(S)] 15 mg three times daily for anxiety; [MEDICATION(S)] 50 mg once daily for obsessive compulsive disorder; and [MEDICATION(S)] 25 mg once daily for [CONDITION(S)]. A review of the monthly pharmacy reports from October 2021 to March 2022 revealed Resident #44 was not reviewed during the months of November 2021, December 2021, January 2022, and February 2022. 2. A review of Resident #58's medical record revealed he was admitted on [DATE] with a readmitted [DATE]. Resident had orders for [MEDICATION(S)] 10 mg once daily for depression and [MEDICATION(S)] 5 mg three times daily for anxiety. A review of the monthly pharmacy reports from October 2021 to March 2022 revealed Resident #58 was not reviewed during the month of November 2021. During an interview with the Director of Nursing (DON) and the Regional Clinical Consultant (RCC) on 3/17/22 at 3:02 PM, the DON stated, they were responsible for making sure the monthly pharmacy reviews were conducted. The RCC explained the DON had received training on the pharmacy review process last week and due to identification of deficiency, they were developing a Performance Improvement Project to address the deficiencies. A review of the facility's policy and procedure titled Section 8.1 Medication Monitoring - Medication Regimen Review and Reporting (PharMerica Corp 2007, 9/2018), Procedures, Item 2-revealed, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. (Photocopy obtained)

Based on record review, staff interview, and policy and procedure review, the facility failed to monitor resident behaviors related to the use of [CONDITION(S)] medication for one (Resident #58) of five residents reviewed for unnecessary medications from a total of 39 residents in the sample. The findings include: A record review for Resident #58 revealed he was admitted on [DATE] with a readmitted [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A review of Resident #58's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A review of the resident's care plan revealed a focus area for [CONDITION(S)] medication. Interventions included administer medications as ordered, observe and document for side effects and effectiveness. A second focus area for behaviors related to episodes of agitations during care revealed interventions that included administer meds as ordered; monitor side effects and effectiveness; approach in a calm manner; assist to develop more appropriate methods of coping and interacting; document behaviors and response to interventions. An interview was conducted with the Director of Nursing (DON) and the Regional Clinical Consultant (RCC) on 3/17/22 at 3:02 PM. They verified there was no documented behavior monitoring for Resident #58 related to the use of [MEDICATION(S)] and [MEDICATION(S)]. A review of the facility's policy and procedure titled Section 8.4 Medication Monitoring - Medication Management (PharMerica Corp 2007, 11/2017) Policy, revealed Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug without adequate monitoring. The facility's medication management supports and promotes the monitoring of medications for efficacy and adverse consequences. (Photocopy obtained)

Based on interviews and record reviews, the facility failed to provide appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #1) residents reviewed for compliance from a total sample of 6 residents. The findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of a total 15 points possible, indicating intact cognition. Resident #1 required extensive assistance with activities of daily living. Review of the nursing progress notes revealed an entry by the Director of Nursing (DON) on [DATE] at 9:57 p.m. which indicated Resident #1 tested positive for COVID-19 (novel coronavirus) and that she had a non-productive cough. The resident was moved to the facility's COVID quarantine unit. A nursing progress note entry dated [DATE] at 2:25 a.m. by LPN G indicated the resident was on isolation and had a mild non-productive cough and was dependent on supplemental oxygen by nasal cannula to maintain appropriate oxygenation. A provider progress note dated [DATE] indicated the resident's pulse was 99 and her oxygen saturation was 94% on three liters of oxygen. The resident was alert and oriented. The provider's plan was to initiate enhanced monitoring and isolation precautions. The resident also presented with congestion and a [MEDICATION(S)] medication was ordered. The note further indicated that the resident was at risk for exacerbation of [CONDITION(S)] due to the COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nursing progress note entry dated [DATE] at 11:18 p.m. by RN F indicated the resident's blood pressure was ,d+[DATE] and was having difficulty breathing. Shortness of breath was noted while the resident was lying flat. The nurse indicated a cough was present and that respiratory secretions were thick. There was no documented oxygen saturation related to these findings. Review of the facility's policy titled COVID-19 Guidance, effective [DATE], revealed direction to staff to conduct enhanced monitoring of a resident's respiratory status, oxygen status, signs and symptoms of COVID-19, and vital signs and that the monitoring was to be completed daily or more often as recommended or the clinical status required. (Photographic Evidence Obtained) Continued review of Resident #1's medical record revealed no enhanced monitoring assessments or oxygen saturation assessments were documented from [DATE] at 4:00 p.m. until [DATE] at 4:00 p.m. A nursing progress note entry dated [DATE] at 4:50 a.m. by LPN G indicated the resident was confused and current state is considered baseline. The nurse also indicated that lungs were not clear to auscultation. The entry did not include the resident's respiratory status, oxygen status, or vital signs. On [DATE] at 3:23 p.m., an interview was conducted with Therapist I and Therapist J. Therapist J explained that she was familiar with Resident #1 and had worked with her since admission to the facility. She explained that Resident #1 was increasingly more confused each day after she was diagnosed with COVID-19. She stated she repeatedly reported the Resident's worsening confusion to RN B but that she wasn't sure anything was being done about it. She stated, I reported it to the nurse pretty much every time I went in there. When asked whether she reported her concerns to anyone else, she stated she had not. Therapist J added that she had not documented anything about the resident's worsening confusion in the resident's therapy notes. On [DATE] at 3:55 p.m., an interview was conducted with LPN A and RN B. Both nurses confirmed that they were familiar with Resident #1. RN B explained that on the day Resident #1 was transferred to the hospital, she received a call from the resident's sister asking her to go and assess the resident. She explained that she was not assigned to the resident but that she responded to the room and assessed the resident per the sister's request. She stated the resident was presenting with more lethargy and confusion that normal. She added that the resident's shortness of breath was much worse. The nurse then stated, When she got COVID she just kept getting worse and worse. RN B explained that she instructed the assigned nurse to call the physician and request the resident be transferred to the hospital. When asked to expand on why she was asked by the resident's sister to assess the resident, she explained that the nurse assigned to the COVID unit (and was caring for Resident #1 at the time) did not have access to a phone on the unit. The other nurse on the unit was responsible for answering the phone and relaying messages. When asked whether Therapist J had informed her of the resident's increasing confusion, RN B stated, Yes but I told her I wasn't assigned to the Resident. During the interview on [DATE] at 3:55 p.m., LPN A explained that the resident's daughter had called on [DATE] and requested that the resident get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A explained that she was not assigned to Resident #1 but was answering questions for the Resident's sister via phone. LPN A added that she contacted the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was also able to recall that the attending physician and his nurse practitioner were both COVID+ at the time and were not coming into the facility to assess the residents. On [DATE] at 4:25 p.m., an interview was conducted with LPN C. She confirmed that she was assigned to care for Resident #1 on the day Resident #1 was transferred to the hospital. She stated she was working on the COVID unit and another nurse ([NAME]) came and told me the sister was wanting us to assess the resident. She stated she and RN B went into the resident's room and assessed her. LPN C added that this was the first time she had worked with Resident #1 and was not familiar with her baseline. LPN C stated she conducted a head-to-toe assessment (which included vital signs) but did not see a reason to transfer the resident to the hospital. She stated the resident was able to sip drinks and talk with her daughter on the phone immediately after the assessment. When asked whether she recalled the resident being confused, she stated, She was confused but I figured that was her baseline. I don't know. LPN C stated she notified the physician of RN B's directive and the sister's request to transfer the resident to the hospital and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services (EMS) arrived to the facility and immediately transferred Resident #1 to the hospital. On [DATE] a 12:30 p.m., an interview was conducted with the Director of Nursing (DON). He explained that he was familiar with Resident #1 and that he had cared for her during her stay at the facility. He stated that he was made aware of the resident's altered mental status when she was transferred to the hospital. He added that the nurse reported a concern about the resident's oxygen saturation at the time of transfer but that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported that the resident's sister was insisting the resident be transferred to the hospital. He added that the altered mental status didn't set off any red flags. When asked about the facility's enhanced monitoring processes for residents with COVID-19, the DON explained that COVID-19 diagnosed residents are monitored for respiratory status and vital signs every four hours until their quarantine timeframe had expired. When asked how the facility was ensuring that this monitoring was being completed, the DON stated, We have had some staffing problems. It's hard to make sure everything is getting done when we are working the floor most of the time. The DON was asked to review Resident #1's medical record. He confirmed that Resident #1 had no documented enhanced monitoring from [DATE] until [DATE] and confirmed that a change in the resident's respiratory status would have been identified with those assessments if one existed. On [DATE] at 1:18 p.m., a call was placed to CNA H. The medical record reflected this CNA had cared for the resident while Resident #1 was in the COVID unit. The CNA's telephone number was disconnected. On [DATE] at 1:20 p.m., a call was placed to CNA E. The medical record reflected this CNA had cared for Resident #1 while she was in the COVID unit. A message was left requesting a call back. A call back was never received. On [DATE] at 1:22 p.m., a telephone interview was conducted with LPN G. She had provided care for Resident #1 while she was in the COVID unit. She explained that she did recall a resident by that name but that she couldn't remember any specifics about the resident. She stated, I wouldn't really notice any changes in condition because they are sleeping the entire time they are on my shift. LPN G added that she worked night shift. When asked how she completed the COVID-19 monitoring assessments if she was not assessing the residents, she stated, The CNAs do it. The nurse was unable to recall who the assigned CNA was but stated nothing abnormal was reported to me. The nurse was not familiar with Resident #1's baseline cognitive function. When asked which staff member obtained the assessment findings, she described in her nursing progress note entry on [DATE] at 4:50 a.m. describing the Resident as confused and with lungs that were not clear, LPN G stated, I don't know. When asked whether she had assessed Resident #1 at all on the [DATE] night shift, LPN G again stated, I don't know. I don't remember. On [DATE] at 2:35 p.m., a follow up interview was conducted with the DON. He explained that the enhanced monitoring assessment was to be completed by the licensed nurse assigned to the resident. He confirmed that the CNA would be able to gather vital sign data but could not assess the resident's respiratory status.

Based on observation, resident interview, staff interview, third party provider interview, clinical record review, facility document review and policy and procedure review, the facility failed to ensure one (Resident #1) out of 3 sampled residents was allowed immediate and reasonable access to visitors of her choosing when a nurse representing an entity providing health, social and other services to her was not allowed to visit her on 8/24/2021. The entity was providing services to Resident #1 prior to her admission to this facility and she wanted to continue to receive their services upon discharge to the community. The findings include: During an observation and interview on 9/28/2021 at 10:05 AM with Resident #1, she was observed walking up and down the hallways on the West Unit near her room dressed in a long orange tee shirt, pajama pants and a bedroom slipper. She was mumbling to herself. When approached, she stated that services from the Florida Assertive Community Team (FACT) were still desirable and proceeded to name the team members from FACT to whom she wanted to continue to work with and receive services. She stated, she wanted the FACT team to come and help her to leave this place. She wanted to return to her former living arrangement. She named the case manager and the leader of the FACT team by name. She explained that the clothes she was wearing were not her own and that she had been trying to get in touch with the FACT team case manager to bring her clothing to the facility. She was not able to reach them. During a phone interview with the FACT program Team Lead on 9/28/2021 at 10:56 AM, she stated that she and her team have not been able to enter the facility to visit with Resident #1. They are willing to keep on serving her, however, they need to meet with her, so she can tell them if she wants to still accept their services or not. She stated that a nurse from the FACT program had gone to the facility to see Resident #1, a current client, on 8/25/2021 and was not allowed to see her. The Social Services Director (SSD) met the nurse at the front door and screened her. She signed the visitor log and was asked who she was there to see. When the nurse informed the SSD who she was and which resident she was there to see, she was refused entry by the SSD and told that the facility had problems in the past with the FACT team and one of their clients that came there for rehabilitation. The nurse left and reported it to the FACT Team Lead. The FACT Team Lead stated she called the facility on 8/24/2021 to speak with the administrator about it but was told he was on another call. She left contact information with the receptionist but did not get any response from the facility. She has not tried to contact them again. The FACT team has not heard from Resident #1 since she has been there. She did not think that Resident #1 had been informed of the FACT team nurse's visit. Resident #1 was originally Baker Acted by the FACT team physician and was sent to a local hospital. When she was discharged from the hospital she was sent to this facility for rehabilitation. She was supposed to be sent to a different nursing home locally and the FACT team did not know she was at this facility right away. When they did find out, they had the nurse go to visit her to see if she wanted to continue services with the FACT team. Usually, if a FACT team client wants to stay long term in a nursing home, the FACT team will discharge the client from their services. They discharge them after their long-term care Medicaid funding is established. In this case Resident #1's Medicaid had yet to begin paying, so she was still on their case load. It is the policy of the FACT program that only the client can tell them that he/she no longer wants their services. The FACT Team Lead explained that she is a nurse, and she has not seen Resident #1 to assess her condition for community placement since she was admitted to this facility, and she would like to see her and ask her if she still wants to continue services with the FACT team. She agreed to come to the facility and meet with Resident #1 today. A review of the facility documents revealed an alpha census dated 9/28/2021 with payor source listed. Resident #1 was listed as Medicaid pending. (Photographic evidence obtained) A review of the facility Visitor Sign-In/Sign-out Sheet dated 8/24/2021 revealed the FACT team nurse had signed in for a visit at 11:55 AM and out at 12:00 PM. (Photographic evidence obtained) A review of Resident #1's admissions records and resident contract revealed, she had signed the contract in all of the required places and dated it 08/11/2021. (Photographic evidence obtained) The section of the admission packet entitled Resident Bill of Rights read: Access to Facility/Visitation Rights: 26. You have the right to receive visitors of your choice at the location of your choosing, subject to the resident right to deny visitation, when applicable and in a manner that does not impose of the rights of the resident. 27. You have the right and the facility must provide immediate access to you by the following: (h) Others, including any entity or individual that provides health, social, legal, or other services to you, subject to your right to deny or withdraw consent at any time. (Photographic evidence obtained) A review of Resident #1's clinical record revealed a hospital discharge summary date of 8/10/2021, that read: 4. Follow-up Appointments. Type of provider: MH (Mental Health) Clinic. Provider Name: MHRC (Mental Health Resource Center)/FACT Team. Address and phone number were listed. Appointment comments: psychiatric care and med management. Continuing Care Referral: FACT Team (MHRC). (Photographic evidence obtained) A review of Resident #1's face sheet revealed, she was her own responsible party with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 8 out of a possible 15 indicating moderate cognitive impairment. Section F read: Resident responded that it is very important to have family, or a close friend involved in discussion about your care. Additionally, Resident responded that it is very important to keep up with the news. Section Q read: Resident EXPECTS TO BE discharged TO THE COMMUNITY; Discharge plan presented that an active discharge planning is already occurring for the resident to return to the community; Referral made to the local Contact Agency. (Photographic evidence obtained) A review of the resident's care plan dated 8/12/2021 read: Activities of daily life: independent on all interventions and tasks. Social Services: Discharge Planning: Discuss with resident /family/representative discharge planning process, referral to local Contact Agency as needed. A FACT Team Summary of Service note dated 8/24/2021. revealed Client: [Resident #1] Procedure: Unsuccessful attempt. Setting: nursing home. Narrative: Writer traveled to [Facility] to visit with [Resident #1] at this time, upon arrival to site, writer signed in, had temperature check, and was escorted across the hall to social services office and was told by staff member [SSD] that FACT would not be allowed today or no longer be allowed to come in and see [Resident #1] as she is a resident of this facility for her weekly home visit. Writer inquired as to why would this be the case, staff member [SSD] states that she is not allowed to receive services from us and [Facility] at the same time, and the last time she let us see someone who was place there, she got in trouble. Writer informed her that we usually cannot see someone once admitted with Long Term Medicaid and asked if this was the case with [Resident #1], staff member said yes, she has been admitted and is seeing their psychiatrist and provider on site. Writer left contact information and took [SSD's] information at this time and was directed to sign out at 12 noon. Later in day closer to 4 pm, writer placed a call to DCF (Department of Children and Families) Abuse line as we will not be given access to [Resident #1] and her wellbeing. Report did not warrant investigation per operator 222, but report was taken for record. Operator suggested AHCA (Agency for Health Care Administration) be called, and report placed with them. (Copy obtained) During a second interview with Resident #1 on 9/28/2021 at 12:00 PM, she was shown the sign in log where the FACT program nurse signed in on 08/24/2021. She stated that she did not get to see her that day. They didn't let her in. When asked if the facility staff informed her of the nurse's visit, she stated No! They didn't let her in! During a meeting with FACT Team Lead, Resident #1, Administrator, and SSD on 09/28/2021 1:50 PM. The FACT Team Lead stated that FACT contacted the facility and left a message after receiving a call back from the Business Office Manager. The FACT team then sent a nurse manager out to the facility on [DATE] to meet with Resident #1. The administrator and the SSD both denied ever receiving any messages from FACT in any capacity. The SSD stated that she did have a brief memory of this but did not know who the nurse was that was attempting to come into the building. She was shown the sign in log dated 8/24/2021 where the FACT team nurse had signed the log. The SSD stated she thought the nurse was a psychiatrist and told her that the facility already has a psychiatrist. She asked if the FACT team nurse stated that she worked for FACT. The administrator stated that he was frankly dumbfounded and not aware of this incident where the nurse was denied entry. He stated that all the residents are allowed to have visitation with whomever they want. He asked if the nurse stated who she was? The FACT Team Lead pointed out to her that the FACT team nurse was wearing a name badge that had her credentials on it and the nurse told the SSD her name and who she worked for. The SSD stated again that she did not remember what she was told. The FACT Team Lead told her it did not matter who the nurse said she was, it would have been up to Resident #1 if she wanted to see her or not and the fact that she was not given the opportunity to make that choice was a violation of her rights. The SSD agreed that it is the resident's choice. The FACT Team Lead told the administrator that she called to speak to him on 8/24/2021 after the nurse was denied access to Resident #1 and the staff told her, he was on another call. She did not leave a message-only a request to let them know that she called and her contact information. The administrator stated he did not know anything about the situation. He stated if he had known he would have allowed the FACT team to come in and meet with the Resident. He stated that staff development and staffing handle appointments and follow-ups. He did not think there was anything in her chart that would have informed the facility of her services from the FACT team. He was then shown the discharge summary from Memorial Hospital where it listed the FACT team under the follow up section along with Resident #1's primary care physician. The administrator stated again that he was not aware of this. Resident #1 was asked if she wanted the FACT team to be her representative and emergency contact and she stated that she wanted FACT to be her representative in helping with finding a place to reside and she wanted to be discharged . A review of the facility policy and procedure titled Visitation read: The facilities will not restrict visitation without a reasonable clinical or safety cause. Federal Disability Rights Law and Protection & Advocacy (P&A) Programs. Section 483.10(f)(4)(i)(E) and (F) requires the facility to allow immediate access to a resident by any representative of the protection and advocacy systems, as designated by the state . Entry of Healthcare Workers and Other Providers of Services. Health care workers who are not employees of the facility but provide direct care to the facility's residents, such as social workers, etc. must be permitted to come into the facility as long as they are not subject to a work exclusion due to exposure to COVID-19 or showing signs or symptoms of COVID-19 after being screened. (Copy obtained)

Based on observation, record review, and staff interviews, the facility failed to maintain an accurate comprehensive assessment for 1 of 37 residents reviewed for comprehensive assessment. (Resident #72) The findings include: An observation on 3/8/20 at 9:47 AM of hospice Resident #72 was laying on his right side with contracted legs in the fetal position wearing a hospital gown. Resident # 72 was awake and alert. Verbal communication with resident was unintelligible. An interview with Resident's #72's family on 3/8/20 at 1:57 PM, revealed the resident is unable to participate in his care due to his condition and he is unable to remember family member's names. A record review was conducted on 3/9/20 at 9:51 AM on Resident #72. On 2/12/20 a Significant Change was documented in the Minimum Data Set (MDS) assessment. In the assessment, it was documented the resident had bed mobility, transfer activity, and toileting that occurred once or twice by the resident. On 1/31/20 an Annual MDS assessment was made on the resident. In this assessment, it was documented the resident needed extensive assistance by staff to assist with bed mobility, transfer activity, and toileting. An interview was conducted with Employee A, MDS Coordinator, on 3/11/20 at 9:41 AM. A review of the MDS assessment for Significant Change on 2/12/20 and the Annual MDS assessment on 1/31/20 was conducted with Employee A. Employee A stated the update was made by Employee B. Employee A confirmed the MDS assessment for Significant Change on 2/12/20 was not an accurate assessment of Resident #72. Employee A stated the resident has not been able to change his bed position or transfer himself for a long time. Employee A stated the Annual MDS assessment made on 1/31/20 was a more accurate assessment of Resident #72. A second interview with Employee A was conducted on 3/11/20 at 1:42 PM. Employee A stated she spoke with Employee B. Employee A stated Employee B created the Significant Change on 2/12/20 because one had not been done when the resident was placed on hospice in July of 2019. Employee A confirmed again the Significant Change MDS assessment on 2/12/20 was not an accurate assessment of Resident #72.

Based on observation, medical record review, and resident/staff interviews, the facility failed to accurately code three Minimum Data Set (MDS) assessments for one (Resident #32) of 60 sampled residents, related to hearing ability and speech clarity. Inaccurate assessments leave residents at risk for not receiving necessary care and services to ensure their highest practicable functional level and mental or psychosocial well-being. The findings include: A review of Resident #32's quarterly MDS assessments dated 8/23/18 and 5/24/18, as well as the annual MDS assessment dated [DATE], revealed all three were miscoded in Section B as follows: Section B (Hearing, Speech, and Vision) coded Resident #32 as having no impairment to hearing and clear speech. A review of the resident's medical record, however, revealed a [DIAGNOSES REDACTED]. During an interview with Employee B, Certified Nursing Assistant (CNA), on 11/6/18 at 1:35 PM, she reported that the resident was very hard of hearing and required additional time to communicate verbally due to a speech impairment. During an interview with the MDS Coordinator on 11/7/18 at 3:00 PM, she confirmed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She confirmed the MDS assessments had been miscoded related to the resident's hearing ability and speech clarity for the past three assessments.

Based on observation, record review and interview, the facility failed to maintain a resident's highest level of function (range of motion and mobility) by not consistently applying a splint as ordered for one (Resident #29) of one residents reviewed for positioning, mobility, and splint application out of a total of 60 residents sampled. This placed the resident at risk for functional decline. The findings include: An observation of Resident #29 in bed on 11/06/18 at 11:12 AM, revealed a male with contractures of both hands. The resident was non-verbal, and was reliant on a communication board to express his needs. The resident had a Brief Interview for Mental Status (BIMS) score of 4 on a scale of 1-15, indicating significant cognitive impairment. Observation of the same resident at 1:43 PM on 11/06/18, revealed the application of splints to both hands. A review of the annual Minimum Data Set (MDS) assessment, dated 08/16/18, revealed a BIMS score of 4 and an indication of a need for one splint. A review of current (November (YEAR)) physician's orders [REDACTED]. A review of the restorative task notes on 11/07/18, revealed no change to orders since last review creation date of 08/02/18. A review of the Task Tracking sheet revealed the task description had been changed to read .continued R and L (right and left) hand splinting indefinitely. The tracking also revealed that for dates 10/10/18 through 10/28/18, the splint application had been noted by restorative staff as Not Applicable. In an interview on 11/07/18 at 4:10 PM, the Director of Nursing (DON) confirmed there was no documentation to explain why the dates from 10/10/18 through 10/28/18 were marked Not Applicable. She also confirmed there was no documentation to describe when the splint should be applied and removed, or how many days per week it should be applied. On 11/07/18 at 4:02 PM, an interview was conducted with Employee C, Program Manager. She confirmed she was not aware Resident #29 had splints applied to both hands on Tuesday, (MONTH) 6, (YEAR). She stated Restorative wrote two task notes that combined: ROM to right and left hand; and splint application. This resulted in restorative implementing use of splints to both hands without a physician's orders [REDACTED]. An interview on 11/08/18 at 12:37 PM with Employee F, Unit Manager, confirmed the Restorative Aide applied and removed splints per the task orders in the system. A review of the facility's policy and procedure for Restorative Nursing revealed documentation should be kept noting how many minutes the program was active. The plan should include detailed descriptions and instructions of each new task created.

Based on observation, record review and interviews, the facility failed to ensure it was free of significant medication errors for one (Resident #27) of six residents observed for medication administration by not checking a blood glucose level before meals as the physician ordered. The blood glucose levels were not being checked before meals which could result in higher readings and the need for more insulin to be administered. The findings include: On 11/7/18 at 11:30 AM, a blood glucose reading was scheduled to be observed with Employee D, Licensed Practical Nurse (LPN), for Resident #27. The LPN reported the resident was eating his lunch in the main dining room. He further stated it would be checked at 12:00 PM. On 11/7/18 at 12:00 PM, Employee D reported the resident was still eating his lunch, and notification would be provided when he was finished. On 11/7/18 at 12:15 PM, Employee D stated the resident was finished eating and would have his blood glucose level checked now. After gathering a glucometer and other materials, Employee D entered the resident's room and checked his blood glucose level. It registered 303 on the glucometer. Employee D administered 11 units of [MEDICATION NAME] in the right upper quadrant of the resident's abdomen after reviewing the sliding scale order for [MEDICATION NAME]to be administered before meals and at bedtime. The LPN confirmed the physician's orders [REDACTED]. The LPN confirmed it was after lunch and 12:30 PM. The LPN reported he checked blood glucose levels and administered insulin after obtaining the glucometer readings. A record review was conducted for Resident #27 which noted an order for [REDACTED]. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 11/7/18 at 1:00 PM, the Director of Nursing (DON) was contacted and asked to furnish a time-stamped copy of when insulin was administered for Resident #27 via the sliding scale order in (MONTH) and (MONTH) of (YEAR). The DON returned at 1:15 PM and reported the information requested to be printed was over 200 pages long, as she could not isolate the sliding scale insulin. The documentation for (MONTH) (YEAR) for the sliding scale coverage for Resident #27 was requested. A list of the meal times was reviewed and revealed lunch was served in the main dining room at 11:30 PM and dinner was served at 5:45 PM. (Photographic evidence obtained) A review of the MAR for (MONTH) (YEAR) revealed documentation for [MEDICATION NAME]per sliding scale reported multiple times the blood glucose level was checked after the meal was finished. Times noted on the MAR indicated [REDACTED]. November 1 insulin was administered at 12:13 PM and 8:17 PM November 2 insulin was administered at 1:30 PM and 8:27 PM November 3 insulin was administered at 12:16 PM November 4 insulin was administered at 12:16 PM November 5 insulin was administered at 2:03 PM and 7:15 PM November 6 insulin was administered at 2:04 PM and 6:10 PM November 7 insulin was administered at 2:21 PM (Photographic evidence obtained) An interview was conducted with the DON on 11/7/18 at 1:51 PM. The DON reviewed the documentation for the (MONTH) (YEAR) blood glucose checks and confirmed that on the dates noted above, the blood glucose level was checked and insulin was administered after the meals had already been consumed. The DON confirmed the blood glucose level should be checked before meals as the physician ordered. The DON reported lunch was served at 11:30 AM and Resident #27 ate in the dining room. An interview was conducted with Employee A, LPN, at 2:30 PM on 11/7/18 . Employee A reported the blood glucose was taken and insulin was administered immediately if needed. An interview was conducted with Employee D, LPN, at 2:32 PM on 11/17/18. Employee D reported he took the blood glucose reading with a glucometer and administered insulin immediately. An interview was conducted with the DON at 9:15 AM on 11/8/18. The DON reported the physician was called, and a incident report was completed due to blood glucose readings not being obtained until after meals were consumed for Resident #27. The physician wanted the orders to remain the same and blood glucose to be monitored as ordered. The DON reported she had started in-service training for the nursing staff concerning checking of blood glucose levels before meals and following physicians' orders. The DON further reported a Quality Assurance Improvement Plan had been initiated.

Based on record review and staff interview, the facility failed to maintain complete and accurately documented residents records by failing to document behavior monitoring on the Behavior Monitoring Record (BMR) for one (Resident #66) of five sampled resident records reviewed. The findings include: A review of Resident #66's Behavior Monitoring Records (BMR) for (MONTH) and (MONTH) (YEAR) was conducted on 11/07/18 and revealed multiple omissions. A physician's orders [REDACTED]. Neither was it documented on evening shift on 10/23, 10/24, or 11/5/18. A physician's orders [REDACTED]. Nor was it documented during the evening shift on 10/23, 10/24, or 11/5/18 . (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 11/07/18 at 2:09 PM regarding missing documentation for the (MONTH) and (MONTH) (YEAR) BMR for Resident #66. After LPN A reviewed the resident's (MONTH) and (MONTH) (YEAR) BMR, she confirmed the above-mentioned documentation was missing, and could not explain why it was missing. An interview was conducted with the Director of Nursing (DON) on 11/07/18 at 3:22 PM regarding the missing documentation in the (MONTH) and (MONTH) (YEAR) BMR for Resident #66. After the DON reviewed the forms, she confirmed the resident was in the facility during the dates in question and all of the documentation in question was missing. She added, I don't have any explanation as to why it wasn't documented. The facility's policy and procedure for Medication Monitoring and Medication Management, dated 09/10, was reviewed. The policy's procedure #4 stated, Non-pharmacological interventions such as behavior modification or social services and their effects are documented as a part of the care planning process, and are utilized by the prescriber in assessing the continued need for medication.