Every finding on record at Harborview Health Center West Altamonte

Based on observation, interview, and record review, the facility failed to honor the food preferences for 1 of 4 residents reviewed for choices, out of a total sample of 36 residents, (#23). Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, type 2 diabetes mellitus with hyperglycemia, anxiety disorder and bipolar disorder. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/17/26 revealed resident #23 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. She did not exhibit any behavioral symptoms and did not reject care that was necessary to achieve her goals for health and well-being. On 8/03/26 at 11:14 AM, resident #23 stated she had expressed to staff that she wanted oatmeal for breakfast but had not received any for the last two weeks. She explained she was told they did not have any. Resident #23 stated she got eggs but did not like eggs and did not eat them. On 8/04/26 at 8:58 AM, Certified Nursing Assistant (CNA) A was observed as she delivered the breakfast tray to resident #23's room. The breakfast meal included scrambled eggs and a bowl of cereal. The meal did not contain any oatmeal. Review of the meal tray ticket from resident #23's tray revealed she should have two cups of oatmeal included in meal and a dietary intervention of no eggs was printed on the ticket. CNA A confirmed resident #23's tray included scrambled eggs and did not include oatmeal as printed on the ticket. On 8/05/26 at 8:52 AM, Registered Nurse E delivered the breakfast tray to resident #23's room. The breakfast tray was noted to contain two bowls of oatmeal, fruit and chocolate milk. The tray ticket from resident #23's tray noted resident was to receive only two bowls of oatmeal, fresh fruit, chocolate milk and no eggs. These printed items were highlighted. There was a handwritten note that read, 2 cereals. The tray was noted not to have any bowls of cereal on the tray. On 8/05/26 at 1:10 PM, the Food Service Manager (FSM) stated she obtained a resident's likes and dislikes upon admission and anytime she was made aware that a resident had a change in preferences. The FSM confirmed she was made aware of the missing items on the tray on 8/04/26 and acknowledged the tray ticket indicated what items should have been on the tray. She was unable to explain why the items were left off. She reviewed the tray ticket for 8/05/26 and was unable to say why an additional hand-written note had been placed on the ticket or who had written it. The FSM stated she would have to look into it and re-educate the staff on following the tray tickets. The facility's policy and procedure for Menus and Adequate Nutrition dated 3/01/26 indicated the purpose of the policy was to assure menus were developed and prepared to meet resident choices which included their nutritional, religious, cultural, and ethnic needs, while using established guidelines.

Based on interview, and record review, the facility failed to maintain accurate and complete medical records for 2 of 2 residents reviewed for advance directives, of a total sample of 36 residents, (#7 & #23). Findings: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses of stroke, dementia, atrial fibrillation, and malnutrition. According to her Annual Minimum Data Set assessment dated [DATE], the resident had severely impaired vision, and she was totally dependent on staff for care. Her Brief Interview for Mental Status assessment score was an 8/15, which showed she was cognitively impaired. A care plan initiated on [DATE] indicated the resident had an order for Do Not Resuscitate (DNRO). Review of the facility's Electronic Health Record revealed the resident had a DNRO form dated [DATE], with the resident's name, doctor's signature, and her son had signed as the power of attorney. Further review revealed there was another DNRO form dated [DATE] with a different resident's name on it. On [DATE] at 3:10 PM, the Social Services Director (SSD) explained there were no code status notebooks on the unit, and the DNR forms were scanned into the system to a resident's chart. If a resident went to the hospital, they printed the document to send with Emergency Medical Services. On [DATE] at 3:12 PM, the Director of Nursing (DON) acknowledged that the wrong DNR was in the chart and instructed the SSD to remove it. 2. Resident #23 was admitted to the facility on [DATE] with diagnoses including partial paralysis and weakness following stroke, affecting right dominant side; type 2 diabetes; and adult failure to thrive. Review of the Minimum Data Set Quarterly assessment with assessment reference date of [DATE] revealed resident #23 had a Brief Interview for Mental Status score of 15 out of 15, which indicated she was cognitively intact. A care plan initiated on [DATE] indicated resident #23 had an advance directive as evidenced by a Do Not Resuscitate order. Review of resident #23's electronic medical record (EMR) revealed an initial physician order dated [DATE] for Do Not Resuscitate. Review of the scanned documents section of the EMR revealed two Do Not Resuscitate Order forms scanned into the EMR on [DATE]. Review of those two forms revealed they contained the name of another resident and were not the Do Not Resuscitate Order forms for resident #23. In three separate interviews on [DATE], Registered Nurse E, Licensed Practical Nurse (LPN) D and LPN F each stated they verified a resident's code status by looking at the EMR and that if a resident was sent out by emergency medical services (EMS), the Do Not Resuscitate order form was printed from the EMR and provided to EMS personnel. On [DATE] at 3:10 PM, the SSD stated she was responsible for maintaining Advance Directives. She explained if a resident did not want to receive Cardiopulmonary Resuscitation (CPR), they would sign a DNRO form and an order was obtained from the physician. The SSD stated the DNRO forms were then scanned into the EMR for staff availability. She confirmed the nurses printed off the DNRO form and provided it to EMS if a resident was sent out to the hospital. The SSD reviewed the EMR for residents #7 and #23. She acknowledged a different resident's DNRO was scanned into the EMR for resident #7 as well as her own and that another resident's DNRO was scanned into the EMR for resident #23 but did not contain resident #23's DNRO. The SSD explained she had someone helping her scan documents into the EMR and a mistake had obviously been made. The SSD acknowledged the medical records for residents #7 and #23 were inaccurate as they contained information for other residents. The facility's policy and procedure for Maintenance of Clinical Records dated [DATE] indicated that in accordance with accepted professional standards of practices, the facility would maintain medical records on each resident that were complete, accurately documented and readily accessible.

Based on interview, and record review, the facility failed to complete a comprehensive significant change in status assessment for 1 of 1 resident reviewed for accidents, out of a total sample of 36 residents, (#3).Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with diabetic polyneuropathy, rheumatoid arthritis, and transient cerebral ischemic attack. Review of the Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 5/18/26 revealed resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. The document revealed resident #3 walked independently with the use of a walker and independently performed Activities of Daily Living (ADLs) for eating, toilet hygiene, upper and lower body dressing and transfers. Review of the electronic medical record (EMR) revealed resident #3 fell in the facility on 5/18/26 and was transferred to the hospital. She returned from the hospital on 5/21/26 with a sling on her right arm and a new diagnosis of unspecified displaced fracture of surgical neck of right humerus (upper arm bone). Review of resident #3's MDS 5-Day Medicare assessment with ARD of 5/23/26 revealed she remained cognitively intact with BIMS score of 15 out of 15. The MDS assessment showed resident #3 had a decline in ADL performance and required setup or clean-up assistance with eating; substantial/maximal assistance with transfers; and was dependent on staff for toilet hygiene and upper and lower body dressing. The assessment documented that resident #3 used a wheelchair and required substantial/maximal assistance to wheel 50 feet with two turns. On 8/04/26 at 8:31 AM, resident #3 confirmed she fell a few months ago and broke her right arm. She explained she went to the hospital but did not have surgery. She recalled her arm was in a sling, and she had some limitations to her range of motion. Resident #3 stated she required more assistance with care and used a wheelchair for a while as she could not hold onto her walker with both hands. On 8/05/26 at 12:42 PM, the Therapy Director reviewed therapy records for resident #3. She reported resident #3 was evaluated on 5/22/26 and placed on therapy caseload. She explained resident #3 remained on services for physical therapy and occupational therapy. The Therapy Director confirmed resident #3 had a fracture of her right arm and required increased assistance. She estimated resident #3 used a wheelchair for about a month after she returned from the hospital. She stated therapy was focusing on ADL performance as well as dressing and bathing. The Therapy Director explained resident #3 still had a non-weight bearing status for her right arm which prevented therapy from working on her range of motion. On 8/06/26 at 9:21 AM, resident #3's MDS assessments and ADLs were reviewed with the MDS Coordinator. He confirmed resident #3 had experienced a fall and had a decline in her ADL performance as a result. He explained resident #3's decline was expected due to the fall and did not see it as a significant change at the time. The MDS Coordinator acknowledged a significant change assessment should have been completed. The Resident Assessment Instrument (RAI) manual updated October 2025 defined a significant change as a major decline or improvement in a resident's status that would not normally resolve itself without intervention by staff and was not considered self-limiting; the change impacted more than one are of the resident's health status; and required interdisciplinary review and/or revision of the care plan. The RAI manual indicated the facility could take up to 14 days to determine if the criteria for significant change were met.

Based on interview, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice that accounted for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 2 residents with diagnosis of Post Traumatic Disorder (PTSD), from a total sample of 36 residents, (#11, and #1). Findings: 1. On 8/05/26 at 1:01 PM, resident #11 said he had past trauma related to his sister's phone call to him prior to her committing suicide. The resident stated he did not answer the call due to being at work and that still weighed heavy on him. He stated at times even hearing a ringing phone was a trigger because he had guilt related to not answering the phone. The resident explained the ringing sound brought back the feelings of guilt. He stated he had many changes in his life recently such as losing his job and having to move out of his house after a recent hurricane severely damaged his home. Resident #11 was admitted to the facility on [DATE] with diagnoses that included muscular dystrophy, seizures, PTSD, and type 2 diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 5/13/26 revealed resident #11 had Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated he had intact cognitive function. The assessment indicated resident #11 had a psychiatric /mood disorder of PTSD. A review of resident #11's current care plan revealed the resident had depression related to disease process, muscular dystrophy, PTSD, and anxiety disorder initiated on 8/28/25. The care plan had no specific or individualized interventions addressing resident #11's PTSD or his triggers. A review of the practitioner's progress notes on 8/13/25 by the Psychiatric Nurse Practitioner revealed listed in the History section the phrase, trauma: did not offer information. Under the review of systems, documentation revealed the resident had excessive anxiety and worry, irritability, and poor concentration due to anxiety and PTSD. In the section Assessment and Plan which addressed PTSD, an excerpt for resident #11 indicated, for PTSD, to continue Sertraline 25 milligrams (mg) once daily, schedule Diazepam 5mg twice a day, monitor for PTSD symptoms, assess their severity, and track the individual's progress over time. The provider directed staff to check for the following signs: intrusive thoughts, avoidance, hyperarousal, changes in behavior and need for medicinal therapy. On 8/05/26 at 2:14 PM, the Social Services Director (SSD) confirmed resident #11 did not have a designated care plan for PTSD. She stated she was aware he had the diagnosis and acknowledged the care plan interventions must have been missed. On 8/05/26 at 3:06 PM, the Director of Nursing (DON) stated her expectation for residents identified as having PTSD was for them to have a personalized care plan which discussed triggers and helped minimize re-traumatization. 2. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included brain dysfunction, respiratory failure, chronic obstructive pulmonary disease and PTSD. Review of the MDS admission assessment with ARD of 5/01/26 showed the resident had a BIMS score of 15 out of 15 which indicated his cognition was intact. The MDS also listed PTSD as an active diagnosis listed under Psychiatric/Mood Disorders. A review of a psychiatrist progress notes dated 5/04/26 revealed the resident had a history of PTSD. The psychiatric progress notes dated 5/11/26 and 6/04/26 revealed the Assessment and Plan for PTSD was to assess the symptoms and their severity and track the individual's progress over time. The Psychiatrist's plan for resident #1 directed those intrusive thoughts, avoidance, hyperarousal, changes in behavior, and need for medicinal therapy should be checked. A review of the Assessments/ Evaluations showed no Trauma Informed assessment was completed even though PTSD was listed as one of the resident's diagnoses. A review of resident #1's Comprehensive Care Plan revealed no specific care plan that addressed his PTSD or his triggers. On 8/04/26 at 4:13 PM, resident #1 was in bed eating potato chips, he answered questions with a yes or no and had a flat affect. The assigned Licensed Practical Nurse (LPN) B was outside the resident's room and said resident #1 recently had difficulty breathing but other than that, they were not doing anything different for him with regards to his care or PTSD. On 8/05/26 at 9:55 AM, the assigned Certified Nursing Assistant (CNA) C said resident #1 had been a little down the last few days. CNA C explained the care he received from her was the same as all residents and she did not do anything different for him. On 8/5/26 at 2:14 PM, in a joint interview with the Social Services Director (SSD) and the DON, the SSD said she was responsible for completing the Trauma Informed Care assessments and the MDS Coordinator would complete the care plan for PTSD. They both acknowledged resident #1 had a diagnosis of PTSD but there was no care plan nor Trauma Informed Care Assessments related to resident #1. The DON explained the expectation was for resident #1 to have a focused care plan for PTSD that was resident specific to prevent re-traumatization. The facility's policy on Trauma Informed Care revised 3/01/26 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.

Based on interview, and record review, the facility failed to ensure implementation of their Quality Assurance and Performance Improvement (QAPI) program by failing to obtain feedback and data to identify issues and concerns with facility systems, as well as opportunities for improvement.Findings:Cross Reference F580, F655, F656, F842In a joint interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 4/08/26 at 4:53 PM, the NHA stated he had only been at the facility for two days and had not been part of any QAPI meetings. The DON expressed she had started last year in June of 2025. The NHA and DON acknowledged the concerns related to notification of change in condition for residents, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that did not include respiratory care, and incomplete/inaccurate medical records. The DON stated she was not aware of the concerns and there were no active Performance Improvement Plans (PIP) related to these concerns. She explained during morning clinical meetings, each department head discussed concerns which would then be brought to the monthly QAPI meetings. These concerns were discussed by the committee and a PIP would be created. The NHA stated the purpose of the QAPI program was to ensure issues were identified, data was collected, and PIPs were created to help prevent systemic breakdown.Review of documentation provided by the NHA from previous QAPI meetings showed the facility had several ongoing PIPs with no supporting documentation, end date, or monitoring. In January of 2025 there was a PIP started for notification of changes in condition. This PIP was created after resident #1's representative was not informed she had been transferred to the hospital after her cardiac arrest. On 4/08/26 at approximately 5:00 PM, the NHA confirmed there was no documentation to show what had been done and how or if the action taken was being monitored. In April of 2025 there was a PIP related to risk management events such as incidents that occurred in the facility but there was no documentation of what had been done. In September of 2025 there was a PIP related to documentation and in June 2025 there was a PIP for care plans and baseline care plans. There was no corresponding documentation for any of these PIPs, which was confirmed by the NHA.Review of the Quality Assurance and Performance Improvement policy date 3/01/22, and revised on 8/01/25, revealed it was the policy of the facility to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focused on indicator of the outcomes of care and quality of life and addressed all the care and unique services the facility provided. The compliance guidelines included the facility develop and implement appropriate plans of action to correct identified quality deficiencies and regularly review and analyze data and act on the available data to make improvements. The guidelines and explanation indicated the facility would maintain documentation and demonstrate evidence of its ongoing QAPI program which may include but is not limited to a written QAPI plan, data collection and analysis at regular intervals, and documentation to demonstrate the development, implementation and evaluation of corrective actions or performance improvement activities.

Based on interview, and record review, the facility failed to ensure the resident's representative was informed of a change in condition for 2 of 2 residents reviewed for change in condition, (#1, and #4), and failed to notify the physician of the change in condition which had the potential to delay medical evaluation and treatment for 1 of 2 residents reviewed for notification of changes, (#4) .Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (abnormal brain function), dysphagia (trouble swallowing), diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive. She was hospitalized on [DATE] due to a difficulty to arouse and labored breathing. Resident #1 returned to the facility on [DATE] with diagnoses of COVID-19, pneumonia, and acute respiratory failure. Review of the Agency for Healthcare Administration (AHCA) Long Term Care Medicaid Transfer form 3008, dated [DATE], revealed resident #1 required a surrogate for decision making. Resident #1's Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed she was severely cognitively impaired, and indicated she required a surrogate for decision making. Review of resident #1's medical records revealed a change in condition progress note dated [DATE]. It was noted that on [DATE] (no specific time given) resident #1 was found unresponsive and had suffered a cardiac arrest. The note indicated she had orders for full code, so cardiopulmonary resuscitation (CPR) was initiated, 911 was called, and an order was obtained from the physician to transfer the resident to the emergency room. The record showed a transfer and discharge form was also completed on [DATE] which noted resident #1 herself was listed as the responsible party that was notified and included her cellphone number. There was nothing in the record to show any other emergency contacts had been notified. Resident #1's assigned nurse and the Nurse Supervisor working on [DATE] were unable to be reached for interview, after multiple attempts were made. In a telephone interview on [DATE] at 11:56 AM, Registered Nurse (RN) B confirmed she worked the 3-11 PM shift on [DATE]. The nurse stated on that day she assisted the assigned nurse during CPR for resident #1. She recalled the Nurse Supervisor was at the desk calling 911, the physician, and the family. RN B said when she returned to work for her shift the next day the former Director of Nursing (DON) called a meeting with her and the other two nurses involved with resident #1's code blue. She recalled the former DON told them that resident #1's daughter was upset because she had not been notified by the facility on [DATE] that her mother had been found unresponsive and transferred to the emergency room. In a phone interview on [DATE] at 12:53 PM, resident #1's daughter confirmed she was her mother's healthcare proxy. She stated that on [DATE] she was not notified by the facility her mother had been transferred to the emergency room after being found unresponsive. The daughter recalled she received a call from the hospital approximately 8:45 PM, asking if she had spoken with the facility, which she told them she had not. The hospital informed her resident #1 had suffered a cardiac arrest and CPR had been initiated at the facility. Resident #1's daughter said she asked the hospital to continue CPR in the hopes that she could make it on time to see her mother alive but a short time later they called back to inform her that her mother had passed away. The daughter said she told the former DON that night on the phone, she was upset about not being notified her mother had been found unresponsive and transferred to the emergency room. She remembered the former DON could not provide an explanation for how staff mixed up the phone numbers. She said the former DON told her they would investigate what occurred, but she never heard back about it. Review of resident #1's face sheet dated [DATE] revealed a list of contacts including the resident as the responsible party and noted her home phone number. Her daughter was listed as emergency contact #1 and resident #1's sister was listed as emergency contact #2. Both of their cellphone numbers were listed. Review of resident #1's medical record revealed during a previous hospitalization on [DATE] during the 7:00 AM to 3:00 PM shift, the resident's daughter had been notified by the facility that resident #1 had a change in condition and would be transferred to the emergency room. The record showed prior to the transfer, on [DATE], the facility called the daughter to ask about an ordered medication for resident #1, which the daughter refused, and the physician was notified of her choice. In a telephone interview on [DATE] at 12:27 PM, the former DON stated that she became aware of resident #1's code blue event and transfer to the hospital the next morning when she arrived at the facility. She said resident #1's assigned nurse for [DATE], informed her she had not called the daughter because she confused the phone numbers. The former DON explained the assigned nurse's first language was not English. She confirmed she had a conversation via phone with resident #1's daughter after the incident and the daughter complained about not being notified of her mother's transfer to the hospital and change in condition. The former DON acknowledged there was no investigation conducted after the incident because they felt there were no issues with how the facility staff conducted the code blue. She said she never spoke to the daughter again after that. She said the family was technically notified of the transfer during a phone conversation with resident #1's granddaughter who called the facility to complain that the family had not been notified, sometime after the resident had been transferred. She was unable to provide an exact time. Review of the facility's undated policy on Change in a Resident's Condition or Status indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/ or status, which included a change in the level of care. The policy described staff were to implement the policy by ensuring the attending or on-call physician was notified when the resident was involved in an incident or accident, which included the discovery of injuries of an unknown source. Furthermore, the nurse would notify the resident's representative when the resident was involved in any incident or accident which resulted in an injury to include those of unknown source and notify when it was necessary to transfer the resident to a hospital/treatment center. 2. Resident #4 had a respite admission to the facility on [DATE]. His admission diagnoses included stroke with right-sided deficit, right heel pressure ulcer, coronary artery disease, and pacemaker. The Discharge MDS assessment dated [DATE] revealed resident #4 had a Brief Interview for Mental Status score of 14/15, which indicated he was cognitively intact. The assessment showed the resident was independent for meals, dependent on staff for toileting, and was frequently incontinent. Review of resident #4's Baseline Plan of Care Summary dated [DATE] included self-directed activities, injury prevention, and potential for alteration in skin integrity. Interventions identified were to discuss preferences in activities, maintain a safe environment, and report skin redness or breakdown. Review of resident #4's admission Nursing Progress Note dated [DATE] at 11:42 PM, revealed skin assessment with no issues noted. Review of the physician's History and Physical dated [DATE] at 4:19 PM, reflected right foot ortho shoe on and resident #4 complaining of right heel pain. There was no documentation in the progress notes regarding arm or leg skin tears. Review of resident #4's Daily Nursing assessment dated [DATE] at 7:25 AM, revealed, No skin issues. Review of the Certified Nursing Assistant (CNA) Task List for skin observation on [DATE] at 12:58 PM, revealed no new skin condition but also noted, skin tear to arm. On [DATE] at 12:22 PM, the skin observation reflected no new skin condition and skin tear to leg. Resident #4's Discharge Summary for [DATE] indicated there were no skin issues at the time of discharge. In a telephone interview on [DATE] at 7:00 PM, resident #4's daughter recalled when she came to pick her father up at the facility upon discharge, she noticed a bandage on his leg. She said her father told her that the facility had taken some of residents out for lunch, and on the way back to the facility some unsecured wheelchairs fell and scratched his arm and put a gash in his leg. The daughter stated no one from the facility called to inform her of the incident or the skin impairments. The daughter stated she had called the Administrator multiple times and no one called back. She recalled she spoke with the Social Worker to voice her concerns and the Social Worker told her that she would ask the Administrator to call her back. The daughter stated she had not heard from anyone yet. On [DATE] at 2:00 PM, the Social Worker stated she did not recall the telephone call. Attempts were made by the survey team to interview the previous Activities Director, but were unsuccessful, the current Activities Director was unaware of resident #4 and had started at the facility that week. On [DATE] at 3:15 PM, the DON stated there should have been a Change in Condition for the skin tears to resident #4's leg and arm. She confirmed the nurse, doctor and daughter should have been notified of the change. Review of the facility's undated Change in a Resident's Condition or Status policy, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/ or status.

Based on interview, and record review, the facility failed to ensure the baseline care plan was effectively implemented to include a plan for staff to provide effective and person-centered care, for 2 of 2 residents reviewed for respiratory care, (#1, and #3), and failed to ensure the resident or representative received a summary of the baseline care plan with the required information, for 1 of 2 residents reviewed for baseline care plans, (#1), of a total sample of 4 residents. Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (brain dysfunction), diabetes, congestive heart failure, acute kidney failure, and adult failure to thrive. She was hospitalized on [DATE] due to a difficulty to arouse and labored breathing. Resident #1 returned to the facility on [DATE] with diagnoses of Coronavirus 2019 (COVID-19), pneumonia, and acute respiratory failure. Review of the Agency for Healthcare Administration (AHCA) Long Term Care Medicaid Transfer form 3008, dated 12/02/24, revealed resident #1 had a primary diagnosis of acute respiratory failure and congestive heart failure (CHF) exacerbation. The transfer form contained documentation the resident used oxygen at 2 liter per minute (LPM) delivered via nasal cannula and she required a surrogate for decision making. Resident #1's Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed she was severely cognitively impaired, and required a surrogate for decision making. The assessment also indicated resident #1 was dependent on staff for bed mobility and getting dressed. The MDS assessment did not show the resident was utilized continuous oxygen therapy. Review of resident #1's current physician orders revealed she was on several respiratory treatments that included continuous oxygen, nebulizer treatments, steroids, and inhalers. Review of resident #1's baseline care plan with an admission date of 12/04/24 and re-admission date 12/21/24, revealed the facility did not include a plan to address the resident's respiratory needs/diagnoses. On 4/07/26 at 12:53 PM, resident #1's daughter stated her mother required continuous oxygen and the facility did not provide appropriate respiratory care. She explained her mother preferred to have the head of bed always elevated when she was in bed to help her breath better and she needed to be reminded not to remove her nasal cannula since she was often confused. The daughter conveyed that on a few occasions when she visited her mother, she noticed she was not wearing her nasal cannula and that the head of her bed was flat. She expressed that all staff needed to make sure they communicated about her mother's preferences and what would keep her comfortable in order to prevent her from declining. Resident #1's daughter confirmed she never received a copy of the initial plan of care nor had not met with anyone at the facility regarding her concerns related to her mother's respiratory status. On 4/08/26 at 4:18 PM, the MDS Director stated he was responsible for completing the comprehensive assessment and care plan, but explained the admitting nurse was responsible for completing the baseline care plan. He confirmed the baseline care plan guided the staff on how to treat the resident immediately upon admission. The Director conveyed the nurse would use the 3008-transfer form, hospital records, resident interview, and family interview to create the baseline care plan. He further explained the resident or resident representative had to sign the care plan and provided with a copy for their records. The MDS Director reviewed resident #1's baseline care plans for both of resident #1's admissions and agreed respiratory care had not been mentioned nor the resident's need for continuous oxygen. He agreed there were no personalized interventions related to the resident's preference to have the head of bed elevated while in bed to assist with breathing. He added the baseline care plan form had been modified since the time of resident #1's admission and now included an area for the nurse to select if the resident was on oxygen. The MDS Director acknowledged the previous form also had areas where the nurse could document other areas of care not mentioned. He stated the expectation was for the baseline care plan to include whether the resident received oxygen therapy. On 4/08/26 at 3:13 PM, the DON explained upon admission the baseline care plan was created by the admitting nurse and was used as the road map in the care of the resident. She relayed the care plan was meant to direct staff to provide pharmacological and non-pharmacological interventions that supported the residents' needs and preferences. She acknowledged the previous electronic form utilized by the admitting nurse to complete the baseline care plan did not have a focus for respiratory care but said there were other areas that allowed the nurse to add notes. The DON acknowledged resident #1's baseline care plan dated 12/21/24 was mostly left blank besides a comment related to the resident 's behavior and diet order and did not include her need for continuous oxygen. She stated her expectation was for baseline care plans to be accurate and complete based on the residents' orders and care needs. Review of the facility's policy and procedure for Baseline Care Plan, last reviewed 3/01/25, revealed the policy was for the facility to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident in accordance with professional standards and quality of care. The policy described the baseline care plan had to be developed within 48 hours of resident admission and had to include the minimum healthcare information necessary to properly care for the resident, like initial goals based on admission orders and physician orders. The document indicated the admitting nurse or supervising nurse on duty should gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and representative. The policy specified the supervising nurse or MDS nurse was responsible for providing the written summary of the baseline care plan to the resident and representative, obtain their signature, and provide them with a copy. 2. Resident #3 was admitted to the facility on [DATE] from an acute care hospital with a past medical history of end stage renal disease on dialysis, cardiac arrest, congestive heart failure, acute and chronic respiratory failure, chronic obstructive pulmonary disease, colostomy secondary to perforated colon, and hypertension. He returned to the acute care hospital on 3/03/26 for a high potassium level and shortness of breath. Review of resident #3's hospital progress notes dated 3/05/26 reflected diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure and oxygen dependency. The record revealed resident #3 returned to the facility on 3/10/26 with a primary diagnosis of acute respiratory failure. The admission Minimum Data Set (MDS) assessment for resident #3 dated 3/17/26 revealed he was cognitively intact, mobile with a walker, and independent for activities of daily living. The assessment did not indicate resident #3 required oxygen therapy. Review of the admission Baseline Care Plan dated 2/19/26 and the readmission Care Plan dated 3/10/26 revealed the care plans did not address resident #3's respiratory status, respiratory medical conditions, or chronic oxygen use. Review of resident #3's physician orders dated 2/19/26 showed orders for administration of three respiratory inhalers. Review of daily skilled nursing notes and vital signs reflected resident #3 used oxygen on the dates 3/13/26, 3/15/26, 3/17/26 and 3/19/26. On 4/08/26 at 4:18 PM, the MDS Director stated he was responsible for completing the comprehensive care plan and the admitting nurse was responsible for completing the baseline care plan. He stated the baseline care plan should be based on the resident's assessment, review of acute care hospital records, and interviews with the resident and family members. The MDS Director reviewed resident #3's baseline care plan for both admissions and agreed a respiratory assessment should have been completed, a care plan focus created, and interventions should have been placed. He explained resident #3 had a history of chronic obstructive pulmonary disease and the expectation for the interventions should have included oxygen as needed, monitoring, head of bed elevated, and observe for respiratory distress. On 4/08/26 at 3:15 PM, the Director of Nursing (DON) stated baseline care plans were completed by the admitting nurse to guide the care provided to residents. She confirmed she was familiar with resident #3 and had personally observed him with oxygen in the hallway and standing in the doorway to his room. The DON agreed resident #3's baseline care plans should have included a respiratory assessment and interventions for his care.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to address oxygen use which placed the resident at risk for potential respiratory complications, for 1 of 1 residents reviewed for Comprehensive Assessment, of a total sample of 4 residents, (#2).Findings: Resident #2 was admitted to the facility on [DATE]. admission diagnoses included end stage liver disease, hepatocellular carcinoma (liver cancer), diastolic congestive heart disease, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #2 required oxygen therapy and had a Brief Interview for Mental Status score of 15/15, which indicated she was cognitively intact. The assessment specified the resident required full assistance from staff with toileting, hygiene, and transfers. Review of resident #2's medical record revealed physician orders dated 12/23/25 for oxygen two liters per minute (LPM) as needed, on 2/03/26 for one LPM of oxygen, and on 3/09/26 two to four LPM, as needed to maintain oxygen level greater than 92 percent. Review of resident #2's pulmonary physician Follow-up Progress Notes included, on 3/29/26 at 6:10 PM, documentation for staff to monitor oxygen saturation and titrate as needed. On 4/04/26 at 9:57 PM, the note directed the resident should receive, supplemental oxygen as needed to maintain oxygen saturation greater than 92 percent and at night while sleeping. Review of the Treatment Administration Record for December 2025 to March 2026, revealed a schedule for staff to change resident #2's oxygen tubing every week beginning 12/28/25. The Daily Skilled Nursing Documentation revealed on 2/21/26 at 10:31 AM, resident #2 was on one LPM of oxygen via nasal cannula and on 3/03/26 at 10:32 AM, documentation indicated the resident was on two LPM of oxygen via nasal cannula. On 4/07/26 at 8:51 PM, resident #2's vital signs included an oxygen saturation of 98 percent with oxygen via nasal cannula. Review of resident #2's care plan revealed there was no care plan for oxygen use. On 4/07/26 at 11:36 AM, resident #2 was in bed wearing a nasal cannula connected to an oxygen concentrator set at five LPM of oxygen. The concentrator was approximately three or four feet away from her bed. The resident stated she used oxygen because she was often short of breath (SOB), had liver cirrhosis, and would often get fluid removed from her abdomen. She stated she had COPD, and did not get out of bed often, since she was so tired. On 4/07/26 at 12:06 PM, Registered Nurse (RN) A confirmed resident #2's oxygen concentrator was set at five LPM of oxygen. The nurse acknowledged resident #2's order was for two to four LPM of oxygen as needed. She explained the resident or her son sometimes changed the rate of the oxygen. She said the resident needed oxygen due to her COPD and SOB. On 4/08/26 at 3:15PM, the Director of Nursing (DON) confirmed resident #2 used oxygen per physician orders. The DON acknowledged resident #2 had no oxygen care plan but should have had one. On 4/08/26 at 4:15 PM, the MDS Coordinator stated he reviewed all physician orders daily. He confirmed resident #2 had no care plan for his oxygen use and explained, we must have missed them. Review of the Comprehensive Care Plan Policy revised on 3/01/25, indicated, . to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview, and record review, the facility failed to maintain complete, accurate, and consistent clinical records, compromising the reliability of the clinical record and the ability to ensure appropriate assessment, treatment, and continuity of care for 2 of 2 residents reviewed for resident records, of a total sample of 4 residents, (#1, #4).Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (abnormal brain function), dysphagia (trouble swallowing), diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive. On [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) C confirmed she was the Night Supervisor on [DATE]. She recalled when she arrived for her shift that night, she was told by 3-11 PM staff that resident #1 had been found unresponsive by an unidentified Certified Nursing Assistant (CNA) who had gone to the room to check on her. LPN C remembered the CNA reported this to the second shift Nurse Supervisor who then reported it to the assigned nurse and a code blue was called. She said after 911 was called, Emergency Medical Services (EMS) arrived and took the resident to the hospital. Several attempts were made to contact resident #1's assigned nurse and the second shift Nurse Supervisor but they did not return the calls and were not present at the facility during the survey. In a telephone interview on [DATE] at 11:56 AM, Registered Nurse (RN) B confirmed she had participated in the code blue for resident #1 on [DATE] during the 3-11 PM shift. She said she was at her cart passing medications when she heard the assigned nurse yelling for help in resident #1's room. RN B recalled the resident was unresponsive when she arrived at the room and the assigned nurse was performing Cardiopulmonary Resuscitation (CPR) on resident #1. She explained the assigned nurse and her were the only two staff members in the room during the code while the Nurse Supervisor called 911, the resident's family, and the attending physician. In a telephone interview on [DATE] at 12:27 PM, the former Director of Nursing (DON) stated she was not informed about resident #1's code blue until the next morning when she arrived at the facility on [DATE]. She recalled the assigned nurse told her that on [DATE] during the 3-11 PM shift she walked into the room to check resident #1's blood sugar and found her breathing abnormally, [NAME]-Stoking. The former DON remembered the assigned nurse stayed by the resident's side until she became unresponsive, at which time she called for a code blue. The DON said the second shift Nurse Supervisor was the only other person in the room during CPR and the assigned nurse was the one who made calls to 911, physician, and the family. The DON acknowledged there was no documentation in the medical record to accurately show what condition the resident was in when she was found nor to show what time the resident was found or by whom. She stated the change of condition form and transfer forms were complete and accurate. [NAME] Stokes breathing is when a person breathes deeply for a period, then gradually breathes more shallowly or sometimes stopping altogether for 5-30 seconds before the cycle repeats. This pattern of breathing could indicate severe illness and could appear in end-of-life stages, (retrieved on [DATE] from www.medical-dictionary.thefreedictionary.com). Review of resident #1's medical records revealed a change in condition note dated [DATE]. The note indicated on [DATE] (no specific time was given) resident #1 was found unresponsive and had suffered a cardiac arrest. The change in condition documentation showed the resident was a full code, so CPR was initiated, 911 was called, and an order was obtained from the physician to transfer the resident to the emergency room. Review of the document revealed it was incomplete as there was no documentation that indicated the condition of the resident prior to becoming unresponsive, who found her, or at what time. On [DATE] at 3:13 PM, the current DON acknowledged there was a lack of documentation related to resident #1's code blue. She stated the expectation was for staff to ensure a complete detail of the code blue was documented and included the staff involved, time of event, and the condition of the resident when they were found along with immediate actions that were taken. Review of the facility's policy on Documentation in the Medical Record dated [DATE], indicated each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 2. Resident #4 was a respite admission to the facility on [DATE]. His admission diagnoses included a stroke with right-sided deficit, right heel pressure ulcer, coronary artery disease, and pacemaker. The Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had a Brief Interview Status score of 14/15 which indicated he was cognitively intact. The assessment revealed he was independent for meals, dependent on toileting, and frequently incontinent. Record review of resident #4's Baseline Plan of Care Summary for [DATE] included self-directed activities, injury prevention, and potential for alteration in skin integrity. Interventions identified were to discuss preferences in activities, maintain a safe environment, and report skin redness or breakdown. In a telephone interview on [DATE] at 7:00 PM, resident #4's daughter stated a few months ago, when she came to pick her father up at the facility for discharge, she noticed a bandage on his leg. She expressed her father told her the facility had taken some of residents on an outing for lunch. The daughter explained her father told her that on the way back to the facility some unsecured wheelchairs fell, scratched her father's arm and put a gash in his leg. She recalled no one from the facility mentioned the new wounds or the incident to her. Review of the CNA Task Record revealed resident #3 refused activity participation in Group Events and Programs on [DATE] and [DATE]. There was no documentation for [DATE] through [DATE] of resident #4's participation in group events or programs. The CNA's skin observation documentation for resident #4 revealed observations of a not new skin condition, tear to the resident's arm dated [DATE] and on [DATE] the skin observation monitor documentation reflected a not new skin condition, tear to resident #4's leg. There was no documentation for skin observations completed for [DATE] through [DATE]. Review of resident #4's [DATE] Treatment Administration Record revealed no wound identification or treatment for the dates of [DATE] through [DATE]. Review of resident #4's physician orders from [DATE] through [DATE] revealed no wound identification or treatment orders. Review of resident #4's Progress Notes revealed an admission Nursing Progress note dated [DATE] at 5:58 PM, which identified the resident's skin assessment was fair condition and no skin issue noted. On [DATE] at 3:26 PM, the Advanced Practice Nurse Admit Visit documentation revealed resident #4's skin was warm and dry. The physician's History and Physical progress notes dated [DATE] revealed complaints of mild right heel pain and skin warm, dry, Other: right foot ortho shoe on. The medical record contained no documentation of notification to nursing, physician, or family of the wound mentioned in the skin observation note of [DATE]. Review of the medical record revealed no documentation of a change in condition regarding the incident and resulting skin impairments, a nursing assessment, or treatment, including a dressing for a wound prior to resident #4's discharge. Review of resident #4's discharge summary on [DATE] revealed No skin issues at the time of discharge. The former Activities Director and the assigned CNA were not available for interview and did not respond to request for interview. On [DATE] at 3:15 PM, the current DON stated she was not aware of resident #4's outing incident. She stated the CNA should have notified the nurse. The DON stated a change in condition should have been completed and documented for resident #4 which included a nursing assessment, provider and family notification, and treatment orders. She stated her expectation was for CNAs to communicate all changes they observe and incidents they had an awareness of to the nurse to ensure appropriate and consistent care. The DON further confirmed there should be documentation by the nurse of any old or new skin issues or conditions.

Based on observation, interview, and record review, the facility failed to provide immediate and thorough nursing assessment and treatment services related to burns for 1 of 2 residents, (#27), and failed to obtain an order for treatment and date a treatment dressing for 1 of 2 residents reviewed for pressure wounds, (#84), of a total sample of 37 residents. The facility's failure to ensure a complete and timely assessment including accurate identification of burns resulted in actual harm. Resident #27 was transferred to a higher level of care initially for treatment and was transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained there for 5 days. Findings: Cross reference F689 and F813 1. Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes), and contracture of the left hand. Hemiplegia and hemiparesis are similar in that they describe effects to one side to your body.hemiplegia refers to one sided paralysis while hemiparesis refers to one sided weakness, (retrieved from www.my.clevelandclinc.org on 10/21/24). The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/21/24, revealed the resident was cognitively intact with a Brief Interview of Mental Status of 14/15. The record revealed the resident had left sided weakness and paralysis due to a stroke. Her left hand was contracted. The MDS indicated she was a set up assistance for eating and could feed herself. Review of Order Summary Report revealed an order dated 10/02/24 for triple antibiotic cream to be applied to a skin tear to left hand. Review of the Weekly Skin Check Sheet dated 10/02/24 revealed the sheet was incomplete/blank except for the date and the nurse's signature. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. There was no further documentation from LPN J or other nurses regarding the assessment/reassessment or treatment for resident #27 in the medical record. On 10/15/24 at 3:45 PM, the Administrator provided an overview of the investigation. She said on 10/02/24 at about 5:30 PM resident #27 had a cup of noodle soup that you add water to and cook in the microwave. Resident #27 asked CNA K to heat it for her and the CNA took it to the unit kitchen and cooked it in the microwave. The Administrator explained the food should have been heated in the kitchen. She stated CNA K told the Administrator it was dinner time, and she warmed up soup for resident #27. The CNA said she rested the soup on the table and then resident #27 tried to move a plate and it bumped the soup. CNA K said she tried to catch it, but it spilled on the resident's left arm. The CNA stated she reported it to the nurse. The Administrator stated she asked CNA K to demonstrate what happened and as CNA K was setting the soup down resident #27 hit the cup with a plate and it spilled toward the resident spilling onto her. The Administrator reviewed the statement from resident #27's assigned LPN J who wrote that CNA K notified him that resident #27 burned herself while she was eating noodle soup. He wrote that upon his assessment the resident had a skin tear on her left hand. He indicated he notified the physician as well as the resident's daughter. The Administrator stated the Director of Nursing (DON) called her around 9:00 PM the night of the incident and explained resident #27 was sent to the hospital. She recalled the DON told her that resident #27 got burned, and after the family came in 911 was called and resident was transported to the hospital. The Administrator stated it did not sound like an urgent situation to her. She said the DON told her the soup got spilled on resident #27's hand and she was treated. She explained she was trying to figure out why resident #27 had to go out if she received treatment. The Administrator stated the incident was being discussed in the morning meeting when the daughter arrived. The Administrator remembered resident #27's daughter came to see her the next morning, 10/03/24. She was upset that the staff did not respond appropriately to her mom. The Administrator explained resident #27's daughter showed her a picture of the resident's arm and it had some discolored skin. There were other areas on her arm that did not look like they were treated. The Administrator stated the daughter explained when she arrived to the facility to see her mother, the nurse was passing medications and CNA K was working in the fall risk area. The daughter stated she knew accidents happened, but the staff did not act concerned about her mother's burns. The Administrator explained the daughter told her that resident #27 called her and told her she needed to come here to see her. The daughter said her mother was in pain when she arrived at the facility around 6:30 or 6:40 PM on 10/02/24 and explained LPN J was still passing medications and had not been back to see resident #27 after the initial visit so the daughter called 911. The Administrator was asked if LPN J should have done a head-to-toe assessment when he first went to see resident #27 and her response was, LPN J stated he treated what he saw and went on to do medication administration. On 10/14/24 at 6:45 PM, via the telephone, resident #27's daughter stated CNA K fixed a cup of soup and after she set it on the table, the soup spilled on her mother. The daughter explained she received a call from the nurse that her mother was burned. The daughter said she came to the facility and spoke to the Supervisor who had no idea her mother was burned. She stated the Supervisor told her he would get the nurse, and they could discuss what happened, but when he found the nurse, the Supervisor went into the room and talked to him. The daughter said she got upset because the nurse and Supervisor were supposed to discuss what happened with her and they went in a room to talk amongst themselves. The daughter said she called 911 because she felt her mother needed to go to the hospital, and the police because she wanted to find out what happened. The daughter explained the Emergency Personnel took her mother to a nearby Hospital emergency room where she was assessed. Shortly afterwards the hospital transferred her to the to the specialized burn unit at a larger Level One hospital. The daughter stated when resident #27 got to the first hospital, they had to pour some kind of liquid on her clothes to remove them, as she the wet clothes had not been removed from the burned areas of her skin by the nursing home staff for almost two hours. She said after that is when they decided to send her to the larger hospital with the burn unit. She remained in the hospital a total of 5 days with second degree burns. On 10/16/24 at 1:47 PM, LPN J was interviewed by telephone. He stated CNA K had called him to say resident #27 burned herself while she was eating noodle soup. He stated he went to the room and the resident was sitting in her wheelchair. LPN J stated he asked the resident what happened and she said see my hand? He recalled the resident told him she had spilled the hot soup and he saw a skin tear on the resident's left arm. The LPN said he left resident #27 sitting in her wheelchair and went to the nurses' station, and called the doctor and daughter about what happened. He stated he came back to the resident's room and applied an antibiotic ointment to the resident's left arm as ordered by the physician then went back out to continue his medication pass. LPN J verified he was not aware the resident had spilled the hot soup on her left leg and stomach. He replied, No she did not tell me that. The LPN stated he did not notice her clothing was wet and had not performed a head-to-toe assessment when he learned of the incident. LPN J explained he was going to reassess resident #27 later when he finished his medication pass. A second degree or deep partial thickness burn involves damage or destruction of the first and second layers of the skin, which will be painful and often blistered. A full thickness burn can destroy nerves so pain might not be felt and will often look brown, black, or white and feel dry and leathery. You should go to the Emergency Department if the skin looks leathery, or there are patches of brown, black or white or if the burn involves the hands, airway, face or genitals. The first thing you should do if someone has a burn is to take off any contaminated clothing unless it is sticking to you and wash the affected area with plenty of cool water for up to 60 minutes. As soon as possible any clothing or jewelry should be removed, unless they are stuck to the burn, then it should be covered with something clean. Consequences of burn injuries that may progress without treatment include ischemia (obstruction of blood flow) due to increased swelling (edema), and infection, (retrieved on 10/31/24 from www.healthdirect.gov). On 10/17/24 at 11:30 AM, the DON stated she would expect the nurse would immediately complete a head-to-toe assessment and provide any necessary emergency treatment as ordered if a resident had a burn or any injury. She explained because it was a burn it should never had been presented to the physician as a skin tear. She added, the resident should have been reassessed because the skin did not always show the extent of the burn(s) right away. On 10/16/24 at 1:10 PM, via telephone interview resident #27 stated the burn occurred around dinner time, on 10/02/24 approximately 5:00 to 5:30 PM. The resident stated staff brought her meal tray and she was eating a piece of pie. She said she tried to move the pie when the cup of noodles spilled the very hot liquid all over. She said when the hot liquid hit her skin it hurt and she started screaming and hollering. Resident #27 said CNA K called the nurse and told him that a couple noodles got spilled on her and by the time LPN J got there her arm was burning. Resident #27 said LPN J later put something on her arm. The resident said she told the nurse her stomach and leg were burning, but he did not even look at it. Resident #27 explained she then called her daughter and told her she needed to come. The resident stated by the time her daughter got there she had a blister down to her thumb. She said her daughter called 911 and the police and she went to the hospital. Resident #27 said when she arrived at the hospital, they poured something on her to remove the clothes that were now stuck to her burned skin. She stated the doctor told her she had second degree burns and they gave her something for pain so she was out of it. The resident said she then went to the burn unit. She explained she could move her arm and leg now, but her stomach still hurt where it was burned. She said she got medication for the pain that took the edge off, so she could move her leg but when they get her up for therapy it hurts. The resident stated, They did not change me I went to the hospital in the same wet clothes. Review of the burn unit hospital records for resident #27, dated 10/02/24, skin assessment revealed, Partial thickness burn wounds with blistering to the left dorsal forearm extending to the lateral aspect of the base of the thumb and extending mid-way to the ventral aspect of the forearm. The open areas blanch well. Partial thickness burn wounds with blistering to the left lower anterior abdominal wall, left anterior and posterior thigh. The total body surface area prior to debridement is approximately 4 %. Mental status: She is alert and oriented to person, place and time. Review of the Skin Assessment Policy, dated 3/01/22 and revised 3/01/24, revealed a full body, or head-to-toe skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission, and at least weekly thereafter and may also be performed after a change of condition. Patients with burn injuries are complex and have high mortality. Burns are traumatic injuries that can cause profound shock within minutes and can affect every body system. Nurses must prioritize assessment of the airway, the cause of burn, depth, and TBSA [total body surface area] during the initial screening. These assessments are important to appropriately resuscitate the patient and decrease the risk of burn shock. Patients with burns are at considerable risk for infection and hypothermia. Nurses should keep patients warm and transfer them to a certified burn center as soon as possible for the best outcomes. Providing early, quality nursing care to patients with burns will make all the difference in the outcome, (retrieved on 10/22/24 from www.nursingcenter.com/cearticle). 50401 2. On 10/17/24 at 3:25 PM, an undated treatment bandage was observed on the right forearm near the elbow of resident #84. The resident stated someone put the bandage on a couple of days ago after an injury. Review of resident #84's Progress Notes, the record of weekly skin checks indicated on 10/07/24, the resident had a skin tear to right elbow. On 10/12/24, the resident had a skin tear to right elbow and treatment was in progress, and on 10/16/24, the weekly skin check also indicated the resident had a skin tear to right arm. On 10/17/24 at 3:27 PM, Registered Nurse (RN) I verified there was an undated bandage on right upper arm near the elbow of resident #84. RN I removed the bandage and noted there to be a gauze dressing under the bandage which was saturated with blood. She confirmed this finding and stated she would change the dressing. RN I then checked the computer record for a physician's treatment order and found there was not one. She stated she needed a physician's order for treatment so she would reach out to the physician for one. The G and R Unit Manager also present verified there was not a physician order for this treatment. She confirmed all treatment needed a physician's order to be provided. The facility's policy entitled Wound Treatment Management dated 3/01/22 and revised 3/01/24, revealed the facility was to provide evidence-based treatments in accordance with current standards of practice and physician orders. This would include dating a bandage when it was placed along with the method used to clean the wound, the type of dressing, and the frequency the dressing was to be changed.

Based on interview and record review the facility failed to prevent an avoidable accident for a resident by not checking the temperature of microwaved noodles provided by staff for 1 of 2 residents reviewed for accidents, of a total sample of 37 residents, (#27). The facility's failure to provide a policy and ensure all staff were educated regarding the heating and reheating of resident food resulted in actual harm. Resident #27 was transferred to a higher level of care, then transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained in the hospital for 5 days. Findings: Cross reference F684 and F813 Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis (one sided weakness and paralysis), type 2 diabetes mellitus with diabetic neuropathy (diabetic nerve damage), and contracture of the left hand. The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/21/24, revealed the resident was cognitively intact with a Brief Interview of Mental Status of 14/15. The record revealed the resident had left sided weakness and paralysis due to a stroke. Her left hand was contracted. The MDS read she was a set up assistance for eating and could feed herself. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. There was no further documentation from LPN J or other nurses regarding the assessment/reassessment or treatment for resident #27 in the medical record. On 10/14/24 at 11:30 AM, resident #11 (roommate of #27) stated she did not see what happened when her roommate got burned, but she heard her and CNA K both scream. She recalled when she looked over CNA K said the soup spilled on her roommate. Resident #11 stated that CNA K made the cup of noodles frequently for resident #27. On 10/14/24 at 6:45 PM, via the telephone, resident #27's daughter stated CNA K fixed a cup of soup and after she set it on the table, the soup spilled on her mother. The daughter explained she received a call from the nurse that her mother was burned. The daughter said she came to the facility and spoke to the Supervisor who had no idea her mother was burned. She stated the Supervisor told her he would get the nurse, and they could discuss what happened, but when he found the nurse, the Supervisor went into the room and talked to him. The daughter said she got upset because the nurse and Supervisor were supposed to discuss what happened with her and they went in a room to talk amongst themselves. The daughter said she called 911 because she felt her mother needed to go to the hospital, and the police because she wanted to find out what happened. The daughter explained the Emergency Personnel took her mother to a nearby Hospital emergency room where she was assessed. Shortly afterwards the hospital transferred her to the to the specialized burn unit at a larger Level One hospital. The daughter stated when resident #27 got to the first hospital, they had to pour some kind of liquid on her clothes to remove them, as she the wet clothes had not been removed from the burned areas of her skin by the nursing home staff for almost two hours. She said after that is when they decided to send her to the larger hospital with the burn unit. She remained in the hospital a total of 5 days with second degree burns. A second degree or deep partial thickness burn involves damage or destruction of the first and second layers of the skin, which will be painful and often blistered. A full thickness burn can destroy nerves so pain might not be felt and will often look brown, black, or white and feel dry and leathery. You should go to the Emergency Department if the skin looks leathery, or if there are patches of brown, black or white or if the burn involves the hands, airway, face or genitals. Consequences of burn injuries that may progress without treatment include ischemia (obstruction of blood flow) due to increased swelling (edema), and infection, (retrieved on 10/31/24 from www.healthdirect.gov). On 10/16/24 at 1:10 PM, via telephone interview resident #27 stated the burn occurred around dinner time, on 10/02/24 at approximately 5:00 to 5:30 PM. The resident stated staff brought her meal tray and she was eating a piece of pie. She said she tried to move the pie when the cup of noodles spilled the very hot liquid all over. She said when the hot liquid hit her skin it hurt and she started screaming and hollering. Resident #27 said CNA K called the nurse and told him that a couple noodles got spilled on her and by the time LPN J got there her arm was burning. Resident #27 said LPN J later put something on her arm. The resident said she told the nurse her stomach and leg were burning, but he did not even look at it. Resident #27 explained she then called her daughter and told her she needed to come to the facility. The resident stated by the time her daughter got there she had a blister down to her thumb. The resident explained her daughter called 911 and said, They did not change me I went to the hospital in the same clothes. At the hospital, she recalled they poured something on her to remove the clothes that were now stuck to her burned skin. She stated the doctor told her she had second degree burns and they gave her something for the pain. The resident said she then went to the burn unit at another hospital. She explained she could move her arm and leg now, but her stomach still hurt where it was burned. She said she got medication for the pain that took the edge off, so she could move her leg but when they get her up for therapy it hurt. Review of the burn unit hospital records dated 10/02/24, skin assessment for resident #27 revealed, Partial thickness burn wounds with blistering to the left dorsal forearm extending to the lateral aspect of the base of the thumb and extending mid-way to the ventral aspect of the forearm. The open areas blanch well. Partial thickness burn wounds with blistering to the left lower anterior abdominal wall, left anterior and posterior thigh. The total body surface area prior to debridement is approximately 4 %. Mental status: She is alert and oriented to person, place and time. On 10/15/24 at 3:42 PM, the Administrator stated on 10/02/24 at about 5:30 PM, resident #27 had a cup of noodle soup that you add water to and cook in the microwave. The resident asked CNA K to prepare it for her which she did. The Administrator stated the food should have been heated in the kitchen, instead of on the unit. The Administrator stated a few weeks prior to the incident she was given a stack a paper from the Weekend Supervisor. It included an in-service regarding a resident asking for food to be reheated because one of the nurses had the misconception that the resident food could be reheated on the unit. The Administrator stated she had the microwaves removed from the units and they had a conversation about not reheating food outside of the kitchen. The Administrator said, somehow there was still one microwave available. The Administrator conveyed that CNA K told her she was not aware of that in-service. On 10/16/24 at 10:41 AM, the former Director of Nursing (DON) who was DON at the time of the incident, stated she was not sure what the food policy was regarding heating or rewarming food for residents. She stated the Administration staff discussed rewarming the food due to a grievance, and that staff were supposed to take it to the kitchen if it needed to be warmed or rewarmed. The DON stated the staff did not get educated at that time. On 10/16/24 at 11:01 AM, the Assistant Director of Nursing (ADON) said the staff had not been educated about warming food prior to the incident. On 10/17/24 at 2:30 PM, the Administrator added the facility looked to see if there was any education provided to the staff regarding heating and reheating food, at any time prior to her administration and were unable to find any record. On 10/16/24 at 1:47 PM, LPN J stated he had never received education regarding heating/reheating food to the appropriate temperature to ensure the food provided was at a temperature to minimize the risk for burning or scalding residents. He stated he was not aware that CNA K had been making the noodles for the resident in the microwave. He said he did not recall ever seeing a thermometer in the unit kitchen to take the temperature of the food. On 10/16/24 at 4:55 PM, LPN L stated he was the Evening Supervisor on the night that resident # 27 was burned. He stated he did not recall getting education regarding heating and reheating resident food. He also said he could not recall seeing a thermometer in any of the unit kitchens for taking the temperature of the food. On 10/15/24 at 5:25 PM, and again on 10/16/24 at 11:37 AM attempts were made to contact CNA K by phone. Voice mail was left with both calls and no return response from the CNA was received. CNA K was no longer employed by the facility. Policy review revealed the facility food policies, Safety of Hot Liquids no date, Food Safety Requirements date implemented 3/01/22, revised 6/01/24, Use and Storage of Food Brought in by Family and Visitors dated 3/01/21 and revised 4/01/23, did not include instructions for staff to take food for the residents to the kitchen to be heated/reheated, nor any guidance for appropriate temperatures for the heating/reheating of food.

Based on interview, and record review, the facility failed to provide a policy or training to staff regarding reheating of food for residents. This lack of instruction caused the resident to receive second degree burns when her food was heated in the microwave, for 1 of 1 resident reviewed for burns, of a total sample of 39 residents, (#27). Findings: Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis (one sided paralysis and weakness), type 2 diabetes mellitus with diabetic neuropathy (diabetic nerve damage), and contracture of the left hand. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. Per interview with the Administrator on 10/15/24 at 3:45 PM, including statements from CNA K revealed on 10/02/24 at approximately 5:30 PM, resident #27 asked CNA K to make her a cup of noodles which she purchased from the Activity Store at the facility. CNA K took the cup of noodles to the staff kitchen on the unit and added extra water per the resident request and cooked it in the microwave. The CNA brought the cup of noodles to the resident and as CNA K placed the noodles on resident #27's over bed tray table, the resident hit the cup and the cup of noodles spilled toward the resident ending in subsequent burns to the resident. On 10/14/24 at 11:30 AM, resident #11 (the roommate of resident #27) stated she did not see what happened, but she heard resident #27 and CNA K both scream and when she looked over CNA K said the soup spilled on the resident. Resident #11 stated that CNA K made the cup of noodles frequently for resident #27. On 10/15/24 at 3:42 PM, the Administrator stated the staff were not supposed to warm food for the residents and should take the food to the facility kitchen to be warmed. She stated she thought there was an in-service given a few weeks prior to the incident informing the staff that they should not warm anything for the residents themselves. She stated the microwaves had been removed from the unit kitchens but she could not explain why there was still one on the General and Restorative Unit which was used by CNA K On 10/16/24 at 10:41 AM, the former Director of Nursing (DON) stated she remembered a discussion about not heating or reheating resident food, but it was only discussed with the Administrative team. She said the staff did not get education at that time. On 10/16/24 at 1:47 PM, during a telephone interview with LPN J he stated he did not receive any education regarding heating resident food or the safe temperature for serving food. He stated he was not aware staff should not heat or reheat resident food. LPN J stated he did not recall ever seeing a thermometer in the unit kitchen for staff to check the temperature of foods. On 10/16/24 at 4:55 PM, LPN L stated he was the Evening Supervisor on the night that resident # 27 was burned. He stated he did not recall getting education regarding heating and reheating resident food. He said he could not recall seeing a thermometer in any of the unit kitchens for staff to check food temperature. On 10/17/24 at 11:30 AM, the Assistant Director of Nursing (ADON) stated the staff did not receive any education regarding reheating or heating food for residents until after this incident. Interview and policy review revealed the facility food policies, Safety of Hot Liquids no date, Food Safety Requirements date implemented 3/01/22, revised 6/01/24, Use and Storage of Food Brought in by Family and Visitors date 3/01/21 and revised 4/01/23, did not include instruction or guidance for staff to heat/reheat food themselves or for them to take resident food to the kitchen to be heated/reheated.

Based on observation, interview, and record review the facility failed to treat residents with dignity and care to promote quality of life by standing while feeding them and referring to residents as feeders for 2 of 6 residents reviewed for assisted dining, of a total sample of 37, (#15 and #29). Findings: 1. On 10/16/24 at 9:45 AM, resident #15's assigned Certified Nursing Assistant (CNA) D was observed in the residents room standing over the resident while feeding her. CNA D stated she was aware she was supposed to sit while feeding residents, but explained she was busy running from resident to resident and didn't get a chair. She stated she knew it was important to sit while assisting residents with their meals to be at eye level with them. On 10/16/24 at 12:41 PM, CNA C was observed as she delivered and set up the lunch tray in front of resident #15, then left the room. Two minutes later at 12:43 PM, resident #15 was observed eating the food from her lunch tray with her hands. At 12:44 PM, CNA D passed by resident #15 in the 'A' bed and delivered the meal tray to the roommate in the 'B' bed. She did not acknowledge resident #15 eating with her hands visibly in front of her, and left the room. A short time later at 12:56 PM, resident #15's daughter, was observed sitting in a chair next to her mother, assisting her with her lunch meal. She stated she was concerned her mother did not receive the assistance she needed to eat her meals. She stated when she walked into her mother's room today, her mother was not being assisted to eat or drink and instead was attempting to do it herself. She stated she had previously voiced concerns to the facility for her mother to get assistance with meals. Resident #15's daughter stated she had been assured this had been handled, and she added she was not here every day to assist her mother. On 10/16/24 at 1:13 PM, CNA C explained when she brought the lunch tray to resident #15 earlier she was not aware if she was a feeder or not. She stated she had asked her co-worker, CNA D, who the feeders were on the unit, and CNA D told her she had six of them. She stated this morning she assisted resident's in the dining room with the breakfast meal and was not that familiar with the residents on this unit. She continued, she was a CNA who worked on a variety of units floating as needed (PRN) and usually worked the overnight shift. She stated she was not aware she should not refer to residents as, feeders, and did not know it was not an acceptable practice. On 10/16/24 at 1:30 PM, CNA D stated if CNA C was not aware that resident #15 was a feeder, she should have left the tray on the cart and asked for clarification instead of just setting up the tray for the resident. CNA D stated she was also a floating PRN CNA and had only been working at the facility a few months. She added, it was important to know which residents were feeders and not to leave the tray at the resident's bedside unattended if they needed assistance for safety and hygiene reasons. She explained the tray could be knocked over by the resident accidentally or they could put their hands in the food and also to keep the food warm. She continued, it was important to help maintain the resident's dignity. She stated she was aware she should not refer to residents as feeders and she didn't do it in front of them. 2. On 10/16/24 at 12:54 PM, CNA D was overheard saying, Feeder, feeder, feeder aloud in the hallway outside resident rooms, to indicate which residents needed assistance with their meals, and as she figured out which resident's room to go to next. On 10/16/24 at 1:05 PM, CNA C was observed standing up over resident #29, feeding him his lunch meal. On 10/16/24 at 1:10 PM, CNA C confirmed she had been standing while she fed resident #29 their lunch today. She explained she stood because she was in a hurry. She stated she was aware she was supposed to sit while she fed a resident in order to be at their level. On 10/17/24 at 4:38 PM, in a joint interview with the G and R Unit Manager and the Director of Nursing (DON), the Unit Manager stated when CNAs assisted a resident with their meal, she expected them to wash their own and the resident's hands, to set up the meal comfortably and then sit down with the resident at eye level. She added that CNAs needed to refer to residents using their preferred name and not use labels, like feeders. The DON added no staff were to use the term feeder, but instead were to use the terminology, assisted diners. The DON continued, when CNAs were working a shift on a unit they were not familiar with, they were expected to get information about the resident's needs as they rounded and huddled in the morning. She explained they could use the Kardex as a resource and they could ask the nurse. They were not to leave a meal tray at a resident's bedside if they didn't know if the resident needed assistance or not, but were to leave the meal on the cart and find out first. They should bring the meal to the resident only when they were ready to assist them for the entire dining process. The facility's policy entitled Promoting/Maintaining Resident Dignity dated 3/01/22 and revised 4/01/22 indicated staff were to pay attention to each resident as an individual, explain care and procedures before initiating an activity, speak respectfully to residents and avoid discussions about residents that may be overheard by others.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed, (#33), and failed to request a Level I and/or Level II PASARR evaluation after a new major mental disorder diagnosis, (#65), for 2 of 2 residents reviewed for PASARR, of a total sample of 37. Findings: 1. Resident #33 was readmitted to the facility from the hospital on 3/29/24 but was initially admitted on [DATE]. On admission she had diagnoses that included cerebral infarction stroke), aphasia (difficulty speaking), vascular dementia with other behavioral disturbances, major depressive disorder, and mood disorder. Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #33 was severely cognitively impaired, had impairments to both upper and lower extremities limiting range of motion, was bedbound, and dependent for all activities of daily living (ADLs). Review of the medical record for resident #33 revealed a PASARR Level I dated 10/25/23 that had no mental illness (MI) diagnoses listed. On 10/17/24 at 1:04 PM, the Director of Nursing (DON) stated she was the person responsible for completing the PASARRs. She explained she was new to the facility and had just gotten around to auditing the PASARRs for all of the residents to make sure they were complete. She confirmed resident #33 had been readmitted to the facility on [DATE] and a new PASARR should have been done. She said that the Admissions office was responsible for verifying that the PASARRs were completed and if they were not, they needed to let the her know so that she could submit a new one. 50875 2. Review of the medical record revealed resident #65 was admitted to the facility on [DATE] from the hospital. Her diagnoses included chronic atrial fibrillation, type 2 diabetes with hyperglycemia, dementia, major depressive disorder, recurrent unspecified, mood disorder due to known physiological condition with mixed features and insomnia. Resident # 65's Quarterly MDS assessment with assessment reference date of 8/05/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she had no cognitive impairment. The assessment indicated she had rejection of care. Her active diagnoses listed non-Alzheimer's dementia, depression and bipolar disorder. Review of resident #65's medical record showed a Care Plan dated 6/13/22, which indicated resident #65 had behaviors, was paranoid, hateful toward her family, aggressive, would ask for her room to be changed if it was shared with a roommate, pulled out her hair, and took items from the activity room then claimed the items were hers. Another care plan dated 11/02/22 revealed resident #65 refused medications, food and showers, and personal care. Resident #65's Order Summary Report and the Medication Administration Record showed the resident had an order for Trazodone 100 milligrams (mg) by mouth at bedtime for depression, Depakote 250 mg in the morning and 500 mg two times a day for dementia and other diseases classified elsewhere, moderate with other behavioral disturbance: mood disorder due to known physiological condition with mixed features. The Order Summary Report also showed resident #65 was evaluated and treated by Psychology for depressive symptoms. On 10/14/24 at 1:26 PM, resident #65 was observed in her room and appeared anxious and upset. She explained her son brought herto the facility and she lost her apartment. She expressed she felt depressed but not to the point of hurting herself. A short time later the assigned nurse and the Unit Manager revealed resident #65 refused to let staff care for her at times. Further review of resident #65's electronic medical records, revealed the PASARR Level I screen dated 5/23/22, was found to be inaccurate as no Mental Illness diagnoses were listed in Section 1A of the form. On 10/16/24 at 1:44 PM, the DON and Assistant DON were asked about PASARRs being updated and the DON stated she was responsible for the PASARRs. She explained the initial PASARR was reviewed on admission and if there was a new diagnosis, the form would be updated. She stated there were no paper charts used at the facility, so the PASARR scanned in the resident's electronic medical record was correct and the only accessible one. On 10/16/24 at 1:53 PM, the Medical Records clerk verified the PASARR Level I dated 5/23/22 was the only one and there were no other updated forms. The DON and Assistant DON verified resident # 65's current diagnoses differed from those on the PASARR. They both confirmed it was an inaccurate PASARR because the mental illness diagnoses were not listed in Section 1A. The DON also acknowledged resident #65's 3008 Transfer form had a diagnosis which should have been listed in Section 1A. The DON said she would correct and update the Level I PASARR for resident #65. Review of the Facility's Policy on Resident Assessment -Coordination with PASARR Program implemented 3/01/22 revealed the facility coordinated assessments with the PASARR program under Medicaid to ensure that individuals with mental disorders, intellectual disability or a related condition received care and services in the most integrated setting appropriate for their needs. Compliance guidelines included a PASARR Level I was completed prior to admission and that a negative Level I screen permitted the admission to proceed and ended the PASARR process unless a possible serious mental disorder or intellectual disability arose later.

Based on interview, record review, and facility's policy review, the facility failed to ensure care and services consistent with professional standards of practice to prevent pressure ulcers was provided, by failing to follow physician's order for weekly skin sweeps for 1 of 4 residents reviewed for pressure ulcer, of a total sample of 37 residents, (#42). Findings: Resident #42, a [AGE] year-old male was admitted to the facility on [DATE], and readmitted on [DATE]. His diagnoses included heart failure, cognitive communication deficit, diabetes type II, peripheral vascular disease, and malignant neoplasm (cancer) of the prostate. The resident's significant change Minimum Data Set assessment, with Assessment Reference Date of 9/08/24, revealed the resident's cognition was moderately impaired, with a Brief Interview of Mental Status score of 10 out of 15. The assessment noted the resident had functional limitation in range of motion to one side of his lower extremity, was dependent on staff assistance for toileting hygiene, and mobility. He required partial/moderate assistance to roll left and right. The assessment noted the resident was at risk for pressure ulcer and had one unhealed pressure ulcer that was classified as an unstageable deep tissue injury. Review of the resident's physician's order summary revealed a physician's order dated 7/03/24 for weekly skin sweeps on the 7 AM-3 PM shift every Wednesday. Physician's order on 9/11/24 was for skin prep wipes to be applied to the resident's bilateral heels three times daily for preventative treatment. Clinical record review revealed a weekly skin sweep was conducted for resident #42 on 7/09/24, and on 8/21/24. Documentation of additional skin sweeps could not be identified. On 10/17/24 at 9:30 AM, Licensed Practical Nurse (LPN) I stated skin sweeps were scheduled, based on the location of residents' beds. She explained that skin sweeps were conducted for residents in the A bed on the 7 AM to 3 PM shifts, and for residents in the B beds on the 3 PM to 11 PM shifts and schedule would be included in the residents' physician's orders. LPN I stated she usually worked on Tuesdays, and Thursdays, and resident #42's skin sweep was scheduled for Wednesdays, on the 7 AM-3 PM shift. The resident's clinical records were reviewed with the LPN, and she acknowledged that skin sweeps were conducted on 7/09/24, and on 8/21/24, and no other skin sweep documentation could be identified. On 10/17/24 at 9:34 AM, the G&R Unit Manager (UM) stated weekly skin sweeps were as per physician's order. She stated skin sweeps were done to monitor the resident's skin, and to identify any skin issue, and the order would populate to the resident's Treatment Administration Record (TAR) or the Medication Administration Record (MAR). The resident's MAR was reviewed with the UM, and revealed signatures on 8/14/24, 8/28/24, 9/04/24, 9/11/24, 9/18/24, 9/25/24, 10/02/24, 10/09/24, and on 10/16/24 indicating skin sweeps were conducted for the resident. However, skin sweep documentation could not be identified for the dates documented/signed off on the MAR. The UM acknowledged the resident's physician's order for weekly skin sweep, and the two completed skin sweep documentation on 7/09/24, and 8/21/24, and acknowledged that no other documentation could be identified to indicate skin sweeps were actually conducted for the resident weekly as ordered by the physician. The UM stated the expectation was that nurses would complete residents' skin sweeps as order and stated a weekly skin assessment was to be completed and documented under the Assessment tab in the resident's electronic medical record (EMR). On 10/17/24 at 9:42 AM, the Assistant Director of Nursing (ADON) reviewed resident #42's MAR. She acknowledged signatures for the dates identified, and confirmed that no weekly skin sweep documents could be identified for the dates signed off on the MAR. On 10/17/24 at 10:07 AM, Registered Nurse (RN) A demonstrated how, and where skin sweeps would be documented in the resident's EMR. She stated that normally the UM provided staff with the schedule for residents' skin sweep daily. RN A stated staff were instructed to follow the User-Defined Assessments calendar for resident's skin sweep schedule. The RN said she never did skin sweeps for the resident, because it was not on the User-Defined Assessments calendar. She stated her signature on the resident's MAR on 8/07/24,8/28/24, 9/04/24, 9/11/24, and 9/25/24 indicated the order for skin sweep was acknowledged, not that it was completed. On 10/17/24 at 10:14 AM, an interview was conducted with the Director of Nursing (DON), the ADON, and the G&R UM. They all stated that if nurses signed off on an order, the signature would indicate that the task was completed as ordered. The facility's policy Skin Assessment implemented on 3/01/22 read, A full body, or head-to-toe skin assessment will be conducted by a licensed or registered nurse upon admission/ re-admission and at least weekly thereafter.

Based on observation, interview, and record review, the facility failed to ensure respiratory therapy was provided as per physician orders for 1 out of 1 resident reviewed for respiratory care, of a total sample of 37 residents, (#93). Findings: Resident #93 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), heart disease, hyperlipidemia, hypotension, history of falling, cognitive communication deficit, ischemic cardiomyopathy, and essential hypertension. Review of the Significant Change Minimum Data Set assessment with reference date 5/29/24, revealed resident #93 had mild cognitive impairment, had no behaviors, nor refused care, and required the use of oxygen. Resident #93 was dependent for transfers and used a wheelchair for mobility. Review of resident #93's Physician Orders for continuous oxygen was 1 liter per minute (LPM) every shift for Shortness of breath. Resident #93 had a baseline Care Plan for required use of oxygen as ordered because of the resident's diagnosis of COPD. On 10/14/24 at 1:33 PM, resident #93 was observed in bed and was alert and oriented. Observation of the oxygen concentrator showed it was set at 1.5 liters of oxygen per minute and the bag attached to the oxygen concentrator dated with 10/14/24 contained the oxygen tubing and nasal cannula. She was not wearing the nasal cannula for the oxygen. Resident #93 stated she did not think she needed it because she rarely used it. On 10/14/24 at 1:48 PM, assigned nurse Licensed Practical Nurse (LPN) F entered resident #93's room to bring pain medication for the resident. After she administered the medication, she placed the nasal cannula which she removed from the bag attached to the oxygen concentrator on the resident. When asked why the resident was not connected to her oxygen, LPN F stated the order was for oxygen as needed. LPN F was then asked to verify the number of liters on the concentrator to which she verified the flow rate was set at 1.5 LPM. After LPN F exited the resident's room, she was asked to verify the physician's orders for oxygen in resident #93's electronic medical record. LPN F confirmed the physician's order was for continuous oxygen at 1 LPM and proceeded to correct the concentrator setting. LPN F explained she often checked at the beginning of her shift and verified the orders but was not sure what happened today. LPN F explained that neither the certified nursing assistant (CNA) nor the resident would have adjusted the flow rate on the oxygen concentrator, and it was the nurse's responsibility. LPN F acknowledged the amount was incorrect and that the physician orders were not followed. On 10/16/24 at 12:30 PM, the Unit Manager (UM) for the Specialized Sub-acute Unit stated the expectation for residents on oxygen was that nurses checked and verified orders on all shifts. On 10/16/24 at 1:25 PM, the Director of Nursing explained the expectation was for nurses to follow the physician orders and check the setting of the concentrator at least once per shift. She acknowledged they failed to follow physician orders for resident #93. Review of the Oxygen Administration Policy implemented on 3/1/22 and revised 3/1/23 revealed oxygen was administered to residents who need it consistent with professional standards of practice, the resident's care plan and the resident's choice. It also indicated as part of the compliance guidelines that oxygen was administered under orders of a physician except in emergencies and once the situation was under control, orders for oxygen were obtained as soon as practicable.

Based on observation, interview, and record review the facility failed to follow proper infection control practices to prevent cross-contamination during wound care for 1 of 1 resident reviewed for pressure ulcers, of a total sample of 37 residents, (#33). Findings: Resident #33 was readmitted to the facility from the hospital on 3/29/24 with diagnoses that included cerebral infarction (stroke), vascular dementia, gastrostomy status, and multiple pressure ulcers. Review of Significant Change Minimum Data Set assessment dated [DATE] revealed that resident #33 was severely cognitively impaired, had impairments to both upper and lower extremities limiting range of motion, was bedbound, and dependent for all activities of daily living. She was at high risk for pressure ulcer development and at the time of the assessment had five facility acquired unstageable pressure ulcers. Review of resident #33's order summary report dated 10/17/24 revealed she had a wound order for the right buttocks. The physician orders directed the nurse to cleanse the wound with normal saline, pat dry, apply Leptospernum Honey ointment, and cover with 4x4 island dressing daily. The medical record also revealed a care plan for ADL self-care performance deficit related to dementia and limited mobility that included interventions for extensive assistance of one person to turn and reposition resident as well as extensive assistance of two people to move resident up in bed. The pressure ulcer care plan's goal as documented by the facility, was for pressure ulcer to show signs of healing and remain free from infection. On 10/16/24 resident #33 had an initial wound evaluation for the right buttocks wound completed by the Wound Care doctor. She diagnosed the wound as a stage 2 partial thickness pressure wound measuring 0.8 centimeters (cm) by 1.5 cm by 0.1 cm deep. The wound had light serous drainage and exposed dermis. The plan was to follow the wound treatment orders and reposition resident per facility protocol. On 10/17/24 at 10:12 AM, wound care was observed for resident #33 with the Wound Care nurse. The nurse had already set up the bedside table with her supplies and proceeded to wash her hands. She donned clean gloves and started dressing the wounds to the resident's bilateral legs and heels with no issue. She washed her hands again before treating the wound on the resident's buttocks. After donning the clean gloves, she went to the bedside table to gather the supplies (4x4 island dressing with Leptospernum Honey ointment already on it, extra gauze, and normal saline) and placed them on the bed. She informed the resident that she would be rolling her onto her left side and proceeded to do so with both hands. She used one arm to keep resident from rolling back and the other to remove the soiled dressing from the resident's right buttock. The wound appeared as described by the Wound Care doctor's documentation on 10/16/24. After removing the soiled dressing, the wound care nurse rolled the resident on her back and then removed the gloves to perform hand hygiene. She then donned clean gloves, rolled resident to her left side and held her with one arm. She used her free arm to moisten a gauze with normal saline and use it to clean the wound. After cleaning the wound, she patted it dry with a clean gauze and rolled the resident on her back and on to the bed. She performed hand hygiene and donned clean gloves again to roll resident on her left side to complete dressing the wound. She applied the 4x4 island dressing with ointment onto the resident's right buttock and rolled her on to her back. On 10/17/24 at 10:20 AM, the Wound Care nurse stated she was unable to have a second person in the room to help her because the Certified Nursing Assistant (CNA) was busy. She said she tried to maintain a clean environment to prevent cross- contamination when doing wound care to prevent infection, but it was not always possible, and she had many other residents to treat. On 10/17/24 at 11:41 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist, stated that she did not observe the Wound Care nurse during wound care because she expected the Wound Care nurse to follow proper infection control practices. She agreed that the Wound Care nurse should have made sure she had proper assistance prior to completing wound care with resident #33 to prevent cross-contamination of the wound due to resident's inability to position herself. The ADON said that if the CNA was not available to assist with wound care, the Wound Care nurse should have asked someone else or should have waited until someone was available. Review of the facility's Policy and Procedures on Clean Dressing Change revised 4/01/23, revealed it was the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Compliance guideline number 8 of 18 prompted the staff member to place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites.

Based on observation, interview, and record review, the facility failed to provide a call device to allow residents to call for staff assistance for 2 of 18 residents observed for call lights, of a total sample of 37, (#30 and 55). Findings: 1. On 10/16/24 at 12:26 PM, resident #30, was observed in bed, alert and oriented to self and place. Resident #30's call device was a large, white square push/touch device seen on the nightstand on her right side, out of her reach. She stated she wanted to get out of bed and into her wheelchair. She then stated she didn't have a call device and had no way to reach staff for help. On 10/16/24 at 1:32 PM, Certified Nursing Assistant (CNA) D verified resident #30's call device was located on the nightstand and was not accessible to the resident. The call bell, was a larger, flat device designed specifically for residents who had difficulty pressing a regular call device. She moved the call device from the night stand and wrapped the cord around the bedrail so it would stay in place. She educated the resident on how and when to use the call device and the resident confirmed understanding and touched the call device, setting it off. 2. On 10/16/24 at 12:20 PM, resident #55's was observed in bed, she was alert and oriented to person, place and time. Her call bell device was observed to be wound up in the bed frame, hanging down toward the ground and not be in reach of the resident. On 10/16/24 at 1:45 PM, CNA C verified resident #55's call light was not accessible to her. The resident verbalized she could use the call bell, tried to reach it but said she could not. CNA C untangled the call light from the bed frame, brought it up within reach, to the resident's bed, and clipped it to the resident's bedsheet so it would not fall but would be within reach for her. On 10/17/24 at 4:38 PM, in an interview with the G and R Unit Manager and the Director of Nursing (DON), the Unit Manager stated call devices for residents needed to be placed within arm's reach of the resident. The DON clarified, call lights should be within hand's reach for all residents. She added, if a resident had difficulty using a call light, the facility provided a special larger, flat call light which just needed to be touched by the resident and was much easier to use. The facility's policy entitled Call Lights: Accessibility and Timely Response dated 1/01/23 indicated each resident should have access to a call light while in their bed and evaluated for any unique needs and preferences to determine any special accommodations needed in order for the resident to utilize the call system.

Based on interview and record review the facility failed to provide showers as scheduled, and as per resident's preference for 2 of 2 dependent residents reviewed for Activities of Daily Living (ADL), of a total sample of 6 residents, (#1, and #5). Findings: Resident #1, a 72 -year-old male was admitted to the facility on [DATE], with his most recent readmission on 11/25/22. His diagnoses included traumatic subdural hemorrhage, peripheral vascular disease, diabetes type II, hemiplegia/ hemiparesis following cerebral infarction affecting left non dominant side, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/27/24 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 03 out of 15. The assessment indicated the resident was dependent on staff assistance for toileting hygiene, shower /bathe, and personal hygiene. The resident's care plan for ADL self-care performance deficit related to history of stroke, Transient Ischemic attack, and weakness initiated on 1/28/20 revealed the resident required the assistance by 1 staff for transfer, personal hygiene, and bathing/showering. Review of the Certified Nursing Assistant (CNA) task for bathing, revealed the resident's scheduled shower days were Tuesday, and Saturday in the evenings. Review of the Point of Care (POC) documentation for the period 3/01/24 through 5/28/24 indicated resident #1 was provided with a shower on 3/16/24, and on 4/16/24. There was no documentation to indicate showers were provided to the resident on any of his other scheduled shower days during this 3-month period. No documentation could be identified to indicate the resident refused his showers on the dates mentioned. On 5/29/24 at 3:09 PM, the Director of Nursing (DON) stated showers were scheduled for residents two days per week, and as per resident preference. She stated that in the morning clinical meeting following the resident's admission, showers would be scheduled and added to the CNA's task, then would be adjusted/changed to accommodate the resident preference. The DON stated the facility had a preprinted schedule, and residents in the A Bed- were scheduled to have their showers during the day shift. Residents in the B-Bed were scheduled to receive their showers during the evening shift, but if resident wanted to change their schedule, their preference would be accommodated and honored. The resident's Documentation Survey Report for the period from March 2024 through May 2024 were reviewed with the DON. She acknowledged the documentation indicated the resident received a shower on 3/16/24, and on 4/16/24 and not again for the month of May. She acknowledged there was no documentation to indicate the resident refused his showers, and a care plan for refusal of showers was not identified. The DON confirmed that based on the records reviewed, showers were not provided for resident #1 as scheduled. She stated if a resident refused showers, the CNA should notify the nurse, and any refusals should be documented. If the resident's preference was for bed baths, the task should be changed to reflect the resident's preference. On 5/29/24 at 4:33 PM, CNA A stated she worked on the 3 PM to 11 PM shift every other weekend, and sometimes picked up shifts during the week. The CNA confirmed she had resident #1 in her assignment sometimes, and stated he did not refuse showers. The resident's Documentation Survey Report was reviewed with CNA A. She acknowledged documentation indicated resident #1 received two showers for the periods reviewed. CNA A stated she could not recall why she provided a bed bath for the resident instead of a shower on his scheduled shower days. On 5/29/24 at 4:44 PM, CNA B recalled providing care for the resident previously, and stated the resident showers were scheduled on the afternoon shift. The resident's Documentation Survey Report was reviewed with CNA B, she acknowledged her signature, but could not recall why she did not provide a shower for the resident on his scheduled shower days. On 5/29/24 at 4:55 PM, CNA C stated if the resident refused showers, she would notify the resident's nurse, and document refusal in the POC. CNA C said resident #1 did not refuse his showers, however, sometimes when the resident was in bed, she provided him with a bed bath, instead of his showers. The CNA said the resident required the assistance of two persons and sometimes there was no one available to assist her. 2. Resident #5, an 82- year-old female was admitted to the facility on [DATE], with diagnose including mitochondrial metabolism disorders, functional quadriplegia, and generalized anxiety disorder. The resident's quarterly MDS assessment with ARD of 2/14/24, revealed the resident's cognition was moderately impaired with a BIMS score of 11 out of 15. Review of the facility's Grievance Log for the period March 2024 to current revealed an entry pertaining to the resident on 3/21/24. Resident #5's responsible party verbalized the resident was scheduled for showers in the PM, and the preference was for showers in the AM. The facility's resolution was for the, Resident to continue to receive accommodation when possible, to have her showers in AM on scheduled days. Review of the CNA tasks revealed she was scheduled for showers on Monday and Wednesday on the 3 PM-11 PM shift. Documentation read, prefers early shower. Review of the resident's Documentation Survey Report for the periods March 2024, April 2024, and May 2024 revealed the resident received showers on 3/02/24 documented at 2:59 PM, 4/08/24, 4/14/24, 4/15/24 documented between 9:15 PM and 10:59 PM, 5/04/24 documented 5:42 PM, and 5/10/24 documented 9:15 PM. There was no documentation to indicate the resident received showers per the resident/responsible party's preference on her scheduled shower days on 3/04/24, 3/06/24, 3/11/24, 3/13/24, 3/18/24, 3/20/24, 3/25/24, 3/27/24, 4/01/24, 4/03/24, 4/17/24, 4/22/24, 4/24/24, 4/29/24, 5/01/24, 5/06/24, 5/13/24, 5/15/24, 5/20/24, and 5/27/24. The Assistant DON (ADON) provided paper documentation to indicate the resident received showers on 5/16/24, and 5/23/24. These dates were not reflected in the POC documentation. When asked why, the ADON stated she could not provide an answer. She stated CNAs should document in the POC and on a shower sheet. On 5/29/24 at 5:05 PM, the DON acknowledged showers were not provided as scheduled/ and as per the resident/responsible person's preference. On 5/29/24 at 5:21 PM, the Unit Manager recalled she was made aware of a grievance filed by the resident's responsible party pertaining to shower preference. The UM stated resident #5's responsible party told staff the resident preferred to have her showers earlier in the shift, and not after dinner. However, documentation on the resident's Documentation Survey Report revealed showers were not provided per the resident's /responsible party's preference. On 5/29/24 at 5:26 PM, the resident was lying in bed on her back, she was alert, but confused and could not answer questions appropriately. The resident's care plan for ADL self-care performance deficit initiated on 11/30/23 with revision on 5/06/24 read, resident has a tendency to refuse showers if not offered when she wants. The facility's policy Activities of Daily Living Maintain Abilities dated 1/24 indicated that staff should ensure, care and services provided are person-centered, and honor and support each resident's preferences.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker website, and review of the facility's policy titled Employee COVID-19 Vaccinations, the facility failed to implement their COVID 19 vaccination policy creating the potential for the spread of COVID 19 to all 97 residents, staff, or visitors. The facility failed to have a process for ensuring all required staff were fully vaccinated. Five (5) of 137 staff, Licensed Practical Nurses (LPN) #'s7 and 8, Certified Nurse Aides (CNA) #'s 9, 10, and 11 were unvaccinated and had not been granted a medical or non-medical exemption. Six (6) of 137 staff, Dietary #1, Medical Doctor (MD) #2, CNA #3, Speech Therapist (ST) #4, CNA #5, and Housekeeper (HK) #6 were partially vaccinated, overdue for their second vaccination and had neither been granted a medical nor non-medical exemption. These failures resulted in a 92% compliance rate for staff being fully vaccinated. In addition, the facility failed to implement additional precautions for all 20 staff who had been granted medical or religious exemptions. The findings include: Review of the Employee COVID-19 Vaccinations policy dated 11/21/21 revealed, The Company requires that all eligible staff be fully vaccinated against COVID-19 .All eligible personnel must have received the first dose of a two dose vaccine series or a single dose COVID-19 vaccine by December 5, 2021, and have completed the vaccine series by January 4, 2022. New hires must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine upon hire or prior to providing any care, treatment, or other services to any care Center and/or its patients. Individuals who decline vaccination because of medical contraindications or religious beliefs must complete the applicable Company form and submit for review by December 5, 2021 . Executive Directors, supervisors, and management personnel are responsible for communicating the requirements for the Company's COVID-19 Vaccination Program to all individuals mentioned above, and for ensuring appropriate compliance . Exempted employees: a. Individuals who request and are granted a medical or religious exemption through the company's exemption review process , or who need to delay vaccination due to CDC recommendations, will receive reasonable accommodations. b. These accommodations will include the need for additional precautions to mitigate the transmission and spread of COVID-19, in compliance with CDC [Center for Disease Control], CMS [Center for Medicare and Medicaid Services] .c. Current guidance, which is subject to change, requires the use of Universal Source Control depending on Community Transmission rates and regular testing for all unvaccinated personnel working in Care Centers. Per the CDC COVID-19 Data Tracker website on 04/13/23, revealed the facility's community transmission rate of COVID-19 was low. Review of the facility's undated resident COVID + list revealed five residents were currently positive and under quarantine for COVID; four of the residents were admitted to the facility with COVID-19, and one acquired it in house on 04/08/23. During an interview on 04/13/23 at 4:38 PM, the Administrator stated there were two staff who tested positive for COVID on 04/08/23; they had not yet returned to work. 1. Review of the COVID-19 Staff Vaccination Status for Providers form completed on 04/13/23 and, the attached untitled documents revealed there were five staff (LPN #'s7, 8, and CNA #'s 9, 10, and 11) were unvaccinated and had not been granted a medical or non-medical exemption. a. LPN #7 was hired on 06/28/22. b. LPN #8 was hired on 01/11/23. c. CNA #9 was hired on 05/03/23. d. CNA #10 was hired on 01/25/23. e. CNA #11 was hired on 10/25/22. During an interview on 04/13/23 at 2:24 PM, LPN #7 stated he was unvaccinated for COVID-19; however, he had been granted a religious exemption at a different long term care facility where he worked previously. LPN #7 stated he had not been asked at this facility to bring in documentation of his exemption from the other facility. LPN #7 stated he was not aware of any additional precautions in place that he had to adhere to based on not being fully vaccinated. He stated he usually wore a surgical mask unless he was working with COVID-19 positive residents. He also stated he did not get regularly tested for COVID-19 and was only tested during outbreaks. During an interview on 04/13/23 at 4:38 PM, the Administrator verified LPN #'s7, 8 and CNA #'s 9, 10, and 11 were unvaccinated and did not have medical or religious exemptions according to the facility's COVID-19 tracking records. 2. Review of the COVID 19 Staff Vaccination Status for Providers form dated 04/13/23 revealed there were six staff who were partially vaccinated and had received the first dose of a two-part series (Dietary #1, MD #2, CNA #'s 3, 5, ST #4, and HK #6). a. Dietary #1was hired on 12/14/22. Review of Dietary #1's Florida Shots record revealed the first dose of the Pfizer vaccine was administered on 10/28/22. b. The facility did not have a hire date for MD #2. Review of MD #2's Vaccination Card revealed the first dose of the Pfizer vaccine was administered on 11/30/21. c. CNA #3 was hired on 05/23/22. Review of CNA #3's Vaccination Card revealed the first dose of the Pfizer vaccine was administered on 12/06/21. d. ST #4 was hired on 01/17/23. Review of ST #4's Florida Shots record revealed the first dose of the Moderna vaccine was administered on 11/13/21. e. CNA #5 was hired on 08/24/22. Review of CNA #5's Florida Shots record revealed the first dose of the Pfizer vaccine was administered on 01/10/22. f. HK #6 was hired on 12/14/22. Review of HK #6's Florida Shots record revealed the first dose of the Moderna vaccine was administered on 04/03/22. During an interview on 04/13/23 at 3:18 PM, CNA #5 stated she had been administered the first dose of the COVID-19 vaccine and had tried to get the second one but was unable to when she arrived at the pharmacy to receive it. CNA #5 stated she was no longer interested in receiving the vaccine. She stated she was aware there was a process to fill out for an exemption but she had not filled it out and no one had asked her to. She stated she was not aware of additional precautions needed for staff that were not fully vaccinated. 3. Review of the COVID 19 Staff Vaccination Status for Providers form dated 04/13/23 revealed there were 20 staff who had been granted either medical or religious exemptions. The facility's policy (noted above) did not identify the specific details regarding additional precautions for staff who were not fully vaccinated. During an interview on 04/13/23 at 1:45 PM, the Director of Nursing (DON) stated both she and the Assistant DON (ADON) had been employed by the facility for about 10 days. The DON stated the ADON was the Infection Preventionist (IP) and she was not available for interview. During an interview on 04/13/23 at 2:32 PM, the Administrator stated the previous ADON was responsible for the tracking of staff COVID-19 vaccinations. The Administrator stated some staff had slipped through the cracks, and he had not been aware, prior to today, of the 11 staff who were either unvaccinated or partially vaccinated. The Administrator stated he had been employed in his role since December 2022. During an interview on 04/13/23 at 4:38 PM, with the Administrator and DON, they stated typically human resources made sure staff had the first vaccination in a two-part series or had an exemption in place prior to working. The Administrator stated it was the role of the ADON/IP to track and make sure both COVID-19 vaccine doses in a two-part series were administered or to ensure an exemption was applied for and granted. The Administrator and DON stated they were not aware of the requirement for additional precautions for unvaccinated staff. When asked about the policy identifying universal source control for unvaccinated staff, DON stated she was not sure what that meant. The Administrator stated he was ultimately responsible for ensuring corrective action was taken for staff who did not adhere to the staff vaccination requirements. Both the DON and Administrator verified staff needed to be fully vaccinated or have an exemption in place to work. During an interview on 04/13/23 at 4:53 PM, Human Resources (HR) stated during the interview for employment, applicants were asked if they had been vaccinated or if they had an exemption. HR stated staff had to bring in the documentation in either case in order to work. She stated the vaccination record or exemption was given to the ADON and it had been her responsibility to follow up. HR stated she was not aware there were staff employed that were either unvaccinated or had only one vaccine in a two-part series.

Based on interview and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent a fall with major injury for 1 of 1 resident reviewed for accidents, of a total sample of 31 residents, (#11). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #11. Findings: Review of the medical record revealed resident #11 was admitted to the facility on [DATE] with diagnoses including seizures, dementia, anxiety, and hypertension. He was hospitalized on [DATE] after a fall with major injury and readmitted from the hospital on 11/25/22 with additional diagnoses of traumatic subdural hemorrhage, repeated falls, weakness and paralysis of the left side and visiospatial deficit and spatial neglect following a stroke. A subdural hemorrhage is bleeding between the covering and surface of the brain that is often the result of a severe head injury. Compression of the brain can cause brain injury or death (retrieved on 3/22/23 from www.medlineplus.gov). Visiospatial deficit and spatial neglect are common consequences of a one-sided brain injury. Persons who suffer from these conditions do not process visual stimuli and images on one side of the body (retrieved on 3/22/23 from www.medscape.com). The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 9/08/22 showed the resident had a Brief Interview for Mental Status score of 4 out of 15, which indicated the resident was severely cognitively impaired. The MDS assessment noted there were no behavioral symptoms or rejection of care and treatment, and the resident required extensive staff assistance for bed mobility, and limited assistance for eating during the look back period. Fall risk evaluations completed on 8/14/22 and 10/26/22 identified the resident as high risk for falls. A Change in Condition form dated 8/14/22 indicated resident #11 was observed sitting on the floor beside his bed. A Change in Condition dated 10/26/22 indicated resident #11 was observed on the floor. Review of a Nursing Progress Note dated 11/15/22 at 9:47 AM, revealed resident #11 was found on the floor in the television room. He informed nursing staff he was asleep and slid out of his chair. Review of a Change in Condition form dated 11/20/22 read, Resident fell out of wheelchair and hit his head. The document indicated resident #11 grimaced and complained of pain, level 8 on a 0 to 10 scale, to the right side of his forehead. The resident required emergency medical transport to the hospital for evaluation and treatment. Review of resident #11's medical record revealed a care plan, initiated on 1/28/20, that indicated he was at risk for falls. The goals, revised on 8/16/22, included minimizing the risk of sustaining serious injury and an intervention directed nursing staff to anticipate and meet the resident's needs. A care plan for an actual fall was initiated on 1/22/20 and had a goal of minimizing the risk of further incidents. An intervention dated 1/24/20 indicated staff were to place items on the right side of the resident's body. An approach dated 2/17/22 directed staff to encourage and assist him to be in the day room or dining room when in the wheelchair. The care plans did not specify the level of supervision or frequency of monitoring required to prevent falls and/or injury, and ensure the resident's safety. The resident's care plan was revised on 11/30/22, five days after readmission from the hospital where he was treated for a subdural bleed, to include increase supervision. However, the care plan still did not provide specific instructions for staff regarding the frequency of rounds and whether or not the resident needed be monitored in a fall prevention program. On 3/09/23 at 5:39 PM, Licensed Practical Nurse (LPN) B stated she observed resident #11 as he fell from his wheelchair to the floor near the entrance door in the dining room on 11/20/22. The LPN recalled she looked around the room for staff and observed two Certified Nursing Assistants (CNAs) behind the double doors, where they were not able to visualize or supervise residents. LPN B stated she evaluated resident #11, noted a large, raised area on his forehead, and immediately initiated emergency medical services to transport him to the hospital. She recalled the residents in the dining room required supervision because they were at risk for falls. LPN B stated she believed the fall could have been prevented if residents in the dining room had been supervised. She stated the two CNAs told her they were not supervising residents in the dining room as they were on their break. On 3/09/23 at 5:58 PM, the Activities Director stated she knew which residents were at risk for falls as they were supervised by a CNA in the common area on the unit. She stated those residents required staff assistance to get to the dining room for activity functions. She explained a CNA remained in the area by those residents for safety. She stated resident #11 was not included in the group of residents with known risk for falls on 11/20/22. The Activities Director recalled on that day, she heard a loud bang in the dining room, looked around, and saw resident #11 on the floor. She stated she did not see the resident fall as she was on the other side of the dining room. On 3/09/2023 at 6:28 PM, the Director of Nursing (DON) acknowledged resident #11 had not been provided with increased supervision although he had a history of multiple falls prior to the fall with major injury on 11/20/022. The DON explained residents identified as at risk for falls should participate in the fall program, and be supervised around the clock. He verified resident #11 should have been placed on close supervision prior to his fall with major injury on 11/20/22 because he had falls before this happened. The facility's policy and procedure for Topic: Fall Prevention Program (undated) indicated the facility would .implement specialized safety precautions to ensure safety. of residents identified to be at risk for falls. The procedure indicated specific interventions for residents deemed to be at high risk for falls included alarms, floor mats, bed bolsters, appropriate recreational activities, and increased supervision, i.e. 1/2 hour observations/monitoring rounds. The facility's policy and procedure for Topic: Risk Management (undated) revealed avoidable accidents occurred when the facility failed to Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of care. The document indicated supervision was an intervention utilized to mitigate fall risk. Adequate supervision was noted to be the type and frequency of supervision required to meet a resident's person-centered care needs.

Based on interview and record review, the facility failed to permit a resident to remain in the facility while her Medicaid application was pending, and failed to provide rationale as to why the resident's needs could not be met at the facility for 1 of 3 residents reviewed for discharge of a total sample of 4 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation post hospitalization for Coronavirus Disease, pneumonia due to Coronavirus Disease, pulmonary emboli and difficulty walking. Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/17/22 indicated her Brief Interview for Mental Status (BIMS) score was 13 of 15 that indicated her cognition was intact. The assessment showed she required extensive assistance of two staff persons for bed mobility, transfers, dressing, toileting, and personal hygiene. She was totally dependent on 1 staff person for bathing. The resident's quarterly MDS assessment with ARD 5/20/22 revealed her BIMS and level of assistance needed remained the same. She required extensive assistance for locomotion with a wheelchair on and off the unit, and did not walk. On 3/23/22, the facility's Interdisciplinary Team (IDT) met with resident #1's daughter to discuss discharge plans. The daughter expressed concerns as she would not be able to take care of her mother at home due to her mother's need for extensive to total assistance for most of her activities of daily living. The daughter stated, I will not be able to change my mother's diapers, I can't pick her up if she falls. The daughter was informed the resident would be financially responsible once the insurance issued a cut letter. A review of resident #1's Business Office records revealed the resident was admitted to the facility with a Medicare Care Plus Health Maintenance Organization (HMO) insurance plan that covered her skilled rehabilitation nursing and therapy services. On 4/8/22, the resident was given a Notice of Medicare Non-Coverage (NOMNC) letter which indicated her insurance company would no longer provide payment for skilled services as of 4/10/22. Review of an email from the Assistant Business Office Manager to the Administrator dated 5/13/22 at 2:57 PM read, Just a head's up that (resident #1) Medicaid application was just submitted today; She can be changed to Medicaid Pending; Please advise in regard to discharge/move to other facility. Both the business office and Administrator were aware resident #1 had Medicaid pending status. On 5/19/22 at 5:43 PM, a nursing progress note written by the Director of Nursing (DON) read, The Ombudsman office called to inquire about resident's allegation that she was being transferred to another facility without her permission. I informed the officer the resident came to us as skilled on short term from hospital and was supposed to have been discharged into the community. She was duly served the NOMNC from her insurance company which she did not appeal, however when the time for her discharge was up, she claimed she does not have a place to go, the facility then began looking for a long term place for her at the [name of another nursing home], she claimed that she was not going to leave and then called their office Review of the Florida Agency for Health Care (AHCA) Nursing Home Transfer and Discharge Notice form revealed the 30 day discharge notice was given to the resident on 5/20/22 with effective date of discharge 6/18/22. The form noted the physician was required to sign the form or give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 30 day notice was not signed by the physician nor was a rationale documented on the form as to why her needs could not be met in the facility. Review of the the resident's medical record and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note written by the Social Services Director (SSD) on 5/23/22 at 10:11 AM, indicated the resident did not want to go to another nursing home and told the SSD she wished to remain at the current nursing home. On 5/20/22, the same day the 30 day discharge notice was given to resident #1, she herself called 911 and was transferred to the hospital emergency room . The discharge MDS dated [DATE] indicated she had been transferred to an acute care hospital and her return was anticipated. The hospital's history and physical (H&P) dated 5/21/22 at 1:44 AM, revealed resident #1 was brought to the emergency room for bilateral leg pain. Once patient got to the hospital the rehab facility refused to accept patient back. The hospital discharge summary indicated she was discharged from the hospital 12 days later on 6/1/22 to another nursing home. On 8/16/22 at 4:56 PM, during a telephone interview with resident #1, she said the nursing home Administrator informed her she was to be discharged as she owed money and she would not be allowed to return to the facility post hospitalization . She reported she would have appealed the discharge notice when she returned to the facility but she was sent to a different nursing home from the hospital. She said she was at the other nursing home now and did not choose to be here. She added this nursing home was too far away from my family and they can't visit me as often. On 8/16/22 at 10:32 AM, during a telephone interview with the Ombudsman, he acknowledged the resident and her daughter were very upset as the facility refused to take her back from the hospital. He explained the hospital had to find another nursing home for the resident which was further from the resident's family. The Ombudsman said he discussed the resident's discharge with the Administrator and she conveyed she would rather 'take the hit' than bring the resident back to the facility. On 8/16/22 at 1:15 PM, the Administrator acknowledged she told the Ombudsman that she would rather take the hit than bring the resident back to the facility. She explained, I guess I was thinking that it was worth her (resident #1) not coming back here. On 8/16/22 at 4 PM, the SSD indicated it would have been appropriate to have the resident come back to the facility from the hospital, allowed her to appeal the 30 day discharge notice and then follow the appeals process to the end result. The resident was not allowed to remain in the facility even though Medicaid application was pending and the facility could not provide rationale as to why her care needs could not be met. The facility's policy and procedure, Permitting Resident to Return to Facility, not dated read, .This is the policy of the facility to permit the resident to return to the facility according to state and federal regulations. Timing of Notice: .At least 30 days prior to any proposed transfer or discharge, the facility will provide advance notice of the proposed transfer or discharge to the resident and, if known to a family member or the resident's legal guardian or representative, except in the following circumstance, the facility shall give notice as soon as practicable before the transfer or discharge

Based on interview and record review, the facility failed to permit a resident to return to the facility after she was transferred to the emergency roiagnom on the same day the facility gave her a 30 day discharge notice for 1 of 3 residents reviewed for discharge of a total sample of 4 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation post hospitalization for Coronavirus Disease, pneumonia due to Coronavirus Disease, pulmonary emboli, muscle weakness, and difficulty walking. Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/22 indicated her Brief Interview for Mental Status (BIMS) score was 13 out of 15 that indicated intact cognition. The assessment showed she required extensive assistance of two staff persons for bed mobility, transfers, dressing, toileting, and personal hygiene. She was totally dependent on 1 staff person for bathing. The resident's quarterly MDS assessment with ARD 5/20/22 revealed her BIMS and level of assistance needed remained same and she required extensive assistance for locomotion with a wheelchair on and off the unit, and did not walk. A Social Services Case Manager progress note dated 3/23/22 at 3:36 PM read, IDT (interdisciplinary team) met the patient's daughter .in reference of discharge plan home and daughter stated, 'I will not be able to change my mother's diapers, I can't pick her up if she falls. I will look for long term care.' Writer told patient's daughter that resident would be financially responsible once the insurance issues a cut letter. A review of resident #1's Business Office records revealed she was admitted to the facility on Medicare Care Plus Health Maintenance Organization (HMO) insurance plan. A Notice of Medicare Non-Coverage (NOMNC) letter indicated her skilled services would end as of 4/10/22. The form was signed by the resident on 4/8/22. An email dated 5/13/22 at 2:57 PM, from the Assistant Business Office Manager to the Administrator read, Just a head's up that (resident #1) Medicaid application was just submitted today; She can be changed to Medicaid Pending; Please advise in regards to discharge/move to other facility. A nursing progress note written by the Director of Nursing (DON) dated 5/19/22 at 5:43 PM read, The Ombudsman office called to inquire about resident's allegation that she was being transferred to another facility without her permission. I informed the officer the resident came to us as skilled on short term from hospital and was supposed to have been discharged into the community. She was duly served the NOMNC from her insurance company which she did not appeal, however when the time for her discharge was up, she claimed she does not have a place to go, the facility then began looking for a long term place for her at the [name of another nursing home], she claimed that she was not going to leave and then called their office A progress note written by the Social Services Director (SSD) on 5/23/22 at 10:11 AM noted SSD spoke to the resident on 5/20/22 and delivered the 30 day notice due to nonpayment and the resident's need for Long Term Care (LTC) placement. The note showed the resident signed the 30 day notice and it was explained to her that she could not stay long term at the facility but she could transfer to another nursing home. This other nursing home would transport her and her belongings. The note indicated the resident did not want to go to another nursing home and told the SSD she wished to remain at the current nursing home. The note showed on 5/20/22, resident #1 called 911 herself and was transferred to the hospital. Review of the Florida Agency for Healthcare Administration's (AHCA) Nursing Home Transfer and Discharge Notice form 3120-0002 Revised May-01, revealed the 30 day discharge notice was given to the resident on 5/20/22 with the effective date for discharge 6/18/22. The reason cited for discharge was, Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. The second reason for discharge read, Your needs cannot be met in this facility. It read, under the Brief explanation to support this action . that resident #1 Refuses to discharge. Refused transfer for LTC placement. The Notice was signed by the Administrator on 5/20/22 and by the resident on 5/20/22. The form noted the physician was required to sign the form or give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record did not show a signed notice by the physician or rationale why her needs could not be met in the facility. Review of the Nursing Home to Hospital Transfer form dated 5/20/22 at 11:23 PM did not show any documentation as to the reason resident #1 went out to the hospital via 911. On 8/16/22 at 4:56 PM, during a telephone interview, resident #1 said the nursing home Administrator had her sign a form that noted they were going to discharge her because she owed money. She recalled the nursing home had packed all her belongings and papers including the 30 day discharge notice and someone from another facility came to pick her up, but she refused to go. She reported she would have appealed the discharge notice. She explained while she was in the hospital, a staff from the nursing home came to her room and told her the facility Administrator would not allow her to come back. She stated, I closed my eyes and didn't want to look at her. She made me feel like a bad penny or something. She was told the hospital would arrange for her to go to the other nursing home when she was discharged . She said she was at the other nursing home now and did not want to be there. She stated this nursing home was too far away from my family and they can't visit me as often. A review of the hospital's history and physical (H&P) note dated 5/21/22 at 1:44 AM noted the resident was brought to the emergency room for bilateral leg pain. Patient relates that she was undergoing rehab at the facility but insisted on heavy doses of opioids that facility refused to increase the dosage but sent her to the hospital. Once patient got to the hospital the rehab facility refused to accept patient back. Hospital records revealed that urinary tract infection was found on 5/23/22 and resident #1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 10:32 AM, during a telephone interview, the Ombudsman acknowledged he had received a call from the resident and her daughter. He said they were very upset and reported that after the resident called 911 to go out to the emergency department, the facility refused to take her back. He indicated the hospital arranged for her to go to another nursing facility which was further away from her family. The Ombudsman verbalized that after resident #1's call, he visited the facility and the Administrator conveyed she would rather 'take the hit' than bring the resident back to the facility. On 8/16/22 at 1:15 PM, during an interview with the SSD and Administrator, the SSD acknowledged that both she and the Administrator had given resident #1 a 30 day discharge notice sometime in the afternoon on the day she called 911 (5/20/22). The Administrator acknowledged she told the Ombudsman that she would rather take the hit than bring the resident back to the facility. She explained, I guess I was thinking that it was worth her [resident #1] not coming back here. On 8/16/22 at 3:09 PM, the facility's Admissions Liaison staff member acknowledged she was informed by the Administrator that resident #1 could not come back to the facility after hospitalization . She said she told the resident she could not come back while the resident was in the hospital. On 8/16/22 at 4 PM, the SSD voiced that from a Social Worker's perspective it would have been appropriate to have the resident come back to the facility from the hospital, allowed her to appeal the 30 day discharge notice which she believed the resident would have done, and then follow the appeals process to the end result. The facility's policy and procedure, Permitting Resident to Return to Facility, not dated read, .This is the policy of the facility to permit the resident to return to the facility according to state and federal regulations. Timing of Notice: .At least 30 days prior to any proposed transfer or discharge, the facility will provide advance notice of the proposed transfer or discharge to the resident and, if known to a family member or the resident's legal guardian or representative, except in the following circumstance, the facility shall give notice as soon as practicable before the transfer or discharge

Based on staff interviews and record review the facility failed to ensure that residents were free of significant medication errors for administration of anticoagulant medication, [MEDICATION NAME] ([MEDICATION NAME]) for 1 of 1 sampled resident, of a total of 10 residents, (#12). This failure resulted in resident #12 missing 22 doses of [MEDICATION NAME] 17.5 milligrams (mg) and his International Normalized Ratio (INR) blood level to drop to subtherapeutic level of 0.9. The resident had to endure large doses of an injectable blood thinning medication, [MEDICATION NAME] along with [MEDICATION NAME]. As per the cardiologist this resident with history of pacemaker, stents, heart valve replacement and [MEDICAL CONDITION] could have suffered an [MEDICAL CONDITION], stroke, [MEDICAL CONDITION] or possible death as a result. The non compliance identified Substandard Quality of Care and Immediate Jeopardy at scope and severity of K pattern starting on 5/02/2019. The Immediate Jeopardy was removed on 6/5/2019 and the scope and severity lowered to E. Findings: Resident #12 was a [AGE] year old male who was admitted to the facility on [DATE] to 5/30/2019 for respite stay while his caregiver recovered from a surgical procedure. Resident #12 was a Veteran and received treatment and services at the Veterans Administration Hospital (VA). The VA arranged to transport resident #12 to the facility on [DATE] from his home. Resident #12 had [DIAGNOSES REDACTED]. Resident #12's admission Minimum Data Set (MDS) assessment dated [DATE] showed he was cognitively intact and scored 15 of 15 on the Brief Interview for Mental status (BIMs). He required extensive assistance of 2 staff persons for dressing, personal hygiene and toilet use. The resident's medication list from the VA showed he was to receive the anticoagulant medication, [MEDICATION NAME] 17.5 milligrams (mg) by mouth daily. A review of the resident's Medication Administration Record [REDACTED]. There were no other previous orders of [MEDICATION NAME] identified on resident #12's MAR indicated [REDACTED] On 5/30/2019 at 9:40 AM, resident #12's wife stated that she received a call from the facility on 5/23/2019 informing her that he had a fall in the facility. She stated this was the second time she was being called regarding her husband sustaining falls in the facility. She had received a call previously on 5/8/2019 that he had fallen. She stated that she told the nurse that her husband was at great risk of bleeding if he falls as he was on blood thinning medication. She said the nurse told her that her husband was not currently receiving blood thinning medication. She stated that when she discovered her husband did not receive the blood thinning medication, she was very upset. She contacted the director of nursing, the cardiologist and VA to report the error. An interview with registered nurse manager staff B on 5/30/2019 at 3:00 PM revealed that the resident was not ordered [MEDICATION NAME] until 5/24/2019. She stated that she did not enter the [MEDICATION NAME] order into the electronic system for resident #12 at admission. She stated that she was assisting the resident's primary nurse, registered nurse (RN) staff C when resident #12 was admitted to the facility on [DATE]. The nurse manager staff B stated she did not enter the order for [MEDICATION NAME] into their electronic system upon admission to the facility because the order looked like a non active medication (medication not being taken by resident #12). Nurse manager staff B said she misread the resident's medication list and thought the Active Non-VA Medications, meant medications that the resident was no longer taking. She did not realize that these medications were active but not ordered by VA. The Non-VA medications were ordered by the resident's specialist physician and not by VA. She did not contact the physician to verify the medication list for resident #12 when he was admitted . She had mistakenly assumed that the the primary nurse had contacted the physician. She could not explain what happened and how she missed entering resident #12's [MEDICATION NAME] order into the computer except that she thought it was no longer a current medication. She stated she was made aware on 5/23/2019, when resident #12's wife informed her that resident #12 should have been taking [MEDICATION NAME] daily. She confirmed that resident #12 missed receiving [MEDICATION NAME] for 22 days. On 5/31/2019 at 12:50 PM, registered nurse (RN) staff C stated she was the nurse assigned to resident #12 when he was admitted to the facility on [DATE]. RN staff C stated she did not call the physician to verify his medications because the nurse manager staff B who was assisting her had contacted the physician. She stated that since the nurse manager was entering the medications into the electronic system, she thought the nurse manager had verified the medication orders with the physician. On 5/31/2019 at 3:35 PM, the director of nursing, (DON) stated that she was made aware on 5/23/2019 that resident #12 had not received the medication [MEDICATION NAME] since admission. The DON stated that nurse manager staff B should have contacted the physician for clarification of the resident's medication list and verified all the medications. She stated that the physician was notified of the medication error and ordered blood work to be done stat for International Normalized Ratio (INR).This test helps doctors determine the dose of [MEDICATION NAME]. On 5/24/2019 the facility received the lab results that showed resident #12's INR to be 0.9. The physician wanted the INR to be above 2.0. The resident was started on an injectable anticoagulant, [MEDICATION NAME] along with [MEDICATION NAME] on 5/24/19. On 5/30/2109 at 3:00 PM, the nurse manager staff B stated that she became aware that resident #12 should have been receiving [MEDICATION NAME] and his blood levels being monitored from the resident's wife on 5/23/2019. She contacted the physician and informed him of the error. She received orders for resident #12 to be started on [MEDICATION NAME] 150 micrograms and [MEDICATION NAME] 17.5 mg. She stated that the resident should have been receiving [MEDICATION NAME] 17.5 mg since his admission on 5/2/19. On 5/31/2019 at 3:35 PM, the DON stated that the facility had a process called Journey Home where all new residents' medications were reviewed within 72 hours of admission. On 5/31/2019 at 5:45 PM, the administrator stated that the case manager was responsible for conducting the Journey Home meeting but the case manager was in training and the meeting did not occur for resident #12. She stated that the pharmacy also reviews the resident's medications and the pharmacy consultant was a double check to the nurse. On 5/31/2019 at 6:30 PM Pharmacy Consultant (E) stated she visited the facility on 5/20/2019 to review the resident's medications. She explained that when there was a newly admitted resident to the facility she looks at the resident's medication list and confirms it with the medications the resident was currently taking then she prepares a report for the facility. The facility's pharmacy Consultation report dated 5/20/2019 through 5/21/2019 showed no new irregularities for resident #12. The pharmacy consultant verified that she did not check the resident's ordered medications with the resident's VA medication list. On 6/17/19 at 10:33 AM, the resident's cardiologist was contacted by phone. He stated resident #12 had a heart valve replacement and had other medical challenges such as [MEDICAL CONDITION] (irregular heart beat). He confirmed that the resident was ordered [MEDICATION NAME] 17.5 mg per day. The cardiologist stated he wanted the resident's INR level range between 2.5 and 3.5. The cardiologist stated the missed [MEDICATION NAME] doses for a long period (22 days) resulted in the INR being below therapeutic range, (INR 0.9). He stated that this could have resulted in heart valve malfunction, clots to the heart and/or brain, [MEDICAL CONDITION] and death. On 5/30/19 at 11:40 AM, resident #12 stated that he was happy to be going home. He stated that while he was at the facility, he had 2 falls and did not get his medications. He said, this is not right. The facility's policy and procedure for Monthly Drug Regimen Review dated 4/21/2017 and last revised 10/10/2018 showed the nurse to provide the consultant pharmacist with resident's current drug regimen . to complete an interim medication regimen review for residents with an anticipated length of stay of less than 30 days The facility's Medications policy- Oral administration dated 11/30/2014 and last revised 9/22/2017 procedure showed staff to obtain and verify physician's orders [REDACTED].>The facility's policy for physician orders [REDACTED]. The facility failed to identify that a resident admitted to the facility received his necessary medications. The Administrator and DON confirmed that resident #12 did not receive his [MEDICATION NAME] for 22 days. Review of the facility's corrective measures revealed the following: An ad Hoc Quality Assurance and Performance Improvement meeting was held in 5/24/2019 with all department heads including the medical director. The incident involving resident #12 was discussed and implementation corrective measures were reviewed. Nurse Manager was disciplined and in service provided on entering admission orders [REDACTED] All residents admitted to the facility since 5/2/2019 medications were reviewed for accuracy. All residents on [MEDICATION NAME] were reviewed for accuracy. All newly admitted residents to the facility were now to have 2 nurses verify all medications with the medication order list the resident comes into the facility with. All staff Nurses were trained to contact the physician for medication orders with every new admission to the facility. They were trained to use the new medication reconciliation form and to add any new or changes made to resident's previous medications to the form. The facility developed a four (4) point plan on 5/31/2019. The facility will conduct audits to ensure resident's medications are entered accurately into the computer system. The facility's administrator stated she had completed all training to all nursing staff on 6/5/2019 and audits are continuing. The survey team expanded the sample and added 4 VA residents and 2 residents newly admitted to the facility. Each resident's medications were reviewed for accuracy against the medication list from the hospital. Interviews conducted with nursing staff on all shifts verified training and medication review and process when admitting residents from home or hospital to the facility.

Based on observation, interview and record review, the facility management failed to administer its resources effectively to monitor the wander guard system and provide enough staff supervision to ensure the safety of 1 of 8 sampled residents of 13 total residents with wander guard devices. This failure resulted in the elopement and placed resident #1 and 7 other residents at risk for potential serious injury/impairment/death, (#2, #3, #4, #5, #6, #7, #8), such as fall injuries, outdoor exposure, dehydration, and pedestrian accidents. On 04/06/19 at approximately 5:30 PM, resident #1, who was cognitively impaired, had limited mobility, required continuous oxygen, had a feeding tube, and was on [MEDICAL CONDITION] precautions left the facility via the facility front entrance doors, unsupervised. The whereabouts of resident #1 was not known by the facility for more than 2.5 hours until he was located by law enforcement at 8:05 PM, 8 miles from the facility. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration failed to identify the level of supervision and proper placement/monitoring of the wander guard device needed for residents at risk for elopement and were unable to provide adequate care that led to an Immediate Jeopardy starting on 3/12/19. The facility administrator was notified of the Immediate Jeopardy on 04/30/2019. The Immediate Jeopardy at a J level was on-going as of the exit date of 5/1/19. Cross reference to F689. Findings: Review of the nurse's progress note dated 3/12/19 at 4:41 PM noted that resident #1 was observed in the parking lot, just outside the front entrance of the facility. The resident told the staff that he was taking the bus to go home. The staff redirected the resident and a wander guard device was placed on the resident's wheelchair. On 4/6/19 at approximately 5:30 PM, the resident walked out the front entrance of the facility, and boarded a bus. The resident transferred on to a second bus that was heading towards his home. The facility staff found the resident's wheelchair at the front lobby with the wander guard device still attached. Since the wander guard bracelet was on the wheelchair instead of on the resident, the wander guard system did not alarm as he exited the facility. The resident was located by law enforcement 8 miles from the facility and was returned to the facility at 8:30 PM. Two days later, the resident was discharged from the facility. A review of the Facility assessment dated [DATE], did not identify wandering or exit seeking residents, as part of the resident population, and the care that was required to keep them safe and free from harm. The facility's administration failed to review the facility's equipment, physical environment, and staffing considerations that were necessary to care for their wandering and exit seeking residents to ensure resident safety. On 4/27/19 at 4:28 PM, the Maintenance Director stated that he had worked at the facility since (MONTH) (YEAR). He stated that only the front entrance door, the service corridor exit door and the 600 Wing exit door were connected to the wander guard system. If a resident nears any of these doors, the door will lock for 15 seconds and then release so that the door can open. He stated that he checked these doors every day to ensure that the wander guard system was working. The Maintenance Director confirmed that resident #1 was able to exit the facility as his wander device was on his wheelchair and not on his person. A review of the wander guard device manufacturer's instruction noted that the device must be placed on the resident's lower extremity. On 4/29/19 at 6:40 PM, the doors were tested with the Maintenance Director. He used a wander guard device to test the doors and the doors alarmed when the device was in close proximity of the sensor. Although the alarm sounded, the doors did not lock. The doors were able to be opened with moderate pressure applied to the release bar/mechanism. After several trials and the door not locking, the Maintenance Director called the wander guard company and found out that the facility's system did not have magnetic locks as part of the wander guard system. The Maintenance Director stated he was under the impression that the doors locked. On 4/28/19 at 2:47 PM, staff supervision was discussed with the Director of Nursing Services (DNS). When the DNS was asked how staff monitored residents with wander guards, she stated they were checked every 2 hours. She stated that all residents' whereabouts was monitored every 2 hours whether they were identified at risk for wandering/elopement or not. There was no indication that the DNS differentiated the supervision needs between residents at risk for elopement from the other residents in the facility. On 5/1/19 at 10:50 PM, the Staffing Coordinator explained that staff schedules were determined according to census. She stated that a formula was used to determine how many aides and licensed nurses were needed for any particular day. She used the State of Florida minimum staffing requirements for Long Term Care Facilities. There was no indication that staffing was based on resident acuity or needs. Review of the facility investigation of resident #1's elopement and interview with the Administrator on 4/29/19 revealed that the facility determined the root cause of the elopement was that resident #1 had wander guard attached to his wheelchair instead of being on his person. The facility assessed/re-assessed all resident and at the time of the survey, the facility identified 13 residents that were at risk for elopement. The administrator stated that staff were educated that the wander guard devices must to be on the resident's body and not attached to wheelchairs or any other ambulatory assistive devices. The Administrator stated that the physician orders [REDACTED]. She stated that wander guard placement was to be checked each shift. The Administrator stated the documentation for the monitoring of wander guards were now on the Medication Administration Record [REDACTED]. A review of residents #2-#8's clinical records revealed physician orders [REDACTED]. Review of the MAR/TAR and progress notes revealed that the wander guard checks were not being done consistently. Resident #2 had a wander guard with orders to check for placement every shift. A review of the MAR/TAR revealed that staff did not check the wander guard placement on the evening of 4/19/19. Resident #3 had a physician order [REDACTED]. The resident was sent to the hospital on [DATE] and returned on 4/25/19. A review of the MAR/TAR revealed that the resident's wander guard placement was checked on 4/24/19 on the night shift despite the resident being in hospital. A review of the MAR/TAR for resident #4 revealed that the wander guard placement was not checked by staff on the evening shifts of 4/19 and 4/26/19. A review of resident #5's MAR/TARs revealed that placement for wander guard was not checked on the evening shifts of 4/19 and 4/26. A review of resident #6's nursing progress note revealed that he had cut off his wander guard on 4/15/19. A new wander guard was applied. A review of the MAR/TAR revealed that his wander guard was not checked on the evening of 4/19/19. A review of resident #7's MAR/TAR noted that the wander guard device's expiration date was for the month of (MONTH) 2019. Resident #7's wander guard placement was not checked on the day shift of 4/6/19, 4/14/19 (day shift), 4/15/19 (evening shift), 4/17/19 (evening shift), 4/18/19 (evening shift), and 4/29/19 (evening shift). Resident #8 was admitted to the facility on [DATE]. On 4/29/19 the DNS stated that the resident had the wander guard device since 3/13/19. A review of the medical record revealed that physician orders [REDACTED]. The physician orders [REDACTED]. On 4/8/19, the physician ordered the wander guard function checks every day. On 4/10/19, the physician ordered expiration checks of the wander guard every 4 weeks. A review of the MAR/TAR for the month of (MONTH) 2019 noted the wander guard was not checked for placement on 4/9/19 (day and night shift), 4/10/19 (day and night shift), 4/12/19 (day shift), 4/14/19 (day and night shift), 4/15/19 (day and night shift), 4/20/19 (evening shift), 4/21/19 (night shift), 4/23/19 (night shift) and 4/27/19 (day and night shift). Further reviews of the MARs and TARs for residents #2 through #8 revealed that the staff were not consistently documenting if the wander guards were on the resident's person. Some documented wander guard on lower extremity, while others did not document a location or put 0 for the location of the wander guard. On 4/29/19 at 2:00 PM, the administrator and DNS acknowledged that the wander guard function and placement checks were not on the MAR/TAR previously. They stated that the restorative aides were checking the function of the wander guard daily and documenting on a separate log. After resident #1's elopement incident, documentation of the wander guard checks was changed to be included in the MAR/TAR. The administrator and DNS were informed of the inconsistent documentation of the wander guards per shift as ordered by the physician for residents #2 through#8. When asked if there was any monitoring or audits to ensure that nursing staff were checking for wander guard placement, the administrator stated that audits were being done by the DNS. At that time the DNS stated that audits of MARs/TARs had not been done. It was evident that administration focused on the improper placement of the wander guard device as the root cause of resident #1's elopement from the facility. They however, failed to assess the physical and environmental features of the facility and the vulnerable exit points in which residents could potentially exit the facility without staff knowledge. They failed to identify the doors did not lock when a resident with a wander guard device neared the door. They did not identify elopement risk residents in their Facility Assessment to determine the care needs and supervision required to keep them safe and free from harm. They also failed to ensure that monitoring of the wander guard devices was done consistently. A review of the administrator's job description (no date) read that the administrator is responsible for, direct the day-to-day functions of the facility in accordance with current federal, state .regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times.

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring of wander guard devices for 8 of 13 residents identified at risk for actual or potential elopement. These failures contributed to the elopement of resident #1, placing him and 7 other residents at risk for potential serious injury/impairment/death, (#2, #3, #4, #5, #6, #7, #8), such as fall injuries, outdoor exposure, dehydration, and pedestrian accidents. On 04/06/19 at approximately 5:30 PM, resident #1, who was cognitively impaired, had limited mobility, required continuous oxygen and was on [MEDICAL CONDITION] precautions left the facility via the facility front entrance doors, unsupervised. The whereabouts of resident #1 was not known by the facility for more than 2.5 hours until he was located by law enforcement at 8:05 PM, 8 miles from the facility. The failure to provide adequate supervision, proper placement and monitoring of the wander guard device according to manufacturer's guidelines resulted in substandard quality of care at the Immediate Jeopardy level, starting on 03/12/19. The facility administrator was notified of the Immediate Jeopardy on 04/30/2019. The Immediate Jeopardy at a J level was on-going as of the exit date of 05/01/19. Cross reference to F835. Findings: Resident #1 was a [AGE] year old, admitted to the facility's rehabilitation unit on 08/09/18 with [DIAGNOSES REDACTED]. tightly, allowing blood to flow backward into the heart causing fatigue and shortness of breath), gastrostomy tube (GT), (a tube inserted through the abdomen that delivers nutrition directly to the stomach), cerebral infarction [MEDICAL CONDITION] hypertension (type of high blood pressure that affects the arteries the lungs and the right side of the heart), dysphagia (difficulty swallowing), [MEDICAL CONDITIONS] (chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs causing breathing difficulty, cough, mucus (sputum) production and wheezing), [MEDICAL CONDITION], acute pain due to trauma, post-traumatic stress disorder ([MEDICAL CONDITION]), anxiety, and history of falls. He was admitted from an acute care hospital [MEDICAL CONDITION] requiring intravenous (IV) antibiotic therapy and rehabilitation therapy services. An Elopement Risk Evaluation completed on 08/16/18, documented he was at risk for elopement. On 10/14/18, he was readmitted to the facility and the Admission/Readmission Data Collection form documented that he was at risk for elopement, had demonstrated exit-seeking behaviors and had the ability to exit the facility. The quarterly minimum data set (MDS) assessment dated [DATE] documented he was cognitively impaired and required extensive assistance of 1 person with transfers, locomotion on and off the unit, and toileting. He was not steady with moving from seated to standing position, walking, turning around or with surface-to-surface transfers. He used a wheelchair for mobility and was always incontinent of bowel and bladder. A feeding tube was in place for nutrition and hydration and he received a mechanically altered diet. A nurse's progress note completed by Licensed Practical Nurse (LPN) A on 03/12/19 at 4:41 PM, documented resident #1 was observed in the parking lot just outside the facility entrance doors. He was very anxious, stating that he was going to take the bus home. an order for [REDACTED]. The Elopement Risk Evaluation dated 03/12/19 documented he was cognitively impaired, was independently mobile (ambulatory or wheelchair), had poor decision-making skills, had demonstrated exit seeking behaviors, wandered oblivious to safety needs, had the ability to exit the facility and was determined to be at risk for elopement. A physician order [REDACTED]. Review of the wander guard manufacturer's guidelines revealed the wander guard was not placed according to the manufacturer's recommendations. The guidelines read, The wander guard is designed to assist the facility in protecting their residents and is not intended as a substitute for monitoring of residents by the facility staff. All transmitters must be worn on a resident's wrist or ankle, require the facility to test the transmitter for proper function on a daily basis, and must ensure the transmitter is in place on each shift. A review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for (MONTH) 2019 for resident #1 did not reveal any documentation for the placement checks or the functioning of the wander guard device every shift as per physician's orders [REDACTED]. Review of resident #1's nursing progress notes dated 03/14/19-04/06/19 did not reveal any documentation of the wander guard's placement or function. Review of the facility's Best Practices - Elopement/Wandering Risk, dated 08/30/17, read, . Electronic Monitoring: . Obtain physician order [REDACTED]. The Comprehensive Care Plan dated 03/13/19 documented risk of wandering related to disorientation to place and impaired safety awareness. The goal was the resident will not leave the facility unattended. Interventions included to check placement every shift and function daily of the wander guard. The care plan also noted that the resident was at risk for falls related to gait/balance problems, [MEDICAL CONDITION], and unaware of safety needs. The care plan included providing a safe environment for the resident and monitoring for [MEDICAL CONDITION] activity. The care plan identified the resident required gastrostomy tube feedings, pureed consistency foods and thin liquids. He required supervision and cues for safe swallowing and monitoring for aspiration. The resident required continuous oxygen at 3 liters per minute via nasal cannula related to [MEDICAL CONDITION] and severe [MEDICAL CONDITION] hypertension. The care plan interventions included monitoring for shortness of breath, wheezing and respiratory distress. On 04/06/19, resident #1 exited the facility at approximately 5:30 PM through the front entrance doors. He left his wheelchair with the wander guard attached in the front lobby. He was able to exit through the front doors without activating the door alarm alerting staff of his attempt to exit the facility. He then walked 325 feet, crossed a busy 4-lane divided street to the bus stop on the other side. While attempting to step up and over the curb, resident #1 fell hitting his head and sustained a hematoma under his right eye and abrasions to his right knee. A review of the bus routes/schedules determined that he boarded the North bound bus and then boarded another bus with the intention of going home. At 6:15 PM, Licensed Practical Nurse (LPN) A found resident #1's wheelchair in the facility's lobby. A search of the facility failed to locate resident #1 until 8:05 PM, when he was located by law enforcement 8 miles from the facility. At 8:30 PM, law enforcement returned resident #1 to the facility (2 1/2) hours after he exited the facility. A further review of the TAR and MAR dated 04/01/19-04/06/19 did not reveal any documentation that the wander guard daily placement and function checks were completed per physician's orders [REDACTED]. A review of the nursing progress notes from 3/13/19 to 4/6/19 did not show any documentation of the wander guard checks. The only documentation of the wander guard was on 03/12/19 when a physician order [REDACTED]. A telephone interview was conducted with resident #1's wife on 04/28/19 at 12:30 PM. She stated that the resident had been verbalizing wanting to leave the facility and that the staff were aware of his wishes. She said that at one time he had a bracelet on his ankle but it was removed and was then placed on his wheelchair. Since there was no one at the front desk after 5 PM, he just left his wheelchair with the wander guard attached, walked out the front door and walked across the street to the bus stop. He fell at the bus stop hitting his head on the curb causing a black eye and he scraped his knee. A woman passing by stopped to help him. He boarded the North bound bus and then changed buses to take another bus to get home. My husband did ask me what bus route I took when I went home from the facility. I do not drive and he has not driven due to having two bad accidents in the past. He was found near a bank close to my sister-in-law's house. He had never taken a bus before and I was very worried about him being out alone by himself. He had $7.00 in his drawer, which he wanted to have so he could buy something if he needed it. He used the money to pay for the bus fare. I did not purchase a bus ticket for my husband. If they had put the wander guard device on his ankle he would never have gotten out of the facility. On 04/27/19 at 1:10 PM, Licensed Practical Nurse (LPN) A stated that she was familiar with resident #1 and was assigned to his care on 04/06/19. She stated that he had dementia, and was confused. He was extremely unsteady on his feet and would attempt to walk on his own. He had told me many times that he wanted to go home. I just told him he needed to speak to his wife. On Saturday, 04/06/19, I found his wheelchair in the front lobby with the wander guard attached. The wander guard was usually placed on the resident's ankle but the resident had cut it off so it was attached to his wheelchair. On 04/06/19, the front entrance receptionist left at 3 PM so there was no one at the front desk after 3 PM. The LPN A confirmed that placing the wander guard on the resident's wheelchair did not assure safety. She stated that wander guard placements should be checked every shift and its function every day with a machine. It is then documented on the Medication Administration Record, (MAR). On 04/27/19 at 2:57 PM, LPN C stated that he had worked at the facility for 5 years and was usually the evening supervisor. He remembered resident #1 as he was a veteran and he was confused. On 04/06/19, I was working as the medication nurse on the Rehabilitation Unit (SSU) and LPN A was the nurse caring for resident #1. I saw resident #1's wheelchair parked in the lobby by the Social Service door. I was not sure why the wander guard was attached to his wheelchair and not on the resident. I had seen some other wander guards attached to the wheelchairs. A wander guard placed on the wheel chair will not prevent the resident from getting out of the facility. On 04/06/19, the road in front of the facility was very busy at 6 PM when the resident crossed it to get to the bus stop. On 4/28/19 at 5:50 PM, Certified Nursing Assistant (CNA) I stated that she worked the 3 PM-11 PM shift. She stated the wander guard devices were used to prevent residents from leaving the facility. She stated that if a resident with a wander guard gets near the door, the door will alarm which lets the staff know that a resident is trying to exit the facility. She stated that the whereabouts of residents with wander guards was checked every 2 hours. On 4/30/19 at 2:00 PM, CNA H stated that she worked the 7 AM-3 PM shift and had worked at the facility for 1 year. She stated that she was currently assigned to 10 residents and 3 of them had wander guards. She stated that she checked on the whereabouts of all her residents every 2 hours. She said that she recently received training on documenting the placement of wander guards on the flow sheet but did not provide a date when this was implemented. On 04/28/19 at 2:47 PM, the Director of Nursing Service (DNS) confirmed that there was a physician's orders [REDACTED]. She stated that the facility policy was to obtain a physician order [REDACTED]. Once the order was entered, daily checks for placement and function checks of the wander guard populated in the TAR for the nurses to complete. The DNS stated that for resident #1, the wander guard order was not entered correctly so the orders for checking placement and functioning never showed up on the TAR. There is no documentation of the wander guard placement or placement checks being completed. At 5:30 PM, the DNS stated that wander guards were to be, placed on the resident's wrist or ankle. She did not provide an answer when asked why resident #1's wander guard device was placed on his wheelchair. When asked how often the whereabouts of residents that were at risk for elopement were monitored, the DNS replied, every 2 hours. The DNS was then asked, how often residents without wander guards were observed. She stated that they were also observed every 2 hours. The DNS did not provide an answer when asked how the facility was meeting the needs of residents who were at high risk for wandering/elopement when they were only being observed every 2 hours. When asked what the facility policy was for checking residents with a wander guard device, the administrator stated that the facility did not have one. She stated that she was aware that resident #1 did not have any nursing progress notes related to the use of his wander guard. We became aware of it on 04/28/19, during the survey. She stated that the last time resident #1 was observed by his CNA (B) was on 04/06/19 at 4:25 PM when she provided incontinent care. The last time resident #1 was observed by LPN A was on 04/06/19 at 5:30 PM when she administered his medications via his gastrostomy tube. The administrator and DNS stated that resident #1's wander guard device was on his wheelchair instead of on his person therefore it did not trigger an alarm when he exited the facility. They stated that new interventions were put in place since the incident. These included checking the wander guard device's expiration date, the placement and function. These interventions were on the MAR/TAR and the licensed nurse documented the expiration date every 4 weeks. The function was checked and documented daily and the placement was checked and documented every shift. They stated that the wander guard device was to be placed on the resident's ankle/lower extremity per manufacturer's direction for use. A review of residents #2-#8's clinical records revealed physician orders [REDACTED]. Review of the MAR/TAR and progress notes revealed that the wander guard checks were not being done consistently. Resident #2 had a wander guard with orders to check for placement every shift. A review of the MAR/TAR revealed that staff did not check the wander guard placement on the evening of 4/19/19. Resident #3 had a physician order [REDACTED]. The resident was sent to the hospital on [DATE] and returned on 4/25/19. A review of the MAR/TAR revealed that the resident's wander guard placement was checked on 4/24/19 on the night shift despite the resident being in hospital. A review of the MAR/TAR for resident #4 revealed that the wander guard placement was not checked by staff on the evening shifts of 4/19 and 4/26/19. A review of resident #5's MAR/TARs revealed that placement for wander guard was not checked on the evening shifts of 4/19 and 4/26. A review of resident #6's nursing progress note revealed that he had cut off his wander guard device on 4/15/19. A new wander guard was applied. A review of the MAR/TAR revealed that his wander guard was not checked on the evening of 4/19/19. A review of resident #7's MAR/TAR noted that the wander guard device's expiration date was for the month of (MONTH) 2019. Resident #7's wander guard placement was not checked on the day shift of 4/6/19, 4/14/19 (day shift), 4/15/19 (evening shift), 4/17/19 (evening shift), 4/18/19 (evening shift), and 4/29/19 (evening shift). Resident #8 was admitted to the facility on [DATE]. On 4/29/19 the DNS stated that the resident had the wander guard device since 3/13/19. A review of the medical record revealed that physician orders [REDACTED]. The physician orders [REDACTED]. On 4/8/19, the physician ordered the wander guard function checks every day. On 4/10/19, the physician ordered expiration checks of the wander guard every 4 weeks. A review of the MAR/TAR for the month of (MONTH) 2019 noted the wander guard was not checked for placement on 4/9/19 (day and night shift), 4/10/19 (day and night shift), 4/12/19 (day shift), 4/14/19 (day and night shift), 4/15/19 (day and night shift), 4/20/19 (evening shift), 4/21/19 (night shift), 4/23/19 (night shift) and 4/27/19 (day and night shift). Further reviews of the MARs and TARs for residents #2-#8 revealed that the staff were not consistently documenting if the wander guard devices were on the resident's person. Some documented wander guard on lower extremity, while others did not document a location or put 0 for the location of the wander guard. On 4/29/19 at 2:00 PM, the administrator and DNS acknowledged that the wander guard function and placement checks were not on the MAR/TAR previously. They stated that the restorative aides were checking the function of the wander guard daily and documenting on a separate log. After resident #1's elopement incident, documentation of the wander guard checks was changed to be included in the MAR/TAR. The administrator and DNS were informed of the inconsistent documentation of the wander guards per shift as ordered by the physician for residents #2-#8. When asked if there was any monitoring or audits to ensure that nursing staff were checking for wander guard placement, the administrator stated that audits were being done by the DNS. At that time the DNS stated that audits of MARs/TARs had not been done. The administrator and DNS were asked if there were concerns of residents cutting off their wander guard devices. They could not provide any evidence of approaches/processes in place to identify the risks. They were asked about room rounds for knives/sharp objects or increased supervision of elopement risk residents but it was apparent that these approaches had not been implemented into the facility's elopement risk program.