Every finding on record at Gulfside Health and Rehabilitation Center

Based on observation, staff interviews, and record review, the facility failed to ensure the kitchen's low temperature dishwashing machine operated per manufacturer specifications. The machine did not reach the required wash and rinse temperatures of at least 120 F (Fahrenheit) in one of one dish machines in the facility.Findings included: During a kitchen tour on 06/08/2026 at 9:50 a.m., the Dietary Manager (Staff F) stated the kitchen uses a low temperature dishwashing machine requiring a wash cycle of at least 120 F, a rinse cycle of at least 120 F, and a chemical sanitizer reading between 50-100 ppm (parts per million). Staff F said the facility's maintenance department normally maintains the machine and denied any temperature issues within the past three months. The tour of the dishwasher room revealed Dietary Aide (Staff E) was operating the machine. Staff E had worked less than two weeks in this role and was responsible for taking the dish machine temperatures before each meal service. Both Staff F and Staff E stated the machine was functioning properly and ready for use.On 06/08/2026 at 9:55 a.m., Staff E began demonstration cycles. Staff F stated the machine sometimes needed to be primed, and pointed to a button staff use to increase water temperature. Staff E ran three empty cycles between 9:55 a.m. and 9:57 a.m. Staff F and Staff E then said the machine should be ready.On 06/08/2026 at 9:58 a.m., Staff E loaded a crate of dishes and started a full wash cycle. The wash cycle reached only 110 F, and the rinse cycle reached only 110 F. At 9:59 a.m., Staff F instructed Staff E to press the prime button again. The same crate of dishes was washed again, and both cycles again remained at 110 F. Staff F pressed a black button on the machine multiple times and stated this should allow the machine to reach proper temperatures. At 10:05 a.m., Staff F ran the dishes again. The wash and rinse temperatures continued to hold at 110 F. Because the machine did not reach temperature requirements, the sanitizer step was not demonstrated. Staff F stated she would enter a work order and believed the temperature gauge was not functioning properly.On 06/09/2026 at 8:00 a.m. and again on 06/10/2026 at 8:00 a.m., Staff F reported the dish machine was still not operating and that maintenance was waiting for a replacement thermometer gauge. Staff F said the kitchen used paper and plastic dishware until the machine was repaired.On 06/10/2026 at 2:00 p.m., the Director of Maintenance (DOM) stated the original thermometer was not working at all, which explained why the needle remained at 110 F on 06/08/2026. He said he replaced the thermometer when the ordered part arrived two days later. The DOM stated the machine does not have a priming function and was unsure what buttons dietary staff were pressing. He confirmed there was no prior work order for repair before 06/08/2026.On 06/11/2026 at 2:00 p.m., the Administrator provided the manufacturer's instruction manual (Model AFB/AFB C and AF 3D S/AFC 3D S, last revision 04/28/2021). The manual cites on page 13, the minimum operating temperature as 120 F (130 F for AFB) and recommends 130-140 F. It also instructs users to verify incoming water is at least 120 F on page 14.

Based on interview and record review, the facility failed to ensure concerns voiced during resident council meetings were documented and processed as grievances in accordance with facility policy in four of five resident council meetings reviewed (12/5/25, 1/19/26, 3/24/26, and 4/20/26).Findings included:On 6/8/26 at 1:02 p.m., a resident council meeting was held with four regular participants (Resident #15, #17, #23 and #34), all of whom had intact cognition/brief interview for mental status (BIMS) scores of 15. The residents reported ongoing, unresolved concerns, including: Lack of grievance follow through - The residents stated the facility does not act promptly and does not provide resolutions. Resident #15 reported the Nursing Home Administrator) NHA stated during a prior meeting that an explanation for the dining room closure after 4:30 p.m. would be provided later, but this follow up was never given. Quality of bedtime peanut butter and jelly sandwiches - Residents #17 and #23 stated the sandwiches are only half sandwiches, thin, with very little peanut butter and no color from the jelly. They reported raising the issue with both dietary and direct care staff. Lunch portion size - Resident #15 stated they previously received larger lunch portions. Residents were told by dietary staff during a council meeting that double portions were not permitted but were never given a reason. Call light response times - All residents reported call light response times of 30 minutes to 1 hour during midnight and weekend shifts. They stated this concern had been repeatedly documented in council minutes.Review of Resident Council Minutes from 12/15/25, 1/19/26, 3/24/26, and 4/20/26 documented multiple concerns including: Lights not answered on time (12/15/25 at 2:02 p.m.) Unsatisfactory/inedible lunch (12/15/25 at 2:02 p.m.) Night staff behavior and supervision concerns (12/15/25 at 2:02 p.m.) Lights concern repeated (1/19/26 at 2:00 p.m.) with no entries under new business review/action plan Shower and housekeeping issues (3/24/26 at 2:00 p.m.) Lack of coffee, call light issues, and dining room closure (4/20/26 at 11:00 a.m.)The review showed despite these concerns being voiced, none were logged as grievances, and no documented investigations, follow up, or resolutions were recorded in the grievance log for 12/2025, 1/2026, 3/2026, or 4/2026.On 6/9/26 at 9:43 a.m., an interview was conducted with the Activities Director (AD). The AD reported she takes notes during council meetings if Resident #17 does not. She stated grievance forms are available at meetings, and the residents can complete them, with staff assistance if needed. She noted concerns are typically dietary related and said no grievance forms had been completed over the last few months. She stated she follows up informally on prior concerns but relies on residents to initiate formal grievances.On 6/9/26 at 12:20 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated double portions are not provided as a general rule because this would require two trays, but residents may receive an extra entree or larger portions if ordered. She stated, I would never say they cannot get it. She reported she was not aware Resident #15 wanted larger portions.On 6/10/26 at 12:40 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated that when a grievance is received, she documents it, investigates, and informs the resident or family of the resolution. She said grievances are reviewed with the NHA and in morning meetings. She reported the AD provides her with council concerns, and she then writes grievances; however, she acknowledged she does not review resident council minutes. She was unaware of the concerns documented for 12/2025, 1/2026, 3/2026, and 4/2026 and confirmed they were not entered into the grievance log.Review of the facility's policy & procedure (P&P) titled, P&P Grievances dated 4/1/22, revealed it will be the policy of this facility to provide residents, resident representatives, family and visitors with methods of sharing grievances and/or concerns with the facility. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC [long term care] facility stay. The resident has a right to, and the facility will make prompt efforts to resolve grievances. Upon request, the facility will give a copy of the grievance policy to the resident. Procedure: 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances (for example, the identity of the resident for those grievances submitted anonymously); issuing written grievance decisions to the resident and coordinating with state and federal agencies as necessary in light of specific allegations. 12. Staff will assist residents/resident representatives/visitors who cannot write or who choose not to write if they request to file a formal grievance. Grievances that are verbally noted by a staff member will be recorded utilizing the facility Grievance Form (on paper or entered in the electronic grievance tracking system form).

Based on observations, interviews, and record reviews, the facility failed to maintain an environment free of pests in one unit (South) of two units observed.Findings Included: On 06/09/2026 at 11:43 a.m., a medium sized brown roach was observed crawling on the floor in room [ROOM NUMBER].On 06/09/2026 at 9:44 a.m., multiple flies were observed in room [ROOM NUMBER], including a fly landing on a resident's face. Staff were observed fanning at the insect; no additional interventions were implemented at the time.On 06/11/2026 at 2:04 p.m., Staff T, Licensed Practical Nurse (LPN) stated she had seen roaches in the facility, especially palmetto bugs.On 06/11/2026 at 2:07 p.m., Staff U (Housekeeper) reported seeing roaches sporadically in the facility.On 06/11/2026 at 2:08 p.m., Resident #10 stated, I saw a fly this morning.On 06/11/2026 at 2:11 p.m., Resident #37 stated, I have seen roaches.A request was made on 06/11/2026 at 3:17 p.m. for pest sighting logs for the previous three months. The facility provided only two sheets, both labeled Pest Sighting Log, each with South handwritten on the page, revealing the following:a. Log Sheet #1 (South): Only one entry for 2026: 5/2/26, with no description of the pest or the location.b. Log Sheet #2 (South): 3/28/26 - cockroach (not Palmetto bug) nurses' station North hallway near 107. 4/6/26 - Palmetto north wing med room. 4/7/26 - North nurses' station palmetto bugs in daytime.The facility was unable to provide pest logs consistent with a comprehensive, facility wide monitoring system.Review of the Pest Control Service Agreement dated 09/30/2025 revealed: Services are provided twice per month. Covered pests include cockroaches, flies, general ants, occasional invaders, rats, mice, and spiders. The scope includes inspection and treatment of interior common areas; inspection/treatment of up to 5 patient rooms per service; exterior treatment; and documentation of all service activity.Review of pest company service report showed the following: 11/25/25: No interior treatment was rendered. 12/31/25: Exterior treatment performed to help prevent and maintain control of pest population that tries to get inside. 1/6/26: Inspected all three logbooks finding no reports of activity .treated room [ROOM NUMBER] and all common areas. 2/3/26: Found roach activity in room [ROOM NUMBER] .treated the room. 3/2/26: No reports of activity .treated room [ROOM NUMBER] .treated south nurses' station and soiled utility room for American roaches. 3/17/26: Exterior treatment performed. 4/7/26: Roaches in downstairs staff area and reports of bed bugs found on resident in room [ROOM NUMBER] .recommended treatment .NHA said corporate approval was needed. 5/19/26: Exterior treatment performed.The review of the pest company service records contained repeated notes of pest activity, inconsistent reporting in the facility's pest-sighting logs, and instances where recommended treatment was delayed pending corporate approval.During an interview on 06/11/2026 at 2:29 p.m. with the Nursing Home Administrator (NHA), Maintenance Director (DOM), Housekeeping/Laundry Manager, and Regional Director of Housekeeping/Laundry, the DOM stated the contracted pest control vendor provides services every other week on Tuesdays, alternating between pest treatment and rodent control. The DOM stated the pest control technician visits each wing, reviews the pest sighting log, and speaks with staff regarding sightings. The NHA stated that Palmetto bug activity is seasonal due to the facility's geographic location.Review of Facility Policy - Infection Control Pest Control (Issued 04/01/2022) revealed the policy: Facility- wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, construction activities, and other regions prone to pest infestations.Procedures to include: On-going measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice, and rats.General measures to decrease pests include the elimination of cracks and crevices, proper lighting and ventilation, use of screens on windows and doors, and use of self-closing doors.Monitor for breaks in screens and doors on a routine basis.

Based on observations, interviews, and record review, the facility did not ensure infection control standards were followed related to a urinary catheter drainage bag for one resident (#71) out of two residents with an indwelling urinary catheter. Findings included:On 6/8/26 at 9:40 a.m., an observation of Resident #71 was conducted. He was laying down in bed, and the urinary catheter drainage bag and tubing was touching the floor. On 6/9/26 at 10:09 a.m., an observation of Resident #71 was conducted with Staff K, Certified Nursing Assistant (CNA) present. Resident #71 was laying down in bed, and the catheter drainage bag and tubing was touching the floor. She said her role as a CNA was to empty out the drainage bag and clip it back to the bed in the same position.A review of Resident #71's admission record revealed an admission date on 6/5/26 with diagnoses to include methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere and neuromuscular dysfunction of bladder, unspecified. A review of Resident #71's physician orders revealed the following:- Suprapubic catheter care every shift every shift, with a start date of 6/6/26.- Suprapubic Catheter: Change foley bag q [every] month every night shift starting on the 6th and ending on the 6th every month, with a start date of 7/6/26. A review of Resident #71's care plan revealed the following: - [Resident #71] has a suprapubic indwelling urinary catheter to assist with bladder elimination associated with a diagnosis of neurogenic bladder. The presence of this catheter increases his risk of developing skin impairment/infection at its insertion site as well as infection of his urine. He has a tendency to pull at his catheter. Date Initiated: 06/08/2026 Revision on: 06/08/2026. Interventions to include, Keep catheter below the level of the bladder but off of the floor as able. Date Initiated: 06/08/2026 Revision on: 06/08/2026. On 6/10/26 at 2:26 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN)/Unit Manager (UM)/Infection Preventionist (IP). She said the catheter drainage bag should be off the floor when a resident is sitting a chair and/or lying in bed. Staff I, LPN/UM/IP stated, It should be off the floor due to germs, the floor is dirty. She said the catheter drainage touching the floor may cause an infection. She said the nurse was responsible for catheter care to include flushes. She said the CNA can empty the catheter drainage bag and clean around the perineal or genital area. A review of the facility's policy titled P&P [policy and procedure] Indwelling Catheters, dated 4/1/22, revealed the following: Policy: It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Procedure: . 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. 10. Staff should ensure proper placement of the catheter tubing as to ensure that it is not kinked, pulled excessively and allows for gravity drainage.

Based on observations, interviews, and record review the facility failed to maintain a clean, safe, and homelike environment and did not ensure equipment was properly maintained and functional in multiple areas of the building. Deficient environmental conditions were identified on the smoking patio, in the north unit shower room, and in ten of the seventeen resident rooms on the north unit (Rooms 120, 121, 122, 124, 126, 129, 130, 131, 134, and 135). Findings included: On 6/8/26 at 9:33 a.m., the north unit shower room was observed with multiple areas of black bio-growth in the crevices and on the caulking around the shower floor. On 6/8/26 at 9:36 a.m., room [ROOM NUMBER] was observed with a standing fan between the residents' beds containing heavy dust and visible trapped particles. Two floor tiles were missing near the fan. On 6/8/26 at 10:26 a.m., the bathroom in room [ROOM NUMBER] contained an uncovered toilet plunger, a bedpan with a brown substance inside, a large rust stain over an uncovered shower/tub drain, and rust and white buildup on the showerhead. On 6/8/26 at 10:59 a.m., the bathroom in room [ROOM NUMBER] had a large rust stain over an uncovered shower drain and rust/white buildup on the showerhead. On 6/9/26 at 2:04 p.m., a resident on the smoking patio reported that only two of the four oscillating fans were working, causing the patio to become hot. During interviews on 6/11/26 at 2:29 p.m. with the Nursing Home Administrator (NHA), Account Manager for Housekeeping/Laundry, District Manager for Housekeeping/Laundry, and the Maintenance Director, the NHA stated they conducted weekly environmental rounds and relied on staff to report issues, which were expected to be documented in the facility's maintenance management system. The District Manager reported that two rooms receive daily cleaning, discharge rooms are deep-cleaned, and each resident room is scheduled for a deep clean once a month. He confirmed housekeeping uses a checklist for daily and deep-clean tasks and that plungers should not be stored in resident bathrooms and must be kept in bags. On 6/11/26 at 2:41 p.m., the smoking patio was re-observed with the NHA and Maintenance Director. One fan required a pull cord, and another was nonfunctional. The NHA stated he knew about the pull-cord issue but was not aware that the other fan was not working. On 6/11/26 at 2:45 p.m., the north shower room was re-observed with the District Manager, who stated housekeeping scrubbed the floor the previous week. He said housekeeping should have notified maintenance, as the shower required re-caulking. He confirmed the shower is cleaned every morning. On 6/11/26 at 2:48 p.m., a tour of the north unit resident rooms was conducted with facility administration with the following observed: room [ROOM NUMBER]: The District Manager confirmed the fan needed cleaning and stated housekeeping should have alerted the Account Manager. The Maintenance Director stated he had replacement tiles but was still cutting them. room [ROOM NUMBER]: The NHA confirmed tubs are not in resident use. He stated the tub should still be cleaned and noted a raised toilet seat should not be stored in the tub. room [ROOM NUMBER]: The NHA was unaware of the four missing tiles until observed. The District Manager reported the room was stripped and waxed the prior week. room [ROOM NUMBER]: Neither the NHA nor Maintenance Director were aware of the toilet's hissing sound or the constant flow of water. room [ROOM NUMBER]: Facility leadership confirmed large areas of rust on the uncovered shower drain and showerhead. The District Manager and Account Manager stated housekeeping should be cleaning the tubs. room [ROOM NUMBER]: The NHA stated the room needed repainting and that the facility began a painting project three to four months earlier, with 20–25% completed. He confirmed the tub should be cleaned even if not in use. room [ROOM NUMBER]: Leadership confirmed the plunger should have been stored in a bag. Rust was observed on the drain and the showerhead. The resident reported using the tub for bathing. room [ROOM NUMBER]: A tub cleaned two days prior had stains and debris resembling clay. The toilet did not flush, and leadership was unaware of the issue. room [ROOM NUMBER]: An uncovered plunger was stored in the bathroom. Brown-colored debris consistent with room [ROOM NUMBER] was observed in the tub. Facility staff suggested possible backflow. Additional environmental observations made on 6/8/26 included: room [ROOM NUMBER]: An upside-down shower chair and brown residue in the tub. room [ROOM NUMBER]: Missing floor tiles, dirty floors, and broken blinds. room [ROOM NUMBER]: Blinds not in good repair. room [ROOM NUMBER]: Missing wall paint and a dirty tub. room [ROOM NUMBER]: [NAME] residue in the tub and scratched/peeling paint on walls. During a follow-up interview on 6/11/26 at 3:25 p.m., the NHA stated he had estimates for tub refinishing but could not locate the documentation. He acknowledged he had not been documenting painting or other environmental projects and stated he was completing them to beautify the rooms. A review of the facility's Environment of Care policy, dated 1/1/26, revealed: It will be the policy of this facility to provide the residents with a safe, clean, comfortable and homelike environment. Procedure: 1. The facility will provide a safe, clean, comfortable and home-like environment, including but not limited to receiving treatment and supports for daily living safely. 2. The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observations, interviews and record review, the facility failed to providetrauma informed care to eliminate or mitigate triggers that may cause re-traumatizationfor one resident (#39) diagnosed with Post Traumatic Stress Disorder (PTSD)out of four residents sampled. Findings included:On 6/8/2026 at 10:00 a.m. Resident #39's room was approached and the door was closed. The hallway was observed with many beds placed to one side, as well as various bedside dressers and other room equipment. Housekeeping services were deep cleaning resident rooms on the hallway. There were very loud floor cleaning machines and other machines overheard through the entire hallway. After knocking several times, the door was opened and Resident #39 was observed seated on the edge of her bed facing the door and had on very large ear/head phones. She stated she was listening to music and trying to drown out the loud noises in the hallway. Resident #39 stated housekeeping services had just come to the hallway this a.m. and without any warning started to clean rooms and use very loud machines. Resident #39 stated she did not really like loud noises, especially not being given time to adjust to it. Resident #39 stated she did have Post Traumatic Stress Disorder (PTSD) and does not like continued loud noises. On 6/8/2026 at 10:00 a.m. the Director of Nursing provided the facility's Resident Matrix report for review. This report showed care criteria for all residents in the building. Review of the report did not indicate Resident #39 had PTSD.Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 4/16/2026. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Pulmonary HTN, Crohn's disease, CHF, Post Traumatic Stress Disorder (PTSD) dated 3/23/2026, Major Depression, Insomnia, Anxiety.Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which revealed resident would have been able to speak related to her medical care and services); (Mood - Nothing documented as exhibited during the timeframe of this assessment); (Behaviors - Nothing documented as exhibited during the timeframe of this assessment); (ADL - Independent with all ADL activities); (Active diagnosis - Checked No for Post Traumatic Stress Disorder (PTSD); Review of the current Physician's Order Sheet (POS) for the month of 6/2026 did not revealed any specific orders or medications related to PTSD/Trauma. Review of the nurse progress notes dated from admission 3/23/2026 through to 6/10/2026, did not reveal any documented evidence of Resident #39 having PTSD/Trauma, or any other type of documentation to support triggers for behaviors. Review of the previous psychiatric assessments dated, revealed;-2/10/2026 17:30 Psychology progress notes - Reason for visit: Psychotherapy provided to treat an active mental health condition, with therapeutic intervention necessary to reduce symptoms, improve functioning, and support progress toward treatment goals. Chief complaint included: Patient presents with symptoms of depression. She reports low mood and sadness related to her circumstances, as will as reports motivation for coping skill use to help with her symptoms. The assessment did not reveal any diagnosis of Post Traumatic Stress Disorder (PTSD), or the treatment of.-Review of the 3/1/2026 17:30 Psychology report notes (dated prior to Resident #39's admission), revealed the reason for visit was reported resident is unstable requiring psychiatric assessment. The assessment did not reveal any diagnosis of Post Traumatic Stress Disorder (PTSD), or the treatment of.-Review of the 3/9/2026 18:30 Psychiatric professional visit and care plan note (dated prior to Resident #39's admission), revealed reason for visit related to history and presentation was discussed in interdisciplinary psychotropic meeting and a collaborative plan of care was made. Following treatment team members attended the psychotropic meeting. The assessment/notes further indicated history of PTSD, depression and insomnia. Diagnosis rationale and justifications; PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the paste. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred with out any substance use or organic brain pathology. Care Plan for PTSD diagnosis: Trauma - Rape, molestation, traumatic childhood experiences. Triggers - LOUD NOISES AND UNWANTED PHYSICAL TOUCH. Care Plan of this assessment revealed to request and notify patient when physical care needs to be provided, explain what will happen and rationale. 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. -There were further psych visits to include dates: 3/12/2026 18:30, 3/30/2026 01:00, 4/9/2026 01:00, 4/20/2026 01:00, 4/29/2026 01:00, 4/30/2026 01:00, and 5/7/2026 11:16. (All these listed assessments mentioned diagnosis to include PTSD and with the same care planning measures as from the 3/9/2026 assessment, and also indicating Resident #39 has triggers of LOUD NOISES AND UNWANTED PHYSICAL TOUCH. On 6/8/2026 Review of the current care plans with a next review date 7/15/2026 revealed the following focus areas: 1. Resident #39 is at risk for a deficit in her functional abilities to complete her ADL self-care tasks such as bed mobility, eating, toileting and personal hygiene, transfers, ambulation and bathing associated with extensive cardiac comorbidities and her tendency to make complaints that when investigated, are found to be untrue regarding her care, with interventions in place as reviewed.2. Resident #39 will exhibit other behaviors. She refuses medications, she will refuse to eat and then state that no one offered her food or fluids. She wanders the hallways with no specific destination apparent. She goes in and out of other resident rooms, wears only a hospital gown and is barefoot. Will get behind the nurse's stations and will not leave and when staff members request that she leaves; she becomes verbally abusive and ripping signage off of the walls, with interventions in place as reviewed. Further review of the care plans on 6/10/2026 did not indicate any problem/focus areas related to specific Trauma/PTSD.On 6/10/2026 at 10:00 a.m. an interview was conducted with Licensed Practical Nurse (LPN) Staff A. She stated she has been working routinely on the same hall where Resident #39 resides for a while and does know Resident #39's care and service needs. Staff A stated Resident #39 is independent with her activities of daily living (ADL) care needs and usually goes out on Leave of Absence on her own most days. Staff A stated Resident #39 does speak with many of the residents throughout the facility, but also keeps to herself in her room a lot and uses her personal computer. Staff A was not aware of Resident #39 having any type of Post Traumatic Stress Disorder (PTSD), and did not believe there were any signs or triggers she and the other staff should be looking for that may cause triggers of Trauma. Staff A revealed the nursing staff are provided with reports upon resident admission, as well as shift pass down from nursing staff that will show if any residents have PTSD. Staff A did confirm Resident #39 is being routinely seen by psychiatric services but did not know why. Staff A stated she believed Resident #39 did not have any PTSD, nor has anyone said anything to her about Resident #39 having PTSD. Staff A reviewed Resident #39's medical record and confirmed through the Minimum Data Set (MDS) assessment and the current care plans, there were no indicators of Resident #39 having a diagnosis of PTSD. On 6/10/2026 at 10:45 a.m. an interview with Certified Nursing Assistant (CNA) Staff B who routinely cares for Resident #39 on her assignment, stated Resident #39 does things on her own and is her own decision maker. Staff B confirmed Resident #39 did not have PTSD as nursing staff would have let her know if she did. Staff B confirmed if a resident had PTSD or other signs of past Trauma, they are provided with information and triggers for them to look out for and to help reduce. Staff B was not aware Resident #39 was triggered through loud noises. Staff B confirmed for residents who have PTSD, they are trained on what specific behaviors/triggers to look out for and will report those behaviors/triggers to the nurse immediately. On 6/10/2026 at 10:50 a.m. an interview with Licensed Practical Nurse (LPN) Staff C, who was the facility's Assistant Director of Nursing (ADON), confirmed she knew Resident #39 well and revealed she is up and out from bed every day and sometimes leaves the facility on leave of absence, sometimes stays in her room and uses her personal electronic devices/computers, and sometimes will attend group resident activities. Staff C also confirmed Resident #39 does interact with many residents throughout the facility. Staff C confirmed she was not aware of Resident #39 having any type of past Trauma/PTSD, nor was she aware of any type of behaviors/triggers that may set off Trauma. Staff C revealed upon admission the Interdisciplinary Team (IDT) will review admission assessments, hospital discharge assessments, speak with the resident/representatives and make observations to see if the resident has any type of past Trauma/PTSD. Staff C also confirmed the IDT will come up with care planning interventions to reduce or take away anything that triggers specific Trauma/PTSD. Staff C did not believe Resident #39 had PTSD and reviewed her record to include the orders and care plans and confirmed she did not have PTSD. Staff C was not aware Resident #39 was triggered by loud noises per her interview. On 6/10/2026 at 11:00 a.m. an interview with Certified Nursing Assistant (CNA) Staff D revealed he knew Resident #39 and has had her on his assignment many times. He was not sure if Resident #39 had any type of behaviors or past trauma for him to look out for. Staff D stated if a resident has PTSD, they are trained and inserviced on what to look out for to include specific behaviors/triggers. He did not believe Resident #39 had any signs of PTSD/Trauma. On 6/10/2026 at 1:00 p.m. an interview with the Director of Nursing (DON) confirmed the facility Resident Matrix report did not identify Resident #39 as having Trauma/PTSD, nor was she aware Resident #39 had any type of past Trauma/PTSD. The DON stated after review of the 3/9/2026 psychiatric assessment/notes, it was confirmed Resident #39 did have past Trauma/PTSD and she should have been identified through IDT with care planning focus areas with interventions to decrease or stop triggers that may create behaviors for that Trauma. The DON stated there are several residents within the facility that do have diagnosis of PTSD/Trauma and they are care planned for with focus areas, goals and interventions to include specific behaviors to look out for that may cause further trauma. The DON stated all direct care staff are trained upon hire date on how to identify triggers and behaviors for residents with Trauma/PTSD, and also are trained on how to report those behaviors so they can be addressed. The DON confirmed that the facility IDT had just missed this focus area for Resident #39 upon her admission. The DON was not able to clarify how the psychiatric assessments were completed prior to her admission, but revealed she had routinely received psychiatric visits upon her admission and only within the last few weeks she has refused those services and obtained her own outside psychiatric services. The DON also confirmed after reviewing the 3/9/2026 psychiatric services assessments/notes, there was a section that revealed Resident #39 had past Trauma/PTSD and had behaviors triggered from LOUD NOISES, UNWANTED PHYSICAL TOUCH. The DON confirmed they were not aware of this and did not take measures to reduce loud noises around Resident #39. The DON also confirmed on 6/8/2026 and 6/9/2026 housekeeping services were making very loud noises and using loud cleaning machines in rooms at and near Resident #39's room and she did not believe Resident #39 was provided with any notification prior to the noises, so she could adjust to it. On 6/11/2026 at 11:00 a.m. the Nursing Home Administrator (NHA) provided the Trauma Informed Care policy and procedure with an issue date 1/1/2026 for review. The Policy stated;It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on sources of trauma may include, but are not limited to:Natural and human caused disasters,Accidents,War, Physical, sexual, mental, and/or emotional abuse (past or present),Rape,Violent crime,History of imprisonment, History of homelessness,Traumatic life events (death of a loved one, personal illness, etc.) Trauma -Informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization.The Policy Explanation and Compliance Guidelines revealed:The facility will work to facilitate the principles of trauma informed care which includea . Safety - Ensuring residents have a sense of emotional and physical safety.b . Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident. c . Peer support and mutual self help - if practicable, assist the resident in locating and arranging to attend support groups (potentially hosted by the facility) which are organized by qualified professionals.d . Collaboration - an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care.e . Empowerment, voice, and choice - Ensuring that resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others.The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Triggered specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but not limited to:a . Experiencing a lack of privacy or confinement in a crowded or small place,b . Exposure to loud noises, or bright/flashing lights,c . Certain sights, such as objects that are associated with their abuser,d . Sounds, smells, and physical touch. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in the evaluation to ensure clear and open discussion and better understanding if interventions must be modified. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Based on record review and interviews the facility failed to ensure PASRR Level I was accurate for one Resident (#9) out of eight residents sampled Findings include:Review of the admission record, dated 06/11/2026, showed Resident #9 was admitted to the facility originally on 4/29/2025 and readmitted on [DATE] with diagnoses to include; Bipolar Disorder, current episode mixed, moderate, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, recurrent, moderate, other specified anxiety disordersReview of Resident #9's Preadmission Screening and Resident Review (PASRR) Level I, dated 5/5/2025, revealed schizoaffective disorder listed as the only qualifying mental health diagnosis. On 06/11/2026 at 1:09 PM an interview was conducted with the Social Service Director and the Director of Nursing [SSD/ DON]. The SSD stated the Preadmission Screening and Resident Review [PASRR] starts with admission. When a resident is admitted they review and update the PASRR as needed. They conduct audits every 3 to 5 months to ensure accurate diagnoses of PASRR's. The SSD stated she reviewed Resident #9's PASRR when she first admitted to the facility. Since then, Resident #9 had Serious Mental Illness diagnoses added to her medical record. The SSD stated Resident #9 PASRR was not reassessed and updated to reflect the new diagnoses. Review of facility policy and procedure titled, Role of Admissions and Social Services in PASRR, issued 4/1/2022, revealed the following: Policy:The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.State Designated Authority:Individuals with a serious mental illness, intellectual disability, or a related condition have special protections under state and federal law to ensure that long-term services and supports are provided in the right setting to meet their needs. [Vendor] contracts with the Agency for Health Care Administration (AHCA) to provide Preadmission Screening and Resident Review (PASARR) Level I and Level Il services for the state of Florida.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided services in the most appropriate setting to meet their needs by following Level II Preadmission Screening and Resident Review (PASRR) recommendations for two residents (#4 and # 37) out of five residents reviewed for PASRRs.Findings included:A review of Resident #4's admission record reveal admission to the facility on 9/26/25 and readmitted on [DATE] with diagnoses including Parkinsonism, major depressive disorder, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of Resident #4's PASRR notice of the need for further evaluation, dated 12/6/22, indicated: Signs of a serious mental illness were found. Level II screening is needed. Results of screening will be sent to you when done.Review of Resident #4's clinical record did not reveal evidence the facility obtained the Level II evaluation results or follow up with the State's PASRR Level II screening entity to obtain required recommendations.Review of the Resident #4's active orders as of 6/11/26 included Depakote 250 mg (milligrams) every 12 hours for mood disorder; Trazodone 150 mg at bedtime for insomnia/depression; and Trazodone 50 mg, one-half tablet twice daily for major depressive disorder.Review of Resident #4's Psychiatry Subsequent Note, dated 6/3/26, documented: Patient is unstable with behavioral outbursts.During an interview on 6/10/26 at 10:20 a.m., the MDS Coordinator stated the resident's significant change assessments, dated 3/18/26 and 5/11/26, were completed due to declines in eating, toileting, transfers, and ambulation.Review Resident #37's admission record reveal admission to the facility on 3/13/26 with diagnoses including schizoaffective disorder, bipolar type, major depressive disorder (MDD) and generalized anxiety disorder.Review of Resident #37's PASRR Level II determination summary report, dated 8/21/25 revealed the following recommendations; should there be a significant change in his mental status, it is recommended that an additional Level II review be conducted.Review of Resident #37's active orders as of 6/11/26 included Depakote 500 mg three times daily for mood disorder, Lithium Carbonate 300 mg ER (extended release) give 1 tablet at bedtime for agitation/ aggression related to schizoaffective disorder, bipolar type, Trazodone 50 mg at bedtime for MDD, Trazodone 50 mg daily for anxiety.During an interview on 6/9/26 at 8:48 a.m. Staff O, Licensed Practical Nurse (LPN) said at times Resident #37 screams and yells, and they are adjusting his Depakote dosages.During an interview on 6/10/26 at 10:33 a.m. the Minimum Data Set (MDS) coordinator said Resident #37 can be belligerent and foul mouth.On 6/9/26 at 11:58 a.m. Resident #37 was observed sitting in the lobby yelling about money. He was confrontational, staff attempted to redirect him, and he was difficult to redirect. This behavior was observed more than once daily throughout the survey.During an interview on 6/11/26 at 1:08 p.m. with the Director of Nursing (DON) and the Social Services Director (SSD), the SSD stated on admission, and during Gradual Dose Reduction (GDR) meetings, residents' diagnoses are reviewed and the PASRR is checked and updated if indicated. The SSD reported she conducts PASRR audits and the last audit was completed 4-5 months ago. When asked about Resident #4's missing PASRR Level II recommendations, the SSD stated, we will follow up on it now. Regarding Resident #37's PASRR Level II recommendation for an additional Level II review if there are significant changes in behavior, the DON stated, 'I thought it [requesting follow-up Level II screen] was related to new diagnoses, not behaviors. that is good to know.'Review of facility policy and procedure titled, Role of Admissions and Social Services in PASRR, issued 4/1/2022, revealed the following: Policy:The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.State Designated Authority:Individuals with a serious mental illness, intellectual disability, or a related condition have special protections under state and federal law to ensure that long-term services and supports are provided in the right setting to meet their needs. [Vendor] contracts with the Agency for Health Care Administration (AHCA) to provide Preadmission Screening and Resident Review (PASARR) Level I and Level Il services for the state of Florida.

Based on observations, record reviews and interviews, the facility failed to ensure one resident (#12) received dialysis services consistent with professional standards of practice out of three residents sampled. Findings include: On 6/08 /2026 at 12:31 PM, Resident #12 was observed sitting in his room eating his lunch. He stated he went to dialysis today and he did not feel like talking. Review of an admission record showed Resident #12 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and dependence on renal dialysis.Review of a progress note, dated 5/18/2026, showed Resident #12 did not go to dialysis. Review of a progress note, dated 5/20/2026, showed Resident #12 refused to go to his scheduled dialysis appointment this morning. Resident #12 went to dialysis yesterday (Tuesday) after missing Monday's treatment due to transportation not arriving on time. Review of a progress note, dated 5/22/2026, showed Resident #12 missed dialysis this morning due to transportation. Overnight nurse set up a chair tomorrow at 10:00 AM. Review of Resident #12 care plan revealed the following;Focus: He has potential for complications related to dialysis for diagnosis of renal failure End Stage Renal Disease [ESRD] has: left chest port and AV fistula dialysis location . Days/Time: Monday, Wednesday, Friday, Chair Time: 6:30 am. Transportation Time of pickup: 5:30 am., date initiated 10/29/2024 , revised date 03/19/2025.The goal for this focus showed Resident # 27 risk for developing complications related to hemodialysis will be minimized through dated initiated 10/29/2024, revised on 10/30/2025.Interventions for this focus showed have resident ready for transportation on dialysis days. Make transportation arrangements for dialysis date initiated 10/29/2024. On 06/09 /2026 at 8:54 AM an interview was conducted with Staff V, the facility transportation driver. Staff V stated he has never taken Resident #12 to dialysis. He was only asked to take him to a cardiology appointment a day ago. Staff V stated he told the facility he did not mind coming in early to take Resident #12 to his dialysis appointments, but no one has followed up with him about it.On 06/10/2026 at 9:34 AM an interview was conducted with Staff I, License Practical Nurse, Unit Manager [LPN/UM]. Staff I stated Resident #12 goes to dialysis on Monday, Wednesday and Fridays. A month ago, he missed his dialysis appointment because of transportation issues. His transport services did not come to pick him up for his appointment. Staff V stated he made it to his appointment when she rescheduled it, but he refused to go to his appointment the next day. Staff V stated Resident #12 missed his appointment on the 18th. He went to his rescheduled appointment on the 19th. Staff V stated she did not know why he missed his appointment on the 20th, 22nd and the 25th of May. Staff V stated they could use the facility transportation, but the driver is not at the facility that early in the morning. On 06/11/2026 12:42 PM an interview was conducted with the Director of Nurses [DON]. The DON stated she was told Resident #12 missed one appointment and the appointment was rescheduled. They are working with the Dialysis center to make sure if he misses his appointment he can still be seen as long as they have an available chair time. The DON stated the process will be to notify dialysis to get Resident #12 in the same day if his transportation services don't show up. A dialysis policy was requested for this citation. The facility administration said they did not have a policy for this cite.

Based on record review and interviews the facility failed to provide the resident/resident representative with proper notice regarding Nursing Home Transfer and Discharge, Bed Hold Policy, and Ombudsmen Notification for two residents (#68 and #74) out of five sampled. Findings Included: 1) Review of Resident #68's admission record revealed an initial admission date of 4/13/26 and a readmission date of 5/16/26 with diagnoses to include: hepatic failure, bipolar disorder, chronic obstructive pulmonary disease (COPD), portal hypertension, viral hepatitis, hepatic fibrosis, and hepatomegaly with splenomegaly. Review of Resident #68's order summary report, including active orders as of 5/13/26, revealed no physician order for hospital transfer dated 5/13/26. Review of Resident #68's general note, dated 5/14/26 at 4:46 a.m. revealed hospitalized / admitted . Review of Resident #68's medical record does not reveal documentation of the bed hold policy, advance directives/ do not resuscitate (DNR), list of current medications, reason for transfer, date and time of the transfer, the location to which the resident was transferred, and notice to a representative of the Office of the State Long-Term Care Ombudsman. Review of a Resident #68's Hospital records revealed an admission date on 5/14/25 and emergency department documentation revealed progressive shortness of breath .recurrent ascites, pleural effusion, fluid overload. During an interview on 6/10/26 at 4:45 p.m., Staff N, Registered Nurse (RN), stated she cared for Resident #68 on 5/13/26 and does not recall any information regarding the resident's hospital transfer. During an interview on 6/11/26 at 9:19 a.m. the Minimum Data Set (MDS) coordinator said to complete assessments she relies on staff, the resident, and observations. The MDS Coordinator said the admission Director informed her of Resident #68's transfer to the hospital on 5/13/26. She said, there is no nursing documentation, not even an evaluation. The MDS coordinator said she did not follow the process to complete Resident # 68's discharge/ anticipated return assessment, dated 5/13/26. During an interview on 6/11/26 at 9:52 a.m. the Regulatory Compliance Coordinator (RCC) said the facility follows the RAI manual, with an emphasis on chapter 3 to complete resident assessments. During an interview on 6/11/26 at 12:41 p.m. Staff Q, Licensed Practical Nurse (LPN) said nurses are responsible to complete the following documentation when transferring a resident to the hospital: transfer form, change in condition form, progress note, and technically a bed hold form. During an interview on 6/11/26 at 10:27 a.m., the Director of Nursing (DON) stated there was no clinical documentation for Resident #68's 5/13/26 transfer to the hospital. She reported a change in condition note, progress notes, and physician orders were not completed, and there was no way to verify the time the resident went to the hospital. 2) A review of Resident #74's admission record revealed an initial admission on [DATE], re-admission on [DATE], and a transfer from the facility to an acute care hospital on 2/25/26. A review of Resident #74's progress notes revealed the following:- 2/25/26, The Change In Condition/s reported on this CIC [change in condition] Evaluation are/were: Altered mental status Unresponsiveness Seems different than usual . Nursing observations, evaluation, and recommendations are: pt [patient] observed to be lethagic [sic] unresponsive to verbal stimuli, o2 stat [oxygen saturation] 77, slow shallow breath observed, 2L [liters] of 02 [oxygen] applied via N/C [nasal cannula], vitals 119/95 HR [heart rate] 103, NP [nurse practitioner] for [primary care physician] notified, ok to send to ER! [emergency room] . -2/25/26, Resident observed to be lethargic and unresponsive to verbal stimuli. Resident transferred to ER via EMS [emergency medical services]. A review of Resident #74's assessments revealed a discharge to hospital assessment, dated 2/25/26, for an unplanned discharge/transfer to the hospital. On 6/11/26 at 12:53 p.m., an interview with the Director of Nursing (DON) was conducted. She said she could not locate the Agency for Healthcare Administration (AHCA) hospital transfer form or the bed hold policy document for Resident #74, that was required upon discharge. She said if the documentation was not in the resident's medical record, then it was not completed. A review of the facility's policy titled: P&P [policy and procedure] Transfer and Discharge, dated 1/1/26, revealed the following:Policy: It is the policy of this facility to provide appropriate transfer and discharge services, documentation that will be included in the medical record, and who is responsible for making the documentation. The facility will allow for sufficient preparation and orientation by informing the resident where he or she is going to take steps to minimize anxiety. Procedure: . Planned Discharges and Transfers to the Hospital: . 10. Upon the transfer the hospital appropriate documentation and required forms such as the Bed Hold policy, Transfer Discharge, Advance directives/DNR, listing of current medications/treatments, face sheet will be sent to the receiving hospital. Unplanned Discharges/Emergency Transfer to Hospital: . 3. Appropriate documentation and forms will be sent to the receiving facility/accompany the resident during transport and attempt to have them signed by the resident/resident representative should be made. The forms can include such items as the Bed Hold policy, Transfer Discharge Notification, listing of current medications/treatments, face sheet, and other forms that may be appropriate if activated.

Based on record review and interviews, the facility failed to follow its grievance process related to missing personal belongings for one resident (#27) of three residents sampled.Findings included: On 06/08/2026, at 3:07 PM, Resident #27 reported that he was missing a mirror, body wash, and a case of water. He stated he had reported the issue to Social Services and to staff, and that this was not the first time belongings had gone missing. He also stated he had been told the facility would reimburse him but had received no further follow up. Record review showed Resident #27 was admitted on [DATE], readmitted on [DATE], and had a brief interview for mental status (BIMS) score of 15, indicating he is cognitively intact. Review of the grievance log from June 2025 through June 2026 showed no grievance filed on his behalf.During an interview on 06/10/2026 at 12:45 PM, the Social Services Director (SSD) explained the facility's process for handling grievances and confirmed that she had spoken to Resident #27 about his missing items and that the Nursing Home Administrator (NHA) had agreed to replace them. She acknowledged that she did not file a grievance and did not follow the grievance procedure.During an interview on 06/11/ 2026 at 12:32 PM, the Director of Nursing (DON) stated she was unaware Resident #27 had missing belongings. She explained that concerns about missing items should be documented on a grievance form, investigated, and followed up with the resident or representative. She stated the grievance process should have been followed in this case.Review of the facility's Grievances policy dated April 1, 2022, showed it will be the policy of this facility to provide residents, residents representatives, family and visitors with methods of sharing grievances and/or concerns with the facility. The residents has the right to voice grievances to the facility or to other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. The residents has a right to, and the facility will make promote efforts to resolve grievances. Upon request, the facility will give a copy of the grievance policy to the resident.Procedure: 8. Facility will ensure all written grievance decision include: the date the grievance was received; a summary statement of the resident's grievance; the steps to taken to investigate the grievance; a summary of the pertinent findings or conclusion regarding the residents' concerns; a statement as to whether the grievance was confirmed or not confirmed; any corrective actions taken or to be taken by the facility as a result of the grievance; and the date the written decision was issued.

Based on observation, record review, and interviews, the facility failed to ensure a care plan was revised for one resident (#53) out of twenty residents reviewed. Findings included: On 6/9/26 at 10:10 a.m., an observation of Resident #53 was conducted with Staff K, Certified Nursing Assistant (CNA) present. A Styrofoam cup on the bedside table revealed a handwritten, harmful phrase towards a political figure. The same message was written on a white sheet of paper located on the wall behind the head of the bed. Staff K, CNA said the resident writes the same phrase on the walls sometimes. She said he's had those behaviors. On 6/9/26 at 10:17 a.m., an interview was conducted with the Social Services Director (SSD). She said Resident #53 does not come out of his room. The SSD said he was quiet and kept to himself. She said the facility had to strategically place him with a roommate who does not yell, make loud noises or is aggressive. The SSD stated the phrase he wrote on his cup and behind his bed, she did not pay much attention to as it was his right. The SSD confirmed she had observed the phrases related to a political figure. She stated, I don't like to cross that line, and tried to be careful with discussing politics. She said the resident had been at the facility for a while and has had no issues. She said the resident is not social and does not leave his room. She said other residents do not go into his room either. She confirmed Resident #53 is being followed by the psychiatric provider. A review of Resident #53's admission record revealed an admission date of 12/10/23. The admission record revealed diagnoses to include major depressive disorder, recurrent, moderate, other specified persistent mood disorders, and generalized anxiety disorder. A review of Resident #53's physician orders revealed the following: - Behavior monitoring - Antidepressants behavior code: 0. None 1. Withdrawn 2. Anorexia 3. Crying 4. Social Isolation 5. Apathy 6. Feeling of Helplessness/ Worthlessness 7. Suicidal Ideations 8. Insomnia 9.PN [progress note] -Other interventions code: 0. None 1. Activities 2. Redirection 3. Repositioning 4. Food/Fluids 5. Rest Period 6. Quiet Environment 7. Medication 8. PN intervention outcome: i=improvement S=Same W=Worsen N/A=Not Applicable. - May be seen by physiatry [sic]. - Zoloft oral tablet 50 mg [milligrams] (sertraline hcl [hydrochloride]) give 1 tablet by mouth at bedtime for depression related to major depressive disorder, recurrent, moderate. - trazodone hcl oral tablet (trazodone hcl) give 75 mg by mouth in the afternoon for depression.- trazodone hcl oral tablet 100 mg (trazodone hcl) give 1 tablet by mouth two times a day for depression.A review of Resident #53's quarterly Minimum Data Set (MDS) assessment, dated 5/19/26, under section E - behavior, revealed no behaviors or behavioral symptoms were indicated. Further review of the quarterly MDS assessment, under section C - cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A review of Resident #53's care plan revealed the following:- [Resident #53] has potential for a mood problem as evidenced by phq9 [Patient Health Questionnaire-9] scores. [Resident #53] strength's include: able to express himself well and enjoys conversation Date Initiated: 12/26/2023 Revision on: 11/04/2025, with interventions to include, Behavioral health consult as needed (psychiatrist, psychologist) Date Initiated: 12/26/2023. - [Resident #53] has potential for Psychosocial Well-being problem r/t [related to] choosing to spend most of time in room Date Initiated: 12/26/2023 Revision on: 06/20/2024. - [Resident #53] is taking Antidepressant use with the potential for side effects. Date Initiated: 08/30/2024 Revision on: 12/07/2025., with interventions to include, Observe for changes in mood/behavior. Record/report changes to MD [medical doctor]. Date Initiated: 08/30/2024, with interventions to include, Psych [psychiatry] consult as needed. Date Initiated: 08/30/2024.- [Resident #53] is receiving psychotropic antidepressant medication as ordered to help alleviate symptoms associated with MDD [major depressive disorder] and Mood Disorder.(refer to MD Orders/EMAR [electronic medication administration record]). His continued use and dosage of this medication will continue to be routinely evaluated, and any adjustments made as is indicated and as per facility policy. Date Initiated: 01/03/2024 Revision on: 05/25/2026., with interventions to include, Monitor/document/report any s/s of adverse side effects associated with use of antidepressant medication which may include a change in usual behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, change in continence, no voiding/anuria; constipation/fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, n/v [nausea/vomiting], dry mouth and/or dry eyes. Date Initiated: 05/25/2026. A review of Resident #53's psychiatric progress note, dated 5/27/26, under Review of Systems and Symptoms Monitoring, revealed the following, We are monitoring the following symptoms and behaviors. Safety: . Thoughts of harming others. Further review of the progress note revealed no documentation related to behaviors observed on 6/9/26. On 6/11/26 at 9:30 a.m., an interview was conducted with Staff J, Minimum Data Set (MDS) Coordinator. She said she relied on staff and resident interviews; and she watched staff during care to complete the resident's MDS assessment. She said she also looked at CNA and nursing documentation. Staff J, MDS Coordinator confirmed she read psychiatry notes. She said if a resident started having behaviors, the Social Services Director (SSD) would initiate a behavior care plan. Staff J, MDS Coordinator said she would update the care plan if she knew about a resident having behavior. She said Resident #53's mood changes, she said he was sometimes pleasant then the next day it changed. She said his mood had improved. Staff J, MDS Coordinator confirmed when she has observed him, he had been in his room. She said if he was having behaviors, there would be a specific care plan. She said she had not been in his room recently and was not aware of him writing harmful messages/phrases about a political figure. Staff J, MDS Coordinator said the staff should have informed her. She confirmed the resident should have a behavior care plan and was going to complete one. On 6/11/26 at 1:28 p.m., a phone interview was conducted with Staff M, Nurse Practitioner (NP). She stated Resident #53 would, Scream out of nowhere about politics because he saw something in the news. Staff M, NP said she was not aware of the resident writing a harmful phrase about a political figure, however she had observed a message using profanity towards the same individual. She confirmed writing messages, such as harmful language about a political figure, would be considered a behavior and confirmed he gets upset/angry about politics. A review of the facility's policy titled P&P [Policy and Procedure] Comprehensive Assessments and Care Plans, dated 1/1/26, revealed the following: Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services]. The assessment will include at [NAME] the following: . (vi) Mood and behavior patterns.

Based on observations, interviews, and record reviews, the facility failed to ensure medications were properly labeled, dated, and stored according to manufacturer guidelines and professional standards of practice in one medication cart (2 North) of three medication carts observed.Findings Included:During an interview and observation of the 2 North medication cart on 6/8/26 at 9:45 a.m. with Staff A, Licensed Practical Nurse (LPN) the following improperly labeled and undated medications were stored:Resident #17: Albuterol AER HFA inhaler found undated, with no open date or expiration date visible.Resident #7: Fluticasone/Salmeterol inhaler open and undated, with no open date or expiration date recorded.Resident #34: Novolog FlexPen found open but not dated, leaving the beyond-use date unable to be determined.During the observation in reference to the dating of the open multiuse medications, Staff A. LPN said medications should be labeled with the open and expiration dates and when first used sometimes staff do not take time to add the dates. During an interview on 6/11/26 at 3:44 p.m. Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON) said during orientation to the medication carts nurses are provided with resources including information about dating opened medications. She said she rounds weekly on medication carts to check in use insulin and inhaled medications are dated.During an interview on 6/10/26 at 2:37 p.m. the Director of Nursing (DON) in reference to dating multi use medications (insulin, inhalers, etc.) said the facility has resources for the nurses to determine the expirations dates.Review of facility policy and procedure titled Medication/Biological Storage issued, 4/1/2022Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner.Procedure:Medications, drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary.The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.Drug containers that have missing, incomplete improper or incorrect labels should be returned to the pharmacy for proper labeling before storing.The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications.Antiseptics, disinfectants and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view.Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents .

Based on observations, interviews, and medical record review, the facility failedto provide one resident (#39) with meals free from ingredients the resident wasallergic to during one of six meals observed. Findings included:On 6/10/2026 at 12:00 p.m. Resident #39 received her lunch meal tray while in her room. She received her lunch meal in a plastic (Styrofoam) container. Resident #39 lifted the lid and the contents included a regular textured alternate meal with chicken, rice, sweet peas and a small dinner roll. Resident #39 stated she did not order the alternate meal and she believed it is expected the kitchen will serve the primary meal unless requested otherwise. Resident #39 stated, It seems the kitchen just cannot get it right with my food, and I did not even get a tray with food at lunch yesterday (6/9/2026). Resident #39 stated she would have eaten the meatloaf, peas and carrots and mashed potatoes that was the primary meal for lunch. Review of Resident #39's meal ticket showed her receiving chicken, rice, peas, roll, which was the alternate meal for lunch service. Resident #39 felt the kitchen was getting things wrong with her meal almost every day to include not getting a meal, receiving items that she is allergic to, and not receiving any condiments for various items. Resident #39 was observed speaking to Licensed Practical Nurse (LPN) Staff A at 12:15 p.m. and told her that she did not want what was served to her and that the kitchen staff will not answer the phone so she can choose the primary meal, in which she should have received in the first place. As of 12:39 p.m. Resident #39 still has not been provided with her primary lunch meal of choice. At 1:53 p.m. it was observed Resident #39 was provided with another meal tray and it included regular texture Meatloaf slices, mashed potatoes, peas and carrots and a dinner roll. Resident #39 completed her meal and consumed 100% of the meatloaf and about 75% of the other food items. Resident #39 stated she did not understand why she was given an alternate meal, and why it took so long to get her meal of choice, which was the primary meal option. On 6/11/2026 at 10:40 a.m. the Regional Nurse Consultant provided for review the meal tickets for Resident #39 from the 6/10/2026 lunch meal service. The tickets revealed;First meal served which was the alternate meal; a. Regular diet, b. no eggs specified, c. Double portions, d. Thyme Chicken Breast, e. Buttered rice, f. Roasted Zucchini, g. Poppy seed diner roll. The meal ticket also revealed Allergies: Egg allergy. The meal ticket indicated this meal was served to the resident. Second meal served which was the then the primary meal (but noted as alternate); Meal choice - Meat loaf. There was no other information on this ticket to include allergies, etc. Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 4/16/2026.Review of the current Minimum Data Set (MDS) admission assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which revealed resident would have been able to speak related to her medical care and services); (Nutrition - Not on therapeutic diet, not on mechanically altered diet).Review of the current 6/2026 month Physician's Order Sheet revealed orders to include but not limited to:-Epi pen 2 pack injection solution auto injector 1 unit IV x 4 hrs PRN for allergic reaction (order date 4/27/2026).-Check all resident's trays before Lunch and Dinner before delivery to resident - every shift for food delivery make sure food and ticket are the same and document. (order date 4/4/2026).-Diet order - NAS diet, regular texture, thin liquid.A review of Resident #39's care plans with a next review date 7/15/2026, revealed the following focus areas:Focus: Is at risk for complications associated with the following allergies: 1. Latex, 2. Eggs, 3. Vancomycin. Interventions to include: Administer medications as ordered, Check any food allergies when offering meals or snacks to Resident #39, Check for allergies whenever a new medication is ordered, Check MEAL TICKET AGAINST WHAT IS ON RESIDENT #39's MEAL TRAY AT EVREY MEAL. If resident requests eggs or egg products, fill out a dietary slip, write exactly what she is requesting and have her initial the meal ticket and give it to dietary staff, Ensure that prior to delivering scheduled meal tray to resident that the meal ticket matches what is on her meal tray. If it does not match, send it back to the kitchen so a correct meal tray can be delivered, Ensure that when preparing meal trays for resident, that the meal ticket matches what is on her meal tray prior to sending tray to her nursing unit for delivery, CHECK MEAL TICKET AGAINST WHAT IS ON RESIDENT'S MEAL TRAY AT EVERY MEAL. On 6/11/2026 at 9:30 a.m. the Dietary Manager was interviewed. The Dietary Manager revealed upon admission the dietary staff will meet with the resident(s) as soon as possible and go over dietary needs, as well as dietary choices. The Dietary Manager explained they go over food allergies during that timeframe as well. The Dietary Manager explained once the resident has been assessed for dietary needs/choices, that information is documented into their electronic record system and each day the meal tickets for all three meals are printed out and identifies food allergies, food likes and dislikes. The Dietary Manager explained the meal tickets are printed out and given to either dietary aide and or herself and the tickets are brought to the food service stations, and both the aide and the cook will review the ticket prior to plating. The Dietary Manager stated she as a manager evaluates and visually audits the meal service to ensure the meal tickets are followed. The Dietary Manager stated at that point the Certified Nursing Assistants (CNAs) and floor nurses, as well as the nurse supervisors will review the meal tickets for accuracy prior to the CNAs serving the meal tray to the residents. The Dietary Manager stated she has only been the manager at the facility for a couple of months and since her employ, she has not identified, nor heard of any residents being served food items that they were allergic to. The Dietary Manager stated on 6/10/2026 during the lunch meal service, Resident #39 was automatically served the alternate meal due to the planned meal having eggs, which the resident was allergic to, mixed into the meatloaf. The Dietary Manager confirmed she, nor any other staff had mentioned to Resident #39 prior to meal service the primary meal had egg product mixed in. The Dietary Manager confirmed Resident #39 should have been made aware, rather than just providing an alternate meal.The Dietary Manager provided the lunch meal service menu with recipe and ingredients for the 6/10/2026 lunch meal. The recipe revealed; Meatloaf, Homestyle with Ketchup Glaze - Corporate Recipe number 7277. Ingredients included; Ground beef, Bread crumbs, 2% milk, Salt, Various spices, EGG, LIQUID, WHOLE, PASTEURIZED, WITH CITRIC ACID, Onion, Bell Peppers, Ketchup. The procedure section revealed to combine all ingredients except ketchup, until mix is blended. An interview with Resident #39 on 6/11/2026 at 10:00 a.m. revealed she ate all the meatloaf that was on her tray the day before on 6/10/2026. She stated she was not aware the meatloaf was made with eggs and if she knew she would not have eaten the meatloaf. Resident #39 stated nobody told her on 6/10/2026 she received an alternate meal initially due to meatloaf having eggs in it, nor was she given any type of indication from staff when she was provided with the the primary meal, the meatloaf did have egg product in it. On 6/11/2026 at 10:20 a.m. a follow up interview with the Dietary Manager confirmed they accidentally let the meal tray go to the resident with meatloaf. The Dietary Manager stated on 6/10/2026 the kitchen caught on the meal ticket the resident was allergic to eggs and therefore, that was the reason they provided her with the alternate meal. The Dietary Manager stated they did not speak to the resident about it, they just provided the alternate meal to her. The Dietary Manager again confirmed they accidentally provided the meatloaf to her later in the meal service and did not speak to Resident #39 to indicate the meatloaf had egg product in it. On 6/11/2026 at 11:00 a.m. an interview with the Director of Nursing (DON), and the Nursing Home Administrator (NHA) was conducted. The NHA and DON could not explain why Resident #39 received a lunch meal tray with the alternate meal rather than the primary meal on 6/10/2026. The DON and NHA both found out Resident #39 was served a lunch tray with meatloaf slices that were made with egg product and stated this was unacceptable, but could not say how and why this happened. An interview with the NHA and DON both stated they did not have a specific food allergy policy and procedure, and it would be the expectation to follow the physician's order, as well as follow the care plan.

Based on observations, record reviews, and interviews, the facility failed to coordinate and ensure follow up dental services for one resident (#27) out of eight residents sampled.Findings included: Review of the admission record dated 06/11/2026 showed Resident #27 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, and muscle wasting and atrophy. A review of the Quarterly minimum data set (MDS) dated [DATE] showed a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact.Review of the active order summary dated 06/11/2026 showed an appointment for Dental (oral surgery) scheduled for April 30th at 2:00 PM, entered on 04/22/2026. Review of a Health Status progress note dated 12/22/2025 documented that the resident underwent a partial tooth extraction, reported increased pain, and that follow up monitoring would continue for potential complications. Review of the electronic medical record showed no documentation that a follow up dental appointment was ever scheduled for Resident #27.On 06/09/2026 at 2:18 PM, an interview with Resident #27's Health Care Surrogate/ Power of Attorney (POA) revealed concerns regarding the family member's dental appointment. She stated he was supposed to have a tooth extracted and that she was never informed whether the appointment occurred. She stated Resident #27 pays monthly for the dental services offered through the facility.On 06/09/2026, Staff V, the facility's transportation driver, reported he took Resident #27 to a dental appointment a few months earlier, but the appointment had been scheduled for the wrong day. After the appointment was rescheduled, he attempted to transport the resident again but encountered a language barrier at the dental office and discovered he was at the wrong location within the building, resulting in the resident missing the appointment. Staff V stated he did not take the resident back after that and did not know whether the resident was ever seen by a dentist.On 06/10/2026 at 4:05 PM, the Social Services Director (SSD) stated Resident #27 had a dental appointment a couple of months earlier, but something happened and the appointment needed to be rescheduled and that the unit managers are responsible for scheduling appointments. On 06/10/2026 at 2:25 PM, Staff I, Licensed Practical Nurse (LPN)/Unit Manager, stated since February, the unit managers have been responsible for appointment scheduling. She confirmed Resident #27 missed the April dental appointment and acknowledged she did not schedule a follow up appointment. She stated the resident had insurance complications and still needed to be seen by an oral surgeon. She further stated she had not attempted to schedule another appointment nor collaborated with Social Services to coordinate dental care.On 06/11/2026 at 12:32 PM, the Director of Nursing stated the resident's dental appointment had to be rescheduled and that the office later informed the facility they could not accept the resident's insurance. The DON stated her expectation was that the unit manager should have continued seeking a dental provider who accepted the resident's coverage.Review of the facility policy titled, Dental Services/Oral Care, dated 4/1/2022 showed it will be the policy of this facility that dental services and oral care are available to meet the resident's oral health services in accordance with the resident's assessment, plan of care or emergency needs. Procedure: 1. Oral health services are available to meet the resident's needs and per the residents wishes. Resident dental/oral status should attempt to be established upon admission and periodically through residency as is needed.2. Dental services (routine or emergency) are provided to our residents through: A contract agreement with a local dentist; or. Referral to the resident's personal dentist; or Referral to community dentist; or Referral to other health care organizations that provide Dental Services. 4. Community dentist available to provide dental services to our residents and assistance can be provided in identifying a community dentist by Social Services. 8. Social Services personnel/designee will be responsible for assisting the residents/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview, and record review, the facility failed to ensure a scheduled meal was provided for one resident (#39) out of forty-one observed, during one of four days observed. Findings included: On 6/9/2026 at 11:45 a.m., Resident #39 was interviewed in her room prior to lunch service. She reported she had been eating meals in her room for several weeks due to her preference to avoid larger groups. She stated she previously ate in the main dining room but had not done so for nearly a month. At 12:04 p.m., meal carts were present in the hallway, however, the resident was not provided a lunch tray.On 6/9/2026 at 1:30 p.m., Resident #39 was observed sitting on the edge of her bed with a box of food from an outside restaurant, which she said had been given to her by another resident. She stated she had not received a lunch meal from the facility and explained she had asked an aide and a nurse twice, but no meal was ever brought to her. She confirmed she would have eaten the facility's lunch if it had been provided.On 6/9/2026 at 1:35 p.m., Certified Nursing Assistant (CNA), Staff D and Licensed Practical Nurse (LPN) Staff A, both confirmed the resident did not receive a lunch meal. Staff D later stated he had heard the resident's tray had been sent to the main dining room and left on the cart there, though he was unsure why, as the resident had been eating in her room for a while now.On 6/10/2026 at 11:15 a.m., the Dietary Manager confirmed the resident did not receive her lunch tray the previous day. She stated she believed the tray was sent to the wrong location. She had no documentation to show where the tray went or evidence that it left the kitchen at all. She acknowledged it was a mix up and that no staff member followed up to ensure the resident received an alternate meal.Record review showed the resident was admitted on [DATE] and readmitted on [DATE]. She was her own decision maker. Her diagnoses included Post Traumatic Stress Disorder (PTSD), Major Depression, Insomnia, and Anxiety. The admission minimum data set (MDS) dated [DATE] reflected a brief interview for mental status (BIMS) score of 15, indicating she was capable of communicating her needs. Resident #39 was not on a therapeutic or mechanically altered diet. The June 2026 Physician's Orders indicated a NAS (no added salt) diet with regular texture and thin liquids.On 6/11/2026 at 1:00 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the resident did not receive lunch on 6/9/2026. The Administrator believed the tray may have been delivered to the main dining room but could not verify this. He stated that even if it had been, staff should have noticed it remained untouched and ensured it was delivered to the resident's room. He acknowledged the failure to follow up and confirmed the resident received no alternate nourishment. The NHA stated the facility did not have a specific policy addressing meal tray delivery and believed the topic fell under resident rights.

Based on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Forty-seven medication administration opportunities were observed, and three errors were identified for two residents (#23 and #47 ) out of four residents observed. These errors constituted a 6.38% medication error rate.Findings included:On 6/9/26 at 9:00 a.m. observed Staff N, Registered Nurse (RN) preparing and administering medications to Resident #23 she said the resident's blood pressure was (BP) 130/72 and blood sugar was 293 mg/dL. Staff N, RN administered the following medications:-Cetirizine HCl (hydrochloride) 10 mg (milligrams) tablet-Cyanocobalamin 1000 mcg (micrograms) tablet-Duloxetine HCl 60 mg Delayed Release- Folic Acid 1 mg tablet-Gabapentin 300 mg capsule-Risperdal 1 mg tablet- Sertraline HCl 50 mg tablet- Xarelto 20 mg Tablet- Advair Diskus Inhalation Aerosol Powder 250-50 MCG/ACT 1 inhalation - Docusate Sodium 100 mg- Lantus SoloStar 100 units/ml (milliliter) pen-injector Inject 20 units- Magnesium Oxide 400 mg tablet- Metoprolol Tartrate 50 mg 1 tablet- Midodrine HCl 10 mg tabletReview of Resident #23's order summary report, dated 6/10/26, revealed the following orders:-Midodrine 10 mg 1 tablet two times daily for orthostatic hypotension hold for systolic blood pressure (SPB) greater than 110.-Metoprolol Tartrate 50 mg 1.5 tablet two times daily.During an interview directly after Staff N, RN administered medications to Resident #23, in reference to not administering Metoprolol 50 mg 1.5 tablets she said, they must have just changed that. During an interview on 6/10/26 at 12:24 p.m. Staff N, RN about administering Midodrine to Resident #23 when the blood pressure was out of parameters she said, that's right thank you.On 6/9/26 at 8:37 a.m. observed Staff O, Licensed Practical Nurse (LPN) preparing and administering medications to Resident #47. Staff O, administered the following medications:-multivitamin with minerals 1 tablet-Glatopa 20 mg/ml Solution prefilled syringe subcutaneously.-Prozac Oral Capsule 10 mg-Prozac Oral Capsule 20 mg-Cranberry oral capsule 2 capsules-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg five capsules-Lyrica Oral Capsule 50 mg- Rifaximin Oral tablet 550 mg-Trazodone HCl tablet 50 mg-Baclofen 5 mg tablet- Metoclopramide 10 mg- Simethicone 80 mgReview of Resident #47's order summary report, active orders as of 6/10/26 revealed an order dated 4/23/23, multivitamin adult oral, give 1 tablet by mouth in the morning for supplement,During an interview on 6/10/26 at 12:16 p.m. in reference to administering multivitamin with minerals Staff O, LPN said I have to notify the doctor I gave that.During an interview on 6/10/26 at 2:37 p.m. the Director of Nursing (DON) about the medication errors she said she expect the nurses to follow medication orders.Review of a facility policy titled Medication Administration, issued 4/1/2022 revealed the following: Policy:It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident.Procedure:2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions.3. Medications should be administered in a timely manner and in accordance with the physician's orders .8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified.

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided in a manner that maintained dignity and privacy for one resident (#2) out of 20 reviewed.Findings included: On 6/9/26 at 9:50 a.m., Resident #2 was observed standing in the doorway of his room with his pants down and his buttocks exposed to the hallway while a Certified Nursing Assistant (CNA) was providing ADL care. The resident's door was fully open, allowing his exposed condition to be visible from the hallway.During an interview on 6/9/26 at 9:59 a.m., Staff L (CNA) stated she left the door open because Resident #2 was a fall risk and she did not want him to fall during hygiene care following a bowel movement and urination.Record review showed Resident #2 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included disorder of autonomic nervous system (unspecified), need for assistance with personal care, generalized muscle weakness, history of transient ischemic attack (TIA), cerebral infarction without residual deficits, right eye blindness, and history of falls. A brief interview for mental status (BIMS) score assessment dated [DATE] showed a score of 13, indicating intact cognition.Review of Resident #2's care plan revealed: No interventions indicating that the door should remain open during ADL care for fall risk precautions. ADL and incontinence care plans directed staff to provide privacy during care, encourage toileting, utilize incontinence products to maintain dignity, and assist with toileting at scheduled intervals.On 6/10/26 at 2:24 p.m., Staff I, Licensed Practical Nurse /Unit Manager (LPN/UM) stated the staff are expected to close the door and privacy curtain when providing toileting or changing assistance. Staff I confirmed that leaving the door open during ADL care is not an intervention for fall risk management and that residents should not be left exposed.A review of the facility's policy and procedure (P&P) titled, P&P ADL Care and Assistance, dated 4/1/22, revealed the following: Policy: It will be the policy of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practical level of function for the resident. Procedure: .3. Staff should be mindful to provide ADL care with dignity, privacy and respect to the resident, unless otherwise indicated by the resident.

Based on record review and interviews, the facility failed to ensure side effect monitoring was implemented based on pharmacy recommendations for psychotropic medications for one resident (#2) out of five residents sampled. Findings included: A review of Resident #2's admission record revealed an initial admission on [DATE] and a re-admission on [DATE] with diagnoses to include major depressive disorder, recurrent, moderate, bipolar disorder, unspecified, generalized anxiety disorder, and mood disorder due to known physiological condition with mixed features.A review of Resident #2's physician orders revealed the following: - trazodone hcl [hydrochloride] oral tablet 50 mg [milligrams] (trazodone hcl) give 0.5 tablet by mouth two times a day for mdd [major depressive disorder], with a start date of 1/31/26. - oxcarbazepine oral tablet 300 mg (oxcarbazepine) give 1 tablet by mouth two times a day for mdd, with a start date of 1/31/26. - depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex sodium) give 2 capsule by mouth two times a day for mood disorder, with a start date of 5/12/26. Further review of physician orders showed no side effect monitoring. A review of Resident #2's care plan revealed the following:- [Resident #2] is at risk for alteration in mood and/or psychosocial decline related to diagnoses of: bipolar disorder, general anxiety disorder, moderate recurrent major depressive disorder and other unspecified persistent mood disorder. [Resident #2] is receiving an antidepressant for depression and anticonvulsant for mood stabilization. Date Initiated: 12/17/2024. Revision on: 11/04/2025, with interventions to include, Monitor/document side effects and effectiveness Date Initiated: 10/08/2025. A review of medication administration record (MAR) and treatment administration record (TAR) showed no side effect monitoring was documented in 5/2026 and 6/2026. A review of the facility's monthly regimen review, conducted by the consultant pharmacist, revealed recommendations were made in 5/2026. A review of the pharmacist's report to nursing, dated 5/26/26, revealed the following recommendations, Please add side effective observations . Please note that any medication with known psychotropic effects, including opioids, antihistamines, seizure medications, muscle relaxants or other neuroleptics must be tracked for adverse effects even if not being used a psychotropic medication. On 6/10/26 at 4:17 p.m., an interview was conducted with the [NAME] President (VP) of Clinical Operations/Registered Nurse (RN). He confirmed pharmacy recommendations were not implemented for Resident #2. The VP of Clinical Operations/RN said side effect monitoring should have been completed as it was the facility's policy. He confirmed there was no documentation the pharmacy recommendations were addressed by the nursing staff or the Director of Nursing (DON). A review of the facility's policy titled P&P [Policy and Procedure] Pharmacist Recommendations, dated 1/1/26, revealed the following: Policy: It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines. Procedure: . 2. The pharmacist must report any irregularities to the attending physician or Licensed Independent Practitioner (LIP) and the facility's medical director and director of nursing, and these reports must be acted upon as soon asreasonably [sic] able, but prior to the following month's MRR. (iii) The attending physician/LIP must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician/LIP should document his or her rationale in the resident's medical record.

Based on observations and interviews, the facility failed to provide prior notification to residents before temporarily displacing them from their rooms for deep cleaning, affecting two residents (#27 and #39) out of eight reviewed. Findings included: 1. On 06/08/2026 at 3:07 p.m., Resident #27 was observed lying in his bed. He stated he was very upset because he had been moved out of his room without any advance notice. He reported he was relocated for 21 hours due to floor waxing. According to the resident, staff came into his room, moved him and his belongings into the hallway, and placed him in another room that had no television. He stated staff did not know he had been moved, making it difficult to receive assistance. He further stated that several of his personal items were stolen after being left unattended in the hallway. Review of the admission record showed the resident was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including unspecified convulsions; hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side; and muscle wasting and atrophy. Resident #27's Quarterly Minimum Data Set (MDS) dated [DATE] showed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. On 06/10/2026 at 2:25 p.m., Staff I, License Practical Nurse Unit Manager (LPN/UM) stated under the previous cleaning company, signs were posted in advance to notify residents of deep cleaning. She stated the new company did not notify residents or staff, and when she arrived that morning, residents' belongings were everywhere and the situation was not right. On 06/10/2026 at 4:05 p.m., the Social Services Director (SSD) confirmed the resident was upset about being moved overnight and returned to his room the following morning. On 06/10/2026 at 4:22 p.m., the Nursing Home Administrator (NHA) stated residents are normally given written advance notice before deep cleaning or waxing. For residents unable to understand the notice, the responsible party would be contacted. He stated residents should have been notified before their rooms were stripped and waxed. He explained that the situation was a special project rather than a routine cleaning. He reported he eventually told the company to return another day due to the disruption and the presence of surveyors. On 06/11/2026 at 12:32 p.m., the Director of Nursing (DON) stated she was informed that residents had to be moved because floors were being deep cleaned. She said typically residents are notified one day in advance, and a sign is posted outside their door, but this did not occur. She stated the expectation is that residents are notified before any temporary displacement from their rooms. 2. On 06/08/2026 at 10:00 a.m., the hallway near Resident #39's room was observed with multiple beds, dressers, and other equipment pushed to one side while housekeeping deep cleaned many rooms. Loud machinery could be heard throughout the hallway. Resident #39 allowed an interview. She was seated on her bed using her personal computer and wearing large headphones to block the noise. She stated housekeeping began removing beds and cleaning rooms without giving any advance notice to residents. At approximately 10:20 a.m., during the interview, a housekeeping employee opened her door without knocking or announcing and stated, we will be cleaning your room today. Resident #39 responded, oh ok, nobody gave me any notice. The staff member closed the door without responding. Resident #39 stated she would have liked advance notice so she could gather her belongings and decide where to go during cleaning. She stated she might have taken a Leave of Absence to the local library because of the noise. She confirmed she received no prior notice.On 06/08/2026 at 10:40 a.m., Staff A (LPN) stated housekeeping had arrived that morning and began deep cleaning multiple rooms. She was unsure if residents were notified and stated residents should receive more than same day notice. Record review showed the resident was admitted on [DATE] and readmitted on [DATE], with diagnoses including Crohn's disease, PTSD, major depression, insomnia, and anxiety. Her 03/31/2026 MDS admission assessment showed a BIMS score of 15, indicating intact cognition. On 06/11/2026 at 3:00 p.m., the NHA stated the facility had no specific policy on notifying residents before room displacement for deep cleaning. He confirmed residents should receive more than a day's notice due to the temporary relocation involved and stated he was aware deep cleaning was occurring but was not aware residents had not been notified.