Every finding on record at Isles of Boynton Nursing and Rehab Center

Based on observations interviews and record review the facility failed to ensure correct medications were given as per physician's orders for 1 out of 25 opportunities for medication administration affecting Resident #155. The findings included: Review of the facility's policy titled, Clinical-Medication Administration with a revised date of 12/10/25 included in part the following: Guidelines for Medication Administration: Have a working knowledge of the medication you are administering; common dosage, common uses, common side effects, and reason the medication is being given to the resident. Use available resources such as drug handbooks, medication package inserts, medication websites, the provider, or the pharmacist if unfamiliar with the medication. Observe the Rights of Medication Administration: Right Medicine. Record review for Resident #155 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Displaced Avulsion Fracture (Chip Fracture) of Left Talus, Pressure Ulcer of Other Site, Acute Kidney Failure, and Type 2 Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #155 revealed in part the following:An order dated 12/22/25 for Ascorbic Acid tablet 500mg give 1 tablet by mouth one time a day for wound healing. There was no order for Saccharomyces Boulardii 500mg for the resident. On 02/10/26 at 9:07 AM, an observation of a medication pass was conducted with Staff H, a Licensed Practical Nurse (LPN), for Resident #155. The nurse prepared Saccharomyces Boulardii 500mg and entered Resident #155's room to administer it. However, the wrong medication was not given to the resident, as the surveyor intervened and prevented the nurse from proceeding. During an interview conducted on 02/10/26 at 9:10 AM with Staff H LPN who was asked about the order for Resident #155 for the ascorbic acid 500mg. The LPN said she thought it was the same as the Probiotic Saccharomyces Boulardii 500mg. When asked what is the other name for ascorbic acid, she looked it up and said it is Vitamin C and acknowledged it was not the same medication.

Based on observations, interviews and record review the facility failed to ensure resident received wound care in a manner consistent with professional standards of practice to promote the healing of pressure ulcers for 1 of 1 sampled resident observed for wound care (Resident #21). The findings included:Review of the facility's policy titled, Dressing -Dry/Clean with an effective date of 04/01/22 included in part the following: Perform hand hygiene, put on clean gloves, Use no-touch technique. Use sterile tongue blades (depressor) and applicators to remove ointment and creams from containers. Apply the ordered dressing and secure with tape or bordered dressing per order. Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Quadriplegia, Chronic Osteomyelitis Left Thigh, Pressure Ulcer of Unspecified Site, Severe Protein Calorie Malnutrition, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #21 revealed in part the following:An order dated 02/06/26 for wound care to sacrum: Cleanse with Dakin's solution 1/4 strength. Pat dry. Skin prep peri wound. Apply hydrogel or SilvaSorb and saturated gauze dressing or kerlix to wound bed. Cover with silicone foam dressing daily and as needed.An order dated 02/06/26 for wound care to right ischial: Cleanse with Dakin's 1/4 strength solution. Pat dry. Skin prep peri wound. Apply hydrogel or SilvaSorb and saturated gauze dressing or kerlix to wound bed. Cover with silicone foam dressing daily and as needed every night shift and every 8 hours as neededAn order dated 02/06/26 for wound care to left ischial: Cleanse with Dakin's 1/4 strength solution. Pat dry. Skin prep peri wound. Apply hydrogel or SilvaSorb and saturated gauze dressing or kerlix to wound bed. Cover with silicone foam dressing daily and as needed every night shift for Wound Healing and every 8 hours as neededAn order dated 02/11/26 for Silver External Gel (Silver) Apply to Sacrum topically every night shift for wound healing and every 8 hours as needed for wound healing. On 02/11/26 at 9:30 AM, an observation of wound care for Resident #21 performed by Staff A Wound Care Registered Nurse (WCRN) Wound Care who stated he has worked at the facility since March 2025; he was assisted by Staff B, Certified Nursing Assistant. Both staff performed hand hygiene. The WCRN gathered supplies. Both staff washed hands and applied a gown and gloves. The WCRN had placed the gown with thumb opening over the gloved hands. The resident was turned to his right side, the WCRN removed the old dressing [it was one dressing covering the sacrum (a triangular bone in the lower back situated between the two hipbones of the pelvis) and both left and right ischium (hip bones)]. He took his thumb out of the opening of the gown, removed his gloves, performed hand hygiene, applied gloves, and left the sleeves of the gown over the gloves without placing his thumb in the opening of the sleeve of the gown. The WCRN proceeded to use gauze pads soaked in Dakin's solution quarter strength and placed the gauze over the 3 wounds (sacrum, left and right ischium) as well as surrounding skin to the three wounds, then proceed to remove the Dakin's soaked gauze pads and use additional Dakin's soaked gauze pads to clean the wound beds (all 3 wounds) as well as the surrounding skin. The left ischium wound had some blackened area in the wound bed and macerated (white) wound edges, the right ischium wound had macerated (white wound edges), and the sacral wound had macerated (white) wound edges, the skin below the sacral wound between the ischium wounds was a dark greyish-black color. The WCRN then used dry gauze to pat dry all three wounds and the surrounding skin to the wounds. The WCRN removed his gloves, used hand sanitizer, pulled back the privacy curtain to open with his right hand to obtain another set of gloves, then pulled the privacy curtain closed with his ungloved right hand and put the gloves on. The WCRN then took a tongue depressor and removed some of the Silver gel from the med cup it had been placed in and proceeded to put the silver gel on each of the three wounds and some of the surrounding skin with the same tongue depressor and repeatedly dipping it in the same silver gel in the med cup. During the process of applying the silver gel, the WCRN's sleeve of the gown was close to the wound bed and the CNA moved his sleeve up his arm for the WCRN (it was unclear if the sleeve of the gown touched the wound). The WCRN then applied skin prep to the outer edge of each wound using a separate skin prep pad for each wound. The WCRN then took rolled gauze and cut a long strip about 24-36 inches long and soaked it in the Dakin's solution, wrung it dry and then placed the one long piece of Dakin's soaked gauze over the right ischium wound, across healthy skin, onto the sacral wound, continuing across more healthy skin, on to the left ischium wound and back to the sacral wound and onto the right ischium wound. The WCRN then used two large, bordered dressings to cover the 3 wounds, however the gauze between the sacrum and the right ischium was not completely covered. When this was brought to the attention of the WCRN, he said he could reinforce it with another bordered dressing. The WCRN then stated, It is because of the position, we just cannot.(and trailed off his words). During the entire process the resident remained on his right side except when the CNA lifted the resident's buttocks up off the bed for the WCRN to place the dressing on the resident's right ischium to reinforce the dressing after the surveyor had intervened. During an interview conducted on 02/11/26 at 10:35 AM with Staff A WCRN, who stated he Felt very confident in what he is doing. When asked about the sacral and ischium wounds for the resident if they were improving, getting worse or staying the same, he said they are staying the same for now. During an interview conducted on 02/12/26 at 7:45 AM with Wound Care Nurse Practitioner WCNP who was asked about 3 wounds for Resident #21, specifically the sacral, left and right ischium wounds, The WCNP stated those particular wounds have improved overall in the past couple of months, and he has debrided the wounds in that time as well. When asked about the wound care orders, he said he does not put them into the facility's system directly, it is in his system and then the orders are put into the facility's system by the (presumably) the wound care nurse. When asked about the order that says hydrogel or SilvaSorb (silver gel), he said he prefers them to use the hydrogel but may substitute with the silver gel. The facility sometimes has difficulty getting hydrogel from pharmacy due to insurance or some other reason so he is okay with either of the medications to be used but would prefer the hydrogel. When asked if the peri wound should be cleaned with the Dakin's solution, he said no, it may compromise the healthy skin surrounding the skin. When asked if the SilvaSorb should be placed in each wound using the same tongue depressor, he said no, that could possibly cross-contaminate the wounds. When asked about placing the SilvaSorb gel on the peri wound (outside edge of the wound), he said no, it is only to be placed on the wound bed, it may damage the heathy tissue. When asked about placing a one piece of Dakin's soaked kerlix gauze across all three wounds and some of the surrounding healthy tissue in between the wounds, he said absolutely not, it would destroy the healthy tissue between the wounds, and it should be placed only in the wound bed of each individualized wound. When asked if the wound and all gauze used would need to be covered, he said yes, due to the resident having issues with incontinence of stool despite having a colostomy. During an interview conducted on 02/12/26 at 2:30 PM with Staff A WCRN who was asked about the wound care he provided for Resident #21, he said he realized after speaking with the Wound Care Nurse Practitioner that he could improve in some areas with the wound care he provides. In summary Staff A WCRN put gloves without performing hand hygiene after touching the privacy curtain twice with his hand, reused the one tongue depressor multiple times for all three wounds, did not perform wound care with good technique putting healthy skin at risk for breakdown, and did not perform wound care as per physician's orders.

Based on observation, interview and record review the facility failed to ensure securing a device in place for 1 of 6 sampled residents with an indwelling catheter (Resident #21). The findings included:Review of the facility's policy titled, Nursing - Physician's Orders with a revised date of 03/10/23 that included in part the following: Treatment orders: all treatments should include the treatment to be used and location of where the treatment should be placed, frequency and if appropriate, how the area should be cleaned and how it should be covered. Reason for the treatment required (diagnosis). Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Quadriplegia, Chronic Osteomyelitis Left Thigh, Pressure Ulcer of Unspecified Site, Severe Protein Calorie Malnutrition, and Major Depressive Disorder. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. Record review revealed an order dated 02/05/26 to include Urinary Catheter: Change Catheter Anchor/Securement Devices as needed Encourage and assist resident to use/apply securing device to catheter as tolerated. May replace and change location as needed. On 02/11/26 at 9:30 AM an observation of wound care was conducted for Resident #21 performed by Staff A, Wound Care Registered Nurse (WCRN), who was assisted by Staff B, Certified Nursing Assistant (CNA). It was also observed during the wound care that Resident #21 had an indwelling urinary catheter that was not anchored. When the WCRN and CNA were finished with the wound care, the CNA removed the adhesive from the anchor that was on the indwelling catheter tubing and secured the indwelling urinary catheter to the resident's upper right thigh. During an interview conducted on 02/11/26 at 10:40 AM with Staff B, CNA ,who was asked about the securing device for the urinary catheter, she said she noticed it was no attached to the resident, so she removed the backing and adhered the anchor to the resident's leg to secure the tubing.

Based on observation, interview, and record review the facility failed to maintain Intravenous (IV) access dressing in a sanitary manner and failed to change an IV access dressing as per facility policy for 1 of 1 sampled resident reviewed for IV access, (Resident #194). The findings included: Review of the facility policy titled Policy and Procedure: Clinical-Medication Administration revised 12/05/2025 documented Purpose: To administer medications as per provider's order and in accordance with regulatory guidelines and practice standards. Intravenous Medication or Fluids (IV therapy): . complete dressing changes as ordered and as needed to the insertion site. Review of the record revealed Resident #194 was admitted to the facility 01/20/26 with a diagnosis of Heart Failure. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #194 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of Resident #194's orders revealed the following: Insert peripheral/midline for IVF bolus give hypotension and persistent AKI. One time only for AKI for 7 Days. (Completed order; Order Date/Time 1/29/2026 11:30 AM; End Date 2/05/2026) D/C MIDLINE one time only for d/c midline until 02/10/2026 23:59(Completed order; Order Date/Time 2/10/2026 10:45 AM) There were no orders for IV dressing changes or monitoring/assessment of IV. Review of the care plans did not reveal any IV/Midline care plans since admission date. An observation and interview was conducted with Resident #194 on 02/09/26 at 10:43 AM and a right upper arm Midline was observed. The dressing appeared dirty with dried dark red blood underneath the dressing. The resident was asked if the surveyor could take a picture of the dressing and the Resident agreed. The dressing was dated 01/29 which was 11 days prior. The resident was asked if she was still receiving anything through her IV, Resident #94 stated her medications had been completed since last week and the nurses had told her they cannot remove it without the doctor's order. When asked if anyone had changed her dressing since inserting it, Resident #194 stated no one had changed it. Resident #194 stated, It hurts and it is pinching my skin. During an interview on 02/10/26 at 12:00 PM, Resident #194 stated her IV was taken out by her nurse today and stated her arm felt better now that it was out. During an interview on 02/11/26 at 1:35 PM when asked how often do you perform an IV assessment and what do you look for, Staff C, Licensed Practical Nurse (LPN) stated it was performed every shift and that she looked for swelling, redness, signs of infection, and that it flushed well. When asked if she expected to see a dressing change order with an insertion of an IV, Staff C stated yes she would expect to see it. When asked how often dressing changes on IVs were performed, Staff C stated every 7 days and as needed. When asked how she knew that, Staff C stated it would be part of the dressing change order. Staff C was shown a picture of Resident #194's IV and asked what she saw in the pictures, Staff C gasped when she saw the pictures and stated oh wow, its bloody, dirty and needs to be changed. During an interview on 02/12/26 at 10:18 AM when asked how often do you perform an IV assessment Staff D, Registered Nurse (RN) stated every shift. When asked if she expected to see a dressing change order with an insertion of an IV, Staff D stated yes she would expect to see it. When asked how often dressing changes on IVs were performed, Staff D stated weekly and as needed. Staff D was shown a picture of Resident #194's IV and asked what she saw in the pictures, Staff D stated the dressing needed to be changed and looked yucky. During an interview on 02/12/26 at 10:30 AM when asked how often do you perform an IV assessment and what do you look for Staff E, LPN, stated every shift and she looked that it was clean, not infiltrated, could flush, signs of infection, and that the line was in place. When asked if she expected to see a dressing change order with an insertion of an IV, Staff E stated yes she would expect to see it and stated normally night shift did it. When asked how often dressing changes on IVs were performed, Staff E stated weekly and as needed. When asked if Staff E expected a care plan to be in place for a Resident with an IV, Staff E stated of course they have to have a care plan. Staff E was shown a picture of Resident #194's IV and asked what she saw in the pictures, Staff E stated that it was past 7 days and needed to be changed, and stated it was crusty and bloody. During an infection control interview on 02/12/26 at 11:09 AM, when asked how often nurses perform IV assessments, the Assistant Director of Nursing (ADON) RN stated every shift. When asked if she expected to see an order for a dressing change, she stated yes and that they were done every 7 days and as needed. The ADON stated they should be making sure the dressing is intact with no signs of infection. The ADON was shown a picture of Resident #194's IV and she stated there was blood on the dressing and acknowledged it was 11 days old and needed to be changed. The ADON was made aware this IV was not removed until 02/10/26 (12 days after insertion), the order stated it was to stay in for 7 days, no IV monitoring/assessment orders were in place, no IV dressing change orders were in place, and no care plan was found. She agreed with the findings and stated she will provide additional education to the nurses. During an interview on 02/12/26 at 12:35 PM, when asked how often nurses are expected to perform an IV assessments, the Director of Nursing (DON) stated she had to double check her policy. When asked how often IV dressing were changed she stated that per facility policy PICC (Peripherally Inserted Central Catheter) and Midlines it were every 7 days and as needed. When asked if she would expect to see a dressing change order with an IV insertion, she stated yes. The DON stated the ADON had already made here aware about these concerns. The DON was shown the picture of Resident #194's IV and agreed with the findings and stated she would provide more education to the nurses. The DON was also made aware there was no care plan for this midline and stated she would look for it. During a follow up interview on 02/12/26 at 2:35 PM the DON stated she agreed that there was no care plan for Resident #194's midline and should have had one.

Based on observation, interview and record review the facility failed to provide respiratory care in a manner consistent with physician orders and facility policy for 1 of 1 sampled resident reviewed for tracheostomy care (Residents #223.) The findings included: Review of the facility's policy titled Policy: Nursing- Tracheostomy Care dated 04/01/22 documented .Equipment and Supplies 1.Gloves (clean and Sterile) 2.Mask and eyewear (as indicated).Procedure Guidelines: 1. Verify Physicians orders.8. Assess patient HR (Heart Rate)/RR (Respiration Rate)/ SaO2 Lung sounds 9.Remove and discard soiled dressing, note drainage and assess stoma site suction trach if necessary.25.Reasses the patient. Using the procedure for tracheostomy suction, suction the resident if needed. Review of the record revealed Resident #223 was admitted to the facility 01/27/26 with diagnoses of Anoxic Brain Damage (when the brain is completely deprived of oxygen, causing brain cells to begin dying)and acute respiratory failure with hypoxia. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #223's Brief Interview for Mental Status (BIMS) was not completed, indicating the resident was severely cognitively impaired. This same MDS indicated Resident #223 received treatments such as tracheostomy care, oxygen therapy, and suctioning. Review of Resident #223's active orders revealed the following: Oxygen Inhalation (via trach collar @ 4lpm as tolerated every shift (Active).Trach care every shift and as needed. Changed gauge around trach flange. as needed trach care AND every shift (Active)Suction trach every shift and as needed as needed suction trach AND every shift (Active) Review of Resident #223's care plan dated 01/28/26 documented Focus: The resident has a Tracheostomy. Goal: The Resident will have no complications, to the extent possible, related to the tracheostomy status through the next review date; Interventions: Monitor/document/Report respiratory status and notify provider of abnormalities observed/reported; Obtain/document/report vital signs as ordered and as needed. Notify provider of abnormal results; Provide suctioning as ordered/tolerated. A tracheostomy care observation for Resident #223 was conducted on 02/11/26 at 1:00 PM with Staff C, Licensed Practical Nurse (LPN). Upon entering the room Staff C performed hand hygiene and donned Personal Protective Equipment (PPE) which included a gown and gloves. Staff C began by setting up her supplies and continued with tracheostomy care. A respiratory assessment was not performed by Staff C. Staff C began to clean Resident#223's trach collar and during the process the resident began to cough and expel secretions and a mucus plug was visualized. Staff C wiped off the secretions on top of the trach canula and the Resident continued to cough and small amounts of secretions were expelled across the room. Staff C verbalized that she should suction the Resident; Staff C did not suction Resident #223. Staff C checked the Resident's pulse oximetry and stated, oh its 97%. Staff C concluded her care, discarded her supplies, and washed her hands. Staff C was asked if she was done with her care and stated yes then walked out of Resident #223's room. Again, Staff C did not perform a respiratory assessment on Resident #223. A follow up interview was conducted on 02/11/26 at 1:25 PM, when asked who normally provides tracheostomy care, Staff C stated she didn't work everyday but the nurses normally provide care and the Respiratory Therapist trained them. Staff C stated this was the first time she performed tracheostomy care by herself on a Resident and last time she trained for it was back in 2022. When asked if she had a competency for performing tracheostomy care at this facility, Staff C stated she did not remember if she had one. When asked how do you perform a respiratory assessment, Staff C stated she would listen to lung sounds and check the oxygen. When asked when she would perform one, Staff C stated anytime and that there was no specific time and then stated when the resident is in distress. When asked if she should perform one before and after tracheostomy care, Staff C agreed. When asked why she didn't perform it, she stated because I only did a dressing change. When asked when would you suction a Resident, Staff C stated when there is phlegm coming out. When asked if she saw any secretions coming out of the Resident, Staff C stated a little bit. When asked if there was a reason she did not perform suctioning she stated she was nervous; Staff C stated she knew how to suction and perform respiratory assessments but did not due to being nervous. Staff C then stated she had never suctioned Resident #223 before and the Respiratory Therapist had been doing it. Review of Staff C's competency titled Trach Care Competency Validation dated 01/28/26 documented, 1. Verify Physicians orders.8. Assess patient HR /RR / SaO2 Lung sounds 9. Remove and discard soiled dressing, note drainage and assess stoma site suction trach if necessary.25. Reassess the patient. Using the procedure for tracheostomy suction, suction the resident if needed. Employee performance is . Acceptable. All skills were verified and signed off by the evaluator, Staff F, RT (Respiratory Therapist) on 01/28/26. During an interview with the Administrator and Director of Nursing (DON) on 02/11/26 at 02:10 PM when asked if all nurses had competencies in tracheostomy care, the Administrator stated the training started on the Med bridge area (short-term care) and the training was ongoing; their goal was for all nurses to be trained. The Administrator stated this training started approximately 4 months ago and they have had 3 tracheostomies since. He stated Staff F was here from Monday to Friday for about 8 hours a day and also on call. During an interview on 02/12/26 at 10:44 AM, when asked how she keeps track of the nurses she has trained on tracheostomy care, Staff F stated she knows them by face but they had a roster that the ADON helped keep track of. When asked how she trained the nurses with tracheostomy care, Staff F stated they had a mannequin, but they also practiced on the actual Resident. Staff F stated the nurses can receive training whenever they want and were able to call her; she stated, she made sure to mark off new nurses and nurses who are per diem since they don't see them everyday. Staff F stated the nurses who are assigned Tracheostomy Residents must be trained. When asked how she performed a competency with a nurse in tracheostomy care, Staff F stated she performed the skill, she asked for return demonstration and then checked them off. When asked what must be done to consider a nurse competent in tracheostomy care, Staff F stated everything on the check list must be done and signed off, if they miss a step they are stopped and must perform it until done properly. During an Infection Control interview on 02/12/26 at 11:09 AM, when asked during tracheostomy care what PPE (Personal Protective Equipment) do you expect to see the nurses wearing, the ADON (Assistant Director of Nursing) stated gown, gloves, and a mask. When asked if she would expect to see any other PPE, the ADON stated if you expect splashing of fluids, a shield too. When asked if she rather them perform tracheostomy care with a shield or eye cover if they don't expect splashing, she agreed. The ADON was made aware Staff C did not perform any respiratory assessments or suction Resident #223 while performing care, she agreed with all findings and stated the nurses needed to receive more education.

Based on observations, interviews and record review, the facility failed to ensure only authorized staff have access to treatment carts for 6 out of 6 treatment carts, failed to ensure med carts are locked at all times for 1 out of 8 med carts, and failed to ensure mediations were secured at the bedside for 1 of 39 sampled residents (Resident #155). The findings included:Review of the facility's policy titled, Clinical - Medication Storage and Labeling with a revised date of 12/09/25 included in part the following: Medications and biologicals in medication rooms, carts, boxes, and refrigerators are to be maintained within secured (locked) locations, accessible only to designated staff. 1) On 02/11/26 at 9:30 AM an observation of wound care performed by Staff A Wound Care Registered Nurse (WCRN) who was assisted by Staff B, Certified Nursing Assistant (CNA), for Resident #21. Upon completion of the wound care, Staff A, WCRN, gave his keys (with keys to all med treatment carts) to Staff B, CNA, to stock the medication treatment carts. During an interview conducted on 0211/26 at 10:35 AM with Staff A, WCRN, who was asked about giving his keys to the treatment carts to Staff B, CNA, Staff, AWCRN, stated this is how they do it, she is a part of his team. When asked if she is authorized to have access to the wound treatment carts, he stated again, she is part of my team, yes of course she is. During an interview conducted on 02/11/26 at 10:40 AM with Staff B, CNA, who was asked if she was authorized to have the keys in her possession for the med treatment cart, she simply said she was going to restock the med treatment carts. During an interview conducted on 02/11/26 at 10:55 AM with the Director of Human Resources she confirmed Staff B, CNA, is not a Qualified Med Tech and there is nothing in her job description about being authorized to have access to medications, including treatment carts. 2) Record review for resident #155 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Displaced Avulsion Fracture (Chip Fracture) of Left Talus, Pressure Ulcer of Other Site, Acute Kidney Failure, and Type 2 Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of the Resident's record revealed no assessment for self-administration of medications. Review of the Physician's Orders for Resident #155 revealed in part the following: An order dated 12/21/25 for Ascorbic Acid Tablet 500 MG, give 1 tablet by mouth one time a day for wound healing.There was no orders for any of the following: Vicks [NAME] Nasal Solution 0.05 %, Magnesium Gummies 336 mg, Tension headache relief acetaminophen 500 mg/65 mg, Tums extra strength 750 mg, Benadryl Allergy Tablet 25 MG (Diphenhydramine HCl). On 02/10/26 at 9:07 AM during a medication pass observation for Resident #155, performed by Staff H, Licensed Practical Nurse (LPN) there on the Resident's overbed table in an open clear container were several over the counter medications including: Magnesium Gummies 336 mg, Tension headache relief acetaminophen 500 mg/65 mg , Tums extra strength 750 mg, Benadryl Allergy Tablet 25 MG (Diphenhydramine HCl), and Vicks [NAME] Nasal Solution 0.05 %. On 02/10/26 at 9:25 AM, during a side by side observation with Staff H, LPN, she acknowledged the medications at the bedside for Resident #155, and acknowledged the resident had no order or assessment for self-administration. 3) During a medication pass observation made on 02/10/26 at 9:07 AM with Staff H, Licensed Practical Nurse (LPN), for Resident #155, the nurse left the medication cart unlocked and unattended when she entered the resident's room to administer the medications. During an interview conducted on 02/10/26 at 9:10 AM with Staff, H LPN, who acknowledged she left the med cart unlocked and unattended when she went into Residents #155's room to administer the medications.

Based on observations, interviews, and record reviews, the facility failed to serve ground meats, per the physician's diet order. This had the potential to affect 1 of 1 sampled resident, who was on a regular texture diet with ground meats (Resident #103). The findings included:A record review revealed that Resident #103 was admitted to the facility on [DATE]. He has received Hospice services since 09/09/2022. His admitting diagnoses included Cerebral Atherosclerosis, Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, and Sarcopenia (muscle wasting). The resident's diet listed in the electronic medical records was for a Regular diet, with Regular texture food, Regular/Thin Liquids consistency, and Ground Meat since 08/06/25. A nutrition progress note dated 08/06/25 revealed that Resident #103's daughter requested that ground meats were added to his diet for ease of chewing. A record review of the Resident #103's diet in the meat ticket program's listing (Dietary List) of diets showed that Resident #103 was on a Regular diet, with Regular texture food, and Regular/Thin Liquids. It did not show that Resident #103 had a diet order for ground meats.Photographic Evidence Obtained An observation on 02/09/26 at 1:05 PM revealed Resident #103 was in bed chewing on something big. The surveyor greeted the resident, and the resident removed brown chewed-up food from his mouth. He held it in his hand and it looked like a half of a small hamburger. There was no tray of food in the resident's room. The surveyor went into the hallway and spoke to the CNA (Certified Nurses Aide) who said she just finished feeding Resident #103. When asked to see the tray of food that he ate from, the CNA removed the tray from the top shelf of the cart. The tray was identified by the meal ticket that had the resident's name and diet printed on it. The meal ticket specified that Resident #103 was on a regular diet, with regular texture foods, and thin fluids. The resident was served regular texture beef pot pie. The plate of his leftover food had a couple of chopped carrots, peas, several green beans, and approximately 2 ounces of stringy beef. The beef should have been ground. The meal ticket had no mention of the diet order that included ground meat. Photographic Evidence Obtained. An interview on 02/09/26 at 1:10 PM, with Staff G revealed that sometimes the CNA's place meat in a piece of bread to facilitate independent feeding. She removed the chewed up food from the resident's hand. She said that Resident #103's daughter wanted him to feed himself when he can. Photographic Evidence Obtained. An observation on 02/10/2026 at 8:20 AM revealed that Resident #103 was served 2 whole waffles, a bowl of corn flakes, and 2 whole round sausage patties. The food served to Resident #103 matched the diet that was printed on his meal ticket. The sausage patties should have been ground. Photographic Evidence Obtained. An interview revealed that Staff I believed that she knew the resident's prescribed diet by reading the diet that was printed on the meal tickets. When asked if the resident's diet was also listed on the Kardex, (the point of care data system that CNA's use to enter details about how much food was eaten), the CNA searched the Kardex. The resident's diet was not listed in the Kardex. When the CNA was made aware that the resident's diet order in the electronic medical records specified ground texture meats, the CNA said she would alert the kitchen about the discrepancy between the diet listed on Resident #103's meal ticket, and the diet in the resident's medical record. Staff I said she would request ground sausage meat for Resident #103.

Based on record review and interview, the facility failed to issue a refund due to the resident or resident representative within 30 days from the resident's date of discharge from the facility, for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3), reviewed for refunds. The findings included: 1. Record review revealed Resident #1 was admitted to the facility on [DATE]. Further record review revealed on 02/20/25 he was discharged to an assisted living facility. During an interview on 06/05/25 at 11:15 AM, Resident #1's family member confirmed the resident was discharged from the facility on 02/20/25, and they still have not received the money owed to them. He explained that they paid privately for his stay through 02/28/25. The family member said he called the Business Office Manager (BOM) more than 2 times, and he also sent emails regarding the refund. During an interview with the BOM (Business Office Manager) on 06/05/25 at 3:45 PM, she said that she sent a request for a refund on 04/21/25 to the corporate biller who processes all refunds. When asked why it took two months to send the request to the biller, the BOM said that Resident #1's family member was sending emails to the previous BOM who held the position before her. When asked if she usually waits for the resident or the resident's family to initiate a request before a refund is processed, the BOM answered, No we don't. She explained that she reviews an Aging Report by phone with the corporate biller every Wednesday and Thursday. The BOM said that she intended to speak with the corporate biller that afternoon, and the surveyor requested that the BOM call the corporate biller to ask why the refund was not issued, but the attempted calls were unsuccessful. The BOM provided the surveyor with a copy of the Aging Report from 09/01/24-05/30/25. The BOM explained that the report included the amount of money that is owed to residents. Review of the report revealed Resident #1 was owed $4,888.20. The BOM said that the resident or the resident's representative should have received the refund right away, and she did not know why it took so long. 2. Record review revealed Resident #2 was admitted to the facility on [DATE]. Further record review revealed she was discharged from the facility on 02/26/25 to a skilled nursing facility. A review of the Aging Report revealed Resident #2 was owed a refund of $2,177.64. The BOM agreed with the findings. 3. Record review revealed Resident #3 was admitted to the facility on [DATE]. Further record review revealed she was discharged from the facility and transferred to the hospital on [DATE]. A review of the Aging Report revealed that Resident #3 was owed a refund of $871.18. The BOM agreed with the findings. During further interview with the BOM at 5:50 PM, when asked how she knew that Resident #2 and #3 hadn't received their refunds yet, she said she was aware that Resident #2 and #3 did not receive their funds because the amounts due were still listed on the Aging Report. Photographic evidence obtained.

Based on interview, record review and observation, the facility failed to protect the residents' right to be free from neglect by failing to provide appropriate supervision to meet the needs 1 of 3 sampled residents (Resident #1), who displayed exit seeking behaviors. The deficient practice allowed Resident #1, on 12/25/24 between 7:15 AM and 7:20 AM, after he removed the right window panel from the window frame in his room, to fall from the window approximately 20 ft to the ground. Resident #1 was found on the ground, in an area approximately three feet wide, between the building and a mature palm tree. Resident #1 was transferred to the hospital by ambulance for evaluation and treatment after suffering from serious injuries. The findings include: Record review revealed the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation, dated October 2019, defined Neglect as follows: Neglect means the failure of the center, its associates or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included, Traumatic Subarachnoid Hemorrhage without a Loss of Consciousness, History of Falling, Major Depressive Disorder, Alcohol use with Intoxication, and Scalp Laceration without foreign body. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was noted to have a Brief Interview of Mental Status (BIMS) score of 99, which indicates Resident #1 was either unable or refused to complete the evaluation. The staff assessment portion of Section C, used when a BIMS score is a 99, indicated Resident #1 was severely cognitively impaired. The MDS also indicated that Resident #1 had 1 to 3 days of wandering behavior. According to the facility's incident report and Resident #1's progress note written by the Director of Nursing (DON), dated 12/20/24, revealed Resident #1 was observed trying to exit the building. On 12/20/24, Resident #1 was then placed on one-to-one (1:1) observation until a bed was available on the second floor. When the bed later became available on 12/20/24, the resident was then moved to the second floor and the 1:1 observation was lifted the same day. The DON's note explained that the second floor of the facility is considered the secured floor because all exits plus the elevator require a keycode to be used before access is granted. Review of Resident #1's care plan created on 12/23/24, documented the following: Focus: Potential/Actual Alteration in Thought Process, AEB [as evidence by]: Inability to respond appropriately to questions; short-term memory deficits; R/T [related to]: brain injury. Goals: Resident will maintain current level of cognitive function through this review period date, target date 3/29/2025. Interventions: Encourage Involvement with Daily Decisions. Give Resident Simple Choices that will not Cause Confusion or Frustration (i.e., Choice Between 2 Items at a Time). Encourage Resident to Attend Activities of Choice. Encourage Resident to Participate as Independently as Possible with ADLS. Provide Simple Clear Directions and Cue Resident as Needed. Ensure Routines are Followed as Closely as Possible Each Shift. Explain All Procedures Prior to Start Minimize/Eliminate Distraction as Much as Possible When Talking to Him. Face Him When Speaking. Speak Clearly and Slowly. On 01/02/25 at 11:13 AM, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) who was the assigned nurse who was working the 11:00 PM to 7:30 PM that spanned from 12/24/24 to 12/25/24. Staff A explained that in the change of shift report from the 3:00 PM to 11:30 PM shift nurse, Staff A had been informed Resident #1 was alert with confusion and had been going from room to room, wandering in and out of residents' rooms, during the shift. Staff A stated this was her first time working with Resident #1 and she was not informed that Resident #1 had been exit-seeking prior to 12/24/24. Staff A stated that on 12/25/24 at around 4:00 AM she noted Resident #1 was wandering in the hall. Staff A stated that she was at the nurses' station when she went to redirect Resident #1 back to his room. Staff A stated that Resident #1 returned to his room on his own before Staff A reached him. The nurse stated that she and Staff C were monitoring Resident #1 every 20 minutes but admitted that the observations were not documented. Staff A stated that she last saw Resident #1 sitting on his bed at around 7:15 AM. Staff A stated that had she had known Resident #1 had been exit-seeking prior to his being moved upstairs she would have placed him on 1:1 observation when he was found by an exit door with the alarm ringing at approximately 6:15 AM, as she reported in the incident report. On 01/02/2025 at 2:23 PM, an interview was conducted with Staff C, a Certified Nursing Assistant (CNA) stated that Resident #1 was awake when she came on the shift at 11:00 PM and she checked on him again at 12:00 AM. Staff C stated Resident #1 was asleep when she checked him around 1:00 AM. Staff C stated Resident #1 was sleeping until about 4:00 AM, when she went on her break. Staff C stated Resident #1 was wandering in the hallway around 4:00 AM and she redirected him back to his room before she went on break. Staff C stated that when she came back from break, at around 4:45 AM she found Resident #1 in his room. Staff C stated the nurse on duty informed her that Resident #1 had tried to flush his diaper in the toilet when she was on break. Staff C stated that the resident was in his room when she helped the nurse clean up the toilet incident. Staff C stated Resident #1 was walking in the hall at 5:00 AM. Staff C stated Resident #1 was in his room from about 6:00 AM to 7:00 AM, which is when change of shift occurs. Staff C stated the last time she saw Resident #1 he was sitting on his bed at 7:16 AM, before she left for the day. On 01/08/25 at 1:06 PM an interview was conducted with Staff E, a CNA, regarding neglect training. Staff E described neglect as not taking care of a resident, leaving them dirty or wet. Staff E stated that the residents should be checked on every 2 hours. Staff E stated if a resident is exit seeking, they have been instructed to stay with the resident and inform the nurse or the supervisor of the situation. Staff E stated exit seeking would be a resident pushing on the door and setting the alarm off. Staff E stated that if a resident states they want to leave or are packing a bag that those are exit seeking behaviors. Staff E stated, in his opinion, if Resident #1 had been on 1:1 observation that the accident that occurred would not have happened. Staff E stated the facility reviewed the incident with staff and they, the staff, were taught what exit seeking behavior was and the importance of 1:1 observation to prevent a resident from exiting the facility. On 01/08/25 at 2:31 PM, an interview was conducted with Staff F, an LPN. Staff F stated he works both the 7:00 AM to 3:30 PM (1st) shift and the 3:00 PM to 11:30 PM (2nd) shift. Staff F stated he has had Abuse/Neglect training and Elopement training within the last few weeks. Staff F stated the facility has been having elopement drills at least once a week. Staff F stated the facility does elopement drills both shifts that he works. The nurse stated the facility was educating the staff regarding exit seeking behavior and how to respond to exit seeking. The nurse stated that a resident going to the stairwells or trying to go on the elevator are physical signs of exit seeking. The nurse stated if the resident tells you he wants to go home or is seen packing his bags those are also signs of exit seeking. Staff F stated that if he had a resident that showed signs of exit seeking, he would assign the CNAs to do 1:1 observation and call the DON to inform her of the situation. Staff F stated that given the information provided about the accident he believes that placing a person on 1:1 observation for elopement would more likely prevent the person from having the accident that occurred on 12/25/24. 01/08/25 at 3:53 PM an interview was conducted with Staff G, a CNA. Staff G explained that when the staff does not provide care to a resident then that is neglect. Staff G explained that if a resident tries to open an exit door, she tries to stop the resident and tells the nurse or supervisor that the resident wants to leave. Staff G stated that if she sees a resident packing and that resident is not discharged then that is a sign of exit seeking. Staff G stated she would call the supervisor to let the supervisor know what the resident was doing and then follow the supervisor's instructions. Staff G stated that if Resident #1 had been on 1:1 observation then the chances that Resident #1 would have gotten out of the window would have gone down. Staff G stated the facility has been doing elopement drills every day. On 01/08/25 at 4:15 PM, an interview was conducted with Staff H, an LPN and Unit Manager on the 2nd floor, Staff H stated she conducts the elopement drills for both the 7:00 AM to 3:30 PM shift and the 3:00 PM to 11:30 PM shift. Staff H stated the DON or night shift, or weekend supervisor conduct the drills for the 11:00 PM to 7:30 AM shift. Staff H stated that the drills were ongoing every day. Staff H stated that if she was informed that a resident is exit seeking, she instructs to staff member to staff with the resident on 1:1 observation until instructed otherwise. Staff H stated she then contacts the DON to inform her and to get instructions for continued 1:1 observation. Staff H stated that if a resident is on 1:1 observation there should be no way the resident could climb out a window. On 01/06/25 at 5:00 PM, the Immediate Jeopardy Removal Plan for Neglect was verified, and the facility was notified that the Immediate Jeopardy was removed. Immediate Jeopardy Removal Plan and Corrective Action plan implemented by the facility: 1. On 12/25/24, Resident was assessed and 911 called to transport to hospital for higher level of care. The resident was transported to Delray Medical Center. -This was verified by review of hospital records provided by the facility on 01/02/25. 2. On 12/25/24, Director of Nursing (DON) notified Interim Administrator, Regional Director of Operations (RDO), Nurse Consultant, [NAME] President of Clinical Services of incident. -This was verified by direct interactions with those identified, excluding the [NAME] President of Clinical Services who was not onsite, during the survey process which began on 01/02/25 and concluded on 01/08/25. 3. On 12/25/24, the Facility conducted a head count of residents currently residing in the facility, all were accounted for and safe. -This was verified by a review of the Midnight Census that was used as a checklist to identify the residents present. There were no missing residents identified. 4. On 12/25/24, RDO and DON notified the Regional Maintenance Director to report to the center to make sure the windows are secure. No new findings. -This was verified by Direct Interactions with the Regional Maintenance Director during the facility tour conducted on 1/3/25 at 11:14 AM. During the tour, the window in room [ROOM NUMBER] was inspected and found to be secured with a screw at the bottom of the window frame that was placed in both the left and right-side window panels. Neither panel was moveable. The security was checked on random windows in resident rooms on both floors. All were secured in the same fashion. 5. Resident is responsible for self. No family. -This was documented in the resident's profile. 6.On 12/25/24, Medical Director, Primary and Advanced Registered Nurse Practitioner (ARNP) notified of incident. -A brief interview was conducted with the Medical Director and the ARNP on 1/8/25 at approximately 9:30 AM, when they were making rounds. They both confirmed they had been notified of the incident on 12/25/24. 7. On 12/26/24, Wandering risk User-Defined Assessment (UDA) was completed on all wandering/elopement risk residents. -A review of documentation provided in the facility's incident binder revealed documentation of the evaluations completed. This review was conducted on 1/2/25 and repeated on 1/8/25 for the removal plan. Two resident records were selected for review, one with a low-risk score of 4 and one with a high-risk score of 10. A comparison was made to the elopement book where it was found the resident with a high-risk score was not in the elopement book. The DON explained that the high-risk score was generated because the resident was taking two or more antipsychotic medications which increase the risk score. The DON further explained that the resident did not have any wandering or exit seeking behaviors. The explanation provided was also documented on the evaluation along with the medications in use. The DON explained that the residents currently were not exhibiting exit-seeking behaviors. The DON stated that under the new protocols any resident who shows exit-seeking behaviors would be placed on a 1:1 observation. 8. On 12/26/24, A Facility wide audit was conducted by DON/Designee to identify other residents who are at high risk for exit seeking and to prevent recurrence of the event. No new findings identified. -This was confirmed in item 7 above as the same evaluation was used for wandering and elopement risk. 9. On 12/25/24, Signs were placed at the main exit doors to residents from exiting. -These signs were noted upon entry into the facility on [DATE] and during the entire survey. 10. On 12/25/24 initiated every shift behavior management drill X 2 weeks then Bi-Weekly drills X 30 days. Monthly X 3 months. Post-test included for drills. -Completed post tests were provided as evidence. On 1/8/25 interviews were conducted with staff regarding the education provided. These interviews were conducted as part of the removal plan evaluation. 11. On 12/25/24, In-services and competencies-initiated by the Director of Nursing/ Designee, facility-wide on prevention of Neglect and placing a resident on 1:1 observation when exit seeking is identified, regardless of the security of the unit, behavioral residents' management. in-services and post-in-service competencies completed on the following dates: a. 12/25/2024 - 50% completed b. 12/26/2024 - 75% completed c. 12/27/2024 - 83.5% completed d. 12/30/2024 - 92%completed e. 12/31/2024- 100% completed f. 30 certified letters sent on 12/27/24 to remaining associates that could not be contacted. g. 2 not contacted due to out of the country. h. No staff members were permitted to work until education and post in-service were completed. The facility provided an Excel file of all departments with completion dates for employee training. 12. Upon hire and as necessary, staff will complete an in-service education on neglect and the elopement system and management of behavioral residents. -This was part of the Performance Improvement Plan that was reviewed and verified on 1/8/25. 13. On 12/25/24, A Performance Improvement Plan was created and an Ad-hoc QAPI initiated as it relates to F600: Freedom from Abuse, Neglect and Exploitation and meeting conducted on 12/26/24. 14. On 12/26/24, Adult Protective Services (APS) was notified online. -This was documented as part of the facility's investigation. 15. Beginning 12/26/24 all newly admitted residents will continue to be screened for exit seeking behaviors on admission, quarterly, annually and as needed. The DON/Designee will audit screens weekly X 4 weeks and monthly for 2 months to ensure that all precautions measures are implemented. -This documentation was reviewed as stated above in item 7. 16. The findings of the above audits will be reported to the Quality Assurance/Performance Improvement Committee weekly until the committee determines substantial compliance has been met. 17. In summary all items required for removal were completed as of 12/27/24 except for ongoing prevention of Neglect and placing a resident on 1:1 observation when exit seeking is identified, regardless of the security of the unit, behavioral residents' management education and practice tests (No staff members were permitted to work until education and post in service were completed). 100% of the education and post-test were completed on 12/31/24. All items above were reviewed prior to exit on 1/8/25 at 5:00 PM. The final removal plan was accepted with the removal date of 12/31/24 as requested. Photographic Evidence Obtained.

Based on interview, record review and observation, the facility failed to provide appropriate supervision to prevent 1 of 1 sampled resident, Resident #1, from falling from a second-floor window. The deficient practice allowed Resident #1, on 12/25/24 at between 7:15 AM and 7:20 AM, after he removed the right window panel from the window frame in his room, to fall from the window approximately 20 ft to the ground. Resident #1 was found on the ground, in an area approximately three feet wide, between the building and a mature palm tree. Resident #1 was transferred to the hospital by ambulance for evaluation and treatment after suffering from serious injuries. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included, Traumatic Subarachnoid Hemorrhage without a Loss of Consciousness, History of Falling, Major Depressive Disorder, Alcohol use with Intoxication, and Scalp Laceration without foreign body. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was noted to have a Brief Interview of Mental Status (BIMS) score of 99, which indicates Resident #1 was either unable or refused to complete the evaluation. The staff assessment portion of Section C, used when a BIMS score is a 99, indicated Resident #1 was severely cognitively impaired. The MDS also indicated that Resident #1 had 1 to 3 days of wandering behavior. According to the facility's incident report and Resident #1's progress note written by the Director of Nursing (DON), dated 12/20/24, revealed Resident #1 was observed trying to exit the building. On 12/20/24, Resident #1 was then placed on one-to-one (1:1) observation until a bed was available on the second floor. When the bed later became available on 12/20/24, the resident was then moved to the second floor and the 1:1 observation was lifted the same day. The DON's note explained that the second floor of the facility is considered the secured floor because all exits plus the elevator require a keycode to be used before access is granted. Review of Resident #1's care plan created on 12/23/24, documented the following: Focus: Potential/Actual Alteration in Thought Process, AEB [as evidence by]: Inability to respond appropriately to questions; short-term memory deficits; R/T [related to]: brain injury. Goals: Resident will maintain current level of cognitive function through this review period date, target date 3/29/2025. Interventions: Encourage Involvement with Daily Decisions. Give Resident Simple Choices that will not Cause Confusion or Frustration (i.e., Choice Between 2 Items at a Time). Encourage Resident to Attend Activities of Choice. Encourage Resident to Participate as Independently as Possible with ADLS. Provide Simple Clear Directions and Cue Resident as Needed. Ensure Routines are Followed as Closely as Possible Each Shift. Explain All Procedures Prior to Start Minimize/Eliminate Distraction as Much as Possible When Talking to Him. Face Him When Speaking. Speak Clearly and Slowly. On 01/02/25 at 11:13 AM, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) who was the assigned nurse who was working the 11:00 PM to 7:30 PM that spanned from 12/24/24 to 12/25/24. Staff A explained that in the change of shift report from the 3:00 PM to 11:30 PM shift nurse, Staff A had been informed Resident #1 was alert with confusion and had been going from room to room, wandering in and out of residents' rooms, during the shift. Staff A stated this was her first time working with Resident #1 and she was not informed that Resident #1 had been exit-seeking prior to 12/24/24. Staff A stated that on 12/25/24 at around 4:00 AM she noted Resident #1 was wandering in the hall. Staff A stated that she was at the nurses' station when she went to redirect Resident #1 back to his room. Staff A stated that Resident #1 returned to his room on his own before Staff A reached him. The nurse stated that she and Staff C were monitoring Resident #1 every 20 minutes but admitted that the observations were not documented. Staff A stated that she last saw Resident #1 sitting on his bed at around 7:15 AM. Staff A stated that had she had known Resident #1 had been exit-seeking prior to his being moved upstairs she would have placed him on 1:1 observation when he was found by an exit door with the alarm ringing at approximately 6:15 AM, as she reported in the incident report. On 01/02/2025 at 1:40 PM, an interview was conducted with Staff B, an LPN. Staff B was the first employee to find Resident #1 after his fall. Staff B explained that when she arrived at work on 12/25/2024 she was late for work. She stated that she had parked her car near the building but not in a spot and went to punch in. Staff B stated Resident #1 had not fallen when she entered the building. Staff B stated that after she punched in, she moved her car to a parking spot. When she was going back in, she saw a person lying on the ground, on his right side, in the fetal position (curled in). Staff B stated that this was around 7:18 AM. Staff B stated she did not know that the person was a resident at the time. The nurse stated she went into the facility and told other staff about the person she just saw outside. The staff followed the nurse outside to investigate and realized the man on the ground was a resident. The nurse stated one of the staff members, she believed he was a housekeeper, saw the resident was lying on top of a window screen. This was how the staff realized the resident had fallen from the 2nd floor window. The nurse stated that some of the other staff were nurses who then assessed the resident and called 911. Staff B stated the primary nurse was informed by that time as well. On 01/02/25 at 11:13 AM, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) who was the assigned nurse who was working the 11:00 PM to 7:30 PM that spanned from 12/24/24 to 12/25/24. Staff A explained that in the change of shift report from the 3:00 PM to 11:30 PM shift nurse, Staff A had been informed Resident #1 was alert with confusion and had been going from room to room, wandering in and out of residents' rooms, during the shift. Staff A stated this was her first time working with Resident #1 and she was not informed that Resident #1 had been exit-seeking prior to 12/24/24. Staff A stated that on 12/25/24 at around 4:00 AM she noted Resident #1 was wandering in the hall. Staff A stated that she was at the nurses' station when she went to redirect Resident #1 back to his room. Staff A stated that Resident #1 returned to his room on his own before Staff A reached him. The nurse stated that she and Staff C were monitoring Resident #1 every 20 minutes but admitted that the observations were not documented. Staff A stated that she last saw Resident #1 sitting on his bed at around 7:15 AM. Staff A stated that had she had known Resident #1 had been exit-seeking prior to his being moved upstairs she would have placed him on 1:1 observation when he was found by an exit door with the alarm ringing at approximately 6:15 AM, as she reported in the incident report. According to the incident report, there were two times Staff A did not determine as exit seeking. The first time was when she found Resident #1 standing at the exit door where the alarm was ringing, indicating he attempted to open the door and set off the alarm. The second time mentioned in the report was when Resident #1 followed Staff A to the supply room and asked for the exit. Resident #1 was redirect to his room on both occasions without further interventions being placed. On 01/02/2025 at 2:23 PM, an interview was conducted with Staff C, a Certified Nursing Assistant (CNA) stated that Resident #1 was awake when she came on the shift at 11:00 PM and she checked on him again at 12:00 AM. Staff C stated Resident #1 was asleep when she checked him around 1:00 AM. Staff C stated Resident #1 was sleeping until about 4:00 AM, when she went on her break. Staff C stated Resident #1 was wandering in the hallway around 4:00 AM and she redirected him back to his room before she went on break. Staff C stated that when she came back from break, at around 4:45 AM she found Resident #1 in his room. Staff C stated the nurse on duty informed her that Resident #1 had tried to flush his diaper in the toilet when she was on break. Staff C stated that the resident was in his room when she helped the nurse clean up the toilet incident. Staff C stated Resident #1 was walking in the hall at 5:00 AM. Staff C stated Resident #1 was in his room from about 6:00 AM to 7:00 AM, which is when change of shift occurs. Staff C stated the last time she saw Resident #1 he was sitting on his bed at 7:16 AM, before she left for the day. On 01/02/2025 3:03 PM, an interview was conducted with Staff D, an LPN. Staff D was one of the nurses who assessed Resident #1. Staff D stated when she was informed by a housekeeper that there was an emergency outside, she and another nurse ran out to see what happened. Staff D stated that she had a portable wrist blood pressure cuff in her pocket and started taking vital signs. Staff D stated the resident's blood pressure was 200 (Systolic Blood Pressure) over something, she did not remember the number (Diastolic). Elevated blood pressure is common with trauma. Staff D stated she remembered the resident's heart rate was around 116 (beats per minute). Staff D stated the other nurse called 911 and the DON. Staff D stated the resident was on his back moving his arms but not moving his legs when she was assessing him. Staff D stated she checked the resident's legs for unusual length and found none. Changes in leg length or unusual positioning can indicate a fractured hip or a hip dislocation. Hospital records, provided by the facility, revealed the following information pertaining to Resident #1: A Computerized Tomography (CAT or CT) scan of the head was performed with the following results: New small acute left subdural hemorrhage measuring up to 4 mm. New small amount left occipital horn intraventricular hemorrhage. Low density right subdural collection may indicate a small hygroma measuring 6 mm. There was also a compression fracture of the third Lumbar Vertebra (L3) that was being treated with a brace. There was no neurosurgery interventions planned. On 01/03/25 at 11:14 AM, a walking tour of the facility was made with the Regional Maintenance Director (RMD) who made the changes to the windows in all resident rooms to prevent the windows from being opened. These changes were made to prevent residents from eloping and to prevent residents from removing window panels and falling from the second floor. The windows were secured with 1-inch self-tapping screws that were placed through the window frame tracks and the bottom of the windows. Windows were tested and found to be unmovable. All residents have fire sprinklers which allows this change to occur as verified by AHCA Life Safety surveyors. On 01/08/25 at 1:06 PM an interview was conducted with Staff E, a CNA, regarding neglect training. Staff E described neglect as not taking care of a resident, leaving them dirty or wet. Staff E stated that the residents should be checked every 2 hours. Staff E stated if a resident is exit seeking that they have been instructed to stay with the resident and inform the nurse or the supervisor of the situation. Staff E stated exit seeking would be a resident pushing on the door and setting the alarm off. Staff E stated that if a resident states they want to leave or are packing a bag that those are exit seeking behaviors. Staff E stated, in his opinion, if Resident #1 had been on 1:1 observation that the accident that occurred would not have happened. Staff E stated the facility reviewed the incident with staff and they, the staff, were taught what exit seeking behavior was and the importance of 1:1 observation to prevent a resident from exiting the facility. On 01/08/25 at 2:31 PM, an interview was conducted with Staff F, an LPN. Staff F stated he works both the 7:00 AM to 3:30 PM (1st) shift and the 3:00 PM to 11:30 PM (2nd) shift. Staff F stated he has had Abuse/Neglect training and Elopement training within the last few weeks. Staff F stated the facility has been having elopement drills at least once a week. Staff F stated the facility does elopement drills both shifts that he works. The nurse stated the facility was educating the staff regarding exit seeking behavior and how to respond to exit seeking. The nurse stated that a resident going to the stairwells or trying to go on the elevator are physical signs of exit seeking. The nurse stated if the resident tells you he wants to go home or is seen packing his bags those are also signs of exit seeking. Staff F stated that if he had a resident that showed signs of exit seeking, he would assign the CNAs to do 1:1 observation and call the DON to inform her of the situation. Staff F stated that given the information provided about the accident he believes that placing a person on 1:1 observation for elopement would more likely prevent the person from having the accident that occurred on 12/25/24. 01/08/25 at 3:53 PM an interview was conducted with Staff G, a CNA. Staff G explained that when the staff does not provide care to a resident then that is neglect. Staff G explained that if a resident tries to open an exit door, she tries to stop the resident and tells the nurse or supervisor that the resident wants to leave. Staff G stated that if she sees a resident packing and that resident is not discharged then that is a sign of exit seeking. Staff G stated she would call the supervisor to let the supervisor know what the resident was doing and then follow the supervisor's instructions. Staff G stated that if Resident #1 had been on 1:1 observation then the chances that Resident #1 would have gotten out of the window would have gone down. Staff G stated the facility has been doing elopement drills every day. On 01/08/25 at 4:15 PM, an interview was conducted with Staff H, an LPN and Unit Manager on the 2nd floor, Staff H stated she conducts the elopement drills for both the 7:00 AM to 3:30 PM shift and the 3:00 PM to 11:30 PM shift. Staff H stated the DON or night shift, or weekend supervisor conduct the drills for the 11:00 PM to 7:30 AM shift. Staff H stated that the drills were ongoing every day. Staff H stated that if she was informed that a resident is exit seeking, she instructs staff member to staff with the resident on 1:1 observation until instructed otherwise. Staff H stated she then contacts the DON to inform her and to get instructions for continued 1:1 observation. Staff H stated that if a resident is on 1:1 observation there should be no way the resident could climb out a window. On 01/06/25 at 5:00 PM, the Immediate Jeopardy Removal Plan for Accident Hazards/Supervision was verified, and the facility was notified that the Immediate Jeopardy was removed. Immediate Jeopardy Removal Plan and Corrective Action plan implemented by the facility: 1.On 12/25/24, Resident was assessed and 911 called to transport to hospital for higher level of care. The resident was transported to the local hospital. -This was verified by review of hospital records provided by the facility on 01/02/25. 2. On 12/25/24, Director of Nursing (DON) notified interim Administrator, Regional Director of Operations, Nurse Consultant, [NAME] President of Clinical Services of incident. -This was verified by direct interactions with those identified, excluding the [NAME] President of Clinical Services who was not onsite, during the survey process which began on 01/02/25 and concluded on 01/08/25. 3. On 12/25/24, the Facility conducted a head count of residents currently residing in the facility, all were accounted for and safe. -This was verified by a review of the Midnight Census that was used as a checklist to identify the residents present. There were no missing residents identified. 4. On 12/25/24, Regional Director of Operations and Director of Nursing notified the Regional Maintenance Director to report to the center to make sure the windows are secure. No new findings. -This was verified by Direct Interactions with the Regional Maintenance Director during the facility tour conducted on 1/3/25 at 11:14 AM. During the tour, the window in room [ROOM NUMBER] was inspected and found to be secured with a screw at the bottom of the window frame that was placed in both the left and right-side window panels. Neither panel was moveable. The security was checked on random windows in resident rooms on both floors. All were secured in the same fashion. This was verified on 1/8/25, by the surveyor, with random room checks of both floors of the facility, especially room [ROOM NUMBER]. 5. On 12/25/24, For added precautions all windows were reinforce with extra screw to window/frame. -Verification identified in #4 above. 6. On 12/25/24, Resident environment was free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents. -This was verified by observations made between 1/2/25 and 1/8/25. 7. Resident is responsible for self. No family. -This was documented in the resident's profile. 8. On 12/25/24, Medical Director, Primary and Advanced Registered Nurse Practitioner (ARNP) notified of incident. -A brief interview was conducted with the Medical Director and the ARNP on 1/8/25 at approximately 9:30 AM, when they were making rounds. They both confirmed they had been notified of the incident on 12/25/24. 9. On 12/26/24, Wandering risk User-Defined Assessment (UDA) completed on all wandering/elopement risk residents. -A review of documentation provided in the facility's incident binder revealed documentation of the evaluations completed. This review was conducted on 1/2/25 and repeated on 1/8/25 for the removal plan. Two resident records were selected for review, one with a low-risk score of 4 and one with a high-risk score of 10. A comparison was made to the elopement book where it was found the resident with a high-risk score was not in the elopement book. The DON explained that the high-risk score was generated because the resident was taking two or more antipsychotic medications which increase the risk score. The DON further explained that the resident did not have any wandering or exit seeking behaviors. The explanation provided was also documented on the evaluation along with the medications in use. The DON explained that the residents currently were not exhibiting exit-seeking behaviors. The DON stated that under the new protocols any resident who shows exit-seeking behaviors would be placed on a 1:1 observation. 10. On 12/25/24, Signs placed at main exit doors to not let any residents exit. -Sign was observed by the surveyor. The sign conveys the message to check with the nurse before allowing a resident to exit. 11. On 12/25/24 initiated every shift elopement drills X 2 weeks then Bi-Weekly Elopement drills X 30 days. Monthly X 3 months. In addition, Every shift behavior management drill X 2 week then Bi-Weekly Elopement drills X 30 days. Monthly X 3 months post-test included for both drills. -Completed post tests were provided as evidence. On 1/8/25 interviews were conducted with staff regarding the education provided. These interviews were conducted as part of the removal plan evaluation. 12. On 12/25/24, In-services and competencies-initiated by the Director of Nursing/ Designee, facility-wide on prevention of Resident Abuse, Neglect, elopement, resident safety, behavior management. in-services and post-in-service competencies completed on the following dates: a. 12/25/2024 - 50% completed b. 12/26/2024 - 75% completed c. 12/27/2024 - 83.5% completed d. 12/30/2024 - 92%completedd e. 12/31/2024- 100% completed f. 30 certified letters sent on 12/27/24 to remaining associates that could not be contacted. g. 2 not contacted due to out of the country. h. No staff members were permitted to work until education and post in-service were completed. -The facility provided an Excel file for all departments with completion dates for employee training. 12. Upon hire and as necessary, staff will complete this in-service education on neglect and the elopement system. -This item was already in place with additional training stated above added to the process as explained by the DON on 1/8/25. All items above were reviewed prior to exit on 1/8/25 at 5:00 PM. The final removal plan was accepted with the removal date of 12/31/24 as requested. Photographic Evidence Obtained.

Based on record review and interview, the facility failed to investigate an injury of unknown origin for 1 of 3 sampled residents reviewed for accidents (Resident #121). The findings included: A review of the facility's policy titled, Exception Reports dated 11/2019, documented: The Charge Nurse or designee must conduct an investigation of the accident/incident by way of completing the Exception Report and adding any additional information to determine the cause of the incident/accident. Resident #121 was admitted to the facility on [DATE]. A record review revealed a comprehensive assessment dated [DATE] that documented the resident had severe cognitive impairment and was dependent on staff for activities of daily living. A progress note dated 07/02/24 documented: The Nurse Practitioner (NP) aware of the positive knee X-ray results. The NP ordered the patient to the hospital ER (emergency room ) for further evaluation. This writer informed the family that the patient c/o (complained of) pain to her knee upon movement with the physical therapist. The family aware the patient had an X-ray and the results are positive for a fracture to the knee, and the NP ordered the patient to go to the hospital ER for further evaluation. A review of the facility's adverse and incident log did not reveal an incident involving Resident #121 for that occurrence. An interview was conducted with the Assistant Director of Nursing (ADON) on 08/28/24 at 9:00 AM. The ADON stated it was believed Resident #121's knee fracture was due to osteoporosis. The ADON was not able to provide any documentation of such diagnosis. The ADON further stated the injury of unknown origin was not investigated.

Based on observation, interview, record and policy review, the facility failed to obtain a Level I PASSAR (Preadmission Screening and Resident Review) for 2 of 6 residents reviewed for a Level 1 PASARR (Resident #67 and #90). The findings included: Record review revealed the facility's policy titled, Preadmission Screening (PASSAR/PASSR) dated March 2020 documented It is the policy of the center to follow the Federal and State regulations with regards to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. 1. Resident #67 was admitted to the facility post hospitalization on [DATE] with diagnoses that included Cerebral Atherosclerosis, Vascular Dementia, Anxiety and Dysphagia. According to the resident's Admission Minimum Data Set (MDS) assessment dated [DATE], she was unable to answer the questions on the Brief Interview for Mental Status. This indicated the resident had severe cognitive impairment. On 08/28/24 at 1:15 PM the surveyor asked the Administrator for the Level 1 PASARR for Resident #67 in the absence of the Social Service Director. On 08/29/24 at 11:00 AM in an interview with the Administrator, she stated there was no PASARR for this resident in the building. They had no record that it was done. 36734 2. Resident #90 was admitted to the facility on [DATE] with diagnoses included Psychotic Disorder. Further review of the resident's record revealed there was no evidence of a Level 1 Preadmission Screening and Resident Review (PASARR), prior to the resident's admission to the facility. An interview was conducted with the Assistant Director of Nursing (ADON) on 08/29/24 at 12:00 PM. The ADON acknowledged the findings.

Based on observation, interview, and record review, the facility failed to address a resident's discomfort in a timely manner for 1 of 1 sampled resident (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE]. A review of the resident's Admission Nursing Data Collection, dated 08/23/24 at 4:04 AM, documented Resident #246 was alert and oriented to person, place, time, and situation. The collection data further documented the resident was admitted with a urinary catheter. An interview was conducted with Resident #246 on 08/26/24 at 1:00 PM. The resident stated her urinary catheter was changed on the night of 08/24/24, due to the catheter being clogged. The resident stated there was a large amount of sediment in the catheter, and her genitals were itching/burning due to what she believed was a yeast infection. Resident #246 stated she told the nurse about the itching/burning of her genitals, and the nurse stated she would get an order for an ointment. The resident stated she has been so miserable, that she was using an antibiotic cream, prescribed for her toe, on her genitals for some relief. The resident pulled out a tube of Gentamycin ointment from her bedside drawer. Resident #246 stated she inquired about the ointment for her genitals this morning, and was told by her nurse that she would look into it. Resident #246 stated her family member was present at the time the urinary catheter was changed and she complained of her genitals itching/burning. Record review did not reveal any documentation of the resident's urinary catheter changed, any complaints of genital discomfort, or any orders for any ointment for the resident's genitals. A telephone interview was conducted with Resident #246's family member on 08/26/24 at 1:50 PM. The family member stated she was present with the resident on Saturday night (08/24/24). The family member stated the nurse changed the resident's urinary catheter due to a blockage. The nurse was told about the resident's itching/burning genitals. The family member stated Resident #246 told her this morning that she had not received any medication for treatment of her symptoms. The family member further stated she was appalled that the resident's concerns were not addressed. An interview was conducted with the Unit Manager (UM) on 08/26/24 at 3:00 PM. The UM stated she had just discontinued (pulled out) Resident #246's urinary catheter. The UM stated she was not aware of the resident's concerns for a yeast infection, and did not observe any concerns with the resident's genitals when she discontinued the urinary catheter. The UM acknowledged there was no documentation of the resident's urinary catheter being changed on 08/24/24, or the resident's complaint of genital discomfort. An interview was conducted with the Desk Nurse on 08/26/24 at 3:05 PM. The Desk Nurse stated Resident #246's nurse told him of the resident's concerns about 2 hours ago. The Desk Nurse stated he had a call out to the physician for orders, and was awaiting a return call. An observation of Resident #246's genitals was conducted with the UM on 08/26/24 at 3:30 PM. The resident's genitals were reddened/inflamed and had some bleeding. The resident showed the UM the Gentamycin ointment she had been applying to her genitals. The UM attempted to confiscate the ointment, and the resident screamed, No, nobody is taking my medication, it is all that I have right now!.

Based on record review and interview, the facility failed to obtain the results of a urinalysis for a resident with a Urinary Tract Infection (UTI) in a timely manner for 1 of 1 sampled resident (Resident #247), resulting in a delay of treatment for a UTI. The findings included: Resident #247 was admitted to the facility on [DATE]. Record review revealed a comprehensive assessment dated [DATE] documented the resident was cognitively intact and was frequently incontinent of urine. Record review revealed an order for Urinalysis Culture and Sensitivity on 12/22/23. Further record review did not reveal any documentation for the reason for the urinalysis order, or any signs or symptoms/condition of Resident #247. A review of Resident #247's urinalysis results revealed the resident's urine was collected and received on 12/23/23. Further review of the results of the Urinalysis Culture and Sensitivity was resulted on 12/27/23, with a specific bacteria. Resident #247 was ordered an antibiotic on 12/27/23. A review or the resident's Medication Administration Record revealed the resident received the antibiotic on 12/27/24 at 5:00 PM (5 days after the order for the urinalysis). An interview was conducted with the Desk Nurse on 08/28/24 at 1:00 PM. The Desk Nurse stated they get a preliminary report for a Urinalysis Culture and Sensitivity within 24 hours. The preliminary results are called into the physician, and if positive, the physician may order antibiotics for the resident, or may wait for the completed sensitivity identifying the microorganism. The Desk Nurse acknowledged a preliminary report was not documented as received. The Desk Nurse further stated the nurse should have followed up on Resident #247's urinalysis within 24-48 hours for results.

Based on interview and record review, the facility failed to provide behavior monitoring for 2 of 5 residents sampled for unnecessary medications (Resident # 63 and #105). The findings included: 1) Resident #105 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Unspecified dementia, and Major Depressive Disorder. The Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 07/07/24. This indicated the resident had severe cognitive impairment. On 05/13/24 physician orders revealed the resident was started on an antipsychotic medication called Seroquel 50 milligrams 1 by mouth 2 times a day for depression. Seroquel is an antipsychotic that can be used to treat major depression. A review for behavior monitoring for this medication revealed there was no behavior monitoring done. On 08/28/24 at 12:59 PM, an interview was conducted with Staff G, a Licensed Practical Nurse (LPN). Staff G was asked where the behavior monitoring would be located in the electronic health record. He stated it would be found in the e-tar (electronic treatment administration record). Staff G and the surveyor looked on the resident's e-tar and did not find any behavior monitoring for Seroquel. Staff G was asked if there would be any other place where behavior monitoring would be found and he replied that there was not. This was discussed with the facility's consultant pharmacist via telephone on 08/28/24 at 1:54 PM. At 2:02 PM the behavior monitoring was entered into the resident's chart. 36734 2) Resident #63 was admitted to the facility on [DATE] with diagnoses included Psychotic Disorder and Major Depressive Disorder. A review of a comprehensive assessment dated [DATE] documented the resident was cognitively intact with no moods or behaviors, and was receiving antipsychotics and antidepressants. A review of Resident #63's orders revealed an order dated 03/16/24 for Duloxetine HCL 60 milligrams one time a day for Depression, and an order dated 02/21/24 for Pimavanserin Tartrate 34 milligrams at bedtime for Psychotic Disorder. Resident #63 was care planned for at risk for behavior symptoms related to depression and psychotic disorder, inappropriate dressing/undressing, and places self on floor/slides off chair. Further review of Resident #63's records did not reveal any documentation of behavior monitoring for the resident.

Based on observation and interview, the facility failed to to secure a resident's medications for 1 of 1 sampled resident (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE]. A review of the resident's Admission Nursing Data Collection, dated 08/23/24 at 4:04 AM, documented Resident #246 was alert and oriented to person, place, time, and situation. An interview was conducted with Resident #246 on 08/26/24 at 1:00 PM. The resident stated she was using an antibiotic cream, prescribed for her toe, on her genitals for some relief of itching/burning. The resident pulled out a tube of Gentamycin ointment from her bedside drawer. An interview was conducted with the Unit Manager (UM) on 08/26/24 at 3:00 PM. The UM acknowledged Resident #246 should not have any medications unsecured at bedside.

Based on observation, interview, and record review, the facility failed to coordinate care with nursing staff related to use of hoyer lift and specialized chair for 1 of 4 residents reviewed for rehabilitation services (Resident #245). The findings included: Resident #245 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required total assistance with activities of daily living (ADL). Resident #245 was care planned for ADL self care deficit as evidenced by laminectomy and physical limitations. An interview was conducted with Resident #245 on 08/28/24 at 1:00 PM. The resident stated he had not been out of bed since admission (14 days). The resident stated he would love to get out of bed. An interview was conducted with the Rehabilitation Director on 08/29/24 at 10:00 AM. The Director stated according to the resident's therapy notes, the resident is seen at bedside. The Director stated the therapy notes did not document why the resident could not get out of bed. An interview was conducted with the Physical Therapist (PT) on 08/29/24 at 10:10 AM. The PT stated he did not think the resident could tolerate getting out of bed due to pain. The PT stated he did not know if the resident had any pain medication ordered. The PT further stated the resident needed a specialized chair, and the resident required a hoyer lift to get out of bed. The PT stated they did not have the appropriate chair for the resident to get out of bed. The PT stated it was the resident's Certified Nurse Assistant (CNA) responsibility to get the resident out of bed. The PT further stated he had not communicated with the CNA that the resident required a hoyer lift to get out of bed. The PT stated it was there responsibility to determine the safest way to transfer a resident. An interview was conducted with Staff H, a Certified Nurse Assistant, on 08/29/24 at 10:30 AM. Staff H stated therapy tells them who can get out of bed, and by what means. Staff H stated therapy just told her today that Resident #245 can get out of bed with a hoyer lift. Staff H confirmed Resident #245 had not been out of bed since admission. An interview was conducted with the Rehabilitation Director on 08/29/24 at 10:40 AM. The Director stated every resident should get out of bed unless contraindicated. The Director stated it was nursing responsibility to get residents out of bed, but therapy could help. The Director stated a recliner chair was not the best choice for the resident, but could be used. The Director stated she spoke with the Assistant Director of Nursing (ADON) in reference to ordering a chair for the resident. An interview was conducted with the ADON on 08/29/24 at 10:50 AM. The ADON stated it was brought to her attention that the the facility did not have the appropriate chair for Resident #245. The ADON stated she was in the process of ordering a chair for the resident. The ADON stated they can get the chair the next day when ordered. The ADON could not provide any evidence/documentation of an attempt to order a chair for Resident #245.

Based on interview and record review, the facility failed to accurately document physician ordered vital signs and cough secretions monitoring for 1of 1 sampled resident (Resident #440). The findings included: Resident # 440 was readmitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Overactive Bladder, Fracture of the neck of right femur, Musculoskeletal weakness, and History of falling. Review of Section C of the MDS (Minimum Data Set) assessment showed a BIMS (Brief Interview of Mental Status) score of 12 on 07/16/23, indicating moderately impaired cognitive function. There was no updated BIMS score as of 08/26/24. Record review of Physician orders dated 08/23/24 revealed Resident #440 was to perform cough and deep breathing exercises for 5 minutes, 4 times daily. It indicated to document the patients tolerance and sputum production after each exercise four times a day for 10 Days. Further record review on 08/27/24 revealed a physician order dated 08/23/24 stating to take vital signs every shift for 3 days then daily every shift. Review of the vital signs on the electronic health record showed BP (Blood Pressure) of 133/57 , temperature of 96.9-degree Fahrenheit, pulse rate of 72 beats per minute (bpm), respiration of 18 breaths per minute (bpm), and oxygen saturation of 93.0 % on 08/22/24 at 7:00 PM. The next set of vital signs were documented on 08/26/24 at 3:30 PM. Additional record review of Resident #440's MAR (Medication Administration Record) and TAR (Treatment Administration Record), revealed the recorded vital signs such as Blood Pressure (BP), Temperature, Pulse, Respiration, and Oxygen Saturation, but did not indicate the shift when the vital signs were taken on 08/26/24, 08/27/24, 08/28/24, and 08/29/24.There were no recorded vital signs on 08/23/24, 08/24/24 and 08/25/24. Further review of the MAR and TAR revealed check marks and Nurses initials on 08/23/24 at 9 PM; on 08/24/24 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM; on 08/25/24 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM; and on 08/29/24 at 9:00 AM. There were no documentation of breath sounds, sputum production, and Resident #440's tolerance. Additional review showed the numerical value 9 was documented on 08/26/24 at 3:30 PM; on 08/27/24 at 1:00 PM, and on 08/28/24 at 9:00 AM and at 1:00 PM. According to MAR's and TAR's legend, number 9 indicates other, or see nurse's notes. Review of Nurses' progress notes on 08/28/24 at 8:30 AM and 1:30 PM showed breath sounds of 1, and no sputum, but nothing was documented regarding Resident #440 's tolerance. There were no other dated documentation of breath sounds, sputum production and Resident #440's tolerance in the Nurses' progress notes. In an interview with Staff D, an LPN (Licensed Practical Nurse) on 08/29/24 at 8:45 AM, who stated he took care of Resident # 440, he clarified that vital signs were taken by both CNAs (Certified Nursing Assistants) and Nurses and recorded on a piece of paper. The Nurses are the ones documenting the results on the electronic health records. When vital signs are not within normal limits, CNAs report them to the Nurses. When asked why Resident #440's vital signs were not recorded according to physician's orders, he stated he did not know. In an interview with the Assistant DON (Director of Nursing) on 08/29/24 at 9:00 AM, when asked why the vital signs were not recorded as ordered, she stated she did not know. When asked what the numerical value 9 means in the MAR and TAR. She stated that the nurse's document the assessment on the progress notes. Upon reviewing the MAR and TAR, and the progress notes (with the surveyor), she stated that she did not know why vital signs, breath sounds, sputum production and Resident # 440's tolerance were not documented as ordered, and why only one RN documented on the progress notes. In an interview with the Administrator and the Assistant DON on 08/29/24 at 4:05 PM, the findings were discussed.

Based on observation, interview, and record review, the facility failed to implement CDC (Center for Disease Control and Prevention) guidelines and recommendations for Contact Precautions for 2 of 2 sampled residents (Resident # 442 and Resident #12); and for Enhanced Barrier Precautions for 1 of 32 sampled residents (Resident # 440). The findings included: CDC Contact Precautions revealed the following: Clean hands before entering and when leaving the room. Providers and Staff must also wear gloves before room entry. Discard gloves before room exit: Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. https://www.cdc.gov/infection-control/media/pdfs/contact-precautions-sign-P.pdf. CDC Enhanced Barrier Precautions revealed the following: Everyone must clean their hands including when both entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy; Wound Care any skin opening requiring a dressing. https://www.cdc.gov/long-term-care-facilities/media/pdfs/EBP-KeepResidentsSafe-Poster-508.pdf. 1. Resident # 442 was admitted to the facility on [DATE] with diagnoses of Right Thoracostomy (surgical opening on the right chest cavity by insertion of a tube) related to Pneumothorax (presence of air in the thoracic (chest/cavity) after surgical care, Essential primary hypertension, Cirrhosis (long term scarring) of the liver, Multiple fractures of ribs. Record review of Minimum Data Set (MDS) dated [DATE] revealed Resident # 442 scored 6 under Section C of the Brief Interview for Mental Status (BIMS), indicating impaired cognitive function. Further record review showed an order for Contact Precautions on 08/28/24 at 4:52 PM related to a rash. In an observation, on 08/29/24 at 10:10 AM, there was a door sign stating Contact Precautions on Resident # 442's room. Additional door signage included: clean hands when entering and leaving room; follow standard precautions; gown and gloves when entering room; use dedicated or disposable equipment; clean and disinfect shared equipment. During an observation on 08/29/24 at 10:45 AM, Staff A, a maintenance personnel stopped his cart outside Resident #442's door, entered the room, touched the left foot side of the bed, lifted the linen on the left foot side of the bed, touched the footboard, door, and left the room. Staff A did not perform any hand hygiene and did not use PPE (Personal Protective Equipment). In an interview with Staff A on 08/29/24 at 10:55 AM, he stated he just checked something inside Resident # 442's room. When asked if he had noticed the Contact Precautions post, he stated, he did not know. 2. Resident # 12 was admitted on [DATE] with diagnoses which included HTN (Hypertension), Chronic Diastolic CHF (Congestive Heart Failure), and Peripheral neuropathy (damage to the nerves of the hands and feet). Review of orders dated 08/29/24 revealed Contact Precautions every shift. During an observation on 08/29/24 at 11:10 AM, Staff L, a Registered Nurse (RN) stated she took the vitals and gave medications to Resident #12. The BP (Blood Pressure) monitoring machine was inside the resident room, and Staff L stated that only Resident # 12 is allowed to use the specific BP machine. There was a signage of Contact Precautions on the door. In an interview with Staff M, a housekeeping personnel on 08/29/24 at 12:30 PM, she stated that the BP machine from Resident #12's room was used by another resident. This surveyor observed the same BP machine parked outside another resident's room. In another interview with Staff M on 08/29/24 at 12:50 PM, she stated that only CNA's and Nurses are wearing the PPE (gown) when entering rooms with Contact Precautions posts. Her responsibility was to put on gloves and clean the bedside table, oxygen machine (if there is one), bed control, meal table, chair, and the resident's bathroom. She did not state that she needs to wash hands before entering the room, but stated she will perform hand hygiene after leaving the resident's room. 3. Resident # 440 was admitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Overactive Bladder, Fracture of the neck of right femur, Musculoskeletal weakness, History of falling. During an observation on 08/26/24 at 10:10 AM, a door signage on Resident # 440's room showed Enhanced Barrier Precautions with the following recommendations: Everyone must clean hands, including before entering and when leaving the room; Providers and Staff must also wear gloves and gown for the following high-contact resident care activities; dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing. In an observation, Staff L, a CNA (Certified Nursing Assistant) on 08/26/2024 at 10:09 AM, was observed assisting the resident in transferring from bed to wheelchair. Staff L was not wearing any (PPE) gown, while her personal clothing touched Resident # 440's bed linen, clothing and wheelchair parts. When asked why she was not wearing a (PPE) gown, she stated that only Resident # 440's roommate is on Enhanced Barrier Precautions. Record review did not show an order for Enhanced Barrier Precautions but showed an order for discontinuation of Foley (urinary catheter's inventor's name) catheter on 08/26/24 at 4:52 PM. Earlier physician order dated 08/23/24 showed a wound care consult for resident as needed by in-house wound services. Review of progress notes dated 08/26/2024 at 3:30 PM showed Foley catheter removed at 1400 hours (2:00 PM).

Based on observation, interviews and administrative record review, the facility failed to ensure that one of two hallways on the Medbridge Unit is maintained and did not have an offensive odor of urine. The findings included: An observation on the Medbridge Unit on 01/31/24 beginning at 1:00 PM revealed the smell of a lingering strong urine odor was noted in the hallway from rooms 172-173 to 178-179. The smell was noted to be the strongest in rooms 176 - 179. An interview was conducted on 01/31/24 at approximately 1:05 PM with the Registered Nurse, Staff C, who confirmed the presence of the offensive odor, by stating, I know. The staff member then returned to her medication cart. An interview was conducted on 01/31/24 at approximately 1:07 PM with the Unit Manager, who also confirmed the presence of the odor and stated she knew who it was. An interview was conducted on 01/31/24 at approximately 1:15 PM with the Housekeeping Director, who reported that they clean the rooms and mop the floor. However, when the residents waste their urinal, then the staff on the floor will need to clean that up. The surveyor requested documentation for cleaning rooms to verify if the rooms were cleaned. According to the paperwork that was provided which documented the housekeeping clean-up of rooms, revealed that the staff had cleaned the aforementioned residents' rooms 01/31/24. An interview was conducted on 01/31/24 at 1:18 PM with the Floor Tech, who reported that he mopped rooms 174, 176 and 178 at approximately 12:10 PM. However, rooms [ROOM NUMBERS] still smelled of urine and the smell permeated into the hallway. Further observations of the rooms beginning at 1:20 PM revealed in room [ROOM NUMBER], there was a strong urine odor noted inside of the room. Further observation revealed there were urinals sitting on the floor, next to each resident's nightstand. room [ROOM NUMBER] also had a strong urine smell. During further observation, it was noted that the resident in 176 B had a feeding tube, wearing an adult incontinent brief. The resident in 176 A, uses a urinal. Random interviews on 01/31/24 beginning at 1:30 PM with residents on the Medbridge Unit also confirmed the persistent presence of the strong urine smell on the unit. One resident stated that he noticed that the urine smell was stronger as of 01/31/24, than it had been previously.

Based on interview and record review it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 of 16 sampled residents who had physician's orders [REDACTED].# 383 and delay in receiving pain medications when needed for Resident #'s 250, 363 and 380 . Findings include: 1) During an interview on 03/29/2011 at 10:50 AM, Resident #383 reported she had been at the facility about one week, was told by staff the pain medications were available every 4 hours and she could have one or two tablets each time. The resident continued to report that on at least four occasions, the medications were either not available upon her request or took an excessively long time to get them. The resident stated that one time it took an hour and forty-five minutes to get the requested dose of pain medication. The resident was unable to provide the specific dates. Resident #383 stated, "Some of the nurses said the medication wasn't here, another said they had to get it out of the E-kit (Emergency Dispensing Kit) and another time they said they 'ran out' and only gave me one [MEDICATION NAME] instead of two." The resident further stated that it is always a challenge to get requested pain medications in the evening and at night and that a few nights she was in tears from the pain and the lack of caring by some of the nurses. During an additional interview on 03/30/2011 at 10:15 AM, Resident #383 stated, "I had a bad night. My pain medication was due at 10:00 PM. I asked for it and didn't get it until eleven something, and I only got one. The nurse told me the medication order had changed and I could only get one (tablet) every six hours instead of every four." The resident stated that when she asked the evening nurse if she was going to have problems getting her pain medications at 3:00 AM, the nurse told her, "It's not my problem." The resident explained that "the nurse with the pony tail" came on last evening and said the medications were not available. The resident further stated that every time the nurse with the ponytail worked she had problems getting her pain medications. The resident stated, "I was in tears last night and ready to call you (referring to the surveyor) in the middle of the night. That nurse doesn't care and doesn't know how to take care of any problems. This morning, the day nurse and the manager (referring to the Director of Nursing) got me my meds." During an interview on 03/30/2011 at 10:40 AM, the Unit Manager of the 100 unit confirmed that Resident #383 had an order as of her admission date of [DATE] to the present time for [MEDICATION NAME] (a pain medication) 5/325 mg one to two tablets every four hours PRN (as needed). Further review of the record with the Unit Manager revealed no other physician orders [REDACTED]. The Unit Manager was unsure as to the reason for the order as the original order was still in effect and there had been no changes. A prescription and a copy of that same prescription dated 03/24/2011 for [MEDICATION NAME] 5/325 mg by mouth every 6 hours PRN pain was noted in the chart. When asked what that prescription was for the Unit Manager stated, "That is the prescription the doctor wrote for her to take home". The resident was scheduled to go home on 03/28/2011, felt she wasn't strong enough, and made arrangements with the business office to stay until today (03/30/2011). A physician's orders [REDACTED]. The Unit Manager confirmed that the order for the [MEDICATION NAME], one to two tablets every four hours as needed was still in effect, and had always been in effect. During an interview on 03/30/2011 at 11:10 AM, the day RN (Registered Nurse) for Resident #383 confirmed there was no narcotic sheet (Controlled Substance Proof-Of-Use Record) on her medication cart, nor any [MEDICATION NAME] available on her medication cart for Resident #383. The RN stated that she would have to use the E-kit to administer any pain medication to Resident #383. Review of the "Controlled Substance Proof-of-Use Record", found in Resident #383's chart documented the removal of the [MEDICATION NAME] from the locked medication box on the medication cart. The first dose from these 30 pills was given to the resident on 03/24/2011 at 5:30 AM and the final pill from this pack was given on 03/26/2011 at 10:30 PM. During the continued interview with managerial staff and the RN on the floor, they stated the original prescription was for 60 pills and they were both unsure as to why the second pack/half of the prescription was not re-ordered or refilled or sent. Review of the record on 03/30/2011 at 11:55 AM revealed the admission pain assessment was completed on 03/23/2011 by the Unit Manager. This assessment documented the resident had pain that was relieved by prescription medications. Since the resident was admitted on [DATE], the MDS (Minimum Data Set/Initial Assessment) and final care plans were completed. Further review of the record revealed the resident was admitted to the facility for care after a traumatic [MEDICAL CONDITION]. The record documented Resident #383 received one [MEDICATION NAME] on 03/29/2011 at 10:45 PM as recorded on the MAR (Medication Administration Record) and did not received any further pain medication until 03/30/2011 at approximately 8:00 AM. As per the interview above, Resident #383 requested the ordered two [MEDICATION NAME] "as needed" at 10 PM on 03/29/2011 and at about 3 AM on 03/30/2011 and did not receive the medications. Review of the original [MEDICATION NAME] prescription, faxed to the facility by the pharmacy on 03/30/2011 at 12:15 PM documented, "[MEDICATION NAME] 5/325 mg PO (by mouth) q4h (every four hours) PRN #60 Sixty," confirming the original prescription was for sixty pills. This revealed that when the first thirty pills had been used by the resident, the facility should have been able to request and receive the second thirty pills, the refill amount. An interview with the Consultant Pharmacist upon receipt of this prescription confirmed this information. During an interview on 03/30/2011 at 3:00 PM, the LPN who cared for Resident #383 on 03/29/2011 in the evening and had also cared for the resident on multiple evenings was asked about the resident's pain management. The LPN stated, "Her order was changed from two [MEDICATION NAME] every four hours for pain to one pill every six hours, and she was unhappy with that. She basically demanded her two [MEDICATION NAME] last night, so I told my supervisor and he got an order for [REDACTED]. Review of the record with the LPN revealed that the LPN thought that the prescription in the front of the chart was a new order, and thus was following that order. The LPN did not know that that prescription was for the resident when discharge from the facility. During this same interview, it was confirmed that this LPN removed the last three doses of [MEDICATION NAME] from the medication cart on 03/26/2011. When asked about ordering the refill/additional thirty tablets, the LPN didn't know that she could do that. This LPN also confirmed that she only gave the resident one [MEDICATION NAME] on 03/26/2011 at 10:30 PM, because there was only one left on the "bubble pack" in the cart, even though the resident had requested two. The LPN also confirmed that she has had to use the E-kit from 03/26/2011 to the present time. An interview with the PTA (Physical Therapy Assistant) on 03/30/2011 at 2:55 PM, who cared for Resident #383, revealed the physical therapy sessions were timed around the resident being able to receive her pain medications. The PTA explained that the resident would tell her when she was expecting her medications, and then the PTA would return shortly after that time to get the resident for therapy. The PTA confirmed that on one occasion the resident's therapy was delayed because of the medication not being administered on time. 2) During an interview on 03/31/2011 at 2:20 PM, Resent #250 confirmed that he had pain medications ordered on an as needed basis. When asked if he gets the medications in a reasonable time frame when requested, the resident became visibly upset and stated, "Are you kidding." The resident verbalized that often when he calls for pain medications via the call bell system, he waits for twenty to thirty minutes and then has to physically go up to the nurse's desk to get his medications. The resident also stated that when he calls the nurse's station on the phone, especially in the evenings or night time, there is often no response. He stated that most of the time he would hang up the phone and go directly up to the nurse's station. The nurse's would be sitting there and did not answer the phone. Review of the record for resident #250 revealed the resident was admitted to the facility for care after orthopedic surgery for [REDACTED]. The MDS (Minimum Data Set/Initial Assessment) revealed the resident was alert and oriented and assessed for pain relieved by pain medications. 3) During an interview on 03/31/2011 at 2:00 PM, Resident #363 along with her daughter confirmed that she does have an order for [REDACTED]. When asked if she receives the medications in a timely manner, the resident stated that about a week ago "I had asked for my medication in the evening, and went the whole night without it." The daughter stated, "The nurse told me that the pharmacy didn't bring it." The resident and family member were unable to provide any specific date or staff member. The resident confirmed her understanding of the need to ask for the medication and stated, "I do ask for it, but don't always get it." Review of the record for Resident #363 revealed the resident was admitted to the facility for care following orthopedic surgery. The record documented an order for [REDACTED]. The record revealed the resident had been assessed as alert and oriented. 4) During an interview on 03/31/2011 at 2:10 PM Resident #380 confirmed that she has an order for [REDACTED]. Sometimes it takes up to an hour to get them." When asked if she has to wait because it is not time yet for the medication, the resident stated, "No, they tell me if it's not time ... they just take too long and have all kind of excuses." Review of the record for Resident #380 revealed the resident was admitted to the facility with a [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented. An additional interview on 03/31/2011 at 2:00 PM with the same LPN who had cared for Resident #383 and was caring for the three additional residents mentioned above, was conducted. The LPN stated that all four residents were alert and oriented, knew that they had to ask for medications when they needed them and asked for the medications at the time they were available. During an interview on 03/31/2011 at 4:55 PM, the Regional Director of Operations stated that there is a system problem and that the resident's should be able to get their ordered medications in a timely and dignified manner. The Director of Nursing stated that in some cases, if a resident is to be discharged within a day or two, "We don't always refill the medications ... We just use the E-kit." The Regional Director of Operations stated that there was "really no reason why we shouldn't have the medications refilled and on the carts ... readily available." During an additional interview on 04/01/2011 at 9:45 AM, the Director of Nursing explained that she reviewed all residents with pain medications last night and stated, "I agree with you ... there is a break in the process."