Every finding on record at Kissimmee Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide appropriate assessment, treatment, and implement ordered interventions for 1 of 1 resident reviewed for skin conditions, out of a total sample of 23 residents, (#54). Findings: Review of resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, human immunodeficiency virus (HIV), major depressive disorder, heart disease, and type 2 diabetes. Review of resident #54's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/14/26 revealed a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment showed resident #54's speech was clear with distinct intelligible words, he made himself understood, and usually understood others, missing some part or intent of message but comprehending most conversations. The MDS assessment indicated resident #54 did not reject evaluation or care needed to achieve his goals for health and well-being. The resident required setup assistance for eating, partial/moderate assistance for oral hygiene, and substantial/maximal assistance for toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. He required partial/moderate assistance to roll from lying on back to left and right side in bed and was dependent on staff for transfers. Resident #54 was always incontinent of bladder and bowel. Review of resident #54's Progress Notes revealed a Change in Condition note dated 3/31/26 documenting old scabs on both arms and legs. The form showed the physician was notified and a new order for Hydrocortisone 2% cream twice daily was obtained. Review of resident #54's physician orders revealed an order dated 3/31/26 for Hydrocortisone External Cream 2.5% to be applied to the arms and legs twice daily. Review of resident #54's Treatment Administration Records (TAR) for April and May 2026 showed the cream was documented as applied daily. On 5/26/26 at 11:48 AM, resident #54 was lying in bed and stated he was itchy all over. He was observed scratching his chest and his right armpit. Red areas were noted on his left arm. When asked how long he had been itchy, he could not say. When asked if he had received a cream that day, he stated he had not. On 5/27/26 at 9:53 AM, resident #54 was again lying in bed and stated he was not feeling better because he continued to itch all over. He again stated he had not received the cream. Multiple small red round areas were observed on his arms, and he was scratching under his right arm. On 5/27/26 at 12:17 PM, Certified Nursing Assistant (CNA) B stated he informed the nurses about any changes in eating, pain, or skin condition for his assigned residents. He shared resident #54 was able to express his needs but frequently refused care, preferred to remain in bed, did not like to wear a shirt, and did not participate in activities. CNA B stated resident #54 only allowed bed baths. CNA B stated the resident did not have wounds but itches a lot. CNA B further stated the resident had some open small bumps on his back and his thighs and frequently requested cream application. CNA B shared he informed the nurse when this occurred. He recalled the resident's skin looked the same for at least four days the prior week and the resident continued scratching. He stated the resident's bed sheets were changed once or twice daily because he bled from scratching. Review of resident #54's physician orders revealed an order for Benadryl 25 milligrams every 6 hours as needed for itching. Review of the TAR showed the Benadryl had not yet been administered. On 5/27/26 at 5:17 PM, Registered Nurse (RN) C stated resident #54 had a cream treatment for his skin and was doing well. She mentioned the facility had a dermatologist who visited residents and believed resident #54 had been evaluated. When asked whether she noticed the resident continued scratching and complaining of itching, she validated she had noticed and stated she would attempt to call the physician later to discuss changing the cream because it did not appear effective. Later at 5:37 PM, RN C assessed resident #54's skin with this surveyor and indicated he had a skin rash throughout his body with visible scratch marks. Multiple red and inflamed bumps, some opened, were observed on the resident's arms, legs, thighs, and chest. On 5/27/26 at 5:49 PM, the Director of Nursing (DON) stated she was not aware of resident #54's skin condition. She indicated she expected changes in condition and physician communication to be documented in the medical record. The DON confirmed the medical record lacked evidence of recent physician notification regarding the resident's skin condition and continued complaints of itching. Review of resident #54's Progress Notes revealed an Interdisciplinary Care Note dated 5/19/26 which indicated a Standard of Care meeting had been held that day with the interdisciplinary team (IDT). The documented medications were reviewed and no behaviors, falls or wounds were noted. The care plan was reviewed and remained appropriate. There was no evidence resident's skin condition and itching was discussed with the IDT. Review of resident #54's Progress Notes revealed a Narrative Note dated 3/31/26 which documented complaints of itching to both arms and legs with multiple areas of old scabbing on the bilateral upper and lower extremities. The note indicated the skin was dry with evidence of previous scratching and no active bleeding or open wounds observed at that time. The resident reported intermittent itching more noticeable during rest periods. The note indicted no redness, warmth, swelling, or drainage was observed. Nursing staff documented they would continue monitoring the condition and report changes. Another Narrative note dated 2/24/26 documented a 2 centimeter (cm) by 2 cm skin tear to the resident's left forearm with slight bleeding. The resident reported the lesion occurred after scratching due to itching. The note indicated resident #54 was educated regarding avoidance of scratching and the area continued to be monitored for signs of infection. Review of resident #54's medical record revealed the last time he was seen by Infectious Disease evaluation occurred on 1/26/26 and there was no evidence the resident had been evaluated by Dermatology prior to 5/27/26. Review of the following Weekly Skin Evaluations revealed:5/26/26 Continue treatment as ordered for itching5/21/26 Continue treatment for itching5/19/26 No new skin issue, continue Hydrocortisone External Cream 2.5 % for itching5/14/26 Itching - treatment in place5/08/26 Continue cream to bilateral legs/arms5/05/26 Receiving treatment for itching4/30/26 Continue with treatment for itching4/23/26 Treatment in place - Hydrocortisone External Cream 2.5 %4/16/26 Treatment in place - Hydrocortisone External Cream 2.5 % Review of resident #54's care plan revealed a focus for skin impairment risk revised on 11/24/25. The care plan indicated he was at risk for skin impairment related to decreased mobility, incontinence and dependence on staff assistance for transfers and mobility. Interventions directed CNAs to observe the skin during hygiene care and report abnormalities to nursing staff. On 5/28/26 at 8:55 AM, the Wound Nurse stated she performed wound care for all wounds in the facility and completed skin assessments for newly admitted residents. She stated she rounded weekly with a wound care provider. The Wound Nurse stated resident #54 was sleeping when she applied the Hydrocortisone cream that morning and she also applied the cream to his back after he turned to his side and he reported no discomfort. She recalled assessing resident #54 approximately two weeks earlier and noted dry skin and scratching. She stated the physician had previously been contacted and ordered Hydrocortisone cream. The Wound Nurse reviewed the skin evaluation notes she completed on 4/07/26 and 5/12/26 and stated the skin was not opened at that time. She stated she instructed the assigned nurse to contact dermatology because the condition would be more appropriately managed by dermatology rather than wound care. The Wound Nurse acknowledged the Hydrocortisone treatment had been in place since April 1st and resident #54 continued to complain of itching with visible red marks on his skin. She confirmed she was the assigned nurse from 7:00 AM to 3:00 PM on 5/28/26 and acknowledged she did not contact the physician or review the effectiveness of the treatment during her shift. She stated she assumed the Unit Manager (UM) was addressing the issue but did not verify this. She further stated resident #54's HIV diagnoses increased his risk for infection because he was immunocompromised. On 5/28/26 at 10:06 AM, the UM stated resident #54's Hydrocortisone cream was ordered based on a nursing assessment completed on 3/31/26. She stated she believed the Wound Nurse applied the cream daily. The UM stated she rounded with resident #54's physician on Tuesday, and the physician ordered Benadryl because the resident was scratching. She indicated she entered the Benadryl order at 1:38 PM and instructed RN D to administer it immediately. The UM reviewed resident #54's MAR and confirmed it showed Benadryl was only administered on 5/27/26 at 6:15 PM. She acknowledged the medical record did not show resident #54 received Benadryl on 5/26/26 as ordered by the physician. The UM stated she instructed RN D twice to administer and document the medication. She further stated she and the physician completed a head-to-toe assessment of resident #54 while he was actively scratching himself. When asked why there was no documentation of the physician assessment or her observations, she stated she did not have time to complete documentation because surveyors arrived that day. She stated resident #54 was not bleeding and he received cream treatment.On 5/28/26 at 10:31 AM, RN D stated she cared for resident #54 on Monday and Tuesday of that week. She stated she was not aware the physician evaluated the resident on Tuesday. RN D indicated she applied the Hydrocortisone cream throughout the resident's body and acknowledged the order specified application only to the arms and legs. She stated she administered the Benadryl on 5/26/26 based on the UM's instruction but did not verify the order or document the administration. She stated she believed the UM had documented the medication administration. On 5/28/26 at 1:43 PM, the DON stated the physician had not yet completed his 5/26/26 progress note. The DON indicated she assessed resident #54 the previous evening and observed redness on the resident's neck, chest, abdomen, arms, and legs. She stated nurses were expected to review physician orders and document medications after administration. The DON further stated staff should follow transmission-based precautions when caring for resident #54 because of his increased infection risk. On 5/28/26 at 2:26 PM, resident #54's physician stated he came to the facility approximately three times weekly or as needed and was the resident's primary care physician. He indicated this was the first time he observed resident #54's skin in that condition. He mentioned staff informed him the resident complained of pain and dry skin. The physician stated the resident's skin appeared excoriated and dry and the condition appeared longstanding. He said he instructed the UM to discontinue the Hydrocortisone cream because prolonged steroid use could further dry the skin and initiate Benadryl for itching. He explained prolonged use of steroid cream could worsen dryness. The physician further stated he instructed the UM to arrange follow up with Infectious Disease due to the resident's HIV diagnosis and discussed a dermatology consultation. He indicated he expected nursing staff to notify him or his office regarding changes in residents' conditions. When informed Benadryl administration was not documented on 5/26/26, the physician said, If it is not documented it is not done. He further stated, Even if the patient cannot request it (the medication), they should see that he needs it. Review of a Progress Note from the Dermatology Nurse Practitioner dated 5/27/26 revealed the resident had experienced itching and eruption about 3 weeks. The resident rated the itching as 8 out of 10. The note documented generalized intermittent pruritus erythematous diffuse eruption with pickers nodules noted on arms and legs. The note also documented concern for bacterial and fungal skin infections related to the resident's immunocompromised status due to HIV. The treatment plan included Cipro, Fluconazole, and Hydroxyzine. Review of the facility's policy titled Medication Administration revised on 1/2025 revealed medications were to be administered as ordered by the physician and in accordance with professional standards of practice. The policy directed nursing staff to review the MAR before administration and sign the MAR following administration. Review of the facility's policy titled Documentation in Medical Record not dated revealed each resident's medical record was required to contain an accurate representation of the resident's condition through complete, accurate, and timely documentation.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected prognosis of life for 1 of 1 resident reviewed for hospice services, (#11) and failed to accurately reflect a treatment for skin impairment for 1 of 1 resident reviewed for skin conditions, (#54), out of a total sample of 23 residents.Findings: 1. Review of resident #11's medical record revealed he was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. His diagnoses included Alzheimer's disease, dementia, and heart disease.Review of the medical record for resident #11 revealed a certification form dated 3/10/26 from hospice. The document included a verbal certification given by the physician that read, Based on the information available, I believe that the patient has a life expectancy of 6 (six) months or less if the disease takes its natural course. Review of resident #11's quarterly MDS assessment with Assessment Reference Date (ARD) of 3/19/26, Section J - Health Conditions, included an inquiry regarding prognosis. J1400 read, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? It was answered, No. 2. Review of resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia human immunodeficiency virus, heart disease, and type 2 diabetes.Review of resident #54's physician orders revealed an order for Hydrocortisone External Cream 2.5% to be applied to both arms and legs topically two times dated 3/31/26. Review of resident #54's Treatment Administration Records (TAR) for April 2026 showed the cream was applied daily. Review of resident #54's quarterly MDS assessment with ARD of 4/14/26 revealed Section M - Skin Conditions included Skin and Ulcer/Injury Treatments and required the selection of treatments in placed that applied to the resident. The list included, Application of ointments/medications other than to feet which was not selected. On 5/28/26 at 11:58 AM, the MDS Coordinator stated she was responsible for completing MDS assessments. She reviewed resident #54's quarterly MDS assessment with ARD of 4/14/26 and indicated resident #54 had an ointment applied during the lookback period which should had been captured in the MDS. She stated she referred to the TAR when reviewing this section, but missed the Hydrocortisone cream treatment. On 5/28/26 at 1:28 PM, the MDS Coordinator reviewed resident #11's quarterly MDS with ARD of 3/19/26. She explained that for residents who received hospice services, the pertinent questions were found in Section J and Section O of the MDS assessment. She acknowledged the prognosis question in section J was answered incorrectly and stated it should have been answered, Yes. She confirmed the information was included in the hospice certification. Review of the facility's policy titled MDS 3.0 Completion, revised on 9/19/22, revealed the facility conducted initial and periodic comprehensive, accurate and standardized assessments of each resident according to federal regulations using the Resident Assessment Instrument specified by the State.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services related to accurate interpretation of a physician order, and inaccurate administration and documentation of medications for 1 of 4 residents reviewed for medication pass, (#47); and failed to appropriately dispose of medications, (#67), for 1 of 4 residents reviewed for medication pass, out of a total sample of 23 residents.Findings:1. On 5/26/2026 at 10:06 AM, Registered Nurse (RN) E stated she was administering the 9:00 AM medications, which could be given one hour before or one hour after the scheduled administration time. She prepared the following medications for resident #47: Aspirin 81 milligrams (mg), Cranberry 450 mg, Iron 325 mg, Acetaminophen 500 mg, Memantine 5 mg, Isosorbide 30 mg, Donepezil 5 mg, Amlodipine 5 mg, and Hydralazine 10 mg. At 10:16 AM, RN E entered resident #47's room and administered the medications.Review of resident #47's Medication Administration Record (MAR) revealed 9:00 AM medications included: Aspiring 81, Cholecalciferol 5000 international units, Cranberry 450 mg, Donepezil 5 mg, Ferrous Sulfate (Iron) 325 mg, Isosorbide 30 mg, Turmeric 500 mg, Amlodipine 5 mg, Memantine 5 mg, Tylenol (Acetaminophen) 325 mg, Eldertonic 15 milliliters, and House supplement 2.0 calorie. Hydralazine 10 mg was scheduled for 8:00 AM. Review of resident #47's Medication Admin Audit Report dated 5/26/26 revealed Hydralazine was documented as administered at 10:55 AM. The medications scheduled for 9:00 AM were documented as administered at 10:56 AM. On 5/26/26 at 1:11 PM, RN E was asked about the documentation time and the additional medications documented as administered during the medication pass observation. RN E stated she was expected to document medications after observing the resident take them and acknowledged she did not document the medications immediately after administration at 10:16 AM. She explained she did not always document medications immediately after administration because she sometimes ran late and later documented them all at the same time. RN E acknowledged the medical record would not accurately reflect the actual administration times. She stated the medications were administered timely, but her documentation did not always reflect the exact time they were administered. RN E further stated the Eldertonic was administered earlier because it was an appetite stimulant. She explained resident #47 preferred Turmeric mixed into pudding, so she opened the capsule and mixed the contents into the resident's breakfast pudding earlier that morning. She also stated resident #47 did not like taking the House Supplement with medications, so she administered the supplement after the medication pass observation. Review of the medical record revealed no documentation of medication administration preferences for resident #47 nor evidence the physician was notified regarding alternative medication administration practices or administration times that differed from the physician's orders.On 5/27/26 at 2:32 PM, the Staff Educator stated the nurses were expected to document medications at time of administration. 2. On 5/26/26 at 10:35 AM, RN D prepared medications for resident #67, which included: Allopurinol 100 mg, Amlodipine 5 mg, Aspirin 81 mg, Duloxetine 60 mg, Tamsulosin 0.4 mg, Triamterene/ Hydrochlorothiazide 37.5-25 mg, Rexulti 1 mg, Donepezil 5 mg, Vitamin B-12, and Dorzolamide/Timolol eye drops. When asked how many pills she had prepared in the medication cups, RN D counted them and stated she had prepared 8 pills, which did not match the 9 oral medications observed by the surveyor. After attempting to reconcile the medications by comparing the bubble packs and medication bottles to the pills in the medication cup, RN D stated she preferred to start over because she did not want to make a mistake and could not identify the discrepancy. RN D then discarded the medications into a small open trash bin attached to the medication cart and began preparing the medications again. She added 2 tablets of Tylenol 325 mg because the resident had complained of pain. After reconciliation, RN D administered the medications and exited resident #67's room. On 5/26/26 at 11:09 AM, when asked the process for discarding unused medications, RN D stated she was supposed to discard medications in a different container and not in the trash bin. She searched the drawers of the medication cart and stated she could not locate the medication disposable bottle she was supposed to use. RN D could not explain why medications should not be discarded in the trash and stated she only knew they were not supposed to be discarded there. On 5/27/26 at 6:19 PM, the Director of Nursing (DON) stated nurses were expected to document medications immediately after residents received them. She indicated documentation should not occur later because the medical record would not accurately reflect medication administration. The DON further stated medications should never be discarded in regular trash because individuals passing by could retrieve them. She acknowledged RN D improperly disposed of the medications and confirmed it was a concern. Review of the facility's policy titled Medication Administration, revised 1/2025, revealed medications were to be administered as ordered by the physician and in accordance with professional standards of practice. The policy included ensuring the six rights of medication administration, including right time and right documentation. The policy also read, Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician, and directed staff to sign the MAR after medication administration.Review of the facility's policy titled Documentation in Medical Record, undated, revealed each resident's medical record was required to contain an accurate representation of the resident's actual experiences through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene during medication administration in accordance with infection control standards to prevent the spread of infection for 1 of 4 nurses reviewed for medication administration, (Registered Nurse E). Findings:On 5/26/26 at 10:02 AM, Registered Nurse (RN) E entered resident #47's room, obtained a pair of gloves, donned the gloves, took the resident's blood pressure, then removed the gloves and exited the room without performing hand hygiene. At 10:06 AM, RN E obtained 3 medication cups and prepared oral medications without performing hand hygiene. After preparing the medications, RN E entered the resident's room at 10:16 AM and administered the medications. At 10:19 AM, when asked about when hand hygiene was expected to be performed, RN E stated it should be done before and after medication administration. She said, I guess I skipped points. RN E explained hand hygiene was important for patient safety and prevention of infection. She acknowledged she should have performed hand hygiene before preparing and before administering the medications. On 5/27/26 at 2:32 PM, the Infection Preventionist (IP) stated nurses were expected to perform hand hygiene prior to donning gloves, before entering a resident's room, after removing gloves, and gloves were to be discarded inside the resident's room. The IP indicated hand hygiene was required prior to medication preparation. The IP shared RN E was a PRN (as needed) nurse but received the same education as full-time staff. On 5/27/26 at 6:19 PM, the Director of Nursing stated nurses were expected to perform hand hygiene every time they had resident contact and before preparing medications. Review of the facility's policy titled Medication Administration, revised 1/2025, revealed medications were to be administered in a manner to prevent contamination or infection. The policy guidelines included washing hands prior to administering medication perf facility protocol. Review of the facility's policy titled Hand Hygiene, revised 1/2025, read, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy further indicated glove use did not replace hand hygiene and, when gloves were required, hand hygiene was to be performed prior to donning gloves and immediately after glove removal. A Hand Hygiene Table within the policy indicated hand hygiene was required prior preparing or handling medications.

Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan for 1 out of 23 residents reviewed for care plans, of a total sample of 23 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, diabetes, and stroke.The Minimum Data Set (MDS) assessment dated [DATE] revealed resident #3 had a Brief Interview for Mental Status of 15 out of 15, which meant he was cognitively intact.Review of the facility's incident log showed the resident fell on [DATE], and again on 12/24/25.An Agency for Health Care Administration Transfer form dated 12/24/26 indicated resident #3 had an unwitnessed fall, hit his head, and was transferred to the hospital. Review of a Physician's progress note dated 2/17/26 revealed the resident had a cervical spine fracture, he refused surgery, and the doctor ordered a neck brace to be worn at all times. A cervical spine fracture is a break to one of the neck bones. Often a doctor recommends a hard collar to support, protect, and limit movement in the neck to keep alignment and allow healing. This device supports the weight of the head and minimizes further damage or injury to the neck. (Retrieved 5/29/26 from https://www.cuh.nhs.uk/patient-information/wearing-a-cervical-hard-collar-a-guide-to-collar-care-for-patients-relatives-and-carers/) Resident #3 had a Care Plan with an intervention dated 1/07/26 that instructed staff to assist the resident with his neck collar. On 5/27/26 at 8:23 AM, resident #3 was observed in the common area listening to music on his phone and bobbing his head, he was not wearing the neck brace. He stated he didn't like to wear the collar while he ate. On 5/27/26 at 11:28 AM, the Administrator said resident #3 sometimes took the collar off. On 5/28/26 at 11:30 AM, the Director of Nursing said if the resident didn't want to wear a neck brace, the doctor should be notified, and the refusal should be documented. The facility was unable to provide any documentation the resident refused the neck collar. On 5/28/26 at 12:00 PM, the MDS Coordinator stated the facility's expectation was that care plans should be updated to include interventions and goals for safety.Review of the facility's Positioning Devices Policy revised January of 2026, noted if a resident refused to use an assistive device to support body alignment, it should be documented in the medical record. According to the facility's Standards and Guidelines for Care Plans, resident assessments should be ongoing, and care plans should be updated as situations change. Residents have the right to refuse treatment, and that refusal should be documented according to the facility's policy.

Based on interview, and record review, the facility failed to resubmit an accurate Preadmission Screening and Resident Review (PASRR) upon admission and after a change in condition for a resident diagnosed with Serious Mental Illnesses (SMI) and Intellectual Disability (ID) for 1 of 1 residents reviewed for PASARR, out of a total sample of 23 residents, (#46).Findings:Review of resident #46's medical record revealed she was admitted to the facility on [DATE] with diagnoses including mood disorder, psychotic disorder, and intellectual disability. Review of resident #46's annual Minimum Data Set (MDS) with Assessment Reference Date 3/20/26 revealed she had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment revealed a Mood Interview was conducted and resident #46 reported feeling down, depressed, or hopeless 7 to 11 days during the lookback period. She also indicated she sometimes felt isolated. The assessment noted no rejection of care necessary to achieve goals for her health and well-being. The assessment showed behavioral symptoms including verbal/vocal symptoms such as screaming and disruptive sounds not directed toward others occurring 1 to 3 days during the lookback period. The MDS assessment also revealed resident #46 received routine antipsychotic medications. Review of resident #46's medical record revealed a State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) Level I Screen form dated 3/21/25. Section I. A, Mental Illness (MI) or suspected MI, (check all that apply), was left blank. Under section I. B., ID or suspected ID, the option onset prior to [AGE] years of age was selected. Section IV, PASRR Screen Completion indicated No diagnosis or suspicion of SMI or ID (Intellectual Disability) indicated. Level II PASRR evaluation not required was checked. The form was electronically signed by a hospital Registered Nurse (RN). A second PASRR form in the medical record dated 4/16/25 was signed by the facility's Director of Nursing (DON). Section I, A. selected Psychotic Disorder and Other: other specified persistent mood disorders. Under Section I. B., none of the listed ID conditions were selected. Section IV again indicated, No diagnosis or suspicion of SMI or ID (Intellectual Disability) indicated. Level II PASRR evaluation not required.Review of resident #46's care plan revealed a focus for the potential for psychosocial well-being problems related to suicidal ideation initiated on 4/22/26. Interventions included hourly checks. Review of a behavioral care plan initiated on 8/21/25 and revised on 4/07/26 revealed resident #46 had the potential to display behaviors including becoming upset when other residents sat at the same table, throwing dentures on the floor, and stating she was pregnant when her abdomen was swollen. Review of the resident's care plan initiated on 3/27/25 and revised on 4/23/26 revealed resident #46 had the potential for adverse effects related to the use of psychotropic medications. Review of a Psychiatry Evaluation Note dated 3/19/25 revealed resident #46 was admitted to the facility with a diagnosis of mood disorder and psychosis. The note showed she was taking Depakote and Risperidone to treat her SMI. Review of a Psychiatry Note dated 4/22/26 revealed the evaluation was completed because resident #46 made some inappropriate comment such as wanted to end her life. If she had a knife, she will cut herself with it. The note further indicated, Patient had been bullied by a few other resident at the facility .Patient stated she has no plan however she's still depressed. The resident was placed on one-to-one (1:1) observation per facility request for safety purposes.Review of a Psychiatry (psych) Subsequent Note dated 5/01/26 indicated resident #46 was seen to assess tolerability and effectiveness after recent medication changes. The note included summaries of prior psychiatric notes which indicated:*1/02/26 Patient had psychosis. Patient had hallucinations of hearing and seeing people. No medication changes. *2/13/26 Patient was psychotic. Patient saw things. No medication changes. *4/22/26 Patient had mood disorder. Medications included Melatonin, Buspirone, Depakote and Risperdal. Started Trileptal at 150 mg twice a day for one month and Lithium 150 mg daily for 2 weeks. *5/01/26 Patient was at baseline. No active psych symptoms. No medication changes.The Plan of Action included Melatonin for insomnia, Lithium and Trileptal for suicidal ideations, Depakote for mood disorder, Buspirone for anxiety and Risperdal to treat psychosis. The note also indicated, Patient has vague symptoms of anxiety, but they are causing distress. Review of resident #46's Interdisciplinary Care Notes revealed the following:*4/22/26 resident with suicidal ideations, 1:1 initiated, Psych Nurse Practitioner evaluated resident with new orders for Lithium and Trileptal. Another note on the same day mentioned the physician was informed and resident to receive plastic utensils with meals. *4/24/26 remained on 1:1. No medication changes during Gradual Dose Reduction meeting with the interdisciplinary team (IDT). *4/27/26 continued on 1:1 with no signs or symptoms of suicidal ideations or behaviors noted.*4/28/26 continued on 1:1 with no signs or symptoms of suicidal ideations.*4/29/26 IDT met to discuss 1:1 supervision for suicidal ideations. No behaviors noted. 1:1 discontinued and 30-minute safety checks initiated.*5/19/26 No signs or symptoms of suicidal ideations. Every 30-minute safety checks changed to hourly. There was no evidence in the medical record a new PASRR Level I was completed or submitted following the resident's change in condition, suicidal ideations, behavioral symptoms, or psychiatric medication changes. On 5/27/26 at 4:30 PM, the Social Services Director (SSD) stated she reviewed PASRR forms upon admission for completeness and accuracy. She explained she reviewed newly admitted residents' diagnosis and psychotropic medications to ensure they matched the PASRR forms. She stated if a resident had SMI, the resident was evaluated by psychiatry. She further stated if psychiatry added a new diagnosis, a new Level I would be completed. The SSD stated when resident #46 was admitted to the facility, she received psychotropic medications and had psychiatric diagnoses that were not reflected on the hospital PASRR form. She explained she completed a new PASRR form, added the missing information, and provided the form to the DON for review and signature. She confirmed the PASRR form signed by the DON on 4/16/25 reflected that process. The SSD further indicated resident #46 exhibited new behaviors such as talking to herself and later experienced suicidal ideations which were addressed by psychiatry with medication adjustments. She acknowledged a new PASRR Level I was not completed or submitted to the State when the facility identified the missing SMI diagnoses or following the resident's behavioral changes and medication adjustments. The SSD stated she was not familiar with the electronic PASRR submission process or the agency responsible for determining whether a Level II was required.On 5/27/26 at 6:14 PM, the DON stated only the Nursing Home Administrator (NHA) had access to the State PASRR website. She explained if a PASRR required revision, she received the completed form from the SSD, reviewed it, and signed it. She stated she had never entered a Level I into the State system. The DON indicated a new PASRR Level I was required if there were changes to psychotropic medications or psychiatric diagnoses. When asked whether a new PASRR Level I was submitted following resident #46's change in condition, the DON stated she did not believe one was submitted. She could not explain why it was not submitted or the purpose of the PASRR evaluation. On 5/28/26 12:36 PM, the NHA stated newly admitted residents arrived with a PASRR Level I form completed by the hospital. He indicated all newly admitted residents were evaluated by psychiatry. He explained if a PASRR required revision, he would submit it through the State website with assistance from the SSD. He stated he had not been aware revisions were required to be electronically submitted. He confirmed neither the PASRR form signed by the DON on 4/16/25 nor a revised PASRR following resident #46's behavioral changes were submitted to the State. He added up to this day, he was the only individual with access to the PASRR website in the facility but had requested access for the DON as well. Review of the facility's policy titled, Resident Assessment - Coordination with PASRR Program, revised January 2026, revealed the facility coordinated assessments with the PASRR program under Medicaid to ensure individuals with mental disorders, intellectual disabilities, or related conditions received care and services in the most integrated setting appropriate to their needs. The policy further indicated the SSD was responsible for tracking each resident's PASRR screening status and referring residents to the appropriate authority. The policy additionally revealed, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder .

Based on observation, interview, and record review, the facility failed to label and date stored food in accordance with professional standards for food safety, failed to ensure the dish machine was operated at proper temperatures and sanitizer was dispensed at proper concentrations, and failed to ensure nutritional supplements and residents' food brought in from family were dated and discarded when expired to prevent foodborne illness. These deficiencies had the potential to affect all the 53 residents residing and eating at the facility. Findings: 1. On [DATE] at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager, (CDM) multiple food items in the walk-in refrigerator were dated with a 30-day span between when they were received/opened and when they were to be discarded. For example, a large, clear bin of diced tomatoes were dated ,d+[DATE]-,d+[DATE], approximately 25 cucumbers which had small, soft, dent spots in them which indicted spoilage, were dated ,d+[DATE]-,d+[DATE], a plastic container of blueberries, which the CDM stated were previously frozen, were smashed and leaking juices, dated ,d+[DATE]-,d+[DATE], a container of lemons were dated ,d+[DATE]-,d+[DATE], a plastic container of leftover mushrooms were dated, ,d+[DATE]-,d+[DATE], and a plastic container of leftover crushed pineapple were dated ,d+[DATE]-,d+[DATE]. The Dietary Manager stated one of the cooks had mistakenly dated these items as good for one month. She added, the previously canned pineapples and mushrooms could, usually be kept about five to seven days. The CDM explained cooks were responsible for discarding outdated items, but could not explain how items dated for use for a month, beginning from [DATE] and [DATE], had not been identified as expired and discarded. The items were still available for use by kitchen staff today, [DATE]. During the tour, several previously opened food items were found undated, for example, a package of shredded cabbage, resealed with plastic wrap, a plastic container of ham base and a container of garlic in water, a cube of butter, and an aerosol canister of whipped cream were all undated. A vacuum-sealed package which held a large piece of raw pork was found without a date on it. The CDM stated the food items should have been dated when opened and the raw meat should have been dated when it was originally refrigerated. There was an opened container of chocolate frosting dated ,d+[DATE] without a date as to when it should be discarded. The CDM stated this frosting was fudge and therefore could be kept a 'long time. Two stacks of American cheese slices were opened and rewrapped: one with approximately 25 slices, the other 40 slices with an illegible date written in pen directly on top of the plastic wrap instead of on a sticker. TheCDM stated leftover cheese could usually be kept about a week' and indicated she could provide a more exact length of time food items could be kept by referring to the online policy. She acknowledged she did not have any of this information posted for staff to reference within the department. The CDM stated many of the staff had been here for a long time and were aware of how long food could be stored, in conflict to what was found during the tour of the refrigerator. In the walk-in freezer, a plastic bag of premade hamburgers was left opened to the air. The CDM noted the burgers had white spots and white areas on them, which were evidence of freezer burn after being exposed to the air. In the dry storage room, two unopened tubs of chocolate frosting had two dates on them, ,d+[DATE] and ,d+[DATE]. The CDM stated she was not sure if the dates indicated when they were received, opened, or when they expired. She speculated the items were received on ,d+[DATE] and expired on ,d+[DATE]. On [DATE] at 11:28 PM, AM [NAME] H stated leftovers, including canned pineapple and mushrooms, could be kept for three days, diced tomatoes for one week, and butter for one month. On [DATE] at 11:40 AM, PM [NAME] I stated he cooked at the facility for the past two months but worked in the food service business for over [AGE] years. He said a person could tell how long food could be kept using their eyes and sense of smell. [NAME] I explained, in general, perishable food could be kept for three days, chopped tomatoes could be kept for one week, and canned mushrooms and pineapple could be kept for five to seven days. He stated American cheese could be kept for about two weeks after it was opened, but should always be checked for mold first. The PM [NAME] acknowledged he received three days of training when he started at the facility by one of the cooks, but had not received any other training from the CDM including what the facility's food storage policies were. On [DATE], the CDM provided a part of the facility's written food labeling and dating policy. She stated she was surprised that their policy indicated prepared foods could be kept for seven days as she had thought it was three days. In addition, some items used at this facility were not listed on this policy. She explained her Regional Manager forwarded an email which indicated opened products with a longer shelf life should be discarded according the manufacture's expiration date on the container and if there were not one, it should be discarded after 30 days. The CDM reached out to food supplier and confirmed some of the information provided by the Regional Manager did not align with the food supplier's guidelines. For example, the food supply company stated their soup bases were good for six months if unopened, but after opened, should be thrown away after two weeks. The food supply company also informed her the Chocolate Frosting could be stored for 18 months if unopened but after opening, should be discarded after four weeks. This meant the opened frosting dated ,d+[DATE], should have been discarded [DATE], over eight months ago. The facility's policy entitled Food Storage: Cold, dated [DATE], indicated all food items would be stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code and would be labeled and dated in a manner to prevent cross contamination. The policy entitled Food Storage: Dry Goods with the same date indicated foods would be stored according to the FDA Food Code and would be date marked as appropriate. 2. On [DATE] during the initial kitchen tour with the CDM, in the dish room there were two thermometers attached to the dish machine; one was a digital electronic thermometer and the other was an analog dial. The thermometer which had an electronic screen indicated the temperature was set at 160 degrees Fahrenheit (F) and the probe currently read 153 degrees F. The CDM stated she really did not know how the electronic temperature gauge worked and preferred to run a separate waterproof thermometer through the dish machine to get her temperature reading. The CDM ran a waterproof thermometer through the dish machine which read 111 degrees F, nine degrees below the required minimum temperature of 120 degrees F for a low temperature dish machine. The CDM then tested the concentration of the chemical sanitizer, which indicated approximately 200 parts per million (ppm). She said the chemical test strips were from a company which had provided their dish machine chemicals and service from over a year ago so she asked to use a different chemical test strip which had been received from the current chemical supply and dish machine maintenance company. The newer strips showed the same result of 200 ppm. The CDM stated the newer company periodically checked the machine and had never informed them there was a problem with the temperatures or concentration of the sanitizer that she knew of. The CDM could not provide the dish machine temperature logs from the month of May, and could not located them anywhere. The temperature logs for April indicated the dish machine temperatures ranged from ,d+[DATE] degrees F, which did not meet the minimum temperature required of 120 F. Review of the [DATE] log revealed temperatures were only recorded for the breakfast and lunch meal service and no dish machine temperatures were recorded for the dinner meals. The CDM initially could not explain why the recorded temperatures were low but explained she thought the reason staff had not recorded the temperatures for the dinner dishes was because the form only had two spots for temperatures to be recorded each day, so staff only recorded breakfast and lunch. The dish machine temperature logs included the chemical sanitizer was at 200 ppm even though the bottom of the form indicated the level of chemical sanitizer should be between ,d+[DATE] ppm. The CDM conveyed she thought levels of ,d+[DATE] ppm were acceptable, because she recalled that was what they were at previous facilities she worked at. The Maintenance Director arrived and explained the electronic temperature gauge was set to 160 degrees F and the probe indicated that actual water temperature. He stated he took care of the electricity and hot water going to the machine, but the calibrations were done by the company that provided the chemicals. During the kitchen revisit on [DATE] at 11:05 AM, the CDM explained dish machine temperatures recorded by the staff were low was because the staff were using the round analog thermometer to obtain the temperatures, which she acknowledged she had instructed them to use because whenever she looked at the electronic thermometer, the screen was blank. She added, when she started working at the facility a year ago, the main dish washing staff told her the electronic thermometer didn't work. In addition, she stated the current chemical company made a visit yesterday and told her the sanitizer strips she used were meant only for the pot sink and that was why it tested at 200 ppm. The representative asked her why she didn't use the correct strips and she told him they used the only ones he had provided. He then gave her the correct package of test strips and stated he would order the correct ones for her. She stated she didn't worry about the wash temperature being lower than the required 120 degrees F on the logs because the dishes always looked clean and they were sanitized after, and the representative never told her things were not OK after he checked the machine during his visits. She added, her Regional Manager made monthly visits and checked the temperature logs, the dish machine temperatures using the analog dial thermometer, and the concentration of the chemical sanitizer, and she was never told any of it was an issue. On [DATE] at 11:40 AM, PM [NAME] I stated he was responsible for washing the dishes after dinner but he did not take the dish machine temperatures at dinner time. Later that day, at 4:05 PM, PM [NAME] I stated he had not been shown how to take the temperatures for the dish machine nor instructed it was his responsibility to do it at the nightly meal. He stated he would do so if someone showed him how it was to be done. On [DATE] at 3:45 PM, the CDM stated new staff got most of their training on the computer from the management company but she provided specific education to the staff as needed. In a telephone interveiw on [DATE] at 8:26 AM, the account manager for the chemical supply company stated he had this account for the past six to seven months and confirmed he came in yesterday to find the CDM used an old strip provided by a prior chemical supply company which might have been too old to record accurately. He stated the CDM used incorrect strips which had been provided for the three-compartment sink and were not for testing the dish machine. He acknowledged it was his responsibility to provide the correct strips for the account but stated the ones they used from the previous company were in a similar container and he had not looked close enough to see if they were correct or not. He added, when he came to service the account, he brought and used his own strips. He stated If the sanitizer concentration was truly at 200 ppm, which was the concentration at which the facility was getting measurements for, one would not want to serve meals from the dishes because that amount that would not be safe for resident to eat from; it would be too much. He also stated he used the analog thermometer, not the one with a digital screen and his own laser thermometer. He added, he had ,d+[DATE] accounts and therefore was not positive but thought the water temperature at this account usually measured between ,d+[DATE] and if he saw the temperature at 110, he primed the water to try to increase its temperature. He stated if he was unable to get the water to the required 120 minimum, he would let the manager know this was a concern. He was unsure if he had brought a concern for the water temperature to the manager's attention, but added he always emailed his report to the manager, usually by the end of the day he visited. In a phone interview on [DATE] at 8:00 AM, the Regional Manager stated she goes biweekly to this account and did monthly audits. She stated she checked the temperature logs to ensure they were completed and for what the temperatures were on the logs, but does not check the actual water temperature of the dish machine herself. When asked if she noticed the temperatures recorded on the logs were consistently between ,d+[DATE] degrees, instead of the required minimum of 120 degrees, and the concentration of chemical sanitizer was consistently at 200 ppm, she stated she has 8 facilities and cannot remember what she saw at this facility a month ago. She stated if she saw that the temperatures were out of line with the requirements, she would have made the manager aware to connect with the maintenance manager and with the chemical supply company to get it corrected and stated she was not sure whether there was an error with the instructions on the form regarding the required sanitizer concentration because she thought it should be 200 ppm. On [DATE] at 11:59 AM, the Regional manager stated she reviewed the dish machine temperature logs and confirmed the April log only recorded the temperatures for breakfast and lunch meals. She confirmed the temperatures recorded were not at the minimum required temperatures and the sanitizer concentration was too high for the requirements. She stated she had not noticed those items when she had checked the logs during her prior visits. She stated she was not worried about the data being out of range because the monthly reports from the company that provided the chemicals indicated there was not an issue with dish machine temperatures or sanitizer concentration. She acknowledged that a check once per month was not adequate and that temperatures needed to be taken and recorded for each meal to ensure any issue with sanitation did not arise in-between the chemical company's visits. Review of the chemical company's monthly reports revealed from [DATE] through [DATE], no visit or report was provided. On the report dated [DATE], no dish machine temperature nor sanitizer concentration measurements were provided. On the report dated [DATE], the wash and final rinse temperatures were both reported at 115 degrees F and on the report dated [DATE], the wash temperature of 110 F and the final rinse temperature of 114 F, which did not meet the minimum required 120 degrees F. On the report dated [DATE], no temperature was documented and no sanitizer concentration information was provided at all. On [DATE] at 5:00 PM, the Maintenance Director and dietary manager were informed of the findings from the reports from the chemical supply company and the maintenance director stated using a laser to take the temperature of the water was much less accurate than what he used as he sticks a thermometer directly into the water and makes sure it matches the electronic thermometer. He stated going forward he would ensure they all used the most accurate way and would remove the analog thermometer to decrease confusion for staff on which thermometer should be used. On [DATE] at 3:05 PM, the facility Administrator, stated he provided oversight to the dietary department by reminding them of things they were supposed to be doing. For example, he went into the kitchen almost daily and reminded them to make sure they were completing the temperature logs and were dating foods, but he stated he does not check the logs nor the dated foods to ensure they were done accurately. He stated audits were completed in the kitchen by the dietary management company, and the dietitian was the one that does them. A review of the Food Safety and Sanitation audits indicated the Dietary Regional Manager completed the audits monthly and the dietitian completes them every other month. The five audits provided were completed between [DATE] and [DATE]th, 2025 with all providing an overall score between ,d+[DATE]% satisfaction. The [DATE]th, 2025 audit completed by the regional manager, with an overall score of 98%, indicated foods that required time and temperature control for safety (TCS) were not held past their expiration date. It also stated a date marking was applied at the time of preparation to foods that require time/temperature control and were dated with a date by which the product must be consumed or discarded and the shelf life does not exceed the management company standards, including the day of preparation. The audit form also indicated chemical sanitizer solutions for dish machines were maintained at the proper concentration per their label instructions and if a violation was found, operation may need to cease until the imminent health hazard was resolved. It continued by indicating the dish machine was properly maintained and wash temperatures met the requirements. It added that dish machine logs were available and were properly completed. The dietary management company's policy entitled Ware washing, dated [DATE], indicated the Dining Services Director ensured the staff was knowledgeable for using proper ware washing techniques, dish machine water temperatures were maintained in accordance with the manufacturer recommendations, and that appropriate temperature and sanitizer concentration logs were completed as appropriate. 3. On [DATE] at 11:30 AM, on a tour of the nourishment room with the Unit Manager (UM), the refrigerator temperatures were recorded on the log twice per day and the freezer temperatures were not recorded at all. A package containing 11 hot dog buns were found in the refrigerator without a label as to whose it was and without a date. There were also seven containers of yogurt labeled with a resident's name; two were dated [DATE] without an expiration date and the other five had varying expiration dated between [DATE] and [DATE]. There was a carton of whole milk for another resident which had been opened but was undated as to when it was opened or when it expired. Two opened, yet undated containers of the nutrition supplement MedPass were noted and the directions on the containers stated they were to be used within 3 days of opening. The UM stated it was the responsibility of the dietary department to record the refrigerator and freezer temperatures on the log and to check residents' food for expiration dates and discard them when expired. She added it was important to check expiration dates for residents to ensure they didn't get food poisoning from spoiled food. The UM acknowledged the nursing staff was responsible to label any food items, including when they opened the MedPass and discard it when expired. She added it was important do this so staff didn't serve spoiled items to the residents and get them sick. On [DATE] at 11:59 AM, the CDM stated she checked the expiration dates of resident's food items when she checked the nourishment refrigerator. She could not explain why expired and unlabeled foods had currently been found in the nourishment room refridgerator. The CDM explained possibly these items had been put in the refrigerator that morning. The Dietary Regional Manager who was present, stated the nursing department was responsible for checking resident food expiration dates and for logging daily temperatures of the nourishment refrigerator and freezer. The CDM stated she informed her staff to write the temperatures on the log if they had not been filled out by nursing when they brought snacks to the nourishment room, and could not explain why this had not been done. On [DATE] at 1:21 PM, the Director of Nursing (DON) and the Staff Development Coordinator stated the dietary department was responsible to take and record the daily nourishment refrigerator temperatures and to throw away resident's expired food items after three days of being in the refrigerator. They acknowledged, nursing was responsible to accept the food items from family members, ensure they were labeled with the resident name and date, and to date the MedPass nutrition supplement when it was opened. The facility's policy entitled Use and Storage of Food brought in by Family and Visitors, dated [DATE], indicated prepared food items brought into the facility for a resident would be thrown away by facility staff if not consumed within three days. The policy did not stipulate which facility staff was responsible for this action.

Based on observation, interview, and record review, the facility failed to ensure qualified staff had the appropriate competencies and skill sets to carry out management and oversight of the food and nutrition services as demonstrated by numerous irregularities including labeling/dating food, training to staff on food safety and preparation, and logs for the dish machine, which had the potential to affect all 53 of 53 residents residing and eating at the facility. Findings: On [DATE] at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), multiple food items in the walk-in refrigerator, freezer and dry storage room had unlabeled, undated, expired, and improperly stored food items. The CDM did not provide required oversight of staff to monitor or address issues including food items left unlabeled, and undated or expired foods. The CDM did not provide to staff readily available policies and procedures for food labeling, storage and the expiration date policy. Instead, staff were directed to discard prepared foods after three days and was not aware of the actual policies of the facility. On [DATE] as the initial kitchen tour continued with the CDM, the dishwashing machine was observed at approximately 9:50 AM. The dishwashing machine's water temperatures were found to be lower than the required and the concentration of the chemical sanitizer was found to be higher than the appropriate level. The dishwashing machine's temperature log, for the previous months, revealed the dish machine temperatures to be out of the required range and entries for the dinner meals to be missing. The temperature log for the current month could not be located. The CDM did not provide the appropriate oversight to identify the concerns, nor to monitor or address the issues as required. Interview of a kitchen staff on [DATE] at 11:40 AM, revealed the cook never received instruction on how to take the dish machine temperatures at dinner meals. Other dietary staff and management were unsure which thermostat to use to record the dish machine temperatures and instructed staff to use one that recorded the temperature below the required minimum temperature. When provided with months of dish machine temperature logs which indicated the temperature did not meet regulatory requirements, management had not provided the oversight to address the inadequate temperatures and missing entries in the logs. The CDM also did not provide the oversight of the chemical sanitizer for the dish machine, review of the temperature logs contained documentation the chlorine disinfectant was at a level too concentrated to be safe for residents, instead she relied on the chemical supply company to notify her, saying she was never told any of it was an issue. Interview with staff and records revealed new staff received training online regarding food safety but documentation of direct staff education at the facility was minimal. A review of the staff training provided by the CDM revealed an in-service was completed on [DATE] reminding staff to fill out temperature logs. Over the next 10 months, only three additional in-services were provided, in [DATE] on the topics of slips and fall prevention, tray presentation and accuracy, and prevention of knife cuts. There were no additional in-services to address food safety, or storage for kitchen staff during that time. On [DATE] at 2:41 PM, the CDM stated it was the cook's responsibility to check food items for expiration and discard them which could be completed anytime during their shift, but she did not say what type of oversight she gave to kitchen staff beyond occasional verbal reminders. The CDM explained the facility's Administrator regularly asked her if staff completed the temperature logs, checked the milk carton dates, or had adequate supply of dish machine chemicals, but didn't inquire if she actually reviewed them regularly. The CDM was unable to say why the facility could not provide documentation of the dish machine temperature log for the month of May, or why she did not recognize or act on dish machine temperatures that were too low or missing entries in previous months' logs. The Dietary Manager had a current food safety certification, an associate's degree in management related to food service, and approximately [AGE] years' food service management experience according to her resume. She was directly employed by and provided oversight by a food service management contract company, yet numerous irregularities were noted which did not meet the Food and Drug Administration Food Code nor standards of practice for the industry.

Based on observation, and interviews, the facility failed to post a complete Nurse Staffing report in a place readily accessible to residents, staff, and visitors. Findings: On 5/27/25 at 2:30 PM, the Nurse Staffing sheet was posted on the wall in the hall leading from the lobby to the resident rooms. It was about six feet from the floor and out of view of the residents. Review of the posting revealed it did not include the facility census as required. On 5/28/25 at 2:00 PM, a facility visitor stated she was not aware of the facility staff posting on the wall. The visitor looked at it and acknowledged she could not read it because the typing was too small. On 5/29/25 at 12:14 PM, the Staffing Coordinator stated she was responsible for creating the staffing document that was posted in the lobby. She looked at the posting where it hung on the wall and acknowledged it could not be seen by anyone sitting in a wheelchair. She said there was another one posted outside her office door. When she looked at it, she agreed the words were too small for anyone in a wheelchair to read. The Staffing Coordinator acknowledged the census was not on either of the postings. She stated she was not aware the census was required on the posting.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan dated 1/18/24, revealed it was designed to be ongoing and comprehensive. The plan detailed the facility used a systematic approach to determine when in-depth analysis was needed to fully understand the problem, its causes and implications of change. The facility used a thorough and highly organized/structured approach to determine the root cause of identified problems. The plan indicated the facility would utilize a variety of tools to describe the current process used and identify any area of breakdown or weakness in the current process. The document described each Performance Improvement Project (PIP) subcommittee would provide the QAA committee with a summary report, analysis of activities, and recommendations. The facility had a deficiency cited at F812 during the previous recertification survey of 2/29/24 for food safety and sanitation. During the current survey, the facility was found to have repeated concerns with food safety and sanitation with dietary services. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 5/29/25 at 4:58 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of the repeat deficiency F812. The NHA explained the Dietary Regional Manager completed monthly audits, but he himself did not have access to those reports and was not aware of any issues within dietary services. The NHA acknowledged there was a breakdown and said the problem was his inability to access the reports. He acknowledged the facility should have access to reports completed by the Regional Manager in order to conduct performance activities to ensure improvements and measures were conducted and sustained.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 of 7 residents reviewed for medication administration, of a total sample of 31 residents, (#10). Findings: Resident #10 was readmitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, emphysema, Alzheimer's disease, dementia, sensorineural hearing loss and dry eye syndrome. A review of the quarterly Minimum Data Set assessment with reference date 4/04/25 revealed resident #10 had moderately impaired cognition. The assessment revealed the resident had no behaviors, nor rejection of care during the lookback period. Review of physician's orders revealed resident #10 was scheduled to receive one drop of Refresh Liquigel Ophthalmic Gel 1% (Carboxymethylcellulose Sodium (Ophthalmic)) in both eyes, four times a day for dry eyes and one drop of Latanoprost Ophthalmic Solution 0.005% in both eyes at bedtime for glaucoma. On 5/28/25 at 9:36 AM, Registered Nurse (RN) E prepared to administer resident #10 his morning medications. RN E prepared the oral medications, then began to look for the resident's prescribed eyedrops. First she took out the Latanoprost eye drops but realized it was not the one to be administered at that time. RN E searched the medication cart and determined the Refresh Liquigel was not available. She stated she would reorder the medication from the pharmacy and notify the doctor. Review of the Medication Administration Record (MAR) Audit report on 5/28/25 revealed documentation completed by RN E at 9:45 AM, the Refresh Liquigel Gel 1% was administered for the 9:00 AM dose at 9:26 AM. The audit report showed the 1:00 PM dose was administered by RN F at 12:15 PM. A nurse's progress note documented at 9:46 AM, confirmed the physician was notified the eye drops were not available at that time. On 5/28/25 at 1:11 PM, RN G and RN F were together in the hallway at the medication cart. RN G said they received resident #10's Refresh Liquigel eye drops and retrieved it from the cart. The medication was in the package, unopened and still sealed. RN G began to label the box with the resident's name. RN F was asked if the resident had received the 1:00 PM dose and she stated she had not given it yet. RN F was then asked to verify on the MAR that the medication was marked as given and the initials of the nurse were in fact hers. RN F verified that the initials were hers and when she realized she had already marked the medication as given in the medical record, she stated oh .ok, I will give the medication now. The nurse could not say why she documented the medication was administered before the package was even opened, or given. On 5/28/25 at 1:27 PM, the Director of Nursing (DON) and RN E reviewed the documentation on MAR with regards to resident #10's Refresh Liquigel eyedrops. RN E's documentation on the MAR completed at 9:45 AM, revealed the 9:00 AM dose was marked as given, which was inaccurate. RN E explained she checked it off in error, however she said that she had given the afternoon dose. RN E retracted her statement, that she had given the afternoon dose of the medication when she realized the initials on the MAR were RN F's, not her own. On 5/28/25 at 1:40 PM, the DON confirmed the documentation on the MAR was inaccurate. She said that she would have RN E strike out the 9:00 AM dose and notify the physician. The DON presented the Medication Administration Audit report which revealed the 1:00 PM dose of Refresh Liquigel eyedrops were documented as administered by RN F at 12:15 PM, before the medication had even been taken out of the package and opened. On 5/28/25 at 1:55 PM, RN F conveyed nurses should not document until after a medication was given and acknowledged she should not have documented the 1:00 PM dose of Refresh Liquigel eyedrops were administered prior to her actually giving it. The facility's Policy and Procedure on Medication Administration revised October of 2023 indicated in the Policy Explanation and Compliance Guidelines number 17, Sign MAR after [medication is] administered.

Based on observation, interview, and record review, the facility failed to implement appropriate dietary recommendations to treat significant weight loss for 2 out of 3 residents reviewed for nutrition, of a total sample of 31 residents, (#43, and #25). Findings: 1. Resident #43 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses that included acute and chronic respiratory failure; partial paralysis following stroke, affecting the left dominant side; type 2 diabetes mellitus, trouble swallowing, unspecified dementia, moderate protein calorie malnutrition, colostomy status and gastrostomy (feeding tube) status. A colostomy is a temporary, or permanent surgical opening in the abdomen to drain stool from the body, (retrieved on www.hopkinsmedicine.org on 6/11/25). Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 5/06/25 revealed resident # 43 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact, had no behaviors nor rejection of care, ate independently and only required set up or clean up assistance during meals. A review of resident #43's Physician's Orders included a regular diet with thin consistency, 90 milliliter (ml) of House 2.0 calorie twice daily for nutritional supplement to be given with med pass (nutritional supplement), 30 ml Prostat AWC (Advanced Wound Care supplement) daily with med pass to promote wound healing. The orders indicated her gastrostomy tube was used for medication administration only. On 5/27/25 at 1:12 PM, resident #43 was in bed with her lunch tray in front of her. The assigned Certified Nursing Assistant (CNA) exited the room and stated she was going to get a grilled cheese sandwich for the resident because the resident did not like the sweet sauce on her mashed potatoes. The CNA mentioned the resident would eat on her own. About an hour later, on 5/27/25 at 2:06 PM, resident #43 was sleeping in bed, one bite of the grilled cheese sandwich was eaten from the plate on her bedside table. On 5/28/25 at 12:34 PM, resident #43 was in the dining room asleep in her wheelchair. One of the CNAs in the dining room reported the resident did not eat her lunch and she was waiting for help to put the resident back to bed. Later, on 5/28/25 at 2:05 PM, resident #43 continued to sleep in her room. A review of CNA documentation of resident #43's percentage of meal eaten for lunch on 5/27/25 was 0-25% and on 5/28/25 for breakfast, lunch, and dinner, it was 0-25%. A review of the medical record indicated the following weights for resident #43 since her re-admission to the facility on [DATE]. On 4/30/25 resident #43 weighed 133 lbs. On 5/01/25 resident #43 weighed 133 lbs. and on 5/02/25 she weighed 132 lbs. There was no record of weights documented after 5/02/25 through 5/28/25. In a telephone interview on 5/28/25 at 6:03 PM, the Registered Dietician (RD) explained, resident #43 had multiple readmissions and came back to the facility on [DATE]. On return from the hospital, resident #43 was placed on med pass supplements twice a day and another supplement, Prostat. The RD explained resident #43 was looked at as a new admission and was weighed every day for the first few days, then weekly for four weeks in order to more accurately assess her nutrition needs. She confirmed she was made aware the weekly weights were not performed and the last weight recorded was on 5/02/25 with no weight recorded thereafter. The RD explained the facility was aware she had asked for newly admitted residents to be weighed weekly since 5/09/25 and had spoken to the team during their last weekly meeting on 5/22/25. She said that the team was aware she was unable to complete her assessments without the weekly weights. On 5/29/25 at 1:12 PM, CNA C and CNA D said their Activities of Daily Living (ADL) tasks in their electronic documentation would indicate which residents needed to be weighed or the nurse would let them know. They explained the restorative CNAs were usually responsible for weighing residents, however they could perform the task as long as they knew it needed to be done. On 5/29/25 at 1:25 PM, Registered Nurse (RN) B explained she followed the physician's orders if there was a weight that needed to be completed. On 5/29/25 at 10:39 AM, the Director of Nursing (DON) and RN A said that restorative CNAs performed the weekly weights but they would not have know which residents needed to be weighed. They acknowledged there was a communication problem within their process for staff to know who should be weighed. The DON confirmed she was told by the RD about the missing weekly weights and acknowledged the facility did not follow the process. The DON stated it was her responsibility to follow through on the issue of the weights, and said they, dropped the ball on this one. 39943 2. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes and need for assistance with personal care. Review of the resident record revealed a current physician order for weekly weights dated 5/09/25. Review of the RD progress note dated 5/09/25 at 7:34 PM, noted resident #25 triggered for significant weight loss over 30 days. Her weight on 5/07/25 was 109 pounds. The resident's previous weight on 4/01/25 was 119 pounds, a 10-pound weight loss or a 5% change over 30 days. The note recommended weekly weights, continue to monitor, and follow up. Review of resident #25's Weight and Vitals Summary revealed the last documented weight to be 109 pounds on 5/07/25. Review of the Nutrition care plan date 4/07/25, had an intervention to obtain weight as indicated. In a telephone interview on 5/28/25 at 6:28 PM, the RD stated she spoke to the Unit Manager (UM) two weeks ago regarding the weekly weights not being performed, and she sent an email to the DON about it. On 5/29/25 at 10:40 AM, the DON and UM stated the RD made them aware that resident #25's weights were not being performed as ordered. The DON stated the restorative CNAs usually did the weights. She stated there was no process in place regarding who would complete the weights if the restorative CNAs were not able to do them. The DON stated she took full responsibility for the weights not being performed, and explained it was due to lack of communication. The Weight Monitoring policy, implemented 11/20/20 and revised 11/30/23, indicated, weights should be monitored as per the schedule below unless otherwise ordered by the healthcare provider. The policy detailed, newly admitted residents' weight should be monitored weekly for four weeks, residents with significant weight loss should be monitored for weights weekly, and all others should be monitored monthly. The policy described that the newly recorded resident weight should be compared to the previously recorded weight.

Based on interview and record review, the facility failed to follow their grievance process related to expressed concerns for care for 2 of 3 residents reviewed for grievances, of a total sample of 8 residents, (#2 and #4). Findings: 1. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included stroke, dementia, and urinary tract infection. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated moderate cognitive impairment. Review of resident #2's medical record showed her son was her responsible party. On 4/29/24 at 4:28 PM, during a telephone interview, resident #2's son stated he found out his mother sustained a fall in the facility when he visited her in the hospital on 4/06/24. He explained he saw a bruise on her left leg and wanted to know the details of her fall. He mentioned his mother mentioned the fall to the hospital staff and they told him that information was not included in the report from the facility. He indicated he called the facility and spoke with the Director of Nursing (DON). He stated he requested a meeting with the Interdisciplinary Team (IDT) to address his concerns about his mother's care, but no one had called him. Review of the Grievance Log for April 2024 revealed no grievances for resident #2. On 4/30/24 at 3:37 PM, the DON recalled receiving a phone call from resident #2's son a couple of days after she was transferred to the hospital. The DON reviewed the transfer to the hospital documentation and acknowledged it did not include information that resident #2 sustained a fall. She stated the documentation listed abdominal pain as the reason for the transfer. She said the resident had complained of abdominal pain that day, but it would have been important for the hospital to know she also fell . She indicated resident #2's son asked why his mother was sent to the hospital. She stated she explained to him the pain she was having during the morning, her refusal for pain medication and then the fall. She confirmed she told resident #2's son they would set up a care plan meeting after resident #2 returned from the hospital. She acknowledged she had not called him to set up the meeting or followed up with him since the phone call over 2 weeks ago. 2. Resident #4 was readmitted to the facility on [DATE]. His diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke, convulsions, and anxiety. Review of the quarterly MDS assessment with ARD of 3/29/24 revealed resident #4 had a BIMS score of 15 which indicated he was cognitively intact. The assessment noted no rejection of care. On 4/29/24 at 11:06 AM, resident #4 stated his meal tray was periodically not included in the carts and it happened mostly for dinner. He explained the last incident happened on Saturday evening. He stated Certified Nursing Assistants (CNAs) were passing out trays to other residents, but his tray was not available. He stated the kitchen staff was, Not making up his tray on purpose. He said he knew when the tray was not included in the cart because his meal ticket would not be included with his tray. He said, It's a joke to them, they do it to be funny. He stated kitchen staff was supposed to include a ginger ale with his meals, but this was not always the case. He indicated he stopped complaining about things because nothing was done. He stated he had spoken to the Social Services Director (SSD) on more than one occasion about his concerns, but the facility did not do anything. He stated he had requested certain CNAs not be assigned to his care, but they still assigned them to him at times. He said, Abuse to an elderly person is a felony, and he required assistance from staff because he was paralyzed on his left side. He stated he called the police on Saturday because this facility did nothing to address his concerns. He mentioned the Administrator came to the facility after he called the police on Saturday but did not come to his room to speak to him. On 4/30/24 at 2:10 PM, during a telephone interview, the weekend supervisor explained her responsibilities included addressing any issues or concerns brought up by residents or families. She stated she completed grievance forms and dropped them in the SSD box. She recalled resident #5 called the cops last Saturday and complained about food portions and he was wet. She stated when staff checked resident #4, he was dry. She mentioned he did not inform staff about his concerns, just called the cops. She stated she accompanied the police officer to resident #4's room but he said he did not want to talk to her, and she left. She stated when the police officer finished talking to resident #4, the officer told her about his concerns which were food portion and being wet. She stated she tried talking to resident #4 again after the police left but he refused to talk to her. She indicated she called the Administrator while the police officer was in the facility. She stated she was not aware of any previous calls to the police by resident #4. She explained she spoke with resident #4's assigned nurse and CNA. She explained the nurse was unaware of any complaints. She indicated CNA A told her she had to go to the kitchen to get his tray because it was not included in the cart. She stated she was aware resident #4 did not want certain CNAs assigned to him so she accommodated his preference. She explained she would normally fill out a grievance form in a situation like this, but this time resident #4 did not want to speak to her, and she would have needed the interview to include it on the form. She stated this was the reason she called the Administrator. On 4/30/24 at 3:19 PM, during a telephone interview, CNA A explained she was assigned to the dining room during supper last Saturday. She stated the floor CNAs passed the trays to her residents. She mentioned the CNAs told her they did not see resident #4's tray in the cart and resident #4 had asked them, You don't see my food in the cart? She said the CNA told him she would get him a tray from the kitchen, and he repeatedly said he did not want it. She stated the CNA went to the kitchen and brought him a tray anyway, which he ate. She stated she did not know why the kitchen forgot his tray, because they have, To go slowly with him. She acknowledged he liked to get ginger ale with his meals and indicated he got mad when he did not get it, which sometimes happened. On 4/29/24 at 3:59 PM, the Administrator stated the SSD was the Grievance Officer, but was not available this week. He explained anyone could file a grievance and the forms were found at the nurses' station and the lobby. He explained they tried to resolve grievances within 72 hours. He explained grievances were discussed in the morning meeting. He stated if a resident or his/her family mentioned they felt neglected, abused, or unsafe, it was reported as required immediately and an investigation was initiated. He said he was the Abuse Coordinator. On 4/30/24 at 12:27 PM, the DON stated the weekend supervisor told her resident #4 had concerns about his food during the weekend. She indicated she went to talk to him and completed a grievance form. She explained resident #4 told her his tray was not included in the cart when staff was passing them. The Administrator stated resident #4 called the police and reported he was not getting enough food. The Administrator indicated he came to the facility last Saturday and spoke with the police. He confirmed he did not talk to resident #4 that day. The Administrator stated he talked to the weekend supervisor who confirmed resident #4 received a meal tray. When asked if resident #4 had called the police previously, both the Administrator and the DON stated he had not. The Administrator explained there were grievance forms by the nurses' station, the weekend supervisor should have completed a grievance form with resident #4's concerns. On 4/30/24 at 4:34 PM, the Unit Manager (UM) stated she was aware of at least 3 CNAs resident #4 did not want assigned to him. She said, Everybody knows which CNAs shouldn't be assigned to him, and confirmed nurses had assigned them at times. She explained last Wednesday she heard resident #4 called the police for the first time because of concerns with his meal. She stated his concerns were discussed with the psychiatrist last Friday. Later at 4:57 PM, the UM stated when she came in a few minutes before 9:00 AM last Wednesday, the police were in the facility talking to resident #4. She recalled the Administrator spoke with the police officer and later the DON and Administrator spoke with resident #4. She stated she learned on Sunday, resident #4 called the police about the same food issue. She indicated she did not write a grievance form last week because the police officer told her he had eaten his meal already and instead she contacted the physician and psychological services. On 4/30/24 at 5:46 PM, the Administrator stated he did not remember resident #4's call to the police last week. The DON indicated they were in a morning meeting when the police came in to speak with resident #4. The Administrator and DON stated they were unaware resident #4's food concerns were discussed during the care plan meeting on 4/17/24. The Administrator stated he did not speak with resident #4 last Wednesday or Saturday after the visit from the police. The Administrator stated a grievance and follow up should have been done to address resident #4's concerns. Review of the Care Plan Meeting Minutes dated 4/17/24 revealed resident #4 was in attendance. The Resident/Family Concerns section read, Some food concerns - all were addressed & noted by dietary. On 4/30/24 at 5:55 PM, the MDS Coordinator and the Dietary Manager explained the food concerns mentioned by resident #4 during the care plan meeting on 4/17/24 were related to food likes and dislikes. The Dietary Manager stated she updated his preferences the next day. The MDS Coordinator stated if a resident brought up a concern about food temperature or an actual concern they completed a grievance form. The MDS Coordinator stated resident #4's concerns, Did not seem like a grievance, to the IDT. Review of the police Event Report dated 4/27/24 at 6:42 PM, read, Subject was complaining of not getting the proper food for meals and staff taking too long to change his diapers. Head Administrator was contacted and wanted a statement from me regarding the incident for them to document. Review of the facility's policy titled Resident and Family Grievances revised on 3/08/22 read, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination reprisal or fear of discrimination of reprisal. The policy included, The Grievance Officer is responsible for overseeing the grievance process; receiving and tracing grievances through to their conclusion; leading any necessary investigation by the facility; maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. The document indicated the grievance may be voiced by a verbal complaint to a staff member or the Grievance Official. The policy revealed the staff member who received the grievance was to record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. The procedure directed staff to Take any immediate actions needed to prevent further potential violations of any resident right. It concluded with The facility will make prompt efforts to resolve grievances.

Based on interview, and record review, the facility failed to provide evidence of the Infection Preventionist's (IP) qualifications for 1 out of 1 staff reviewed for specialized training in infection prevention and control. Findings: Review of the infection prevention and control module certificates provided by the Nursing Home Administrator and the Infection Preventionist (IP) indicated that only six modules were completed by the IP on September 25, 2021. There was no evidence presented to confirm completion of the Infection Prevention Training Course by the IP. On 2/29/24 at 4:17 PM, the Infection Preventionist (IP) stated she had been the IP at the facility for three years. She acknowledged she completed the CDC (Center for Disease Control) Infection Prevention and Control training course in 2021. The IP verified she was unable to provide proof of completion for the infection prevention training course and could only present evidence of having completed six modules on September 25, 2021. The facility's Infection Control Preventionist job description/job requirements read, Infection Control and Prevention Certification required. The facility's Infection Prevention and Control Program read, The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff . It also read, All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.

Based on interview, and record review, the facility failed to fully implement and monitor Performance Improvement Plans (PIPs) for identified resident care deficits. Finding: In an interview on 2/29/24 at 2:48 PM, the Director of Nursing (DON) said nurses were expected to monitor residents who received dialysis for complications and notify the doctor if there were concerns. She explained, she had been working at the facility for less than a week and said the previous DON was, working with dialysis for the check site bleeding. On 2/29/24 at 3:20 PM, the DON stated she had a PIP related to dialysis residents with fluid restrictions. She provided documents she referred to as a PIP with logs titled Dialysis Audit Tool with handwritten entries dated from 1/19/2024 to 2/19/2024 and a blank form titled, Dialysis Communication Tool. She explained that the former DON had developed a new form and implemented the project two months prior. On 2/27/24 at 3:50 PM, a review of the Dialysis Book kept at the nurse's station revealed it contained blank and completed forms titled, Dialysis Transfer Form updated December 2017. RN A checked the binder and explained the forms were used to monitor and track conditions of residents on dialysis. The book did not contain the new form identified by the DON as new and included in the current PIP. On 2/29/24 at 6:07 PM, the Nursing Home Administrator (NHA) said the Quality Assurance Performance Improvement (QAPI) review was delayed because he had difficulty locating PIP records. In a joint interview with the NHA and DON on 2/29/24 at 6:14 PM, the NHA explained the QAPI committee met monthly to review, discuss, and identify root causes and develop plans for improvement. He said the committee used track and trending reports from its members and resident council to identify performance deviations, audit tool development, and any needs for ongoing PIP revisions. The DON said the dialysis PIP did not include evidence that indicated nurse education was provided as outlined in the actions. She reviewed the PIP documents and acknowledged the audit forms were incomplete with several missing entries. She could not explain why the Dialysis Book had not contained the new forms indicated in the PIP and stated, it was not successful; the interim DON told me it wasn't working, and I have to continue. The NHA said in October 2023, the committee identified concerns related to a high number of resident falls after meals. The NHA recalled that there was a PIP and audit tool created and forms were presented at the last two QAPI meetings however, he was unable to locate the records. He explained, the DON planned to bring the concern to their next QAPI meeting and said, we will start over next month. The NHA explained, monitoring and tracking of PIPs in QAPI and Quality Assessment and Assurance (QAA) programs was essential to facilitate improvement with facility identified concerns for the residents and stated, you know we bring it forward to QAPI to establish a root cause and try to improve on whatever needs improvement. Review of the Quality Assurance Performance Improvement (QAPI) Plan dated 1/18/24 read, .Guiding Principle #3: The outcome of QAPI in our organization is the quality of care and the quality of life of our residents. Guiding Principle #6: Our organization makes decisions based on data . Guiding Principle #7: Our organization sets goals for performance and measures progress toward those goals. The aim is safety and high quality with all clinical interventions . The committee shall maintain meeting agendas, minutes, attendance records, and QAPI program progress reports. A scorecard/dashboard(s) for individual performance improvement projects are used to communicate progress and outcomes of individual QAPI projects. The information is compared against the benchmark set by the QAA Committee and results are listed and graphed. The QAPI Lead or Coordinator is responsible for cataloging and maintaining these reports.

Based on observation, interview and record review, the facility failed to ensure food was stored in a safe and sanitary manner in the kitchen's walk in refrigerator and 1 of 1 nourishment room and failed to ensure 2 of 3 employees observed followed appropriate hygienic practices in food preparation areas. Findings: 1. An initial visit to the kitchen on 2/26/24 at 9:06 AM revealed a tray of refried beans and a tray of ravioli with tomato sauce in the walk-in refrigerator were covered with a plastic wrap but were not labeled or dated. The Certified Dietary Manager (CDM) stated they had to be from the weekend and acknowledged all leftovers in the refrigerator had to be properly labeled and dated. 2. On 2/29/24 at 5:56 PM, observation of a refrigerator located in the nourishment room with Certified Nursing Assistant (CNA) D revealed two Styrofoam cups with leftover shakes. One cup had a room number and 2/26 written and the other cup had 2/29 written but did not have a resident's name and room number. CNA D discarded both cups and stated they should not use food in the refrigerator after a couple of days and residents' leftovers had to be labeled with the appropriate name and room number. 3. On 2/29/24 at approximately 6:05 PM, Cook E was observed wearing large yellow hoop earrings and Dietary Aide F was eating from a Styrofoam cup while wrapping and labeling leftovers in the food preparation area. On 2/29/24 at 6:13 PM, Cook E stated she was not supposed to wear big hoop earrings when she worked. She explained the earrings could fall off in the food during preparation. On 2/29/24 at 6:15 PM, Dietary Aide F stated she was eating potato salad. She said they had already finished serving. She explained after serving food it is okay to do, not during working time when food is being served. Dietary Aide F then acknowledged she was not supposed to eat in the kitchen. On 2/29/24 at 6:17 PM, the CDM stated it was not acceptable for staff to eat while working, and staff were supposed to take a break to eat outside the kitchen. She indicated she did not notice Cook E wore long loop earrings today and acknowledged that was not acceptable attire for work. Review of the facility's policy Refrigerators and Freezers not dated read, This facility will ensure refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy included Use by dates were to be completed with expiration dates on all prepared food in refrigerators. Review of the policy Staff Attire dated October 2019 read, It is the center policy that all Dining Services employees wear approved attired for the performance of their duties. The policy included dangling jewelry was not permitted.

Based on observation, interview, and record review, the facility failed to ensure nurses monitored complication risks for 1 of 1 resident reviewed for Dialysis, of a total sample of 27 residents, (#5). Finding: Review of the medical record revealed resident #5, an [AGE] year old female was admitted to the facility on [DATE]. Her diagnoses included end stage renal (kidney) disease, dependence on renal dialysis, chronic respiratory failure, hypoxemia (low blood oxygen), congestive heart failure (heart pumping dysfunction), cardiomyopathy (heart muscle disease), Chronic Obstructive Respiratory Disease (COPD), anemia, type 2 diabetes mellitus, malnutrition, major depressive disorder, and acquired absence of both legs above the knee. After re-hospitalization , on 2/18/24 she was readmitted back to the facility with additional diagnoses that included pleural effusion (fluid in the lung space) and acute cystitis (bladder inflammation). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) 11/19/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment showed there were no rejections of evaluation or care. The assessment noted the resident required maximum assistance and was dependent on staff for mobility and to complete Activities of Daily Living (ADLs). She had gained 5% or more unplanned weight in the last month or 10% or more in the previous month, and she received hemodialysis while a resident during the look back period. The Care Plan showed there were Focus items for altered cardiovascular status, chronic and acute pain, high-risk medication adverse effects, high-risk for falls, incontinence, ADL self-care performance deficits, end stage renal disease and dialysis complication risks with interventions that nurses monitored and assessed vital signs, port access, and weights after treatments. The Order Summary Report showed active physician orders for Consistent Carbohydrate Diet/Renal Diet puree texture with a 1000 milliliters (ml) daily fluid restriction. On 2/26/24 at 10:30 AM, resident #5 was observed in her room lying in bed. On 2/27/24 at 9:53 AM, Registered Nurse (RN) C stated the resident was out of the facility for dialysis treatment. On 2/27/24 at 3:39 PM, RN A said nurses were expected to complete a handwritten dialysis communication form every time a resident went out for dialysis treatment. She stated, all completed forms were kept at the nurses station in a binder under a tab with the resident's name. The nurse explained the forms were important to track the resident's condition and monitor for changes and complications so they could notify the physician if needed. On 2/27/24 at 3:50 PM, a review of the Dialysis Book kept at the nurse's station revealed it contained a total of six Dialysis Transfer Forms for resident #5 that dated back to April 29, 2023. The form noted three sections for nurses to complete before, at, and after dialysis treatments. The middle section was to be completed by the dialysis center, and a bottom section for facility nurses that read, Completion upon return to Center following dialysis appointment. All six of the resident's forms were missing entries from the dialysis center and facility nurses upon the resident's return. RN A checked the binder and acknowledged there were only six forms for the resident, and all six were incomplete. She said she had not yet completed the current days form. Review of the Weights and Vitals Summary Report revealed from August 2023 to February 2024, resident #5 was not weighed after dialysis treatments 78 out of 92 times. The report did not include vital signs entries. In an interview on 2/29/2024 at 2:48 PM, the Director of Nursing (DON) said nurses were expected to follow physician's orders for dialysis treatments, monitor for complications, and notify the doctor if there were concerns. She stated weights were expected to be done upon the resident's return to the facility from dialysis. She explained, she had been working at the facility for less than a week and said the previous DON was, working with dialysis for the check site bleeding. Review of the Dialysis Book revealed it contained instructions for nurses that read, 1) Verify that the middle portion of the original form has been completed by the nurse at the dialysis center. If incomplete, immediately contact the dialysis center. You may need to fax the form to them for completion. 2) Complete the bottom portion of the dialysis transfer form and file under resident's tab in dialysis book. Review of the facility's undated standards and guidelines titled Care Planning Special Needs - Dialysis read, . 3. Interventions will include, but not limited to: a. Documentation and monitoring of complications b. Pre- and post- weights c. Assessing, observing, and documenting care of access sites, as applicable . f. Vital signs .

Based on interview and record review, the facility failed to provide personal fund quarterly statements to 1 out of 1 resident reviewed for personal funds out of a total sample of 27 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] from the hospital. His diagnosis included unspecified convulsions, hemiplegia, and hemiparesis following cerebral infarction, depression, and anxiety disorder. The most recent annual Minimum Data Set (MDS) with an assessment reference date of 12/29/23 revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. On 2/26/24 at 11:05 AM, resident #44 stated the facility held funds on his behalf but he had not received information regarding the balance in his account. He said he had never received financial statements from the facility. He explained he wanted to order some take out food but was uncertain about the balance in his facility held account. On 2/28/24 at 1:15 PM, the Business Office Manager (BOM) conveyed she had worked in her position for 1 year. She stated residents could choose to have their personal funds managed by the facility and quarterly statements were provided to the residents who were alert and oriented, or to their Power of Attorney (POA) if applicable. The BOM acknowledged there was not a system in place to ensure resident's quarterly statements were sent out. She checked resident #44's account and remarked, He does have a personal fund account. I was not aware he had an account. She verified the resident had not received his personal fund quarterly statements because she was not aware he had an account. Review of the facility's Resident Personal Funds Policy noted if the resident chooses to deposit personal funds with the facility, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage and account for the personal funds of the resident deposited with the facility. The individual financial record must be available to the resident through quarterly statements and upon request.

Based on observation, interview, and record review, the facility failed to honor resident's rights to choose their preferred morning wake-up time for 1 of 6 residents reviewed for choices out of a total sample of 27 residents, (#22). Findings: Review of the medical record revealed resident #22 was admitted to the facility on [DATE]. Her diagnosis included Alzheimer's Disease, dementia, major depressive disorder, and adjustment disorder. Resident #22's Annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/23/23 revealed the resident was the primary respondent for daily and activity preferences, and it was very important to her to choose her daily preferences such as her own bedtime. The resident's Quarterly MDS assessment with ARD of 11/17/23 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment noted the resident was totally dependent on staff for transfers and required maximal assistance with bathing and dressing. The Documentation Survey Task Report noted that during February 2024, resident #22 was dressed and transferred with a mechanical lift before 7 am on the 11 PM-7 AM shift. The Documentation Survey Task Report also indicated that on seven occasions during February, she was dressed and transferred between 1:45 AM and 2:32 AM. Review of the facility's daily Get Up List for Breakfast, updated on 2/23/24, noted resident #22 was on the 11 PM to 7 AM Get Up List with two asterisks (**) by her name. The Get Up List read, 11-7 shift are to have residents showered/bathed and dressed ready for breakfast in the dining room. Residents with the ** are to be up in their WC (wheelchair). Residents w/o (without) the ** are to be bathed, dressed, and left in bed for 7-3 shift to get up on their shift. On 02/27/24 at 11:39 AM, resident #22 stated the staff consistently woke her up at 6 AM every day of the week, although she preferred to sleep longer and not be up that early. She stated she informed the staff of her desire to wake up at 7 AM, but they insisted that 6 AM was the designated time for her to get up and did not accommodate her wake up time preference. On 2/27/24 at 2:50 PM, Certified Nursing Assistant (CNA) B stated she worked at the facility since 2019 and worked the 7 AM-3 PM shift. CNA B confirmed staff on the 11 PM-7 AM shift always got resident #22 up in the morning. She confirmed that when she arrived on shift at 6:45 AM, the resident was always up and dressed in her wheelchair. On 2/27/24 at 3:04 PM, Registered Nurse (RN) A stated she had been working at the facility for 1 month and worked the 7 AM-3 PM shift. RN A confirmed that when she arrived at 6:45 AM, resident #22 was always up in her wheelchair and ready to be taken to breakfast. She acknowledged the resident was taken to breakfast at 7:30 AM. On 2/28/24 at 8:42 AM, resident #22 stated the staff got her up at 6 AM today. She explained she informed the staff that it was too early and she wanted to stay in bed longer. She noted the staff insisted that she had to get up. She reiterated that she preferred to be up between 7 AM to 8 AM but the staff did not allow her to choose. On 2/29/24 at 3:30 PM, the Director of Nursing (DON) stated she had worked at the facility for 2 weeks. She explained if resident #22 chose to remain in bed and not wake up at 6 am, she had the right to do so. The DON acknowledged that if residents preferred not to get up at 6 AM, staff needed to respect their wishes, recognizing the facility was their home. The Resident Rights Policy read, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. It also read, The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to the resident has a right to choose activities, schedules (including sleeping and waking times) .

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident with physical limitations reviewed for Environment was provided call light device access, of a total sample of 27 residents, (#5). Finding: Review of the medical record revealed resident #5, an [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included end stage renal (kidney) disease, dependence on renal dialysis, congestive heart failure (heart pumping dysfunction), Chronic Obstructive Pulmonary Disease (COPD), and acquired absence of both legs above the knee. After re-hospitalization , on 2/18/24 she was readmitted back to the facility with additional diagnoses that included pleural effusion (fluid in the lung space) and acute cystitis (bladder inflammation). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) 11/19/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment showed the resident did not reject care, required maximum assistance and was dependent on staff for mobility and to complete Activities of Daily Living (ADLs). The assessment indicated she was incontinent of bladder and bowel functions, had shortness of breath or trouble breathing when lying flat, and she received high risk insulin, opioid, and antiplatelet medications during the look back period. On 2/26/24 at 10:30 AM, resident #5 was observed in her room lying in bed. The call light cord was observed to the right of the resident and hung from the wall with the activation device lying on the floor beside the bed. The resident looked distressed and yelled out, I need somebody in here. From 10:40 AM to 10:43 AM, the resident was heard yelling out for staff assistance multiple times. At 10:44 AM, the Director of Nursing (DON) was observed as she exited the resident's room. On 2/26/24 at 10:55 AM, from the nurses' station approximately 50 feet away, resident #5 was heard as she called out for staff assistance. Certified Nursing Assistant (CNA) M was observed as she walked by the resident's room. At 11:03 AM, the DON was observed as she exited the resident's room and closed the door. At 11:04 AM, the resident stated she could not find her call light and asked for repositioning assistance. She explained she wanted her room door open and stated, all night, all day, open. In a joint observation with Registered Nurse (RN) C and CNA M on 2/26/24 at 11:08 AM, resident #5 was observed in her room lying in bed. RN C and CNA M acknowledged the resident's call device was on the floor and the resident could not reach it. The RN explained that staff were expected to always check and make sure the device was within the resident's reach before they left the room. CNA M clipped the cord to the resident's bed sheet and said, she knows how to use it; she knows what it is. The resident placed the device in her right hand, squeezed it and said, call light. On 2/26/24 at 3:22 PM, the DON said staff were expected to check residents' call lights before they left the room. She recalled she had responded twice earlier the same day to resident #5 when she heard her call out for assistance. She was informed the resident's call light was on the floor, out of the resident's reach. She explained, she was not aware the call device had been left on the floor and said, I must've missed it. The Comprehensive Care Plan showed there were Focus items for altered cardiovascular status, chronic and acute pain, high-risk medication adverse effects, incontinence, end stage renal disease and dialysis complication risks, ADL self-care performance deficits related to weakness, poor balance, decreased endurance, decreased mobility (bilateral BKA) (below the knee amputation of both legs) with an intervention that read, Encourage the resident to use bell to call for assistance, high-risk for falls with an intervention that read, ensure call light is within use and encourage use .

Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility, failed to conduct accurate elopement risk evaluations, and failed to implement appropriate interventions to address wandering risk for 1 of 5 residents reviewed for elopement, out of a total sample of 5 residents (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost or been hit by a car. On 6/05/21 at approximately 3:00 PM, the facility failed to prevent resident #1 from exiting the facility unsupervised through the B Hall double doors and an exterior exit door. Resident #1 left the facility through the exit door that led to a back parking lot. He traveled across a grassy area, passing by uneven ground, loose stones, small pieces of wood and an air conditioning unit that protruded from a wall at head-level. Resident #1 walked approximately 120 feet to the sidewalk which had a significant drop-off to the street below. Resident #1 was found near a moderately-trafficked commercial district, in close proximity to a popular ice cream store. The facility was unaware of resident #1's whereabouts until a Good Samaritan observed him on the sidewalk and called the facility's front desk. There was a total of 10 residents who were identified at risk for elopement. The facility's failure to conduct accurate evaluations and ensure a safe and secure environment placed all residents who wandered at risk. This failure resulted in Substandard Quality of Care and Immediate Jeopardy starting on 6/05/21. The Immediate Jeopardy was removed on 6/08/21. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: Resident #1 was admitted to the facility on [DATE] and hospitalized on [DATE] for altered mental status (AMS). He was readmitted on [DATE] with diagnoses including metabolic [CONDITION(S)] (a disease that affects brain structure or function), dementia, generalized muscle weakness, stroke, and alcohol dependency. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 5/15/21 revealed resident #1 was alert and disoriented but could follow simple instructions. The form indicated he ambulated with assistance, did not require a wheelchair or other type of mobility device, and needed assistance from 1 person for transfers. The facility's Elopement Evaluation, dated 5/15/21, was completed on resident #1's initial admission. The document revealed resident #1 was ambulatory and had diagnoses including dementia and gait or mobility issues. The evaluation reflected a score of 9 and deemed resident #1 at risk to wander. Review of resident #1's Interim Admission (Interdisciplinary Care Plan) or baseline care plan, dated 5/15/21, showed neither documentation of his risk for wandering nor goals and interventions to ensure his safety. A care plan for risk for falls related to weakness directed staff to cue resident #1 for safety awareness and keep his environment safe. Resident #1 had a care plan for risk for abnormal bleeding or hemorrhage related to use of anticoagulant (blood thinner) medication. A nurse's note, dated 5/17/21, revealed resident #1 had a change in condition and was sent to the hospital for evaluation of new neurological symptoms, AMS (altered mental status), and to rule out a stroke. On re-admission, the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 5/20/21, revealed resident #1 was hospitalized to rule out seizures and a stroke. The document indicated he was at risk for falls, ambulated with assistance and remained alert but disoriented. Resident #1's re-admission Elopement Evaluation, dated 5/21/21, showed a score of 1, which indicated he was at very low risk for wandering. The score reflected inaccurate responses to questions regarding resident #1's mobility and cognitive status. The evaluation revealed resident #1 did not move independently, did not have a dementia diagnosis and other issues with gait and mobility. The admission nurse noted she was unable to appropriately determine resident #1's mobility status as no Physical Therapists were available to evaluate him at that time. Review of the medical record did not contain documentation regarding follow-up or revision to the resident's elopement evaluation. Review of resident #1's baseline care plan, dated 5/21/21, revealed potential concerns including risks for falls and abnormal bleeding. Baseline care plans were not initiated for wandering risk and behavioral symptoms on re-admission. On 6/20/21 at 11:23 AM, the Minimum Data Set (MDS) Coordinator stated either the Unit Manager or the admission nurse was responsible for initiating baseline care plans for all residents on admission and re-admission. She explained the purpose of a baseline care plan was to inform staff of individualized care needs for every resident. The MDS Coordinator reviewed resident #1's medical record and confirmed his baseline care plans, dated 5/15/21, did not include interventions related to wandering, although his elopement evaluation indicated he was at risk for elopement. She confirmed resident #1's re-admission baseline care plan, dated 5/21/21, also did not contain any interventions for wandering behaviors. She stated baseline care plans were to be completed within 48 hours and reviewed along with newly admitted residents' charts in the daily interdisciplinary team (IDT) meeting. The MDS Coordinator explained the chart review process involved comparing physician's orders to baseline care plans, but evaluations and assessments were not usually reviewed for content or accuracy. She acknowledged the chart review process did not promote the development of appropriate and individualized care plan interventions. Review of the policy and procedure Baseline Care Plan, implemented on 2/12/21, revealed each resident would have a baseline care plan that provided instructions necessary to provide appropriate, individualized care and services. The policy indicated nurses would initiate interventions to address Any health and safety concerns to prevent decline or injury, such as elopement. Any identified needs for supervision, behavioral interventions. The MDS Admission assessment, with assessment reference date of 5/27/21, revealed resident #1 had a Brief Interview for Mental Status score of 10, which indicated moderate cognitive impairment. He required limited assistance for bed mobility, transfers, and walking. The MDS assessment revealed resident #1 had unsteady balance, was only able to stabilize with staff assistance, and did not use a device for mobility. Resident #1 received anticoagulant medications daily during the lookback period. Review of a Psychiatry Subsequent Note, dated 6/04/21, revealed resident #1 was seen by a psychiatric Advanced Practice Registered Nurse (APRN) for treatment of a change in condition. The APRN wrote, He has been having increased disorganized behaviors with confusion; he would take his clothes off and walk in the hallway. The note indicated resident #1 was unstable due to exacerbation of dementia and mood disorder and symptoms are occurring almost daily and causing severe distress. Review of nurse's progress notes from 5/15/21 to 6/04/21 did not contain any documentation of the behaviors that were reported verbally to the APRN by nursing staff. A progress note, dated 6/05/21 at 3:25 PM, revealed resident #1 was observed outside the facility, and the physician recommended 1:1 supervision. On 6/19/21 at 12:41 PM, the Director of Nursing (DON) stated resident #1 exited the facility through double doors on the B hall. At 12:47 PM, the administrator demonstrated the functionality of the alarms on the B hall double doors. He explained the facility added screamer alarms to all doors to ensure staff were immediately alerted when a door was breached. The administrator showed the path resident took through the B hall double doors to the exterior exit door on the left side of the service area. The administrator opened the exit door, but the instant screamer alarm did not sound. He checked the device and noted the switch was in the off position. The administrator acknowledged the screamer alarm had been disengaged. He confirmed staff defeated the purpose of alarms if they disabled them for convenience or any other reason. On 6/19/21 at 1:30 PM, the administrator and DON reviewed the facility's incident investigation and confirmed resident #1 exited the facility unsupervised on 6/05/21. The administrator recalled staff notified him by telephone at about 3:20 PM that resident #1 was found at the back of the building. The administrator stated when he arrived at the facility later that afternoon, resident #1 was able to show the doors through which he left the building and explained that he simply wanted to go home. The DON stated resident #1 was cognitively impaired, at risk for falls, and would not have been safe unsupervised in the community. On 6/19/21 at 2:41 PM, in a telephone interview with the weekend receptionist, she stated on 6/05/21 she received a telephone call at the front desk. The receptionist said, A woman spoke in Spanish. She said there was an old man in a gown outside the center. I was so surprised. She told me she was in front of the ice cream place. The receptionist stated she ran to the nursing unit to notify the staff. On 6/19/21 at 2:48 PM, Registered Nurse (RN) D described resident #1 as confused and said, He always used to say he wanted to go home. It was normal for him. RN D recalled resident #1 often became increasingly anxious in the afternoons starting at about 3:00 PM. RN D stated at about 3:15 PM on the day resident #1 exited the facility, a Certified Nursing Assistant (CNA) informed him the resident was not in his room. RN D explained a few minutes later, another CNA informed him resident #1 was outside, and he accompanied other staff members to retrieve the resident. On 6/19/21 at 3:47 PM, Licensed Practical Nurse (LPN) E recalled resident #1 was alert with confusion and unsteady on his feet, but walked without an assistive device. She stated she was assigned to resident #1 on the day he left the facility unsupervised. LPN E said, I was doing med (medication) pass on the C Hall when the lady at the front desk ran to the unit and said someone called and said there was a resident walking outside by the ice cream shop. LPN E stated she immediately ran to the back of the facility where she saw a woman standing on the street with resident #1 on the sidewalk above her. LPN E stated the facility staff thanked the woman and assisted resident #1, who wore a hospital-style gown and yellow socks, back into the facility. LPN E stated when resident #1 was outside, he was in a dangerous situation because of his confusion. She explained he probably would not have been able to cross a street safely and was at risk for injury from a fall, especially if he hit his head since he took anticoagulant and antiplatelet medication that could cause severe bleeding. On 6/19/21 at 4:15 PM in a telephone interview, CNA B stated she was assigned to care for resident #1 on 6/05/21 from 7:00 AM to 11:00 PM. CNA B stated on that day, she did not yet have access to the facility's electronic care plans because she worked for a staffing agency. CNA B stated she received report on her assigned residents verbally at the start of the shift and was not informed resident #1 was at risk for wandering. CNA B recalled at about 2:55 PM that afternoon, she assisted resident #1 to change from regular clothing to a hospital-style gown and yellow socks and left him in a wheelchair outside the doorway of his room. She stated resident #1 walked without assistance but was unsteady on his feet. CNA B said, It was a cause for concern, and he was a fall risk, so I used the wheelchair as a safer option for him to push himself around. She stated she continued her rounds and after she completed care for 2 other residents, she noticed an empty wheelchair facing the double doors at the end of the B Hall. CNA B explained she immediately told other staff members, and they started searching for resident #1 in the facility. She explained someone came to the nursing unit and informed staff that resident #1 was behind the building. CNA B stated she ran outside and was the first staff member to reach resident #1. She recalled he was on the sidewalk, facing the nearby ice cream store, and was in the company of a woman. CNA B acknowledged resident #1 could have easily fallen and hurt himself anywhere outside. On 6/20/21 at 4:42 PM, CNA C stated resident #1 displayed a change in condition in the days before his elopement. She said, At first he didn't have behaviors, but after a while he started getting agitated. He always said he wanted to go home. I did not report it to the nurse because everyone knew he said that. On 6/19/21 at 5:55 PM, resident #1's elopement route was retraced. He left the nursing unit through the B Hall double doors and entered a service area. Resident #1 then exited the building through an exterior door that led to the back parking lot which the facility shared with an office building. He probably turned right and walked across a grassy area between a large tree and the back wall of the facility. Resident #1 would have passed an area of uneven ground, loose stones, and small pieces of wood at the base of the wall. An air conditioning unit protruded approximately 12 to 18 inches from the wall. The unit was painted the same color as the wall and was about 4 feet above ground level, at the level of an average person's head. Resident #1 traveled approximately 120 feet to the sidewalk opposite the ice cream store. The sidewalk was approximately 8 inches above a concrete ledge which was an additional 8 inches above the level of the adjacent street. The moderately-trafficked street was under construction and hazards included barrels, barricades, and signs. (Photographic documentation obtained). Cars entered the street from a nearby main thoroughfare and U-turned to park near the ice cream store. Review of historical weather data revealed on 6/05/21 at 2:56 PM, the temperature was 85 degrees Fahrenheit with mixed sun and clouds (retrieved on 6/19/21 from www.timeanddate.com). On 6/20/21 at 10:28 AM, the administrator stated the facility determined the root cause of resident #1's elopement was that an unknown staff member unlocked the B Hall double doors and did not monitor the door for the 20 seconds required for the alarm to automatically reset after it closed. He surmised resident #1 was able to tailgate the staff member and access the exterior exit door which did not have a screamer alarm at that time. The DON confirmed on admission, resident #1 was identified as at risk for wandering and elopement but appropriate baseline and comprehensive care plans interventions were not developed and implemented prior to the incident. She could not explain how the Interdisciplinary Department Team (IDT) reviewed resident #1's chart without noticing the missing baseline care plan on admission and the inaccurate elopement risk evaluation on re-admission. The DON was informed interviews with staff revealed resident #1 often stated he wanted to go home. She confirmed the resident always talked about going home but it was never documented by nurses in the progress notes and CNAs on a Stop and Watch written tool used to report issues including behavioral symptoms. The DON stated she was never made aware of behaviors such as disrobing and walking in the hallway. However, she described an incident when resident #1's brother arrived at the facility to pick him up after receiving a telephone call from the resident. The DON stated she informed the brother that resident #1 was confused and was not being discharged from the facility. The DON explained any nurse could have initiated a care plan with appropriate interventions to address resident #1's behaviors. The DON acknowledged neither she nor any other nurse did this. The administrator stated staff did not use all the tools they had to prevent resident #1's elopement and said, There was a breakdown in the process. Review of the policy and procedure Elopements and Wandering Residents, implemented on 11/01/20, revealed the facility would provide adequate supervision for residents who wandered or were at risk for elopement. The document indicated residents would receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy indicated residents would be assessed for elopement risk on admission, and the IDT would develop and implement a personalized care plan with interventions to ensure safety. In addition, the facility would monitor and record the effectiveness of interventions and ensure staff were aware of updated approaches. An attachment to the policy and procedure titled Tips for Prevention of Elopements directed staff to react to residents' statements related to wanting to go home, observe for wandering and anxiety, and ensure unauthorized areas are properly locked to prevent resident entry. The document cautioned staff never to assume everyone knew which residents wandered. The Facility Assessment Tool, reviewed on 4/05/21 by the Quality Assurance and Performance Improvement (QAPI) committee, revealed the facility could meet the needs of residents with common psychiatric and mood disorders including impaired cognition, anxiety and behaviors that require intervention. The document indicated the facility would provide person-centered care and identify hazards and risks to residents. Review of removal of immediacy actions implemented by the facility revealed the following, which were verified by the survey team: *On 6/05/21, resident #1 was returned to the facility, assessed, and did not have any injury or distress noted. He was immediately placed on 1:1 supervision, re-evaluated for elopement risk and his care plan was updated. *On 6/05/21, all residents in the facility were confirmed to be present. *On 6/05/21, all egress doors were checked for functionality and validated by an outside contractor. The facility initiated 24-hour door monitoring with documentation required every 2 hours. *On 6/05/21, staff education and elopement drills were initiated on the 3:00 PM to 11:00 PM shift. * On 6/06/21, the DON completed elopement risk evaluations on all current residents and identified 5 additional residents who were deemed to be at risk. Care plans were updated as indicated. Elopement binders were updated with residents' demographic information. Increased supervision was initiated for these residents, with documentation required every hour. *On 6/06/21, staff education was on-going related to elopement policy and procedures and elopement risk assessments/evaluations. *On 6/06/21, an ad hoc QAPI committee meeting was held. A Performance Improvement Plan was developed and implemented after approval by the Medical Director. *On 6/06/21, elopement drills continued on the 11:00 PM to 7:00 AM and 7:00 AM to 3:00 PM shifts. *On 6/06/21, temporary screamer door alarms were installed. *On 6/06/21, the Regional Resource Nurse completed a Quality Review Post Event to validate the facility's elopement process. *On 6/07/21, the facility ordered permanent screamer door alarm annunciators. Validated by review of the purchase order. *On 6/07/21, the facility provided updated education for 2 newly hired staff members. * On 6/07/21, the facility initiated weekly quality monitoring of the Elopement Risk Alert binder. * On 6/07/21, the facility reviewed the elopement risk status of new admissions, re-admissions, and residents with changes in condition. *On 6/08/21, the facility achieved 100% compliance with staff education on elopement and wandering residents, and the elopement policy and procedure. Staff members who received education by telephone were required to receive verbal re-education prior to the next assigned shift. *Review of in-service attendance sheets validated elopement education was completed using the facility's elopement policy and procedure, with 100% facility and contracted staff, between 6/05/21 and 6/08/21. The facility obtained signatures of staff members who were initially educated by telephone when they were received 1:1 verbal re-education from the administrator. *Review of Elopement Assessment Documentation in-service attendance sheet for nurses revealed 10 of 14 nurses (71%) received education on 6/06/21. *Review of Elopement Drill Documentation Form and sign-in sheets revealed all scheduled staff participated in elopement drills conducted every shift for 24 hours after the incident. Ongoing additional corrective actions include: *Daily door audits with documentation required every 2 hours. *The DON audits all elopement risk evaluation for newly admitted or readmitted residents for accuracy and verifies appropriate care plans are implemented. *The DON and/or designee audits documentation of hourly monitoring for residents identified at risk for wandering every shift. *As of 6/18/21, the facility has educated 75% of nurses on accuracy of elopement risk evaluation/assessment. *On 6/18/21, the QAPI committee reviewed the results of audit tools. Audits will continue until 100% compliance is achieved. The following activities were completed to verify removal of immediacy. Review of the QAPI binder revealed audit forms were completed according to circumstances and scheduled frequency required by the committee's Performance Improvement Plan. Audit forms validated (1) All residents at risk for elopement had hourly safety checks done. (2) Elopement binders at the nurses' station and receptionist's desk were updated and in place. (3) All exterior doors and the B Hall double doors were checked every 2 hours for functionality of alarms and doors and (4) Elopement evaluation forms, physician orders and nursing/CNA care plans of all new admissions, re-admissions and residents who had a change in condition were reviewed. Interviews conducted from 6/19/21 to 6/20/21 with 14 facility staff and 2 nursing agency staff (8 CNAs representing all shifts, 1 Physical Therapy Assistant, 2 RNs, 4 LPNs and 1 receptionist) revealed they were knowledgeable of the elopement policy and procedure, supervision of residents at risk for elopement, and the need to ensure doors were secured behind them. The sample was expanded to include 4 additional residents, #2, #3, #4 and #5. Observations, interviews, and record reviews revealed no concerns related to accuracy of elopement risk assessments and appropriateness of care plan interventions for these residents.