Every finding on record at Lake Haven Nursing and Rehab Center

Based on observations, interviews, and record reviews, the facility failed to ensure intravenous (IV) medications were administered by qualified, competent, and IV certified licensed nursing staff in accordance with State of Florida practice requirements. This deficient practice affected three of three residents in the sample (Residents #10, #11, and #12) and resulted in unqualified staff administering IV antibiotics and fluids and the facility's failure to ensure proper verification, tracking, and oversight of IV certified personnel.Findings included: On August 2, 2026 at 11:30 A.M., an observation revealed Staff B, Licensed Practical Nurse (LPN), disconnected the IV tubing from Resident #10, primed a bag of Cefepime antibiotics, and connected the tubing to Resident #10's IV access to administer the antibiotic. A review of Resident #10's physician orders revealed the following antibiotic orders:Vancomycin HCl Intravenous Solution Reconstituted, Use 1 gram intravenously every 12 hours for osteomyelitis for 8 WeeksFlush Mid\/PICC line with 10 mL of 0.9% Normal Saline before and after each antibiotic administration every shiftCefepime HCl Intravenous Solution, Use 2 gram intravenously every 8 hours for osteomyelitis for 8 Weeks A review of the August 2026 medication administration record (MAR) revealed IV medications for Resident #10 were administered by Staff B, LPN, Staff C, LPN, Staff D, LPN, Staff E, LPN, and Staff F, LPN. An observation and interview on 8/2/2026 at 9:50 A.M., with Resident #11 was conducted. Resident #11 said she was admitted to the facility a few days ago for IV antibiotics. Resident #11 said Staff A, LPN administered her IV antibiotics on today. An observation revealed Resident #11 had a PICC on the right upper arm. A review of Resident #11's physician orders revealed the following antibiotic orders:Vancomycin HCl in NaCl Intravenous Solution, Use 1 gram intravenously three times a day for Antibiotic for 19 DaysSodium Chloride Solution 0.9 % Use 10 ml intravenously three times a day for flushFlush PICC with 10ml N\/S before and after medication administration three times a day A review of Resident #11's MAR showed IV medications had been administered by Staff C, LPN, Staff G, LPN, and Staff J, LPN. A review of Resident #12's physician orders for July 2026 revealed the following antibiotic orders:Amikacin Sulfate Injection Solution 500 MG\/2ML Use 760 mg intravenously one time a day for osteomyelitis for 8 Weeks A review of Resident #12's MAR revealed IV medications were administered by Staff A, LPN. An interview on 8/2/2026 at 1:49 P.M. with Staff A, LPN, was conducted. Staff A, LPN said she connected Resident #11's IV antibiotic on 8/2/2026. Staff A, LPN said she administers IV antibiotics and fluids. Staff A, LPN said she had been administering IV medications since she started at the facility. Staff A, LPN said she was not IV certified in the State of Florida. An interview on 8/2/2026 at 1:58 P.M. with Staff B, LPN was conducted. Staff B, LPN said she was IV certified and she was allowed to hang IV fluids or antibiotics.A review of an undated list of LPNs revealed Staff A, LPN, Staff B, LPN, Staff C, LPN, Staff D, LPN, Staff E, LPN, Staff F, LPN, Staff G, LPN, and Staff J, LPN were not IV certified to administer medications to residents. An interview on 8/2/2026 at 2:33 P.M. with the Nursing Home Administrator (NHA) was conducted. The NHA said Staff A, LPN had administered IV antibiotics to Resident #11 on 8/2/2026. The NHA said Staff A, LPN had not been IV certified in the State of Florida and should not be administering IV medications. An interview on 8/2/2026 at 4:08 P.M. with the Director of Nursing (DON) was conducted. The DON said medication should be administered as ordered and according to the facility policy. The DON said only the nurse administering the medication should be documenting the administration of that medication. The DON said the LPNs were not IV certified and should not have administered IV medications. An interview on 8/2/2026 at 4:20 P.M. with Staff H, Human Resources (HR) was conducted. Staff H, HR said she had a list of staff members that were IV certified. Staff H, HR said she asks the LPNs upon hire if they are IV certified. Staff H, LPN said the binder was kept in the nursing office. She said the list in the binder was incorrect. An interview on 8/2/2026 at 4:28 P.M. with Staff I, Staffing Coordinator (SC) was conducted. Staff I, SC said she had not talked to the DON about which nurses were IV certified. Staff I, SC said she thought all the nurses were IV certified. A review of a policy effective 8/7/2023 titled, Medication Administration Policy - Intravenous revealed the policy was This policy sets forth the procedures relating to intravenous medication administration. Facility staff should also comply with Applicable Law and the State Operations Manual when administering medications as indicted to ensure intravenous medication is administered safety. The procedure was 1: Licensed Nurses should comply with Facility Policy, Applicable Law, and the State Operations Manual when administering intravenous medications.

Based on observation, record review, and interview, the facility failed to ensure residents' right to retain and use their personal possessions. The facility did not return or replace missing personal items for two residents (Rooms #127 W and #111 P) out of two reviewed for missing belongings.Findings include: On 06/29/2026 at 9:32 AM, an interview with the resident in room [ROOM NUMBER] W revealed the resident had informed staff on several occasions that personal belongings were missing. The missing items included clothing, tennis shoes, and a blanket. The resident reported staff had labeled the items with the resident's name using a black marker. The resident said the missing items were neither returned nor replaced. On 06/29/2026 at 9:40 AM, an interview with the resident in room [ROOM NUMBER] P revealed the resident had reported missing personal items to several facility staff members and had not received any resolution regarding the missing items. A review of the grievance log revealed six grievances filed between 12/11/2025 and 05/01/2026 in which residents reported missing personal items. The grievances documented that the residents' items were neither returned nor replaced. On 06/30/2026 at 1:30 PM, an observation of the laundry room revealed several collections of clothing, shoes, and blankets labeled no names. These items were observed in a laundry cart, on a table against the wall adjacent to the dryers, and on a shelf perpendicular to the aforementioned table. Staff A verified the items did not have name labels and said staff were unsure which residents the items belonged to. On 06/30/2026 at 1:22 PM, an interview with the Social Services Director (SSD) revealed most grievances filed with the facility were related to missing items. The SSD said an increase in laundry staff could help reduce the number of missing items. On 06/30/2026 at 1:30 PM, an interview with Staff A, Laundry Assistant, revealed Staff A does not deliver clothes to residents because, as the only laundry staff during the shift, resident linens and towels are the priority. Staff A also said the laundry area had recently received an influx of clothing items without name labels. Staff A said clothing without names usually accumulates in the laundry room and another staff member attempts to return the items to residents; however, the piles of unnamed clothing continue to increase. On 06/30/2026 at 1:40 PM, an interview with the Nursing Home Administrator (NHA) revealed clothing items without name labels are donated to a charitable organization about once per month. The NHA said that at other times, clothing items without name labels are given to residents who have fewer personal belongings. The NHA also said some items in the laundry room are occasionally delivered to the activities room so residents can attempt to identify their missing items. Upon request, a policy related to missing personal items was not provided by survey exit.

Based on record review and interview, the facility failed to ensure sufficient nursing staff to provide adequate supervision and prevent accidents. On 06/28/2026 during the 11 PM-7 AM shift, the facility assigned only one Certified Nursing Assistant (CNA) to the East Unit and one CNA to the Reflections Unit, affecting three residents (Residents #30, #117-P, and #111-P) out of three residents interviewed regarding staffing concerns. Residents reported delays in care and needing to rely on other residents for assistance due to inadequate staffing. Findings include:A review of the facility's Daily Assignment Sheet dated 06/28/2026 for the East Unit revealed one CNA was assigned to Rooms 100-128 for the 11 PM-7 AM shift. A review of the Daily Assignment Sheet for the Reflections Unit revealed one CNA was assigned to Rooms 200-210 for the same shift. A review of the Daily Assignment Sheet for the [NAME] Unit revealed two CNAs were assigned: one CNA was assigned to one resident in room [ROOM NUMBER] and the other CNA was assigned to Rooms 213-229. A review of the facility's Daily Staffing Form for 06/28/2026 showed the census was 85 residents. On 06/29/2026 at 9:40 AM, interviews with Resident #30, the resident in room [ROOM NUMBER] P, and the resident in room [ROOM NUMBER] P revealed that during the 11 PM-7 AM shift on 06/28/2026, there was only one CNA assigned to the unit where they resided. The resident in room [ROOM NUMBER] P reported concerns related to residents calling out for help without receiving a response. All three residents stated that on 06/28/2026, residents asked other residents for assistance due to the lack of staff and to avoid burdening the single CNA. All three residents also reported there were occasions when they needed assistance but chose not to request help because the facility was understaffed. On 06/29/2026 at 3:21 PM, an interview with the Staffing Coordinator revealed the role includes ensuring the facility is staffed according to the census. The Staffing Coordinator confirmed that during the 11 PM-7 AM shift on 06/28/2026, one CNA was assigned to the Reflections Unit and one CNA was assigned to the East Unit. The Staffing Coordinator said several attempts were made to staff the shift, but staff declined to work. The Staffing Coordinator stated one CNA was assigned to Rooms 100-128 in the East Wing and said this assignment was not safe due to the number of residents but clarified this was their personal opinion. The Staffing Coordinator also said the facility did not have enough nurses on the roster to assign them to work as CNAs. At the time of the interview, the Staffing Coordinator had not spoken to residents to determine whether there were lapses in care during the 11 PM-7 AM shift on 06/28/2026. On 06/29/2026 at 6:32 PM, an interview with the Director of Nursing (DON) revealed that during the 11 PM-7 AM shift on 06/28/2026, one CNA was assigned to a 1:1 assignment in the [NAME] Wing, one CNA was assigned to the remainder of the [NAME] Wing, one CNA was assigned to the East Wing, and one CNA was assigned to the Reflections Unit. The DON stated the Nursing Home Administrator (NHA) was notified of the staffing shortage because approval was required to offer bonuses to staff who might agree to work the shift. The DON stated the facility does not use agency staffing.

Based on observations, interviews and record review, the facility failed to maintain resident rooms in a safe, functional, and comfortable condition by not ensuring air conditioning (A/C) units were operational, adequately sealed, and free of environmental contaminants, and free from bio growth, in two units (100 and 200) out of three units observed. This resulted in room temperatures exceeding 81 degrees Fahrenheit and unsealed wall openings exposing residents to outside elements. Findings include: On 6/29/26 at 3:24 p.m., an interview was conducted with Resident #2. Upon entry into the room, a noticeable increase in temperature was observed. Resident #2 stated the air conditioner had been broken since before they moved into the room. Resident #2 stated the facility was aware of the non functional A/C and provided a fan until repairs could be completed. Resident #2 stated they had lived in the room for at least three weeks without A/C, and their family member brought an additional fan due to the heat. Resident #2 stated the facility told them the unit required a replacement part, which they were informed about approximately two weeks prior. Resident #2 said they had been miserable due to the heat and were always sweating. By the end of the interview the room temperature measured 87.8 degrees Fahrenheit ( F). A review of Resident #2's admission record revealed an admission date of 3/4/26 with diagnoses including paraplegia, polyneuropathy, chronic pain, and a traumatic brain injury (TBI). A review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On 6/29/26 at 4:00 p.m., an interview was conducted with Staff B, CNA. Staff B stated Resident #2 had been without A/C since moving into the room and stated multiple rooms in the locked unit were experiencing similar issues with non functional A/C units. On 6/29/26 at 4:20 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated they were aware Resident #2's room did not have air conditioning and stated it was the resident's choice to stay in the room. The NHA stated the facility had been waiting a couple of weeks for a replacement part. On 6/29/26 at 4:45 p.m., Staff C, CNA, walked through multiple rooms in the locked unit where A/C units were not functioning or cooling properly. Staff C stated Rooms 201, 206, 207, and 209 had not had working A/C for 'a while now. On 06/29/26 between 4:45 p.m. and 6:30 p.m., observations in the 200 hall revealed non functional A/C units in 10 resident rooms, including rooms [ROOM NUMBER], with temperatures above 81 F:room [ROOM NUMBER]: 82.2 [NAME] 206: 82.4 [NAME] 207: 83.4 [NAME] 216: 81.3 [NAME] 221: 81.3 [NAME] 222: 83.1 [NAME] 224: 83.1 [NAME] 225: 84.3 [NAME] 229: 83.1 F On 06/29/26 at 5:15 p.m., interviews with the NHA and DON revealed they were aware of A/C issues in only two rooms, rooms [ROOM NUMBERS], and stated replacement units had been ordered. On 06/29/26 at 5:25 p.m., the Social Services Director (SSD) stated no grievances had been submitted by Resident #2 regarding A/C concerns and confirmed the A/C unit remained nonfunctional. On 06/29/26 at 5:32 p.m., the A/C unit in room [ROOM NUMBER] was observed with visible biological growth inside the unit. The resident in Bed B of room [ROOM NUMBER] had documented respiratory concerns. A large circular black area of biological growth was observed on the ceiling tile above the sink. On 6/29/26 at 5:36 p.m., an interview was conducted with the Director of Maintenance (DOM). The DOM stated they had previously conducted temperature checks but had not documented them, despite having binders designated for recording facility issues. The DOM stated they were aware of only two rooms without working A/C. The DOM stated that if a room exceeded 81 F, a plan needed to be made for the resident, which could include changing rooms or exchanging units with an empty room. On 06/29/26 at 5:45 p.m., Staff C, CNA, stated the resident rooms 'are always hot' and stated administration had known 'for months' that several units were not working. Staff C stated the issue had been reported multiple times. During an interview on 06/29/26 at 6:14 p.m., the DOM stated he was new to the building and had been 'trying to patch things up.' The DOM stated the replacement A/C units were smaller than the original units, resulting in unsealed openings around the units that exposed residents to outside elements. The DOM stated he intended to purchase plywood to close the openings and was working with the NHA to obtain approval for complete replacement of the A/C units. On 6/30/26 at 9:51 a.m., an observation and interview were conducted with the NHA and Regional [NAME] President of Operations (RVPO) in room [ROOM NUMBER]. The NHA and RVPO were unable to identify the biological growth in the resident's A/C unit and on the ceiling tile above the sink and acknowledged the conditions were unacceptable and required immediate attention. A review of the facility's maintenance log showed no entries documenting malfunctioning A/C units in any rooms in the 200 hall. A review of the facility's Preventative Maintenance Checklist revealed that room inspections required checking A/C units, thermostats, and filters for proper operation. No completed room inspection checklists were available for the facility. A review of the facility's DOM Job Description revealed the following: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing the facility to ensure it is maintained in a safe and comfortable manner. The DOM is responsible for the upkeep of the facility, including the building, building systems and grounds. Develop and ensure implementations of a preventative maintenance plan, which describes specific tasks, to be completed and the time frame for completion. Establish a equipment and utilities maintenance program. Participate in regular safety inspection tours of the facility and ensure documentation of findings. Determine and ensure implementation of corrective action needed as a result of internal or external safety inspections. A review of the facility's Safety Plan-Elevated Temperatures- Heat revealed the following:Dedicated staff member to pass ice/water/cool cloths throughout the day/night.Offer popsicles, ice cream, etc.Nursing: Take vitals to include temperatures every 4 hoursSend any residents who have signs and symptoms of overheating to the hospitalRecord ambient temperatures in various areas of the building and resident rooms. Be sure to keep a record. If a residents room are above 81 degrees, move to a cool zone or cooler area of the facility.

Based on interviews and record review, the facility failed to reevaluate and reassess interventions to prevent falls for one resident (#2) out of three reviewed. This resulted in Resident #2 sustaining a head laceration and transfer to acute setting for further evaluation. Findings included: Review of the facility's Incident Log showed Resident #2 had falls on 4/15/26 and 5/10/26. Review of Resident #2's progress noted showed:5/8/26 5:20 p.m. Patient found after unwitnessed fall with noted head injury. No acute distress noted. Upon assessment, light bleeding noted to head. Patient alert and responsive. Vital signs obtained and within normal limits (WNL). Provider notified of findings and new orders received for Computed Tomography (CT) scan. Patient transferred for CT scan per provider order. 5/10/16 10:47 a.m. Resident was noted to have an unwitnessed fall. Resident was observed lying on the floor, alert and at baseline mental status. Bleeding noted to the right side of the head. First aid was administered and vital signs were obtained. 911 was called for further evaluation and treatment. NP (Nurse Practioner) notified and responsible party (RP) made aware. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including encephalopathy, nontraumatic subarachnoid hemorrhage and unspecified symbolic dysfunctions. Review of Resident #2's Care Plan showed a focus area of risk for falls and fall related injuries r/t [related to] dx [diagnosis] of hepatic encephalopathy, BIMS [Brief Interview for Mental Status] score of 99 [indicating interview was unable to be completed], schizophrenia, and bipolar disorder. Revised on 2/20/26.Interventions included:-Bed in lowest position. Date Initiated: 2/12/26-Observe for and report changes in mobility and/or Range of Motion. Date Initiated: 2/12/26-Call bell in reach. Date Initiated: 2/12/26-Assist as needed with transfer/ambulation. Date Initiated: 2/12/26-Toilet before and after meals. Date Initiated: 2/17/26-Monitor blood glucose per orders. Date Initiated: 2/20/26-Ensure appropriate footwear worn. Date Initiated: 3/6/26-PT [physical therapy] evaluation. Date Initiated: 4/20/26-Mat on side of bed, therapy screen. Date Initiated: 4/20/26-Review of medications. Date Initiated: 4/20/26-Q15 minute check as ordered. Date Initiated: 5/5/26-Transfer/Gait belt for transfers and/or ambulation. Date Initiated: 5/11/26 The Care Plan did not show any updates or added interventions after the fall on 5/8/26. An interview was conducted on 6/1/26 at 3:17 p.m. with the Director of Nursing (DON). The DON said she did not know anything about Resident #2 having a fall on 5/8/26. She reviewed Resident #2's medical record, read the progress note about the resident's fall on 5/8/26 and confirmed a change of condition was not completed and there were not any records from the CT scan or the resident returning to the facility. The DON said Resident #2 had a fall on 5/10/26 that caused bleeding to the right side of his head, and he went to the hospital. An interview was conducted on 6/1/26 at 4:27 p.m. with the Regional DON. He said the expectation was that when a fall occurred, a change of condition be completed, the fall would be reviewed at the interdisciplinary team (IDT) meeting, and the resident's care plan would be updated with new interventions. The Regional DON reviewed Resident #2's medical record and said he did not see care plan updates, added interventions, or any information related to the fall on 5/8/26 except the progress note stating there was a fall that occurred. He confirmed the resident fell again on 5/10/26. An interview was conducted on 6/1/26 at 6:22 p.m. with the Nursing Home Administrator (NHA). He said he did not know what happened with Resident #2's fall on 5/8/26 and was not sure why it was not reviewed. He said on 5/11/26 the IDT reviewed Resident #2's fall on 5/10/26 but missed the fact Resident #2 had a fall on 5/8/26 as well. The NHA said the 5/8/26 fall should have been reviewed, and nursing staff should have put interventions in place immediately after that fall to prevent Resident #2 from falling again on 5/10/26. Review of a facility policy titled Falls, revised 2/11/26, showed:Overview:Patient centered interventions are initiated, based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor, other lower level or an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Policy:Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury.B. Fall Mitigation Strategies:1. Develop resident centered interventions based on resident risk factors2. Update the resident's care plan with interventionsC. Post Fall Strategies:1. Resident will be evaluated, and post fall care provided as indicated2. Initiate Neurological checks as per physician order3. Notify the Physician and resident representative4. Update Care plan with intervention(s)

Based on observations and interviews, the facility did not ensure adequate supply of linens for two (100 and 200) out of three units in the facility.Findings included: An observation was conducted on 6/1/26 at 9:10 a.m. of the linen closet on the 100 unit. There were no towels or washcloths in the closet. An interview was conducted on 6/1/26 at 1:45 p.m. with Resident #8. She said there is a problem with having towels and washcloths. Resident #8 stated when they do get towels, they are very rough. Resident #8 said she could shower herself but often had to wait because there were no towels available. An interview was conducted on 6/1/26 at 5:11 p.m. with Resident #7. Resident #7 stated on multiple occasions that towels were not available for showers. Resident #7 said it would be nice to have towels when showering. An interview was conducted on 6/1/26 at 12:56 p.m. with Staff E, Certified Nursing Assistant (CNA). She said there were concerns regarding having linens available for residents, specifically towels. She said often residents had to wait to receive showers until towels were available. Staff E said many residents complained about the towels and described them as feeling like sandpaper. She said residents sometimes need to be cleaned and ask if they can use sheets, so they don't have to wait on towels. Staff E said some staff have used sheets to clean residents. An interview was conducted on 6/1/26 at 4:36 p.m. with Staff G, CNA. Staff G said she worked on the 200 unit and had concerns about having supplies available. Staff G said the unit intermittently had towels available and often did not have wipes to use in place of towels to clean residents. Staff G said she knew there had been issues with laundry equipment and staffing and more support was needed to maintain the supplies. An interview was conducted on 6/1/26 at 5:28 p.m. with Staff D, CNA. Staff D was observed in the linen closet on the 100 unit looking for towels and washcloths. Staff D said she did not have any towels or washcloths available and it was always a problem. She said it makes it difficult to clean residents and get resident showers completed because there are no towels and no wash clothes or wipes to clean residents. An interview was conducted on 6/1/26 at 1:35 p.m. with Staff C, Laundry. Staff C said she delivered clean linen to the units about five times a day and divides them between the units based on where more residents are. Staff C said the facility did not have an extra supply of linens or towels beyond those that were in circulation currently. An interview was conducted on 6/1/26 at 2:29 p.m. with the Housekeeping Director. He said he is new to the facility, but is responsible for ordering linen, washcloths, and towels. He also noted one of the facility dryers was broken and in the process of being repaired. On 6/1/26 at 5:55 p.m. the Director of Nursing said the facility did not have a policy regarding linens or supplies on the units.

Based on interviews and record review the facility failed to ensure advanced directives were implemented as requested for one resident (#2) out of three reviewed.Findings included: Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including cirrhosis of liver, thrombocytopenia, chronic obstructive pulmonary disease, and hepatic encephalopathy. Review of Resident #2's orders showed an active order for Full Code, dated 4/19/26. Review of Resident #2's medical record revealed a signed Do Not Resuscitate (DNR) order signed by the resident's healthcare surrogate on 5/7/26. The DNR was not signed by a provider until 5/26/26. Review of the DNR books at the nurses' stations did not show a DNR form for Resident #2. An interview was conducted on 6/1/26 at 4:14 p.m. with Staff A, Licensed Practical Nurse (LPN). Staff A said she was assigned to care for Resident #2. Staff A said if a resident were to go into cardiac arrest she would check the resident's orders and the DNR book to confirm their code status. Staff A verified Resident #2 had an active full code order, and he did not have a DNR form in the DNR book. Staff A said Resident #2 was a full code. An interview was conducted on 6/1/26 at 3:50 p.m. with the Social Services Director (SSD). The SSD said when a resident on hospice changes their code status, the hospice vendor completes the paperwork. The SSD reviewed Resident #2's signed DNR form and confirmed that a hospice provider signed the form. The SSD said she didn't know why there was a 19-day gap in the healthcare surrogate signing the DNR form and the provider signing the form. She said usually they both sign on the same day. She said she did not know who brought the form to the facility or who it was given to. The SSD said I think it gets lost in translation when hospice does it regarding putting DNR orders in the medical record and the form in the DNR book. The SSD reviewed Resident #2's medical record and confirmed Resident #2 had an active full code order. An interview was conducted on 6/1/26 at 4:19 p.m. with the Director of Nursing (DON). The DON confirmed Resident #2 did not have a signed DNR form in the DNR books. She reviewed the signed DNR from the medical record and said Resident #2's orders should have been updated and a copy of the DNR form should have been placed in each DNR book. An interview was conducted on 6/1/26 at 4:25 p.m. with the Nursing Home Administrator (NHA). The NHA said they do weekly audits for code status but Resident #2's might not have been caught on the audit because the full code order in the medical record matched what was in the DNR books. The NHA confirmed not reviewing the medical chart during the audits. Review of a facility policy titled Advanced Directives, revised 2/28/24, showed:Policy:The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative.Procedure:2. If an advance directive exists, the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record.3. If the resident has not executed an advance directive but wishes to establish an advance directive, Social Services/designated center representative will assist the resident/ resident representative with obtaining the state approved advance directive documents. Formulating an advance directive is the choice of the resident and is not required.4. Upon completion of Advanced Directives Discussion Document, Social Services or nurse will notify thePhysician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record.5. Advanced Directives will be reviewed: Quarterly Hospice admission Additional times as need or requested by the resident/resident representative,Reviews are designed to: Identify and clarify the content and intent of the existing care instructions, and whether the resident wishes to change or continue these instructions Identify situations where health care decision-making is needed. Review the resident's condition, mental capacity to make health care decisions, and existing choices and continue or modify approaches Any changes to advanced Directives will require the previous document to be filed in the thinned record.5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly.

Based on record review, observations, and staff interviews, the facility failed to fully implement its abuse prevention policy by not preventing Resident #11 from further accessing alleged victims and by not implementing effective interventions to protect other residents from additional abuse for two residents (#9 and #12) of three residents sampled.Findings included: During an interview on 6/11/26 at 1:22 p.m., the facility's psychiatric ARNP (advanced registered nurse practitioner) reported she saw Resident #11 weekly due to behavioral concerns. She stated on 4/23/26, she evaluated him after staff reported he had touched another resident inappropriately. At that time, he had been placed on 1:1 supervision two days earlier. The ARNP stated a CNA (Certified Nursing Assistant) witnessed Resident #11 groping Resident #12, who was his roommate. Both residents were assessed and then placed on 1:1 supervision together in the same room. The ARNP said that on 5/22/26, staff contacted telehealth to report a second incident involving Resident #11, during which a staff member observed him exposing himself to Resident #9. After this second incident, Resident #11 was moved to the semi locked unit due to sexual attempts. She stated Resident #11 did not understand his actions due to dementia. The ARNP reported his medications were increased, he was placed on estrogen to decrease libido, and monitoring was increased. She stated he had a fixation on male residents, was confused, and both alleged victims were impaired. The ARNP confirmed Resident #11 had been on 1:1 supervision, but it was discontinued at some point and replaced with 15 minute checks; the second incident occurred during the period he was not on 1:1 supervision.On 6/11/26 at 10:28 a.m., an interview with Staff H, Licensed Practical Nurse (LPN), and Staff I, CNA, revealed they were not working at the time of the event but had heard about a situation involving Residents #11 and #9. Staff I reported, I heard the two men were found 'doing it.' Staff H stated Resident #9 was confused and would not know what was going on. Staff H stated Resident #11 was the one acting out sexually toward Resident #9. Staff I stated this occurred about a month before the interview; both men were on the same wing but not in the same room. She also reported that Resident #9 was later moved to the secured unit.On 6/11/26 at 11:15 a.m., an interview was conducted with Staff J, CNA who was observed providing 1:1 supervision to Resident #11. She stated the 1:1 supervision began the last week of May due to an incident that happened about 3 weeks earlier. She reported hearing that Resident #11 had groped a male resident. Staff J stated Resident #11 wandered, posed safety concerns, and needs supervision. She explained that he was directed to men and had been trying to touch male residents for some time.On 6/11/26 at 11:20 a.m., an attempt to interview Resident #11 was unsuccessful. He appeared drowsy and did not open his eyes.Record review for Resident #11 indicated an admission date of 4/20/26 with diagnoses including dementia, mood disorder, major depression, and a right femur fracture. A 4/20/26 psychiatry evaluation documented staff reports of yelling, grabbing, and inappropriate touching; he was placed on 1:1 observation.A 4/21/26 APRN note documented concerns for potentially touching another resident inappropriately; he was moved to the secured unit for wandering. A 4/22/26 behavior note documented that he attempted to grab another male resident's genital area and was redirected by his 1:1 CNA.A 4/28/26 H&P (history and Physical) noted continued reports of inappropriate touching. A 5/4/26 APRN note documented he was still on 1:1 supervision, with a plan to discontinue it and initiate 15 minute checks. A 5/7/26 APRN note documented he was observed touching another patient sexually and the residents were separated. A 5/12/26 progress note documented ongoing inappropriate sexual behavior; Resident #11 stated he was helping people.A 5/8/26 BIMS score for Resident #11 was 11, indicating moderate impairment. Staff reported disruptive and hypersexual behaviors.A 5/22/26 nursing note documented that a CNA observed him in the wrong room allegedly touching another resident, and he was placed on 1:1 supervision. A 5/22/26 psychiatry note documented continued sexually inappropriate behaviors, posing significant safety concerns.A care plan initiated 4/21/26 listed interventions including 1:1 supervision as much as possible. The care plan was not updated following the second incident on 5/22/26.Record Review for Resident #12 revealed he was admitted on [DATE] with dementia, mood disorder, psychotic disorder, and depression. A 4/21/26 psychiatry note documented he was evaluated for suspected inappropriate touching by another resident; he did not recall the incident.A 4/28/26 follow up note documented he was pleasantly confused and stable. A 5/7/26 thirty day follow up documented he had been separated from Resident #11 and moved to another room. He was unable to recall events and had no reported pain.On 6/11/26 at 11:20 a.m., Resident #12 did not respond to interview attempts. Staff L (LPN) described him as confused, quiet, and keeping to himself. Staff K stated, I don't believe he would grope anybody.On 6/11/26 at 10:30 a.m. on 6/11/26, Resident #9 was observed lying in bed, confused, and unable to participate in an interview. Family members present stated he had recently been moved to the secured unit for his safety. They stated he complained of pain two days after the move and were unsure if the pain was related to a physical encounter because he was severely confused.Resident #9 was admitted on [DATE] with diagnoses including Alzheimer's disease, aphasia, mood disorder, major depression, hallucinations, and suicidal ideation. A 4/28/26 neurology note documented he was disoriented, mostly non verbal, and unable to answer questions. A 5/22/26 psych note documented he did not recall the incident and stated he felt good. A 5/26/26 acute care note documented he had been involved in unwanted sexual behavior by another resident but had no noted physical or psychosocial harm.On 6/11/26 at 1:17 p.m., an interview was conducted with the Social Services Director (SSD) who reported she only updated admission goals and smoking related care plan sections and did not update care plans related to behavior concerns. She stated she did not know why the care plan listed 1:1 supervision as much as possible, explaining she believed 1:1 should mean continuous supervision. She explained the MDS nurse updated behavioral care plans; however, that nurse was unavailable for interview.While reviewing Resident #11's 15 minute check sheets (4/22-6/9) with the Director of Nursing (DON) on 6/11/26 at 4:13 p.m., multiple missing entries were noted, including entire shifts and full days. The DON stated she was overwhelmed, lacked unit managers, and could not verify that 1:1 supervision occurred. She said missing documentation meant the monitoring didn't happen. She confirmed the skin assessment for Resident #9 was not completed until four days after the incident and stated assessments following allegations should occur immediately.During an interview conducted with the NHA on 6/11/26 at 4:54 p.m., the NHA stated the facility did not separate the residents after the first incident; both residents remained in the same room on 1:1 supervision. He stated Resident #12 was not moved until 5/7/26, 16 days later, due to limited space. He stated Resident #11 was moved on 5/12/26. The NHA acknowledged missing and falsified check sheets, stating the repeated signatures were due to staff laziness. He stated he expected staff to provide continuous eyes on 1:1 supervision and notify him of concerns.On 6/11/26 at 5:18 p.m., the NHA stated that on 5/22/26, a CNA found Resident #11 in the wrong room with his private area exposed toward Resident #9. He stated the skin assessment completed on 5/26/26 was not timely. He reported Resident #11 was taken out of the facility and later returned. Police were present during the investigation. He stated the CNA involved later recanted and was suspended for not cooperating. The NHA stated no physical harm had been identified but could not speak to psychosocial impact. He stated missed supervision may have contributed to the second incident.During the interview on 6/11/26 at 1:22 p.m. with the facility's psych ARNP, she stated all three residents were severely impaired and that there was no evidence of psychosocial impact, though she acknowledged it was difficult to determine. She stated Resident #11 was redirectable and did not discuss the incidents. The ARNP said, They are all confused and severely impaired. Hard to rule out psychosocial impact, but it was not evident.Review of a facility policy titled, Abuse Prevention Program, Revised 2006, revealed a policy statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.Policy Interpretation and Implementation:I. Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents. or any other individual.3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern as a minimum: c. Identification of patterns of potential mistreatment/abuse. Timely and thorough investigations of all reports and allegations of abuse. h. An ongoing review and analysis of abuse incidents and i. The implementation of changes to prevent further occurrences of abuse.

Based on observations, record review, and interviews the facility failed to assess and monitor one (Resident #10) of one resident following an off-campus accident resulting in a transfer to an acute care facility by emergency services for examination and testing.Findings included: An observation on 06/11/2026 at 12:06 p.m. showed Resident #10 sitting in wheelchair in the resident's room. The resident was alert and oriented during the observation and interview. Resident #10 reported sometimes having a different kind of stabbing pain. The resident reported being hit by a car in the parking lot of the store across the street from the facility while sitting in the wheelchair. Resident #10 reported grabbing the wheelchair frame under and slightly in front of the armrests while the car hit the side of the chair. The resident did not fall out of the chair and was transferred to the acute care facility by emergency services. Resident #10 stated upon returning to the facility, everyone asked me how I was. Resident #10 stated feeling scared, nervous, and frightened now about potentially falling out of the chair. Review of Resident #10's admission Record showed the resident was admitted on [DATE] with diagnosis not limited to type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy and other intervertebral disc degeneration lumbar region with discogenic back pain and lower extremity pain. Review of Resident #10's progress notes revealed the following:6/4/26 effective 11:00 a.m., nursing note: pt (patient) signed out LOA (leave of absence) to go to [name of store].6/4/26 effective 11:20 a.m., nursing note: received notification that pt was struck by motor vehicle while in [name of store] parking lot. Paramedics [sic] with pt face sheet and med list given to paramedics.6/4/26 effective 4:38 p.m. nursing note from Registered Nurse (RN): Resident educated on the importance of safety and being aware of surrounding when out of the facility on independent LOA. Resident voices understanding. The resident received one tablet of Oxycodone-Acetaminophen 10-325 milligram (mg) on 6/4/26 at 4:33 p.m. per every 6 hours as needed (prn) physician order.6/4/26 effective 5:15 p.m. nursing note: md [medical doctor] notified new order received for no LOA till evaluated by MD.6/4/26 effective 5:58 p.m. nursing note: received call from [acute care facility] regarding CT [computed tomography] results. There is no FX [fracture] of the pelvis, previous x-ray stated possible. Per CT no FX.6/4/26 at 9:24 p.m. The resident's dose of Oxycodone-Acetaminophen was unknown. The same nurse documented at 10:30 p.m. another dose for leg pain. The staff documented the dosage was effective at 11:32 p.m.The review revealed no other progress notes were completed for the resident on 06/04/2026 by any staff member. Review of Resident #10's assessments revealed no assessments were completed for Resident #10 from 06/1/2026 to 06/08/26, three days prior to the accident and four days after the accident. A skin evaluation was completed on 06/08/2026, four days after the accident. Review of Resident #10's June 2026 Medication Administration Record (MAR) revealed daily vital signs were scheduled once a day at 6:00 a.m.Morphine Sulfate Extended Release 15 mg - one tablet by mouth every 12 hours for chronic pain. Hold for sedation, systolic blood pressure (SBP) less than 110, heart rate (hr) less than 60, oxygen (O2) saturation (sat) less than 90%. The administration was scheduled for 9:00 a.m. and 9:00 p.m. Oxycodone - Acetaminophen 10-325 mg - one tablet by mouth every 6 hours as needed for moderate to severe pain until 6/9/26 at 11:59 p.m. Hold for sedation, SBP less than 110, HR less than 60, O2 sat less than 90%. The documentation showed the blood pressure, pulse, O2, and pain level were taken at 4:33 p.m. and 10:30 p.m. to correspond with the administration of the medication. The MAR showed the medication was administered at 10:30 p.m. for a pain level of 0. An interview was conducted with Social Service Director (SSD) on 06/11/2026 at 10:12 a.m. The SSD reported Resident #10 was hit by a car in the parking lot of the store across the street (from facility). The resident was alert and oriented with no behavioral issues. The SSD reported not speaking with the resident after the incident and agreed the incident could have been traumatic. During a continued interview with the Director of Nursing and the SSD at 10:22 a.m. the SSD reported doing a Brief Interview of Mental Status assessment quarterly, a trauma-centered Post Traumatic Stress Disorder (PTSD) assessment only at admission and did not have any other assessment to complete. The DON stated psychiatry came in weekly to see the resident. An interview was conducted with the Medical Director on 06/11/2026 at 10:48 a.m. The MD reported an accident, which occurred with Resident #10, could have caused psychosocial and trauma however when the MD spoke with the resident on Friday (06/05/2026) the resident did not express any concerns at that time. During an interview on 06/11/2026 at 11:41 a.m. the Director of Nursing stated when a resident returns from the hospital, the facility staff need to do a re-admission assessment, even when the resident doesn't spend the night, if the resident was gone less than 24 hours staff still do a re-admission, and if a resident goes out to the hospital for a couple of hours staff are supposed to do a re-admission assessment. The Director of Nursing reviewed Resident #10's assessments and pointed out a skin evaluation created on 06/01/2026 (three days prior to the incident) and which was locked on 06/05/2026 (the day after incident). The DON then stated a re-admission assessment was only done if a resident came back from the hospital with new orders. The DON stated an evaluation was to be completed by staff when a resident returned (from hospital), the staff was to check vital signs which included blood pressure, pulse, respirations, temperature, and oxygen level, evaluate pain, complete a skin assessment, verify medical orders, and notify family and physician. The DON reviewed the resident's chart and stated the nurses did not do a skin assessment upon the resident's return and (staff could) do better. An interview was conducted with the Assistant Director of Nursing on 06/11/2026 at 4:45 p.m. The assistant reported there were no assessments done on 06/04 and 06/05/2026 for Resident #10. An interview was conducted with the Nursing Home Administrator (NHA) on 06/11/2026 at 4:52 p.m. The NHA stated staff should be doing an assessment when a resident comes back from the hospital after being hit by a car. The NHA reported the facility did not have a policy regarding a resident returning from the hospital.

Based on observation, interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, related to failure to ensure weekly skin checks were completed for two residents (#2 and #3) of three sampled residents. Findings included: Resident #3 was admitted to the facility on [DATE] and discharged on 09/07/25. Review of the admission record showed diagnoses included but not limited to vascular dementia with other behavioral disturbance, stage III chronic kidney disease, diabetes, anxiety disorder, major depressive disorder, and cerebrovascular disease. Review of the physician orders for Resident #3 showed to perform weekly skin checks. Review of the skin evaluation dated 09/05/2025 showed - scratches on the bilateral arms. Multiple superficial scratches to bilateral arms. Dried blood present around the affected area. No active bleeding observed. Review of Resident #3's electronic medical record (EMR) revealed there were no other documented skin evaluations for the period August through September 2025. Review of the care plans showed there was no care plan for skin integrity or a focus addressing weekly skin checks. During an interview on 10/13/25 at 12:40 p.m. Staff A, Licensed Practical Nurse (LPN) stated she does not normally work in the resident's area. She stated the nurses are supposed to do weekly skin checks and document it under the assessment tab of the electronic medical record. She stated the Weekly Skin Only Evaluation Schedule was listed by room numbers, which was subdivided by the day of the week and the shift. Staff A stated the nurses were to see which room was due on their shift, and perform the weekly skin check. During an interview on 10/13/25 at 12:45 p.m. the acting Director of Nursing (DON) stated the nurses were to perform weekly skin checks. He stated the nurses were supposed to do them and document them in the assessment section in the electronic medical record. He reviewed Resident #3's electronic medical record and stated the resident did not have any weekly skin assessments performed. During an interview on 10/13/25 at 1:44 p.m. Staff B, Nurse Practitioner (NP) stated she sees her physician provider's residents only. She stated she was at the facility 5 days a week. Staff B stated they have 88 or 90 residents in the facility. She stated she does not see all of their residents weekly. She stated she tries to see the long-term care residents at least every 2 weeks and sometimes only monthly. She stated she will see a resident more often for a specific concern. She stated she does not do a head-to-toe skin evaluation on every visit. She stated she will evaluate the residents if they have rash or something. She stated the nurse would tell her if there was an issue she needed to evaluate. She stated she did not evaluate the resident's skin on every visit. During an interview on 10/13/25 at 2:36 p.m. the DON stated all residents should have a skin integrity care plan. He reviewed Resident #3's care plans and stated she did not have a skin integrity care plan. He stated he did not see an intervention showing to perform weekly skin checks. 2. A review of Resident #2's admission record revealed an admission date of 10/2/25 with diagnoses to include osteomyelitis of vertebra, lumbar region, acute hepatitis b with delta-agent without hepatic coma, other psychoactive substance abuse, uncomplicated, and septic pulmonary embolism without acute cor pulmonale. A review of Resident #2's physician orders revealed there were no orders for skin assessments. A review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 10/2025 revealed there was no documentation of skin checks or assessments. A review of Resident #2's assessments revealed a skin evaluation dated 10/3/25. Review of Resident #2's EMR revealed there were no other documented skin evaluations/assessments. A review of Resident #2's care plan revealed a focus initiated on 10/03/2025, Impaired/Risk for impaired skin integrity AEB [as evidenced by]/Related to: Dry, fragile skin Date Initiated: 10/03/2025, with interventions to include, Weekly skin checks per protocol. A review of Resident #2's physician notes revealed the following: On 10/10/25, . Patient presents with increasing swelling of bilateral lower extremities and left upper arm. Swelling generally improves after lying down, but today it has remained the same. Patient is also being treated for thoracic osteomyelitis with intermittent daily fevers since admission, which improve with Tylenol. Blood cultures currently negative. Skin: Warm, Dry, IV [intravenous] Access, Pink, Normal for ethnicity, Other: multiple healing scabs, various stages, of extremities . On 10/13/25 at 1:50 p.m., an interview was conducted with Staff C, LPN. She said the east unit does not have a weekly skin assessment schedule for the residents. Staff C, LPN said they are supposed to. An observation of the east unit nurses station revealed no skin check sheet or schedule was observed for Resident #2. On 10/13/25 at 12:42 p.m., an interview was conducted with Staff A, LPN. She said the weekly skin only assessment schedule is supposed to be completed on every unit/hall. On 10/13/25 at 12:54 p.m., an interview was conducted with the DON. He confirmed the skin assessment was missing for Resident #2 on 10/10/25. He said it should have been completed. The DON said the provider saw Resident #2 and looked at his skin. He said the provider's note counted as a skin assessment. A review of the facility's policy titled, Skin and Wound, effective date 8/1/23 and a revision date of 9/24/24, revealed the following, Policy: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Further review of the policy, under procedure, revealed the following, . License nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record.

Based on interview and record review, the facility failed to provide wound care for three residents (#2, #3, and #4) of three residents reviewed. Findings included: Review of Resident #2's admission Record revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include unspecified injury at T11-T12 level of thoracic spinal cord, subsequent encounter, wedge compression fracture of lumbar vertebra, wedge compression fracture of thoracic vertebra, multiple myeloma not having achieved remission, and other co-morbidities. Resident #2 discharged to the hospital on 5/11/2025. Review of Resident #2's Medical Certification for Medicaid Long-Term Services and Patient Transfer Form (AHCA Form 3008) dated 4/30/2025 under the section titled Skin Care - Stage and Assessment revealed: 1. Left leg skin tear; 2. 4 punctures - spine status post (s/p) kyphoplasty; 3. RU (right upper) leg skin tear. Review of Resident #2's Specialty Physician Wound Evaluation & Management Summary dated 5/6/25 revealed: Site 1, Skin tear wound of the Left, distal shin full thickness, duration greater (>) than 26 days, wound size (Length x Width X Depth): 3.2 x 0.8 x 0.1 centimeters (cm); exudate: Light Serous; Slough: 50%, granulation tissue: 50%. Treatment Plan: Xeroform Gauze Dressing (a gauze of fine mesh impregnated with petrolatum and 3% Bismuth Tribromophenate), apply three times per week and as needed; and [Brand Name] gauze roll 4.5 apply three times per week and as needed, Tape for retention apply three times per week and as needed. Site 2, Skin tear wound of the Right, dorsal forearm, full thickness, duration >1 days, wound size (L x W x D): 7 x 5 x 0.1 cm, exudate: Light Serous, granulation tissue: 100%. Treatment Plan: Xeroform gauze apply three times per week and as needed, and [Brand Name] gauze roll 4.5 apply three times per week and as needed and tape for retention apply three times per week and as needed. Review of Resident #2's physician order summary report revealed an ordered dated 5/7/2025, cleanse skin tear to Left (L) shin with wound cleanser, dry, apply Xeroform, and wrap with [Brand Name] gauze roll 4.5, three times per week and as needed.; Cleanse skin tear to Right (R) forearm with wound cleanser, dry, apply Xeroform, and wrap with [Brand Name] gauze roll 4.5 three times per week and as needed; and tape for retention three times per week and as needed. Review of Resident #2's Treatment Administration Record (TAR) for May 2025 revealed no skin care orders prior to 5/7/2025 and the treatment for the left shin and right forearm occurred only on 5/10/2025 during the resident's stay. During an interview on 6/11/2025 at 10:21 a.m., the resident's responsible party (RP) stated visiting Resident #2 daily while in the facility. The RP said the facility did not provide consistent wound care for Resident #2 during the stay. During an interview on 6/11/2025 at 4:54 p.m., Staff A., Licensed Practical Nurse (LPN) and Unit Manager (UM) stated Resident #2 required wound care treatments throughout his stays at the facility and was unsure why the orders were not implemented on admission. Review of the admission Record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of right buttock, resistance to vancomycin, methicillin resistant staphylococcus aureus, and other co-morbidities. Review of Resident #3's AHCA form 3008 dated 5/15/25 revealed: Left foot (plantar) wound care, cleanse wound (and pat dry) with normal saline wound cleanser, apply skin barrier to peri-wound: to wound of left foot (plantar), cleanse wound, pat dry, paint with betadine, leave open to air and change every 12 hours. Wound care, sacrum, cleanse wound (and pat dry) with wound cleanser, apply dressing with [brand name], apply dressing with gauze 4x4, bordered gauze; right and left ischial tuberosity, cleanse wounds, pat dry, apply [brand name] to wound bed and undermining, cover with gauze and [brand name] dressing, twice a day (bid). Review of Resident #3's Nursing admission Screening/History dated 5/17/205 at 12:58 a.m., revealed under the Skin section: unstageable pressure area to right toe(s), Stage IV pressure area to sacrum, Stage III pressure area to left gluteal fold, and Stage III pressure to the right gluteal fold. Review of Resident #3's Specialty Physician Wound Evaluation & Management Summary dated 5/20/25 revealed: - Site 1: Stage 4 Pressure wound sacrum full thickness, noted present on admission, wound size (L x W x D): 8.5 x 12.5 x 1 cm, undermining 2.5 cm at 5 o'clock; exudate: moderate serous, granulation tissue 70%; other viable tissues: 30% (muscle, fascia, bone), Treatment: collagen powder apply once daily and as needed, if saturated, soiled, or dislodged. Alginate calcium apply once daily and as needed, cover with island gauze with border once daily. - Site 2: Stage 4 Pressure wound of the Left Ischium Full thickness, noted present on admission, wound size: 6.5 x 5.5 x 1 cm, undermining 1 cm at 9 o'clock; exudate: moderate serous; slough 20%; granulation tissue: 60%; other viable tissues: 20% (muscle, fascia, bone), Treatment: collagen powder apply once daily and as needed, if saturated, soiled, or dislodged. Alginate calcium apply once daily and as needed, cover with island gauze with border once daily. - Site 3: Stage 4 Pressure wound of the right ischium full thickness noted present on admission, wound size 7.0 x 3.5 x 2 cm; undermining: 0.5 cm at 5 o'clock; exudate: moderate serous; slough 20%; granulation tissue: 70%; other viable tissues: 10% (muscle, fascia, bone), Treatment: collagen powder apply once daily and as needed, if saturated, soiled, or dislodged. Alginate calcium apply once daily and as needed, cover with island gauze with border once daily. - Site 4: Unstageable (due to Necrosis) of the left foot full thickness noted to be present on admission; wound size 2.3 x 1.7 x not measurable cm; 100% thick adherent black necrotic tissue (eschar): Treatment: betadine apply once daily for 30 days. Recommendations: low air loss Mattress, upgrade off-loading chair cushion, Vitamin C 500mg BID (twice daily) and Zinc Sulfate 220mg daily for 14 days. Review of Resident #3's physician order summary report revealed: 1. 5/17/25 consult wound care; 2. 5/21/25 cleanse bilateral ischium (buttock folds) wounds with wound cleanser, dry, apply collagen powder, apply calcium alginate, and finish with bordered gauze dressing daily and as needed for if soiled or dislodged. 3. 5/21/25 cleanse bilateral ischium buttock fold wounds with wound cleanser, dry, apply collagen powder, apply calcium alginate, and finish with bordered gauze dressing daily. 4. 5/21/25 Cleanse sacral wound with wound cleanser, dry, apply collagen powder, apply calcium alginate, and finish with bordered gauze dressing daily. 5. 5/21/25 Cleanse sacral wound with wound cleanser, dry, apply cotton allergen powder, apply calcium alginate and finish with bordered gauze dressing daily. Review of Resident #3's facility record lacked documentation of wound care until 5/21/25. Review of Resident #4's admission Record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses to include end stage renal disease, and other co-morbidities. Review of Resident 4's AHCA form 3008 dated 6/7/25 revealed unstageable sacrum, coccyx wounds x 2, 2 ulcers on the midline back. Review of Resident #4's Nursing admission Screening/History dated 6/10/205 at 16:35 (4:35 p.m.). revealed under the Skin section: unstageable pressure to the Vertebrae (upper-mid); Unstageable wound on coccyx; Unstageable wound on coccyx; unstageable wound to sacrum; and unstageable wound to sacrum; treatment ordered or required is marked. Review of Resident #4's physician order summary lacked any wound care orders. During an interview on 6/12/25 at 11:15 a.m. Staff B, LPN stated when a resident was admitted to the facility an admission evaluation was completed. The evaluation included completing a head to toe skin evaluation. If the skin had any marks, breaks or abnormal openings, these openings would be indicated on the evaluation. The nurse would notify the physician and obtain orders for treatment of these skin impairments, as well as wound care consult. During an interview on 6/12/25 at 11:20 a.m., Staff C, LPN stated upon a resident's admission an evaluation of their skin was completed for any breaks or bruises. The nurse contacts the physician and obtains orders for treatment to the areas. During an interview on 6/12/25 at 11:46 a.m., the Director of Nursing (DON) said the expectation for the nurses upon a resident's admission was to complete a full Nursing admission Evaluation which included a complete evaluation of the resident's skin. If the nurse noticed any skin issues the nurse should notify the physician to obtain orders to treat the area. The DON reviewed the following documentation: -Resident #2's TAR and confirmed no orders were obtained until 5/7/2025 and the 3008 indicated the skin issues on the form at admission. -Resident #3's Nursing admission assessment dated [DATE] showed: sacral, left and right gluteal fold, and area on the foot and confirmed admission orders were only received for the foot and sacrum not the left and right gluteal folds. -Resident #4's 3008 revealed resident was admitted for wound care, unstageable pressure ulcers to the: sacrum, left and right coccyx , and two ulcers to to the mid back and the facility TAR lacked orders for any wound care. The DON stated the expectation was not met for Residents #2,3, and 4. Review of the facility's policy and procedure titled, Skin and Wound with a revision date of 9/24/2024 revealed: Policy: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of pressure injury. Procedure: * on admission/readmission the resident's skin will be evaluated for baseline skin condition and documented in the medical record . *Licensed nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record .*Provide treatment per physician order with documentation in the medical record. QAPI: Patterns and trends of newly developed and/or worsening skin conditions will be reviewed by the QAPI team.

Based on record review and interviews, the facility did not ensure medical records were completed and accurate for one resident (#2) out of three sampled residents. Findings included: Review of admission Records showed Resident #2 was admitted to the facility from the hospital on 5/2/25 and discharged from the facility on 5/11/25. On 6/11/25 at 10:30 a.m. Resident #2's Nursing admission Screening/History, dated 5/2/25, was reviewed. The Nursing admission Screening/History was blank with the exception of the vitals signs that auto populate when the documented is initiated. There was no documentation under the sections for admission details, level of consciousness/orientation/neurological, social history/lifestyle concerns, general appearance, HEENT (head, eyes, ears, nose throat), respiratory/chest, cardiac/circulation, GI (gastrointestinal)/bowel, GU (genitourinary)/bladder, extremities/gait/mobility, skin, ADL's (activities of daily living)/functional devices, other relevant diagnoses/concerns, pain, and medications. On 6/11/25 at approximately 12:45 p.m. a request was made to the Chief Nursing Officer (CNO) to print Resident #2's Nursing admission Screening/History, dated 5/2/25. The CNO was notified the assessment was not completed. On 6/11/25 at 4:45 p.m. a printed copy of Resident #2's 5/2/25 Nursing admission Screening/History was provided. At that time the assessment was observed to have all sections fully completed. Upon review of the electronic medical record it was noted the assessment had been locked on 6/11/25 at 4:37 p.m. by Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM). An interview was conducted on 6/11/25 at 4:54 p.m. with Staff A, LPN/UM. When asked about Resident #2's Nursing admission Screening/History from 5/2/25 Staff A immediately put her head down and her shoulders slumped. Staff A said she noticed the assessment had not been completed so she filled it out today, 6/11/25. She said she was not the nurse that did Resident #2's admission. She said the nurse that did the admission assessment no longer worked at the facility. Staff A said she did remember looking at the resident every day when she came in. Staff A said she did not know why the admission assessment was not completed. She said she normally did not go in and fill out documentation late, especially for things she did not do herself. When asked what made her look at Resident #2's Nursing admission Screening/History on 6/11/25, she said they requested I look at it. When asked whom she was referring to, Staff A stated the CNO went to her and asked her to make sure everything is there and good on Resident #2's 5/2/25 admission assessment. Staff A said she knew she should not have completed the documentation when she didn't do the assessment. An interview was conducted on 6/12/25 at 1:47 p.m. with the facility's CNO. The CNO said there was a list of assessments and documents the admitting nurse should complete when a resident is admitted to the facility. She confirmed this included the Nursing admission Screening/History. She said when the Nursing admission Screening/History is completed, it should be signed and locked. She said if is not locked by the nurse it will stay in progress. She said if someone else noticed it wasn't locked and locked the document for the nurse, that person should not change or add any documentation. She said she expected if a nurse started an assessment, they should finish it, sign it, and then lock it. In regard to Resident #2, the CNO said she asked Staff A, LPN/UM to help her print the documents that had been requested. She said she did not remember being told the 5/2/25 Nursing admission Screening/History for Resident #2 was blank, but she should have been notified. The CNO said she was trying to do multiple things. She said the assessment should have been fully completed when Resident #2 was admitted on [DATE]. She said nurses were not supposed to enter information if they were not there, even if they knew the resident. She said her expectation was that all documentation should have been completed within 72 hours at the most. She said if it was more than 72 hours after admission and an assessment was not fully completed, she would expect the nurse to print the incomplete documentation and scan it into the miscellaneous section of the medical record, then start a new assessment and complete it. The CNO said the only documentation that should be put in a resident record after they are discharged would be a recap of the resident's stay if that is needed. The CNO confirmed Resident #2 was discharged from the facility on 5/11/25, one month prior to the Nursing admission Screening/History being completed and locked. The CNO reviewed Resident #2's 5/2/25 Nursing admission Screening/History and confirmed it was locked on 6/11/25 by Staff A, LPN/UM. The CNO said Staff A, LPN/UM should not have completed the documentation. The CNO said she did not ask Staff A to look at Resident #2's assessment and complete it. The CNO stated the facility did not have a policy documentation of admission assessments. Review of a facility policy titled Ethics, revised 12/11/24 showed under policy: It is the policy of [Corporation name] that all employees are governed by the Company's Policies and Procedures and shall conduct company business in a manner which is at all times legal, ethical and integral and in alignment with as outlined by the corporate officers. The procedure showed: The employee handbook provides general guidelines for employees in order to meet the highest standards of business conduct as set forth in the policy statement above.

Based on observations, interviews, and record review, the facility failed to provide a therapeutic diet according to physician orders for two residents (#1 and #25) out of four residents reviewed. Findings included: 1. Review of Resident #1's Admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of cerebral infarction due to embolism of left posterior cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, and altered mental status. An interview was conducted on 2/26/25 at 10:30 a.m. with Resident #1. He was observed sitting in the main dining room at a table watching television. He raised his hand and told Staff D, Certified Nursing Assistant (CNA) he wanted coffee and a snack. Staff D, CNA said I am going to get him a snack because he was in therapy during snack time. She was observed going to another room off the main dining area and obtained a soft cookie and placed it on the coffee cart. Staff D, CNA was overheard asking another staff member what Resident #1's diet was and the other staff member said he needed thickened liquids. Staff D, CNA prepared Resident #1s' coffee with nectar thickener and provided it to Resident #1. He did not receive a snack. An interview was conducted on 2/26/25 at 10:54 a.m. with Resident #1. Resident #1 was observed with no snack in front of him. He said, I haven't gotten my snack. She's giving me the run around. It's my snack and I want it, I'm hungry. Review of Resident #1's February 2025 physician orders revealed an order with a start date of 2/25/25 and no stop date, NAS/CCD [no added salt/carb-controlled diet], pureed texture, Nectar/Mildly thick consistency. Double portion protein/entree each meal. An interview was conducted on 2/26/25 at 11:26 a.m. with Staff D, CNA. She said for residents who are on pureed diets, they can have pudding for a snack. She said Resident #1 asked her for a snack a while ago but she was not sure what his diet order was. She said she could ask his nurse but she didn't want to leave all the residents in the dining area unsupervised. She said she could wait until he gets his lunch tray to see what kind of diet he has and then give him a snack at that time. She said to the resident's lunch will arrive at 11:30 a.m. A lunch observation was conducted on 2/26/25 at 11:35 a.m. Resident #1 was observed sitting in the main dining room with a plate of sliced carrots, a scoop of scalloped potatoes, and ground beef with gravy on it. An interview was conducted on 2/26/25 at 11:36 a.m. with Staff E, Registered Nurse (RN). She said she is in the dining room helping out because the other nurse was on break. She confirmed she gave Resident #1 his meal tray and she observed his lunch plate and said he received mechanical soft food, and she was not sure if it was double portions of protein or not. She obtained his meal ticket and confirmed the meal ticket said, Double protein mechanical soft with nectar thick liquids. An interview was conducted on 2/26/25 at 11:50 a.m. with the Director of Nursing (DON). She said speech therapy will assess a resident and make recommendations for their diet order and, I have to approve it, then nursing will put the order into the medical record and a dietary communication form is competed and given to someone in the kitchen, then we follow up with the Dietary Manager to ensure they are aware of the change in the diet order. An interview was conducted on 2/26/25 at 11:52 a.m. with the Dietary Manager. She said when a diet is changed a dietary communication form is filled out and given, to me, and I make sure the order is changed in the system. She said she also reviews residents' medical records every day, and sometimes twice a day, for any dietary changes. The Dietary Manager confirmed Resident #1 received a mechanical soft diet for lunch and confirmed she provided him with an extra portion of mechanically soft textured meat. She said she was not here yesterday (2/25/25) and was not aware Resident #1's diet changed to puree and said that was a problem. She asked Staff F, Corporate Traveling RN, if Resident #1 was on a puree diet and she said, yes, his diet was downgraded yesterday and Staff F, Corporate Traveling RN told the dietary manger to get the Speech Therapist to sit with the resident. An interview was conducted on 2/26/25 at 11:59 a.m. with the Speech Therapist. She said Resident #1 was at high risk for aspiration and he was on a mechanical soft diet with thickened liquids, but she trialed him with a peanut butter and jelly sandwich yesterday (2/25/25) and he immediately started coughing, so she downgraded his diet to puree because she didn't want him on a mechanical soft diet and someone giving him a sandwich because of his risk for aspiration. She said when she changed his diet, she filled out the diet change slip and gave it to, a guy in the kitchen. She said Resident #1 does well when his food is all mixed together and when he eats, he automatically mixes it all together. She said he is a resident who will eat anything and everything and you have to watch out for him because he is on a pureed diet but he will eat anything. Review of Resident #1's physician notes dated 2/24/25 revealed .Dysphagia following cerebral infarction ST [speech therapy] to following - discussed with ST, will maintain puree diet at this time on pureed diet with moderately thick liquid Nursing to assist with feeds as needed. A follow up interview was conducted on 2/26/25 3:38 p.m. with the Dietary Manager. She said the dietary electronic system is different from the medical record, so in order for diets to get updated on the meal tickets she relies on the dietary change forms, and she did not receive a dietary change form for Resident #1. She said someone handed the dietary change form to the dishwasher yesterday and from there the form is missing and the dietary system did not get updated. 20536 2. On 2/26/25 at 10:53 a.m., an interview was conducted with Resident #25, while seated in the main dining room. He said he was supposed to get double portions with his food items but has not been getting double portions. Resident #25 revealed he used to get four pieces of toast, then he got three, then two, and now he gets no toast at breakfast at all. He continued to say he only gets one scoop of eggs for breakfast as well and he is continually hungry and he keeps losing weight and is not getting double portions like he is supposed to. On 2/26/2025 at 11:30 a.m. the main dining room was observed for the lunch meal service. During the observation, there were approximately twenty residents seated at various tables, all being assisted by six staff members with their meal trays. Staff were observed removing meal trays from tray carts and placing the trays on tables in front of the residents. Staff were identified lifting lids to the trays and setting up the meal per resident choice and the need for assistance. At 11:38 a.m., Resident #25 was observed seated at a table and already received his lunch tray. Observations of his lunch tray included what appeared to be one small Salisbury steak patty covered with brown gravy, a small scoop of what appeared to be cheese potatoes, and six small carrot slices. Resident #25 also received two small plastic cups of red liquid juice and one plastic wrapped cookie. It appeared all the food items were a Regular texture base. Resident #25 did not receive double portions with any of the food items. Review of the lunch meal ticket positioned next to the resident's tray revealed, Double Protein, which was highlighted in yellow, and regular diet No Added Salt (NAS). The ticket did not have any dislikes noted. (Photographic Evidence Obtained) An interview was conducted on 2/26/25 at 11:42 a.m. with the CDM. She reviewed Resident #25's lunch meal ticket and plate of food and confirmed he should have received two pieces of the Salisbury steak and he did not. A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to dementia and need for assistance with personal care. Review of Resident #25's February 2025 physician orders revealed the following: 1. Heart Healthy Diet, Regular Texture, Regular/thin consistency - Double Portion meat/entree at each meal for diet, order date 1/9/25. 2. Med Pass 2.0 TID [three times a day] 120 ml [milliliters] record % consumed, order date 1/15/25. Review of Resident #25's Progress Notes and Registered Dietician Assessment/Notes, with look back period from 11/27/24, revealed: - A Weight Change Note dated 1/15/25 at 5:00 p.m., weight loss of 17% in 30 days. Diet is NAS regular, thin liquid. Will add Med Pass 2.0 supplements, 120 ml TID and also double portion meat/entre each meal. Will follow as need. - A Weight Change Note dated 2/24/205 at 2:15 p.m., weight has become more stabilized and is 186 lbs. Diet is NAS, regular, thin liquid. Double portion entree was added last month when he had weight loss. His BMI [body mass index] 25. - 7.5% lost. Med Pass 2.0 PO [by mouth] 120 ml TID was put in place due to weight loss he had last month. Will follow as need. On 2/26/25 at 2:20 p.m., an interview with the facility's Registered Dietician (RD), who has been employed as the RD for about 6 months. She revealed she was aware Resident #25's weight loss upon his readmission from the hospital on 1/8/25. She also revealed she had interventions to include double portions for protein as well as Med Pass three times a day to increase weight. She noted Resident #25 generally consumes 75 to 100% of meals and although Resident #25 has had some weight loss, she continues to monitor his weights and he is stable and within his BMI range. She continued to say she will keep Med Pass and Double Portions for him. The RD reviewed the photo of the resident's lunch meal and she confirmed he did not receive double portion for meat. She revealed he should have received two patties instead of one and the meal ticket also revealed, double portion. The RD confirmed the CDM and the tray line staff should have caught that today and followed the meal ticket/order. She revealed there are times she is at the tray line and she supervises and reviews tickets as to what is served on tray line. Review of Resident #25's current care plans, with a next review date 4/9/25, revealed the following: - Resident has nutritional problem or potential nutrition problem of having unplanned weight loss with interventions in place to include but not limited to: Provide and serve supplement as ordered; Provide and serve diet as ordered (double portions entree each meal); Monitor and record each meal; RD to evaluate and make diet changes as recommended and as need; Weigh per protocol. On 2/27/25 at 7:15 a.m. an interview and observation was conducted with the CDM in the facility kitchen, where she demonstrated the meal service process in the kitchen. Staff A, Cook, Staff B, [NAME] in training, Staff C, Dietary Aide, and the CDM, all were getting ready to plate and send out breakfast meal trays to residents. The CDM revealed either the day before or a couple of days prior, Staff A, [NAME] will receive paper meal tickets and place them in a pile on the steam table counter area. The CDM also revealed Staff A, [NAME] or whoever is the cook for the day will review each ticket one a time as the plate is being prepared. The CDM revealed the Staff A, [NAME] reads meal ticket and looks out for things to include the type of diet, type of texture, allergies, likes and dislikes, adaptive eating equipment, and also if double portions are ordered. She revealed if the meal ticket says double portions, the cook for the day will honor the meal ticket and plate as read. She revealed double portions would be defined as two times the normal scoop for soft food items and double portions of other items such as steak or chicken. For the breakfast meal, the double portion would be two hard boiled eggs instead of one, a scoop size of six ounces of hot cereal instead of two, and double cups of liquid. Staff A, [NAME] confirmed the process the CDM explained and is the process he follows. The CDM further revealed when the meal tray is plated, the Dietary Aide, in this case Staff C, Dietary Aide, will review the meal ticket and plated food items for accuracy. Staff C, Dietary Aide confirmed she looks at all the food items on the meal tray and the meal ticket to determine if the cook provided the right diet and menu items. The CDM also revealed that she monitors the tray line for the breakfast and lunch meal service, many of the dinner meal services, and at times during the weekends. The CDM revealed the cook on assignment when she is not at the facility is the person who is responsible for reviewing the meal tickets and following them for accuracy. Further interview with Staff A, [NAME] and Staff C, Dietary Aide, who both worked on 2/26/25 in the kitchen, confirmed they did not know how several plates of food got out to residents that did not follow the meal ticket. Staff A, [NAME] and Staff C, Dietary Aide also confirmed they found out Resident #25 and a couple of other residents did not receive double portions as per their meal ticket order for the lunch meal service. The CDM also confirmed that should not have happened and she was not sure how the meal tickets were not followed. On 2/27/25, the Nursing Home Administrator, Director of Nursing, and the CDM all confirmed the facility did not have a Following/honoring meal tickets/diets policy and procedure for review.

Based on record review and interviews, the facility failed to protect residents' rights to be free from verbal and physical abuse perpetrated by a staff member (Staff J, Certified Nursing Assistant) toward two residents (#11 and #12) of seventy-four residents in the facility. On 12/20/2024, Staff J, Certified Nursing Assistant (CNA) was witnessed by Staff I, CNA slapping Resident #11 and Resident #12 on the legs, sides of their bodies, and buttocks during care. Staff I, CNA failed to report the abuse until three days after the event, leaving other facility residents at risk of further verbal and physical abuse. Findings included: Review of Resident #11's Admission Record showed the resident was admitted on [DATE] and had diagnoses including but not limited to unspecified quadriplegia, unspecified not intractable epilepsy without status epilepticus, sever intellectual disabilities, legal blindness as defined in USA, unspecified scoliosis, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #11 had no speech, no Brief Interview of Mental Status (BIMS) score as the resident was rarely/never understood, had bilateral upper and lower extremity Range of Motion (ROM) impairments, and was dependent on staff for eating, hygiene needs, and mobility. Review of Resident #12's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record showed diagnoses including but not limited to sequelae traumatic subdural hemorrhage with loss of consciousness status unknown, sequelae diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified psychosis not due to a substance or known physiological condition, generalized muscle weakness, and sequelae pedestrian on foot injured in collision with heavy transport vehicle or bus in traffic accident. Review of the quarterly MDS dated [DATE] showed Resident #12 had no speech, a BIMS score of 00, indicative of a severe cognitive impairment, no Range of Movement impairment, was dependent upon staff for hygiene needs, and required substantial/maximum assist for bed mobility. The comprehensive assessments showed the resident had been discharged with return anticipated on 12/25/2024 and returned on 12/29/2024. On 1/2/2025 at 10:22 a.m., a handwritten sign was observed posted inside the [NAME] wing nurses station showing [Resident #11] is on 15 min[ute] checks. When [Resident #12] returns [pronoun] is on 15 min[ute] checks as well. DO NOT STOP! - Management 12/27/24 Call on-call for any questions. An interview was conducted with Staff A, Registered Nurse (RN) on 1/2/2025. Staff A, RN observed the handwritten sign informing staff Resident #11 and Resident #12 were on 15-minute checks and reported having to clarify the 15-minute checks for Resident #11. The staff member removed the sign and folded it in half, saying it was out of date. An interview was conducted with the Nursing Home Administrator (NHA) on 1/3/2025 at 2:01 p.m. The NHA reported nurses were doing 15 minute checks on the two residents (#11 and #12) and reported an incident occurred on 12/20/2024. However, CNA did not report it until three days later on 12/24/2024 and the checks were started at that time. The NHA stated Staff I, CNA came to speak with the Staffing Coordinator and wanted to report an incident. The administrator stated Staff J, CNA was assisting Staff I, CNA with care for Resident #11 and Resident #12 and felt Staff J, CNA was rough while changing the residents. A review of employee statements was conducted with the NHA following the interview. Review of the statement made by Staff I, CNA on 12/23/2024 revealed on 12/20/2024, Staff J, CNA and Staff I, CNA were changing Resident #11 and Resident #12 and Staff J, CNA said the residents were combative. Staff I, CNA reported the residents were not being combative and Staff J, CNA slapped both of the residents' multiple times on the legs, sides of their bodies, and buttocks. Staff I, CNA reported a handprint was left on Resident #11. The staff member reported not saying anything about Staff J because they were scared due to past trauma (per NHA, was a personal incident) and did not want to be targeted. The witness statement revealed Staff I, CNA attempted to inform a nurse but could not find one. Instead, Staff I, CNA informed Staff K, Door Monitor, who informed Staff I, CNA of past instances of seeing Staff J, CNA pulling an unidentified residents hair and verbally abusing them, then added another resident seemed to have been scared of Staff J, CNA when the staff member was changing them. Review of a statement provided by Staff K, Door Monitor dated 12/23/2024 revealed on Friday 12/20/2024, an employee reported Staff J, CNA was being mean, rough, and hitting patients. Staff K, Door Monitor reported seeing Staff J, CNA previously pull a resident's hair and verbally abuse them by calling the resident's faggots and pieces of shit. Staff K, Door Monitor reported speaking with the 7 p.m. - 7 a.m. Registered Nurse (RN), who informed the staff member she had also heard of this, but the staff members chose not to say anything so as to not affect their jobs and prevent backfire on them. The NHA identified the 7 p.m. - 7 a.m. RN as Staff L, RN. Review of a statement dated 12/24/2024 from Staff L, RN revealed, I did not have any reports of any type of incident of abuse. The statement added Staff L, RN was unaware of the incident until questioned by a police officer. Review of Staff J, CNA's statement via email dated 12/24/2024 at 2:28 p.m. revealed, On the day in question I provided care to [Resident #11 and Resident #12], Bed A had a [bowel movement] which I changed him and my hall partner to help me pull him up in the bed. During the interview and review of witness statements, the NHA stated the incident happened on 12/20/2024 and they would expect to be notified immediately. The NHA reported Staff J, CNA was suspended on 12/23/2024, who was later terminated, and interviews were started with Staff I, CNA and K, Door Monitor. The next morning, a statement was provided from Staff L, RN. The NHA reported law enforcement and state agencies were notified of the incident on 12/23/2024. The NHA stated based on information provided by Staff I, CNA and follow up from Staff K, Door Monitor, they believe the incident did occur. The NHA also stated they understood Staff I, CNA was new to the facility, but the residents are vulnerable adults and the facility has zero tolerance for abuse. Review of policy titled Abuse Prevention Program, revised August 2006, revealed the Policy Statement: our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The Policy Interpretation and Implementation regarding Preventing Abuse showed: 1. Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The policy revealed under Abuse Prevention Program: 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policy and procedures that govern, as a minimum: a. Protocols for conducting employment background checks; b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, dealing with violent behavior, or catastrophic reactions, etc; c. Identification of occurrences and patterns of potential of mistreatment/abuse; d. The protection of residents during abuse investigations; e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident to resident abuse, and resident to staff abuse; f. Timely and thorough investigations of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse; h. An ongoing review and analysis of abuse incidents; and i. The implementation of changes to prevent future occurrences of abuse. The policy, under Assessment and Recognition, defines abuse as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on interviews and record reviews, the facility failed to report an incident of verbal and physical abuse perpetrated by a staff member (Staff J, Certified Nursing Assistant) toward two residents (#11 and #12) of seventy-four residents in the facility. Findings included: Review of Resident #11's Admission Record showed the resident was admitted on [DATE] and had diagnoses including but not limited to unspecified quadriplegia, unspecified not intractable epilepsy without status epilepticus, sever intellectual disabilities, legal blindness as defined in USA, unspecified scoliosis, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #11 had no speech, no Brief Interview of Mental Status (BIMS) score as the resident was rarely/never understood, had bilateral upper and lower extremity Range of Motion (ROM) impairments, and was dependent on staff for eating, hygiene needs, and mobility. Review of Resident #12's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record showed diagnoses including but not limited to sequelae traumatic subdural hemorrhage with loss of consciousness status unknown, sequelae diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified psychosis not due to a substance or known physiological condition, generalized muscle weakness, and sequelae pedestrian on foot injured in collision with heavy transport vehicle or bus in traffic accident. Review of the quarterly MDS dated [DATE] showed Resident #12 had no speech, a BIMS score of 00, indicative of a severe cognitive impairment, no Range of Movement impairment, was dependent upon staff for hygiene needs, and required substantial/maximum assist for bed mobility. The comprehensive assessments showed the resident had been discharged with return anticipated on 12/25/2024 and returned on 12/29/2024. An interview was conducted with the Nursing Home Administrator (NHA) on 1/3/2025 at 2:01 p.m. The NHA reported nurses were doing 15 minute checks on the two residents (#11 and #12) and reported an incident occurred on 12/20/2024. However, CNA did not report it until three days later on 12/24/2024 and the checks were started at that time. The NHA stated Staff I, CNA came to speak with the Staffing Coordinator and wanted to report an incident. The administrator stated Staff J, CNA was assisting Staff I, CNA with care for Resident #11 and Resident #12 and felt Staff J, CNA was rough while changing the residents. A review of employee statements was conducted with the NHA following the interview. Review of the statement made by Staff I, CNA on 12/23/2024 revealed on 12/20/2024, Staff J, CNA and Staff I, CNA were changing Resident #11 and Resident #12 and Staff J, CNA said the residents were combative. Staff I, CNA reported the residents were not being combative and Staff J, CNA slapped both of the residents' multiple times on the legs, sides of their bodies, and buttocks. Staff I, CNA reported a handprint was left on Resident #11. The staff member reported not saying anything about Staff J because they were scared due to past trauma (per NHA, was a personal incident) and did not want to be targeted. The witness statement revealed Staff I, CNA attempted to inform a nurse but could not find one. Instead, Staff I, CNA informed Staff K, Door Monitor, who informed Staff I, CNA of past instances of seeing Staff J, CNA pulling an unidentified residents hair and verbally abusing them, then added another resident seemed to have been scared of Staff J, CNA when the staff member was changing them. Review of a statement provided by Staff K, Door Monitor dated 12/23/2024 revealed on Friday 12/20/2024, an employee reported Staff J, CNA was being mean, rough, and hitting patients. Staff K, Door Monitor reported seeing Staff J, CNA previously pull a resident's hair and verbally abuse them by calling the resident's faggots and pieces of shit. Staff K, Door Monitor reported speaking with the 7 p.m. - 7 a.m. Registered Nurse (RN), who informed the staff member she had also heard of this, but the staff members chose not to say anything so as to not affect their jobs and prevent backfire on them. The NHA identified the 7 p.m. - 7 a.m. RN as Staff L, RN. Review of a statement dated 12/24/2024 from Staff L, RN revealed, I did not have any reports of any type of incident of abuse. The statement added Staff L, RN was unaware of the incident until questioned by a police officer. During the interview and review of witness statements, the NHA stated the incident happened on 12/20/2024 and they would expect to be notified immediately. The NHA reported Staff J, CNA was suspended on 12/23/2024, who was later terminated, and interviews were started with Staff I, CNA and K, Door Monitor. The next morning, a statement was provided from Staff L, RN. The NHA reported law enforcement and state agencies were notified of the incident on 12/23/2024. The NHA stated based on information provided by Staff I, CNA and follow up from Staff K, Door Monitor, they believe the incident did occur. The NHA also stated they understood Staff I, CNA was new to the facility, but the residents are vulnerable adults and the facility has zero tolerance for abuse. Review of the report sent to the state agency by facility showed the incident involving the abuse of Resident #11 and Resident #12 had occurred on 12/20/2024 at 7 p.m. and the NHA was notified by Staff I, CNA on 12/23/2024 at 2:50 p.m., approximately 68 hours after the event. Review of the policy titled Reporting Abuse to Facility Management, revised February 2014, revealed the Policy Statement: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy showed under Responsibility of Person(s) Observing Incidents of Abuse: any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. The policy also revealed under Notification of Administrator/DNS (DON) After Hours: The Administrator or Director of Nursing Services must be immediately notified of a suspected abuse or incidences of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident.

Based on observation, record review, interview the facility failed to ensure an effective infection prevention control program was maintained related to: 1. not reporting rashes to the local health department and not ensuring four residents (#62, #46, #12 and #22) received appropriate testing for a possible contagious epidermal condition out of four residents reviewed, 2. not ensuring a blood stained pillow case was changed for one resident (#13) of one resident reviewed with a bloodborne pathogen, and 3. not following the infection control practice of sanitizing equipment after use for one resident (#2) of five residents observed during medication administration. Findings included: 1. An observation on 09/23/24 at 10:09 a.m. revealed a red substance that resembled blood stains on Resident #13's pillow as Resident #13 laid in bed asleep. An observation and interview on 09/23/24 at 11:15 a.m. revealed the red substance that resembled blood stains on Resident #13's pillow as Resident #13 sat in the bed awake. Resident #13 stated the red stains on the pillow were blood and probably from her wound on her shoulder. Resident #13 pulled the arm sleeve up on her shirt and presented her right shoulder area. Resident #13's top right shoulder revealed a red, raw and bloody wound that was open to the air. Review of the Admission Record showed Resident #13 was admitted to the facility on [DATE] with diagnoses that included [bloodborne pathogen]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C- Cognitive Patterns Resident #13 had a Brief Interview for Mental Status (BIMS) score of 08 (moderate cognitive impairment). Section E- Behavior showed Resident #13 exhibited no behaviors during the 7 day look back time period. Section M- Skin Conditions showed Resident #13 had no pressure ulcers and no venous or arterial ulcer. Review of the Order Summary as of 9/24/24 included the following orders: - Apply moisturizer to right shoulder for radiation skin care. at bedtime for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. - Apply moisturizer to right shoulder for radiation skin care. two times a day for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. Review of a Physician Wound Note, dated 09/17/24, showed: Wound Evaluation and Management Summary. Additional Wound Detail: has started radiation tx [treatment] and requested to discontinue silver sulfadiazine. Dressing Treatment Plan: Primary Dressing(s) Hydrocolloid sheet (satin) apply once daily for 30 days. Dressing Treatment Plan: Note: Add Hydrocolloid Sheet (Satin) Once Daily 30. Discontinue Silver Sulfadiazine. An observation on 09/24/24 at 9:27 a.m. revealed the blood stains on Resident #13's pillow as observed on 09/23/24. An observation on 09/24/24 at 12:53 p.m. revealed the blood stains on the pillow and visible from the hallway when looking into Resident #13's room. (Photographic Evidence Obtained) During an interview on 09/24/24 at 2:12 p.m. the Nursing Home Administrator (NHA) stated any blood smeared on a pillow case should be changed immediately and it was an infection control concern. During an observation on 09/24/24 at 2:20 p.m. with the NHA Resident #13's pillow remained stained with blood and asked staff to please change the pillow case immediately. During an interview on 09/24/24 at 2:34 p.m. the Director of Nursing (DON)/Infection Preventionist (IP) stated even if Resident #13 didn't have a bloodborne pathogen any blood on a pillow case for days at a time is an infection control concern for me. During an interview on 09/24/24 at 2:35 p.m. Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated having blood spread around is definitely an infection control issue. The soiled linen should have been changed immediately. During an interview on 10/02/24 at 10:00 a.m. the DON/IP stated he was aware of four residents that developed rashes over the past couple weeks. The DON/IP stated he did not report the rashes to the local health department because they were just rashes and could not classify the rashes as scabies; because the residents were not tested for scabies. The DON/IP stated he was unaware, until today, the four residents were being treated with a medication to treat scabies. The DON/IP stated he confirmed with the Maintenance Director there was no change in detergents or water; so maybe it was just dermatitis. The DON/IP stated he does track and trend and used a color coded map to watch for infections, but he was not tracking the four residents with rashes on the color coded map. The DON/IP stated the only infection he was tracking and monitoring in the facility was a case of Candida Auris (C-Aureus). Review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, revised date April 2013 showed: Purpose: To provide for general infection control while caring for residents. General Guidelines: 1. Standard Precautions will be used in the care of all residents in all situation regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucus membranes. Review of the facility's policy titled, Infection Control, undated showed: Policy: This facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission and infections. Policy Interpretation and Implementation: 2. The objective of the infection control policies and practices are to: a. Prevent, detect, investigate ad control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public .f. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. Review of the facility's policy titled, Environmental Infection Control- Laundry and Linen, undated showed: Policy: Soiled linen shall be handled in a manner that prevents gross microbial contamination of the air and persons handling them. Procedures: Bagging and Handling Soiled Linen 1. All soiled linen must be placed directly into a plastic bag 2. Do not sort or pre-rinse soiled linens in resident care areas 3. Place any linen saturated with blood and body fluids into a plastic bag 4. Handle soiled linen as little as possible to prevent agitation. 48441 2. On 09/23/24 at 11:58 a.m. an observation was made of Resident #22 in the common room of the Reflection hallway. Resident #22 was self-propelling herself in the room with one sock missing and the other sock halfway off. Resident #22 had exposed skin on her feet. Both feet were with heavy red streaks with small scattered open areas and a small amount of blood noted. Another resident was ambulating in the common room without socks. An observation was made of a staff member searching for socks for the ambulating resident and another staff member approached Resident #22, who asked Resident #22 where her other sock was. This staff member stated to the resident she needed to put cream on her foot. Resident #22 agreed her feet were itchy. On 10/01/24 at 12:31 p.m. an observation was made in the Reflection hallway common room of Resident #22 scratching her legs while eating her meal and sitting to the left of another resident at her table. Staff L, Licensed Practical Nurse (LPN) stated Resident #22 received oral Ivermectin along with three other residents, and the nurse practitioner did not feel a skin scrapping was necessary; just treatment. On 10/02/24 at 9:00 a.m. an interview was conducted with Staff D, LPN/Unit Manager (UM). Staff D, LPN/UM stated rashes for the residents are most likely caused from the laundry detergent. On 10/02/24 at 9:09 a.m. an interview was conducted with Staff M, Certified Nursing Assistant (CNA) in Resident #22's room. Staff M, CNA stated Resident #22 and her roommate Resident #62 received the Ivermectin and she noticed some improvement in their rashes. A record review was conducted of Resident #22's weekly Skin Only Evaluation for the months of August 2024 to 9/25/24. The skin evaluations prior to 9/18/24 showed no current skin issues. A review of the Skin Only Evaluation, dated 9/18/2024, showed Resident #22 with a new rash located on the arms, legs, feet and hands. The rash continued to be documented during the Skin Only Evaluation dated 9/25/2024. A review of Resident #22's September physician orders showed an order for Ivermectin oral tablet 3 milligrams (mg) to give 4 tablets by mouth one time only for rash for one day dated 9/22/2024. A review of Resident #22's September and October Medication Administration Records showed an entry for Ivermectin 3 mg (milligrams) give 4 tablets by mouth one time only for rash as given on 9/25/24. An order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #22's progress note, dated 9/23/24, showed the resident with ongoing scratching of chest and bilateral upper arms. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Chronic rash per facility staff reports, comes and goes. Patient as started on hydrocortisone 1% cream 9/12/24 until 9/28/24 Add oral Ivermectin one dose (4 tablets) now, repeat in 2 weeks Monitor for resolution of symptoms Currently waiting for delivery of Ivermectin form pharmacy Order for Loratadine 10 mg daily to help with itching Consider hydralazine if Loratadine ineffective, caution, with potential sedation side effect, high fall risk. A record review of Resident #62's weekly Skin Only Evaluation for the months of August 2024 up to 8/29/24 showed no current skin issues. A review of the Skin Only Evaluation dated 9/05/24, showed Resident #62 with a new rash located all over the thighs and Triamcinolone cream was applied as ordered. On 9/19/24 the weekly Skin Only Evaluation showed a rash to arms, legs, back and abdomen and a skin note showed resident does have a treatment in place for her rash, skin is clean dry and intact. On 9/26/24, the weekly Skin Only Evaluation showed a skin issue but not specified and the skin note showed resident has itching and on Ivermectin for the scabies rash. A review of Resident #62's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day dated 9/22/24. An order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #62's September Medication Administration Record showed an entry for Ivermectin 3 mg give 4 tablets by mouth one time only for rash as given on 9/25/24. A review of Resident #62's progress note, dated 9/22/24, showed the resident with ongoing, worsening rash with staff reports of itchy and scratching a lot. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Ivermectin one dose now (4 tablets), followed by repeat dose in 2 weeks. Continue Loratadine 10 mg orally daily for 30 days. Continue with Triamcinolone cream 0.1% three times a day for 14 days. Keep area of rash clean and dry. Wash with mild soak and warm water, pat dry. A record review of Resident #46's weekly Skin Only Evaluation for the months of August 2024 up to 8/21/24 showed no current skin issues. A review of the Skin Only Evaluation, dated 8/28/2024, showed Resident #46 with a new rash on chest, back and abdomen and a skin note showed resident previous rash noted back abdomen and stomach and treatment in place for itching. On 9/11/24 the weekly Skin Only Evaluation showed a current skin issue of rash with a skin note of rash to bilateral arms, chest and back persists treatment orders in place. On 9/18 and 9/25/24 weekly Skin Only Assessment showed rash continued with current treatment in place with an added area of rash to thighs on 9/25/24. A review of Resident #46's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day dated 9/24/2024. An order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day with a start date of 10/06/24. A review of Resident #46's September Medication Administration Record showed an entry for Ivermectin 3 mg give 6 tablets by mouth one time only for itching as given on 9/25/24. A review of Resident #46's progress note, dated 9/25/24, showed resident still with intermittent itchiness secondary to recent rash. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Received dose of Ivermectin. A record review of Resident #12's weekly Skin Only Evaluation for the months of August 2024 up to 9/26/24 showed no skin issue, but chronic leg skin tear to left shin. A review of Resident #12's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day dated 9/22/24. An order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #12's September Medication Administration Record showed an entry for Ivermectin 3 mg give 6 tablets by mouth one time only for itching as given on 9/23/24. A review of Resident #12's progress note, dated 9/22/24, showed staff notes of resident with worsening rash to trunk and bilateral lower extremities and scratching a lot. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Ivermectin times one doe now (weight based, 6 tablets, verified with pharmacist), repeat in 2 weeks. Triamcinolone cream twice a day for 14 days. Consider Hydroxyzine at bedtime for pruritus if symptoms do not improve and patient continues to scratch. On 10/02/24 at 9:48 a.m. an interview was conducted with the primary Advance Practice Registered Nurse (APRN) for Residents #62, #22, #46, and #12. The APRN stated she was aware of the skin conditions and ordered steroidal creams upon initial assessment. The APRN stated she was suspicious of the ongoing skin conditions and chose to prescribe Ivermectin orally. The APRN stated a skin scrapping had been considered but was not aware of a dermatologist the facility utilized. The APRN stated she did not have a conversation with the Director of Nursing, but stated she had multiple conversations with the nursing staff for these residents. The APRN stated she contacted her physician on the process for getting a dermatologist consult through their company. The APRN stated if a potential positive diagnosis of scabies was reported, the whole unit should be treated, but compliance may be an issue with applying lotion and bathing. On 10/02/24 at 11:34 a.m. an interview was conducted with the NHA. The NHA stated the facility has daily meetings related to resident clinical concerns in which all department heads attend. The NHA stated she was not aware of residents with orders for Ivermectin and cannot conclude scabies was the rationale behind the orders for the four residents in the Reflection hallway. The NHA stated scabies is not a reportable criterion for infection surveillance to the [State Agency]; therefore, the facility's infection control policy would be the process for the facility to follow. The NHA stated the orders for Ivermectin were put in last week. The NHA stated they will follow their process and have the residents sent out to be tested . The NHA stated the Director of Nursing/Infection Control Preventionist (DON/IP) should have been notified of the concern the moment it was discovered. A record review of the facility's Order Listing Report, dated 9/24/2024 at 1:42 p.m., showed: Resident #12 with an order for Ivermectin oral tablet 3 milligrams give 6 tablets by mouth one time only for rash for one day, order date 9/22/24. Resident #22 with an order for ivermectin oral tablet 3 milligrams give 4 tablets by mouth one time only for rash for one day, order date 9/22/24. On 10/02/24 at 12:00 p.m. a telephone interview was conducted with the Medical Director (MD) and primary physician for Residents #62, #22, #46 and #12. The MD stated he was aware of the residents' rashes and of the orders for Ivermectin. The MD stated the rational for the Ivermectin was empiric coverage but not clear on what the primary cause was. The MD stated Ivermectin would be the medication utilized for a potential diagnosis of scabies. The MD stated he noticed residents itching on his last visit to the facility; but could not state he witnessed definitive signs of scabies. The MD stated that to send a resident out for testing could take time and to treat empirically would make sense. The MD stated two weeks ago his suspicions were low for a potential diagnosis for scabies. On 10/02/24 at 12:20 p.m. a telephone interview was conducted with an epidemiologist at the [State Agency] for Pinellas County. The epidemiologist stated not only are scabies a reportable criterion to the [State Agency] but rashes of any nature in which two or more residents and/ or staff members are involved should be reported. The epidemiologist stated the [State Agency] will provide recommendations to assist the facility. The epidemiologist denied any phone calls were made to the [State Agency] from this facility regarding rashes and/ or potential scabies. A review of the facility's Surveillance For Infections undated policy showed the policy statement as: The Infection Control Nurse will conduct ongoing surveillance for Health Care Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and may require transmission -based precautions and other preventive interventions. 1. The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include those with a. evidence of transmissibility in a healthcare environment b. available processes and procedures that prevent or reduce the spread of infection. c. clinically significant morbidity or mortality associated with infection and d. pathogens associated with serious outbreaks for example invasive streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza . 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Infection Control Nurse/ DON as soon as possible. 6. If a communicable disease outbreak is suspected, this information will be communicated to the Infection Control Nurse/ DON immediately. 7. When infection or colonization with epidemiological important organisms is suspected, cultures may be sent, if appropriate to the lab for identification or confirmation period cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8. The Infection Control Nurse/DON will notify the physician of suspected infections. a. the Infection Control Nurse /DON will notify the physician to determine if laboratory tests are indicated and whether special precautions are warranted b. the Infection Control Nurse/DON will determine if the infection is reportable. c. The physician will determine the treatment plan for the resident. 9. If transmission- based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Control Nurse/ DON will collect data to help determine the effectiveness of such measures 10. when transmission of HAIs continues despite documented efforts to implement infection control and prevention measures; the appropriate state agency and /or a specialist in infection control will be consulted for further recommendations. Gathering Surveillance Data: 1. The infection control nurse is responsible for gathering and interpreting surveillance data. The QAPI committee may also be involved in the interpretation of data. 2. The surveillance should include a review of any or all of the following information to help identify possible indications indicators of infections: a. laboratory records b. skin care sheets c. infection control rounds or interviews d. verbal reports from staff e. infection documentation records f. temperature logs g. pharmacy records h. antibiotic review . 51097 3. On 10/01/24 at 11:28 a.m. Staff H, Licensed Practical Nurse (LPN), was observed placing the glucometer used for Resident #2 during medication administration into the medication cart without cleaning or sanitizing after its use. Staff H stated every resident is supposed to have their own glucometer and she normally cleans them with an alcohol wipe. On 10/01/24 at 11:30 a.m. an interview with the DON/IP was conducted. The DON/IP stated there are only supposed to be two glucometers on the cart. The residents don't have their own glucometer anymore. The glucometers are supposed to be cleaned with bleach wipes after each use. Review of the competency checklist titled, Skill Competency Assessment: Glucometer, revealed the following: 3. Inspect, clean and disinfect the glucometer utilizing a disinfectant wipe per manufacturer's recommended wet time. A review of user instruction manual of the manufacturer of the glucometer at www.arkrayusa.com revealed the following: Blood Glucose Testing: The meter should be cleaned and disinfected after use on each patient .

Based on observations, interviews, and record review the facility did not ensure a clean, safe, sanitary, and homelike environment for five resident rooms (#113, #123, #214, #222 and #223), nine resident bathrooms (#122, #213, #214, #215, #216, #218, #219, #221, and #223), one shower room (West Wing), one housekeeping closet (West Wing) and two halls located on the [NAME] Wing during four of four days observed (09/23/24, 09/24/24 and 10/01/24 and 10/2/24). Findings included: An observation made on 9/23/2024 at 9:52 a.m. in the hallway outside of Resident room [ROOM NUMBER] revealed a petrified worm about one inch from the wall on the floor. The worm remained there until after 9/24/2024 at 5:00 p.m. An observation was made on 9/23/2024 at 10:08 a.m. of Resident room [ROOM NUMBER]'s bathroom that revealed the floor near the window having brown streaks in various locations. The bathroom sink counter was protruding from the particle board, creating a space and uncleanable surface. The counter had brownish stains surrounding the sink bowl all the way to the wall edge. Underneath the sink, the floor had an accumulation of dirt and debris, including a petrified lizard and worm. The floor next to the toilet had brown colored marks in various locations. The toilet seat had brown colored buildup of dirt. An observation was made on 9/24/2024 at 12:21 p.m. of Resident room [ROOM NUMBER]'s bathroom revealing the side of the toilet bowl had a blackish color, rough patch appearing as a small hole, the toilet bowl had brownish color around the top rim of the bowl and a brown ring where the water level resides. The connection point for the grab bars next to the toilet was cracked and had a buildup of debris, some flaking off. In addition, an observation of the remote control on the resident's bed in room [ROOM NUMBER] revealed it had wires exposed. An observation was made on 9/23/2024 at 10:13 a.m. of Resident room [ROOM NUMBER] and the bathroom. The observation revealed the wall beneath the window had a space between the drywall and cove base, and the resident room floor had brown/black colored stains on the floor. The toilet had a brown/yellow buildup of debris where the seat connects to the bowl. Inside the toilet bowl was a brown ring, and marks throughout the bowl. The toilet tank had a plastic shelf partially covering the toilet tank water. The cove base under the toilet paper holder was separated from the floor. At the base of the toilet and the floor was brown/yellow debris build up. The grab bars had brown stains covering them. The connection point of the grab bars to the toilet bowl had a whitish buildup and a raised metal piece. A petrified worm was next to the toilet opposite the toilet paper roll. An observation was made on 9/23/2024 at 10:18 a.m. in the bathroom of Resident room [ROOM NUMBER]. The toilet had a brown/yellow buildup of debris where the seat connects to the bowl. Inside the toilet bowl was a brown ring coming down from the rim, and marks throughout the bowl. The toilet bowl had a brown substance running down the front of the bowl to the floor. The floor surrounding the base of the toilet was brown/yellow in color. Significant debris was built up on the base of the toilet. The base of the toilet near the back had a brownish substance running to the floor. Dirt and debris were surrounding the bathroom walls. [NAME] colored marks were observed on the door frame going into the resident room, and the light switch and wall to the entrance of the other resident's room (shared bathroom). No toilet paper was observed in the dispenser, and a roll was on top of the dispenser (open) with brown stains on the paper and a roll in the manufacturer paper. An observation was made on 9/23/2024 at 10:28 a.m. in the bathroom of Resident room [ROOM NUMBER]. The toilet seat was cracking and had a brownish color surrounding. Inside the toilet bowl was a brown ring, and marks throughout the bowl. Dirt and debris was built up surrounding the bathroom floor and wall. The emergency call cord next to the toilet had a black cloth tied in a knot and the cloth was observed to have small blotches of a brownish substance on it. An observation was made on 9/23/2024 at 10:30 a.m. of the bathroom of Resident room [ROOM NUMBER]. The wall next to the toilet had a brownish color running down a few tiles. The base of the toilet and bowl had various smudges of yellow/brown color and build up of debris surrounding the toilet. An observation was made on 9/23/2024 at 10:45 a.m. of the bathroom of Resident room [ROOM NUMBER]. The toilet bowl base had a significant build up of a brownish substance. The toilet paper dispenser was empty, and two open rolls, sat atop of the dispenser. An observation was made on 9/24/2024 at 12:34 p.m. in Resident room [ROOM NUMBER] of the remote for the bed with wires exposed. An observation was made on 9/23/2024 at 10:51 a.m. of Resident room [ROOM NUMBER]'s bathroom. The toilet bowl and floor were soiled with a brown/black/yellow substance. An observation of the room revealed the bed remote had exposed wires. An observation was made on 9/23/2024 at 10:04 a.m. of the [NAME] Wing Unit walls. The two hallways with Resident Rooms #211 to #229 had numerous locations with a beige substance splattered on the walls. Debris was in the cutout of the fire extinguisher near Resident room [ROOM NUMBER]. An observation was made on 9/23/2024 at 10:34 a.m. of the [NAME] Wing Unit's housekeeping closet. The door was unlocked, and the housekeeping carts were located inside. The housekeeping carts were unlocked and had chemicals stored in them. On the back wall of the closet a chemical dispensing machine was on the wall. An observation was made on 9/23/2024 at 11:58 a.m. of the [NAME] Wing Unit's shower room. The shower stall had black bio growth along the floor, walls and drain. The shower chair had a pink bio growth surrounding the connection points of all four of the chair legs. The seat of the shower chair had hair and brown substance on the left side. The shower bed had a white buildup on the straps. During an interview on 10/1/2024 at 1:48 p.m. the Maintenance Director (MD) stated he was also in charge of housekeeping and laundry. The MD toured the [NAME] Wing Unit hallways and specified rooms above. The MD stated, This is horrible. The MD continued to state a plan was in place to strip and wax the floors. The MD confirmed the issues being pointed out are not with stripping and waxing. The MD stated this just needs to be cleaned. The MD confirmed the above findings and stated, This should not be this way, we will need to get cleaning this. During an interview on 10/2/2024 at 11:55 a.m. the Nursing Home Administrator (NHA) confirmed the findings above. A review of the facility policy titled, Complete Room Procedure, undated, revealed: . 3) Scrub bathroom floor (if ceramic tile) A) soak bathroom floor with mop water B) scrub floor with swivel scrub brush C) wet mop bathroom floor . *** Remember to detail clean all walls, doors, furniture*** . A review of the facility policy titled, 10 Step Cleaning Process, undated, revealed: . Step 4 Sanitize all horizontal surfaces * use germicide properly. Germicide kills harmful microorganisms.* Let surfaces air dry.* Don't forget door knobs and telephones. Step 5 Spot Clean all vertical surfaces * use germicide or all-purpose cleaners * don't forget to clean around waste receptacles and light switches. * Chemicals need time to work effectively. Step 6 Clean The restroom * pre spray shower to give chemical time to work. * Do not use toilet bowl brush outside of toilet bowl. Don't forget to fill the dispensers . Step 9 Damp Mop/Microfiber Mop the floor * change the germicidal solution in your mop bucket every three rooms. * Don't forget the restroom floor . 43453 On 09/23/2024 at 10:42 a.m. a tour was conducted of Resident room [ROOM NUMBER] with concerns noted in the bathroom. An observation was made of the inside of the toilet with brown stains. The toilet base was observed with brown matter on the surface. The walls and floors were observed with brown stains. The floor under the sink and the walls under the sink were observed with black and brown substances. The resident stated the brown substances were fecal matter. She stated she had asked them to clean it. On 09/23/2024 at 10:44 a.m. a tour of Resident room [ROOM NUMBER] revealed concerns related to dirt, dust and small dead insects on the window seal. The ceiling above the resident's bed was observed with cobwebs, dust and small debris. The air conditioning unit was observed with black matter on the inside of the vents. On 09/23/2024 at 1:47 p.m. an observation of Resident room [ROOM NUMBER] revealed a side table and bedside table with non-cleanable surfaces. The surfaces were observed with disintegrated particle board surfaces. This same observation was made on 09/24/2024, 10/01/2024 and 10/02/2024. On 09/24/2024 at 1:10 p.m. an observation of Resident room [ROOM NUMBER] revealed previously identified concerns in the bathroom. The toilet, floors and walls were observed with brown substances on the surfaces. On 10/01/2024 at 11:32 a.m. Resident Rooms #122 and #123 were observed with the same previously noted concerns. On 10/01/24 at 2:05 p.m. an interview was conducted with the NHA. She stated the resident rooms should be cleaned daily. She stated she was aware they need to replace some furnishings in the resident rooms. The NHA stated all non-cleanable surfaces should be replaced. (Photographic Evidence was Obtained)

Based on observation, interview and record review the facility did not ensure accurate accountability and storage of controlled medications in two (East Cart 1, East Cart 2) out of three medication carts inspected. Findings included: On 10/01/2024 at 2:15 p.m. an observation was made of narcotic count discrepancies during medication storage observation, with Staff H, LPN. A count of the controlled medication drawer in the East Wing Carts 1 and 2 revealed the following: - One small loose light-yellow pill in the narcotic box of the medication cart (Photographic Evidence Obtained), - A card containing 26, Clonazepam 1.0 milligram (mg) tablets. The controlled substance record documented 27 remaining on the card. - A card containing 29 Clonazepam 0.5 mg tablets. The controlled substance record documented 30 remaining on the card. - A card containing 21 Oxycodone HCL 5 mg tablets. The controlled substance record documented 23 remaining on the card. - A card containing 26 Tramadol 50 mg tablets. The controlled substance record documented 27 remaining on the card. - A card containing 16 Hydrocodone/APAP 5-325 mg tablets. The controlled record documented 17 remaining on the card. - A card containing 30 Tramadol 50 mg tablets. Review of the electronic medical record showed the resident was discharged on [DATE]. On 10/01/2024 at 2:40 p.m. during an interview conducted with Staff H, LPN stated she was busy and just did not get around to signing the medications out and stated, It was a hectic morning. Staff H, LPN stated medication should be signed out when the medication is administered. Staff H, LPN stated discharged narcotics should have been removed from the narcotic medication box, but the DON (Director of Nursing) oversaw disposing of all narcotic returns. On 10/01/2024 at 3:30 p.m. an interview was conducted with the DON. The DON stated narcotic medication should be documented immediately after the medication is administered. The DON stated he oversees the disposal of narcotics when the nurses inform him of a return and he was unaware of a narcotic medication card from a discharged resident in the medication cart. A review of the facility policy titled, Controlled Substance, effective 9/07/2023, revealed under the section titled Policy showed the facility shall comply with all law, regulations, and other requirements related to handling, storage, and documentation of Scheduled 11 and other controlled substances. A review of the facility policy titled, Medication Storage, effective 12/08/2023, revealed under section Policy showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy revealed under the section titled Procedures . Number 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes. ) Containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (Photographic Evidence Obtained)

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed, and ten errors were identified for four residents (#4, #67, #11, #2) out of five residents observed. These errors constituted a 28.57% medication error rate. Findings included: 1. On 10/01/24 at 8:24 a.m. an observation was made of Staff H, Licensed Practical Nurse (LPN). Staff H dispensed the following medications for Resident #4: -Baclofen 10 milligram (mg) tablet -Calcium 600 mg with Vitamin D3 tablet -Clonazepam 0.5 mg tablet -Colace 100 mg tablet -Iron (ferrous sulfate) 325 mg tablet -Valproic Acid 250 mg/5 milliliters (mL) -Levetiracetam 100 mg/10 mL -Risperidone 3 mg tablet -Vitamin C 500 mg tablet -Simethicone 80 mg tablet. Staff H, LPN confirmed dispensing 8 tablets, 5 mL of Valproic Acid and 10 mL of Levetiracetam. The observation revealed 5 mL of Levetiracetam was dispensed. Upon entering the resident room, Resident #4 was alert and asked Staff H if she could take the tablets by mouth and the liquid medication through her gastric tube (G-tube). The staff member administered the oral tablets and assisted resident with water cup. Staff H then washed her hands, gathered G-tube supplies and administered 15 mL of water to G-tube by gravity to flush. The staff member administered 5 mL of Valproic Acid through the G-tube by gravity, flushed with 10 mL of water by gravity, administered 5 mL of Levetiracetam by gravity followed by a flush of 20 mL of water by gravity. Staff H clamped the G-tube, washed hands and exited the room. Review of the Resident #4's October 2024 Medication Administration Record (MAR) revealed the following orders related to the observed administration of medications: - Ferrous Sulfate Oral Solution 220 (44 Fe) [44 Iron] MG/5ML (Ferrous Sulfate) Give 5 ml via PEG-Tube [Percutaneous Enterogastric tube] one time a day for anemia, 0900 (9:00 a.m.), - Calcium Oral Tablet (Calcium) Give 500 mg via PEG-Tube two times a day for supplement, 0900 and 2100 (9:00 p.m.), - levETIRAcetam Oral Solution 100 MG/ML (Levetiracetam) Give 10 ml via G-Tube two times a day for Seizure Disorder, 0100 (1:00 a.m.) and 0900. 2. On 10/01/24 at 8:55 a.m. an observation was made of Staff I, Registered Nurse (RN). Staff I dispensed the following medications for Resident #67: -Vitamin B complex with vitamin B12 tablet -Aspirin 81 milligram (mg) tablet -Lasix 20 mg tablet -Carvedilol 12.5 mg tablet -Lisinopril 40 mg tablet -Tylenol 500 mg 2 tablets. Staff I, RN confirmed dispensing seven tablets. Upon entering the resident room, Resident #67 was alert. Staff I took a manual blood pressure prior to administering the oral tablets. Review of the Resident #67's October 2024 MAR revealed the following order related to the observed administration of medications: - Thiamine HCl [hydrochloride] Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth one time a day for supplement, 0900. 3. On 10/01/24 at 9:05 a.m. an observation was made of Staff I, RN. The staff member dispensed the following medications for Resident #11: -Aspirin 81 mg enteric coated tablet -Tamsulosin 0.4 mg capsule -Hydroxyzine 25 mg tablet -Trihexyphenidyl 2 mg tablet -Metoprolol Succinate 50 mg tablet - Potassium Chloride Extended Release 20 milliequivalents (MEQ) tablet -Duloxetine 60 mg Delayed Release capsule -Plavix 75 mg tablet -Folic Acid 1 mg tablet -Donepezil 5 mg tablet -Aripiprazole 5 mg tablet - Amlodipine 5mg tablet -Pioglitazone 30 mg tablet -Glipizide 10 mg tablet. Staff I, RN confirmed dispensing 2 capsules and 12 tablets. Staff I placed all the tablets in a medication bag to be crushed. Staff I, RN stated, I crush all of these first, then open the capsules and put them on top. After the medications were crushed into a powder, the staff member took a medication cup, added a spoonful of vanilla pudding and poured the medication powder on top. The capsules were opened and added to the medication cup with the pudding and other medications. Another spoonful of vanilla pudding was added to the medication cup and stirred together mixing the crushed medications into the pudding. Upon entering the resident room, Resident #11 was alert and sitting in the bed. Staff I set the medication cup with the pudding medication mixture on the bedside table. After the vital signs were taken, Staff I assisted Resident #11 by spoon feeding him the medication mixture. Review of Resident # 11's October 2024 MAR revealed the following orders related to the observed administration of medications: - Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for CAD [coronary artery disease], - Metoprolol Succinate ER [extended release] Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for HTN [hypertension], - Potassium Chloride ER Tablet Extended Release 20 MEQ Give 1 tablet by mouth one time a day for Hypokalemia, - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for Depression, - Pioglitazone HCl Tablet 45 MG Give 1 tablet by mouth one time a day for diabetes mellitus. 4. On 10/1/24 at 11:17 a.m. an observation was made of Staff H, LPN, obtaining a blood glucose level, preparing medication, and injecting Resident #2's insulin. Staff H assisted the resident back to the room, washed hands, donned gloves, cleaned the resident's right middle finger with an alcohol pad, and lanced the finger unsuccessfully. Staff H cleaned the resident's right pinky finger, lanced the finger, and obtained a blood glucose level of 285. On 10/1/24 at 11:25 a.m. Staff H, LPN removed Resident #2's Novolog Flexpen from the medication cart, placed an insulin needle on the pen, dialed 3 units on the dosage selector and returned to the resident's room. The staff member cleansed the resident's right lower abdominal quadrant with an alcohol pad, the dosage selector of 3 units was verified prior to the injection of insulin. The staff member verified the dosage selector had returned to zero. On 10/1/24 at 11:28 a.m. Staff H, LPN stated she did not prime the insulin pen prior to administration. Staff H stated she is only supposed to prime the insulin pen the first time the pen is used. Review of the manufacturer information for Novolog Flexpen, located at https://www.novo-pi.com/novolog.pdf revealed the instructions to use the air shot or prime the needle before each injection. Small amounts of air may collect during normal use. To avoid injecting air and ensure proper dosing, perform an air shot. -Turn the dose selector to 2 units -Hold flexpen with needle pointing up. -Tap cartridge gently a couple times to make any air bubbles collect to the top of the cartridge. -Keep the needle pointing upwards and press the push-button all the way in. The dose selector then returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the Novolog Flexpen. On 10/2/24 at 8:29 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated the nurses are supposed to prime the Novolog flex pens prior to each use. He stated they are supposed to point the tip upward, dial 2 units and push it out, then dial select the appropriate dose. On 10/2/24 at 12:00 p.m. an interview with the Medical Director was conducted. The Medical Director stated extended-release medications should not be crushed. It would be contraindicated to crush Metoprolol Succinate extended release. On 10/2/24 at 12:20 p.m. an interview with the Pharmacist was conducted. He stated extended-release medications should not be crushed. Metoprolol Succinate should not be crushed. Potassium Chloride ER cannot be crushed because it has microbeads in it, this medication can be dissolved in water and administered separately. Duloxetine can be opened and sprinkled in apple juice or applesauce and administered separately; it is not appropriate to open the capsule and mix with other medications in pudding. A review of the policy titled, Medication Administration Policy-General, dated 08/07/23, revealed the following: 3. Dose Preparation: 3.7 Verify that the medication name and doe are correct when compared to the medication order on the medication administration record. 3.10 Crush oral medications only in accordance with Pharmacy guidelines. 4. Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule.

Based on observations, interviews and record review, the facility failed to ensure three residents (#8, #3 and #27) observed for assisted dining in two (100 and 200) of two halls received a dignified dining experience. Findings included: 1. Resident #8 was admitted to the facility on [DATE] with a primary diagnosis of amyotrophic lateral sclerosis. Review of the September 2024 physician orders for Resident #8 revealed the resident received a regular diet, pureed texture, nectar/mild thick consistency. A care plan for Resident #8, initiated on 05/02/19, showed the resident required staff assistance with ADLs (Activities of Daily Living). Interventions showed the resident needed staff assistance with eating. On 09/23/24 at 12:00 p.m. an observation was made of Staff A, Certified Nursing Assistant (CNA) standing while assisting the resident with their meal. A chair was observed by the resident's bed with the resident's personal clothes stacked on top of it. On 09/24/24 at 2:09 p.m. an interview was conducted with Staff A, CNA. She said, Yes, I was standing. There was a chair in the room. I should have been sitting. Staff A stated she would normally sit but she did not sit on that day. She stated she received education. She said, They said I should sit when assisting with feeding. On 09/24/24 at 2:25 p.m. an interview was conducted with the Director of Nursing (DON). He stated the staff should be sitting at eye level when assisting the resident with meal. On 09/24/24 at 2:40 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the expectation was for the CNA to sit at eye level during meal assistance. 51097 On 09/23/24 at 12:00 p.m. Resident #3 was observed being taken to the resident's room for the lunch meal. Staff J, CNA was observed feeding Resident #3 while standing next to him. 48223 On 09/23/24 at 12:26 p.m. Resident #27 was observed sitting up in her bed and being assisted with the lunch meal. Staff J, CNA was observed to be standing next to the resident's bed while assisting the resident. Staff J, CNA then sat on the resident's bed to finish the dining process. During an interview on 09/23/24 at 1:30 p.m. Staff J, CNA stated, Yes, I was sitting on the resident's bed. I know, I am not supposed to sit on the bed. Staff J continued and stated there are not enough chairs. We only have one folding chair. Review of facility policy and procedure titled, Resident Rights, undated, revealed: Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . t. privacy and confidentiality .

Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#3) out of 14 residents at risk for elopement with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. The facility failed to ensure the secured unit exit door and door alarms were operating properly, failed to check the surroundings when the exit door alarmed, and failed to account for the whereabouts of all elopement risk residents on 3/6/2024. Resident #3 exited the secured unit of the facility via a maglock alarming dining room exit door on 3/6/24 at approximately 3:45 PM and was located at approximately 5:30 p.m. 0.8 miles away. The resident would have traveled across a busy 6-lane intersection with a speed limit of 45 MPH to reach this destination. The facility staff did not recognize the resident was missing. Resident #3 was returned to the facility approximately 2 hours later by an off-duty staff member. No assessment, interventions, or supervision measures were put in place and the resident eloped from the facility a second time approximately 20 minutes later using the same alarming exit door. The resident was observed outside by a nurse on break who notified additional staff to help intervene. Resident #3 became increasingly agitated/aggressive and crossed a two-lane road in front of the facility with a speed limit of 35 MPH where he was nearly hit by a vehicle before emergency services were contacted for assistance. This neglect created a situation that resulted in the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Ongoing Immediate Jeopardy beginning on 3/6/2024. Findings Included: A review of Resident#3's hospital records revealed a History of Present Illness (HPI) dated 02/02/2024 at 4:48 AM by a Physician's Assistant (PA). Chief complaint: Altered Mental Status [AMS]. HPI narrative: [AGE] year-old male with a history of inguinal hernia, cognitive disorder/dementia, alcohol use disorder, and homelessness presents to the emergency department by PD [Police Department]. According to what I can ascertain by triage the patient was found by PD in a convenience store. Patient appeared confused and was brought to the ER [emergency room ]. A review of the ER exam narrataive revealed the patient is disheveled and has urine soaked close [sic]. The medical decision narrative revealed the patient is alert to person and place but confused on date and time. The plan was to perform an AMS workup. On 02/02/2024 at 9:12 AM, Security voiced concern that the patient was wandering outside and did not seem to know where he was going or where he was. Registered Nurse (RN) went outside and reassessed the patient. He says he knows where he is going, but cannot tell us how to get where he is going. He keeps repeating himself. He cannot provide an address. His orientation is the same as previous. The PA reported this is chronic for this patient. The Advanced Registered Nurse Practitioner (ARNP) did not feel the patient was safe to be discharged from the hospital. He was escorted back inside. The ARNP discussed the patient with case management (CM), and the patient was admitted to work on getting patient capacity and possible long-term placement. Differential Diagnosis included AMS, dementia, Alzheimer's, and homelessness. A review of Resident #3's hospital case management notes revealed: 02/02/2024 at 9:18 AM - the patient was residing in a group home since August 2023 and now required a locked facility. 02/02/2024 at 2:01 PM resident has been accepted for transport to current skilled nursing facility. Review of Resident #3's Hospital to Nursing Home Medical Certification Transfer Form (Form 5000-3008), dated 02/02/2024, showed the resident required a surrogate for medical decision making and a primary diagnosis of AMS. The transfer form showed a patient risk alert for elopement and documented the patient was alert and disoriented but could follow simple instructions. Review of Resident #3's initial nursing evaluation collection tool, dated 02/02/2024 at 10:30 PM revealed a diagnosis of AMS, poor cognitive recall, orientation to person and place only. The resident was refusing care and had permanent medical needs with no plans to discharge from the facility anticipated. Review of a Nurse's Note dated 02/02/2024 at 11:30 PM showed Resident #3 refused to enter the facility initially and was eventually transported into the facility by wheelchair. The resident was alert and confused. Review of Resident #3's initial admission Wander Data Collection Tool, dated 02/02/2024 showed a score of 7 (3 or more Yes answers - Definite Risk for elopement.). The score of 7 was from the following Yes responses: 1. Has the resident wandered before, at home or in previous living settings? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place? 3. Is the resident cognitively impaired with poor decision-making skills? 4. Is the resident a new admission and not accepting the new living arrangement? 5. Does the resident ambulate independently with or without an assistive device? 6. Does the resident talk about his desire to go home, talked about going on a trip, or packed up his belongings to leave? 7. Does the resident's former profession reflect the current behavior of wandering? (Documented past profession of truck driver). The sections of the wander data collection tool to list Resident #3's interventions and summary of findings was not completed for the initial admission on 02/02/2024. Review of Resident #3's Baseline Care Plan dated 02/02/24 at 11:30 p.m. revealed checkmarks were made for: No safety issues. Elopement risk - Intervention(s): ____________ The space to document elopement intervention(s) was blank. A review of Resident #3's Brief Interview for Mental Status (BIMS), dated 2/4/24, revealed seven of seven cognitive function indicators had a score of zero. The BIMS summary score section was blank; however, the total score of zero indicated severe cognitive impairment. The Staff Assessment for Mental Status, dated 2/4/2024 showed Resident #3 had short-term and long-term memory problems. The resident's Memory/Recall Ability revealed the resident did not know the current season, staff names and faces, or that he was in a nursing home. Resident #3 knew the location of his room. A review of Resident #3's Progress Note-MD [Medical Doctor] History & Physical dated 2/5/24, by the resident's physician (who is the facility's Medical Director) confirmed the resident's recent history of dementia, homelessness, and past alcohol use with recent admission to the nursing home after the hospital determined discharge to be unsafe without supervision. The physician described Resident #3 as pleasantly confused, oriented to self and not sure of the date, current location, or how he arrived to the facility. The resident alluded to having things to do and referred to people/situations that don't appear grounded in reality. Resident stated, I've got to go take these things somewhere, states he knows where but doesn't share the location. Resident wants to know how much longer he will be here. Per report has intermittently been kicking and sleeping under secure unit door. Assessment/Plan revealed diagnoses of dementia in other diseases classified elsewhere, unspecified severity with anxiety. Reported behavioral disturbances - intermittent anxiety/agitation and exit seeking. Begin Hydralazine 25 mg by mouth every six hours as needed (PRN) for agitation. A review of a Nurse's Note dated 2/6/23 [sic] at 10:00 AM showed Resident #3 was alert with confusion. Constantly looking for exit door to go back to Daytona. A review of the February 2024 Medication Administration Record (MAR) revealed the resident was administered Hydralazine 25 mg for anxiety on 2/6/24. This medication was not administered again, and the order was discontinued on 2/14/24. Review of a Psychiatric Evaluation and assessment for medical decision-making capacity, dated 2/8/24 by the psychiatric Advanced Registered Nurse Practitioner (ARNP), showed Resident #3 was alert, oriented to self only. The staff said resident was exit seeking upon arrival to the facility but was redirectable. The patient is not able to recognize his medical condition and the probable consequences of lack of treatment, nor the treatment options. The patient is not able to engage in a rational process of manipulating relevant information. Patient is unable to discuss the risk and benefits of his choices, and the alternative to treatment. In my opinion, this patient lacks the capacity to make decisions related to his need for health care, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burdens, risks, and benefits of treatment. In my opinion, the patient can benefit from a guardian or POA [Power of Attorney]. The mental status exam noted the resident's insight and judgment were impaired due to dementia. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] showed a BIMS score of 0 (severe cognitive impairment), the resident exhibited inattention and disorganized thinking behavior that fluctuates (comes and goes, changes in severity). The resident had physical and verbal behavioral symptoms toward others for 1 to 3 days of the 6-day observation period. This behavior significantly interfered with the resident's participation in activities or social interactions. The resident rejected care for 1 to 3 days of the 6-day observation period. The resident wandered daily, and the wandering placed the resident at significant risk of getting to a potentially dangerous place. The resident was independent with all Activities of Daily Living (ADL's) except for needing supervision to shower/bathe. The resident had an active diagnosis of dementia. Review of Resident #3's care plan initiated on 2/20/24 revealed exit seeking behavior related to dementia and behaviors. Resident #3 was documented on the care plan as an elopement risk with goals to always keep the resident safe and to decrease exit seeking by 50% through the next review date (target date 5/20/2024). Resident #3's interventions included: redirect resident away from exits, encourage attendance at group activities, place resident's picture and information in elopement book, ensure all staff aware of exit seeking behavior, and other: secure unit. The bottom of the care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3's problems included few relationships, self-isolation, anger at self or others, impaired concentration and difficulty making decisions related to a mood disorder. The goal for this care plan was try to engage Resident #3 in activities (target date 5/20/2024). The interventions included: look for opportunities to help the resident see there are choices that can be used to control life, listen with patience, and compassion, and acknowledge sadness, irritability, or withdrawal. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed the resident had behavior issues related to being socially inappropriate, physically abusive, verbally abusive, wandering, sexually inappropriate, resistive to care, hoarding, and a propensity for taking things that belonged to others. The goal for this care plan was to not harm self or others and to redirect and encourage activity involvement (target date 5/20/2024). The interventions included: administer and monitor the effectiveness and or side effects of medications as ordered, intervene to protect the rights and safety of others, approach in calm manner, provide psych consult and psychological counseling. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3 required long term care in a secured unit with a risk/challenge of unsafe discharge. The goal documented Resident #3 was not safe to transition to a lesser level of care and would remain in the secured unit until the next review date of 5/20/2024. The interventions included assess the needs of resident/caretaker during stay, anticipate needs and services, involve resident in discharge planning process, provide written and verbal instructions at the resident's level of understanding, assess for community resources that may be needed, and document all discharge teaching. The bottom of this care plan noted the resident was cognitively impaired. Review of Nurse's Notes revealed: 2/21/24 at 11:00 a.m. Resident #3 was alert with confusion. 2/27/24 At approximately 6 PM Resident sitting in [NAME] hall dining room after dinner. Reports sitting on edge of chair and slipped off landing on floor. Denies any pain/discomfort, able to stand by himself, and denies hitting head. Resident able to move all extremities with no limitations. Physician Assistant made aware of episode with no new orders. Call placed to family member and phone number has been disconnected. A review of an ARNP Progress Note dated 2/28/24 revealed resident was seen for a follow up visit due to fall without injury on 2/27/24. The resident was alert with confusion, resided in the secure unit and was ambulatory without assistance. Continue watchful monitoring for changes, decreased mobility, and pain. Review of Resident #3's physician's orders revealed a telephone order dated 2/29/24 to change Hydroxyzine to 25 mg every 6 hours as needed for 14 days. Review of Resident #3's Treatment Record dated 2/29/24, time not legible showed Hydroxyzine 25mg was administered once. No additional notes were present in the medical record to indicate why the medication was administered on 2/29/24 or if it was effective. A review of a Physician Progress Note dated 3/4/24 revealed resident was seen for capacity to manage benefits. Resident oriented to self only, unsure of date, location, or circumstances. Pleasantly confused. The physician documented given degree of dementia/loss of insight, do not feel he has capacity to manage own benefits . Review of Resident #3's Nurse's Medication Notes and PRN documentation, dated 3/6/24 at 9:00 a.m. showed Hydroxyzine 25 mg was administered for increased anxiety. No additional information was present in the medical record related to the signs and symptoms of the anxiety and if the medication was effective. Review of a document, signed by Resident #3's physician dated 3/6/24 at 6PM, revealed the resident has a diagnosis of moderate dementia with behavioral disturbance, and the resident could not determine for himself whether examination was necessary; and there was substantial likelihood that without care or treatment the individual would cause serious bodily harm to self and others in the near future as evidenced by combative behavior with staff and law enforcement officer. The resident refused to return to the facility and the secure unit. The sources providing this evidence included the physician, Director of Nursing (DON) and the Nursing Home Administrator (NHA). No additional notes could be found in the medical record pertaining to an event prompting this involuntary transfer to the hospital for evaluation on 3/6/24 at 6:00 PM. A review of the facility's March 2024 Event Log used to document resident related incidents revealed no entry related to Resident #3. A tour of the facility on 03/27/2024 beginning at 9:00 a.m. revealed the secured unit where Resident #3 resided was located within the facility's [NAME] wing. The secured unit consisted of 10 resident rooms with two locked exit doors leading directly to the exterior of the facility with no patio or fencing. One of the two exit doors was located inside of the dining room used by the secure unit. This exit door had the ability to release after pushing on the bar and an alarm would sound to notify staff. A staff member was present in the unit with the assignment of door monitor. A review of the resident census on 3/6/2024 revealed 15 residents were living on the secured unit. A review of the 3/6/2024 Daily Staffing Assignment Sheet revealed the [NAME] wing had 2 licensed nurses and 3 Certified Nursing Assistants (CNA's) working on the 3:00 PM - 11:00 PM shift. The total resident census on 3/6/2024 for the [NAME] wing was 41 with 15 of the 41 residents residing on the secured unit. A telephone interview was conducted on 3/27/24 at 11:24 a.m. with the facility's Speech Therapist (ST). She said while leaving a local grocery store on 3/6/24 at approximately 5:30 PM she saw Resident #3 on the grassy area near the store's parking lot. She immediately called her manager, the Director of Rehabilitation (DOR) to see if the resident had been discharged from the facility. She reported seeing the resident from a distance and did not see a shopping cart near him. She thought the resident was wearing a long sleeve shirt, pants, and footwear. The ST reported that the DOR said he was pulling into the parking lot and visualized Resident #3. Once she knew the DOR was present, she left the parking lot and did not make contact with the resident during the observation. An interview was conducted on 3/27/24 at 10:44 a.m. with the DOR. The DOR stated the ST called him on 3/6/2024 after 5:00 p.m. and said she saw Resident #3 in the local grocery store parking lot. He called the NHA to confirm the resident had not been discharged from the facility. The DOR reported he was on his way to the local grocery store that day and approached Resident #3 around 5:24 PM. The resident was pushing a grocery cart on the sidewalk and had a black grocery bag. The DOR was unsure of the bag's contents. The DOR said Resident #3 was pleasant and not combative and went into the DOR's vehicle willingly without incident. The DOR drove the resident back to the facility. While in the vehicle Resident #3 told the DOR he was out of the facility for about 3 hours and was thirsty. The DOR reported the resident was dressed appropriately for the weather. After returning to the facility, the DOR provided fluids to the resident shortly after returning to the facility and escorted the resident back to the secured unit with the Assistant Director of Nursing (ADON). The DOR said there were two routes the resident may have taken to get to the local grocery store and assumed the resident traveled down County Road because it was a straight shot from the facility. Observation of the route likely traveled by Resident #3 from the facility to the local grocery store located at 1491 Main Street in Dunedin, Florida revealed it was 0.8 miles and approximately an 18-minute walk from the facility. The resident likely walked: 1. East on San [NAME] Drive toward Scotswood Glen for 0.4 miles. This is a 2-lane road located in front of the facility. 2. Turn right onto [NAME]/County Road 1 for approximately 0.3 miles. This is a four-lane road with turning lanes at the intersection. 3. Continue on [NAME] Rd for 469 ft. to the intersection of Main Street. There are six lanes going east and west with 4 turning lanes at this intersection. There are two lanes going north and south with one turning lane at the intersection. The speed limit was 45 miles per hour and the resident would have had to cross this intersection. 4. Turn left and travel 250 ft on Main Street 5. Turn right 100 ft into parking lot 6. Turn left and walk for about 280 ft to reach the entrance to the local grocery store. Observation of this route and shopping plaza on 3/28/24 revealed this was a highly traveled area with busy traffic and uneven terrain and obstacles like curbs and parking bumpers. The temperature in Dunedin, FL on 3/6/24 at approximately 5:00 PM was 72 degrees with no rain. On 3/27/24 at 2:13 p.m. a follow-up interview was conducted with the DOR (in the company of the NHA, DON, and ADON). The DOR confirmed Resident #3 did not display any behaviors when they returned to the facility from the local grocery store. He gave Resident #3 snacks and was unsure what happened to cause Resident #3 to dash out the door, leaving the facility a second time through the secured unit dining room door. A telephone interview was conducted on 3/27/24 at 10:59 a.m. with Staff E, CNA. Staff E said she worked on 3/6/24 and was assigned to care for Resident #3 during the 3:00 PM -11:00 PM shift. Staff E had witnessed the resident trying to leave the facility and stating he wanted to go to Daytona prior to the 3/6/2024 event. He was usually redirected when offered snacks and fluids. Staff E recalled on the day of the elopement, Resident #3 was stating he wanted to go back to Daytona, and she told him to talk to the staff about it tomorrow. Staff E said she last saw the resident on 3/6/2024 at approximately 3:45 PM, but stated at about 3:45 PM she heard the secured unit dining room door alarm going off while she was providing care to another resident. Staff E said she poked her head out of the room of the resident she was caring for and saw Staff A, Registered Nurse (RN) in the hallway. Staff A told Staff E, she would take care of that. Staff E assumed Staff A, RN meant the alarm and would determine the cause of the alarm. She did not follow up with the RN following this and reported she was unaware Resident #3 was out of the building until he was returned around 5:20 PM that evening. Staff E stated he must have left through the dining room door. Staff E stated Resident #3 was aggressive, angry, and upset upon his return. She was not asked to provide the resident with any additional supervision or services. Approximately 5-10 minutes after he had returned to the building, he went out the same door again. He eloped twice that day. The second time he was in the road in front of the facility. They could not redirect him, the local law enforcement and paramedics were called. It was very bad. Staff E said the facility does not have enough staff and reported having 13 residents on the secured unit the day Resident #3 eloped twice. Staff E reported that a second CNA was assigned to care for the remaining 2 residents on the secured unit along with additional residents outside of the secured unit. Staff E reported the Licensed Nurse assigned to the secured unit worked a split assignment between the secured unit and additional residents residing on the [NAME] wing. Staff E, CNA said often times, she was the only staff member inside the unit at any given time due to the split assignments. Since the incidents on 3/6/2024 a door monitor has been assigned to watch the emergency exit doors in the secured unit. The staff monitoring the door was not offered breaks, and the nurses do not want to sit back in the secured unit to monitor the exit doors. No additional staff outside of the door monitor had been added since the elopement occurred. Staff E stated there have been times when one CNA is assigned to all residents in the secured unit. Staff E did not feel this amount of staffing met the needs/supervision levels needed for the residents living on the secured unit. On 3/27/24 at 11:20 AM an attempt to contact Staff A, RN was made via telephone. An automated message was received saying the phone line was disconnected. Another phone number for Staff A was called on 3/29/24 at 11:19 AM. A voicemail was left but no return call was received. A telephone interview was conducted on 3/27/24 at 12:07 PM with Staff I, Licensed Practical Nurse (LPN). Staff I said on 3/6/2024 she received a phone call from the DON to check Resident #3's room, when she checked the room, the resident was not there. Staff I, LPN said she was told the resident was found at a local grocery store. When Resident #3 returned to the facility he was fine and calm. Staff I, LPN said twenty minutes later, at approximately 6:00 p.m., she was outside on break and saw Resident #3, was outside the building again. He was walking by himself on the roadway at the back of the facility. Staff I, LPN said Resident #3 was carrying a drink and holding a black plastic bag with chicken. She said she called the ADON to notify her Resident #3 had eloped again. Staff I said she was unable to redirect the resident to return to the facility. Resident #3 became aggressive, combative and was walking in the middle of San [NAME] Drive and almost collided with a vehicle. Staff I, LPN, said three law enforcment officers and two Emergency Medical Service (EMS) vehicles responded to the scene for assistance. Staff I, LPN confirmed the staffing levels on the secured unit as one CNA having two residents on the secured unit close to the entrance, along with additional residents on the [NAME] Wing outside of the secured unit. The second CNA was assigned to the remainder of the residents in the secured unit. The nurse assigned to the secured unit was responsible for all residents on this unit along with additional residents outside of the unit residing on the [NAME] Wing front unit. On 3/27/24 at 2:41 p.m., a follow-up interview was conducted with Staff I, LPN. Staff I, LPN said Resident #3's 2nd elopement occurred during mealtime. Staff I, LPN said she was not sure how Resident #3 could get out of the facility a second time without supervision. Staff I, LPN reported the secured unit dining room door had been found open before. It was broken, not alarming, the door would beep randomly at times. Additionally, when the emergency doors alarm, the sound for each door was the same so you have to figure out which door was alarming. She said the facility leadership knew the secured unit dining room door was broken. Staff I said she had reported the door issues to the DON prior to the event (date unknown). On 3/28/24 at 9:01 AM, an interview was conducted with the ADON. The ADON said on 3/6/24 when the DOR returned Resident #3 to the facility from the local grocery store, the resident was walking and talking. The ADON and DOR escorted Resident #3 back to the secured unit without difficulty. The ADON said she did not assess Resident #3 and returned to her office for a short time before receiving a phone call from Staff I, LPN notifying her Resident #3 was outside of the facility behind the building. When the ADON observed Resident #3 was outside again, she went to the secured unit and observed the dining room door was open, and the alarm was sounding. Nurse A, RN was in the vicinity passing medications. The ADON said several staff members were with Resident #3 prior to her arriving on the scene including the DOR, Staff I, LPN and Staff E, CNA. Resident #3 walked on the grass and roadway to the front of the facility and crossed a two-lane road in front of the facility. The ADON said in this intersection the resident and staff who were trying to intervene were almost hit by a white vehicle in the intersection. The physician was notified, and law enforcement was contacted to transport the resident to the hospital. An interview was conducted on 3/27/24 at 1:34 PM with Staff J, CNA. Staff J said on 3/6/24 she was in the main dining room and observed staff running and screaming. Staff J was not assigned to the secured unit and normally works on the East Wing. She asked a nurse, what's going on? She heard someone say, [Resident #3] got out. Staff J, CNA said she did not observe anything but heard the secured unit dining room emergency exit door was not secure and anybody could go in and come out. Staff J, CNA said there were not enough employees. An interview was conducted on 3/28/24 at 2:38 p.m. with Resident #3's physician, who is the facility's Medical Director. Resident #3's physician said on 3/6/24, he was notified by the NHA that Resident #3 almost got out and was having behaviors. The NHA said local law enforcement and EMS had been notified. The physician/Medical Director proceeded to document the event to have the resident transported involuntarily to the hospital. Resident #3's physician said, I do not recall knowing [Resident #3] eloped to a grocery store on that day. He was not aware of the situation with the DOR transporting Resident #3 back to the facility. A follow-up interview was conducted on 3/29/24 at 3:38 p.m. with Resident #3's physician/facility Medical Director. He said after a resident elopes from the facility, he expects the resident to be returned to the secure unit and continue the measures to prevent elopement. The Medical Director said he would definitely expect an assessment to be completed after an elopement and 72-hour hourly checks. The resident's care should be documented, physician notification, and possible pharmacy and psych teams ' involvement. On 3/27/24 at 9:37 AM, an interview and observation of the secured unit was conducted with Staff M, LPN. Staff M, LPN said all staff members are expected to respond to emergency door exit alarms. The keys for the emergency exit door alarms on the secured unit are now kept on the nurses ' key ring. The key must be used to deactivate the door exit alarms. Prior to this, a code was used to deactivate the door alarms. Staff M confirmed that the staffing on the secured unit had remained unchanged post the 3/6/24 elopement, apart from the door monitor. Staff M, LPN confirmed that the nurse was still assigned to both the secured unit and the [NAME] Wing Front unit. Staff M, LPN said the residents on the secured unit are like little toddlers and must be watched all the time. On 3/27/24 at approximately 9:39 AM, an interview was conducted with Staff L, CNA. Staff L was assigned to monitor the secured unit emergency exit doors. She said Resident #3 likes to talk a lot, walks around the unit saying he wants to go to Daytona, and attempts to get out of the door. On 3/27/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON said he completed an investigation of the event. The DON said on 3/6/24, unsure of the specific time, the NHA notified him Resident #3 was located at a local grocery store. The DON called staff at the facility and verified Resident #3 was missing from the facility. The DOR transported Resident #3 back to the facility from the grocery store, and Resident #3 refused to enter the facility. Resident #3 walked into the roadway in front of the facility. Local law enforcement officers were notified and transported to the hospital. The DON determined Staff A, RN heard the secured unit dining room emergency exit door alarm, closed the door, and deactivated the alarm. The DON said Staff A, RN did not check outside or notify facility leadership the alarm had been activated. The DON said when the emergency exit door alarms are activated the facility expects staff to respond to the alarm. Since the event, the DON said staff are expected to count all residents at the beginning of their shift. The facility's department leadership also counts residents twice daily, five times per week. The DON said new alarms were installed on the two exit doors in the secured unit after the elopement. The new alarms are louder than the previous alarms and a key is now needed to deactivate the alarm (prior to this only a code was needed to deactivate the alarm). The DON said the facility had not completed elopement drills in 2024 prior to Resident #3's elopement on 3/6/24. The DON was not aware that 2 separate elopement events occurred with Resident #3 on 3/6/24 at the time of this interview (21 days post event). An interview was conducted on 3/27/24 at 1:47 p.m. with the NHA. The NHA said on 3/6/24 during the event Staff A, RN was the nurse assigned to the secured unit where Resident #3 resided. She said at approximately 3:45 PM, Staff E, CNA was providing care in a resident's room and heard the door alarm sounding. Staff A, RN asked Staff E, CNA for the code to stop the door alarm on the secure unit dining room exit door. The NHA said Staff A, RN

Based on record review and interviews, the facility failed to protect resident's rights to eb free from medical neglect, failed to ensure individuals employed at the facility were licensed in accordance with applicable state laws to prevent medical neglect, when the facility failed to verify the identity, credentials, and licensure of an individual (Staff A) prior to employment as a registered nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening also showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the Admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] for pain and on ,d+[DATE] and ,d+[DATE] checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Review of the Admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Acetaminophen was administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Bumetanide and lactulose were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. One daily multivitamin and senexon were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: ,d+[DATE]=0U [units] ,d+[DATE]=2U ,d+[DATE]=4U ,d+[DATE]=6U ,d+[DATE]=8U ,d+[DATE]=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than ,d+[DATE] days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's ,d+[DATE] fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of ,d+[DATE], with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening also showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust and verify their audits and to make sure nothing is coming up on the screening roster. The facility just hired a new HR person that was trained yesterday. Continuing, she said when a person is hired, they have 3 days from the 1st day they are physically working to show proof of identifications they are legally allowed to work in the U.S. Staff I said they just got approval for E-Verify about a week ago. E-Verify is an obligation that they have to submit hires through the government portal. They will validate social security numbers and addresses to make sure they are legitimate. On [DATE] at 10:19 a.m., during an interview Staff F, Director of Labor Management, report [TRUNCATED]

Based on record review and interview, the facility failed to ensure policies and procedures were implemented to prohibit and prevent medical neglect when failing to ensure individuals employed at the facility were licensed in accordance with applicable state laws, when the facility failed to verify the identity, credentials, and licensure of an individual (Staff A) prior to employment as a registered nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the Admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] for pain and on ,d+[DATE] and ,d+[DATE] checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Review of the Admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Acetaminophen was administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Bumetanide and lactulose were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. One daily multivitamin and senexon were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: ,d+[DATE]=0U [units] ,d+[DATE]=2U ,d+[DATE]=4U ,d+[DATE]=6U ,d+[DATE]=8U ,d+[DATE]=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than ,d+[DATE] days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's ,d+[DATE] fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of ,d+[DATE], with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust and verify their audits and to make sure nothing is coming up on the screening roster. The facility just hired a new HR person that was trained yesterday. Continuing, she said when a person is hired, they have 3 days from the 1st day they are physically working to show proof of identifications they are legally allowed to work in the U.S. Staff I said they just got approval for E-Verify about a week ago. E-Verify is an obligation that they have to submit hires through the government portal. They will validate social security numbers and addresses to make sure they are legitimate. On [DATE] at 10:19 a.m., during an interview Staff F, Director of Labor Management, reported he p [TRUNCATED]

Based on interview and record review, the facility administration failed to administer the facility in a manner to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility administration failed to ensure an employee (Staff A) had a Level II Background Screening, failed to implement policies and procedures to verify the identity, credentials and licensure of an individual (Staff A) prior to employment as a licensed practical nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the Admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] for pain and on ,d+[DATE] and ,d+[DATE] checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Review of the Admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Acetaminophen was administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Bumetanide and lactulose were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. One daily multivitamin and senexon were administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: ,d+[DATE]=0U [units] ,d+[DATE]=2U ,d+[DATE]=4U ,d+[DATE]=6U ,d+[DATE]=8U ,d+[DATE]=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than ,d+[DATE] days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's ,d+[DATE] fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of ,d+[DATE], with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening also showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust and verify their audits and to make sure nothing is coming up on the screening roster. The facility just hired a new HR person that was trained yesterday. Continuing, she said when a person is hired, they have 3 days from the 1st day they are physically working to show proof of identifications they are legally allowed to work in the U.S. Staff I said they just got approval for E-Verify about a week ago. E-Verify is an obligation that they have to submit hires through the government portal. They will validate social security numbers and addresses to make sure they a [TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop a plan of care related to an uncomfortable skin condition for 1 (#80) out of 26 sampled residents. Findings include A clinical record review revealed that Resident #80 was a [AGE] year old male who was admitted to the facility on [DATE]. The last quarterly MDS (Minimum Data Set) assessment, dated 5/2/2014, indicated that his BIMS score was 15. His medical [DIAGNOSES REDACTED]. It is a psychogenic disorder also called Neurodermatosis. That leads to Pruritus (severe itching) from prolonged vigorous scratching. It starts with a patch of itchy skin, but scratching it makes the area even itchier. It spuds like atopic [MEDICAL CONDITION], an immune or genetic condition. It cannot be cured but the symptoms can be controlled, as defined by Mayo Clinic and Taber's Cyclopedic Medical Dictionary). Further review revealed a Progress Note from Resident #80's dermatologist, dated 04/25/2014, which had a [DIAGNOSES REDACTED]. Then treat with [MEDICATION NAME] to the affected areas 2 x day for 2 weeks only (discontinue 06/24/2014)." The order also stated to keep his fingernails cut short. Further review of the clinical record revealed no follow-up since then and no documentation of when the itching/rash recurred. On 07/23/2014, at 08:42 a.m., an interview was conducted with Resident #80. He stated "I'm not sure what is wrong with my skin but I keep scratching it." The Resident's left arm to his elbow appeared purple in color, with multiple scabbed areas and circular patches of white. The Resident's fingernails were long, extended beyond his finger- tips, and appeared to be caked with dark reddish brown debris under the nails. The Resident stated he had been to a dermatologist back in April (4/25/14 per physician progress notes [REDACTED]. The Resident stated that he had told several staff members about his discomfort due to the itching, but had received no relief. When asked if the facility was trimming his nails, the Resident #80 stated, "No, they do not cut my finger nails for me because of my diabetes. I have a friend that lives close by, and he comes to see me and he will cut my finger nails for me. " On 07/23/2014 at 11:40 A.M. in an interview with Employee B and the Resident regarding the itching to his left arm and elbow, the surveyor asked the Resident if he was still itching and he responded, "I was until they put some lotion on". The surveyor and Employee B, an LPN, observed his nails which were long and extremely soiled with a dark substance noted under the nails. The nurse confirmed the Resident's nails were long and should be trimmed. It was observed by the surveyor and Employee B that his left elbow was significantly red in areas where the Resident had scratched the skin off of his elbow. The observation of his left elbow at this time as compared to an observation at 08:42 a.m. indicated that the left elbow now had open areas where the Resident had scratched so much due to the itching that he now had scratched off the top player of his skin. It was observed that there were several areas of dried blood on the Resident ' s left elbow. Employee B confirmed the observation. A review was conducted of the following care plans for July 2014 including, but not limited to: [MEDICAL CONDITION] drug therapy; pain; elevated or decreased blood sugar; skin breakdown; ADL rehab potential; cognitive loss and potential for skin breakdown related to decreased mobility. Upon review of the care plans it was noted that the facility failed to implement a care plan that included this Resident ' s skin condition. The comprehensive care plan, dated 11/07/2013, listed the potential problem or need as "potential for skin breakdown due to decreased mobility, incontinence and appetite changes." The comprehensive care plan listed the contributing factors as [MEDICAL CONDITION] and [MEDICAL CONDITION]. It was brought to the attention of the DON that the Resident had this skin condition ([MEDICAL CONDITION]-Pruritus), with a note from a dermatologist, dated 04/25/2014. The Resident did not have a care plan or any other documentation to monitor the Resident's ongoing skin condition. On 7/23/2014, at 1:30 p.m., the MDS Coordinator returned the Comprehensive Nursing Care Plan that was updated since the original medical record review on 07/23/2014 at 09:46 a.m. It was noted, under the problem with altered skin integrity, that "scratching areas" and "to keep finger nails cut short" had been added with no date. On 07/23/2014, at approximately 1:40 p.m., the updated care plan was brought to the attention of the Administrator and the Administrator confirmed that it had been updated during the survey period, after the surveyor had reviewed the plan. The surveyor also brought to the Administrator's attention that the Resident's medical record had been reviewed at 09:46 a.m. and that the Resident's skin issue was not identified as a problem nor was keeping the Resident's nails cut short listed as an intervention at that time. On 07/23/2014, at approximately 2:00 p.m., the MDS coordinator and the Administrator approached the surveyor and provided the Resident's care plan and confirmed that the MDS Coordinator had updated it this morning. The date of the update was noted to be 07/22/2014. This date was still not correct. The surveyor informed the Administrator that the date should reflect the date the care plan was actually updated. The MDS Coordinator stated she would put 07/23/2014 as the date the care plan was updated. On 07/23/2014, at 5:50 p.m., an interview was conducted with the Resident #80 regarding how long he had been itching. The Resident responded, "Since my last dermatologist appointment." The Resident also stated, "it had been real bad this week." The surveyor asked the Resident if he had told anyone about the itching; he stated that he had told the nurse but he was unable to recall who it was. The Resident then stated, "thank you for having them cut my finger nails. That is the first time the staff have done that for me." The Resident also mentioned that he did not like to go out of his room or attend activities when his arms looked so bad.

Based on observations, interviews, and record review, the facility failed to provide the appropriate follow- up with a dermatologist for an uncomfortable skin condition, and the hygiene needed to prevent complications of the skin disorder for one (#80) out of 26 sampled residents. This failure compromised the Resident's physical comfort and psychosocial functioning not limited to decreased participation in social interactions and activities. Findings Include: On 07/23/2014 at 08:42 a.m. an interview was conducted with Resident #80. He stated " I am not sure what is wrong with my skin but I keep scratching it." The Resident's left arm to his elbow appeared purple in color, with multiple scabbed areas and circular patches of white. The Resident's fingernails were long, extended beyond his finger- tips, and appeared to be caked with dark reddish brown debris under the nails. The Resident stated he had been to a dermatologist back in April (4/25/14 per physician's progress note), but there had been no physician follow up since then. The Resident stated that he had told several staff members about his discomfort due to the itching, but had received no relief. When asked if the facility was trimming his nails he stated, "No, they do not cut my finger nails for me because of my diabetes. I have a friend that lives close by, and he comes to see me and he will cut my finger nails for me." On 07/23/2014, at 11:40 a.m., an additional observation was conducted with Employee "B" who stated that she was the nurse that was assigned to the Resident. She confirmed that the Resident's nails appeared long and soiled. It was also observed by the surveyor and the nurse, at this time, that his left elbow was significantly red in areas where the Resident had scratched the skin off, which appeared to have open, red areas due to the Resident's scratching with his fingernails. The observation of his left elbow at this time, as compared to an observation at 08:42 a.m. on 7/23/2014, indicated that the area now had open areas where the Resident had scratched so much due to the itching that he had scratched off the top player of his skin. It was observed that there were several areas of dried blood on the Resident's left elbow. Employee B confirmed this observation. 07/23/2014 at 5:50 p.m. an interview was conducted with the Resident regarding how long he had been itching and the Resident responded, "Since my last dermatologist appointment." The Resident also stated, "it had been real bad this week." The surveyor asked the resident if he had told anyone about the itching. He stated he had told the nurse, but he was unable to recall who it was. The Resident then stated, " thank you for having them cut my finger nails. That is the first time the staff have done that for me." The Resident also mentioned that he did not like to go out of his room or attend activities when his arms looked so bad. On 07/23/2014 at 2:32 p.m. a telephone interview was conducted with a family member of Resident #80. The family member confirmed that the Resident's elbow "looked terrible." The family member stated that the Resident was seen by a dermatologist in April of this year. The family member stated that they provided the transportation for the resident to the dermatologist. The family member also stated that the dermatologist gave the resident a prescription for a topical medication that they had filled for the resident and provided it to the facility. The family member stated she had not been notified by the facility that his skin condition was an issue again. The family member was also unaware if the topical medication continued, or if it was still available to the resident. The family member was unaware if there had been any follow-up with the dermatologist, or if the medication had been re-filled. The family member stated that the Social Services Director told her they would arrange transportation services for a fee. The family member stated that she would continue to drive him but, it would be nice if the facility assisted her in making the appointments and if they would let her know when he needed to go. The family member stated that because of the resident's history of diabetes, she was especially concerned about infection and consequences. A clinical record review revealed that Resident #80 was a [AGE] year old male who was admitted to the facility on [DATE]. The last quarterly MDS (Minimum Data Set), assessment, dated 5/2/14, indicated that his BIMS score was 15. His medical [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] starts with a patch of itchy skin, but scratching it makes the area even itchier. It is a psychogenic disorder also called Neurodermatosis. That leads to Pruritus (severe itching) from prolonged vigorous scratching. It starts with a patch of itchy skin, but scratching it makes the area even itchier. It spuds like atopic [MEDICAL CONDITION], an immune or genetic condition. It cannot be cured but the symptoms can be controlled, as defined by Mayo Clinic and Taber's Cyclopedic Medical Dictionary). On 07/23/2014 a review of the Resident's care plan indicated no entries regarding the skin rash/scabs/itching until 07/23/2014 when the omission was brought to the facility's attention. Further review revealed a Progress Note from Resident #80's dermatologist, dated 04/25/2014, that had a [DIAGNOSES REDACTED]. Then treat with [MEDICATION NAME] to the affected areas 2 x day for 2 weeks only (discontinue 06/24/2014)." The order also stated to keep his fingernails cut short. Further review of the clinical record revealed no further follow-up and no documentation of when the itching/rash recurred. On 07/23/2014, the weekly skin assessment, documented by nursing staff for July 2014, was reviewed and it was documented under findings dry skin to upper bilateral extremities for the assessment dates of: 7/2/14, 7/10/14 and 7/16/14. On 07/23/2014 at 1:08 p.m. in an interview, Staff "C" confirmed that the trimming of Resident's finger nails was part of routine care for residents. The nurse also confirmed that the Resident was not care planned for this skin condition and had not been back to the dermatologist since April 25, 2014. The nurse stated she would call the Resident's family member to see if she would take him to the dermatologist. On 7/23/2014 1:30 p.m. the MDS Coordinator returned the Comprehensive Nursing Care Plan that was updated since the original medical record review on 07/23/2014 at 09:46 a.m. It was noted, under the problem with altered skin integrity under interventions, scratching areas and to keep finger nails cut short had been added with no date. During review of the Resident's care plan it was confirmed that the facility failed to develop a care plan for this Resident's specific skin condition. The comprehensive care plan, dated 11/07/2013, listed the potential problem or need as potential for skin breakdown due to decreased mobility, incontinence and appetite changes. The comprehensive care plan listed the contributing factors as [MEDICAL CONDITIONS]. It was brought to the attention of the DON that the Resident had this skin condition ([MEDICAL CONDITION] - Pruritus), with a Progress Note from a dermatologist, dated 04/25/2014; and the resident did not have a care plan or any other documentation to monitor the Resident's ongoing skin condition. On 07/23/2014, at approximately 1:40 p.m., the updated care plan was brought to the attention of the Administrator and the Administrator confirmed that it had been updated during the survey period, after the surveyor reviewed the plan. The surveyor also brought to the Administrator's attention that the Resident's medical record had been reviewed, at 09:46 a.m., and that the Resident's skin issue had not been identified as a problem, nor was keeping the Resident's nails cut short listed as an intervention, at the time of the review. On 07/23/2014, at approximately 2:00 p.m., the MDS coordinator and the Administrator approached the surveyor. They provided the Resident's care plan and confirmed the MDS Coordinator had updated it this morning. The date of the update was 07/22/2014. This date was still not correct. The surveyor informed the Administrator that the date should reflect the date the care plan was actually updated. The MDS Coordinator stated that she would put 07/23/2014 as the date the care plan was updated. Policy and Procedure for:" Activities of Daily Living," effective January 2006, from the Clinical Guidelines Manual Restorative under guidelines section C Grooming: "May include trimming nails" on page 2 of 2. Policy and Procedure for: "Notification of Resident/Patient Change in Condition," effective January 2006, from the Clinical Guidelines Manual Administrative under guidelines number 2 states: "The facility will notify the resident/patient's Physician and family or legal representative at the earliest possible time, during waking hours, if there is a change in condition (unless requested to do otherwise)," page 1 of 1.