Every finding on record at Gainesville Health and Rehabilitation

Based on record review and interview the facility failed to review advance directives options with 18 residents, Resident #2, #6, #7, #10, #11, #12, #46, #59, #67, #75, #76, #85, #86, #89, #92, #95, #100, and #109 reviewed for advance directives. Findings include: 1) Review of Resident #10's medical record documented an admission date of 2/6/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #10. Review of Resident #10's Advance Directives/Informed Consent form showed the form was not completed, dated or signed by Resident #10 or facility staff. 2) Review of Resident #11's medical record documented an admission date of 9/4/2021. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #11. 3) Review of Resident #67's medical record documented an admission date of 1/8/2026. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #67. 4) Review of Resident #85's medical record documented an admission date of 3/17/2026. The medical record did not contain documentation the facility had reviewed advance directives options with Resident #85. 5) Review of Resident #109's medical record documented an admission date of 8/12/2026. The medical record did not contain documentation the facility had reviewed advance directives options with Resident #109. During an interview on 8/18/2026 at 11:45 AM, the Social Services Director stated she was unable to locate documentation advance directive options had been reviewed with Residents #10, #11, #67, #85, and #109. Review of the policy and procedure titled, Advance Directives Code Status, last reviewed 7/15/2026 read Guideline ADMISSION/readmission Code status verified upon admission with Resident/Representative and confirms decision with the attending physician (MD) [Medical Doctor]. 6) Review of Resident #89's medical record documented an admission date of 3/12/2024. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #89. 7) Review of Resident #59's medical record documented an admission date of 12/18/2023. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #59. 8) Review of Resident #86's medical record documented an admission date of 7/17/2026. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #86. 9) Review of Resident #92's medical record documented an admission date of 5/27/2026. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #92. 10) Review of Resident #2's medical record documented an admission date of 6/3/2016. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #2. During an interview on 8/19/2026 at approximately 10:30 AM the Director of Nursing stated, the facility did not have a process in place to verify Advance Directives with residents. 11) Review of Resident #6's medical record documented an admission date of 7/26/2024. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #6. 12) Review of Resident #7's medical record documented an admission date of 04/16/2026. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #7. 13) Review of Resident #12's medical record documented an admission date of 05/20/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #12. 14) Review of Resident #76's medical record documented an admission date of 09/08/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #76. During an interview on 08/18/2026 at 2:20 PM the MDS Nurse (Minimum Data Set) stated if I don't have an order for code status the status is reverted automatically to Full Code by default. I don't follow up on that. During an interview on 08/19/2026 at 11:58 AM the DON (Director of Nursing) I am going to be honest with you only four Advance Directives have been found being completed from 2022. If a code status needs to be known in an emergency situation the information is in (Name of the electronic record program) and there is a DNR(Do Not Resuscitate) book at the nurses station that Social Services keeps updated. 15) Review of Resident #46's medical record documented an admission date of 09/11/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #46 and did not contain an admission Agreement. During an interview on 8/18/2026 at approximately 8:30 AM the DON stated awareness that some of the residents did not have an admission Agreement in their medical record. The DON confirmed the documentation of Advanced Directives were part of the admission Agreement. During an interview on 8/18/2026 at approximately 12:00 PM the MDS Nurse stated if there was not a DNR (Do Not Resuscitate) order or another form of documentation for an Advanced Directive, she entered a Care Plan for residents as being a Full Code. During an interview on 8/19/2026 at approximately 10:30 AM the DON stated there has not been a process in place for educating or verifying Advanced Directives with residents. Review of Resident #46's medical record revealed he was admitted on [DATE] with medical diagnoses that included other cerebral infarction due to occlusion or stenosis of small artery (primary diagnosis); dysphagia, oropharyngeal phase; muscle weakness (generalized); other muscle spasm; type 2 diabetes mellitus with hyperglycemia 16) Review of Resident #95's medical record documented an admission date of 12/12/2024. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #95. The medical record did not contain an admission Agreement. 17) Review of Resident #75's medical record documented an admission date of 10/30/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #75. 18) Review of Resident #100's medical record documented an admission date of 04/28/2026. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #100. During an interview 08/19/26 at 11:37 AM, the Director of Nursing stated, We didn't know that we needed to document the discussion during admission about advanced directives.

Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data in a uniform format.Findings include:Review of the CASPER (Certification and Survey Provider Enhanced Reports - a system and database used by healthcare facilities) report for quarter one (1/01/2026 through 3/31/2026) revealed that the facility triggered for 24 dates with zero registered nurse (RN) hours. During an interview on 8/18/2026 at approximately 9:00 AM the DON (Director of Nursing) stated that there had not been any days when an RN (registered nurse) was not in the facility. During the week, Monday through Friday, she and the ADON (Assistant Director of Nursing) and other nurses on the management team were in the facility. If there was a call out during off hours (nights and weekends) a member of the nursing management team would come in to cover the RN hours.During an interview on 8/18/2026 at 3:50 PM the ADM (Administrator) stated that he did not have access to the shared drive for the staffing calculations or the reporting. They utilized an outside company for staffing/scheduling. Review of the staffing calculations from 1/01/2026 through 3/31/2026 revealed there were at least 8 consecutive hours of RN coverage every day. During an interview on 8/20/2026 at approximately 10:00 AM the ADM stated that he believed the COO (Chief Operating Officer) was overseeing the process for submitting the PBJ (Payroll Based Journal) data. There used to be someone on site who he thought managed the data submission, but that person had been terminated. Most services, such as HR (human resources), the Business Officer Manager, and scheduling were either outsourced or were offsite. He was not sure who actually submitted the PBJ data. During an interview on 8/20/2026 at 10:51 AM the Chief Operating Officer (COO) stated that she was overseeing operations and she helped with staffing. They had uploaded the quarter 1 PBJ data to the CMS (Centers for Medicare and Medicaid) website, but the data had errors and was rejected. They used a 3rd party who entered the PBJ information for them. The 3rd party was told by CMS that after multiple attempts to resend the PBJ data, they could not submit it. Review of the policy and procedure titled, Payroll and Payroll Based Journal (PBJ), with the last review date of 7/15/2026 read, Purpose: To ensure employees are paid accurately and timely and that complete, accurate, and auditable staffing information is submitted to CMS through the Payroll-Based Journal (PBJ). Policy: The facility will maintain reliable payroll and timekeeping records, protect payroll information, and submit PBJ data in accordance with 42 C.F.R. S 483.70(p), current CMS instructions, and applicable wage-and-hour requirements. Use of a payroll or PBJ vendor does not transfer the facility's responsibility for accuracy or timeliness. Responsibilities: The Administrator provides oversight and approves the final PBJ submission or designates a qualified approver. The PBJ coordinator collects employee, agency, contractor, and census-related information; reconciles the data; submits it; and retains validation reports. 5. PBJ Data Requirements: Report required direct-care staffing hours for facility employees and agency or contract staff using current CMS job-title and pay-type codes. 7. Reconciliation and Submission: The submission must be accepted by CMS no later than 11:59 p.m. Eastern Time on the 45th calendar day after the quarter ends. The facility will target submission at least 10 calendar days earlier to allow corrections. Before submission, reconcile PBJ hours to payroll, timekeeping, schedules, agency records, invoices, employee rosters, hire/termination information when used, and applicable MDS census information. After upload, review the PBJ/CASPER Final File Validation Report and available staffing reports. Correct rejected or inaccurate records and resubmit before the CMS deadline. The PBJ coordinator and Administrator or designee will document final review and approval. The last accepted file before the deadline is treated as the final submission. 8. Corrections, Security, and Noncompliance: Suspected payroll or PBJ errors, missing contractor data, duplicate hours, improper codes, or system problems must be reported immediately to Payroll, the PBJ coordinator, and the Administrator. Corrections must preserve an audit trail. Access to payroll and PBJ systems is limited to authorized users; credentials may not be shared. Late, incomplete, inaccurate, or unsupported PBJ data may result in CMS noncompliance or enforcement. Repeated issues will be reviewed through QAPI and corrective action.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for residents on 3 of 3 hallways. Findings include: 1) During an interview on 8/17/2026 at 9:47 AM Resident #89 stated, The sink in the bathroom is loose. During an observation on 8/17/2026 at 9:47 AM of Resident #89's bathroom, the floor surrounding the toilet was noted to have multiple areas of brown matter build up and staining. There were missing tiles on the bathroom floor. The sink had a small separation from the wall. During an interview on 8/20/2026 at 9:15 AM the Administrator stated, I am currently acting as the Maintenance Director and looking to hire someone for the position. During an observation on 8/20/2026 at 9:17 AM the Administrator confirm there was brown matter build up to the base of the toilet, tiles were missing and the sink was separated from the wall. The Administrator stated, The bathroom should not look like this. It needs repairs. 2) During an observation on 8/17/2026 at 10:16 AM Resident #63's shower stall in his bathroom had clothing and equipment stored in the shower stall. The toilet bowl was observed to have a dark green to black ring at the water line. During an observation on 8/17/2026 at 11:05 AM Resident #5's room had clothing the resident stated was dirty, piled on the floor. Resident #5's bedside table had a cup of old dip and a washcloth with a large amount of a brown substance on it. There were Styrofoam cups, lids, and other trash observed on the floor. Resident #5's bathroom had areas on the wall with missing plaster and exposed metal. The toilet bowl was observed to be brown with a dark rim at the water line. During an interview on 8/19/2026 at 10:20 AM the ADM (Administrator) stated he was overseeing housekeeping. During review with the Administrator of photographic evidence of Resident #5 and #63's rooms and bathrooms, the ADM stated that the conditions were not acceptable. The showers in the residents' bathrooms should not have items stored in them and there should not be piles of dirty clothing and trash in resident rooms. The ADM stated that he does not make rounds to inspect rooms in the facility. 3) During an observation on 08/17/2026 at 9:26 AM, Resident #29 was lying in bed. There was an air vent on the wall above the resident's head soiled with a dark brown and black colored substance. The ceiling above the vent was damaged. Two roach traps were visible behind the headboard of Resident #29's bed. During an interview on 08/19/2026 at 9:35 AM, the Maintenance Assistant stated that there are currently no Maintenance Director and no Housekeeping Director. The administrator is currently acting as the housekeeping director, and housekeeping is responsible for cleaning the air vents. During an interview on 08/19/2026 at 9:40 AM, the Administrator viewed the soiled air conditioning vents and ceiling in Resident #29's room and stated, That should not look that way. Those vents should be cleaned daily. During an observation on 08/17/2026 at 9:50 AM, the flooring of the 300 hallway had multiple areas where flooring planks were damaged with visible gaps and exposed areas beneath the flooring. During an interview on 08/19/2026 at 9:55 AM, the Administrator stated that he is aware of the damaged flooring, and they are working on ordering the materials to repair the flooring. Review of the policy and procedure titled, Safe and Homelike Environment last reviewed on 01/01/2026 read, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. a. The facility will allow residents to use their personal belongings, including furnishings and clothing (as space permits) to assist in creating and maintaining a homelike environment. This must not infringe upon the rights or health and safety of other residents. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. 5. The facility will provide sufficient individual closet space in each resident room.

Based on interview and record review, the facility failed to ensure notification was provided to the Office of the State Long-Term Care Ombudsman for 2 of 3 residents (Resident #113 and Resident #108) reviewed for discharge, and 3 of 3 residents (Resident #115, Resident #116, and Resident #79) reviewed for [NAME] Act. Findings include: 1) Review of Resident #113's medical record documented an admission date of 05/30/2026 and a discharged date from the facility of 07/21/2026. There was no documentation of notification to the Office of the State Long-Term Care Ombudsman of the discharge. During an interview on 08/20/2026 at 1:50 PM, the Social Services Director stated, I am responsible for the discharge notices. I used to send notifications of all discharges to the Ombudsman. I have not sent any discharge notices to the Ombudsman because we no longer have an Ombudsman for our facility. I did not notify the Ombudsman when [Resident #113's name] was discharged . A request was made for documentation of the notification to the Office of the State Long-Term Care Ombudsman related to the discharge of Residents #113, # 108, #115, #116, and #79. None was provided. During an interview on 08/20/2026 at 2:00 PM, Staff L, MDS [minimum data set] nurse stated, We no longer have a volunteer Ombudsman that comes into the facility, but we have a fax number for the Ombudsman, and we can send notifications that way. 2) Review of Resident #108's medical record documented the resident discharged from the facility on 06/04/2026. There was no documentation of notification to the Office of the State Long-Term Care Ombudsman of the discharge. During an interview on 8/20/26 at 2:16 PM the Social Services Director stated that no Ombudsman Notification Form was found for Resident #108. 3) Review of Resident #116's medical record documented Resident #116 was involuntarily discharged (Baker Act) from the facility on 5/30/2025 following an episode of agitation, aggression and combativeness; for a mental health evaluation and treatment. There was no documentation of notification to the Office of the State Long-Term Care Ombudsman of the involuntary discharge. 4) Review of Resident #79's medical record documented Resident #79 was involuntarily discharged (Baker Act) from the facility on 8/22/2025 following an episode of threatening behavior toward other residents and staff; for a mental health evaluation and treatment. There was no documentation of notification to the Office of the State Long-Term Care Ombudsman of the involuntary discharge. 5) Review of Resident #115's medical record documented Resident #115 was involuntarily discharged (Baker Act) from the facility on 3/21/2026 following an episode of agitation, threatening behavior and attempting to fight staff members; for a mental health evaluation and treatment. There was no documentation of notification to the Office of the State Long-Term Care Ombudsman of the involuntary discharge. During an interview on 8/20/2026 at 11:15 AM, Staff A, Licensed Practical Nurse confirmed there was no documentation that showed the Ombudsman's office had been notified of Resident #116's, Resident #79's and Resident #115's involuntary discharge from the facility. Review of the policy and procedure titled, Transfer and Discharge (including AMA [Against Medical Advice]), last reviewed 7/15/2026 read, 12. Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.

Based on observation, interview, and record review, the facility failed to ensure drugs were secured and/or not in active use when expired in accordance with professional standards for 2 of 4 medication carts, and unsecured in residents' rooms unattended for Residents #42, #80, and #100. Findings include: 1) During an observation on [DATE] at 10:04 AM of Resident #80's room, an opened bottle of ketoconazole shampoo was on the resident's bedside table. 2) During an observation on [DATE] at 10:25 AM of Resident #100's room, a bottle of hydrogen peroxide was in the resident's bathroom on the ledge of the mirror, above the sink. During an interview on [DATE] at 12:06 PM, Staff A, Licensed Practical Nurse (LPN)/Unit Manager stated residents cannot keep medications, including hydrogen peroxide, in their rooms. The Unit Manager confirmed hydrogen peroxide was present in the bathroom and said, that shouldn't have been there. The Unit Manager confirmed the ketoconazole shampoo was present on the bedside table and said, An aide might have left that in there, it can't be left there. During an interview on [DATE] at 12:21 PM the Director of Nursing stated residents are not allowed to keep medications in their rooms. 3) During an observation on [DATE] at 10:15 AM of Resident #42's room, a cup containing medications was on the resident's bedside table. The resident was resting with eyes closed. During an interview on [DATE] at 10:17 AM Staff P, LPN (Licensed Practical Nurse) stated Resident #42 does her own scheduling (for medications). She should be a self-administration. She has a lot of over-the-counter medications in there too (in the medication cup). Review of Resident #42's MAR (Medication Administration Record) for [DATE] documented the medications were administered on [DATE] at 0900 (9:00 AM) by Staff P, LPN. The medications listed as administered consisted of Amlodipine 10 mg (high blood pressure), Bisoprolol-Hydrochlorothiazide 6.25 mg (high blood pressure), Clopidogrel 75 mg (coronary artery disease), Duloxetine 60 mg (depression), Farxiga 10 mg (diabetes), Ramipril 5 mg (high blood pressure), Sertraline 150 mg (depression), Amoxicillin 875 mg (antibiotic), Depakote ER 500 mg (mood disorder), Pradaxa 150 mg, Gabapentin 800 mg, 4) During an observation on [DATE] at 8:46 AM with Staff T, Licensed Practical Nurse (LPN) of Station 1 Medication Cart 1 there was a Lantus insulin not stored in the pharmacy bag and was not dated. There was one bottle of Prednisolone Acetate [NAME] 1% OP (Ophthalmic) not dated, one bottle of Ciprofloxacin Ophthalmic Solution 0.3% not dated, one expired bottle of Olopatadine Hydrochloride Ophthalmic Solution USP 0.1% dated [DATE] and one dated [DATE]. During an interview on [DATE] at 9:00 AM Staff T, LPN, stated, Medication should be bagged and dated when opened. Any expired medication should be removed from the medication cart. 5) During an observation on [DATE] at 9:03 AM of Station 3 Medication Cart with Staff S, LPN, there was an expired Insulin Lispro with an open date of 7/17, the package was labeled Throw away any medication that remains 28 days after first use. During an interview on [DATE] at 9:09 AM Staff S, LPN, stated, That insulin is good for six (6) weeks. I would not consider it to be expired. During an interview on [DATE] at 4:14 PM the Director of Nursing stated, Medication should be dated when opened. The medication should be stored in pharmacy packaging. The medication that is expired should be discarded. Review of the facility policy and procedure titled, Administration of Eye Drops or Ointments with a last review date of [DATE] read, Policy Explanation and Compliance Guidelines: 1. Verify orders and labeling prior to administration: d. Label new bottle with date open and follow manufacturer's instructions for when to discard and replace. Review of the facility policy and procedure titled, Labeling of Medications and Biological with a last review date [DATE] read, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Review of the facility policy and procedure titled, Labeling of Medications and Biological with a last review date [DATE] read, Policy: It is the policy of this facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

Based on interview and record review the facility failed to provide laboratory services for 2 of 6 residents (Residents #9 and #89) reviewed for laboratory services. Findings include: Review of Resident #9 physician order dated 5/25/2026 read, lipid panel. Review of Resident #9 medical record did not reveal a lab result for lipid panel ordered on 5/25/2026. Review of Resident #9 physician order dated 1/25/2026 read, AMMONIA LEVEL every night shift every 30 day(s). Review of Resident #9 medical record documented ammonia levels drawn on 1/26/2026. No other ammonia level results were documented. During an interview on 8/20/2026 at 9:24 AM with the Director of Nursing stated, I was unable to locate the lab results for the lipid panel ordered on 5/26/2026 and the monthly Ammonia levels order for [Resident #9's name]. During an interview on 8/20/2026 at 2:42 PM with Staff A Licensed Practical Nurse Unit Manger stated, We were unable to locate the labs. The lipid panel order did not show up in the treatment record we would not have known it was ordered. Review of Resident #89 physician order dated 10/6/2025 read, CBC, CMP, B12, Ferrous, Vitamin D, TSH, Lipid Panel every night shift every 90 day(s). Review of Resident #89 Lab results were dated 4/26/2026. There were no lab results for the month of July 2026. During interview on 8/19/2026 at 4:09 PM with the Director of Nursing stated, I was not able to locate any lab results for the month of July for [Resident #89's name]. During an interview on 8/20/2026 at approximately 9:23 AM with the DON stated, I was not able to locate any labs for Resident #89 for the month of July 2026. Review of the facility policy and procedure titled Laboratory Services with a last review date of 7/15/2026 read, Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.

Based on observation, interview, and record review, the facility failed to maintain food service equipment and food storage areas in a clean and sanitary condition in the kitchen and 3 of 3 nourishment room refrigerators and freezers. Findings include: During an observation on 08/17/26 at 09:18 AM conducted with the Lead Dietary Aide of the facility's walk in refrigerator, there was a tub of ham salad covered with a sheet of tin foil observed on the top (third) shelf of the right shelving unit. The tub of ham salad was not labelled or dated. On the second shelf, there was a large carton of eggs with no cover, one of the eggs was broken. On the first (bottom) shelf, there was a metal tub of food covered with a sheet of tin foil that was dated. The eggs were stored above the metal tub of food. During an interview on 08/17/26 at 09:19 AM, the Lead Dietary Aide stated that all items in the cooler should be labelled and dated. He stated that the ham salad was improperly stored. He also stated that the eggs were improperly stored. He explained that eggs should not be stored above other food items. During an observation on 08/17/26 at 09:20 AM of the facility's walk in freezer, there was an open box of imitation crab meat stored without a date, an open box of hamburger buns without a date and there was a clamshell takeout container with a half-eaten piece of cake inside without a label or date. During an interview on 08/17/26 at 09:22 AM, the Lead Dietary Aide stated that all items in the freezer should be labelled and dated. He stated that the piece of cake should not have been in the freezer. During an observation on 08/17/26 at 09:25 AM of the kitchen, there were two open bags of cereal stored on shelves above the microwave. They were stored without a label or date. During an interview on 08/17/26 at 09:26 AM, the Lead Dietary Aide stated that the bags of cereal should have been stored in the pantry with a label and date. During an observation on 08/17/26 at 09:36 AM, the Station One Nourishment Room refrigerator was observed to have food items unlabeled and undated including: a frozen bag of pizza rolls, an opened carton of milk, two take-out food containers, a pizza box, a bag of baby carrots, a container of pasta salad, a container of black beans, and a plastic storage container with unidentified food inside. During an observation on 08/17/26 at 09:41 AM, the Station Two Nourishment Room refrigerator was observed to have food items unlabeled and undated including: a frozen bottle of soda, a frozen opened carton of milk, a bottle containing a red liquid, a plastic bag filled with assorted groceries, and a paper bag with unidentified food inside. During an observation on 08/17/26 at 09:46 AM, the Station Three Nourishment Room refrigerator was observed to have multiple food items unlabeled and undated including: a carton of ice cream, a plastic storage container with unidentified food inside, a paper bag with unidentified food inside, and an open energy drink can. During an interview on 8/17/26 at 9:47 AM, the Lead Dietary Aide stated that all foods in the nourishment room refrigerators should be labeled and dated. Review of the Refrigerator/freezer logs for the nourishment rooms revealed temperatures were not documented since 8/14/26. During interview on 8/18/26 at 7:56AM, the Dietary Manager stated that clinical staff are supposed to document refrigerator/freezer temps and throw out unlabeled and undated food. Review of the facility policy and procedure titled Use and Storage of Food Brought in by Family or Visitors, reviewed 1/1/26, showed it read, Policy statement: It is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. 2. All food items that are already prepared by family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. C. Of not consumed within 3 days, food will be thrown away by facility staff.

Based on observation, interviews and record review the facility failed to ensure garbage and refuse were properly disposed of for 3 of 3 dumpsters observed. The dumpsters were not maintained in a manner that ensured waste was properly contained and/or covered, and the surrounding garbage -storage area was not maintained in a sanitary condition to prevent the harborage and feeding of pests. Findings include: During an observation on 08/17/26 beginning at 09:32 AM with the Lead Dietary Aide, the first dumpster located closest to the kitchen was observed to have Styrofoam bowls, cups, wrappers, straws, and plastic silverware accumulated in the grass in front of the dumpster. Flies were observed on and flying around the trash on the ground. The second dumpster was observed with one lid open and vinyl gloves, plastic cups, and straw wrappers accumulated in the grass in front of and on the right side of the dumpster. The third dumpster was observed with both lids open, piled high with carboard boxes. During an Interview on 5/18/26 at 7:56 AM, the Dietary Manager stated that maintenance is supposed to clean around and maintain the dumpsters. During an interview on 8/19/26 at 8:53 AM, the Assistant Maintenance Director stated that it is the kitchen's responsibility to maintain the dumpsters. During an interview on 8/19/26 at 12:45 PM, the Administrator stated that maintenance oversees the cleaning of the dumpster as well as housekeeping and kitchen staff. Review of the facility policy and procedure titled, Outdoor Dumpster and Waste-Storage Area, last reviewed date of 1/1/26 showed it read, To keep the facility's outdoor dumpster and waste -storage area sanitary, secure, accessible to authorized collection personnel, free of pests and fire hazards, and compliant with applicable waste-separation, biomedical-waste, worker-safety, stormwater, and local collection requirements. Policy-Only properly bagged ordinary solid waste approved for the contracted municipal or commercial waste stream may be placed in the outdoor solid-waste dumpster. The dumpster and the enclosure will remain closed, secure, clean, serviceable, free of overflow, leakage, loose debris, standing water, and unauthorized access. Regulated or special waste will never be placed in the ordinary dumpster unless expressly permitted by law and accepted in writing by the waste contractor.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 3 units and the kitchen. Findings include: 1) During an observation on 08/17/26 at 09:27 AM, a dead small blackish brown insect was observed on the floor of the kitchen near a cart of clean dishware. During an observation on 08/17/26 at 09:28 AM, a live small blackish brown insect was observed in the empty sanitization compartment of the 3-compartment sink. During an interview on 08/17/26 at 09:29 AM, the Lead Dietary Aide stated that there are more pests in the kitchen than normal, management is aware. During an observation on 08/19/26 at 08:57 AM, a live small blackish brown insect was observed on the outside of the dishwasher cover. During an interview on 08/19/26 at 08:58 AM, the Dietary Manager stated that the pest control company has been coming to the facility, but she questions how effective the treatment is because she keeps finding pests. 2) During an observation on 8/17/2026 at 10:16 AM, Resident #63's shower stall had clothing and equipment stored in it. A small brown bug was observed to run across the bathroom floor and into the shower stall. During an observation on 8/20/2026 at 10:00 AM, a small brown insect was observed on the shower head in Resident #63's shower stall. Review of the Pest Control Log from 4/01/2026 through 8/16/2026 revealed documentation on 4/19/2026 that read, [Resident #63's Room Number], roaches everywhere. Review of the Pest Control Log from 4/01/2026 through 8/16/2026 revealed documentation on 6/28/2026 that read, [Resident #63's Room Number], Roaches. Review of the Pest Control Log from 4/01/2026 through 8/16/2026 revealed documentation on 7/22/2026 that read, [Resident #63's Hall Room Numbers], roaches, gnats, and flies. During an interview on 8/19/2026 at 10:20 AM the ADM (Administrator) stated he was overseeing housekeeping. In review of the photographic evidence of Resident #63's bathroom, the ADM stated that the conditions were not acceptable. He was not aware of issues or complaints with roaches in [Resident #63's Name] room. He does not make rounds to inspect rooms in the facility. Review of the facility policy and procedure titled Integrated Pest Management and Pest Control reviewed on 1/1/26, showed it read, Purpose statement: To prevent, identify, and eliminate insects, rodents, birds, wildlife, bed bugs, and other pests through an integrated pest -management (IPM) program that protects residents, staff, visitors, food, medications, supplies, and the physical environment while minimizing unnecessary pesticide exposure. Policy-[Name of Facility] will maintain all interior and exterior areas free of pest infestation and conditions that attract or harbor pests. The facility will use sanitation, exclusion, moisture control, monitoring and targeting treatment in that order whenever practical. Pesticides may be selected and applied only in accordance with the product label and applicable law by authorized, trained personnel or a properly licensed pest-control contractor.

Based on observation, interview and record review the facility failed to implement policies regarding smoking, smoking areas and smoking safety for 5 residents, Resident #7, Resident #12, Resident #15, Resident #37 and Resident #85, of 8 residents reviewed for accidents. Findings include: 1) On 8/17/26 at 11:58 AM, Resident #85 was observed seated in a side small courtyard area. Resident #85 was smoking a cigarette in a non-designated smoking area. During an interview on 8/17/2026 at 12:07 AM, the Administrator stated residents were not supposed to smoke in the small courtyard. He stated the residents knew the rules and if residents did not follow the smoking rules, they would be issued a 30-day notice. During an interview on 8/18/2026 at 8:56 AM, the Activities Director stated there was no ashtray in the small courtyard area and the small courtyard area was not a smoking area. During an observation on 8/18/2026 at 9:03 AM, of the interior door leading to the small patio area where Resident #85 was smoking showed signage that read NO SMOKING VAPING THANK YOU. Observation on 8/18/2026 at 9:04 AM, of the exterior door leading out of the small patio area showed signage that read NO SMOKING VAPING THANK YOU. Observation on 8/18/2026 at 9:05 AM, of the grounds surrounding the small patio area showed multiple cigarette butts on the ground surrounding the small patio area. Review of Resident #85's medical files, documented the smoking policy was signed by Resident #85 on 3/17/2026. 2) During an observation on 08/17/26 at 10:41 AM, observed Resident #75 demonstrate that he hides his lighter inside of an empty cigarette box. Review of Resident #75's Smoking Evaluation dated 07/09/26 read, Does the resident currently smoke? Yes; Is the resident able to acknowledge understanding of smoking policy? Yes. During an observation on 08/20/26 at 12:12 PM, Staff A, Unit Manager, entered Resident #75's room and asked him if he had a lighter in his bedroom. He (Resident #75) indicated that there was a lighter in an empty cigarette box lying on the ground. During an interview on 08/20/26 at 12:13 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager stated that residents cannot keep lighters in their bedrooms. During an interview on 08/20/26 at 12:21, the Director of Nursing confirmed that residents are not allowed to keep lighters in their bedrooms. 3)During an observation on 08/17/2026 at 12:00PM, Resident #37 was in the small courtyard unattended with a lighter in hand lighting his cigarette, a non-designated smoking area. During an observation on 8/18/2026 at 11:02 AM, Resident #37 was observed smoking in the small courtyard unattended. Review of Resident #37's Smoking Evaluation dated 7/24/2026 read, Does the resident currently smoke? Yes. During an interview on 8/20/2026 at 9:16 AM, Staff G, LPN stated, Residents are not supposed to keep the lighters with them. If we see them, we are to take them away immediately and they are only to smoke in the smoking patio. During an interview on 8/20/2026 at 9:30 AM, the Director of Nursing stated, Lighters are to be kept in station 2 in a lock box by the smoking area. Activities and/or smoking aide has the key. Residents are not allowed to have lighters with them and are to only smoke in the smoking patio at designated times. 4) During an observation of Resident #7 on 08/20/2026 at 12:55PM, she was seated in her wheelchair in her room with a purple pack of 305's cigarettes beside her. During an interview with Resident #7 on 08/19/2026 at 12:25PM, she was sitting in bed with money in her right hand and a full pack of new 305 cigarettes in her left hand. She stated the staff buy them for me, not social services. Review of Resident #7's Smoking Evaluation dated 05/26/2026 read, Section A. History 1. Does the resident currently smoke? b. No Resident #7's Smoking Evaluation dated 02/26/2026 read, Section A. History 1. Does the resident currently smoke? a. Yes Review of Resident #7's Care Plan dated 04/21/2026 documented a focus: Resident must smoke with supervision r/t (related to) facility policy: potential for noncompliance. 5) During an observation on 08/17/2026 at 9:42AM, Resident #12 was outside smoking in a non-smoking area with other Residents holding a lighter in his hand. During an interview on 08/17/2026 at 9:42AM, Resident #12 stated, I have my lighter here in my cart under my seat. I just need her (nurse) Staff N, to give me cigarettes. I don't know yet where I am going to go outside to smoke at.Review of Resident #12's records, documented a smoking policy signed by Resident #12 on 05/29/2025. Review of Resident #12's records revealed no smoking evaluation completed. 6) During an observation on 08/17/2026 at 10:12AM, Resident #15 had a black cigarette case in her wheelchair seat. Review of Resident #15's records revealed no smoking evaluation completed. Review of the policy titled Smoking Policy, last reviewed on 7/15/2026 read, To ensure maximized safety, all residents who choose to smoke will be supervised smokers. Each resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. All smokers will be supervised during smoking without exception. Smoking is only permitted in designated resident smoking areas, which are located outside the building.The designated smoking area will be staff supervised during all hours posted for resident use. Smokers who fail to return smoking materials after smoking may lose their smoking privileges. Those who repeatedly fail to comply with safety rules may receive a 30-day notice of discharge from the facility. By Signing below, I affirm that I have read and agree to the tobacco smoking policy detailed above for Gainesville Health and Rehabilitation Center. I am aware that all paraphernalia must be stored and locked for safe keeping, and that I may not smoke tobacco products anywhere but the designated area at the facility. By signing below, I also agree to the completion of a smoking evaluation.

Based on interview and record review, the facility failed to ensure the resident's physician and the resident's representative were notified when the resident experienced a significant weight loss for 1 of 6 residents, Resident #46, reviewed for dietary/nutritional concerns.Findings include:Review of Resident #46's weight documentation dated 02/22/2026 the resident's weight was 175.2 lbs (pounds), 03/03/2026 - 171.2 lbs, 06/03/2026 - 164.6 lbs., 07/01/2026 - 160.6 lbs, and 08/01/2026 - 154.4 lbs; a 11.87% weight loss. Review of Resident #46's assessments and progress notes documented the last nutritional evaluation was completed in December of 2025.During an interview on 8/18/2026 at 12:25 PM, Resident #46 stated lunch was, So so and commented the food was the reason he had lost weight recently. Review of Resident #46's medical record revealed he was admitted on [DATE] with medical diagnoses that included other cerebral infarction due to occlusion or stenosis of small artery (primary diagnosis); dysphagia, oropharyngeal phase; muscle weakness (generalized); other muscle spasm; type 2 diabetes mellitus (DM) with hyperglycemiaReview of Resident #46's most recent MDS (Minimum Data Set) Assessment, a quarterly assessment dated [DATE] documented his BIMS (Brief Inventory of Mental Status) Score as 15 out of 15 which indicated he was cognitively intact. He received a mechanically altered diet.Review of Resident #46's Care Plan read, Focus - [Resident #46' name] is at risk for nutritional problem r/t [related to] dysphagia, modified consistency diet, use of specified diuretics, laxatives, cardiovascular medications, DM with diabetic diet, osteomalacia, vitamin/mineral deficiencies. Goal - Maintain adequate nutrition by consuming at least 75% of most meals by next review date. Interventions included - Monitor and report to the physician: Signs/symptoms of malnutrition Significant weight loss Chewing/swallowing problems; Nutrition assessment quarterly and PRN [as needed] to determine effectiveness of nutrition therapy. Focus - The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t fragile skin.Review of Resident #46's Task List for the % [percentage] intake of meals for the past 30 days documented Resident #46 consumed 0-25% of the meals ten (10) times, and 25-50% of the meal nine (9). During an interview on 8/19/2026 at 11:25 AM the RD (Registered Dietitian) stated that Resident #46 had a 12% weight loss since February. The process was residents were to be seen on admission, quarterly, and annually. He confirmed that he had not seen Resident #46, and that Resident #46 had not been evaluated by a dietitian since December of 2025.During an interview on 8/19/2026 at 2:30 PM Physician #1 stated that he was not aware that Resident #46 had a significant weight loss. If he were aware of Resident #46's weight loss, he would have contacted the dietitian to have Resident #46 seen.During an interview on 8/19/2026 at 3:16 PM Staff A, LPN stated that in the weight loss meetings, they would go over weights both weekly and any daily weights. If there was a significant change, they would put in a change of condition, notify the family and the medical doctor. They had not had a dietician in the facility for some time. During an interview on 8/20/2026 at approximately 10:15 AM the Restorative CNA (Certified Nursing Assistant) stated that she obtained regular weights on residents. After she got the weights, she gave them to the ADON (Assistant Director of Nursing) or the Nurse. Once they put the weights in the medical record, they compare the weight to the previous weight. They reweigh the residents if needed. She had taken Resident #46's most recent weight on 7/30/2026 and had given the weights that day to the ADON. [Resident #46's name] really didn't eat. Review of the policy and procedure titled, Weight Monitoring, with the last review date of 7/15/2026 read, Policy: It is the policy of the facility to minimize the risk of a resident's significant weight loss and for residents to maintain acceptable parameters of nutritional status. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight or insidious weight loss may indicate nutritional problems. 5. Weights shall be monitored as per the schedule below unless otherwise ordered by the healthcare provider. B. Residents with significant weight loss - monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previously recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month (30 days) b. 7.5% change in weight in three months (90 days) c. 10% change in weight in six months (180 days). 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. c. The resident and/or the resident's family member or legal representative should be informed of a significant change in weight. e. The registered dietitian or dietary manager should be consulted to assist with interventions; actions should be recorded in the medical record. Review of the policy and procedure titled, Notification of Changes, with the last review date of 7/15/2026 read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with a resident's physician or notify the resident's family member or legal representative when there is a change by such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health mental or psychosocial status. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify the resident's representative, if known.

Based on interview and record review the facility failed to resolve a grievance for 1 of 3 residents, Resident #111, reviewed for grievances.Findings include: Review of Resident #111's Grievance Form dated 7/21/2026 read, Detail of Complaint/Grievance: On Friday morning I spoke with the nurse wrote a grievance form for asking repeatedly to have my trash changed due to having food scraps and not wanting to leave trash to have more bugs. When the nurse called the CNA [Certified Nursing Assistant] meeting [Staff Q's Name] said I would be free 'Free in the streets & a freak in the sheets. Date Compliant/Grievance Occurred: 7/17/26. What Shift Did The Complaint /Grievance Occur? 7-3. Person Completing this form: [Social Services Director]. Grievance Official Follow-Up: Educated {sic} was provided to resident that medication administration is one hour before and one hour after. Notification of Representative (Name/Date): 7/23/2026 Resident choose not to sign. During an interview on 8/20/2026 at 12:21 PM a request was made to the Social Service Director for in-service training for Resident #111 grievance and resolution of the grievance concern written. None was provided. During an interview on 8/20/2026 at 12:29 PM with the Social Services Director stated, I receive the grievances and give them to the Assistant Director of Nursing if it is nursing related. I also speak about them in the morning meeting. The grievance follow up does not address the grievance reported. During an interview on 8/20/2026 at 12:34 PM the Assistant Director of Nursing stated, She [Social Services Director] will not give them [grievances] to me, she will go over them in the morning meeting and the only thing I remember was in regard to the trash. During an interview on 8/20/2026 at 12:38 PM the Director of Nursing stated, I was not here during that morning meeting, and I was not aware of the allegation. The grievance was not addressed. Review of the policy and procedure titled, Resident and Family Grievance with a last review date of 7/15/2026 read, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledge of a complaint /grievance and actively working towed resolution of that complaint/grievance. Policy: 1. The Social Services Director or designee will serve as the designated Grievance Official for the facility. 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decision to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievance and actively working toward a resolution of that complaint/grievanec.12. The facility will make prompt efforts to resolve grievances.

Based on interview and record review the facility failed to report alleged allegations of verbal and physical abuse for 2 of 3 residents, Resident #76 and #111, reviewed for abuse allegations. Findings include: 1) Review of Resident #111's Grievance Form dated 7/21/2026 read, Detail of Complaint/Grievance: On Friday morning I spoke with the nurse wrote a grievance form for asking repeatedly to have my trash changed due to having food scraps and not wanting to leave trash to have more bugs. When the nurse called the CNA [Certified Nursing Assistant] meeting [Staff Q's Name] said I would be free 'Free in the streets & a freak in the sheets'. Date Compliant/Grievance Occurred: 7/17/26. What Shift Did The Complaint /Grievance Occur? 7-3. Person Completing this form: [Social Services Director]. Grievance Official Follow-Up: Educated {sic} was provided to resident that medication administration is one hour before and one hour after. Notification of Representative (Name/Date): 7/23/2026 Resident choose not to sign. During an interview on 8/20/2026 at 12:21 PM the Director of Nursing (DON) stated, I was not aware of the allegations. It would need to be reported. During an interview on 8/20/2026 at 12:29 PM the Social Services Director stated, I receive the grievance and give them to the Assistant Director of Nursing, if it is nursing related. I also speak about them in the morning meeting. I did not report it because I gave the grievance to the Assistant Director of Nursing. They will review it and if needed they will notify the Administrator and it will be reported. During an interview on 8/20/2026 at 12:29 PM the Administrator stated, I was not aware of this allegation. I will need to report it. During an interview on 8/20/2026 at 12:34 PM the Assistant Director of Nursing (ADON), stated, I was not aware of the allegations. She [Social Service Director] will not give them [grievances] to me she will go over them in the morning meeting and the only thing I remember was in regard to the trash. During an interview on 8/20/2026 at 12:37 PM with Staff R, Registered Nurse Manager stated, I was in the morning meeting that day. The DON was not here. I do not remember the Social Services Director saying anything about the freak in the sheet's allegation. During an interview on 8/20/2026 at 12:38 PM the Director of Nursing stated, I was not here during that morning meeting, and I was not aware of the allegation. During an interview on 8/20/2026 at approximately 1:00 PM with the Social Service Director stated, I did give the grievance to the ADON, and she was aware of the allegations. They are the ones to fill out the bottom section not me. Review of the facility policy and procedure titled, Abuse, Neglect, Exploitation with a last review date of 7/15/2026 read, Policy: It is the policy of this facility to provide protections for the health, welfare and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting /Response 1. Reporting of all alleged violations to the Administrator/designee, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2) Review of Resident 76's medical record documented diagnosis to include personal history of other venous thrombosis (formation of a blood clot) and embolism (blockage of blood vessel). During an interview on 08/17/2026 at 9:29 AM Resident #76 stated, I got my fingers broken here by a nurse who I would not give a medicine cup to. She laid on top of me and yanked my fingers back and dug it out of my hand. That was two months ago they never got me an orthopedic appointment my daughter did. The same nurse hurt my right leg. I ended up in the hospital for 16 days after developing a blood clot. She still works here. During observation of Resident #76 on 08/17/2026 at 9:30 AM two fingers of the resident's left hand, the little finger and ring finger had a black strap velcroid around them. During an interview on 08/17/2026 at 2:25 PM the Administrator was asked regarding the abuse allegations made by Resident #76, the Administrator stated, I believe DCF (Department of Children and Family) came in, and the Office of the Attorney General came in. I will bring you the investigation reports. During an interview on 08/19/2026 at 10:21 AM via telephone Resident #76's Family Member #1 stated after my mother went to the ER (Emergency Room) for her DVT (deep vein thrombosis) she got from (Staff M's name) punching her in the leg multiple times to wake her up. The hospital tried to find a different place to send her (Resident #76), but nobody would take her. She has to stay in that place due to financial reasons. My mom said DCF came in and talked to her in the hospital. I have not heard anything about any investigation being done by the facility. My mom called the police herself to make a report. They (law enforcement) came and talked to her. During interview on 08/19/2026 at 2:19 PM Physician #1 stated (Resident#76's name) has a history of Factor 5 Leiden (gene mutation that makes blood more likely to form abnormal clots) she came from the hospital with Lovenox (blood thinner) injections and is starting Xarelto (blood thinner). She had previously been on Rivaroxoban (blood thinner). The likelihood of blunt trauma causing her blood clot is a low likelihood. I have a good relationship with the resident and her daughter. I know there are interpersonal issues between the Resident and the staff. Review of an x-ray for Resident #76 dated 06/08/2026 read, Findings: Acute nondisplaced proximal fifth proximal phalanx (finger bone) fracture. Review of the On Call Telemedicine Visit dated 06/12/2026 by Physician #1 read, S (Situation): Nurse called in stating that the patient is noted to have fracture of left pinky finger. The patient has gastroesophageal reflux disease and gets omeprazole scheduled at 06:00 AM. They ran out of the oxycodone 5 mg (milligrams) q6h (every 6 hours) dose. The patient instead has been given Loratadine. which she does not like. [Family Member #1's name] is concerned that her mother has higher chance of blood clot due to genetic disorder. [Family Member #1's name] is inquiring if the oxycodone dose can be increased from 5mg to 10 mg and given a 1 month's supply.[ Family Member #1's name] is concerned about her mother's health. They are very unhappy with short-supply of medications despite having the medication order for 2 months. Nurse called in again to update about the medication order. Chart was reviewed. O (Observation): In distress due to pain. Review of the Change in Condition summary by Staff B and Staff P for Providers on 06/17/2026 read, Situation: The change in condition/s reported on the CIC (Change in Condition) Evaluation are/were: Edema (new or worsening) New or worsening pain change in skin color or condition. New testing orders: Venous Doppler. Review of the Hospital Discharge Summary, admission Date 06/25/2026 and discharge date : [DATE] read, Hospital Course: Trauma to leg caused DVT. Hematology consulted and believes it was not a failure of Xarelto given. Opioid induced constipation. Concern for elder abuse which DCF (Department of Children and Families) is investigating but agreed to return to rehab while investigation continues. Appealed discharged 7/3 so remained in patient over the weekend and ortho evaluated at patient's request. No changes made to the management of L (Left) 5th digit fracture. Per Radiology US (ultrasound) Extremity Non-Vascular Limited Area Result - Date:06/27/2026. History: right lateral thigh pain with warmth and bruising around the area evaluation for hematoma. Procedures: Findings likely representing a soft tissue hematoma, less likely evolving abscess. Review of the Report of Consultation dated 06/16/2026 read, Report of consultation: Left displaced and angulated 5th proximal phalanx (finger) fracture bruising, swelling of the hand healing dorsal (top of hand) hand laceration. Splint Device applied

Based on interview and record review, the facility failed to ensure each resident received an accurate assessment, reflecting the status at the time of the assessment for 2 of 15 residents, Resident #46 and Resident #75), reviewed for Minimum Data Set assessments. Findings include: 1) Review of Resident #46's MDS (Minimum Data Set) Assessment, the quarterly assessment dated [DATE], documented Resident #46 is administered anticoagulant medications which were documented as high-risk medications. Review of Resident #46's physician orders revealed there was no current orders for anticoagulant medications. Review of Resident #46's MAR (Medication Administration Record) from 6/01/2026 through 8/16/2026 revealed there was no documentation of the administration of anticoagulant medications. During an interview on 8/18/2026 at 2:25 PM the MDS Nurse stated Resident #46's MDS assessment with anticoagulants marked was a mistake on her part. During an interview on 8/19/2026 at 5:50 PM the DON (Director of Nursing) stated that the expectation for MDS Assessments was that they would be accurate, as well as reviewed and updated when indicated. Review of the policy and procedure titled, MDS 3.0 / Resident Assessment, with a last review date of 7/15/2026 read, 1. Purpose: To ensure MDS assessments are timely, accurate, supported by the clinical record, properly certified, submitted to CMS [Centers for Medicare and Medicaid], and used for care planning. 4. Assessment and Coding: Use resident interviews, observation, staff on all shifts, orders, diagnoses, medications, treatments, therapy, dietary, social services, and other reliable records. Code only information that meets the MDS definition and is supported by the record. 2) Review of Resident #75's MDS (Minimum Data Set) Assessment, a quarterly assessment dated [DATE] documented the resident was not receiving therapy services. Review of Resident #75's physician order dated 07/21/26 read, SLP [speech language pathology] to evaluate and treat as indicated for dysphagia and dysarthria. Review of Resident #75's Speech Language Pathology Evaluation and Plan of Treatment documented a start date of 07/20/26. Review of Resident #75's Speech Therapy Encounter Notes documented dates of service completed on 07/20/26, 07/24/26, and 07/30/26. During an interview on 08/19/26 at 01:24 PM, the MDS Coordinator stated Resident #75 received speech therapy services for three (3) days during the lookback period and should have been added to the 07/30/26 MDS assessment.

Based on record review and interview, the facility failed to ensure residents with newly evident or known diagnosis of serious mental disorders have a coordinated Preadmission Screening and Resident Review (PASRR) for 2 of 8 residents, Resident #10 and Resident #75, reviewed for PASRR. Findings include: 1) Review of Resident #10's admission record documented an initial date of admission of 2/6/2025. On 06/28/2025 Resident #10 was diagnosed with major depressive disorder, recurrent, moderate. Review of Resident #10's Level I Preadmission Screening and Resident Review (PASRR) under psychotic disorder was documented as a mental illness or suspected mental illness but did not document Resident #10's diagnosis of major depressive disorder, recurrent, moderate. During interview on 8/19/2026 at 12:56 PM, the Social Services Director stated she reviewed the residents' PASRR screenings. She confirmed Resident #10's Level I PASRR did not document Resident #10's diagnosis of major depressive disorder, recurrent, moderate and needed to be updated to document that diagnosis. Review of the policy and procedure titled, Preadmission Screening and Resident Review with a last review date of 7/15/2026, read 6.7 Significant change and resident review. Staff will immediately notify the charge nurse of changes that may indicate a need for resident review. The RN [Registered Nurse]/MDS [Minimum Data Set] Coordinator and PASRR Coordinator will evaluate the change and submit the Florida resident-review request promptly when the resident has a prior Level II or newly evident/possible SMI [Serious Mental Illness], ID [Intellectual Disability] or newly evident/possible SMI, ID, or related condition. 2) Review of Resident #75's admission record, documented an initial date of admission of 10/30/25. On 10/30/2025 Resident #75 was diagnosed with alcohol abuse, generalized anxiety disorder, major depressive disorder, and other psychoactive substance abuse. Review of Resident #75's Level I Preadmission Screening and Resident Review (PASRR) dated 05/27/26 did not have the diagnosed substance abuse disorder documented. Review of Resident #75's psychiatry notes dated 05/06/26 read, Nicotine use disorder: The history suggests that the patient struggled with Nicotine abuse which has resulted in negative consequences on the patient's life. Despite negative consequences, the patient has a history of continuing the use of Nicotine Alcohol use disorder: The history suggests that the patient struggled with alcohol abuse which has resulted in negative consequences on the patient's life. Despite negative consequences, the patient has a history of continuing the use of alcohol. During an interview on 08/19/26 at 01:06 PM, the Social Services Director stated that she is aware of accuracy issues with the facility's PASRRs.

Based on interview and record review, the facility failed to ensure each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and individuals identified with MD or ID were evaluated for care and services to meet their needs for 3 of 8 residents, Resident #12, Resident #63, and Resident #80, reviewed for PASARR (Preadmission Screening and Resident Review). Findings include: 1) Review of Resident #63's PASSAR (Preadmission Screening and Resident Review dated 7/09/2025 documented anxiety disorder as the only mental health concern. Review of Resident #63's medical record documented the resident was admitted on [DATE] with medical diagnoses to include brief psychotic disorder, alcohol use, unspecified with unspecified alcohol-induced disorder, generalized anxiety disorder, other recurrent depressive disorders, other bipolar disorder. Review of Resident #63's Progress Notes documented a [name of the Mental Health Provider Group] note dated 8/12/2026 that read, Chief Complaint: Psychosis, bipolar disorder, depression, anxiety, insomnia and alcohol abuse. History of Presenting Illness: This is a [AGE] years old patient with history of psychosis, bipolar disorder, depression, anxiety, insomnia and alcohol abuse. Review of Resident #63's Care Plan documented, Focus – [Resident #63's name] is at risk for substance abuse related to a history of addiction, alcohol abuse. Focus - The resident uses antidepressant medication. Focus – [Resident #63's name] is at risk for complications such as dry mouth, dizziness, constipation, etc. related to the use of psychotropic drugs r/t [related to] depression, h/o [history of bipolar] bipolar disorder. Review of Resident #63's physician order dated 7/22/2026 read, TraZODone HCl Tablet 100 mg [milligrams]: Give 2 tablet by mouth at bedtime for MDD (Major Depressive Disorder) as directed. Related to major depressive disorder, recurrent, moderate. Review of Resident #63's physician order dated 6/29/2026 read, Sertraline HCl Oral Tablet 25 mg (Sertraline HCl): Give 1 tablet by mouth one time a day related to Related to major depressive disorder, recurrent, moderate. During an interview on 8/19/2026 at 12:57 PM the Social Services Director (SSD) confirmed Resident #63's PASSAR did not document all the mental health diagnoses that were documented and made a part of the medical record at the time of the resident's admission. During an interview on 8/19/2026 at 1:55 PM the MDS Nurse confirmed Resident #63's Care Plan did not include anxiety or psychosis which were both present on admission. During an interview on 8/19/2026 at 5:50 PM the DON (Director of Nursing) stated the expectation for PASARRs was that they would be reviewed and updated if indicated. 2) Review of Resident #12's PASARR dated 05/29/2025 documented mental health concerns of substance abuse. depressive disorder, psychosis or Traumatic Brain injury (TBI) are not included, Only substance abuse is documented. Review of Resident#12's medical record dated 05/29/2026, documented diagnosis to include traumatic subdural hemorrhage with loss of consciousness (severe head blow tears blood vessels), psychosis not due to substance (mental state where a person losses touch with reality because of underlying mental health issues), major depressive disorder, alcohol abuse, psychoactive substance abuse (substance that affect how the brain works/mental process). 3) Review of Resident #80's medical record documented the resident's initial date of admission as 10/30/2025 with diagnosis to include post-traumatic stress disorder, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of Resident #80's Level I PASRR dated 10/22/25 did not have documentation of mental illness or suspected mental illness. Review of Resident #80's physician order dated 10/24/25 read, FLUoxetine HCl Capsule 10 mg: Give 1 capsule by mouth one time a day for depression. Review of Resident #80's physician order dated 04/02/26 read, Ingrezza Oral Capsule 40 mg (Valbenazine Tosylate): Give 1 capsule via NG [nasogastric]-Tube one time a day for Depression related to major depressive disorder, recurrent, moderate. Review of Resident #80's physician order dated 07/30/26 read, TraZODone HCl Oral Tablet 100 mg (Trazodone HCl): Give 1 tablet via G [gastrostomy] Tube at bedtime for MDD [major depressive disorder.] Review of Resident #80's physician order dated 04/25/26 read, Valproic Acid Oral Solution 250 mg/ml [milliliter] (Valproate Sodium): Give 10 ml via G Tube one time a day for Mood disorder. Review of Resident #80's psychiatry note dated 08/12/26 read, Brief Psychosis: History suggests that this patient suffers from psychotic symptoms that are not consistent and long lasting. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Mood Disorder: The history suggests that the patient has experienced severe mood swings causing emotional distress. As the mood swings are severe requiring monitoring and as needed intervention, the patient qualifies for that diagnosis. MDD, Recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient, and they have occurred without any underlying substance use or organic brain pathology. During an interview on 08/19/26 at 01:06 PM, the Social Services Director stated she is aware of accuracy issues with the facility's PASRRs.

Based on observation, interview, and record review, the facility failed ensure the development and/or implementation of comprehensive, person-centered care plans for 2 of 12 residents, Residents #63, and #37, reviewed for comprehensive, person-centered care plans.Findings include: 1) During an observation on 08/17/2026 12:00 PM Resident #37 was observed in the courtyard lighting a cigarette with a lighter to smoke unattended/supervised. During an observation on 8/18/2026 at 11:02 AM Resident #37 was observed smoking in the courtyard unattended. Review of Resident #37 Smoking Evaluation dated 7/24/2026 read, Does the resident currently smoke? Yes. Does the resident require a protective assistive device while smoking? No. Review of Resident # 37's care plan did not document a smoking focus. During an interview on 8/18/2026 at 2:23 PM with Minimum Data Set (MDS) Coordinator stated, It can be a failure on my part that I did not know he [Resident #37] was a smoker. During an interview on 8/19/2026 at 3:52 PM with the MDS (Minimum Data Set) Coordinator stated, [Resident #37's name] care plan needed to be corrected to add that he is a smoker. During an interview on 8/20/2026 at 9:23 AM the Director of Nursing stated, [Resident #37's name] should have a care plan for smoking. Review of the policy and procedure titled, Care Planning with a last review date of 7/15/2026 read, 1.Purpose: To ensure every resident has a current, individualized care plan that guides staff in providing safe, person-centered care and supports the resident's goals, choices, highest practicable well-being, and discharge plans. 2. Policy: The facility will develop, implement, review and revise each resident's care plan within required timeframes. The plan will be based on assessment findings, orders, diagnoses, risks, strengths, preferences, PASRR recommendations when applicable, and resident and representative input. Staff must know and follow the current plan. 2) Review of Resident #63's medical record documented the resident was admitted on [DATE] with medical diagnoses to include atherosclerotic heart disease of native coronary artery without angina pectoris; brief psychotic disorder; alcohol use, unspecified with unspecified alcohol-induced disorder; generalized anxiety disorder; other recurrent depressive disorders; other bipolar disorder. Review of Resident #63's Care Plan the care plan did not document focus areas, goals or interventions related to Resident #63's diagnoses of anxiety and psychotic disorder. Review of Resident #63's Progress Notes revealed a [name of the Mental Health Group] note dated 8/12/2026 that read, Chief Complaint: Psychosis, bipolar disorder, depression, anxiety, insomnia and alcohol abuse. History of Presenting Illness: This is a [AGE] years old patient with history of psychosis, bipolar disorder, depression, anxiety, insomnia and alcohol abuse. Review of Resident #63's physician order revealed an order dated 7/22/2026 read, TraZODone HCl Tablet 100 mg [milligrams]: Give 2 tablet by mouth at bedtime for MDD [major depressive disorder] as directed related to major depressive disorder, recurrent, moderate. Review of Resident #63's physician orders revealed an order dated 6/29/2026 that read, Sertraline HCl Oral Tablet 25 mg (Sertraline HCl): Give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, moderate. During an interview on 8/19/2026 at 1:55 PM the MDS Nurse confirmed Resident #63's Care Plan did not include anxiety or psychosis which were both present on admission. During an interview on 8/19/2026 at 5:50 PM the Director of Nursing stated the expectation for Care Plans was that they would be reviewed and updated when indicated.

Based on interview and record review the facility failed to review and revise, based on changing goals, preferences, and needs of the resident, the comprehensive care plan for 1 of 6 residents, Resident #46, reviewed for dietary/nutritional concerns.Findings include:Review of Resident #46's weight documentation dated 02/22/2026 the resident's weight was 175.2 lbs (pounds), 03/03/2026 - 171.2 lbs, 06/03/2026 - 164.6 lbs., 07/01/2026 - 160.6 lbs, and 08/01/2026 - 154.4 lbs; a 11.87% weight loss. During an interview on 8/18/2026 at 12:25 PM, Resident #46 stated lunch was, So so and commented the food was the reason he had lost weight recently. Review of Resident #46's medical record revealed he was admitted on [DATE] with medical diagnoses that included other cerebral infarction due to occlusion or stenosis of small artery (primary diagnosis); dysphagia, oropharyngeal phase; muscle weakness (generalized); other muscle spasm; type 2 diabetes mellitus (DM) with hyperglycemiaReview of Resident #46's Care Plan the care plan did not have documentation for a focus area, goals, and interventions regarding the resident's significant weight loss.Review of Resident #46's most recent MDS (Minimum Data Set) Assessment, a quarterly assessment dated [DATE] documented his BIMS (Brief Inventory of Mental Status) Score as 15 out of 15 which indicated he was cognitively intact. He received a mechanically altered diet.Review of Resident #46's Task List for the % [percentage] intake of meals for the past 30 days documented Resident #46 consumed 0-25% of the meals ten (10) times, and 25-50% of the meal nine (9). During an interview on 8/18/2026 at 2:21 PM, the MDS Nurse stated they had monthly weight loss meetings where they discussed residents with significant weight loss. During an interview on 8/19/2026 at 11:25 AM the RD (Registered Dietitian) stated Resident #46 had a 12% weight loss since February. During an interview on 8/19/2026 at approximately 1:30 PM the MDS Nurse stated that Resident #46's Care Plan should be updated or revised to include weight loss as a focus area.During an interview on 8/19/2026 at 3:16 PM Staff A, LPN stated that in the weight loss meetings, they would go over weights both weekly and any daily weights. If there was a significant change, they would put in a change of condition, notify the family and the medical doctor. The MDS Nurse attended the meetings so she could update the residents' MDS and Care Plans if needed.Review of the policy and procedure titled, Weight Monitoring, with the last review date of 7/15/2026 read, Policy: It is the policy of the facility to minimize the risk of a resident's significant weight loss and for residents to maintain acceptable parameters of nutritional status. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight or insidious weight loss may indicate nutritional problems. 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: c. Identify resident-specific interventions e. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new cause of nutrition related problems are identified. 7. Documentation: f. Observation pertinent to the resident's weight status should be recorded in the medical record as appropriate.Review of the policy and procedure titled, Care Planning, with the last review date of 7/15/2026 read, 1. Purpose: To ensure every resident has a current, individualized care plan that guides staff in providing safe, person-centered care and supports the resident's goals, choices, highest practicable well-being, and discharge plans. 2. Policy: The facility will develop, implement, review, and revise each residence care plan within required time frames. The plan will be based on assessment findings, orders, diagnoses, risks, strengths, preferences, PASRR [Preadmission Screening and Resident Review] recommendations when applicable, and resident and representative input. Staff must know and follow the current plan. 9. Review and Revision: Review progress toward each goal and determine whether it was met, partially met, unmet, or no longer appropriate. Revise the plan promptly after falls, new wounds, weight changes, infections, hospitalizations, medication changes, behavioral changes, functional decline or improvement, repeated refusals, new equipment, or other material changes.

Based on observation, interview, and record review, the facility failed to ensure necessary assistance with activities of daily living (ADLs) in a manner that enabled the resident to participate in and receive necessary care by failing to ensure staff used an appropriate translator or interpreter to communicate with a resident who had limited English proficiency for 1 of 5 residents (Resident #79) reviewed for ADL care. Findings include: Review of Resident #79's medical record documented the resident was admitted to the facility on [DATE] with diagnoses which included developmental disorder of scholastic skills, cognitive communication deficit, schizophrenia, major depressive disorder, and bipolar disorder. During an observation on 08/18/2026 at 8:52 AM Resident #79 was seated alone at a table in the dining room eating breakfast which consisted of boiled eggs, toast, and fruit. An Interview was attempted on 08/18/2026 at 8:52 AM Resident #79 did not respond to questions. During an interview on 08/18/2026 at 8:45 AM the Kitchen Manager stated, [Resident #79's name] destroyed the phone in his room. The resident tried to hurt a lab person before the resident came to this facility. The resident does not speak English, The resident does not speak Swahili, he speaks some other dialect and the CNAs [certified nursing assistants] tried to use google translate and they can't even figure out what language the resident was speaking. I do not communicate with [Resident #79's name], no one can. The resident just walks around or lays down on the floor in the hallway, where we can't get the carts past. The resident taps things and points. I don't know the resident's likes or dislikes or allergies because I cannot communicate with the resident. I just follow the diet orders on the resident's chart. It would help to have a translator or some way to communicate with the resident. We do not have a translator here. The resident has been here for quite a while. During an interview on 08/19/2026 at 8:09 AM, Staff K, CNA (Certified Nursing Assistant) stated, How we communicate with [Resident #79's name] is really just a lot of guessing at what the resident wants. The resident can say some words, like the resident can say soda and can say eat. The resident points to things. You can tell if the resident is whining, the resident is either frustrated or in pain, as you work closely with the resident, you get to know the resident. I don't know what language the resident speaks. I believe there is a phone number we can call for translations, but I am not sure how to call it directly. I was told there is a phone number we can call, but I have never personally used it. During an observation on 08/19/2026 at 8:20 AM, Resident #79 was standing in the 300 hallway speaking loudly in his primary language while multiple staff members walked past and did not address the resident. During an interview on 08/19/2026 at 8:20 AM, Staff G, LPN (Licensed Practical Nurse) stated, We just pretty much guess at what [Resident #79's name] wants. I think there is an app on the phone we can use, but I think you need to pay for it. During an interview on 08/19/2026 at 8:25 AM, the Director of Social Services stated, [Resident #79's name] speaks a dialect, I forgot what it's called. We used to have a staff member that could translate. The staff use [name of language translation app] on their phones. When I first started here, I was very focused on the resident. I contacted [Representative for Resident #79]. The Representative was more involved at first, but then [Representative for Resident #79] stopped answering the phone. [Resident #79's name] is being referred for Guardianship services. I attempted to complete a BIMS [brief interview of mental status] score and I attempted to use an interpreter for it, but it wasn't effective. [Resident #79's name] kind of moans and groans a lot instead of using words. Sometimes [Resident #79's name] seems a bit frustrated. During an interview on 08/19/2026 at 9:15 AM, the Assistant Director of Nursing (ADON) stated, We do the best we can to communicate. I think the resident speaks [name of Resident #79's primary language]. We also use phones for translation and we have a robot. The robot works well, and [Resident #79's name] is coherent and able to communicate. During an observation on 08/19/2026 at 9:15 AM, the Assistant Director of Nursing showed the robot to the surveyor and attempted to demonstrate the translator service. Each time the ADON clicked the screen, the Robot stated it was docking in home base. The ADON stated possibly the battery is dead, however, the battery indicator read 100%. The ADON made three attempts to tap the screen of the robot/tablet, and it continued re-docking itself. During an interview on 08/19/2026 at 4:01 PM Physician #1 was asked whether the language barrier and staff not using interpreter or language line to communicate to Resident #79 may have worsened frustration/mental illness and/or contributed to history of [NAME] Acts. Physician #1 stated, I know [Resident #79's name] very well. I see the resident often because the resident is complex. I do not believe [Resident #79's name]'s [NAME] Acts was related to staff being unable to communicate with Resident #79. Resident #79's family lives far away, in Chicago, I believe. Resident #79 has some difficulties from being separated from family, and [Resident #79's name] also has a very extensive psych history with schizophrenia and bipolar disorder, and difficulty regulating emotions. The staff should use the translator to communicate with the resident. During an interview on 08/19/2026 at 4:47 PM, APRN #2 (Advanced Practice Registered Nurse) stated, I believe [Resident #79's name] was hospitalized due to psychiatric issues, and family separation. [Resident #79's name] calls out for [name of Resident #79's representative] sometimes. The language barrier with the staff is difficult, but I believe [Resident #79's name] was hospitalized due to psychiatric illnesses. I have spoken to [name of Resident #79's representative]. The Representative told me that the resident speaks in their native language, and [Resident #79's name] when incoherent, the Representative can't understand him. Review of Resident #79's care plan dated 07/12/2026 read, [Resident #79's name] has a communication problem due to: Cognitive impairment, Language barrier, developmental delay. Interventions: language line [phone number for language line]. Allow ample time to respond. Ask simple yes/no questions. Call by name or light touch to get their attention. Call family as able to assist with translation. Use alternative communication tools Communication board/book Translation board/book Writing pad/pen/pencil as able and needed Gestures Signs Pictures. Review of MDS [minimum data set] dated 07/29/2026 section A read, A. What is your preferred language? Kirundi. B. Do you need or want an interpreter to communicate with a doctor or health care staff? Yes. Review of policy and procedure titled, Communications Within and External to the Facility review date 01/01/2026 read, Policy: The facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. Definitions: Reasonable access means that telephones, computers, and other communication devices are easily accessible to residents and are adapted to accommodate resident's needs and abilities, such as hearing or vision loss.

Based on interview and record review the facility failed to ensure medications were administered per the physician orders for 1 of 2 residents, Resident #76, reviewed for blood thinner medication injections. Findings include: Review of Resident #76's medical record documented the resident was admitted with diagnosis to include personal history of other venous thrombosis (formation of a stationary blood clot) and embolism (blood clot that travels through the system).During an interview on 08/19/2026 at 10:21 via telephone Family Member #1 for Resident #76 stated when the resident came back from the hospital there was an order for Lovenox 100 mg (milligrams) and they [the facility] ran out. Some of the nurses were able to give 40 mg and 60 mg injections to make up the 100 mg as ordered. Others [other nurses] just did not give it.During an interview on 08/19/2026 at 2:19 PM Physician #1 stated the Resident#76 has a history of Factor 5 [NAME] (genetic mutation that increases your risk of developing harmful blood clots). The resident came from hospital after having been treated for a blood clot with Lovenox (blood thinner) injections and starting Xarelto (blood thinner). The resident previously had been on Rivaroxoban (blood thinner). If she was not receiving blood thinner medication regularly as ordered the resident could develop more blood clots.Review of Resident #76's Medication Administration Record (MAR) for July 2026 documented a physician order for Enoxaparin Sodium Injection Prefilled Syringe 100 mg/ml (milligrams/milliliters) Inject 1 ml subcutaneously every 12 hours for blood clot prevention. Start Date 07/11/2026 D/C (discontinue) Date 07/14/2026. Documented on the MAR dated 07/13/2026 at 9:00 AM and 2100 (9:00 PM) was Code 9 = See Progress notes, dated 07/14/2026 at 9:00 AM Code 9 = See Progress Notes.Review of Resident #76's medical record did not contain documentation dated from 07/13/2026 through 7/16/2026 for Lovenox not being administered as ordered.Review of Resident #76's MAR for July 2026 through August 2026 documented a physician order for Lovenox/Enoxaparin Sodium Injection Prefilled Syringe 100 mg/ml Inject 1 ml subcutaneously every 12 hours for blood clot prevention. Start Date 07/14/2026 D/C Date 08/11/2026. Documented on the MAR dated 07/20/2026 at 2100, no documentation of the Lovenox being administered, dated 07/29/2026 at 2100 there was no documentation of the Lovenox being administered, dated 08/02/2026 at 2100 Code 9, 08/03/2026 at 9:00 AM Code 5 = Hold/See progress note, 08/05/2026 at 9:00 AM Code 5, 08/09/2026 at 2100 Code 9, 08/10/2026 at 9:00 AM and 2100 Code 9, and 08/11/2026 at 9:00 AM Code 9.Review of Resident #76's medical record, the record did not contain progress notes over the period of 08/01/2026 through 08/12/2026 related to Lovenox not being administered as ordered by the physician.Review of Resident #76's Care Plan read, [Resident #76's name] Focus: is at risk for injury or complications related to use of anticoagulant and antiplatelet medications, History of DVT [deep vein thrombosis] v. Afib [atrial fibrillation].Review of the policy and procedure titled, Timely Medication Reordering with a last review date of 07/15/2026 read, 1. Purpose: To prevent avoidable missed or late medications doses by ensuring medications are reordered, received, checked, and available before the current supply is exhausted. 2. Policy: The facility will maintain an organized refill system for routine and emergency medications. Licensed nurses will monitor medication supply, place reorders early, track unresolved requests, and promptly escalate any barrier that could interrupt treatment.

Based on record review and interview, the facility failed to permit 1 of 3 sampled residents, Resident #1, to return to the facility after specialized residential center treatment. Failure to permit the resident to return to his facility home resulted in a decrease in his psychosocial wellbeing. Findings include: Review of the current resident census revealed Resident #1 was not residing in the facility on 08/27/2020. During an interview on 08/27/2020 at approximately 8:45 AM with the Administrator and the Director of Nursing (DON), the Admission/Transfer and Discharge List was discussed. The Administrator and the DON verified Resident #1 received a physician's orders [REDACTED]. Review of Resident #1's record revealed his date of admission was 03/13/2017. His [DIAGNOSES REDACTED]. Resident #1 was transferred to hospice on 06/25/2020. Review of Resident #1's progress notes dated 06/25/2020 at 7:43 PM read, This resident was transferred to have (sic.) hospice house this afternoon. The resident had come up to this nurse this morning to complain of new onset of pain and discomfort. The resident described the pain as at his right flank with the pain radiating to his abdomen. Several contacts were made with (local hospice's name) today with the majority of the conversation between this nurse and (the hospice nurse's name) who is employed by (Hospice's name). Once the resident's condition shared with nurse (hospice nurse's name). She indicated that she would be contacting the hospice physician and will get back to the nurse. She did returned (sic.) the call and indicated that the doctor had made the decision to transfer the resident to (local hospice's name) for further evaluation. Indications were that the resident would be transferred between 3 PM and 3:30 PM. The transfer was at 4:15 PM this afternoon. All necessary paperwork were sent with the resident. This facility's ADON was made aware of the resident's condition and what action (local hospice's name) had taken. During an interview with the Hospice Case Manager for Resident #1 on 08/27/2020 at 10:28 AM, she stated Resident #1 was residing in their center. He was transferred to hospice on 06/25/2020. There was no documentation regarding a discharge or appeal process provided to the resident. She stated he wanted to go back to the facility because his friends were there. She called the facility and talked to the Director of Nursing but was told they did not have enough room for him. Review of the records provided by the Hospice Case Manager for Resident #1 revealed an entry dated 07/13/2020, He stated he wanted to return to (facility's name). Dated 07/14/2020, Called SW (Social Worker) at facility to discuss bed availability and needs in the way of COVID testing for pt (patient) return. There were no definite answers. SW faxed referral to (facility's name). Dated 07/16/2020, Hospice Liaison spoke with DON of (facility's name). She relayed to SW that pt would not be able to return there and (name) should find another placement for him. Call made to Ombudsman Office during week of 07/20/2020 by Patient Care Manager for assistance for pt. Pt should have received 30-day notice for discharge and appeal process information, pt denied receiving this. Dated 07/20/2020, SW made three calls to (facility's name). SW was unable to reach DON. Transferred to facility SW and left message, not returned. Dated 07/21/2020, SW placed call to DON at facility, message left for (name) with information for message return. No return call. Dated: 07/22/2020, SW placed call to DON at facility. Receptionist paged the DON twice but she did not answer. SW explained this was third attempt. Previous calls not returned. Receptionist stated she would email the DON. There was no return call. Dated 07/27/2020, SW placed call to facility spoke with receptionist. Requested number of regional or corporate office. She looked for but was unable to provide this information. Transferred call to facility SW. She stated she worked there a short time and did not have the information either. SW asked to speak with Administrator. She said he was not in yet and had no expected time. SW asked to leave message for him. SSD (Social Services Director) offered leaving message for DON. SW explained messages left with no return calls. Transferred to Administrator's voice mail which was full. SW spoke with pt about calling state agency hotline. He stated he wanted to return to this facility again. Dated 07/28/2020, SW and pt made complaint to state agency. He stated he wished to return to facility because that is where his friends live. During an interview with Resident #1 on 08/27/2020 at 4:00 PM, he stated he wanted to go back to this facility because his friends were there, and he did not have family. He stated he did not realize when he left, he would not be able to return to the facility. He stated he had been very unhappy without the ability to see his friends since he had no one else. Review of the facility floor plan with the DON and the Administrator revealed the location of the facility rooms. Some of the rooms were color highlighted to note the rooms that had air conditioning units. The Administrator stated they used the floor plan to show the rooms that are to be painted. The Administrator provided a list of rooms located on the 300 hall which had been repainted. The Administrator stated they determined they wanted to make all the rooms private rooms and they had a goal of 79 residents. A request was made for the written action plan for the downsizing. No documentation was provided. During an interview with the Administrator and the DON on 08/27/2020 at 9:45 AM, they confirmed they told the Hospice Case Manager for Resident #1 to find another placement for him when he was ready to leave the hospice. They stated they were new to the facility, employed about three months there. They stated at the time the Hospice SW attempted to return the resident, they rejected him, by stating they did not have room. They felt they were over their target amount. They were able to provide all of the care and services the resident needed. They confirmed there was no known change to Resident #1's care and services, compared to his stay prior to the transfer, on 06/25/2020. They confirmed the census is currently 80 and they were licensed for 120 beds. They denied any awareness the Hospice SW was trying to reach them. There was no further information provided.